9. Medulla Oblongata Including the Fourth Ventriele.—Symptonis referable to the auditory, glossopharyngetil, pneumogastrie, hypoglossus, medullary nucleus of the spinal accessory; also deafness, paralysis of the muscles of deglutition; difficult speech; aphonia; atrophy of the tongue; disturbances of the cardiac and respiratory functions; crossed paralysis of the extremities. Rapid extension, involvement of the oppo site side; simultaneous involvement of several cranial nerves (in basal lesions the nerves are attacked in succession). Tumors in the fourth ventricle, such as cysticerei floating free in the cavity, give rise to very inconstant symptoms without any loeal signs of loss of function.
10. Cerebellum.—Cerebellar ataxia; vertigo; rapid appearance of severe symptoms of cerebral pressure, particularly choked dise, head ache, vomiting, stiffness in the muscles of the neck. Bernote pressure symptoms referable to the quathigemina, the pons and the medulla oblongata, with the above-mentioned symptoms which follow the ataxia. If these remote symptoms are distinctly present only on one side of the body-, it may be possible to locate the tumor in one or the other half of the cerebellum.
11. Base of the Brain.—When the tumor begins in the bones or other structures at the base of the skull, rupture into the eyes, nose, or pharynx often occurs (exophthalmus). Very violent pain; early in volvement of the eyes; often unilateral, associated palsies of several cra nial nerves. The tumor can sometimes be seen in the X-ray photograph (Oppenheint, Schuller). Anterior fosse oi the skull: Aside from the above-mentioned general symptoms there are few local symptoms, which correspond to that portion of the cortex which is injured by the press ure. Middle fossa of the skull: Disturbances of the optic nerves, of the visual field (bitemporal hemianopsia), blindnes.s. An amaurosis may occur. before the development of choked disc or atrophy of the optic nerve. Later, ocular palsies (ptosis); symptoms of trifacial irritation (neuralgia, facial ana-sthesia, atrophic paralysis of the muscles of the jaws, neuroparalytic keratitis). Tumors of the hypophysis produce the same symptoms and, in addition, obesity and hypoplasia of the genital organs (see also acromegaly). Posterior fossa of the skull: Pressure symptoms referable to the cerebrum, the pons and the medulla oblon gata. The occurrence of ataxia is preceded by paralysis of the cranial nerves, which develops more slowly than when the lesion is situated within the medulla. Often association of facial and auditory. paralysis, especially in primary tumors of the auditory nerve (neurotibromatosis, Oppenheim).
The following definitions are given to explain some of the above mentioned symptoms: Alotor aphasia is inability- to form words, although the power of understanding the words is preserved; in children it appears that when the speech centre on the left side has: been destroyed, a new centre may be developed on the right to take its. place.
In sensory aphasia (word deafness) the patient can speak and hear spoken words, but does not understand their meaning. He is approxi mately in the position of "a foreigner who does not understand our language." In optic aphasia the patient is unable to name an object that is shown to him, although he is perfectly acquainted with its nature and in conversation speaks of it by its correct name.
Agraphia is the loss of ability to write, although the motor function of the arms is not affected. Alexia is inability to read in individuals
with normal vision, who have been able to read all their lives.
Psychic blindness manifests itself in inability to associate with visual impression of an object a proper conception of its use, size, distance, etc.
In bilateral homonymous hemianopsia one half of the retina of both eyes on the side corresponding to a lesion of the optic tract or of the occipital lobe is insensitive, hence the opposite halves of the visual field are not seen.
In Ititemporal hernianopsia both temporal fields are wanting owing to insensitiveness of the two median retinal halves (occurs in diseases of the chiasm).
Correct interpretation of the pressure symptoms and an attempt to determine the seat of the neoplasm from the focal symptoms that are present usually exhaust the possibilities of accurate diagnosis. To determine the character of the neoplasm is much more difficult and can usually be done only by other concomitant symptoms.
In children, the most important diagnosis is that of tubercle, and we shall therefore add a few remarks about the various forms which it may assume. As a rule the disease occurs in children who have previously shown scrofulotuberculous symptoms (glandular enlargement, suppura tion from middle ear, diseases of the eyes, cutaneous tuberculides or bone caries). The brain symptoms may come on gradually with head ache, vomiting, peevishness, so that tuberculous meningitis appears more likely than brain tumor. If the eyegrounds are examined at this stage, the condition may be explained by the finding of a choked disc; if this is absent, as is often the case, especially in multiple tubercles of the cerebrum, the absence of further signs of meningitis, the occurrence of localized palsies or symptoms of irritation, and the fact that the general brain symptoms remain constant for some time, will awaken the suspicion of a brain tumor. In other cases the indefinite initial stage is interrupted by cortical or unilateral convulsions, which are often followed immediately by paralysis. Gradually developing unilateral palsies not infrequently constitute the only symptom of a brain tumor and, if other pressure symptoms are indistinct, may for a time cause confusion with infantile cerebral palsy. Instead of a simple spastic hemiplegia, tremor, chorea or athetoid movements—without any symp tom of tumor—sometimes give the first intimation of the presence of brain tubercle. Indeed, the picture of bilateral chorea may be simulated by tuberculosis of the brain. Finally-, brain tubercle in the child quite often produces no symptoms whatever; the patient may present the picture of a possibly not quite typical meningitis and at the autopsy' a solitary tubercle is found in the brain. It must of course not be inferred from the present description of the more obscure forms of brain tubercle, that typical cases of the disease, that is,. cases with distinctly localizable focal symptoms and characteristic signs of brain pressure, are rare in childhood. On the contrary, tubercle situated in the pons, in the corpora quadrigemina, in the cerebral peduncles and in the cerebellum quite frequently furnish instructive examples for the focal diagnosis of a neo plasm and permit the observer to follow the slow growth of the tumor quite distinctly by the clinical signs.