we observe alternations of the vertigo and the fits in the same subject. It is by no means rare, however, to find, after from one to ten years' time, the fits entirely displace the vertigo."

There is no type of epilepsy so fearfully and fatally destructive to the intelligence as that previously described. It is generally associated with obscure and not easily detected or defined changes in the cerebral tissue. These pathological alterations are more particularly diagnosed in the advanced stage of the affection. Hence the grave importance of an early recognition of this subtle and insidious form of vertigo, and the necessity for a speedy administration of remedies for its cure.

HEADACHE. This type of hyperæsthesia of the brain will be considered more in detail when, in the concluding section of the work, I address myself particularly to an analysis of the general principles of diagnosis. It may be affirmed, as a postulate, that all organic diseases of the brain are accompanied by vertigo, headache, acute and chronic, or by some abnormal physical sensation within the cranium. Cephalalgia, however, may be considered as an almost invariable accompaniment of all cerebral affections. This symptom is rarely absent, particularly in the early or acute stage of the encephalic disease. In some forms of tumour, and in those obscure alterations of tissue connected with general paralysis, the patient often positively denies that he has headache, or ever was subject to any cerebral pain or uneasiness. I have, however, after minute inquiry, generally ascertained that cephalalgia has existed, but been forgotten by the patient, arising in many instances from an impairment of intelligence and loss of memory. In cases of advanced general paralysis and chronic softening of the brain, the patient stoutly maintains that he is quite free from all headache, and will not admit that he suffers from vertigo, or any description of uneasiness within the cranium, but his

actions clearly demonstrate that there exists an hyperæsthesia of the brain.

"With the exception of atrophy," says Romberg, none of the diseases of the brain occur unaccompanied by headache." Nasse affirms that pain of the head is one of the most constant symptoms associated with cerebral tumours. It always exists, particularly in central softening of the brain involving the corpus callosum, septum lucidum, fornix, and the ventricular parietes. Dr. Todd says, that disease of the corpus striatum and optic thalamus is attended with little or no localized pain pointing out the exact seat of the lesion.

In abscess of the brain headache, paroxysmal in its character, is rarely absent. In all the affections of the encephalon consequent upon chronic otorrhoea, the same symptom is generally present. Apoplexy is almost invariably preceded by either severe vertigo, noises in the head, confusion of intellect, or severe paroxysms of cephalalgia. In cerebral hemorrhage, the patient is often heard to complain, immediately prior to the attack, of a sensation. in the head giving rise to the impression that an actual laceration of the cerebral substance has taken place.

Pain of the head does not always denote the character of the cerebral lesion. It may accompany, as Andral remarks, the most varied morbid condition of the contents of the cranium, bones, membranes, injection of their tissue, formation of concretions on the free surface of the arachnoid, purulent infiltration of the pia mater, or effusion of pus or serum into the ventricles.

According to the opinions of some authorities, this symptom of organic disease of the brain has been somewhat exaggerated.* It has been asserted that headache

Cephalalgia is a symptom of less frequent occurrence than we might have anticipated-a fact which negatively demonstrates the necessity of additional care in attending to other signs indicating disturbance of

is not invariably present in encephalic affections. Cases undoubtedly occur where the patient makes no complaint of headache, but it would be unsafe to infer from this repudiation of the symptom that it has not, at any stage of the disease, existed. I have never carefully examined a case of clearly developed disease of the brain, without having assured myself that vertigo, headache, or some the nervous centres. The analysis of authentic cases of this description also shows that there is no definite relation, except in the instance of the cerebellum, between the site of the lesion and the site of the previous pain. With a view to determining these points, I have gone through the cases recorded in Dr. Abercrombie's work on diseases of the brain, and Andral's fifth volume of that monument of talent, industry, and logical induction, the Clinique Médicale.' The results of the experience of the British and the French physician are numerically wider apart than we should have expected, though they coincide in proving that undoubted cerebral mischief frequently is unassociated with cephalalgia.

"We take first-by the laws of courtesy-the foreign author. He gives one hundred and eight cases in which death was manifestly due to intracranial disease, as confirmed by post-mortem examination; or in which, though the fatal issue was immediately due to other causes, the cadaveric section demonstrated coincident cerebral disorganization.

"In conformity with the observations of Andral, the ratio in which headache accompanies intra-cranial mischief is as forty-five to sixty-one, or nearly as two to three if we subtract the apoplectic cases, in which this symptom is comparatively of less import, we obtain a ratio of thirty-nine to forty, in other words, the frequency and absence of headache are almost equal, or, to use a sporting phrase, it is an even chance whether the intra-cranial disease is or is not accompanied by cephalalgia.

"According to the analysis of Dr. Abercrombie's one hundred and thirtynine histories of intra-cranial diseases, the ratio in which headache is a concomitant of organic disease of the brain is as ninety-two to thirty-eight, or nearly three to one; while, by eliminating the apoplectic cases, we obtain the still higher ratio of seventy-four to fifteen, or nearly five to one.

"We cannot stop to inquire into the causes that determine so great a want of accordance between the two authors; it certainly is not due to any bias on one side or the other, because both are eminently impartial observers, and neither upholds any peculiar theory in regard to cerebral affections; nor can we suppose that the national constitution of the French and English habit of body is so different as to afford an adequate explanation of the discrepancy. Still the numbers given demonstrate that headache is an important symptom in the local affections of the cerebral system, while they also show that its absence must not be regarded as trustworthy evidence of the immunity of the cranial contents. When we examine into the occurrence of headache in the individual varieties of cephalic disease, we see that the ratio varies considerably; it is comparatively rare, as we have already seen, in apoplectic disorders; here the cerebral tissue itself is commonly primarily involved. The cases of cerebral softening in which headache is absent also

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form of abnormal cerebral sensation, pain, or uneasiness, has not been referred to by the patient.

ANESTHESIA (loss of sensation) is more closely connected with certain morbid cerebral states than the condition previously referred to.

These lesions of sensibility occur occasionally a few days and hours before acute attacks of brain disease; sometimes, however, the loss of sensation has been noticed to exist for years prior to anything like active cerebral symptoms manifesting themselves. This impairment of sensation is often most obscure in its origin, as well as insidious in its progress. For some time before the patient complains of any diminution of sensibility, he is conscious of the cutaneous surface of some predominate largely over those in which it occurs; while the reverse is the case in meningeal disease, where the frequency of cephalalgia to its absence is, according to Andral's observations, as four to three. This is in harmony with what we observe in all the organs of the body; for, it is a rule almost without exception, that disease affecting the envelopes is accompanied by pain in a severer form and more frequent ratio then when it seizes upon the actual parenchyma of the viscera. This point is also one that may be made available in estimating the probable locality affected in the chronic or periodical forms of cephalalgia. The relation of the envelopes of the brain, in a physiological point of view, to their contents, is even of more importance, if such a remark is justifiable, than in the case of most other viscera, since they serve not only for protection and for the facilitation of change of form and place, but are, at least in part, eminently the medium of nutrition. The liver, the kidneys, the spleen, the heart, the lungs, and the muscles, receive their supplies of the nutrient fluid by conduits that enter directly into their structure, by immediate vascular connexion with the nearest arterial trunk. The great bulk of the blood conveyed to the brain is, as it were, filtered through the ramifications contained in the pia mater, while it quits the organ in a less indirect course, though still in a much more circuitous manner than commonly prevails elsewhere. Both the pia mater, therefore, as the arterial membrane, and the dura matter, sit venia verbo, as the venous membrane, claim our attention in a point of view distinct from that presented by the epithelial, serous, or fibro-serous membranes occurring elsewhere. I am far from asserting that we are able to localize every case of headache in any one of the intracranial tissues; but it is the more necessary to establish all the elements which may enter into the determination of the question, as it is one upon which we are comparatively ignorant; and the whole history of medicine teaches us that we can only arrive at positive results by minute attention to all the items constituting a complex of morbid phenomena."-Dr. Sieveking, Medical Times and Gazette, August, 1854.

part of his body being in an abnormal state. He is observed to be rubbing his hands, arms, legs, or scalp, for the purpose of giving activity to the circulation of the blood in these parts. The sensation at this period is simply that of numbness, in its first or earliest stage of manifestation. The patient recognises this symptom, and eventually directs attention to it. I attended a gentleman with hemiplegia who was annoyed by this feeling of slight numbness for several years before an attack of cerebral hemorrhage. He was often seen to be applying friction to his hands, arms, as well as the scalp, by means of a flesh-brush, with a view of reviving the sensibility of these portions of the body.*

I attended, a few years ago, a gentleman slightly insane. He was melancholic, and imagined, without any valid reason, that his pecuniary circumstances were in an embarrassed state. Six months before his death, he complained of numbness in his left hand and arm. I examined him carefully, but could detect no other symptom of threatening acute cerebral disease. He left London for the country, and, whilst residing there with his family, had an apoplectic fit. The lesion of sensibility referred to, existed for some months as the only premonitory symptom of the approaching attack.

The mucous membrane of the conjunctiva exhibits, occasionally, in the early stage of disease of the brain, a remarkable state of insensibility. Andral remarks, that

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* "When we read the history of trials for witchcraft," says Dr. Michéa, "we observe that the inquisitors attached a high value to the existence of cutaneous anesthesia as a sign of demoniacal possession. When an individual was charged with the alleged crime, the experts, after having bandaged the eyes, passed a magnifying glass over all parts of his body, previously shaved, with a view of discovering the mark of Satan, stigmata diaboli.' The slightest spot on the skin was probed with a needle. If the puncture did not cause a painful sensation, if it provoked no cry or movement, the poor creature was a sorcerer and condemned to be burnt alive. If, on the contrary, he felt the wound he was acquitted: Satan had not impressed his claw upon him.”—(P. Gray, "Chirurgia," 1609, lib. vii. c. 10.)