An Essay on the Shaking Palsy

by James Parkinson

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 assume here, has been that the disease depends on a disordered state of that part of the medulla which is contained in the cervical vertebræ. 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 pass 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 canal, 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 assuming 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) circumstance. 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 quantity. Should the blisters be found too inconvenient, or a sufficient quantity 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].

Could it have been imagined that such considerable benefit: indeed, that such astonishing 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 vertebræ, 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 analogy 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 circumstance 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 accomplishing, 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 harassing 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 mass or volume by interstitial addition, the consequence of increased action in the minute vessels of the part. In that case, should the instituting 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.