most remarkable fact connected with the case was, that although he appeared generally to know when he spoke wrongly, yet he was unable to speak correctly notwithstanding, as is proved by the preceding specimen. He was completely free from any paralytic affection of the vocal organs.

MORBID IMITATIVE MOVEMENTS OF ARTICULATION.-I have not yet spoken of a singular affection of the imitative movements of articulation which is sometimes witnessed in the early, as well as advanced, stage of cerebral disease. Romberg refers to the phenomenon, and terms it the "echo" sign. The patient exhibits this symptom by repeating, in a monotonous tone of voice, the words and sentences spoken, not only by persons near him, but by those with whom he is immediately engaged in conversation.

I have often observed this symptom at the commencement of acute attacks of disease of the brain, particularly of inflammatory softening. The physician says "Good morning;" the patient echoes the question, without giving any kind of response to the interrogatory. "The pulse is weak," observes the physician to an anxious bystander; "The pulse is weak," echoes the invalid. "Let me see the tongue," asks the physician; "Let me see the tongue," repeats the patient, at the same moment protruding it from his mouth.

I recollect a remarkable illustration of this morbid condition of the imitative movements of articulation, in the case of a gentleman to whom I was called, suffering from many of the alarming symptoms premonitory of paralysis. He repeated every question I put to him, as well as the remarks made by others. This symptom is often observed in chronic conditions of imbecility and insanity.

"A lady," says Romberg, "who died of softening of the brain, invariably repeated my questions, as 'Show me your tongue,' or Will you lift up your arm?' without doing as she was bid. I am acquainted with an idiot of eleven years, who in this way mimics music in a remarkable manner. The same phenomenon has occurred to me in two young girls laboring under typhus fever, when the disease was at its height."

A gentleman, who had suffered acute mental distress, and whose mind was never remarkable for its vigor, exhibited symptoms of softening of the brain. I examined him. He had, to a singular degree, the "echo" symptom, repeating almost every question I addressed to him. His friends, who accompanied the patient to

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my house, were themselves struck with this symptom, although they had never before observed it. This patient subsequently had an attack of decided paralysis, and, after death, there was found extensive softening in the whole of the right hemisphere of the brain.

I presume the "echo" phenomenon may, to some extent, arise from that sluggish and abstracted state of thought amounting to reverie, which is so often seen in cases of long-existing and undetected, because obscure, affection of the brain. The mind appears incapable, under these circumstances, of apprehending the most simple questions, and parrot-like repeats them. I have noticed this symptom in other conditions of depressed vital and nervous power, but it more particularly accompanies softening of some portion of the brain.

INVOLUNTARY ARTICULATION, OR THINKING ALOUD.—Whilst referring to the morbid phenomena of speech, it will not be out of place to direct attention to a precursory symptom, not only of approaching paralysis, but of insanity. I allude to the practice of many patients, suffering from incipient brain and mind disease, of talking aloud, when alone. A distinguished physician observed this symptom to precede an attack of paralysis, in the case of a nobleman who for many years ruled the destinies of this country.

In many conditions of brain irritation and disease, the patient is observed to talk to himself, and the commencement of insanity is often detected by this symptom. I am fully aware that this eccentric habit is quite consistent with a perfect state of health of body and mind; but, nevertheless, it is a symptom that should be carefully regarded in all cases of suspected disease of the brain, coming on at a critical period of life, particularly if conjoined with other signs of cerebral disorder.

MORBID VOCAL PHENOMENA ACCOMPANYING INSANITY. — In some cases of insanity all power of speech appears, for a considerable period, to be lost. Insane patients have been known to continue for years without uttering a vocal sound. This does not generally arise from any paralysis of the organs of speech, although this affection sometimes exists, but it is owing to the mind being intensely absorbed or preoccupied in the contemplation of predominant insane ideas.

Dr. Brierre de Boismont relates the case of a man who was for fifty-two years insane, but who had not spoken for thirty years!

When perseveringly interrogated, he gave a kind of grunt, and ran away. About fifteen days before his death, this patient recovered the use of his speech, and answered perfectly well all questions put to him.

There are certain peculiarities characteristic of the voice and speech of the insane, and these are occasionally recognized in the incipient stage of the malady. I am acquainted with a gentleman subject to attacks of recurrent insanity, whose paroxysms are always preceded by singular alteration and eccentricity of voice. For a week or ten days, and occasionally for a fortnight, before the mind exhibits symptoms of aberration, the voice becomes remarkably sharp and shrill. This warning of the approaching relapse is immediately appreciated by the family, and steps are at once taken to prevent any mischief that might ensue from the violence of a sudden maniacal outbreak. In another case, a lady, who has had repeated attacks of insanity, begins to clip her words and leave her sentences half-finished in the early period of the attack. Some patients, in the incipient stage, speak snappishly, sharply, and quickly. In other forms of insanity, the voice assumes a solemn and grave character. These latter alterations are observed to precede attacks of acute melancholia. I have known the voice to undergo very remarkable modifications, and sometimes a complete metamorphosis, in the incipient stage of insanity.

A lady, some years ago, consulted me respecting her husband, who had, according to the observation of her friends, exhibited symptoms of mental unsoundness. She had not, however, herself noticed any remarkable change in his mental condition, such as to justify her entertaining a suspicion of approaching aberration of mind. She, however, admitted she had remarked a singular alteration in the character of his voice, which was attributed to a cold which she presumed he was suffering from. She could not accurately describe his voice to me. "It sounded (she observed) hollow, as if it came through a large empty tub." Two months subsequently to this consultation, the gentleman was in confinement as a dangerous lunatic.

M. Morel refers to a case of insanity, in which the patient was subject to dangerous periodical attacks of violent homicidal delirium. His relations always knew when the maniacal crisis was about to occur, from a singular alteration that took place in his voice. It had at these periods a bell-like sound. He spoke in

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what is designated by French pathologists, "Voix de Polichinelle,' or, Punch's voice.

Guislain, when alluding to the subject of morbid vocal phenomena as associated with insanity, observes:

"The speech is altered from the natural tone and style; the articulation becomes embarrassed. It is not so distinct as usual, or it is clipped, or hurried, or weak, or too emphatic, or prosy, or drawling. Some words are cut short like a drunken man's, or single words are repeated hastily, or a syllable of a word is repeated, or there is a difficulty in uttering certain letters, such as T's and R's, or words requiring an emphasis, or when several consonants come together. At times the patient stammers, and seems to be at fault in finding the proper word, expletive, epithet, or phrase, which in health he was both apt and fluent in using; or, it may be, that instead of being cautious and studied in his speech, he is all of a sudden voluble, redundant, and profusely garrulous. But at other times the speech is perfectly natural in utterance and rational in what is said, and yet the patient is deeply attainted with insanity all the time. There shall not be a single unreasonable or ill-spoken word uttered. But at the same time there is a retired, reserved manner, a slinking out of sight, a refusal to speak to an old friend, or answer the queries of the medical man; an ill-temper or sulkiness, that is worse than imperfect articulation. At length he speaks with irritation: 'I know their designs

he is not my friend; he has been informed of everything. I am surrounded with freemasons, or papists, or tories, or dissenters. I know there is a God,' &c. &c. Such a person is still insane in spite of his good articulation."

CHAPTER XX.

MORBID PHENOMENA OF SENSATION.

THE sensibility is very frequently affected in organic disease of the brain, and exalted, depressed, or perverted states of this important function are to be found among the early and premonitory symptoms of all cerebral affections. The sensation may be,

a. Exalted.

B. Impaired or lost.
r. Vitiated.

EXALTATION OF SENSATION (HYPERÆSTHESIA). In many affections of the nervous system unconnected with organic disease of the brain, the sensibility exhibits great acuteness; and to such a degree do we occasionally witness this state of morbid exaltation, that the slightest touch of the skin, or puff of cold air, has been known to throw the patient into a paroxysm of convulsive agony. In hydrophobia this condition of acute sensibility is observed, perhaps, in its highest degree of development, and it is frequently seen to exhibit itself for some time after death has apparently taken place.

In these cases, such is the morbid peripheral acuteness of sensibility, that the minimum portion of cold wind, or even a faint puff of air from the mouth, coming in contact with the cutaneous surface of the hydrophobic patient, has often induced a fearful paroxysm of spasmodic suffering. In cases of acute visceral inflammation involving some of the ganglia of the great sympathetic nerve, the general sensibility has become keenly acute. In certain hysterical affections of women the sensation is often intensely manifested. To such a degree has this hyperæsthesia been observed, that the patients have been known to scream violently