Secondary changes, dtte to the rapid growth of the tumor, are almost always seen in post-mortem examinations of brain tumors, particularly internal hydrocephalus, flattening of the cerebral convolutions and ero sion of the cranial bones.
Symptoms.—The symptoms of brain tumor are subdivided into those which are produced by the increased pressure in the brain and those which are due to the seat of the neoplasm. The most important pressure symptoms are headache, vomiting, vertigo, choked disc, slotting of the pulse and convulsions. Headache, one of the earliest signs of brain tumor, may be persistent or occur paroxysmally, and in the latter case particularly may be excessively violent. When the pain is localized in the occiput and radiates into the neck, a cautious diagnosis of neoplasm in the posterior cranial fossa may be made. Marked variation in the intensity of the headache is regarded by Allen Starr as a sign of great vascularity of the tumor and therefore points rather to glionm or sarcoma than to tubercle. Localized pain, elicited by percussing the skull, some times enables the examiner to locate the seat of a neoplasm. Vomiting usually coincides with the period of greatest intensity of the headache and, in general, is more marked during the beginning of the disease, becoming rarer if the duration is protracted. It comes on suddenly— " projectile vomiting"—and does not always bring the relief that follows gastric vomiting.
Owing to the occurrence of choked disc and the impairment of vision which it causes, older children with brain tumors are often seen first by the oculist. Choked disc is an early characteristic symptom, partic ularly when the tumor is situated in the cerebellum, crus cerebri or the base of the brain; in fact, optic neuritis with atrophy may occur in these cases before other symptoms of tumor are present. On the other hand there are brain tinnors, particularly multiple tubercles, in which choked disc occurs late or not at all and causes only slight discomfort. Oculists now-a-days make a sharp distinction between choked disc, accompanied by marked mclenia at the entrance of the optic nerve, and inflammation of the optic nerve or optic neuntis. The former is a con comitant symptom of brain tumor only; the latter is seen with every kind of intracranial inflammatory process. Ophthalmologists are (Bided on the question whether choked disc is the result of the increase in intra cerebral pressure or of a secondary' inflammatory cedema; the majority are in favor of the former view. Unilateral choked disc and hemianopsia
point to a disease focus in the chiasms or in one of the optic nerves. Persistent or paroxysmal vertigo may be a general symptom of brain tumor or the result of disease of tbe cerebellum or of one of the crura eerebelli, or it may accompany palsies of the ocular muscles. Slowing of thc pulse is particularly frequent at the height of an attack of head ache, especially in diseases of the posterior cranial fossa. Marked varia tions in the pulse are frequently observed as the patient changes from the recumbent to the erect position, particularly if the change is sudden. During the terminal stage slowing of the pulse (initation of the vagus) is replaced by acceleration (paralysis of the vagusy Yawning, sobbing and anomalies of the respiration are other concomitants of brain tumor, especially in the advanced stage of the disease. Psychic changes also, particularly depression, disinclination to play, anorexia or even persistent hebetude belong to the picture of brain tumor. Disturbance of speech is not rare and is not necessarily a focal symptom. Convulsions, both general and cortical, are not at all infrequent, especially in brain tubercle in children. Many cases of this disease are first recognized by the sudden occurrence of convulsions; and paralysis of the extremities, accompanied by convulsions, is not infrequently the first symptom. General convul sions are also quite common during the terminal stage of brain tumor in children and, in cases of brain tubercle, may be attributed to a second ary meningitis. Cortical (Jacksonian) convulsions are observed in brain tumor at the beginning of the disease, and usually indicate that the tumor is on the surface of the brain. They consist in localized twitching of the face, or in one arm or leg, at first without disturbance of conscious ness, the latter occurring only when the convulsions attack the other side of the body also. Loosening of the cranial sutures and enlargement of the circumference from secondary hydrocephalus are frequent symp toms of brain tumor in early childhood. Percussion of the skull, particularly of the frontal and parietal bones, gives a ringing sound similar to the cracked-pot sound heard over a pulmonary' cavity.