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This gradually increased. The limbs became heavy, and the motor power began to fail. At the end of six years, the sip/it became obscured, and the patient had dzlnlopia and slrabz'smus. Then followed great difliculty of walking. The gait subsequently became vacillaliny, and the feet appeared ylued at every step to the ground." Important and significant incipient symptom of paralysis! “ The patient then was attacked with a general numbness and paraplegia. He next was subject to cramps afl‘ecting the extensor muscles of the great toes. A year afterwards he had tetanic spasms of the muscles of the back, and the paraplegia was converted into paralysis of the upper and lower extremities. The paralysis ultimately became general, deglutition and respiration were impossible, and the patient is said to have died with his intellectual faculties unimpaired!” The post morfem examination revealed a state of softening of the pyramidal and olimry bodies, as well as of the left half of the pans varolz'i. The restiform bodies were slightly coloured red.
MUSCULAR Tarmoa—In the precursory stage of disease of the brain, a tremulous state of the muscular fibre is occasionally observed. In one remarkable case, for nearly a fortnight previously to the manifestation of any acule head symptoms, the patient was observed to have a tremulous state of the hand. He appeared at the time otherwise in good health. This condition of the muscles was succeeded by violent paroxysmal attacks of headache, causing the patient to scream from the intensity of the pain. He subsequently died paralytic. When examined, after death, a malignant tumour was found in the substance of the brain.
A tremulous state of the tongue has been noticed as the forerunner of acute cerebral attacks. A military gentleman, who had for many years honourany served
MUSCULAR TREMORS SYMPTOMATIC or BRAIN DISEASE. 475
his Queen and country in a tropical climate, returned to England invalided. He had, when in India, suffered from two strokes of the sun. The effect of these attacks, however, rapidly subsided, and he was soon able to do duty in the field. Several months after his arrival home he complained of feeble memory and general want of muscular vigour. The symptoms, however, which caused most alarm, and induced him to obtain my opinion, were, an extreme state of tremor of the tongue whenever he protruded it from his mouth, and an almost unceasing state of agitation when retained _within the lips. It required, on the part of the patient, a resolute effort of the will to keep the tongue at all quiescent for many consecutive minutes. These symptoms continued with slight intermissions for nearly three months. One morning, whilst dressing for dinner, he was seized with extreme vertigo, and fell down in a violent epileptic convulsion. He had a succession of epileptic fits, at varying intervals, for a period of twelve months, when his mind became deranged, and in this state of mental alienation he died, about two years subsequently to the first epileptic seizure. In this case, the extreme tremor of the tongue was certainly the first significant symptom of existing, or approaching lesion of the brain. I have observed in the incipient stage of cerebral disease this tremulous state of the tongue in several cases of acute and chronic softening of the brain, as well as in general paralysis.
In some cases the patient complains for some time before decided symptoms of paralysis exhibit themselves, of suffering from a qaasmodz'e affection of the muscles of the leg and arm, but particularly of the former. In other instances the legs are stiff, and show a want of ' suppleness, independently of any loss of sensibility, or actual want of muscular power. These symptoms often precede paralytic attacks, but they are generally asso
ciated with other characteristic evidences of cerebral mischief. I have known a patient for some months before an attack of hemiplegia complain of acute spasm of muscles of the calf. Occasionally the spasm seizes hold of the whole of the leg, which becomes quite lclam'c. This symptom is observed in the early stages of acute cerebral irrilalz'on, connected in some cases, but not always, with organic disease of the nature of inflammatory softening of the brain. A sensation of slight stiffness of the limbs, combined with pain, analogous to that of rheumatism, spasm, and convulsive twitching of the muscles, if accompanied by headache, mental confusion, vertigo, &c., should never escape careful medical observation.
IRREGULAR MUSCULAR ACTION.—In the second stage of disordered motility, the patient exhibits an inequality and unsteadiness in the action of the muscular system. There is an absence of co-ordination in the motility, a want of consentaneousness in the motor movements, “ a disturbance," to quote the language of Romberg, “ either in the antagonism, or in the symmetrical muscular balance.” This condition of the motor power is analogous to that affection termed by the French pathologists, Paralysie croise'e.
The patient in walking always crosses one leg over the other. For example, he places the right foot invariably before the left, and the latter again before the right; in doing this, the front of the foot is turned inwards, the individual generally stepping upon his toes, and but rarely upon the external margin of the entire sole; the large toe of one foot strikes the Achilles tendon of the other.
Romberg has described with great accuracy these affections of motility. When alluding to the incipient signs of brain disease, he says: “ the gait becomes tottering and insecure, especially when the patient is
MORBlD WANT OF MUSCULAR CO-ORDINATION.
walking slowly. When he wishes to walk from one place to another, he is obliged to give himself an impulse repeatedly, which renders his mode of progression the more peculiar. When complicated movements, such as climbing or jumping, are attempted, the exertions made to achieve them bear no relation to the result attained. When the patient has fairly commenced to advance, he can accelerate his movements, and even run; when lying in bed, so that the trunk is supported, he has no difficulty in moving his feet. As the disease advances, articulation becomes still more limited, and very indistinct; it is almost necessary to guess the words; the legs are almost deprived of their power to support the body. When the insane person rises from his chair and walks, he rests his hands upon the back of his chair; raises himself up slowly, and, like a child that is measuring its first steps, bends to the right, and bends to the left, then makes an attempt and drags himself slowly along in a zigzag direction. He stumbles over the most trifling impediment, and is constantly tumbling down.”i These affections of the motility may exist for a long period before symptoms of a more decided and alarming character awaken attention and excite apprehension.
Romberg candidly admits that he is unable to satisfactorily explain these phenomena. The irregular action of the motor power, he observes, occurs in hemiplegic subjects, and especially in cases of cerebral hemorrhage. The patient, when in active locomotion, advances with the healthy foot, which forms the fulcrum of the body, while the paralysed extremity, with the toes pointed downwards, performs circular or semicircular movements slowly, and with a sort of slide. The other is met with in hydrocephalic patients, before the supervention of complete immobility, and has been accurately described by Golis.
9 “ A Manual of the Nervous Diseases of Man,” by M. H. Romberg, LLD. Translated from the German by E. H. Sievcking, M.D. London, 1853.
When engaged in walking the patient drags one of his legs, as if it were heavier than the one on the opposite side. This symptom occasionally exists to so slight a degree, that it may be present for some time and be unnoticed, unless the attention were particularly directed to the state of the muscular system and powers of locomotion.
The patient is often seen to roll himself about like a drunken man, as if he had entirely lost his balancing power. In cases of approaching general paralysis, this symptom is often observed in a remarkable degree. The gestures, gait, and walk closely resemble that of a man slightly inebriated. These irregular actions of the muscular system are allied to the phenomena observable in the earlier as well as in the more advanced stage of C/lorea.
CONVULSIVE ACTION.—I have now to consider those irregular and morbid states of the motor power or muscular fibre generally grouped under the head, convulsion. Among this class of afl‘ections, epilepsy, in all its varied types and degrees of manifestation, occupies a prominent position.
This disease admits of a threefold division, viz. :
(Nocturnal in its character, and accompanied
7. Epileptic Vertiqo.
(\Vithout muscular convulsions.)