An Essay on the Shaking Palsy Part 3

One of the arms, in all the cases which have been here mentioned, has been the part in which these symptoms have been first noticed; the legs, head, and trunk have then become gradually affected, and lastly, the muscles of the mouth and fauces have yielded to the morbid influence.

The arms, the parts first manifesting disordered action, of course direct us, whilst searching for the cause of these changes, to the brachial nerves. But finding the mischief extending to other parts, not supplied with these, but with other nerves derived from nearly the same part of the medulla spinalis, we are of course led to consider that portion of the medulla spinalis itself, from which these nerves are derived, as the part in which those changes have taken place, which const.i.tute the proximate cause of this disease.

From the subsequent affection of the lower extremities, and from the failure of power in the muscles of the trunk, such a change in the substance of the medulla spinalis may be inferred, as shall have considerably interrupted, and interfered with, the extension of the nervous influence to those parts, whose nerves are derived from any portion of the medulla below the part which has undergone the diseased change.

The difficulty in supporting the trunk erect, as well as the propensity to the adopting of a hurried pace, is also referable to such a diminution of the nervous power in the extensor muscles of the head and trunk, as prevents them from performing the offices of maintaining the head and body in an erect position.

From the impediment to speech, the difficulty in mastication and swallowing, the inability to retain, or freely to eject, the Saliva, may with propriety be inferred an extension of the morbid change upwards through the medulla spinalis to the medulla oblongata, necessarily impairing the powers of the several nerves derived from that portion into which the morbid change may have reached. In the late occurrence of this set of symptoms, and the extension upwards of the diseased state, a very close agreement is observable between this disease and that which has been already shown, proved fatal to the Count de Lordat. But in this case, the disease doubtlessly became differently modified, and its symptoms considerably accelerated, in consequence of the magnitude of the injury by which the disease was induced.

CHAP. V.

CONSIDERATIONS RESPECTING THE MEANS OF CURE.

The inquiries made in the preceding pages yield, it is to be much regretted, but little more than evidence of inference: nothing direct and satisfactory has been obtained. All that has been ventured to a.s.sume here, has been that the disease depends on a disordered state of that part of the medulla which is contained in the cervical vertebrae. But of what nature that morbid change is; and whether originating in the medulla itself, in its membranes, or in the containing theca, is, at present, the subject of doubt and conjecture.

But although, at present, uninformed as to the precise nature of the disease, still it ought not to be considered as one against which there exists no countervailing remedy.

On the contrary, there appears to be sufficient reason for hoping that some remedial process may ere long be discovered, by which, at least, the progress of the disease may be stopped. It seldom happens that the agitation extends beyond the arms within the first two years; which period, therefore, if we were disposed to divide the disease into stages, might be said to comprise the first stage. In this period, it is very probable, that remedial means might be employed with success: and even, if unfortunately deferred to a later period, they might then arrest the farther progress of the disease, although the removing of the effects already produced, might be hardly to be expected.

From a review of the changes which had taken place in the case of Count de Lordat, it seems as if we were able to trace the order and mode in which the morbid changes may proceed in this disease. From any occasional cause, the thecal ligament, the membranes, or the medulla itself, may pa.s.s into the state of simple excitement or irritation, which may be gradually succeeded by such a local afflux and determination of blood into the minute vessels, as may terminate in actual but slow inflammation. The result of this would be a thickening of the theca, or membranes, and perhaps an increase in the volume of the medulla itself, which would gradually occasion such a degree of pressure against the sides of the unyielding ca.n.a.l, as must eventually intercept the influence of the brain upon the inferior portion of the medullary column, and upon the parts on which the nerves of this portion are disposed.

From this review, and a.s.suming that the morbid changes in this disease may not be widely dissimilar from those which occurred in the case of Count de Lordat, the chance of relief from the proposed mode of treatment may appear to be sufficient to warrant its trial.

In such a case then, at whatever period of the disease it might be proposed to attempt the cure, blood should be first taken from the upper part of the neck, unless contra-i(n)dicated by any particul(ar) circ.u.mstance. After which vesicatories should be applied to the (sa)me part, and a purulent discharge obtained by appropriate use of the Sabine Liniment; having recourse to the application of a fresh blister, when from the diminution of the discharging surface, pus is not secreted in a sufficient quant.i.ty. Should the blisters be found too inconvenient, or a sufficient quant.i.ty of discharge not be obtained thereby, an issue of at least an inch and a half in length might be established on each side of the vertebral columna, in its superior part. These, it is presumed, would be best formed with caustic, and kept open with any proper substance[16].

[Footnote 16: Cork, which has been hitherto neglected, appears to be very appropriate to this purpose. It possesses lightness, softness, elasticity and sufficient firmness; and is also capable of being readily fas.h.i.+oned to any convenient form. The form which it seems would be best adapted to the part, is that of an almond, or of the variety of bean called scarlet bean; but at least an inch and a half in length.]

Could it have been imagined that such considerable benefit: indeed, that such astonis.h.i.+ng cures, could have been effected by issues in cases of Palsy of the lower extremities from diseased spine? although satisfied with ascribing those cases to scrofulous action, we are in fact as little informed respecting the nature of the affection, inducing the carious state of the vertebrae, as we are respecting the peculiar change of structure which takes place in this disease.

Equally uninformed are we also as to the peculiar kind of morbid action, which takes place in the ligaments of the joints; as well as that which takes place in different instances of deep seated pains and affections of the parts contained in the head, thorax, and abdomen, and in all which cases the inducing of a purulent discharge in their neighbourhood is so frequently productive of a cure. Experiment has not indeed been yet employed to prove, but a.n.a.logy certainly warrants the hope, that similar advantages might be derived from the use of the means enumerated, in the present disease. It is obvious, that the chance of obtaining relief will depend in a great measure on the period at which the means are employed. As in every other disease, so here, the earlier the remedies are resorted to, the greater will be the probability of success. But in this disease there is one circ.u.mstance which demands particular attention; the long period to which it may be extended. One of its peculiar symptoms, Scelotyrbe festinans, may not occur until the disease has existed ten or twelve years, or more; hence, when looking for the period, within which our hopes of remedial aid is to be limited; we may, guided by the slow progress of the malady, extend it to a great length, when compared with that within which we should be obliged to confine ourselves in most other diseases.

But it is much to be apprehended, as in many other cases, that the resolution of the patients will seldom be sufficient to enable them to persevere through the length of time which the proposed process will necessarily require. As slow as is the progress of the disease, so slow in all probability must be the period of the return to health. In most cases, especially in those in which the disease has been allowed to exist long unopposed, it may be found that all that art is capable of accomplis.h.i.+ng, is that of checking its further progress. Nor will this be regarded as a trifle, when, by reference to the history of the disease, is seen the train of hara.s.sing evils which would be thus avoided.

But it seems as if there existed reason for hoping for more. For supposing change of structure to have taken place, it is extremely probable that this change may be merely increase in ma.s.s or volume by interst.i.tial addition, the consequence of increased action in the minute vessels of the part. In that case, should the inst.i.tuting of a purulent discharge, in a neighbouring part, act in the manner which we would presume it may-should it by keeping up a constant discharge, not merely alter the determination, but diminish the inordinate action of the vessels in the diseased part; and at the same time excite the absorbents to such increased action as may remove the added matter; there will exist strong ground for hope, that a happy, though slow restoration to health, may be obtained.

Until we are better informed respecting the nature of this disease, the employment of internal medicines is scarcely warrantable; unless a.n.a.logy should point out some remedy the trial of which rational hope might authorize. Particular circ.u.mstances indeed must arise in different cases, in which the aid of medicine may be demanded: and the intelligent will never fail to avail themselves of any opportunity of making trial of the influence of mercury, which has in so many instances, manifested its power in correcting derangement of structure.

The weakened powers of the muscles in the affected parts is so prominent a symptom, as to be very liable to mislead the inattentive, who may regard the disease as a mere consequence of const.i.tutional debility. If this notion be pursued, and tonic medicines, and highly nutritious diet be directed, no benefit is likely to be thus obtained; since the disease depends not on general weakness, but merely on the interruption of the flow of the nervous influence to the affected parts.

It is indeed much to be regretted that this malady is generally regarded by the sufferers in this point of view, so discouraging to the employment of remedial means. Seldom occurring before the age of fifty, and frequently yielding but little inconvenience for several months, it is generally considered as the irremediable diminution of the nervous influence, naturally resulting from declining life; and remedies therefore are seldom sought for.

Although unable to trace the connection by which a disordered state of the stomach and bowels may induce a morbid action in a part of the medulla spinalis, yet taught by the instruction of Mr. Abernethy, little hesitation need be employed before we determine on the probability of such occurrence. The power, possessed by sympathy, of inducing such disordered action in a distant part, and the probability of such disordered action producing derangement of structure, can hardly be denied. The following Case seems to prove, at least, that the mysterious sympathetic influence which so closely simulates the forms of other diseases, may induce such symptoms as would seem to menace the formation of a disease not unlike to that which we have been here treating of.

_A. B._ A man, 54 years of age, of temperate habits and regular state of bowels, became gradually affected with slight numbness and p.r.i.c.kling, with a feeling of weakness in both arms, accompanied by a sense of fulness about the shoulders, as if produced by the pressure of a strong ligature; and at times a slight trembling of the hands.

During the night, the fullness, numbness, and p.r.i.c.kling were much increased. The appet.i.te had been diminished for several weeks; and the abdomen, on being examined, felt as though containing considerable acc.u.mulation.

Before adopting any other measures, and as there appeared to be no marks of vascular fulness, it was determined to empty the bowels. This was done effectually by moderate doses of calomel, with the occasional help of Epsom salts; and in about ten days, by these means alone, the complaints were entirely removed.

Before concluding these pages, it may be proper to observe once more, that an important object proposed to be obtained by them is, the leading of the attention of those who humanely employ anatomical examination in detecting the causes and nature of diseases, particularly to this malady. By their benevolent labours its real nature may be ascertained, and appropriate modes of relief, or even of cure, pointed out.

To such researches the healing art is already much indebted for the enlargement of its powers of lessening the evils of suffering humanity. Little is the public aware of the obligations it owes to those who, led by professional ardour, and the dictates of duty, have devoted themselves to these pursuits, under circ.u.mstances most unpleasant and forbidding. Every person of consideration and feeling, may judge of the advantages yielded by the philanthropic exertions of a HOWARD; but how few can estimate the benefits bestowed on mankind, by the labours of a MORGAGNI, HUNTER, or BAILLIE.

FINIS.