PREMONITORY SYMPTOMS OF PARALYSIS AGITANS. 319 the fork, not being duly directed, frequently fails to raise the morsel from the plate: which when seized, is with much difficulty conveyed to the mouth. At this stage the patient seldom experiences a suspension of the agitation of his limbs. Commencing, for instance, in one arm, the wearisome agitation is borne until beyond sufferance, when, by suddenly changing the posture, it is for a time stopped in that limb, to commence, generally, in less than a minute in one of the legs, or in the arm of the other side. Harassed by this tormenting round, the patient has recourse to walking, a mode of exercise to which the sufferers from this malady are in general partial, owing to their attention being thereby somewhat diverted from their unpleasant feelings, by the care and exertion required to insure its safe performance. "But, as the malady proceeds, even this temporary mitigation of suffering from the agitation of the limbs is denied. The propensity to lean forward becomes invincible, and the patient is thereby forced to step on the toes and fore part of the feet, whilst the upper part of the body is thrown so far forward as to render it difficult to avoid falling on the face. In some cases, when this state of the malady is attained, the patient can no longer exercise himself by walking in his usual manner, but is thrown on his toes and fore part of the feet; being, at the same time, irresistibly impelled to take much quicker and shorter steps, and thereby to adopt unwillingly a running pace. In some cases it is found necessary entirely to substitute running for walking; since otherwise the patient, on proceeding only a very few paces, would inevitably fall. "The sleep now becomes much disturbed. The tremulous motions of the limbs occur during sleep, and augment until they awaken the patient, and frequently with much agitation and alarm. The power of conveying the food to the mouth is at length so much impeded that he is obliged to consent to be fed by others. The bowels, which had been all along torpid, now in most cases demand stimulating medicines of very considerable power; the expulsion of matter from the rectum sometimes requiring mechanical aid. As the disease proceeds towards its last stage, the trunk is almost permanently bowed, the muscular power is more decidedly diminished, and tremulous agitation becomes violent. "The patient walks now with great difficulty, and unable any longer to support himself with his stick, he dares not venture on this exercise unless assisted by an attendant, who walking backwards before him, prevents him falling forward by the pressure of his hands against the fore part of the shoulders. His words are now scarcely intelligible, and he is not only no longer able to feed himself, but when the food is conveyed to the mouth, so much are the actions of the muscles of the tongue, pharynx, &c., impeded by impaired action and perpetual agitation, that the food is with difficulty retained in the mouth until masticated, and then as difficultly swallowed. Now, also, from the same cause another very unpleasant circumstance occurs; the saliva fails of being directed to the back part of the fauces, and hence is continually draining from the mouth mixed with the particles of food which he is no longer able to clear from the inside of the mouth. "As the debility increases, and the influence of the will over the muscles fades away, the tremulous agitation becomes more vehement. It now suddenly leaves him for a moment; but even when exhausted nature seizes a small portion of sleep, the motion becomes so violent as not only to shake the bed-hangings, but even the floor and sashes of the room. The chin is now almost immovably bent down upon the sternum. The fluids with which he is attempted to be fed, with the saliva, are continually trickling from the mouth. "The power of articulation is lost. The evacuations are passed involuntarily; and at the last constant sleepiness, with slight delirium and other marks of extreme exhaustion, announce the fatal result." AFFECTIONS OF THE SPINAL CORD.-As a general rule, the motor power is affected in all cases of softening of the spinal marrow, but there are on record exceptional cases. Dr. Janson, of Lyons, has published the particulars of one in which the spinal marrow was, for the most part, in a state of bouillie, yet the patient had no impediment in the power of motion. M. Velpeau cites an instance in which the cervical portion of the spinal cord was morbidly softened without impairing the motor power. In animals the spinal cord has been damaged without interfering with the muscular movements. Andral, when addressing himself to this subject, observes: "Do all not know that the fœtus, during uterine life, has free power of motion, although its spinal cord at that period is far from having that consistence which it acquires subsequently." M. Rullier relates a case where there was considerable softening of the spinal cord, but communication was maintained between its upper and lower portions merely by a slight though firm slip; there was no relation between the part of the cord affected and the parts of the body capable of being moved; the patient could walk, but his arms were paralyzed and contracted. There is a form of acute softening of the spinal marrow which develops itself very suddenly, progresses with great rapidity, and speedily terminates in death. These cases of acute ramollissement of the spinal cord resemble, in many of their features, those of cerebral hemorrhage. The patient, in the first instance, appears to have an attack of severe lumbago. This is succeeded by great muscular debility in the spinal column, as well as in PERIPHERAL PARALYSIS. 321 the lower extremities. Coma then speedily supervenes, the limbs become forcibly contracted, and the patient dies in a state of tetanic spasm. In many cases, however, even in acute softening of the spinal cord, the mind often continues unclouded until the moment of death. PERIPHERAL PARALYSIS.-I have not yet spoken of those lesions of the motor power which commence in the peripheral extremities of the nerves, and which are occasionally seen to progress upward from the lower limbs, and ultimately involve the great nervous ganglia, and eventually the brain itself. I have seen several remarkable cases of this kind. The early symptoms of this affection are occasionally altogether overlooked in consequence of their great obscurity. A patient complains of general failure in the muscular tone of his feet and legs. He (if accustomed to active walking) is conscious of his inability to take his usual amount of exercise. He notices for some time no other alteration in the motor power. The loss of muscular strength is confined to the foot and leg. This state of local partial paralysis may exist for years before the patient has any apprehension of danger, or feels under the necessity of obtaining medical advice. In one remarkable case that came under my notice, I was informed that this failure of muscular power had been progressing gradually for six years. It was first observed in the foot, it then extended to the legs and arms, and it was not until the expiration of seven years that the brain became involved. Occasionally the paralysis is confined to the legs, and appears in an inexplicable manner to be arrested there in the course of its ascent to the brain. CHAPTER XIX. MORBID PHENOMENA OF SPEECH. THIS subject will be considered in the following order: 1. CEREBRAL LOCALIZATION OF SPEECH. 4. MORBID IMITATIVE MOVEMENTS AND INVOLUNTARY ACTS OF ARTICULATION. Attempts have been made to localize the organs of speech, and to ascertain by carefully executed post-mortem examinations, as well as by accurately observed physiological experiments upon animals during life, the precise portion of the brain influencing and regulating this faculty. Gall, Serres, Pinel, Grandchamp, Belhomme, and Bouillard, maintain that the anterior lobes of the brain preside over the organ of speech, and a number of cases of total and partial loss of this function have been cited, in which this portion of the encephalon has been discovered after death to be in a state of organic disease. In 1845, at L'Académie Royale de Médecine, M. Belhomme read a memoir "On the Localization of Speech in the Anterior Lobes of the Brain," in which, by a reference to ten cases which he narrates, he endeavored to prove that the cerebral organ which regulates speech was seated in the anterior lobes of the brain. M. Belhomme arrived at the following conclusions: 1. "Affection of the faculty of speech depends either on a cerebral affection, or on a lesion of the organs of communication between the brain and the organs of speech. 2. "The sudden loss of speech depends on hemorrhagic or other lesion of one or more frequently of both anterior lobes of the brain. 3. "It is necessary to guard against confounding convulsive and paralytic disorders, which affect the power of speech with that sudden loss of memory of words, and consequent difficulty of speech, depending on affection of the anterior lobes of the brain. 4. "In disorder or partial destruction of the anterior lobes of the brain, the speech is suddenly arrested, and it is only after a LOSS OF SPEECH CAUSED BY CEREBRAL PARALYSIS. 323 cicatrix has formed in the brain that the organ recovers more or less of its former function." Out of thirty-seven cases carefully observed and analyzed by Andral, as well as by other pathologists, relative to hemorrhage and other cerebral lesions, in which the morbid affection resided in one of the anterior lobes or in both, speech was abolished in twenty-one and retained in sixteen. The particulars, however, of fourteen cases were collected by Andral, where the speech was abolished without any alteration in the anterior lobes. Of these fourteen cases, seven were connected with diseases of the middle, and the same number with diseases of the posterior lobes. The loss of speech is not, then, as Andral concludes, the necessary result of the lesion of the anterior lobes. It may take place in cases where examination does not reveal any alteration at all in the structure of these lobes.1 M. Lallemand has cited a case in which no other change was detected than softening of the white substance of the left lobe of the cerebellum. In this case the faculty of speech was completely lost." Olivier records the particulars of a patient in whom occurred the phenomenon of loss of speech, at first partial, and then complete. In this case there was organic disease of the pons varolü, but no affection of the anterior lobes. The former part of the brain was found softened at its lower surface to the size of a filbert.3 Cruveilhier cites some remarkable cases of extensive disorganization of the anterior lobes of the brain, the functions of speech remaining intact. Modern pathologists have placed upon record similar instances. I have, in fifty-four cases, detected, after death, a considerable amount of organic disease of the anterior cerebral lobes, without being accompanied during life with perceptible loss of speech. In one case of softening of the cerebellum, where the anterior lobes were free from all organic alteration, the principal symptom was great perversion of the faculty of speech without complete loss of power over this function. In another case a large encysted abscess was discovered at the base of the brain, which produced, during life, a remarkable modification in the faculty of speech. The patient's misplacement of words was at times both eccentric and grotesque, and he occasionally appeared to have lost all power of articulation. In a third case, a tumor of a malignant character was found in the cerebellum, which produced a complete loss of speech. Undoubtedly, cases occur of loss of, or serious alterations in the faculty of speech, clearly associated with structural changes in the anterior lobes of the brain; but to prove anything like a Letter ii, p. 134. 1 Andral's "Clinique Médicale," p. 119. |