Sometimes the disease begins with extensive paralysis. This was the case with a little girl, aged four years, in whom the first sYmptoms noticed were left hemiplegia and vomiting four or five months before her death. In other cases the onset of the illness may be indicated by a muscular tre mor or a convulsive attack. In the majority of instances, however, severe headache precedes the other symptoms.
On account of the frequency with which tubercle occupies the cerebellum in children it is important to be aware of the phenomena which usually accompany a growth situated in this region of the brain. The characteristic group of symptoms consists of vomiting, occipital headache, amaurosis, and a staggering gait..
The vomiting is especially obstinate. It is a frequent accompaniment of all cerebral tumours, but when combined with occipital pain is very sug gestive of a cerebellar growth. The headache is the consequence of pres sure upon and stretching of the tentorium. It affects the occiput especially, and may radiate to the back of the neck. If, as sometimes happens, it is accompanied by rigidity of the muscles of the nucha, we find a curious re semblance to cervical caries which may be a source of perplexity. Amau rosis from optic neuritis is a common symptom of this as well as of all other forms of intracranial tumours, but growths in the cerebellum are especially apt to press upon the venous channels in the neighbourhood and impede the escape of blood from the retina. Staggering gait is the most charac teristic symptom of cerebellar tumour, and when combined with the preced ing is sufficient to establish a diagnosis. Dr. Bastian compares the walk of such patients to that of one who paces the deck in a rough sea. In the case of a child it looks as if the patient were only now learning to walk, and if combined, as it often is, with a certain stiff way of carrying the head, the effect in the elder children is very curious. After a time the weakness extends to the limbs, which then become unable to support the trunk. Tonic contractions, too, may affect the muscles of the back and limbs as well as those of the nucha, and are sometimes very severe. Tonic rigidity is much more common than clonic convulsions when the tumour affects this region of the brain. Dr. Stephen Mackenzie lays it down as a general rule that "tonic contraction is a product of cerebellar, clonic of cerebral dis ease." These contractions, like the paresis, affect the muscles of the trunk before those of the limbs.
The pops and medulla oblongata are also frequently visited by tuber culous formations. In the former situation the growth may produce neu ralgia, anaesthesia, or paralysis of the fifth nerve, difficulty of deglutition, and disturbance of the function of the bladder. If the growth occupy the
anterior lateral half, the third and fourth nerves may be paralysed. If it lie in the posterior lateral half, there may be paralysis of the fifth and facial nerves, and in either case there may be hemiplegia of the opposite half of the body.
In the medulla oblongata the growth may produce wide-spread mis chief. Extensive paralysis is common ; there may be difficulty of degluti tion and articulation and incontinence or retention of urine from paralysis. of the bladder. Convulsions are common in these cases.
Tuberculous tumours, when they occur in infants, are almost invariably a part of a general formation of tubercle in the body. They are very apt to be complicated with catarrhal pneumonia excited by the presence or the gray granulation in the lungs, and in a large proportion of these cases, as has been said, the illness closes with all the signs of the third stage of tubercular meningitis. In older children the formation of tubercle may not be general. Still, we often find evidence of scrofulous consolidation of lung, or caseous bronchial glands, and in such cases the cerebral mass might, perhaps, be more strictly described as scrofulous cheesy matter than true tubercle. In exceptional cases no other sign of disease is to be found in any part of the body.
existence of a tumour of the brain can only be ascer tamed by careful attention to the course of the illness and the character istic grouping of symptoms to which it gives rise. If the combination of headache, vomiting, and double optic neuritis be discovered, it is highly probable that a cerebral growth is present ; but in infants, although the existence of headache and vomiting is easy to ascertain, an ophthalmo scopic examination of the eyes is often a far from easy matter, and even the question of impairment of sight may be a difficult one to decide. It is probable that many instances of supposed dulness of mind at this early age are really instances not of imbecility, but of blindness. The child ceases to recognise familiar faces because he has ceased to see them. In such cases the test of a bright light passed before the eyes is a valu able one ; for if the eyes follow the light the infant is evidently not un conscious, and the retina is usually still capable of appreciating a lumi nous jet, although its sensitiveness to ordinary objects is impaired. If then, in an infant who is subject to headache and vomiting, we can ascertain in addition that the sight has failed, we have gone far to establish the exist ence of tumour. If now a local paralysis arise, or tremors or convulsive spasms are noted in special muscles, we may feel satisfied that our diag nosis is a correct one.