right arm, being occasionally observed to drop things from the right hand, but did not admit that he felt any muscular weakness. He made no complaint in this stage of headache or giddiness, but admitted that he was weak and in an exhausted condition, and did not feel himself able to bear much fatigue. Eighteen days afterwards he exhibited confusion of thought, and when endeavouring to write a letter, was obliged to relinquish the attempt. He complained that he could not make sense of what he was engaged in writing. "The words as he wrote them appeared," he said, "to run one into the other." The letter when finished was scarcely legible, and the lines were very crooked. He died nine days afterwards of apoplexy.

The loss of motor power in incipient disease of the brain is occasionally confined to one of the fingers, this being the only appreciable symptom calculated to excite alarm. These are curious and inexplicable cases. A partial affection of this kind has been recognised as one of the first threatening symptoms of paralysis and apoplexy. A gentleman, for some months before he had an attack of cerebral hemorrhage, complained of loss of motion in the little finger, and called the attention of his physician to the fact. There was no marked headache at the time, but about a week or ten days after this premonitory symptom of paralysis was observed, the patient said his head felt as if it were "a lump of lead." There was also a slight defect in the hearing; but these symptoms were not considered at the time of any consequence.

For two months before an attack of paralysis a patient was unable to swallow with facility or put any liquid into his mouth without slabbering himself, or spilling a portion on the table or on his clothes. This caused much irritation at the time, but it was not considered a symp tom of any importance. It was, however, the first appre

ciable sign, and, in fact, the commencement of a morbid affection of the motor power. Three weeks afterwards the right hand became so weak that the patient could not hold anything steadily in it. Subsequently he was seized, whilst dressing for dinner, with an attack of paralysis, and continued for a short time in a state of unconsciousness, out of which he eventually rallied, but with his mind much enfeebled. A paralysis of the powers of deglutition is often observed as an incipient symptom of disease of the brain.

"I have known a person first lose the strength of his legs, then talk childishly, fiddle with his knife and fork during dinner, to the confusion of his family, attempt in vain to direct the morsel to his mouth, and at length carried to bed several hours before he became apoplectic."

Inability to hold the pen when writing, to draw on the boots, (in consequence of morbid loss of motor power in the muscles of the arm); to handle the razor steadily when shaving, (in consequence of defective muscular strength in the fingers,) to play the piano with the usual vigour and facility, have been observed (in several cases) to be the first warnings of approaching paralysis.

Dr. Ulric of Berlin has detailed an exceedingly interesting case illustrative of this incipient stage of paralysis. It is also valuable as pointing out the gradual, insidious, stealthy, and progressive march of cerebral disease, when once established within the cranium.

In this particular instance, the first symptom of disease of the brain was observed at eighteen, the patient dying at the age of twenty-six!

The progress of the malady was as follows: "For six years a condition of muscular sluggishness existed.

* On Nervous Diseases, in 2 vols.; vol. 1, On Apoplexy, &c.; by John Cooke, M.D., 1820.

This gradually increased. The limbs became heavy, and the motor power began to fail. At the end of six years, the sight became obscured, and the patient had diplopia and strabismus. Then followed great difficulty of walking. The gait subsequently became vacillating, and the feet appeared glued 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 affecting 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 mortem examination revealed a state of softening of the pyramidal and olivary bodies, as well as of the left half of the pons varolii. The restiform bodies were slightly coloured red.

MUSCULAR TREMOR.-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 acute 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 honourably served

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 spasmodic 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 tetanic. This symptom is observed in the early stages of acute cerebral irritation, 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 croisée.

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 against 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