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TUMORS OF THE CEREBELLUM 
 
 CHARLES K. MILLS, M. D. ' 
 
 CHARLES H. FRAZIER, M.D. 
 
 GEORGE E. DE SCHWEINITZ, M. D. 
 
 T. H. WEISENBURG, M.D. .'•'''" 
 
 EDWARD LODHOLZ, M. D 
 
 Reprinted from the 
 
 New York Medical Journal and Philadelphia Medical Journal 
 
 for February ii and i8, 1905 
 
 NEW YORK: 
 
 A. R. Elliott publishing company 
 
 66 West Broadway 
 1905 
 
a, X 
 
 Copyright, 1903, by A. R. Elliott Publishing Co. 
 
TABIvE OF CONTENTS 
 
 1. The Diagnosis of Tumors of the Cerebellum, Espe- 
 
 cially with Reference to Their Surgical Removal. 
 By Chari^es K. MiIvI,s i 
 
 2. Remarks Upon the Surgical Aspects of Tumors of 
 
 the Cerebellum. By Chari^ES H. FraziER . . 39 
 
 3. Cases Illustrating the Papers of Dr. Mills and Dr. 
 
 Frazier 86 
 
 4. The Ocular Symptoms of Cerebellar Tumors. By 
 
 George E. de Schweinitz 119 
 
 5. The Pathology of Cerebellar Tumors. By T. H. 
 
 WEisEneurg 135 
 
 6. The Functions of the Cerebellum. By Edward 
 
 IvODHOLZ 171 
 
 ILLUSTRATIONS 
 
 Fig. I. Vertical section of head, showing the compara- 
 tively small cavity in which the cerebellum 
 is contained and its inaccessibility .... 38 
 
 " 2. A head rest that may be used to advantage in 
 
 operations upon the head 47 
 
 ' ' 3. Photograph of a horizontal section of the head 
 cut on a level with the external auditory 
 meatus 61 
 
 " 4. Operation for the combined exposure of one 
 cerebellar hemisphere and the occipital lobe 
 of the cerebrum 66 
 
 " 5. Operation for the simultaneous exposure of 
 both cerebellar hemispheres, necessitating 
 ligation of the occipital sinus 67 
 
 Fig. I. Sarcoma in left cerebellopontile angle . . . 144 
 
 " 2. Fibroma compressing the lateral lobe of the 
 cerebellum and the lower surface of the tem- 
 poral lobe 152 
 
 " 3. Fibroma compressing the lower surface of the 
 
 cerebellum and the left side of the pons . .155 
 
THE DIAGNOSIS OF TUMORS OF THE 
 CEREBELLUM AND THE CEREBEL- 
 LOPONTILE ANGLE, ESPE- 
 CIALLY WITH REFERENCE 
 TO THEIR SURGICAL 
 REMOVAL. 
 
 By CHARLES K MILLS, M. D., 
 
 PHILADELPHIA, 
 
 PROFESSOR OF NEUROLOGY, UNIVERSITY OF PENNSYLVANIA; 
 
 NEUROLOGIST TO THE PHILADELPHIA GENERAL HOSPITAL. 
 
 In time it is probable that as regards tumors 
 of the cerebrum, especially those located on its 
 lateral aspect anywhere from the cephalic tip to 
 the occipital pole, success both in diagnosis and 
 in operative treatment will reach from twenty- 
 five to fifty per cent. By success is meant the 
 exact localization and removal of tumors, the 
 operation from the surgical point of view being 
 entirely successful, and partially so from the point 
 of view of the removal of the disease. Supposing 
 that fifty per cent, of such cases are reached, ten 
 to fifteen per cent, will not recur, or at least not 
 in periods varying from three to ten years. In 
 the remainder the painful and distressing general 
 symptoms of brain tumor will be removed for a 
 
time, the neoplasms recurring in some cases after 
 an interval, while in others the cases may termi- 
 nate fatally. Life in most instances will not only 
 be prolonged, but will be made much more com- 
 fortable. Tumors of the mesal aspect and of the 
 base of the brain will always be uncertain in re- 
 sult, although an occasional growth situated on 
 the orbital or temporal surface may be success- 
 fully reached. We must, therefore, after growths 
 located on the lateral aspect of the cerebrum, look 
 to tumors of the cerebellum and cerebellopontile 
 angle for our next highest percentage of successes 
 in spite of the hitherto unsatisfactory, and in some 
 instances even disheartening, results of surgical 
 procedure. 
 
 The surgical aspects of the subject, including 
 the methods and results of operation and statisti- 
 cal details, will be fully considered by Dr. Frazier ; 
 but as I have had much experience in observing 
 operations on the cerebellum, I may be permit- 
 ted, in introducing a discussion of the symptom- 
 atology and diagnosis of cerebellar tumors, to 
 say a few words about the accessible sites for 
 operation. 
 
 Although an operation is difficult and often un- 
 successful, tumors in certain cerebellar locations 
 may be regarded as "operable." These are: i. 
 Tumors situated wholly or in large part in one 
 
lateral lobe. 2. Tumors situated upon or in part 
 invading the vermis or middle lobe. 3. Tumors 
 of the cerebellooblongatopontile angle. Only in 
 the case of a tumor located in large part in one 
 lateral lobe of the cerebellum does an operation 
 afford a really good chance for success, but in rare 
 cases both tumors of the vermis and of the cere- 
 bellobulbar angle can be reached and removed. 
 
 With regard to tumors of the vermis or mid- 
 dle lobe, the writer has had no personal experi- 
 ence with operative procedure. I believe, how- 
 ever, that in some instances tumors resting upon 
 or even invading the vermis may be reached and 
 removed. The operation in this case should in- 
 clude an opening on each side of the median line, 
 and possibly the ligation of the sinus and the re- 
 moval of the bone intervening between the two 
 openings. Such an operation is feasible, al- 
 though, perhaps, difficult. 
 
 The diagnosis of the existence of a tumor in 
 the cerebellum is as a rule comparatively easy, 
 but to exactly locate and infer the size and ex- 
 tensions of such a growth is a more difficult task ; 
 and yet when operation for removal of the tumor 
 is under discussion, the focal diagnosis becomes 
 of paramount importance. 
 
 In the first place, brief consideration will be 
 given to general symptomatology and diagnosis. 
 
In a large majority of cases of cerebellar neo- 
 plasm the well known general symptoms of brain 
 tumor, namely, headache, nausea, and vomiting, 
 optic neuritis, and vertigo, are present and are of 
 pronounced character. 
 
 While the headache in many cases is intense, 
 and in some even agonizing, in others it is of 
 moderate severity and in rare instances, of which 
 a few have come under my observation, it may 
 be entirely absent or it may not appear until late 
 in the course of the disease. In about half the 
 cases the headache is referred to the back of the 
 head or to this region, and at the same time to 
 other parts, as to the nape of the neck and va- 
 rious portions of the cranial vault. Frontal head- 
 ache of a severe type is occasionally observed in 
 cases of cerebellar tumor, just as in some in- 
 stances of frontal neoplasm the pain is most in- 
 tense or is present alone in the occipital region. 
 Too much stress therefore must not be placed on 
 the site of the pain. 
 
 Nausea and vomiting are symptoms of fre- 
 quent occurrence, although they occasionally dis- 
 appear for long periods in the progress of a case. 
 The mechanism of these symptoms is much the 
 same as that of the vertigo due to dural irrita- 
 tion, which will presently be considered. 
 
 With regard to optic neuritis and its conse- 
 
quences, it is only necessary to say that our ex- 
 perience is similar to that of others who have 
 found this sign of intracranial tumor more con- 
 stant in cerebellar tumors than in those located 
 in almost any other region of the brain. The 
 development of the choked disc or optic neuritis 
 is often rapid, or at least goes on at a much ac- 
 celerated pace after it has reached a certain mod- 
 erate height. The choking of the disc is extreme, 
 and haemorrhages are numerous. Unless opera- 
 tive interference checks the progress of the in- 
 flammation, blindness speedily occurs, and this is 
 one of the reasons for early surgical procedure, 
 even when the case has not a hopeful outlook 
 as regards removal of the growth. 
 
 Dr. de Schweinitz, in his paper on the ocular 
 phenomena of tumors of the cerebellum, to which 
 the reader is referred, fully considers the oph- 
 thalmoscopic appearances and conditions in this 
 affection. Nearly all the cases included in the 
 series from which the inferences contained in this 
 paper are drawn were seen by him. 
 
 The vertigo which is so frequently a general 
 symptom of brain tumor, wherever situated, is 
 usually due to irritation of branches of the tri- 
 geminal nerve, which are distributed near the 
 inner surface of the dura, the irritation of the 
 fifth nerve beins: reflected to the bulbar nuclei of 
 
this nerve and thence to the pneumog-astric nu- 
 cleus. This is usually one of the causes of the 
 vertigo in tumors of the cerebellum when the 
 growth is connected with the dura, which is not 
 the rule. In other cases it should be regarded 
 as a focal rather than as a general symptom of 
 cerebellar tumor, as it is caused by the disturbing 
 influence exerted by the tumor upon the cere- 
 bellovestibular apparatus. 
 
 A distinction must always be made between 
 cerebellar vertigo and cerebellar ataxia, although 
 the two are often so interblended that this is not 
 easily done. Subjective vertigo is common, the 
 patient usually describing it as a feeling of dizzi- 
 ness. Both subjective and objective vertigo may 
 be extreme and exhibit striking characteristics 
 which indicate their focal origin. In a case re- 
 corded by Osborne,^ for example, in which a large 
 glioma was situated in the right cerebellar lobe, 
 the patient was unable to sit up, and could not 
 turn her head without having an attack of ver- 
 tigo. The dizziness was relieved by complete 
 rest in bed, but came on again with less fre- 
 quency, although with much severity. The pa- 
 tient would always lie with her head to the right, 
 saying that she became dizzy if it were turned 
 
 1 Osborne, O. T., Journal of Nervous and Mental Diseases. 
 N. Y., Vol. xxix, October, 1902. 
 
to the left. Later epileptoid seizures took the 
 place of the vertigo. 
 
 I shall discuss next the strictly focal symp- 
 toms of tumor of the cerebellum. 
 
 Nystagmus is one of the most frequent symp- 
 toms of cerebellar tumor. It is present in growths 
 variously situated in the cerebellum or jointly 
 in the cerebellum and adjacent parts, as for in- 
 stance in the middle lobe, in one lateral lobe when 
 the neoplasm is close to its junction with the 
 middle lobe, in the prepeduncle or jointly in this 
 and the oblongata. A tumor or other lesion con- 
 fined to the flocculus is said to give rise to nystag- 
 mus. The nystagmus of cerebellar or cerebello- 
 pontile disease may be of various types, as re- 
 gards the manner of its occurrence, its direc- 
 tion, and the rapidity or slowness of the oscilla- 
 tions. It may be present when the eyes are quiet 
 and looking straight forward, or under these cir- 
 cumstances it may be absent, but capable of be- 
 ing elicited by having the eyes turned either to 
 the right or to the left, or upward or downward. 
 It may be horizontal or vertical or both in the 
 same case. The movements are sometimes rapid 
 and fine or slow and comparatively coarse. In 
 the case of Bruce referred to later in this paper, 
 the nystagmoid movements, which were present 
 in all positions, were increased on lateral move- 
 
ments; on looking to the right the oscillations 
 were slower and larger. They were of inter- 
 mediate rapidity and extent in looking upward 
 or downward. It has been suggested that the 
 nystagmus can be brought out when it is not 
 present, or that it is greater if present, when the 
 eyes are turned toward the side of the lesion, a 
 view which was supported by one case of cere- 
 bellar abscess recorded by Spiller,^ but was not 
 confirmed by a case of cerebellar tumor reported 
 by this writer in the same paper. We have not 
 been able as yet to make any inferences of local- 
 izing value from a study of cerebellar nystagmus, 
 although it would seem probable that in a case 
 of destructive lesion affecting the cerebellovesti- 
 bular tract, the nystagmus would be greater when 
 the eyes were directed toward the side of the 
 tumor. I shall refer presently to the views of 
 Bruce on this subject. 
 
 The question of the existence of a true paresis 
 or paralysis as the result of a cerebellar lesion is 
 one that has been discussed both by physiologists 
 and clinicians. That a general paralysis has 
 been observed as both the result of experimental 
 lesions of the cerebellum and of cerebellar haem- 
 orrhage, tumor, or abscess in man cannot be 
 
 * Spiller, W. G., Amer, Jour, of the Med. Sciences^ February, 
 1904. 
 
doubted, but in many cases at least this symp- 
 tom is due to the effect of the lesion on neighbor- 
 ing parts, as for instance on the pyramidal tract 
 or tracts. Asthenia or muscular weakness is, 
 however, a real cerebellar symptom. Sometimes 
 it is overlooked, the symptoms which are depend- 
 ent upon this weakness being attributed to inco- 
 ordination or other cause. 
 
 In a valuable paper by Grainger Stewart and 
 Gibson^ these writers report at length their obser- 
 vations with regard to the state of voluntary 
 movements in the five patients which form the 
 basis of their paper. In all of these cases the 
 patients exhibited weakness of the legs, as tested 
 not only in standing and walking, but also by 
 movements in bed. Weakness of the spinal mus- 
 cles was present in three cases. Niemeyer, Hugh- 
 lings Jackson, and Risien Russell, who are cited 
 by Stewart and Gibson, have shown that paresis 
 or weakness of the spinal or trunkal muscles re- 
 sults from cerebellar lesion. Jackson believes 
 that destructive lesion of the vermis causes pa- 
 ralysis or paresis, most marked in the muscles 
 of the trunk, next in the lower extremities, and 
 least in the upper limbs. Discussing the weak- 
 ness of the spinal muscles, Stewart and Gibson 
 
 2 Stewart, T. Grainger, and Gibson, G. A., Edinburgh Hospi- 
 tal Reports, Vol. v, Edinbnrgh and London, 1898. 
 
10 
 
 referred to the relief which is sometimes afforded 
 by the use of crutches. In several cases of tumor 
 of the cerebellum I have observed distinct evi- 
 dences of weakness of the muscles supporting the 
 vertebral column. It is probable that some of 
 the difhculty experienced by the patients in main- 
 taining their equilibrium, and some of the tend- 
 ency to fall or pitch to one side or the other, are 
 dependent in part at least upon asthenia or pare- 
 sis rather than entirely upon incoordination. In 
 Case V of the series appended to this article and 
 that of Dr. Frazier the general musculature was 
 flaccid, and the head showed a tendency to fall 
 backwards or a little to one side, apparently be- 
 cause of weakness of the supporting muscles of 
 the neck. 
 
 Batten* has called attention to what he believes 
 to be the diagnostic value of the position of the 
 head in cases of cerebellar disease. He refers 
 to the fact that Risien Russell has observed in 
 animals after ablation of a cerebellar hemisphere, 
 that the head sinks on the shoulder on the side 
 on which the operation is performed, the eyes 
 being deviated to the same side and upward, and 
 the chin to the opposite side. The spinal col- 
 umn is concave on the side of the ablation. Bat- 
 ten observed a case of tubercle of the right lateral 
 
 * Batten, T. E., Brain, Part 101, Spring, 1903. 
 
11 
 
 lobe of the cerebellum in which the patient's head 
 sank towards the left shoulder, the face looked 
 upwards toward the right and the chin rotated 
 to the right. The spinal column, as in animals 
 experimented upon, was concave towards the 
 same side. The same symptoms have been ob- 
 served by Batten in hydrocephalus. 
 
 At a meeting of the St. Louis Medical Society 
 on September 17, 1904, at which some remarks 
 were made by the writer on the diagnosis of cere- 
 bellar tumors. Dr. J. J. Putnam, of Boston, spoke 
 in the discussion of a case in which this symp- 
 tom or some modification of it was present. 
 
 The symptom known as hemiasynergia, first 
 described by Babinski,^ who believes it to be 
 present on the side on which a cerebellar tumor 
 or other lesion exists, has been sought for in all 
 cases of cerebellar tumor recently observed, but 
 so far it has not been found a reliable sign of 
 cerebellar disease. This symptom is brought out 
 in the lower extremity by having the patient, 
 with his eyes shut, flex the leg fully on the thigh 
 and the thigh on the abdomen, and then require 
 him to extend the limb to its full length. If the 
 extension is done normally, the leg and thigh 
 movements are performed synchronously or 
 rather synergically, but the leg is first straight- 
 
 ' Babinskl, Bevue neurologique. May 30, 1902, p. 470. 
 
12 
 
 ened out and then the entire limb is brought to 
 a horizontal position by a second movement. I 
 have noted the presence of this symptom in sev- 
 eral cases, but in some instances when shown at 
 one examination it would fail to be elicited at 
 another in the same extremity. It was present 
 on the side of the lesion on several occasions 
 when one of the cases recorded in connection with 
 this paper was examined. On other occasions 
 the limb was extended synergically. Shortly 
 after eliciting the sign at an examination made in 
 the ward of the hospital, this patient was taken 
 before the class in the amphitheatre and hemia- 
 synergia could not be demonstrated. In the case 
 of Spiller, several times referred to in this paper, 
 it was present on the side of the tumor and was 
 observed by the writer. 
 
 As is said elsewhere, a tumor circumscribed to 
 the outer part of one lateral lobe may not give 
 rise to any symptoms, or at least, to any of diag- 
 nostic value. Excepting cases of this kind, all 
 tumors of the cerebellum cause, or at least may 
 cause, incoordination. Some grade of ataxia has 
 been present in all cases of cerebellar tumor stud- 
 ied by me. The degree and character of .this 
 ataxia have varied greatly in different cases. It 
 is always present in tumors of the vermis, unless 
 it may be in cases to which Bruce has referred, 
 
13 
 
 in which a symmetrical distribution and slow 
 development of the tumor prevent the appearance 
 of the ataxia. The Romberg symptom is practi- 
 cally always present, but it may differ greatly 
 in degree. It differs from the static ataxia of a 
 case of advanced tabes in that it is much less 
 markedly increased by closing the eyes. The 
 sway is, however, usually somewhat increased 
 with the eyes shut; but unless the cerebellar dis- 
 ease is much advanced, the patient will often be 
 able to keep relatively steady on his feet for a 
 considerable time. 
 
 The cerebellar gait is, as it has often been de- 
 scribed, a staggering or titubating gait. The 
 steps are more irregular in their lateral and ver- 
 tical amplitude than those of a tabetic, unless the 
 disease in the latter case is advanced to a point 
 where the patient can barely maintain himself in 
 the erect position while walking. The pose and 
 the gait of a case of cerebellar tumor, or of other 
 lesions of the cerebellum, are due not alone to 
 incoordination. Vertigo and muscular weakness, 
 specially weakness of the muscles attached to the 
 spinal column, as well as incoordination, act in 
 their production. 
 
 The direction in which the patient sways on 
 standing or tends to pitch or fall in walking may 
 be a matter of much diagnostic importance. 
 
14 
 
 Often it plays a considerable part in the discus- 
 sion of the site of operation. According to 
 Starr" the staggering in four fifths of the cases 
 of cerebellar tumor is away from the side of the 
 lesion. This is not my own experience. In those 
 cases coming under my observation in which 
 either necropsy or operation has revealed the 
 tumor, the swaying or staggering has been of- 
 tener toward the side of the lesion than toward 
 the opposite. In two cases reported by Schede/ 
 because the patient tended to fall toward the left, 
 the tumor was located on the right, and in both 
 cases an operation showed that it was situated 
 on the left. In one of these cases the tumor 
 could have been successfully removed. In sev- 
 eral cases of which the writer has personal knowl- 
 edge the focal diagnosis was wrong as to the side 
 on which the operation was performed, although 
 we should certainly have the data to enable us to 
 avoid this mistake — one which is not made by 
 skillful diagnosticians with regard to any other 
 region of the brain, unless it is occasionally the 
 prefrontal. 
 
 In discussing this question of the side of the 
 cerebellum on which a lesion is situated, as de- 
 termined by a study of the symptomatology of 
 
 * Ktarr, M. A., Orgmrtie Nervous Diseases, 1903, p. 612. 
 ' Schede, Deutsche med. Wochenschr., July, 1900, No. 30. 
 
15 
 
 the case, it should first be borne in mind that one 
 half of the cerebellum exerts its influence on the 
 same side of the body as itself, its action on the 
 spinal cord being direct and not crossed. Bruce 
 has so well presented the facts which should guide 
 us in determining the side on which a tumor is 
 situated that I shall take the liberty of present- 
 ing his views, founded as they are upon both close 
 pathological and clinical investigation. 
 
 The limits of a paper intended to be chiefly 
 clinical will not permit me to present at length 
 the facts and arguments of this article, one of 
 the most valuable contributions to cerebellar lo- 
 calization of recent years. I shall, however, sum- 
 marize a few of its most salient points. 
 
 The cortex of the vermis contains the termini 
 of at least six different tracts from the spinal cord. 
 Bruce^ holds that the direct cerebellar tract and 
 the anterolateral tract of Gowers, which go to 
 the cortex of the middle lobe, are afferent to the 
 cerebellum. One tract from the nucleus of Dei- 
 ters passes downwards into the anterolateral col- 
 umn of the spinal cord ; another tract sends fibres 
 to both the sixth and the third nuclei. The first 
 of these tracts, which has been given the name 
 of the vestibulospinal tract, has been traced to 
 
 8 Bruce, Alexander, Trcma. of the Edinl). MetlAco-OMrurg^cal 
 8oc., January, 1899. 
 
16 
 
 the lowest part of the thoracic cord, and gives off 
 fibres to the anterior cornua, these distributions 
 being to the same side of the spinal cord as the 
 nucleus. The third connection of Deiters's nu- 
 cleus is with the roof nucleus of the middle lobe 
 of the cerebellum. This tract is efferent. The 
 cortex of the middle lobe of the cerebellum is con- 
 nected by sagittal fibres with the roof nuclei. 
 
 The dentate nucleus is the chief seat of origin 
 of the prepeduncle, fibres passing by wa)^ of the 
 prepeduncle to the red nucleus and the thalamus. 
 This nucleus being partly in the middle and part- 
 ly in the lateral lobes, a tumor situated deeply 
 enough to invade it or fibres passing from it to 
 the prepeduncle will cause disturbance of equi- 
 libration of a peculiar kind. 
 
 " We may expect," says Bruce, " disturbances 
 of equilibrium to be produced by symmetrical 
 lesions situated within an area bounded by the 
 intracerebellar path of the two inferior peduncles, 
 of the two superior peduncles, and the dentate 
 nuclei, in which the latter arise. This area con- 
 tains the middle lobe (superior and inferior ver- 
 mis, the roof nuclei, and the sagittal fibres con- 
 necting the latter with the cortex), and the cere- 
 bellovestibular tracts from the roof nuclei to the 
 nucleus of Deiters. Lesions within this area may 
 produce no such disturbances, provided they are 
 
17 
 
 symmetrically situated with reference to the me- 
 sial plane, and especially if their growth is so slow 
 that compensation is established pari passu with 
 the disturbances they may tend to cause. On the 
 other hand, lesions situated in the lateral lobes 
 may produce no disturbance of equilibrium, pro- 
 vided they are situated entirely external to the 
 intracerebellar paths of the upper and lower 
 peduncles and of the nucleus dentatus (area of 
 possible latency). If, however, these structures 
 are interfered with, either by pressure or by di- 
 rect involvement, then the characteristic symp- 
 toms of cerebellar disease will be produced, and 
 will depend in their character and amount on the 
 nature and extent of this interference. If the 
 cerebellovestibular tract, or Deiters's nucleus, be 
 injured, then the usual stimuli will not pass either 
 to the anterior cornua of the cord or to the sixth 
 (fourth) or third nuclei. Hence may result the 
 weakness of the same side, the tendency to fall 
 to that side, the impairment of the conjugate dev- 
 iation to that side, the tendency of both eyes to 
 be directed to the opposite side, and the lateral 
 nystagmus which occurs, especially when the 
 eyes are directed towards the same." 
 
 In what is here said the tumor is regarded as 
 acting destructively, but if it acts as an irritative 
 lesion it may cause rigidity or spasm of the same 
 
18 
 
 side, with a tendency to fall toward the opposite 
 side, the eyes being turned to the same side by 
 irritation of the sixth nucleus of that side. 
 
 It may be asked. How is one to determine 
 whether the tumor is acting as an irritative or a 
 destructive lesion? The answer to this should 
 be found in a study of the spastic or non-spastic 
 condition of the limbs of one side, and a careful 
 consideration of the side to which the eyes are 
 turned. 
 
 In the case of Dr. Spiller, which was operated 
 on by Dr. Frazier, the patient tended to always 
 pitch or fall toward the right, and the tumor was 
 found at necropsy on this side. The same was 
 true of several cases observed by me. 
 
 Bruce,® in a second paper, has recorded a case 
 of cerebellar tumor in which the principles of 
 localization as taught in his first paper, were suc- 
 cessfully put into practice. In this case the 
 ataxic, asthenic, and ocular symptoms pointed to 
 the left side, the patient pitching towards the left. 
 The tumor was found on this side. 
 
 The diagnosis of a tumor confined to the mid- 
 dle lobe is relatively easy, and has already been 
 indicated in the references just made to the two 
 articles by Bruce. 
 
 » Bruce, Alexander, Scottish Medical and Surgical Journal, 
 September, 1899. 
 
19 
 
 In one of three cases recorded by Preston^° a 
 tumor of the vermis, probably " operable," was 
 revealed by necropsy. This case exhibited abo- 
 lition of the muscular sense (?) in both arms 
 and leg-s, with inability to stand or walk and a 
 tendency to always fall backward, never to either 
 side. Necropsy showed a bilobar tumor com- 
 pressing the vermis like a saddle in its inferior 
 part. It also exerted some compression upon 
 the quadrigeminum ; it apparently had attach- 
 ments to the callosum, falx, and tentorium. 
 
 While all the facts necessary for final decision 
 regarding the effects on the brain of the direc- 
 tion of movement of lesions situated in different 
 parts of the vermis are not yet at our command, 
 it is probable, as usually taught, that destruction 
 of the cephalic portion of the vermis will cause a 
 tendency to fall forwards and irritation a tend- 
 ency to fall in the opposite direction ; while de- 
 struction of the caudal portion will cause a tend- 
 ency to fall backwards, and irritation will bring 
 about the muscular adjustment necessary to coun- 
 teract this tendency. It has already been shown 
 that destructive lesion involving the lateral lobe 
 and vermis or that part of the lateral lobe con- 
 taining portions of the cerebellovestibular and 
 cerebellospinal mechanisms causes a tendency to 
 
 10 Preston, Alienist and Neurologist, St Louis, April, 1892. 
 
20 
 
 sway or fall to the side of the lesion an irritative 
 lesion bringing about the opposite result. 
 
 In connection with these discussions of the 
 direction of movement as symptom of cerebellar 
 tumor, it is probable that the lesions more often 
 act as destructive than as irritative factors. 
 
 Physiologists, as the results of their experi- 
 ments upon animals, have frequently observed 
 spasticity or rigidity. In some cases curvatures 
 of the body, apparently the result of spastic con- 
 ditions, have taken place. In some clinical re- 
 ports spasticity and contractures are set down 
 as among a comparatively common phenomena 
 of cerebellar tumor. 
 
 Retraction of the head and neck, opisthotonos, 
 and general tetanic rigidity have been recorded. 
 In the experience of the writer tonic spasms and 
 contractures are very rare in tumors strictly lim- 
 ited to the cerebellum. I have, however, seen 
 these symptoms associated with hydrocephalus 
 and in cases in which the tumor has invaded parts 
 outside of the cerebellum, as for instance, the 
 oblongata or pons. When present, the tonic spas- 
 ticity may be on the side of the lesion or on the 
 opposite side. The spasticity may be a transient 
 symptom. It has never proved of diagnostic im- 
 portance in my studies of cerebellar disease. 
 
 One reason for the difference between the re- 
 
21 
 
 ported results of lesions of the cerebellum experi- 
 mentally produced and the effects of tumors re- 
 sides in the fact that the former immediately and 
 for a long time are irritative phenomena, while 
 the latter, owing to their usually slow growth, 
 produce their effect by inhibition, pressure, and 
 destruction. 
 
 The asthenia, atonia, and astasia which Luciani 
 so strongly emphasizes as the chief effects of 
 destructive lesions of the cerebellum experiment- 
 ally produced are well illustrated by clinical facts. 
 The case of cerebellar tumor is asthenic, although 
 not paralyzed, is atonic or flaccid rather than 
 spastic, and is astatic or incoordinate. The ex- 
 tent and position of his asthenia, atonia, and 
 astasia depend upon the extent and location of 
 the lesion. 
 
 While clonic spasm is an infrequent local symp- 
 tom of cerebellar tumor, it is occasionally ob- 
 served. In a case recorded by Spiller, which 
 was seen by the writer in consultation, the patient 
 had at times fine twitching movements of the 
 right extremities, although at times the move- 
 ments were on both sides of the body. 
 
 Tremor, especially of the head and upper ex- 
 tremities, has been recorded as one of the results 
 of physiological experiment on the cerebellum. 
 It occurs in a large percentage of the cases of 
 
32 
 
 cerebellar tumor, and was a notable symptom in 
 one or two of the cases seen jointly by Dr. Frazier 
 and the writer. 
 
 My experience indicates that the muscular 
 sense is not lost in cases of cerebellar disease. 
 The patient may be ataxic as well as asthenic and 
 atonic, and yet on testing him carefully for the 
 muscular sense or its components, the so called 
 senses of pressure, weight, posture, location, etc., 
 these are not affected. Grainger Stewart, and 
 Gibson carefully tested the muscular sense and 
 found it unaffected in their five cases. Others 
 have recorded the loss of muscular sense in cere- 
 bellar lesions, but as a rule without any details, 
 and it is a question in these cases whether the 
 loss of muscular sense has not been confounded 
 with other manifestations, such as ataxia. Stere- 
 ognostic perception is also unaffected in tumors 
 and other lesions of the cerebellum. 
 
 In a series of cases appended to the papers of 
 Dr. Frazier and the writer, the muscular sense, 
 stereognostic perception, and all forms of cuta- 
 neous sensibility were studied, but with negative 
 results, except in one instance in which a doubt- 
 ful cutaneous hypsesthesia was present. When 
 impaired sensation in the distribution of the fifth 
 nerve is present in cerebellar disease it is prob- 
 ably an indirect or pressure symptom. I am not 
 
23 
 
 speaking now of cases of tumor of the cerebello- 
 pontile angle, in which the fifth nerve or its roots 
 may be directly implicated. The cerebellum is 
 above all a motor organ ; its most distinctive focal 
 symptoms, vertigo, ataxia, asthenia, and nystag- 
 mus being affections of motility. 
 
 A few words might be said in this connection 
 about the diagnosis of cerebellar neoplasms from 
 tumors of one or two other regions of the brain. 
 
 Tumors situated in one lateral lobe, but invad- 
 ing deeply so as to involve the cerebellovestibular 
 apparatus and perhaps the vermis, may need to 
 be dififerentiated from tumors of the superior 
 parietal region. The chief diagnostic points in 
 favor of the tumor being cerebellar are the ab- 
 sence of astereognosis and that of symptoms 
 showing the loss or disturbance of muscular or 
 cutaneous sensibility. Nystagmus as a rule is 
 not present in parietal tumors, although this is 
 a rule not without exception, especially if the 
 tumor should extend far enough backward to in- 
 volve the visual motor region of the cerebral cor- 
 tex. Vertigo may be present in a parietal tumor, 
 but the peculiar and extreme form of vertigo 
 which has been described as due to disturbance 
 of the cerebellovestibular tracts and centres is 
 not observed in parietal cases. These cases are 
 generally more distinctly unilateral in their symp- 
 
24 
 
 toms, although unilaterality is occasionally quite 
 marked in cerebellar tumors. The invasion symp- 
 toms of parietal tumor will help in diagnosis. 
 
 Tumors of the cerebellum need occasionally to 
 be differentiated from prefrontal growths. This 
 diagnosis is difficult only when the tumor is con- 
 fined to the external portion of one lateral lobe, 
 so that the symptoms given, such as ataxia and 
 nystagmus, are not marked or are not present at 
 all. I have seen but little of the frontal ataxia 
 of Bruns ; so little indeed as to make me doubt- 
 ful of its existence as a true ataxia. The symp- 
 tom when present is probably a pseudoataxia due 
 to the impaired mentality of the patient in conse- 
 quence of which his powers of attention and in- 
 hibition are so affected that he does not govern 
 his movements quite normally. When a prefron- 
 tal growth is situated on the left, mental symp- 
 toms of a distinctive character are present, these 
 being absent in cerebellar growths. The cere- 
 bellar patient is often feeble in pursuing his men- 
 tal processes, which, however, are in themselves 
 quite clear. If the prefrontal tumor invades 
 backward, aphasia, agraphia, and unilateral mo- 
 tor paralysis may ensue. 
 
 As indicated when discussing the subject of 
 nystagmus, disorders of ocular movements, and 
 especially of associated movements, are among 
 
25 
 
 the most frequent symptoms of cerebellar dis- 
 ease. Various cranial nerve symptoms are often 
 observed in tumor of the cerebellum, but these 
 are not necessarily present. They are the result 
 either of pressure in the case of tumors of large 
 size and marked density or of the invasion of the 
 oblongata and pons and the nerve roots by tumors 
 situated toward the inferior surface of the cere- 
 bellum. I am not speaking here of the special 
 forms of tumor of the cerebellopontile angle, as, 
 for instance, those which arise from the eighth 
 nerve, but of growths which originate in the 
 cerebellum proper. Neural symptoms when 
 present are of much importance in questions of 
 focal diagnosis and of prognosis; in the former 
 in deciding the side on which the lesion is sit- 
 uated, in the latter by pointing to a less favorable 
 outcome than when the neoplasm is confined to 
 the substance of the cerebellum. 
 
 The nerve symptonis may be referable to any 
 of the cranial nerves or their connections from 
 the third to the twelfth. Among the most fre- 
 quent are those indicating paralysis or paresis of 
 associated ocular movements, paresis of the mus- 
 culature supplied by the sixth or the seventh 
 nerve, impairment of hearing from implication 
 of the cochlear portion of the eighth nerve, dis- 
 orders of taste due to involvement of the glosso- 
 
26 
 
 pharyngeal or chorda tympani, and loss or per- 
 version of sensation because of trigeminal dis- 
 turbance. The nerves, their roots, or the tracts 
 with which they are connected in the oblongato- 
 pons may be involved separately or conjointly. 
 When the neural symptoms are due to pressure 
 they are probably usually to be referred to direct 
 nerve or nerve root involvement. While uni- 
 lateral symptoms may point to true nerve impli- 
 cation, this distinction is by no means a sufficient 
 one, as tumors of the cerebellum not infrequently 
 involve jointly one lobe, one peduncle, and one 
 side of the oblongata or pons. 
 
 Among the pontooblongatal pressure symp- 
 toms which may result from a cerebellar tumor 
 are hemiparesis and vasomotor, cardiac, and res- 
 piratory disturbances. Convulsions, unilateral 
 or general, but more commonly the latter, with 
 unconsciousness, have occurred in a considerable 
 percentage of the cases which have come under 
 my observation. 
 
 With our present knowledge and views regard- 
 ing the anatomy and physiology of the cerebral 
 olfactory apparatus, it is at times difficult to de- 
 termine how loss of smell, which is common in 
 cerebellar tumors, is produced. In some cases it 
 may originate in much the same way as optic 
 neuritis and blindness occur, that is, from neural 
 inflammation or from nerve choking. 
 
27 
 
 With regard to the deep reflexes, little that is 
 of value in focal cerebellar diagnosis is as yet 
 at our command. We have observed the knee 
 jerks lost, exaggerated, crossed, and differing on 
 the two sided either as regards loss, impairment, 
 or increase. Unilateral differences are sometimes 
 of corroborative value when the question of the 
 side on which a tumor is situated is under 
 consideration. In one of the cases appended, 
 for instance, the knee jerk was exaggerated 
 on the side opposite to that on which the tu- 
 mor was presumably situated, probably because 
 the neoplasm exerted pressure downward on the 
 pyramidal tract before its decussation. The Bab- 
 inski response is usually absent, although it was 
 present on the side opposite the lesion in one 
 case. The superficial reflexes are usually un- 
 changed. 
 
 Incontinence of urine and faeces is present in 
 a few cases apparently as symptoms referable to 
 the presence of the tumor. Such incontinence is 
 of course present in cases of tumor of the brain, 
 no matter what its situation, when the disease 
 has advanced to such a point, or the suffering of 
 the patient has become so great that his mind is 
 obtunded. 
 
 Other symptoms which have been occasionally 
 
28 
 
 recorded in cases of tumor of the cerebellum are 
 polyuria, glycosuria, and muscular wasting. 
 
 In the discussion of the papers of Bruce refer- 
 ence is made to the fact that tumors of one lateral 
 lobe of the cerebellum may in some instances not 
 give rise to symptoms, and, as indicated by Bruce, 
 this is in those cases of lateral lobe disease in 
 which the lesion does not extend inward far 
 enough to invade the cerebellovestibular or cere- 
 bellospinal apparatus. This is not, however, the 
 only explanation of cerebellar lesions without 
 cerebellar symptoms. In other cases of very 
 slowly developing tumors the cerebellum grad- 
 ually accommodates itself to the lesion. It is 
 well known that cases both of cerebral and cere- 
 bellar tumors are recorded in which the growths 
 have undoubtedly been present for many years, 
 and the fact was ,not discovered until they were 
 unexpectedly revealed by necropsy. 
 
 Bruce, as already indicated, has also called 
 attention to the fact that a tumor symmet- 
 rically disposed as regards the vermis, ihat 
 is so developing as to uniformly implicate 
 both halves of the vermis and equally the 
 adjacent portions of the lateral lobe may not 
 cause miarked disturbance of equilibrium. Those 
 cases of tumors of parts adjacent to the cerebel- 
 lum, like the quadrigeminum, for example, in 
 
29 
 
 which symptoms are not present, although ne- 
 cropsy seemed to show that the cerebellum was 
 markedly compressed, can only be explained on 
 the theory of compressed brain substance accom- 
 modating itself functionally to the gradually de- 
 veloping conditions. The same thing is observed 
 in a notable degree in some cases of internal hy- 
 drocephalus in which, although the brain is al- 
 most reduced to a shell, the cerebral centres and 
 tracts continue to functionate. 
 
 With regard to cases such as have been re- 
 corded by Spiller and others, and which are re- 
 ferred to by Weisenburg, in which a large por- 
 tion or almost the entire cerebellum has been 
 absent or sclerotic, some evidences of the lack 
 of cerebellar influence will usually be found on 
 close investigation. 
 
 In a series of eight cases, Nonne has reported 
 three cases which presented the symptoms of tu- 
 mor of the cerebellum. The symptoms of brain 
 tumor disappeared either under mercurial treat- 
 ment or spontaneously. Nonne believed that in 
 none of them was syphilis present. Partial nerve 
 atrophy was left in some of the cases. Nonne," 
 in his discussion of the cases, excluded such diag- 
 noses as encephalitis, meningitis, abscess, throm- 
 
 " NoDBe, Deutsche Zeitschrift fUr Nervenheilkunde, Vol. Ml, 
 1904. 
 
30 
 
 bosis, multiple sclerosis, chlorosis, nephritis, in- 
 toxications, and infections, also syphiloma and 
 tubercle. He also believed that they were not 
 cases of hydrocephalus, although he was some- 
 what doubtful on this point. 
 
 In two cases of tumor not situated in the cere- 
 bellum, but so located as to obstruct the ventricu- 
 lar outlets, hydrocephalus was produced and the 
 symptoms of cerebellar tumor were present. In 
 three other cases in which no signs of internal 
 hydrocephalus were present, cerebellar symptoms 
 were exhibited. The necropsy in these cases 
 showed absolutely nothing. 
 
 Cases such as these must be borne in mind 
 when considering the diagnosis of a tumor of the 
 cerebellum. 
 
 TUMORS OF THE CEREBELLOPONTILE ANGLE. 
 
 With regard to the connections of the growths 
 with the nervous system, at least two forms of 
 tumors are found in the cerebellopontile angle or 
 recess, and this fact should be recognized when 
 surgical procedure is contemplated. In the first 
 place, the tumor mass may involve the substance 
 of the cerebellum or one of its peduncles, and the 
 oblongatopons, and, secondly, the tumor may 
 originate in one or two of the cranial nerves and 
 be largely confined to them, the acoustic being 
 
31 
 
 especially the seat of such growths. With re- 
 gard to tumors in both the substance of the cere- 
 bellum and of the bulb, many have been put on 
 record and several have been seen by the writer. 
 In a case of multiple sarcomatosis for several 
 weeks under my care, and later passing into the 
 hands of Dr. Spiller,^^ who records the case in 
 full in a paper on multiple sarcomatosis, tumors, 
 probably sarcomatous, involved the nervous sub- 
 stance in both cerebellar recesses, numerous 
 other tumors being present in other regions both 
 of the brain and spinal cord. When a tumor in- 
 volves somewhat deeply the substance of the 
 cerebellum and pons, it can only be partially re- 
 moved, and even to accomplish this it will be nec- 
 essary to assume considerable risk, as the opera- 
 tion is both difficult and dangerous. The cere- 
 bellopontile tumors most amenable to operation 
 are the fibromata of the eighth nerve, which will 
 next be briefly considered. 
 
 Besides reviewing the literature of the subject, 
 Fraenkel and Hunt have recorded five cases of 
 tumors of this kind with necropsies. With re- 
 gard to the particular nerves on which these tu- 
 mors occur, they say that " the eighth shows a 
 marked predisposition and is most frequently in- 
 
 " Spiller and Hendrickson, Am. Jour, of the Med. Set., Jaly. 
 1903. 
 
32 
 
 volved, rather rarely on both sides. The trigem- 
 inus is next in order. The facial is believed by- 
 some to be occasionally the seat of these tumors ; 
 its proximity to the acoustic nerve renders path- 
 ological decision difficult." One point of great 
 importance with regard to these tumors of the 
 acoustic nerve is their peculiar formation, the 
 manner in which they are encapsulated and the 
 ease with which they can be removed with opera- 
 tion if they are or become accessible through the 
 work of the surgeon. They are usually oval or 
 rounded and vary in size, some being as large as 
 a hen's egg. They are attached to the nerve 
 trunk, which has undergone atrophy because of 
 their presence. 
 
 The pathology of fibromata of the acoustic and 
 other cranial nerves is fully considered by Weis- 
 enburg. 
 
 Although an acoustic neurofibroma is so close- 
 ly related to the brain stem as to be within a few 
 millimetres of it, nevertheless the symptoms of 
 bulbar involvement may be entirely absent. This 
 has been pointed out by von Monakow, in whose 
 case vomiting, difficulty in deglutition, and bul- 
 bar disorders of circulation and respiration were 
 entirel}'- absent. Von Monakow^^ indicates as 
 the best diagnostic points for a neurofibroma 
 
 " Berl. kUn. Wochenschr., August 13, 1900, No. 33, p. 721. 
 
33 
 
 of the acoustic, the absence of such symptoms 
 as vomiting, dysphagia, etc., on the one hand, 
 and on the other hand, the presence of general 
 symptoms of cerebral tumor, such as headache, 
 vertigo, and choked discs in association with cere- 
 bellar ataxia, rapidly developing deafness, pare- 
 sis of the seventh and fifth nerves on the same 
 side as the deafness, with associated ocular palsy, 
 also on the same side, dysarthria and Gerhardt's 
 symptom being absent. In such cases in addi- 
 tion, peripheral ear disease should be excluded. 
 If ataxia is present, the tendency will usually be 
 to deviate or fall tov\rard the side of the lesion. 
 
 In the five cases of cerebellopontile nerve 
 tumors reported by Fraenkel and Hunt, operation 
 was attempted in only one ; it would probably 
 have been successful in one or two others if the 
 procedure had been undertaken at the right time. 
 In the case on which operation was performed 
 the growth was nodular, was in the left ponto- 
 oblongatal cerebellar space, and was of about the 
 size of a hen's egg. It was broken up by the in- 
 dex finger and the fragments removed. The pa- 
 tient died of symptoms pointing to central car- 
 diac and respiratory disorders. 
 
 Two cases of fibromata of the acoustic, of 
 which photographic illustrations are given in the 
 paper of Dr. Weisenburg, have recently fallen 
 
34 
 
 under my observation. In one case an operation 
 was performed over the cortical facial region and 
 a lesion was found in this position. The main 
 lesion, however, was undoubtedly the tumor of 
 the cerebellopontile recess. The chief focal symp- 
 toms were one sided deafness, tinnitus, facial 
 monospasm, hypaesthesia on one side of the face, 
 nystagmoid movements, slight paresis of right 
 abducens, vasomotor and cardiac disturbances ; 
 severe headache, nausea, vomiting, and optic neu- 
 ritis were also present. 
 
 The fuller history of this case is given in the 
 paper of Dr. Weisenburg. The notes of the 
 other case are appended. 
 
 In this case a fibromatous tumor of the acous- 
 tic was unexpectedly found at necropsy in the 
 cerebellooblongatopontile space. The record of 
 this case is given to show how such a growth can 
 be entirely overlooked. The necropsy revealed 
 not only the presence of this tumor, but also 
 marked hydrocephalus, which may have ac- 
 counted for most of the symptoms presented by 
 the patient, such as spasticity, mental hebetude, 
 headache, and optic neuritis, but it was insuffi- 
 cient to account for them all. The patient's hear- 
 ing on each side was never positively deter- 
 mined. Examinations for any of the special 
 senses were unusually difficult after she came 
 
35 
 
 to the hospital, and grew more and more so as 
 days advanced. It is probable that she had loss 
 of hearing on the side of the growth. 
 
 The patient was a woman forty-eight years 
 old. The facts which could be obtained regard- 
 ing her history before admission to the Univer- 
 sity Hospital were meagre. It was learned, how- 
 ever, that three or four years before she had an 
 attack which was supposed to be one of grippe, 
 and following this, inflammation of the middle 
 ear on both sides accompanied by pus, which re- 
 quired the membrane of the tympanum on the 
 right to be opened. This history clouded the diag- 
 nosis as regarded involvement of the acoustic 
 nerve by intracranial neoplasm ; in addition, as 
 already stated, it was difficult to make a care- 
 ful examination, owing to her mental state. 
 
 It was also learned from one of her physicians 
 that two or three years before coming into the 
 hospital she had complained of a feeling of cush- 
 ions under her feet, and that at this time she had 
 some anaesthesia of the right side of the face and 
 of the right hand and leg. About a year before 
 admission her legs began to grow stiff and she 
 had sharp shooting pains in them. This stiff- 
 ness increased and she had some difficulty of gait. 
 At times she had been troubled with double 
 vision. She had always been a sufferer from 
 headache, but it was stated that this had not in- 
 creased. For a year she had had difficulty in 
 controlling her bowels and bladder. 
 
 Examination showed the patient to be dull and 
 
36 
 
 apathetic. Her memory was greatly impaired, 
 she was easily confused, and it was at times al- 
 most impossible to fix her attention. Her legs 
 were markedly spastic, being flexed at nearly a 
 right angle. The Babinski reflex was not pres- 
 ent. The knee jerks were exaggerated. The left 
 pupil was considerably larger than the right. Sen- 
 sation was apparently everywhere preserved, al- 
 though it was difficult to test for fine differences 
 in sensation. Facial and masseter paralysis were 
 not present, and except as above noted, the exam- 
 inations, which were thoroughly made, were neg- 
 ative. An eye examination by Dr. de Schweinitz 
 showed double choked discs and many hsemor- 
 rhages ; there was no apparent muscle palsy. 
 
 An operation was performed by Dr. Frazier in 
 this case for the relief of her general symptoms, 
 the prefrontal region being selected. The ven- 
 tricle was reached a short distance from the sur- 
 face after the trephine opening had been made. 
 
 Probably a diagnosis could have been made in 
 this case if the patient had been studied early 
 and continuously. Late in the case the general 
 symptoms were those of brain tumor, but the only 
 focal symptoms which could be clearly deter- 
 mined by a study of the case and its history were 
 the ansesthesia of one side of the face, and the 
 probable impairment of hearing. Some of the 
 symptoms, like the double spasticity, parsesthesia 
 of the feet, and sharp shooting pains, seemed to 
 point to spinal disease. 
 
Fig. 1. — Vertical section of head, showingthe comparatively small cavity 
 in which the cerebellum is contained and its inaccessibility. Note 
 the distance between the cerebellum and the cutaneous surface ; 
 note also the angle of the tentorium and the position of the lateral 
 sinus. 
 
REMARKS UPON THE SURGICAL ASPECTS 
 OF TUMORS OF THE CEREBELLUM. 
 
 By CHARLES H. FRAZIER, M. D., 
 
 PHILADELPHIA, 
 
 PROFESSOR OF CLINICAL SURGERY^ UNIVERSITY OF PENNSYL- 
 VANIA; SURGEON TO THE UNIVERSITY HOSPITAL. 
 
 ANATOMICAL CONSIDERATIONS. 
 
 The difficulties that attend any attempt on the 
 part of the surgeon to expose, much less remove 
 tumors from the cerebellum, differ very materially 
 from those encountered in tumors of the cerebrum. 
 Speaking upon this subject on another occasion I 
 said that it seemed as though, in encompassing the 
 cerebellum with such large cranial sinuses, nature 
 has intimated that this organ was never to be sub- 
 jected to exposure at the hands of the surgeon. 
 When one takes into consideration the position of 
 the lateral and the occipital sinuses with relation to 
 the only means of access to the cerebellum, and the 
 plane of the tentorium cerebelli, one realizes at once 
 that there are especial technical difficulties in sur- 
 gical atacks upon the cerebellum. (See Fig. i.) Fur- 
 thermore, it must be remembered that there are very 
 distinct dangers attending manipulations upon the 
 cerebellum and more particularly, if, in an attempt to 
 get sufficient exposure to excise a tumor, one should 
 
40 
 
 make too much traction upon the medulla oblongata. 
 Even when one has removed a considerable portion 
 of the skull below the superior curved line, there 
 will be exposed to view but a small portion of the 
 gross surface area of the cerebellum. Neither the 
 upper surface, that is in relation with the tentorium 
 cerebelli nor the anterior surface which is in rela- 
 tion with the petrous surface of the temporal bone, 
 nor the mesial surface will be exposed to view by 
 this procedure ; whereas in the cerebrum the entire 
 cortex and a considerable portion of the base can 
 be laid bare by a very simple osteoplastic opera- 
 tion. Furthermore the cavity of the cerebellum is 
 very much smaller than that of the cerebrum, so 
 that there is very much less space in which to con- 
 duct the manipulations necessary either for ex- 
 posure or removal of the tumor. In the adult skull 
 one hemisphere of the cerebellum is contained in 
 a cavity whose greatest dimension is only 10.5 cm. 
 In addition to the difficulties that are associated 
 with operations in a space so small and difficult 
 of approach one is hampered further by the fact that 
 even under normal conditions the cerebellar hem- 
 ispheres are compressed in a relatively smaller 
 space than the hemispheres of the cerebrum, and 
 are under such tension that when tension is relieved 
 by the reflection of a dural flap the cerebellar tissue 
 almost invariably protrudes through the opening. 
 
41 
 
 The tissues cannot be displaced or retracted neither 
 to the same degree nor with as much ease as can 
 the cerebral lobes. Thus the operator will be em- 
 barrassed in attempting- to expose a lesion deeply 
 situated, as for example at the cerebellopontile 
 angle, a favorite seat for tumors. 
 
 In addition to the larger sinuses, the lateral and 
 occipital, certain tributaries of sufficient size to 
 cause, when injured, profuse and sometimes alarm- 
 ing haemorrhage, penetrate that portion of the occi- 
 pital bone which must be removed. The most con- 
 stant of these is a branch of the lateral sinus which 
 passes obliquely through the skull and appears in 
 the surface between one and two centimetres to the 
 inner side of the mastoid process; occasionally one 
 or more will be found just below the superior curved 
 line in the neighborhood of the occipital protuber- 
 ance. 
 
 The occipital bone overlying the cerebellum is 
 very variable in thickness. In the region of the 
 mastoid process and of the occipital protuberance 
 the bone is exceedingly thick, but from these two 
 processes the thickness of the bone gradually de- 
 creases until at a point about midway between the 
 two it will be found comparatively thin. 
 
 INDICATIONS FOR OPERATION. 
 
 In general terms it may be said that the indica- 
 tions for operation in cases of suspected tumors 
 
43 
 
 of the cerebellum do not differ materially from 
 those which have been endorsed in the treatment 
 of tumors of the cerebrum. In both classes of 
 cases once the diagnosis has been made, operation 
 if it is to be performed at all, should not be post- 
 poned for any length of time. Physicians are too 
 prone to put off the time indefinitely almost and to 
 spend months in the often fruitless administration 
 of antisyphilitics, or to spend an unwarrantable 
 amount of time in efforts to establish a diagnosis 
 beyond a peradventure of doubt, or to localize the 
 tumor with mathematical accuracy. Kocher says 
 there should be less delay in bringing to the surgeon 
 a lesion of the encephalon, whether it be a neoplasm, 
 tubercle, gumma or abscess. " There is no more 
 excuse to-day for delaying operation in cases of 
 tumors because the tumor could not be exactly local- 
 ized, than there would be for declining to operate 
 upon a case of intracranial haemorrhage because one 
 was unable to determine positively the seat of the 
 clot. Failing in one place to find the tumor, other 
 trephine openings may be made or a very extensive 
 area may be exposed by an osteoplastic resection. 
 How often, Kocher says, has one trephined over the 
 anterior branch of the middle meningeal artery when 
 the autopsy revealed the clot in the region of the 
 posterior branch." The surgeon might come in 
 for his share of criticism because of his lack of 
 
43 
 
 precise knowledge concerning the neurological as- 
 pects of the disease. In order that the very best 
 results be obtained the internist and the surgeon 
 must work hand in hand in this as well as other 
 fields. In cases of suspected tumors of the viscera 
 an exploratory operation is now regarded as per- 
 fectly justifiable, and why? Because physicians 
 have come to realize that if operation is postponed 
 until the presence of the tumor can be demonstrated 
 by palpation or other means, the lesion is by this 
 time so extensive that the time for a radical opera- 
 tion has passed. As the exploratory operation is 
 recognized as the surest, safest, and most reliable 
 diagnostic measure in tumors of the stomach, it 
 should be considered of equal value and importance 
 in tumors of the brain. Postponement of operation 
 should be discountenanced if for no other reason 
 than because in cases of long duration patients with 
 tumors of the brain make very poor subjects for 
 operative intervention ; the operation is of itself one 
 of considerable gravity and the condition of the 
 patient should be so good as to enable him to with- 
 stand its depressing efifect. 
 
 Unfortunately tumors of the cerebellum are in 
 the majority of instances more difficult of localiza- 
 tion than tumors of the cerebrum and in many 
 cases localization is well nigh impossible. Instead 
 of regarding this, as has been the case so often, as 
 
44 
 
 a reason for delay, the difficulty of localization 
 should be considered rather as an indication for an 
 early exploratory operation. Just so soon as the 
 diagnosis is with a reasonable degree of certainty 
 assured, just so soon should the operation be per- 
 formed, providing other measures have failed and 
 the operation per se is not contraindicated. 
 
 Operation as a Palliative Measure. — Under cer- 
 tain circumstances we despair of being able to 
 perform a radical operation ; either the tumor can- 
 not be found or cannot be localized; it may be in- 
 accessible, or it may have attained such proportions 
 as to make its removal impracticable. In any of 
 these contingencies a palliative operation is justifi- 
 able and in some cases should be regarded as im- 
 perative. The headache, vertigo, and vomiting, so 
 constant in cerebellar tumors, make the life of the 
 patient pitiable and yet he may be relieved of all 
 of these symptoms for a considerable time by 
 adopting such measures as will reheve pressure. 
 But the strongest argument against delay of opera- 
 tion in the treatment of cerebellar tumors is the 
 possibility of being able to save the patient's vision : 
 choked disc is one of the most constant symptoms 
 and if permitted to continue unrelieved too long,, an 
 optic neuritis will develop and the time for complete 
 or even partial restoration of vision will have 
 passed. Nothing could be more striking than the 
 
45 
 
 results of palliative operation in one ©f our patients 
 (Case 4). The patient before the operation suf- 
 fered from intense headache, was almost blind, and 
 vertigo was so pronounced that he could not stand 
 without support. The tumor could not be found 
 but a large portion, perhaps one third to one half 
 of one cerebellar hemisphere, was removed. His 
 headache was relieved at once, within a week he 
 was able to see as he lay in bed small specks on 
 the ceiling, and on getting up was able to go about 
 with but very little instability. Nothing could be 
 more gratifying to the physicians in attendance than 
 the relief which was afforded the patient by this 
 comparatively simple procedure. In one of Krause's 
 cases, after a palliative operation, the patient was 
 relieved of many of the subjective disturbances and 
 lived for a period of three years in comparative 
 comfort. 
 
 Operative Technique, — Regarding the position of 
 the patient, it is advisable to operate with his head 
 and shoulders considerably elevated. This will 
 diminish the haemorrhage to a certain extent. The 
 effect of the elevated position upon the blood pres- 
 sure may be counteracted by applying a firm band- 
 age to the lower extremities. In order to afford 
 greater freedom for the necessary steps of the opera- 
 tion, I use an extension — a very simple appliance — 
 which is easily attached to the operating table and 
 
46 
 
 upon which the head rests (see Fig. 2). While 
 using it in all operations upon the brain I find it 
 most serviceable in operations upon the cerebellum 
 where the quarters are especially cramped. In two 
 operations upon the cerebellum Schede placed his 
 patients in the sitting posture, leaning far forward. 
 This posture, according to Schede, diminishes to a 
 considerable degree the haemorrhage, but the posi- 
 tion is a very awkward and difficult one in which 
 to retain the fully anaesthetized and relaxed patient. 
 The patient may be placed upon his side but it is 
 difficult to retain the patient in this position and 
 there is always the tendency of the patient to roll 
 over on his side, in which position the respiratory 
 act will be embarrassed, and, inasmuch as many of 
 the sudden deaths are due to respiratory failure, it 
 is advisable to take such precautionary measures 
 as will avoid any disturbance of the respiration. 
 
 Incision. — The incision should begin at the tip 
 of the mastoid process on the affected side and 
 follow a line parallel with, but one centimetre above 
 the superior curved line, to the median line. From 
 this juncture a vertical incision may be made down- 
 wards to enable one to reflect the flap sufficiently 
 to expose the field of operation. Haemorrhage from 
 the scalp in this region is so profuse that some 
 precautions should be taken to reduce to a minimum 
 the amount of blood lost. A very excellent plan is 
 
49 
 
 to incise but an inch or an inch and a half at a time, 
 proceeding at once to arrest the haemorrhage in one 
 section before incising the next. Considerable 
 bleeding may be prevented if one reflects the peri- 
 cranium simultaneously with the overlying muscles 
 and their attachments. If this precaution is taken 
 the muscles will not be mutilated to the same extent 
 as would be necessary if an attempt was made to 
 reflect them independently of the overlying peri- 
 osteum. What may be not only a troublesome, but 
 an alarming feature is the haemorrhage from the 
 various sinuses that traverse the occipital bone; 
 these have already been referred to in the section 
 on the anatomy. Suflice it to say that one should 
 always be prepared with suitable means for con- 
 trolling the bleeding from this source, since if un- 
 controlled, the patient may lose in a very short time 
 a pint of blood or more. In one of our cases (Case 
 5) two anomalous sinuses almost as large in diame- 
 ter as a quill were found near the occipital pro- 
 tuberance. Before the haemorrhage could be 
 checked the patient lost so large a quantity of blood 
 that it was deemed advisable to suspend further 
 interference until the patient had recovered fully 
 from the effects of this complication. Following 
 the administration of appropriate remedies, the pa- 
 tient reacted within a reasonable time, but about 
 twelve hours after the operation, suddenly and 
 
50 
 
 without any warning, the cardiac and respiratory 
 functions failed and within ten minutes the patient 
 was dead. Whether the loss of so much blood had 
 anything to do with the termination of the case, is 
 a matter purely of speculation. This instance is 
 cited solely as an illustration of what may be a very 
 serious complication, namely, haemorrhage from 
 the venous channels traversing the occipital bone. 
 One should try to control the bleeding first with 
 Horsley's wax and if, as in the case above referred 
 to, this fails, the outlet of the sinuses should be 
 closed with plugs of wood, which can be whittled to 
 the proper thickness and length from ordinary 
 swab sticks. 
 
 There need be no anxiety about the cranial 
 sinuses as a possible source of haemorrhage. The 
 lateral sinus is fully exposed to view when the bone 
 has been removed, and injury to this structure could 
 result from carelessness only. The occipital sinus 
 does not come within the field of operation unless 
 one intends to remove the intervening bone, in 
 which case the sinus will be exposed to view, and if 
 necessary may be ligated (see Fig. 5). 
 
 Removal of Bone. — With Krause, Schede, and 
 others I believe that it is unnecessary to preserve 
 the overlying bone, therefore, the osteoplastic flap, 
 which has done so much to revolutionize the surgery 
 of tumors of the cerebrum, is not to be employed 
 
51 
 
 in the exploration of the cerebellum. As both V. 
 Bergmann and Kocher have said, the muscles and 
 aponeurosis are thick enough at this point to 
 offer adequate protection to the underlying struc- 
 tures and to make bony closure of the opening un- 
 necessary. 
 
 An opening in the skull is made preferably with 
 a chisel at a point about midway between the occi- 
 pital protuberance and mastoid process. Here the 
 bone is comparatively thin and as Foirier says this 
 is the point of greatest safety. The opening so 
 made is enlarged with rongeur forceps in all di- 
 rections; outwards as far as one can go without 
 opening the mastoid cells, upwards until the lateral 
 sinus is entirely exposed to view, inwards to within 
 a centimetre of the median line, and downwards to 
 a point at least one centimetre distant from the fora- 
 men magnum. The removal of bone will be facili- 
 tated by using rongeur forceps, the blades of 
 which are at an angle of about 65 degrees with 
 the handles. As one approaches the region of the 
 lateral and occipital sinus, the forceps should be laid 
 aside for a moment and a dural separator intro- 
 duced to separate the dura and the sinuses from 
 the skull. 
 
 I prefer the chisel to the trephine for making the 
 initial opening for two reasons: first because the 
 opening can be made more rapidly with a chisel, 
 
52 
 
 and secondly because the operation of a trephine 
 in this region is a somewhat awkward procedure. 
 
 Exploration. — After a dural flap, with its base 
 downwards, has been reflected, one proceeds to 
 search for the tumor, unless it has been decided to 
 resort to the two stage operation. The principles 
 which we have applied in deciding this question 
 are precisely those which have been adopted in our 
 operations for tumors of the cerebrum (see Ameri- 
 can Journal of the Medical Sciences, February, 
 1904). If, when the preliminary stages of the opera- 
 tion have been completed, the condition of the pa- 
 tient, as revealed by the blood pressure and pulse 
 record, is one of depression or shock, the final stage 
 of the operation should be postponed until the pa- 
 tient has reacted. Having decided to continue the 
 operation the surgeon proceeds to inspect and pal- 
 pate the surface exposed to view. If the cerebellar 
 tissues protrude considerably through the opening 
 once the dura is incised, the presence of a tumor 
 or an internal hydrocephalus should be suspected. 
 It should be borne in mind, however, that under 
 normal conditions the cerebellum is under greater 
 tension than the cerebrum, and when the dura is 
 incised the normal cerebellum w']1 protrude in many 
 cases through the opening to a slight degree. 
 
 If the clinical symptoms, to which are added the 
 presence of an anomalous condition revealed by 
 
53 
 
 the sense of sight or touch, lead one to believe the 
 tumor is situated in the lateral hemisphere, the 
 subsequent steps of the operation should consist in 
 an exploratory incision into the cerebellar tissue, 
 and, if the tumor is found, in its complete extirpa- 
 tion. The impunity with which we can freely in- 
 cise the cerebellar hemisphere without the risk of 
 such disturbance of function as would follow a sim- 
 ilar procedure in the motor area of the cerebral 
 cortex should be borne in mind. A failure to find or 
 expose a tumor of the cerebellar hemisphere because 
 of an insufficient exploratory incision should be 
 regarded as inexcusable unless the tumor was of 
 very small dimensions. If on the other hand there 
 is reason to believe the growth is situated at the 
 cerebellopontile angle, a favorite site for cerebellar 
 tumors, the subsequent steps of the operation will 
 be attended with some difficulty. It may be possi- 
 ble in exceptional cases with the aid of a retractor 
 to displace the cerebellar tissue sufficiently to expose 
 the tumor, but in the great majority of cases one 
 must resort to one of two methods to bring the tu- 
 mor into view; either a portion of the cerebellar 
 hemisphere must be removed or the ventricles must 
 be punctured. 
 
 PUNCTURE OF THE VENTRICLES. 
 
 This procedure has been resorted to for two pur- 
 poses, first as a purely palliative measure to relieve 
 
54 
 
 tension and again to relieve tension in order to 
 render it possible to make a more thorough ex- 
 ploration of the cerebellar surfaces. Puncture of 
 the ventricles is unfortunately an operation of un- 
 usual gravity and the danger attending it is so great 
 in comparison to the possible benefit as to make it 
 a procedure of questionable propriety. Many cases 
 have been reported in which the results were dis- 
 astrous. In one reported by Krause, a scalpel was 
 introduced into the lateral ventricle, a drain intro- 
 duced and about 200 c.c. of cerebrospinal fluid were 
 withdrawn. The intracranial tension was relieved 
 to such a degree that the operator was able to see 
 the superior vermiform process, but the patient col- 
 lapsed immediately after the fluid was withdrawn. 
 Heidenhain's experience was equally disastrous. 
 Thinking he was dealing with an idiopathic hydro- 
 cephalus and that the relief of pressure would have 
 a beneficial effect he tapped one lateral ventricle and 
 the patient died suddenly on the night of the opera- 
 tion. Heidenhain attributed his death to the sud- 
 den disturbance of pressure. The operation has 
 been practised by a number of surgeons, and in one 
 instance with favorable results, but in the majority 
 of cases the patient died immediately or soon after- 
 wards. 
 
 LUMBAR PUNCTURE. 
 
 V. Bergmann attributes the relief which follows 
 palliative operations for tumors of the brain more 
 
55 
 
 to the escape of cerebrospinal fluid than to the re- 
 moval of a large section of the skull. Therefore in 
 those cases in which the pressure symptoms are 
 very marked but the tumor cannot be localized he 
 recommends the removal of the cerebrospinal fluid 
 by Quincke's lumbar puncture. This procedure 
 he says is much to be preferred to any others, but 
 failing in this recourse should be had to direct 
 puncture of the lateral ventricles. According to 
 Oppenheim lumbar puncture is indicated in a very 
 limited number of cases, chief among which are 
 those in which the tumor is associated with an 
 internal hydrocephalus and especially when the 
 tumor encroaches upon the posterior fossa and 
 threatens the life of the patient. In a series of 50 
 cases collected by Piollet (Archives provinciales de 
 chirurgie, Vol. x, p. 728) lumbar puncture was 
 employed in eight cases ; in four patients there was 
 transitory amelioration, and four died within a few 
 days. The sudden disturbance of pressure is no doubt 
 responsible for a large majority of the fatalities. 
 In a few cases the fatal issue has been attributed to 
 the pressure of the structure of the posterior fossa 
 against the foramen magnum, an accident which 
 could easily happen when the communication be- 
 tween the cerebral and spinal cavities was partly 
 or altogether shut off and the vacuum created by 
 aspiration drew the pons and medulla forcibly into 
 
56 
 
 the foramen magnum. If lumbar puncture is re- 
 sorted to, such an apparatus should be used as 
 Koenig suggested, in which the pressure is recorded 
 while the fluid is being withdrawn. With this 
 precautionary measure the danger of lumbar punc- 
 ture would be reduced to a minimum. Fiirbinger 
 who is very much opposed to this practice attributes 
 the deaths to pressure exerted upon the bulb by the 
 arrest of cerebrospinal fluid from the ventricles at 
 the foramen of Magendie. 
 
 CONTINUOUS OR INTERMEDIATE DISCHARGE OF 
 CEREBROSPINAL FLUID. 
 
 The advisability of affording means for the es- 
 cape of cerebrospinal fluid as a palliative measure 
 might well be considered in connection with punc- 
 ture of the lateral ventricle or lumbar puncture. 
 There are cases on record in which, subsequent to 
 operation, the flap has been punctured repeatedly 
 for the purpose of relieving tension. After an ex- 
 ploratory operation, in which the tumor was not 
 found,Terrier punctured the flap repeatedly and 
 withdrew a considerable quantity of fluid, but the 
 patient died in the third week after this form of 
 treatment was adopted. Jaboulay noticed the bene- 
 ficial effect attending the escape of cerebrospinal 
 fluid through a fistula in the cicatrix and recom- 
 mends the establishment of such a fistula in cases 
 
57 
 
 in which the improvement after operation was only 
 transitory or in which there was no improvement. 
 Theoretically at least such a treatment should af- 
 ford some relief from the effects of intracranial 
 pressure and might be justifiable in inoperable cases, 
 but one must bear in mind the constant danger of 
 infection that must needs attend the presence of a 
 communicative tract between the surface and the 
 underlying structures. 
 
 EXPOSURE OF THE CEREBELLOPONTILE ANGLE. 
 
 To return to the question of exploration from 
 which we digressed to consider the propriety of 
 puncture of the lateral ventricles : To enable one 
 to expose a tumor situated in the cerebellopontile 
 angle two methods were proposed, tapping of the 
 lateral ventricles, and removal of a large portion 
 of the cerebellar hemisphere. The former method 
 we disapprove of on the grounds that it is so fatal 
 in its tendencies. The alternative on the other hand 
 is attended with very different results. The im- 
 punity with which large sections of cerebellar tissue 
 may be cut away not only without endangering life 
 but without disturbance of function is an observa- 
 tion which was made by physiologists long ago. 
 That the deduction naturally to be drawn from this 
 bit of laboratory information has not been made use 
 of by surgeons more generally is a matter of some 
 
58 
 
 surprise. The danger of exerting undue pressure 
 or traction upon the pons or medulla in attempting 
 to expose or remove the tumor is more to be dreaded 
 than any other stage of the operation. It was only 
 recently that Woolsey (Annals of Surgery, Septem- 
 ber, 1904) reported a case of neurofibroma of the 
 acoustic nerve ; the tumor was removed but the pa- 
 tient died three hours after the operation, and death 
 was believed to be due to haemorrhage within the 
 pons. Woolsey was convinced that this was due 
 to the traumatism indispensable to the frequent in- 
 troduction and withdrawal of the fingers engaged in 
 the removal of the tumor. Here is a case in which 
 had a considerable portion of the hemisphere been 
 removed prior to the attempts to extract the tumor 
 it is more than likely that the unfortunate accident 
 would not have occurred. My experience with this 
 procedure has been limited to two cases which will 
 be referred to again. In one of these (Case 2) a 
 considerable portion — from one third to one half — 
 of the hemisphere was removed deliberately in 
 searching for the tumor, without any appreciable 
 effect upon the patient's general condition. In an- 
 other case (Case 4) the same practice was adopted 
 with equally negative results in so far as the pa- 
 tient's respiratory or circulatory functions were con- 
 cerned. In neither of these cases was the tumor 
 found at the first operation, but the amelioration 
 
59 
 
 that followed was striking. At a second operation 
 upon one of these (Case 2) the tumor presented 
 itself upon the surface of the remainder of the cere- 
 bellar tissue and was removed without any difficulty. 
 This experience at once suggested to my mind what 
 would seem to be additional argument in favor of 
 the deliberate removal of a large portion of the 
 hemisphere; on the one hand serving as a means 
 of affording adequate exposure with the minimum 
 degree of traumatism to pons and medulla, on the 
 other serving as a means of relieving intracranial 
 tension temporarily, and at the same time, by re- 
 moving a certain amount of resistance, of facilitat- 
 ing the growth of the tumor toward the surface of a 
 point where it can be more easily seen and removed. 
 Last year Hudson (American Journal of the Medi- 
 cal Sciences, September, 1903) reported two opera- 
 tions for cerebellar tumors, in one of which at least 
 a large portion of the hemisphere was removed in 
 searching for the tumor. The patient reacted 
 promptly and although the tumor was not found, 
 began at once to improve. On a subsequent occa- 
 sion the wound was reopened and a large cyst found 
 and evacuated. I feel convinced that this procedure, 
 if more universally adopted, will do much toward 
 increasing the percentage not only of tumors found, 
 but of tumors removed, and will at the same time 
 reduce the mortality. 
 
60 
 
 SHORTEST ROUTE TO THE CEREBELLOPONTILE ANGLE. 
 
 Before concluding our remarks upon the means 
 of exposing tumors in the cerebellopontile angle a 
 word should be said concerning the best method of 
 approach. One has but to turn to a cross section 
 of the cerebellum to see that the shortest distance 
 from the surface of the skull to this snug corner is 
 along a line parallel with the petrous portion of the 
 temporal bone (see Fig. 3). Krause, in describ- 
 ing an operation for the division of the eighth nerve 
 {Beitrdge zur klinische chirurgie, Bd. XXXVII, 
 Heft. 3), and others have made this anatomical ob- 
 servation. The distance along this line being the 
 shortest it goes without saying that the cerebello- 
 pontile angle should be approached from the lateral 
 rather than superior or inferior aspects of the cere- 
 bellum. The bony opening should extend as near to 
 the mastoid process as possible. This is not only 
 the shortest but the safest route in that the manipu- 
 lations are carried on at a point farthest distant 
 from such vital structures as the pons and medulla. 
 
 OPERATIONS UPON THE FIFTH AND EIGHTH NERVES 
 IN THE CEREBELLAR FOSSA. 
 
 In an exploration of the anterior aspects of the 
 cerebellum in the cerebellopontile angle for tumors, 
 one exposes the posterior plane of the petrous por- 
 tion of the temporal bone, and with it the fifth, 
 
Fig. 3.— Photograph of a horizontal section of the head cut on a level 
 with the external auditory meatus ; a, representing a point at the 
 cerebellopontile angle ; b, the auditory nerve entering the internal 
 auditory meatus ; c, d, e, three points on the skull. Note the dis- 
 tance between point a, and the points c, d, and e as illustrating the 
 shortest route to the cerebellopontile angle respectively. The 
 shortest distance from the skull to the angle is measured along a 
 line drawn between a and c. The farther away from c or the 
 nearer to e the greater will be this distance. 
 
63 
 
 seventh, and eighth nerves (see Fig. 4). The 
 seventh and eighth nerves will be seen passing from 
 the cerebellum to enter the internal auditory meatus. 
 The eighth nerve is the larger of the two and over- 
 lies the seventh nerve in such a way that it almost 
 entirely conceals it from view. Farther along, at 
 the apex of the petrous portion of the temporal 
 bone, will be seen the sensory root of the trigeminus 
 as it passes into the groove in which it traverses 
 the petrous bone to enter the Gasserian ganglion. 
 These three nerves, together with the ninth, tenth, 
 and eleventh, may be said to be accessible, so that 
 it is quite possible, if the indications arise, to divide 
 any of them. It is not likely that, in operations for 
 the relief of trifacial neuralgia, one would be called 
 upon to divide the sensory root in the cerebellar 
 fossa because the root and ganglion are more easily 
 approached by the temporal route. In one of the 
 cases of our series we seriously discussed the possi- 
 bility of dividing the root in the cerebellar fossa 
 and fully intended to do so under certain conditions. 
 The case was one in which there were certain symp- 
 toms of cerebellar tumor and in addition intense 
 trifacial neuralgia. If the tumor could not be found 
 it was thought best to afford the patient relief at 
 least from the neuralgia by dividing the sensory- 
 root. However, a cyst was found and evacuated 
 and no further intervention seemed advisable. The 
 
64 
 
 patient was relieved entirely and has remained free 
 from pain now more than a year since operation. 
 There is no conceivable indication for any opera- 
 tive attack upon the seventh nerve within the fossa, 
 but in the case of the eighth nerve Krause has 
 recommended and practised its division for the re- 
 lief of persistent tinnitus aurium. As recommended 
 for tumors of the cerebellopontile angle, so here 
 the nerve should be approached from the lateral 
 rather than posterior aspect as from this point is 
 measured the shortest distance from the skull to the 
 nerve. The only difficulty, if there is any in the 
 operation, will be met with in separating the eighth 
 from the seventh nerve. The latter as has been said 
 lies directly behind as one views the field from the 
 side and the precaution must be taken to separate 
 one from the other before attempting a nerve sec- 
 tion. This is readily done with the aid of a small 
 blunt hook (see Fig. 4). 
 
 SIMULTANEOUS EXPOSURE OF BOTH HEMISPHERES; 
 BILATERAL CRANIECTOMY. 
 
 The difficulty in localizing cerebellar tumors is 
 known to all cHnicians. In an analysis of the 116 
 cases which we have collected we find that in 55 per 
 cent, the operation was a failure because the tumor 
 was not found. The diagnosis of cerebellar tumor is 
 in many cases not so difficult, but in many of these 
 
Fig. 4. — The larger figure to the left illustrates the operation 
 for the combined exposure of one cerebellar hemisphere and 
 the occipital lobe of the cerebrum. The smaller figure, 
 
above and to the right, illustrates the structures in relation 
 to the anterior aspect of the cerebellum and the petrous 
 portion of the temporal bone. Attention is called especially 
 to the position of the 5th, 7th, and 8th cranial nerves. 
 This drawing was made by viewing the structures from the 
 lateral aspect, such an exposure as would be made In ex- 
 ploring for tumors of the cerebellopontile angle. 1. Osteo- 
 plastic flap reflected in an operation for the combined ex- 
 posure of occipital lobe and cerebellum. 2. Ninth, tenth, 
 and eleventh cranial nerves. 3. Auditory nerve drawn to 
 one side by refractor in order to expose. 4. The facial 
 nerve which lies directly beneath it. 5. The root of the 
 trigeminus as it enters the groove at the apex of the 
 petrous portion of the temporal bone. 
 
 Fig. 5. — Operation for the simultaneous exposure of both cere- 
 bellar hemispheres, necessitating ligation of the occipital 
 sinus. 1. The occipital sinus, which has been ligated previ- 
 ously and reflected with the dura. 2. Mastoid process. 3. A 
 large tributary of the lateral sinus, invariably opened In 
 cerebellar craniectomies and of varying dimensions ; said to 
 be sometimes as large as the lateral sinus. 4. Lateral sinus. 
 5. Occipital protuberance. 6. Occipital sinus. 
 
69 
 
 it will be almost impossible to determine beforehand 
 whether the tumor is in the right or left lobe. 
 Therefore in the course of an exploratory opera- 
 tion, when one has failed after a thorough search 
 to find the tumor on the side which was opened first 
 one must decide whether to proceed at once to ex- 
 plore the opposite side. In most instances further 
 exploration should be postponed until the patient 
 has reacted from the effects of the injury already 
 inflicted. In one of our cases already referred to 
 (Case 4) a section of the cerebellar hemisphere was 
 removed to relieve tension temporarily and with 
 most gratifying results. But whether this pro- 
 cedure is justifiable in the light of the probable ex- 
 istence of a tumor on the other side, might with 
 propriety be questioned. In order to enable one to 
 examine both hemispheres at one sitting the authors 
 discussed the feasibility of performing a craniec- 
 tomy on both sides and removing the intervening 
 bone. This operation was performed upon the 
 cadaver from which the illustration in Fig. 5 
 was drawn. The operation may be carried out as 
 follows: An opening is made on either side in a 
 manner similar to that when the operator is con- 
 fined to one side. The dura and with it the superior 
 longitudinal sinus are separated so that they may 
 escape injury when the overlying bone is divided; 
 a pair of forceps or preferably a Gigli saw may be 
 
70 
 
 used to section the intervening bridge of bone. The 
 Gigli saw is to be preferred because it is less likely 
 to comminute the bone, which must be divided very 
 near the foramen magnum. The falx cerebelli is 
 punctured in either side of the occipital sinus and 
 the sinus divided between two ligatures (see Fig. 
 5). This will enable one to reflect a flap of the 
 dura covering both hemispheres and afterwards 
 to displace the cerebellum with greater freedom 
 than would be possible if an unyielding bridge of 
 bone remained between the two openings. In the 
 preparation of this paper we found upon perusal 
 of the literature that this procedure has been recom- 
 mended by Kocher, Nothnagel (Path. u. Ther., Vol. 
 IX), and Krause {Beitrdge zur klin. Chir., Bd. 
 XXXVII). The latter performed this operation in 
 a case in which there was much uncertainty as to 
 the position of the tumor ; in order to relieve tension 
 still further, he punctured one lateral ventricle. The 
 results were reported to be satisfactory in so far 
 as the freedom with which the various aspects of 
 the cerebellum could be exposed. The patient died 
 one week later and the autopsy revealed an internal 
 hydrocephalus, but no tumor. We are not prepared 
 to endorse this operation as a routine procedure 
 but believe it should be restricted to those cases in 
 which the tumor is believed to occupy a position 
 near the mesial surface. Under any circumstances 
 
71 
 
 it should be practiced at two sittings ; the additional 
 trauma and haemorrhage which must accompany 
 such an extensive incision and the removal of such 
 an extensive section of bone would we believe add 
 materially to the gravity of what under any cir- 
 cumstances is an extraordinarily serious opera- 
 tion. 
 
 LIGATURE OF THE LATERAL SINUS. 
 
 A discussion of the operative procedures in the 
 region of the cerebellum would be incomplete did 
 we not include some reference to ligation of the 
 lateral sinus. In an attempt to expose tumors par- 
 ticularly of the anterior surface of the cerebellum 
 the operator is hampered by the tentorium cerebelli, 
 and the suggestion has been made by Kocher, 
 Krause, and others that the tentorium cerebelli be 
 divided down to the petrous portion of the tem- 
 poral bone after the lateral sinus has been ligated. 
 It is stated by Krause that one of the sinuses can 
 be ligated without much risk, and on at least one 
 occasion the idea was put into effect. The advan- 
 tage to be gained by this modification of the tech- 
 nique I do not believe compensates for the additional 
 risk that must be entailed. If the mortality follow- 
 ing operations upon the cerebellum is to be reduced, 
 the technique must be as simple as possible, the least 
 
72 
 
 degree of traumatism must be inflicted, the smallest 
 possible insult ojffered to the tissues; therefore we 
 should discard the more complicated procedures 
 and those which interfere to a greater degree with 
 the circulation and functional activity of the struc- 
 tures concerned. 
 
 SIMULTANEOUS EXPOSURE OF THE OCCIPITAL LOBE 
 AND CEREBELLAR HEMISPHERE. 
 
 Included on the list of doubtful diagnoses are 
 those in which there is a reasonable doubt as to 
 whether the tumor is situated in the cerebellum or 
 the occipital lobe. In such cases one could at one 
 sitting explore first the cerebellum by a craniectomy 
 and the occipital lobe by a craniotomy (see Fig. 
 4). 
 
 RESULTS. 
 
 To speak first of the results of the cases which 
 have come under the author's observation: During 
 the past twelve months, six patients have been sub- 
 jected to operation at the University Hospital : five 
 of them were patients of Dr. Mills, and one was a 
 patient of Dr. McCarthy. The records of these 
 cases appear below, but the results may be expressed 
 briefly in the following table : 
 
73 
 
 -CASES UNDBE AUTHOR'S OBSERVATION DUBING PAST 
 TWELVE MONTHS. 
 
 Case 1 . 
 
 Case 2. . 
 
 Case 3. 
 
 Case 4 . 
 
 Case 5. . 
 
 Case 6. . 
 
 Craniectomy. 
 
 Craniectomy. 
 
 Unilateral cra- 
 niectomy. 
 
 Craniectomy. 
 
 Craniectomy ; 2 
 stage operatioT 
 planned. 
 
 Craniectomy . 
 
 Tumor found 
 and removed. 
 
 Tumor found 
 and removed. 
 
 Tumor not 
 found . 
 
 Tumor not 
 found ; one- 
 third of 
 hemisphere 
 removed 
 
 Dura not 
 opened. 
 
 Cyst found 
 and evacu- 
 ated. 
 
 Recovery. 
 
 Recovery.* 
 
 Recovery from opera- 
 tion, without im- 
 provement. Patient 
 would not consent to 
 further exploration. 
 
 Striking improvement. 
 Restoration of vi- 
 sion, relieved of 
 headache, vomiting, 
 and vertigo. 
 
 Death, sudden and un- 
 accountable, twelve 
 hours after first 
 
 Recovery from opera- 
 tion ; great relief of 
 headache and other 
 symptoms. 
 
 * Since this writing there has been a recurrence of the growth. 
 
 Still further condensed the results were as fol- 
 lows : Of 6 cases : i died after first stage of opera- 
 tion ; 2 recovered after removal of tumor ; i relieved 
 after evacuation of cyst, no recurrence more than 
 a year after operation; i considerably improved 
 after palliative operation ; i no improvement ; tumor 
 not found. 
 
 My personal experience with this series of cases 
 leads me to believe that the dangers attending cere- 
 bellar operations have been somewhat exaggerated. 
 
74 
 
 The present generation of surgeons has inherited 
 the traditional fear of operations within the cranial 
 cavity. It was not very long ago that operations upon 
 the Gasserian ganglion were regarded as desperate 
 undertakings, when it was a case of kill or cure, 
 whereas at the present time the operation is under- 
 taken with no especial concern except upon individ- 
 uals, who on account of their advanced years might 
 be unfavorable subjects for any major operation. 
 And so it is with tumors of the brain generally and 
 especially with regard to tumors of the cerebellum. 
 Physicians put off the question of operation until 
 the patient's condition becomes critical and the 
 surgeon undertakes the operation with fear and 
 reluctance. It was not so long ago that Oppenheim 
 classed all tumors of the cerebellum as inoperable, 
 but in the last editions of his book (1902) he frank- 
 ly confesses that his opinion on this point is in need 
 of revision. 
 
 The dangers and risk peculiar to this operation 
 lie in the proximity of the medulla and pons to the 
 field of operation and the traumatism to which they 
 may be subjected in the course of the operation. It 
 is on this account that stress has been laid upon 
 the advisability of approaching the cerebellopontile 
 angle from the lateral aspect in order not to injure 
 these structures. In a case of Woolsey's previously 
 referred to, the autopsy revealed a haemorrhage in 
 
75 
 
 the pons which the operator attributed to the trau- 
 matism to which it was subjected while he was re- 
 moving piecemeal a tumor of the auditory nerve. 
 If in the fatal cases a careful examination of pons 
 and medulla had been made we believe that in a 
 majority some evidence of traumatism would have 
 been found. It is only in the avoidance of every 
 possible source or degree of traumatism to these 
 vital structures that surgeons can hope to obtain 
 better results. In this connection we refer again 
 to the impunity with which a considerable portion 
 of one cerebellar hemisphere can be removed, since 
 by so doing the operator not only can explore and 
 expose the tumor, but also remove it without the 
 necessity of exerting undue traction or pressure 
 directly or indirectly upon the pons. This of course 
 applies especially to tumors that were not within 
 the hemisphere. 
 
 We have been struck especially with the com- 
 paratively slight depression attending operations 
 upon the cerebellum and with the rapidity with 
 which reaction ensues. In one of our cases the pa- 
 tient lost a large quantity of blood in a very short 
 time, but recovered promptly from the effects, after 
 the administration of appropriate remedies. This 
 patient died twelve hours after the operation sud- 
 denly and unexpectedly, but ten minutes before he 
 died his general condition was reported as excellent. 
 
76 
 
 Our experiences, however, we believe to be excep- 
 tional, as there are recorded in literature many cases 
 in which the patients died on the table or a few hours 
 after the operation. 
 
 We have noted, however, that the gravity of the 
 operation does not seem to have been affected by 
 the act of removing the tumor; whether the opera- 
 tion was solely exploratory or palliative, or whether 
 a tumor was removed, the effect upon the patient 
 was the same. 
 
 In all these operations careful records, of the 
 blood pressure were made, with a view of ascer- 
 taining whether the actual removal of the tumor 
 was attended with or followed by lowering of the 
 blood pressure. The results, however, were nega- 
 tive. 
 
 STATISTICAL STUDY OF Il6 CASES OF OPERATION 
 UPON THE CEREBELLUM, COLLECTED BY FRAZIER. 
 
 The following statistics were compiled from the 
 ii6 cases of cerebellar tumors found in the ap- 
 pended table, pp. 334 to 337: 
 
 Per cent. 
 
 Tumors found 45 
 
 Tumors not found 55 
 
 Removal with recovery 15 
 
 Removal with improvement 13.9 
 
 Removal without improvement 0.9 
 
 Improvement without removal 13.9 
 
 No improvement without removal 13.9 
 
 Death when tumor was removed 12.9 
 
 Death when tumor was not found and not removed 28.7 
 
77 
 
 A COMPABISON OF THE STATISTICS OP SUCCESSIVE DATES, SHOW- 
 ING AN INCKBASE IN THE PEECENTAGB OF EECOVBEIES AND 
 IMPEOVEMENTS, AND A EEDUCTION IN THE MOETALITY. 
 
 Frazier's Buret's Oppenheim'a 
 
 table.— 1904. table.— 1903. table.— 1902. 
 
 Results. Per cent. Per cent. Per cent. 
 
 Recovery 15 14 7.5 
 
 Improved 28 25 7.5 
 
 Unimproved 15 . . 13 
 
 Mortality 42 60 71 
 
 A COMPAEISON OF THE STATISTICS OF TOTAL NUMBBE OF CASflS 
 IN FEAZIEE'S COLLECTION WITH THE STATISTICS OF THE 
 LAST FIVE YEAESj SHOWING A MANIFEST IMPEOVEMENT IN 
 THE EBSOLTS. 
 
 Cases 
 reported during 
 Total number past five years, 
 of cases. 1899—1904. 
 
 Results. Per cent. Per cent. 
 
 Recovery 15 24 
 
 Improved 28 28.5 
 
 Unimproved 15 11 
 
 Mortality 42 35.8 
 
 From a review of these tables one is struck at 
 once with the progress that has been made in this 
 field of surgery from every point of view. The per- 
 centage of tumors found is yearly growing larger, 
 the percentage of partial or complete recoveries is 
 larger and the mortality has fallen from 70 per cent, 
 to 38 per cent. We believe that the results of sur- 
 gical intervention upon the cerebellar hemisphere 
 will continue to improve, if not generally, at least in 
 the hands of those who are giving this subject es- 
 pecial thought and attention. 
 
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CASKS II.I.USTRATING PAPERS OF DR. 
 MILIvS AND DR. FRAZIBR. 
 
 Case I. — Tumor of the left lateral lobe of the 
 cerebellum ; operation ; recovery. 
 
 L. P., white, single, aged twenty-three years, 
 was admitted to the Hospital of the University of 
 Pennsylvania December 7, 1903. Her family his- 
 tory was negative. She was strong and well un- 
 til the beginning of the illness, which brought her 
 to the hospital. 
 
 In February, 1903, she began to have severe 
 headaches with attacks characterized by vertigo, 
 especially when standing and walking, but occa- 
 sionally when lying down. She also at times 
 early in the attack had a series of visual and ocu- 
 lar phenomena, including temporary hemianop- 
 sia ; scotoma either early or late ; light flashes 
 sometimes lasting throughout an attack ; sub- 
 jective images, especially about the time of her 
 coming to the hospital, when she saw dogs, cats, 
 mice, bugs, spiders, etc. ; and diplopia in which 
 one image would be in advance of the other, this 
 being especially constant in the left eye. Nausea 
 preceded, accompanied, or came on late in the 
 attack. Vomiting generally appeared late in the 
 attack and gave the patient some relief. 
 
 Her headache was located in the forehead or 
 at the base, or more commonly in both regions at 
 the same time. From February, 1903, to Septem- 
 ber, 1903, the patient had suffered from these at- 
 tacks once every five days, with the exception of 
 
87 
 
 two weeks in July. About the middle of August, 
 1903, and in October, 1903, her gait became stag- 
 gering. During the latter part of November up 
 to the time of admission to the hospital she had 
 been unable to walk more than a few steps with- 
 out support. Since August, 1903, the headaches 
 had been more or less constant. On admission 
 to the hospital she complained especially of nau- 
 sea and of severe frontal headache, of pain in the 
 back of her head and neck, and in her back. This 
 patient was admitted to the University Hospital 
 under the care of Dr. J. D. Steele, and was later 
 transferred to the service of Dr. Mills. Careful 
 examinations were made by Dr. Steele, but with 
 negative results, except as regards her nervous 
 system, and the existence of patches of brown 
 pigmentation over the entire body. Examina- 
 tions of both urine and blood were negative. 
 
 Later repeated examinations were made by Dr. 
 Mills and also by Dr. Spiller in consultation. The 
 results of these examinations can be summarized, 
 as but little change took place until the time of 
 operation, except for the worse as regards par- 
 ticular symptoms, like optic neuritis, headache, 
 nausea, and ataxia. The patient exhibited marked 
 ataxia of station. The incoordination in stand- 
 ing was usually not increased by closing the eyes. 
 Numerous examinations showed a tendency of 
 the patient to deviate, pitch, or fall to the left in 
 standing and walking; exceptionally the tend- 
 ency was in the other direction. Testing the ex- 
 tremities separately, fairly marked ataxia was 
 present on the left, and to a slighter extent on 
 
the right. On several examinations the patient 
 showed distinct asynergia in the left lower ex- 
 tremity. The symptom was not, however, uni- 
 formly present, and on at least one occasion some 
 asynergia seemed to be present in the right. The 
 Babinski response was present on the right ; both 
 knee jerks were absent and the tendon and mus- 
 cle jerks in the upper and lower extremities were 
 generally depressed. Apparently the movements 
 of both external straight muscles were at times 
 impaired, although the report of Dr. de Schwein- 
 itz showed abducens weakness only on the left. 
 On the negative side nystagmus was absent, as 
 were also involvement of the fifth, seventh, or 
 other cranial nerves, and of disturbances of sen- 
 sation. The patient continued to suffer greatly 
 from headache, vertigo, nausea, and vomiting, the 
 optic neuritis increasing and becoming of the 
 highest grade. 
 
 Eye examinations were made by Dr. G. E. de 
 Schweinitz, who reported as follows : December 
 8, 1903, the vision of each eye equals hand move- 
 ments. The pupils react sluggishly to light and 
 convergence. There is a history of diplopia and 
 there probably is paresis of the left external rec- 
 tus, but the double images cannot be elicited, and 
 this is inferred only from the failure of rotation 
 in the line of the direction of the action of the 
 left externus. The ophthalmoscope reveals the 
 following conditions : in the right eye there is a 
 high grade of papillitis (choked disc), the apex 
 of the swelling being 7 D. It is intensely in- 
 jected, and the sloping margins of the elevation 
 
89 
 
 are thickly infiltrated with haemorrhages. In the 
 left eye there is an exactly similar condition, and 
 in addition a typical macular figure resembling 
 that seen in albuminuric retinitis. Careful test- 
 ing of the visual field indicates that while it is 
 contracted there is no hemianopic defect. 
 
 December ly, 1903, Dr. Frazier operated. An 
 incision was made, following and a little above 
 the superior curved line from the mastoid proc- 
 ess to the occipital protuberance, and thence 
 downwards in the median line for a distance of 4 
 cm. The opening in the skull was made with the 
 chisel and enlarged with the rongeur forceps. 
 The dura was normal in appearance and seemed 
 thinner than usual, and seemed unusually tense, 
 A dural flap was reflected and the surface of the 
 hemisphere inspected. Failing to determine the 
 presence of a tumor by the sense of sight or touch, 
 an incision was made in the left cerebellar hemi- 
 sphere, which revealed a small encapsulated tu- 
 mor of about the size of a hazelnut ; the tumor 
 was easily shelled out. The protrusion of the 
 cerebellar tissue was so great that it was neces- 
 sary to remove, in addition, about one fourth 
 of the cerebellar hemisphere in order to be able 
 to close the dural wound. The patient reacted 
 promptly from the operation, and convalescence 
 was uninterrupted. 
 
 The following reports were made by Dr, de 
 Schweinitz after the operation : 
 
 December 20, 1903. — The changes evident to 
 the ophthalmoscope are almost exactly those 
 which have been recorded, with the exception of 
 
90 
 
 some fresh haemorrhages which have appeared on 
 the nasal halves of the swollen nerve heads. 
 
 January 4, 1904. — The ophthalmoscopic ap- 
 pearances noted by Dr. Shumway are double op- 
 tic neuritis, plus 6 D. The vision of the right eye 
 is doubtful light perception. The left eye is ab- 
 solutely blind. A repetition of his examination 
 on the following day by Dr. de Schweinitz con- 
 firmed the observations. No changes were noted 
 at the next examination, on the 7th of January. 
 
 Examination, January 17, 1904. — There is 
 marked subsidence of the swelling of the discs, 
 the apices of which are not more than 3 D., and 
 the edges of the disc margins are beginning to 
 appear. The macular figure noted before is very 
 marked, and is now evident in both eyes. The 
 retinal vessels are beginning to shrink and atro- 
 phy is rapidly supervening. There is no light 
 perception. This examination was repeated on 
 January 25th, with practically the same results, 
 possibly still further diminution of the swelling 
 of the discs. Some weeks later, after the patient 
 was dismissed from the hospital, the ordinary 
 signs of postneuritic atrophy were present. The 
 eyes were divergent, the pupils large and not re- 
 sponding to light. 
 
 This patient who presented the typical symp- 
 toms of a tumor involving in large part one lateral 
 lobe of the cerebellum, and therefore one of the 
 most desirable cases for operation, was greatly 
 benefited so far as the focal symptoms of a cere- 
 bellar tumor and the general symptoms of an 
 intracranial growth were concerned. Her head- 
 
91 
 
 ache, nausea, vomiting, and vertigo disappeared 
 in spite of her almost total blindness; her ataxia 
 was also almost entirely relieved. The optic neu- 
 ritis had advanced to such a degree, even before 
 she was admitted to the hospital, that operation 
 did not save her from blindness, although sur- 
 gical procedure was adopted about ten days from 
 the time of her admission. 
 
 Case II.— Tumor of left lateral lobe of the 
 cerebellum; operation; recovery; relapse. 
 
 F. M., ten years old, was referred to the Uni- 
 versity Hospital by Dr. D. J. McCarthy, with a 
 diagnosis of tumor of the cerebellum, and was 
 admitted to the wards of Dr. Frazier, March 7, 
 1904. After admission to the hospital he was 
 seen in consultation by Dr. William G. Spiller 
 and also by Dr. Mills. 
 
 One point of interest in the family history was 
 the fact that one brother of the patient had some 
 pulmonary disease, chronic in character. The pa- 
 tient, up to the time of his present illness, had 
 been a healthy child, had gone to school at the 
 age of six years, and had been able to keep up 
 with his classmates. 
 
 Toward the end of December, 1903, the mother 
 noticed that the boy was not as lively as before, 
 and that he stayed in the house in preference to 
 going out of doors. She took him to the Epis- 
 copal Hospital, where he was treated for a cough. 
 At this time he had lost some weight and was 
 generally run down in health. After treatment 
 he improved, gaining weight, but he was un- 
 steady in walking. 
 
92 
 
 About the middle of January, 1904, the boy be- 
 gan to suffer from severe headaches, apparently 
 causeless, these being accompanied by vertigo. 
 At this time the patient held his head up straight 
 and avoided stooping, fearing increased dizziness. 
 During two or three weeks vomiting had been 
 added to his other symptoms, this occurring two 
 or three times a week. Evacuation of the con- 
 tents of the stomach did not bring relief. 
 
 At about the time of his admission it was noted 
 that he had not had any convulsions, that his 
 hearing was unaffected, that he had not com- 
 plained of interference with vision, that a grad- 
 ual increasing ataxia was present, and also that 
 his headache, vertigo, and vomiting were aug- 
 menting. 
 
 The analysis of his urine showed no albumin, 
 casts, or sugar, and a specific gravity of 1.018, the 
 examination being practically negative. 
 
 Examination showed that his' mental state was 
 distinctly that of lassitude; he was drowsy, took 
 little notice of his surroundings, and manifested 
 when examined, a degree of impatience which 
 was almost irritation. General physical exam- 
 ination of heart, stomach, and other viscera 
 showed nothing of special importance, except of 
 the lungs as given below. 
 
 The respiratory excursions were of fair ampli- 
 tude, apparently equal on both sides. The per- 
 cussion note showed an impairment over the left 
 apex down to the third rib. Over this area faint 
 crepitant rales were heard on inspiration. Ex- 
 piration was prolonged, somewhat blowing. 
 
93 
 
 • 
 
 Fremitus, both local and tactile, were slightly in- 
 creased. Various examinations showed ataxia, 
 this present to some extent in the upper extremi- 
 ties as well as markedly present in the lower. No 
 Romberg sign was noted. The examination by 
 Dr. Spiller given below covers, however, the im- 
 portant points in his neurological symptomatol- 
 ogy. His pupils were dilated and there was a 
 suggestion of photophobia. 
 
 The patient complained of severe headache, 
 locating the pain in the frontoparietal region. 
 Tapping with the finger elicited pain all over the 
 head, this being especially marked over the tem- 
 peroparietal portion on the left. No scars or 
 other evidences of injury were discovered. 
 
 Shortly after admission while suffering from 
 severe headache, the patient's pulse became ex- 
 ceedingly irregular, both as to volume and 
 rhythm, and its rate was greatly decreased and 
 weakened. 
 
 Eye examination of the patient was made by 
 Dr. G. E. de Schweinitz and Dr. John T. Carpen- 
 ter. The examination made March 8th showed 
 the following : V. of O. D. V^, of O. S. V^.^. The 
 amplitude of accommodation of each eye is 12 D. 
 The pupils are round and the irides react prompt- 
 ly to light and accommodation and convergence. 
 With the exception of a slight esophoria, there is 
 no defect of muscle balance and no diplopia. The 
 ophthalmoscope reveals the following conditions : 
 Right eye papillitis (choked disc), the apex of 
 the swelling being 4 D., the vessels on the sur- 
 face of the disc i^ D. higher. The nerve edges 
 
94 
 
 are entirely obscured. The surrounding retina is 
 not involved. In the left eye there is an exactly 
 similar swelling of the disc, with the exception 
 that its riasal edge is more involved. There is a 
 moderate concentric contraction of each visual 
 field, more marked upon the left than upon the 
 right side. 
 
 Examination by Dr. Spiller on March 9th 
 showed the following: The tenderness of the scalp 
 to percussion formerly noted had disappeared. 
 He held his head retracted, because he said it 
 caused him pain to hold it straight. There was 
 no distinct rigidity of his neck; movements of 
 the head were free in all directions ; passive move- 
 ments caused headache. The movements of the 
 eyeball were free in all directions ; some nystag- 
 moid movements were present when looking to 
 the extreme right or left. The fifth and seventh 
 nerves were not involved on either side. The 
 tongue showed a slight tendency to deviate to the 
 right when protruded; no distinct fibrillary tre- 
 mors of the tongue were noted. 
 
 The grasp of each hand was fair and equal on 
 both sides. The finger to nose test did not re- 
 veal distinct ataxia. The upper limbs were slightly 
 but not distinctly atrophied. The biceps, triceps, 
 and wrist reflexes were not distinct on either side. 
 The voluntary movements of the upper limbs 
 were normal. There was no loss of sensation to 
 touch or pain. The muscles of the trunk were 
 fairly well developed. 
 
 The voluntary movements of the lower limbs 
 showed normal muscular power and no wasting. 
 
95 
 
 The patellar reflex was lost on both sides; even 
 when sitting on the edge of the bed with reinforce- 
 ment there was no response. The Achilles jerk 
 was not present on either side ; the Babinski re- 
 flex could not be obtained on either side; there 
 was no ankle clonus. The heel to knee test did 
 not reveal ataxia. Sensation for touch and pain 
 was normal. At the time of this examination the 
 gait was not ataxic with eyes open ; it was slight- 
 ly so when the eyes were closed. There was no 
 sway when standing erect, either with the eyes 
 open or closed. No hemiasynergia was present 
 on either side ; Koenig's sign was also absent on 
 both sides. The operation was performed by Dr. 
 Frazier on March 13, 1904. The bone overlying 
 the left lobe of the cerebellum was very thin and 
 the dura was unusually tense. Immediately after 
 the dura was opened the hemisphere protruded to 
 a much greater degree than usual. No adhesions 
 were found either between the skull and dura or 
 between the dura and cerebellum. The latter did 
 not pulsate. A thorough exploration of the left 
 hemisphere failed to reveal the presence of a tu- 
 mor. As a palliative procedure one third of the 
 cerebellar hemisphere was removed. The pa- 
 tient's condition immediately after the operation 
 caused some anxiety, but after intravenous injec- 
 tion and mild stimulation the patient improved 
 rapidly and spent a comfortable night. The 
 wound healed by first intention. On March 27th 
 the patient's condition was noted as being greatly 
 improved. His whole disposition had changed ; 
 
96 
 
 he was bright and cheerful and complained 
 neither of headache nor vomiting. 
 
 In November, 1904, the patient returned to 
 the hospital, because of recurrence of some of 
 the symptoms. On the following day an incision 
 was made, following the line of the old cicatrix, 
 and an infiltrating tumor of about the size of a 
 walnut was found in the hemisphere, apparently 
 taking its origin from some point near the cere- 
 bellopontile angle. The patient reacted prompt- 
 ly after the operation, the wound healed by first 
 intention throughout, and convalescence was un- 
 interrupted. The tumor was a glioma. After 
 the notes of the case were sent to the press the 
 patient relapsed, showing that the growth was 
 probably infiltrating and had not been fully re- 
 moved. 
 
 Eye examination made after the operation by 
 Dr. G. E. de Schweinitz and Dr. J. T. Carpenter, 
 March 14th. The condition of the right disc is 
 unchanged. On the left side there has been a 
 subsidence of the swelling, which is now 3 D. in 
 place of 4 or 43^ D. 
 
 Case III. — Tumor of the cerebellum, probably 
 of the vermis and left lateral lobe ; operation ; tu- 
 mor not found; recovery from operation, with re- 
 lief of symptoms. 
 
 J. H., forty-one years old, was admitted to the 
 University Hospital March 6, 1902, under the care 
 of Dr. Mills and Dr. Frazier. No history of nerv- 
 ous or tuberculous disease or of tumor could be 
 ascertained, but an aunt had suffered from can- 
 
97 
 
 cer of the face, probably dying from this affec- 
 tion. The patient denied syphilis. 
 
 About two years before admission to the hos- 
 pital he began to have headache, most marked 
 behind the eyes and in the temporal regions. His 
 sight also began to fail at this time, and his gait 
 became unsteady, he tending to totter or fall to 
 the right side. His headache improved under 
 treatment, but his sight and gait remained the 
 same. 
 
 In May, 1901, he had a crisis of vomiting, which 
 lasted for about a week ; he vomited almost daily, 
 immediately after eating, there being little retch- 
 ing or straining accompanying the vomiting. The 
 left leg at this time seemed weaker than the right. 
 His bowels were constipated, and were moved by 
 laxatives daily for two years before he came to 
 the hospital. He had no pain in the anus or in 
 the legs. He was not paralyzed and had no vesi- 
 cal symptoms. There was no history of vertigo ; 
 his hearing was not disturbed and his memory 
 was good. On rising in the morning he had on 
 a few occasions attacks of faintness or weakness, 
 but he had never lost consciousness. 
 
 Examination of the urine two days after ad- 
 mission to the hospital was negative. 
 
 Several examinations of this patient, made by 
 Dr. Mills and Dr. Spiller shortly after admission, 
 gave the following results: Vertical nystagmus 
 was present when the eyes were at rest or when 
 they looked upward or downward, the nystagmus 
 becoming lateral when the eyes were turned to 
 the right or left. The patient in walking took 
 
98 
 
 short, unequal steps, showing a lack of confi- 
 dence ; at times he exhibited a tendency to go to 
 the right. In standing the feet were kept wide 
 apart, as he swayed greatly and would have fallen 
 if not supported when the feet were together. 
 The sway was not distinctly increased by closure 
 of the eyes. Ataxia was present in the left upper 
 extremity, and doubtfully in the right. Speech 
 and mental response were both slow. The tongue 
 was protruded straight and without fibrillary 
 tremor. The knee jerks were prompt, the left 
 distinctly exaggerated. The Achilles jerk was 
 present on each side. Ankle clonus was not pres- 
 ent on the right, but was slightly indicated on the 
 left. The Babinski reflex was not present on 
 either side, the movement of the toes being that 
 of slight flexion on both sides. 
 
 An eye examination was made by Dr. Howard 
 Mellor, March 7th, the date of his admission. 
 Visual acuity and the amplitude of accommoda- 
 tion were not recorded. He reported the follow- 
 ing: The pupils are equal in size and the irides 
 react promptly to light and in convergence. The 
 ophthalmoscope reveals the following conditions : 
 A low grade neuritis with involvement of the sur- 
 rounding retina (neuroretinitis), which is most 
 marked in the left eye. There is very distinct ver- 
 tical nystagmus when the patient looks directly 
 forward, and extremely marked lateral nystag- 
 mus on looking to either side. When the gaze is 
 directed upwards or downwards, the vertical nys- 
 tagmus increases. The rotations of the eyeballs 
 are normal in all directions. 
 
99 
 
 The patient left the hospital and was readmit- 
 ted on October 9, 1902. His difficulty in walking 
 had gradually increased until he was able to walk 
 only a few steps with a cane, and at times he fell. 
 When assisted he walked by raising the leg and 
 foot high, and bringing it down heavily. His 
 feet were always wide apart. Ataxia was 
 marked. He had not vomited since leaving the 
 hospital. The nystagmus was the same as on the 
 first admission. A twitch of the orbicular mus- 
 cle in the left eye was noticeable at times. He 
 could hear a watch at three feet, on the right side, 
 on the left he could hear it at a distance of two 
 inches. He had no tinnitus or other abnormal 
 sounds. He complained of no trouble with the 
 bladder or rectum. He had no astereognosis. 
 
 Examination by Dr. de Schweinitz, October 9, 
 1902.— V. of O. D. V22, of O. S. V22. The patient 
 reads J. 2 at 33 cm, with each eye. The pupils 
 are equal and respond promptly to light and con- 
 vergence. The nystagmus recorded in the pre- 
 vious examination continues unchanged. The 
 ophthalmoscope reveals the following conditions : 
 The right optic nerve is beginning to be atrophic, 
 the vessels being reduced in calibre, and there is 
 an area of atrophy of the chorioid surrounding the 
 nerve head. In the left eye a moderate neuritis 
 with indications of beginning atrophy is evident. 
 
 No atrophy, rigidity, contractures, or spasticity 
 was present in the lower extremities on either 
 side. Late in the case the muscles of mastica- 
 tion were normal on the right, and distinctly 
 weak, although not paralyzed fully, on the left. 
 
100 
 
 When the mouth was opened the jaw tended to 
 go slightly toward the left. Sensation was unim- 
 paired everywhere. No hemiasynergia was pres- 
 ent on either side. 
 
 The prominent symptoms in this case just be- 
 fore the operation were secondary optic atrophy, 
 headache and vomiting, nystagmus, cerebellar 
 gait, exaggerated reflexes, deafness on the left 
 side, weakness of the left motor fifth, and prob- 
 ably some weakness of the soft palate on the left 
 side. 
 
 October 25, 1902, the patient was operated upon 
 by Dr. Frazier. Upon the left side of the head 
 a horseshoe-shaped flap was reflected, the inci- 
 sion beginning at the tip of the mastoid process 
 following the superior curved line, and termi- 
 nating in the median line of the neck, opposite 
 the spinous process of the second cervical ver- 
 tebra. The skull was opened as usual with a 
 chisel and mallet, and the opening enlarged with 
 a rongeur forceps. There was an escape of a 
 moderate amount of cerebrospinal fluid. Inspec- 
 tion and palpation of the cerebellar hemisphere 
 revealed no abnormity. There was no thicken- 
 ing of the meninges, no alteration in color or con- 
 sistence of the cerebellar tissue. It was deemed 
 inadvisable to make any further inspection and 
 the wound was closed. The patient recovered 
 from the effects of the operation, and declined 
 any other intervention, although Dr. Mills and 
 Dr. Frazier advised an exploratory operation 
 upon the opposite side. 
 
101 
 
 Case IV. — Tumor of the cerebellum or cere- 
 bellopontile angle ; tumor not found, but lateral 
 lobe partly excised with great benefit. 
 
 G. E., twenty-three years of age, was referred 
 to Dr. Mills for opinion and treatment. When 
 the patient presented himself to the hospital he 
 was suffering from most distressing headache, 
 which was almost constant, and from vertigo and 
 ataxia, to such an extent that it was impossible 
 for him to walk alone or without support. Nor 
 could he even stand alone, unless leaning against 
 some stationary object. His vision was so af- 
 fected that he could not see gross objects, and 
 examination of his eye grounds revealed the pres- 
 ence of very marked choked discs and optic neu- 
 ritis. 
 
 The patient was suffering to such an extent 
 that it did not seem justifiable to postpone oper- 
 ation for further and more elaborate study of the 
 case. Accordingly within a week of his admis- 
 sion to the hospital a left cerebellar craniectomy 
 was performed by Dr. Frazier. The dura was 
 noted to be unusually tense, and upon reflecting 
 the dural flap a considerable portion of the cere- 
 bellar hemisphere protruded through the open- 
 ing. It was found to be almost impossible on ac- 
 count of the protrusion of cerebellar tissue to 
 make further exploration, so the operator pro- 
 ceeded to remove from one third to one half of 
 the lateral lobe. After this was accomplished ex- 
 ploration was continued, but to no avail. No tu- 
 mor could be seen or be felt in any portion of the 
 left cerebellar fossa. The postoperative record of 
 
102 
 
 this patient is one of unusual interest, because of 
 the remarkably rapid improvement which fol- 
 lowed. Within one week of the operation the 
 patient's headache had entirely disappeared, his 
 vision was restored so that he could see minute 
 objects on the ceiling as he lay in bed, and his 
 vertigo and ataxia had almost entirely disap- 
 peared. At no time during the convalescing pe- 
 riod was the patient's condition such as to give 
 any concern. He was kept under observation in 
 the hospital for a period of two months, and inas- 
 much as there was not the slightest return of 
 symptoms he was allowed to go home with the 
 understanding that he would return to the hos- 
 pital if any of his cerebellar symptoms recurred. 
 
 Case V. — Tumor probably of the cerebellum 
 involving the vermis and right lateral lobe ; oper- 
 ation in two stages planned; death from haemor- 
 rhage from bony sinuses twelve hours after first 
 operation. 
 
 J. C, fifteen years old, was referred by Dr. 
 Samuel Freeman and Dr. Frank V. Cantwell, of 
 Trenton, N. J., to Dr. Mills for opinion and treat- 
 ment. He had a history that fifteen months be- 
 fore coming under observation he had begun to 
 suffer with headache, this having been preceded 
 by dizziness ; he also began to suffer from vomit- 
 ing six months before, and exhibited a staggering 
 gait one month later. The attacks of headache, 
 dizziness and nausea and vomiting increased in 
 frequency and in severity, and the uncertainty 
 of gait became steadily more and more marked. 
 
 When the patient was first examined it was 
 
103 
 
 found that he was suffering intensely from head- 
 ache, which was almost continuous, while his diz- 
 ziness, nausea, and vomiting were of frequent oc- 
 currence. 
 
 The eye examination made by Dr. G. E. de 
 Schweinitz, July 5, 1904, resulted as follows: V. 
 of O. D. V9J of O. S. ^/g. Amplitude of accom- 
 modation markedly defective, the patient being 
 able to read only D. = i at 18 cm. The pupils 
 are large, but their reactions are normal. There 
 is paresis of the left external rectus muscle, and 
 lateral nystagmus develops when the eyes are 
 directed to the left, that is to say, in laevoversion. 
 The ophthalmoscope reveals the following con- 
 ditions : In the right eye papillitis, the apex of the 
 swelling being 3 D. It is vascular in the extreme, 
 but the centre of the disc is not markedly filled in. 
 The veins are full and carry very dark-colored 
 blood. There is no macular figure. In the left 
 eye the papillitis is greater than on the opposite 
 side, the apex of the swelling being 5 D. with 
 decided engorgement, and the appearance to 
 which the name choked disc is ordinarily given. 
 The veins are even fuller and darker than upon 
 the other side. The peripheral visual field for 
 form of each eye is normal. There are no scoto- 
 mas. 
 
 Comment. — The double optic neuritis (choked 
 disc), together with paresis of the left external 
 rectus muscle and lateral nystagmus, especially 
 when the eyes are directed towards the left, are 
 ocular signs frequently seen in cerebellar dis- 
 eases. 
 
104 
 
 At one examination it was noted that in stand- 
 ing or walking the patient was markedly ataxic 
 and asthenic, always tending to the right, and 
 that ataxia, less marked, was present also in the 
 upper extremities as determined by having him 
 touch his nose with the finger and in other ways. 
 This ataxia was doubtfully more marked on the 
 right. Hemiasynergia was not present. 
 
 His mental condition was good, except in so 
 far as he was irritated, depressed and worried by 
 the pain. 
 
 His muscles were flaccid and atonic. There 
 was no distinct paralysis of the extremities, but 
 his head showed some tendency to drop back- 
 wards, especially when he would look upward. 
 This was probably due to weakness of the sup- 
 porting muscles of the neck. 
 
 At a second examination a few days later it was 
 noticed that he swayed markedly to the right, 
 standing with eyes shut and considerably with 
 eyes open. He invariably staggered or tended 
 to the right in walking, his gait being somewhat 
 titubating. There was some ataxia in both arms, 
 possibly a little more on the right. No hemi- 
 asynergia was present. Tremor was marked in 
 both upper extremities, a little more so on the 
 left; it was coarse, jerky and increased by action. 
 The muscular sense was preserved, as was also 
 stereognostic perception. The right side of. the 
 face was apparently hypassthetic, as were also 
 the arm and leg of the same side. This symp- 
 tom, however, seemed variable or doubtful, as 
 the patient did not always answer in the same 
 
105 
 
 way as regards the impression made. The head 
 was not carried towards either shoulder, but, as 
 stated above, sometimes it had a tendency to 
 droop or fall backwards. Both knee jerks were 
 plus. The Babinski response was absent on each 
 side. Incontinence of urine or faeces was not 
 present. 
 
 Paresis of the left external rectus, with nystag- 
 moid movements when the eyes are turned far 
 to the left, was present ; no such movements were 
 shown when the head was turned to the right up- 
 wards or downwards. When the patient fol- 
 lowed the finger with his eyeballs von Graefe's 
 sign was very distinct. About }i inch and pos- 
 sibly even more of the white of the eyeball was 
 seen between the iris and the upper lid on each 
 side. 
 
 The knee jerks were slightly plus; the ankle 
 jerks about normal; the muscle jerks a little be- 
 low normal. The tongue was protruded straight 
 and was not atrophied. It exhibited no fibrillary 
 tremor. 
 
 Speech was a little peculiar, but the patient 
 said that it had always been the same as it was 
 at this time. 
 
 According to Dr. B. A. Randall's report, the 
 patient had nearly normal ears in appearance -and 
 function with possibly a trace of tympanitic re- 
 duction of hearing; the auditory nerves seemed 
 to be in perfect condition. 
 
 There was no thyreoid or other glandular en- 
 largement of the neck. The thorax was small, 
 narrow, and poorly shaped and developed; the 
 
106 
 
 supraclavicular and infraclavicular spaces were 
 prominent ; the expansion was poor. In front 
 and back of the lungs the breath sounds were 
 clear but faint. The action of the heart was regu- 
 lar; there were no murmurs. The abdomen was 
 flat. 
 
 The patient came under observation July 6, 
 1904, and was admitted the same day to the Uni- 
 versity Hospital, where he was seen by Dr. Spil- 
 ler in consultation with Dr. Mills. The diagnosis 
 of tumor of the cerebellum probably involving 
 the right lateral lobe, was made. 
 
 The operation was performed by Dr. Frazier 
 July 9, 1904, with the object of exposing the right 
 lateral lobe of the cerebellum. The usual inci- 
 sion was made and the skull opened in the cus- 
 tomary way. Upon reflection of the musculo- 
 cutaneous flap, two large anomalous sinuses were 
 exposed, making their exit at a point about 2 cm. 
 from the occipital protuberance and a little be- 
 low the superior curved line. The blood poured 
 out from these sinuses in great quantities, and 
 every attempt which was made to control the 
 haemorrhage by pressure, Horsley's wax, etc., 
 failed, until some small plugs of wood, made from 
 swab sticks, were driven into the bone. By this 
 time the patient had lost a considerable amount of 
 blood, and was evidently suffering from its effect. 
 Stimulation was resorted to ; a hypodermic of 
 strychnine was given and a pint of i to 50,000 
 adrenalin salt solution was administered intra- 
 venously. By this time the blood pressure had 
 fallen to 55, and for the next fifteen minutes re- 
 
107 
 
 mained at 50. It then fell to a point too low to 
 estimate, and another pint of i to 50,000 adrenalin 
 salt solution was given intravenously. In twenty- 
 five minutes the blood pressure rose to 100, and 
 the adrenalin was discontinued. The blood pres- 
 sure began to fall again and resort was had again 
 to intravenous injections of adrenalin. Owing to 
 the excessive hsemorrhage it was decided to post- 
 pone the actual exploration for the tumor until 
 the patient had fully reacted. The operation was 
 performed at 2 p. m., and from that on to i a. m. 
 on the following morning the patient's condition 
 gradually improved. At i a. m. his pulse was 
 only 96 and of fair volume. His color good and 
 his respirations were 15. At 1.15 a. m. his pulse 
 was 98, and his respirations were 14. At 1.30 
 a. m. his condition was reported as unchanged, 
 with the exception that his respirations had 
 dropped to 11. At 1.40 a. m., without any warn- 
 ing, the pulse suddenly shot up to 120, respira- 
 tions dropped to four. The patient became 
 cyanotic and died at 1.45 a. m. No autopsy was 
 permitted. 
 
 It is difficult to account for the death of this 
 patient. One can hardly attribute it to the ex- 
 cessive haemorrhage at the time of the operation, 
 although this may have been a contributory 
 cause. The condition of the pulse and blood 
 pressure showed that the patient had almost fully 
 reacted soon after the operation. The slow re- 
 spiratory rate suggests the possibility of an in- 
 jury to the respiratory centre, although this would 
 hardly have been inflicted by any step in the oper- 
 
108 
 
 ation, inasmuch as no attempt was made to ex- 
 plore the cerebellar fossa. 
 
 Case VI. — Cerebellopontile operation for tu- 
 mor of pons ; probable second lesion in parietal 
 lobe; cyst evacuated; permanent disappearance 
 of severe headache and facial neuralgia. 
 
 This patient, a woman, about forty-five years 
 old, first came under the care of Dr. Mills in 
 November, 1902. One year before coming un- 
 der observation she had an attack of vertigo with- 
 out unconsciousness and after this partial paraly- 
 sis of the left third nerve was observed, ptosis, di- 
 lated pupil and paresis of the internal rectus be- 
 ing present, according to the physician then in 
 attendance. She also appeared from the history 
 to have had temporary paralysis of the left side 
 of the face. She had subsequent similar attacks, 
 some of these shortly before coming under obser- 
 vation. In one of the recent seizures she was 
 found in the cellar, pacing up and down with her 
 hands above her head, eyes dilated and apparently 
 struggling against suffocation. She was taken 
 upstairs and put to bed ; she tried to speak, mov- 
 ing her jaws without uttering any sound; her 
 face was pale, her eyes were open. At the time 
 of the first examinations she had paresis of the 
 left side of the face, partial ptosis, pupils equal 
 and responsive, the superior rectus not being as 
 active on the left side as on the right. 
 
 In the fall of 1902 the patient was under the 
 care of Dr. Mills in a private hospital. During 
 this period her chief symptoms were occasional 
 headache, general nervousness, and at times slight 
 
109 
 
 mental confusion. The partial palsies of the 
 third and seventh nerves as above noted were 
 present. 
 
 In the summer of 1903 she went to a mountain 
 resort, and while there she had an attack of con- 
 vulsions, after which she had partial paralysis in 
 the right half of the body. The physician called 
 in to see the patient because of the attack of 
 spasm, wrote to me as follows regarding his 
 observations : 
 
 " When I saw the patient she was in a semi- 
 comatose state, and from superficial observation 
 and the history given I thought that I had a hys- 
 terical condition. A dose of potassium bromide 
 aroused her from the stupor following the convul- 
 sions, which, with the stupor, had lasted eight 
 or ten hours. The spasms had not been espe- 
 cially pronounced, and had subsided some three 
 hours previous, with the exception of some twitch- 
 ing around the mouth. From the account given, 
 the contractions were alike on each side, and at 
 the time of my visit no paralysis was present, 
 although it was stated that at some previous 
 time she had had left-sided paralysis, but not 
 in this attack. Mentally she was unbalanced. 
 She seemed to grasp the purport of a ques- 
 tion, but generally gave meaningless answers. 
 She was hunting for some imaginary thing 
 which she had lost, and every moment or 
 two earnestly asked the time of day. On at- 
 tempting to arise in the morning, she fell from 
 the bed, prone, evidently the commencement of 
 her convulsive attack. Inquiry elicited the fact 
 
no 
 
 that there had been some previous brain lesion, 
 which I could not definitely locate, but the knowl- 
 edge of which, with the other symptoms, ex- 
 cluded the idea of hysteria." 
 
 When seen shortly after this, in addition to 
 the symptoms already noted, she also showed 
 some amnesia for names, and some mental change 
 or weakening hard to describe and complained 
 much of headache. Ophthalmoscopic examina- 
 tion made about this time by Dr. S. D. Risley 
 showed no optic neuritis, but bad eye grounds, 
 probably due to eye strain. 
 
 An eye examination was made by Dr. G. E. de 
 Schweinitz on September lo, 1903, who reported 
 as follows : V. of O. D. V^, of O. S. V5. Ampli- 
 tude of accommodation, 4 D. The pupils are 
 round and react normally to light, accommoda- 
 tion and convergence. There is slight ptosis of 
 the left eye and paralysis of the left inferior rectus 
 muscle. The ophthalmoscope reveals the follow- 
 ing conditions : Both optic nerves are round, their 
 nasal and upper edges being veiled. The central 
 lymph sheaths are fuller than normal and the 
 veins somewhat overdistended. This is particu- 
 larly true of the lower temporal vein of the left 
 side. The veiling of the disc edges is evident, as 
 well by indirect as by direct method of ophthal- 
 moscopy, and taken into consideration with the 
 overcapillarity of the disc surface, may be re- 
 garded as indicating a congestion of the nerve 
 heads. Actual neuritis is not present, as there is 
 no swelling of the papillae. The visual fields are 
 normal. 
 
Ill 
 
 The patient was examined by Dr. Mills, Dr. 
 Dercum, and Dr. Spiller in consultation on Sep- 
 tember II, 1903. Resistance to passive move- 
 ments in the lower limbs was about equal. Knee 
 jerks were much exaggerated on both sides ; ankle 
 clonus was easily obtained and persistent on the 
 right; it was faint and not persistent on the left. 
 Her station was erect and normal with eyes open. 
 She swayed distinctly with eyes closed, the sway 
 being greater towards the right. Her gait was a 
 little uncertain, much more so with the eyes 
 closed. She showed a slight tendency to drag 
 the right foot as if it stuck to the floor. In walk- 
 ing backward with her eyes closed she put the 
 left foot backward and drew the right foot to it. 
 The Babinski reflex was doubtfully present on 
 the right side, but was not obtained at all on the 
 left, the toes responding by plantar flexion. 
 When a pencil was laid lengthwise or crosswise 
 on either foot she was unable to give the correct 
 position; the position seemed to her usually as 
 being across the toes. Touch was felt every- 
 where, but distinctly better in the upper and lower 
 limbs on the left side and on the left side of the 
 face than in the corresponding parts of the right 
 side. Pain stimulus was felt everywhere, but like 
 tactile sensation was more distinct in the left 
 upper and lower limbs and left side of the face. 
 Sensation for cold and heat Vv^as everywhere nor- 
 mal. 
 
 The grasp of the right hand was distinctly 
 weaker than that of the left. The fingers of the 
 right hand were kept partially flexed at the junc- 
 
112 
 
 tion of the second and third phalanx, the thumb 
 extended. She could fully extend the fingers, 
 with the exception of the middle one. Appos- 
 ing the thumb to the little finger on the right hand 
 was very difficult. Triceps tendon jerks and 
 wrist reflexes were exaggerated on each side, dis- 
 tinctly more so on the right than on the left. The 
 palm of the right hand was a little puffy, but not 
 distinctly cedematous. She could raise the right 
 upper limb to the full extent above the head ; re- 
 sistance to passive movements was much im- 
 paired in the right upper limb. She experienced 
 difficulty in placing the first finger of the right 
 hand on the nose, usually carrying it to one side 
 of the nose. She was uncertain as to the posi- 
 tion of her little finger when it was raised, usually 
 saying it was the ring finger ; she knew the other 
 fingers on the right hand when they were raised. 
 Stereognostic perception was greatly impaired on 
 the right hand and not on the left. She could not, 
 for instance, recognize a knife, pencil, or other 
 object in the right hand, but recognized them 
 promptly in the left. The sense of position of 
 the toes of both the right and the left foot seemed 
 to be preserved. She exhibited a slight weakness 
 in drawing up the right corner of her mouth, but 
 drew the left side up better. She closed her eye- 
 lids firmly on each side, and wrinkled her fore- 
 head well and equally on the two sides. The 
 tongue was protruded straight and showed fibril- 
 lary tremor. She said that her tongue had felt 
 numb and stiff for two days before the examina- 
 tion. The masseters and temporals contracted 
 
113 
 
 firmly on each side. She heard a low ticking 
 watch only when it approached to within about 
 two inches of either ear, the hearing seeming to 
 be the same in each ear. Sugar and salt were 
 tasted promptly on each side of the tongue. 
 
 Dr. J. W. McConnell examined the patient on 
 September 12, 1903, and reported that subsequent 
 to the above examination she had an attack of 
 twitching of the right arm and the right leg with 
 unconsciousness. There were no changes from 
 the examination of the previous day. She com- 
 plained of intense pain in the left parietal region, 
 and also said that she had some numbness in the 
 left arm and leg. 
 
 After this she was seen from time to time by 
 Dr. Mills, and on several occasions for him by 
 Dr. T. H. Weisenburg, who made a few notes as 
 follows : September 14, 1903. Paresis of the left 
 internal rectus was present. Astereognosis was 
 not present in the right hand, and the sense of 
 position of the right hand was normal. 
 
 September 16, 1903. — She had a left-sided peri- 
 pheral facial palsy, also a paresis of the left ex- 
 ternal rectus and of the internal rectus. No sen- 
 sory changes were present on the left side. 
 
 The patient was again examined by Dr. Mills 
 and Dr. Spiller on September 22, 1903. The left 
 side of the face was paralyzed in the entire dis- 
 tribution of the seventh nerve. She complained 
 of much pain, confined to the left side of the face 
 and in the distribution of the fifth nerve. The 
 masseter and temporal muscles contracted well 
 in chewing on each side. No distinct objective 
 
114 
 
 disturbance of sensation on the left side of the 
 face was made out. The left external rectus 
 seemed to be the only external ocular muscle dis- 
 tinctly paretic. Astereognosis in the right hand 
 was almost complete. 
 
 She complained of much pain on both sides of 
 the forehead, extending down the left side of the 
 face to the lower border of the lower jaw. The 
 pain did not extend below the median line of the 
 lower jaw; it extended to the mastoid process, 
 but not beyond this on the left side; it did not 
 extend into the neck. She had constant pain in 
 both temples, but it was greater in the left than 
 in the right. All points of exit of the fifth nerve 
 were painful to pressure ; as much so on the right 
 side as on the left. Sensation for touch and for 
 pain on the two sides of the face seemed to be 
 normal; she felt a touch or pin prick as well on 
 the left side of the face as on the right. In such 
 instances as when chewing a hard crust of bread, 
 the left masseter contracted, but not so well as 
 the right; in opening the mouth the lower jaw 
 did not deviate distinctly. She complained of a 
 sense of numbness in the left side of the face ; this 
 involved the entire distribution of the fifth nerve 
 and extended up on the left to the temple, but not 
 far beyond the border of the hair. There was con- 
 siderable improvement in the paralysis of the 
 orbicularis palpebrarum. There was complete 
 paralysis in the lower distribution of the left 
 facial nerve. The right side of the face was nor- 
 mal. 
 
 She did not have any nausea and seldom had 
 
115 
 
 spells of vertigo, although formerly the latter oc- 
 curred frequently. She showed a tendency at 
 times to fall backwards or towards the left, but 
 did not stagger as much as formerly ; closing the 
 eyelids did not affect the gait very distinctly. 
 Hemiasynergia was not present on either side. 
 
 As the patient was slowly getting worse and 
 was suffering extremely with pain in her head and 
 face, it was finally decided to remove her to the 
 University Hospital for the purpose of having an 
 operation, which might at least be palliative. Her 
 pain increased until it became torturing, and for 
 days before the operation it was necessary to keep 
 her continuously under the effects of morphine 
 or codeine. No change of any moment occurred 
 in her focal symptoms after the above recorded 
 notes. 
 
 The operation was performed by Dr. Frazier 
 on October 14, 1903, under ether anaesthesia. A 
 musculocutaneous flap together with the perios- 
 teum was reflected and an opening was made in 
 the skull with the chisel and enlarged with Ron- 
 geur forceps. Nothing abnormal as regards pul- 
 sation nor consistency of the left lateral lobe of 
 the cerebellum was noted. The dural flap was 
 reflected; at one point this flap was adherent to 
 the underlying brain. Cerebellar tissue bulged 
 only moderately through the wound. On explor- 
 ing with the index finger in the region of the 
 cerebellopontile angle some adhesions were sep- 
 arated on the lateral aspect of the cerebellum. 
 This was followed by a gush of fluid which had 
 evidently been walled off by adhesions. After 
 
116 
 
 the evacuation of the cyst the bulging subsided 
 immediately and with a brain retractor it was 
 possible to inspect the region of the cerebello- 
 pontile angle and to demonstrate to those present 
 at the operation, the fifth, seventh, and eighth 
 cranial nerves. It was noted on the blood pres- 
 sure chart that when the dura was opened the 
 blood pressure dropped thirty points, and that 
 upon introducing gauze packing or upon com- 
 pressing the brain with the retractor that the 
 blood pressure rose forty points. The patient's 
 condition was not depressed to any considerable 
 degree by the operation ; upon her return to bed 
 her pulse was 145 ; respirations were 40, and blood 
 pressure was 115. 
 
 The interesting feature of the case was the ease 
 with which the cranial nerves were exposed after 
 the cyst had been evacuated. 
 
 The patient reacted well after the operation 
 and passed a fairly comfortable night. There was 
 very profuse oozing of blood and cerebrospinal 
 fluid, necessitating frequent reinforcement of 
 dressing. The patient was much nauseated, vom- 
 iting curds of milk and bile stained fluid. She 
 complained of pain in her temples. A hurried 
 examination showed that sensation was present 
 on both sides of the face a'nd no inequality of 
 pupil was noted. 
 
 On October 15th the wound was dressed; it 
 was found in good condition ; the drainage was 
 removed ; there was a free flow of cerebrospinal 
 fluid. 
 
 An examination by Dr. Mills and Dr. Spiller 
 
117 
 
 on this date (October 15th) resulted as fol- 
 lows : No cutaneous anaesthesia was present on 
 either side ; not even any hypsesthesia on the left. 
 There was great impairment of the motor divi- 
 sion of the fifth nerve, the masseter and pterygoid 
 muscles being tested. Complete paralysis in the 
 muscles supplied by both the upper and lower 
 branches of the seventh nerve was present. She 
 was completely deaf in the left ear. Slight pa- 
 ralysis in the right upper extremity was noticed. 
 Astereognosis or pseudoastereognosis was pres- 
 ent in the right hand. Anaesthesia for both touch 
 and pain and hypersesthesia were absent. She 
 had had no pain in the face or head since the 
 operation, and had required no anodynes. 
 
 On October 19th the wound was again dressed 
 and the stitches were removed ; the wound was 
 all healed, with the exception of one angle; a 
 small piece of gauze was inserted for drainage. 
 The patient's general condition had been very 
 good. Her pupils were now normal. 
 
 On October 24th the surgical condition was 
 entirely satisfactory ; the wound was all healed, 
 with the exception of one spot, which was rapidly 
 granulating. The patient's general condition had 
 rapidly improved since last noted. She was re- 
 gaining strength, had been sitting up and was 
 quite comfortable. 
 
 On October 29th the patient was discharged, 
 the surgical condition left nothing to be desired ; 
 the wound was completely healed ; there was no 
 bulging of the flap, no signs of inflammation or 
 oedema of the scalp. The patient had not had 
 
118 
 
 any pain in the head or ears ; the only discomfort 
 had been some irritation of the conjunctiva of the 
 left eye, which was probably due to facial palsy. 
 
 This patient has continued under the observa- 
 tion of Dr. Mills and Dr. Frazier from the time 
 of operation until that of writing (December, 
 1904). From the time of operation until the 
 present she has not had any pain in the head, al- 
 though as previously stated, the pain for some 
 time before the operation was of the most intense 
 character. In other respects, her general con- 
 dition has been good. She still, however, con- 
 tinues to be partially paralyzed with astereogno- 
 sis and sensory changes on the right side, and 
 still has paralysis in the distribution of the left 
 seventh nerve. It is altogether probable that a 
 lesion of some sort is still present; not improb- 
 ably she has more than one lesion, as the symp- 
 toms point both to the pons and to the left parietal 
 lobe. The case is especially interesting as show- 
 ing how in some cases the cerebellopontile angle 
 can be exposed and how pain and other symp- 
 toms of brain tumor are sometimes relieved even 
 when full success is not obtained. 
 
THE OCULAR SYMPTOMS OF CEREBEL- 
 LAR TUMOR. 
 
 By G. E. de SCHWEINITZ, M. D, 
 
 philadelphia, 
 
 professor of ophthalmology, university of pennsylvania. 
 
 The ocular signs of cerebellar growth are chiefly 
 concerned with changes in the fundus oculi, par- 
 ticularly the nerve head, and with anomalies of the 
 external ocular muscles and the movements of the 
 eyeballs. 
 
 I. PAPILLITIS, OR CHOKED DISC, 
 
 (a) Frequency. — In order to ascertain the per- 
 centage of choked disc or papillitis in cases of sus- 
 pected intracranial tumor, Dr. John Weeks^ has 
 collected the reports of 677 brain tumors, and finds 
 that those which involve the corpora quadrigemina 
 give the highest percentage, namely, 100; next 
 come tumors of the parietooccipital region, with a 
 percentage of 87.8, while new growths of the 
 cerebellum furnish a percentage of 87.2. In his list 
 are the records of 164 cases of cerebellar tumor, and 
 only 21 times was optic neuritis absent. In an 
 analysis of intracranial tumors with respect to the 
 existence of optic neuritis published by Edmunds 
 and Lawford,^ 23 case s of neoplasm of the cerebel- 
 
 1 Transactions of the Section on Ophthalmology of the Ameri- 
 can Medical Association^ 1899. 
 
 2 Transactions of the Ophthalmological Society of the United 
 Kmgdom, IV, 1884, p. 82. 
 
120 
 
 lum are reported, and in 20 of them optic neuritis 
 was present, being absent only three times. It is 
 not necessary to elaborate these statistics, because 
 the fact would not materially be altered that with 
 the exception of growths of the corpora quadri- 
 gemina, and possibly those of the parietooccipital 
 region, cerebellar tumors yield the highest percent- 
 age of papillitis, or so called choked disc. 
 
 (b) Character of the Neuritis and Nerve Head 
 Changes. — It is a matter of common observation 
 that optic neuritis develops with rapidity in cerebel- 
 lar tumors, indeed, with greater rapidity than when 
 they are elsewhere situated. In the words of Mr. 
 Gunn, intense double optic neuritis, with great en- 
 gorgement of the papillae and with surrounding 
 retinal change coming on quickly, suggests a 
 cerebellar growth. In addition to a papillitis of an 
 intense type, that is, one having the characteristics 
 to which the term choked disc is applied, a cerebel- 
 lar growth may also originate a more moderate 
 swelling of the nerve head, somewhat condensed 
 in appearance and comparatively free from undue 
 capillarity. 
 
 It is not possible to state exactly how much time 
 must be consumed before the optic neuritis of 
 cerebellar neoplasms is evident. As already stated, 
 the development is usually a rapid one, and the 
 neuritis may appear within a few weeks, or even a 
 
121 
 
 few days, after other signs of involvement of this 
 region are evident, for example, intense headache, 
 vomiting, and vertigo. Sometimes longer periods 
 of time are required before optic neuritis is dis- 
 covered. In one of my cases with other well 
 marked signs of cerebellar growth there was no 
 neuritis; six months later there was well marked 
 neuritis in one eye and intense papillitis in the other. 
 
 It not infrequently happens that patients come 
 to ophthalmoscopic examination after the papillitis 
 has already subsided and a postneuritic atrophy is 
 present, or at a period when the swelling of the 
 disc is rapidly disappearing and atrophy beginning. 
 Optic nerve atrophy, without signs of preexisting 
 neuritis, and blindness, unassociated with ophthal- 
 moscopic lesions, have been reported. 
 
 It is well known that the papillitis of intracranial 
 tumor is sometimes unilateral and that when there 
 is a one sided optic neuritis, or a marked difference 
 between the two sides, it is suggestive of the fact 
 that the cerebrum is the seat of the growth, and, on 
 the whole, in favor of the tumor being on the same 
 side as the excess of neuritis. Less frequently 
 unilateral neuritis occurs in cerebellar tumor. It 
 was noted four times in 164 cases of the Weeks 
 collection. Referring to this point Mr. Gunn' 
 writes as follows : " Taking the important analysis 
 
 3 Brain, XXI, 1898, p. 335. 
 
122 
 
 of 6oi cases of tumor made by Dr. J. M. Martin, 
 and paying attention to the relation between posi- 
 tion, occurrence of optic neuritis, and difference of 
 neuritis on the two sides, I find that there was 
 unilateral neuritis (or excess) in lo cases of frontal 
 tumor, and in 8 of these it occurred on the same 
 side as the tumor. In four cases of neuritis differ- 
 ence, in cases of temperosphenoidal growths, the 
 one sided excess was always on the same side. Put- 
 ting these together, we have the unilateral excess 
 of neuritis on the same side as the tumor in 12 out 
 of 14. The unilateral character of the neuritis was 
 noted in 10 cases of tumor of the parietooccipital 
 lobes and in the cerebellum. In 5 of these it was 
 on the same side as the tumor and in 5 on the op- 
 posite side." 
 
 He further points out that a one sided difference 
 of neuritis is more common in tumors of the ce- 
 rebral lobes than in tumors of the cerebellum. In 
 the collection before referred to it occurred in 20 
 per cent, of all of the cases of neuritis with tumors 
 of the cerebrum, and in only about 3 per cent. c>f 
 those associated with tumor of the cerebellum. I 
 have not seen unilateral neuritis in cerebellar 
 growth, although, as in the present collection, I 
 have noted an excess of neuritis on one side as 
 compared with the other. 
 
 (c) Retinal Changes. — It has been known since 
 
123 
 
 the observations of von Graefe, Schmidt, and 
 Wegner, more than thirty years ago, that appear- 
 ances exactly simulating those seen in retinitis al- 
 buminurica, particularly the so called macular 
 figure, may be found in brain tumor. This stellate 
 macular figure, in addition to the swelling of the 
 nerve head, has been noticed with particular fre- 
 quency in cerebellar tumors and has been the sub- 
 ject of comment especially by Dr. James Taylor 
 and Mr. Marcus Gunn.* While it is more common 
 to find this stellate figure in cerebellar growths than 
 in others elsewhere situated, it is not peculiar to 
 them, and Mr. Gunn himself remarks that he has 
 seen it in frontal tumors. One of the best marked 
 examples in my own observation occurred in a 
 growth which was certainly in the cerebrum, al- 
 though its location was not proved by autopsy, and 
 another excellent example appeared in a subcortical 
 growth of the midregion of the brain which had 
 pressed upon the optic tracts and produced hemian- 
 opsia, and which was removed by Dr. Hearn and 
 Dr. Da Costa in the Philadelphia Hospital. I have 
 also seen it in perfect degree in several cerebellar 
 tumors, one particularly in the Orthopaedic Hos- 
 pital and another under the care of Dr. Mills and 
 Dr. Frazier in the University Hospital, a full eye 
 
 * Transactions of the Eighth International Medical Congress, 
 
 Edinburgh, 1894. 
 
124 
 
 examination of which is recorded in the present 
 paper. 
 
 Other retinal changes not significant of cerebel- 
 lar tumor may also appear, for example, postneuritic 
 atrophy, perivasculitis, areas of atrophy marking 
 the position of former haemorrhages, exudations 
 and sclerotic alterations in the retinal vessels, if 
 the patient has also been the subject of general 
 arteriosclerosis. 
 
 (d) Visual Acuity. — It is well known that optic 
 neuritis caused by intracranial growth is perfectly 
 compatible with good visual acuity, but if the 
 growth is situated in the cerebellum there is apt to 
 be early great disturbance of vision, rapidly pro- 
 ceeding to blindness. Edmunds and Lawford re- 
 ferring to the frequency of blindness under these 
 circumstances, compare it with the optic neuritis 
 which occurs in tumors of the basal ganglia, which 
 in their table yield next to cerebellar growths the 
 highest percentage of optic neuritis, but in only five 
 of the twenty cases was blindness present, as against 
 nine which progressed to blindness in twenty-three 
 cases of cerebellar tumor. Moreover, of the twenty 
 cases with optic neuritis, seven were blind on ad- 
 mission to the hospital and two others became blind 
 before death. They suggest that as cerebellar tu- 
 mors are not so rapidly fatal as basal tumors, time 
 
125 
 
 is allowed for the neuritis to pass on to atrophy 
 and to blindness. 
 
 Dercum^ in 1893 tentatively advanced the follow- 
 ing explanation of early blindness in cerebellar 
 growths: "The proximity of the quadrigeminal 
 bodies naturally suggests itself as in some way ex- 
 plaining this blindness. A consideration of anatomy 
 will show that if a growth be situated in the vermi- 
 form process, especially anteriorly, and that if this 
 growth continues to enlarge, it will sooner or later 
 press upon the superior cerebellar peduncles, and 
 very probably upon the quadrigeminal bodies them- 
 selves. Now if we recall the relation which the 
 fibres of the optic tracts bear to the primary optic 
 centres one can readily understand how, if pressure 
 or irritation occurs at this point, a neuritis would 
 be the consequence. Further, the irritation being 
 direct, one can, perhaps, understand why the neu- 
 ritis should be of a high grade; and finally, also, 
 why this neuritis should be associated, sooner or 
 later, with total blindness." Recognizing, however, 
 that this hypothesis, especially in so far as it refers 
 to the development of the neuritis, is unsatisfactory, 
 Dercum has abandoned it. 
 
 Oppenheim® thinks that upon the hydrocephalus 
 which almost always accompanies in considerable 
 
 " Journal of Nervous and Mental Disease, 18, 1893. p. 683. 
 * Die Oeschwiilste des Gehirns, by Prof. Dr. H. Oppenheim, 
 Wien, 1896, p. 144. 
 
126 
 
 degree tumors of the cerebellum, depends the de- 
 cided choked disc and its prompt arrival, as well 
 as the early amblyopia, to be followed later by 
 amaurosis. According to him, the rapid, sometimes 
 sudden, appearance of amaurosis is due to a com- 
 pression which injures the chiasm and which is 
 caused by a bulging forward of the floor of the 
 third ventricle. A similar explanation is applicable 
 to those cases of amblyopia and blindness without 
 eyeground changes which have been observed by 
 Curschmann, Gerhardt, and others. The optic 
 nerve atrophy, which is sometimes noted in cerebel- 
 lar disease without evidence of much preexisting 
 neuritis, Oppenheim also attributes to pressure upon 
 the chiasm. 
 
 It would seem, therefore, that the blindness may 
 be explained in part by direct pressure from hydro- 
 cephalus, and in part by the compression of the 
 optic nerve fibres and their subsequent atrophy 
 owing to the high grade of engorgement oedema, or 
 to an actual neuritis. The relation which the de- 
 struction of the ganglion cells of the retina bears 
 to this blindness requires further study, and it may 
 be that their disintegration will account for some 
 of the cases of early and even sudden blindness in 
 cerebellar tumor associated with papillitis of marked 
 degree. 
 
 (e) Effect of Operation on Papillitis. — In so far 
 
127 
 
 as the patholog-ical examinations of cerebellar optic 
 neuritis are concerned, they do not differ from those 
 which have been made in the optic neuritis of other 
 intracranial growths, and it is not germane to the 
 present topic to discuss this subject concerning 
 which there is still much difference of opinion. In 
 general terms, microscopical examination would 
 seem to indicate that in a certain number of cases 
 of papillitis, be they of cerebral or cerebellar 
 origin, there is a true engorgement cedema, and 
 that the evidence of inflammation, in any decided 
 degree at least, is lacking, while in other cases the 
 inflammatory signs are marked. When the en- 
 gorgement oedema is the marked feature, the oph- 
 thalmoscope reveals the typical picture of choked 
 disc. When, on the other hand, the inflammatory 
 condition predominates, the elevation of the disc 
 may be less marked and the process may extend to 
 the surrounding retina. In other words, there is an 
 iniiammatory optic neuritis. Now, if one sees the 
 case during the period of engorgement oedema, be- 
 fore inflammatory exudates are present, naturally 
 it is desirable to reduce the swelling of the nerve 
 head. Horsley, Bruns, Erb, James Taylor, and 
 many others have called attention to the fact that 
 there may be a subsidence of the optic neuritis after 
 operation undertaken with a view to the removal 
 of an intracranial tumor, even when the tumor was 
 
138 
 
 not removed, and Taylor has recorded a number 
 of examples of this character. Certainly, as Hors- 
 ley points out, removal of pressure is one of the 
 factors in the reduction of optic neuritis in intra- 
 cranial tumors, and as Hill Grififith has said, should 
 there be recovery after blindness with optic neuritis 
 by trephining, the indications are that the optic 
 nerv^e condition was produced by pressure. 
 
 Saenger''' reports prompt subsidence of double 
 sided choked disc after palliative trephining for 
 cerebellar growth and advises this operative pro- 
 cedure in tumors which cannot be removed in order 
 to relieve pressure symptoms and especially to avoid 
 impending blindness. In seven cases of double 
 choked disc he has noted a disappearance of this 
 condition after such trephining. In two of the pa- 
 tients described by Dr. Mills in the present paper 
 and trephined by Dr. Frazier, with removal of the 
 growth, there was decided and comparatively 
 prompt subsidence of the choked disc. In one of 
 these blindness occurred, but the patient was prac- 
 tically blind when she was trephined. In the other 
 the visual acuity before the operation, which was 
 good, that is, two thirds of normal, has been main- 
 tained until the present time and the neuritis has 
 partly subsided.* 
 
 '' Miinch. med. Wochenschr., XLVIII, 1901, p. 2. 
 
 ^ Since this sentence was written the patient has been seen, 
 and the vision has begun to fail and a partial ophthalmoplegia 
 has developed ; evidently there has been recurrence. 
 
129 
 
 If it be true, as Merz declares, that increased 
 intracranial tension alone is sufficient to produce 
 choked disc, provided this tension shall be main- 
 tained uninterruptedly for a certain time, and if 
 further it is true, as would seem from reported 
 cases, that there is reduction of such tension by 
 trephining, even where the tumor is not removed, 
 then certainly Saenger's advice that such palliative 
 trephining should be performed early, especially in 
 the choked disc of cerebellar tumor, which is 
 almost sure to produce blindness, is sound and 
 should be followed. 
 
 II. — ANOMALIES OF THE OCULAR MUSCLES AND OF 
 THE MOVEMENTS OF THE EYEBALLS. 
 
 Owing to the anatomical relations of the cere- 
 bellum, tumor formation in this region may bring 
 about involvement of certain of the cranial nerves, 
 particularly the facial and the auditory. In so far 
 as the eye muscle nerves are concerned, the abducens 
 is by far the most frequently ajffected, and conver- 
 gent paralytic strabismus with involvement of one 
 or both abducens nerves is not an unusual symptom 
 in cerebellar growth. In a case reported by Saenger 
 with gliosarcoma of the left cerebellar hemisphere, 
 there was double abducens paralysis with marked 
 thinning of the nerves, and in a similar growth re- 
 corded by Sander the abducens paralysis was ex- 
 
130 
 
 plained by finding a lesion in its nucleus. Wernicke 
 states that sixth nerve paralysis is most apt to be 
 present as a distant symptom when the tumor is 
 situated in the cerebellum. In this respect the sixth 
 differs from the third nerve, v^^hich, as Swanzy has 
 well shown, is more likely to give distant symptoms 
 with a lesion of the cerebral hemisphere. 
 
 In one case recorded by Dr. Mills in the present 
 paper where the cerebellum and the pons oblongata 
 were exposed and a cyst was discharged, there was 
 paralysis of the branch supplying the left levator 
 palpebrae and the left inferior rectus. According 
 to Oppenheim ptosis and reflex immobility of the 
 pupil without loss of sight and paresis of accom- 
 modation have been observed, and he quotes 
 Mackenzie, Bruns, and other authors as having 
 observed a more or less complete ophthalmoplegia.^ 
 A rare ocular muscle palsy is one that affects the 
 superior oblique, that is to say, the trochlearis is 
 involved. Referring to the setiology of these con- 
 ditions, Oppenheim remarks that the paralyses must 
 depend upon a lesion of the nerve trunks them- 
 selves, or UDon pressure exerted on the region 
 of their nuclei. When ophthalmoplegia is evident, 
 it may be explained by an involvement of the cor- 
 pora quadrigemina. 
 
 » In one case at present under my observation there is paraly- 
 sis of all external ocular muscles except the inferior recti, which 
 are beginning to be involved, and the superior obliques. 
 
131 
 
 Bruns/° referring to the difficulty of telling on 
 which side of the cerebellum a tumor has its sit- 
 uation, speaks of the help obtained in this respect 
 when certain nerves are paralyzed, for example, 
 the trifacial, the facial, and the auditory, and refers 
 as a frequent symptom to the presence of associated 
 paralyses of ocular movements which then appear 
 toward the side of the tumor. So frequent are these 
 paralyses that in large tumors of the cerebellum 
 Bruns considers them to be constant. 
 
 Oppenheim, discussing the same subject, remarks 
 that this symptom, that is, a paralysis of associated 
 parallel movements of the eyes toward the side of 
 the tumor with deviation of the eyes toward the 
 opposite side, depends upon a one sided compres- 
 sion of the pons. It is, therefore, the rule that the 
 eyes of these patients cannot be moved toward the 
 side of the tumor. He warns, however, that the 
 symptom cannot be absolutely trusted, inasmuch as 
 in two cases under his own observation there was 
 paralysis of associated parallel movements toward 
 one side when the vermiform process was the part 
 involved in the tumor formation. 
 
 According to Gowers, an unsymmetrical position 
 of the eyes, one directed upward and inward and 
 the other one downward and outward, has been ob- 
 
 " Neurologisches CentraVbl., 18, 1899, p. 519. 
 
132 
 
 served as a rare symptom of tumor of the middle 
 peduncle of the cerebellum. 
 
 Nystagmus is almost always present in cerebellar 
 tumors. It may be rotary or vertical, but is most 
 frequently lateral. Sometimes it is not observable 
 when the gaze is directed forward but develops at 
 once in right or left Isevoversion. 
 
 It would seem also that in a certain number of 
 cases the nystagmus is evident only when the eyes 
 are turned toward the side on which the tumor is 
 situated, and, indeed, that such nystagmus may be 
 the sole ocular sign of the cerebellar growth. For 
 example, Pineles^^ observed in a patient with normal 
 eyegrounds nystagmus only when the eyes were 
 directed to the left. Post mortem examination re- 
 vealed a walnut sized tubercle in the left cerebellar 
 hemisphere, the middle of the lobus quadrangularis 
 being also involved. This development of nystag- 
 mus when the eyes are rotated toward the side of 
 the tumor has been commented upon by a number 
 of observers. It has been noticed by Mills, Spiller, 
 and by myself in several cases which we have exam- 
 ined together. In place of a true nystagmus, a 
 nystagmoid movement is often observable when the 
 eyes are turned from side to side, particularly if 
 there is an associated paralysis of the external rec- 
 tus. There is no doubt that nystagmus may be 
 
 " Arbeiten aus Oiersteiner's Laioratorium, Heft 4, 1899. 
 
133 
 
 regarded as a direct cerebellar symptom. It has 
 also been referred, according to Amheim who 
 quotes Russell in this respect, to a paralysis of the 
 ocular muscles. 
 
 That double optic neuritis, internal strabismus, 
 and nystagmoid movements on looking both to the 
 right and to the left, must not, however, be regarded 
 as characteristic or pathognomonic of cerebellar 
 tumor, is evident from a case recorded by Bram- 
 well,^^ in which these symptoms were present and 
 the lesion consisted of a dilatation of the ventricles, 
 especially of the fourth ventricle, the result of a 
 previous meningitis and an obliteration of the fora- 
 men of Magendie. The oscillation of the globes in 
 blindness from cerebellar tumor must not be con- 
 fused with true nystagmus. 
 
 There is nothing characteristic in the pupil reac- 
 tions in disease of this region. If there is blindness 
 and loss of light perception, there is naturally loss 
 of the light reflex, while, if light perception remains, 
 this reflex is preserved. 
 
 So, also, the field of vision furnishes no charac- 
 teristic changes. It may be perfectly intact or con- 
 centrically or irregularly contracted, according to 
 the degree of atrophy existing in the optic nerves. 
 In some cases there seems to have been hemian- 
 opsia, but probably only a contraction of the 
 
 "Brain, XXII, 1899, p. 68. 
 
134 
 
 visual field resembling this phencmenon due to 
 atrophy in the optic nerve, or alteration in the gang- 
 lion cells of the retina. It is of course conceivable 
 that hemianopsia could occur as an associated 
 symptom if with the cerebellar growth there were 
 other lesions which pressed upon some portion of 
 the optic pathway. 
 
THE PATHOLOGY OF CEREBELLAR 
 TUMORS.* 
 
 By T. H. WEISENBURG, M. D., 
 
 philadelphia, 
 
 instructor in neurology and neuropathology, univer- 
 sity of pennsylvania; assistant neurologist to 
 the philadelphia general hospital. 
 
 It is not the purpose of this paper to consider 
 minutely the histology of cerebellar growths, as 
 this information can be obtained in any textbook 
 on neurology. The pathological aspects of the 
 various conditions which give the symptoms of 
 cerebellar tumor will be considered, especially in 
 a surgical sense. 
 
 It is difficult to make a satisfactory classifica- 
 tion of such a subject, but the following plan 
 will be adopted: 
 
 1. The ordinary tumors in their order of frequency, as 
 glioma, tuberculoma, cysts, and so forth, of the cerebellum 
 itself. 
 
 2. Growths of the surrounding regions giving cerebellar 
 symptoms, as of the fourth ventricle, medulla oblongata, 
 pons, and corpora quadrigemina. 
 
 3. Growths in parts besides those mentioned, giving cere- 
 bellar symptoms. 
 
 4. Abscess of the cerebellum. 
 
 * From the Neuropathological Laboratory of the University 
 of Penrsylvania. 
 
136 
 
 5- Internal hydrocephalus, with symptoms of cerebellar 
 tumor. 
 
 6. Cerebellar symptoms without any lesions. 
 
 7. Lesions of the cerebellum without any symptoms. 
 
 Excellent statistical studies of the frequency 
 of the cerebellar and other cranial growths have 
 been made, and without the desire to add to the 
 already voluminous literature on the subject, it 
 has been thought advisable to give a brief report 
 of the brain tumors now in the neuropathological 
 laboratory of the University of Pennsylvania, 
 which is under the direction of Professor Wil- 
 liam G. Spiller. This collection has largely been 
 accumulated in the last three or four years, and 
 is from the services of Dr. Mills and Dr. Spil- 
 ler, although in a number of instances specimens 
 have been obtained from other sources. 
 
 Tumors of the cerebral cortex and subcortex 27 
 
 Cerebellar tumors 9 
 
 Tumors of the brain stem 9 
 
 Tumors implicating both brain and cord 4 
 
 Tumors of the cerebral cortex and subcortex : 
 
 Sarcoma 13 
 
 Fibrosarcoma 2 
 
 Endothelioma 4 
 
 Glioma 3 
 
 Gumma 2 
 
 Carcinoma 1 
 
 Adenoma 1 
 
 Tuberculoma X 
 
 Cerebellar tumors : 
 
 Glioma 5 
 
 Sarcoma 1 
 
 Fibroma (in the cerebellopontile angle) 3 
 
137 
 
 Tumors of the brain stem : 
 
 Pons : Tuberculoma 2 
 
 Glioma 1 
 
 On the pons and medulla oblongata : Sarcoma 1 
 
 On the medulla oblongata : Chondrosarcoma 1 
 
 Within the fourth ventricle : Sarcoma 2 
 
 On the corpora quadrigemina : Fibroma 1 
 
 Within the corpora quadrigemina : Glioma 1 
 
 Tumors of the brain and cord : General sarcomatosis, with 
 
 large tumors, especially in the cerebellopontile angle 4 
 
 Sections of at least seven other brain tumors 
 were not considered, because definite knowledge 
 of the location of the growths was lacking. 
 
 According to statistics tumors of the cerebel- 
 lum are less frequent than of the cerebrum. 
 Schuster, in a statistical table of some thousand 
 cases of brain tumor, found 21.6 per cent, to be 
 cerebellar. When the relative size of the cere- 
 bellum and the cerebrum is considered, it is prob- 
 able that new growths are more frequent in the 
 former. 
 
 Tuberculous growths are more common in per- 
 sons below the age of twenty years, while gli- 
 oma, sarcoma, and cysts of various kinds are 
 more frequent in the adult. The frequency of 
 fibroma, especially of the acoustic nerve, is be- 
 coming better recognized. Syphilitic tumors of 
 the cerebellum are rare. Of the other forms of 
 new growths, as carcinoma, lipoma, angeioma, 
 psammoma, and dermoid cysts, there are very 
 few instances in the literature. 
 
138 
 
 The lateral lobes of the cerebellum possibly 
 because of their greater size, seem to be more 
 frequently the seat of tumors than the middle 
 lobe, although writers differ upon this point. Tu- 
 mors within the middle cerebellar peduncle are 
 rarely found, although a tumor within this 
 peduncle is present in one of the specimens in 
 the laboratory. Growths in the anterior and 
 posterior cerebellar peduncles are also uncom- 
 mon. The angle formed by the cerebellum, me- 
 dulla oblongata, and pons is a favorite seat for 
 new growths, these tumors growing either from 
 within or upon the acoustic, facial, or trigeminus 
 nerves, and frequently are fibromata. 
 
 Tuberculoma. — In 152 tuberculous brain tumors 
 collected by Allen Starr, occurring in childhood, 
 47 were in the cerebellum. In the adult they are 
 found with equal frequency in this region and 
 in the pons and the cerebral cortex. They are 
 nearly always multiple, and secondary to a tuber- 
 culous process elsewhere in the body. A tend- 
 ency to symmetrical arrangement is also ob- 
 served (Oppenheim). Their size varies from a 
 small nodule to a large fist. Macroscopically, it 
 is hard to distinguish a tuberculoma from a syph- 
 iloma. Both have poor blood supply and a tend- 
 ency to caseate, the tuberculous growth to pus 
 formation. Again, both have a tendency to grow 
 
139 
 
 from the meninges, although the tuberculous 
 growths are found in the substance of the brain, 
 and may have granulation areas and miliary tu- 
 bercles about their border. It must be recalled, 
 however, that syphilitic tumors of the cerebel- 
 lum are rare. 
 
 The growth of a tubercle may be either rapid 
 or slow. Tuberculous tumors may give no clin- 
 ical symptoms. This has been explained by the 
 slowness of the growth, the cerebellum gradually 
 accommodating itself to increased pressure. 
 Very recently, however, Raubitschek was able to 
 demonstrate the persistence of the axis cylinders 
 in tuberculous growths by Bielchowsky's meth- 
 od. This, as in multiple sclerosis, explains the 
 persistence of function. Surgically, it is not ad- 
 visable to operate upon these growths, as they are 
 multiple and cannot be removed. 
 
 Glioma. — The cerebellum is a favorite seat for 
 glioma. Five of our cerebellar growths were of 
 such nature. Gliomata are almost always pri- 
 mary and single, although metastasis has been 
 noted. The tumor may be as small as a cherry 
 or as large as a hen's egg; it always grows from 
 the brain substance itself, and is of slow growth. 
 It is not sharply defined, but infiltrates into the 
 brain substance, and it is difficult to tell it from 
 normal brain tissue, although sometimes there 
 
140 
 
 is an increased consistence to pressure and there 
 may be a slight swelling. The border zone of 
 the tumor may present an increased number of 
 blood vessels and there may be islets of new tis- 
 sue. 
 
 Gliomata may be hard or soft, depending upon 
 the excess of cells or fibrils, and have a yellowish 
 white or reddish appearance. Cystic formation 
 is very common, some authors believing that the 
 whole tumor mass may disappear, leaving noth- 
 ing but a cyst wall, and that it is necessary to 
 examine microscopically the capsule to deter- 
 mine the gliomatous origin. Cysts form in the 
 neighborhood of these tumors, and the surgeon 
 may tap one of these cystic formations, believ- 
 ing it to be the only lesion present. It is wise, 
 as Oppenheim has pointed out, to remove always 
 a part of the cyst wall for microscopic examina- 
 tion. The fluid inside of these cysts may be 
 whitish or bloody in character. Fatty, hsemor- 
 rhagic, and myxomatous changes occur in glioma- 
 tous tumors. 
 
 Microscopically, it is difficult to distinguish a 
 glioma from a sarcoma unless a differential stain 
 has been employed. There is some doubt as to 
 the simultaneous occurrence of glioma and sar- 
 coma, the so called gliosarcoma, some authors be- 
 lieving this to be impossible, as the former is of 
 
141 
 
 ectodermal and the latter of mesodermal origin. 
 Others believe that by metaplastic processes a 
 sarcomatous structure may develop from neuro- 
 gliar tissue. According to certain pathologists, 
 a gliosarcoma should only be diagnosticated 
 where a sarcomatous, perivascular cellular mass 
 is found within a glioma. 
 
 It can readily be understood from the slow 
 growth and from its infiltrating character why 
 clinical symptoms of brain tumor do not always 
 appear, or not until late in the disease. Sur- 
 gically, it is difficult or even impossible to re- 
 move completely such a tumor. Sections made from 
 the specimens removed at the operation in Cases 
 I and II of Dr. Mills and Dr. Frazier showed a 
 glioma in each instance. 
 
 Sarcoma. — This form of brain tumor is about 
 as common as the glioma, although in our ex- 
 perience sarcomata have been more frequently 
 found. The growth may be small, flat, or nodu- 
 lar, or may be of large size. It is primary and 
 usually solitary. Sarcoma always grows from 
 the meninges, periosteum, or cranial bones, or 
 from the pial covering of the blood vessels. It 
 never grows from the brain substance, and there- 
 fore, unlike the glioma, it often compresses the 
 brain tissue and may be distinct from it, although 
 not infrequently it infiltrates the latter. Even 
 
142 
 
 when growing within the brain a distinct mar- 
 gin sometimes may be found, due to the softened 
 area surrounding it. It is usually harder in con- 
 sistency than a glioma, and is slow in its growth. 
 
 The tumor may soften or caseate. Myxoma- 
 tous, hemorrhagic, and cystic changes are not 
 uncommon. Cystic changes are especially com- 
 mon in the cerebellum, not only in sarcomata, 
 but also in gliomata. In one of Dr. Spiller's cases 
 small sarcomatous masses were found in the 
 walls of a cyst. If the fibrous tissue is very 
 marked we have a fibrosarcoma. 
 
 Sarcoma may manifest itself as a diffuse mul- 
 tiple sarcomatosis. In an excellent article Spil- 
 ler recorded two such cases and called attention 
 to the rarity of this disease. He quotes Schle- 
 singer, who subdivided the tumors under the 
 head of multiple sarcomatosis into 
 
 (a) Diseases of the nervous substance and 
 meninges, 
 
 (b) Multiple sarcomatosis of the membranes 
 without sarcoma of the brain or cord, when it is 
 (i) in the form of multiple small tumors, or (2) 
 a diffuse sarcomatous infiltration of the mem- 
 branes. 
 
 Of twenty cases recorded by Schlesinger, four- 
 teen implicated the brain and cord or their mem- 
 branes. " In nine of these fourteen cases cere- 
 
Pig. 1. — Sarcoma in left cerebellopontile angle. Small tumor in 
 right cerebellopontile angle does not show in photograph. 
 
145 
 
 bellar tumor was found, and in three the medulla 
 oblongata was affected. It appears, therefore, 
 that when the brain or its membranes are im- 
 plicated in sarcomatosis, usually the structures 
 of the posterior cranial fossa are affected, and 
 that in about two thirds of the cases a tumor of 
 the cerebellum is found." 
 
 In Spiller's first case a large sarcoma was 
 found in the left cerebellar lobe, and in his sec- 
 ond case a tumor was found in each cerebello- 
 pontile angle, the larger one being on the left 
 side, as shown in Fig. i. Tumors were also 
 found in this case in the Gasserian ganglia, pitui- 
 tary body, floor of the fourth ventricle, right in- 
 ternal auditory meatus, and right jugular fora- 
 men, and numerous small tumors were found in 
 the pia of the spinal cord. 
 
 It may be impossible, as in Spiller's second 
 case, to make a correct diagnosis in sarcomatosis 
 of the brain and of the pial covering. Extensive 
 alteration may cause few clinical symptoms, be- 
 cause the soft tumor masses grow in the pia and 
 about the cranial nerves and spinal roots, and 
 may produce little or no compression or destruc- 
 tion of the nervous tissue. Spiller insists upon 
 the importance of remembering this fact, for 
 when evidences of sarcomatosis are found, the 
 case is an inoperative one. 
 
146 
 
 Occasionally th^ process may invade the brain 
 substance, while the nerve roots may escape. It 
 is, according to Spiller, because of this escape of 
 the nervous tissue in many cases that a correct 
 diagnosis of the extent of the process may be 
 impossible. 
 
 The infiltration of the pia may resemble that 
 caused by syphilis or tuberculosis. Again, as in 
 Nonne's case, the macroscopical examination 
 may be normal. 
 
 Sarcomatous tumors, according to Westphal, 
 occur more often in the young. When tumors 
 occur in the posterior cranial fossa they have a 
 predilection for the cerebellopontile angle and 
 the internal auditory meatus. 
 
 Isolated sarcomata whether of the cere- 
 bellum or of any other region of the brain are, 
 next to fibromata, among the most favorable 
 forms of tumor for surgical removal. Of course 
 the question of multiple sarcomatosis must al- 
 ways be carefully considered when deciding upon 
 operation. With regard to surgical procedure 
 the hard non-infiltrating sarcomata are the most 
 favorable. Experience shows, however, that a 
 sarcoma which appears to be infiltrating when 
 the brain and tumor mass are first exposed, is 
 often separable from the brain substance. 
 
 Syphilitic Growths. — Gummata are rarely found 
 
147 
 
 post mortem, although they are possibly the most 
 common cranial growths. They are especially 
 rare in the cerebellum. The resemblance be- 
 tween this growth and tuberculoma has already 
 been discussed. In a recent article Mills recorded 
 two cases in which the diagnosis of a tumor in 
 the cerebellopontile angle was made. At the 
 necropsy no tumors were apparent, but micro- 
 scopically in the first case a diffuse syphilitic 
 basal meningitis was found and in his second 
 case besides a meningitis at the base, there were 
 numerous areas of softening throughout the 
 brain, extending from the gray into the white 
 matter. These areas of softening were yellow- 
 ish red in color, soft in consistence, and were 
 well defined from the surrounding brain sub- 
 stance. Microscopically, there was an intense 
 round cell infiltration about the blood vessels 
 and within the tissues. 
 
 These cases illustrate well the nature of syph- 
 ilitic new growths. It is well known that a syph- 
 ilitic basal meningitis, or meningoencephalitis, 
 may attack any cranial nerve or combination of 
 cranial nerves, but according to Mills they show 
 a predilection in favor of the nerves from the sec- 
 ond to the seventh inclusive, of these the fifth 
 perhaps most frequently escaping. 
 
 Syphilitic growths are rapid in development. 
 
148 
 
 but it must be remembered that the various path- 
 ological conditions which lead on to these 
 growths have been long present. 
 
 Fibromata. — These tumors are rare, but they 
 are relatively more frequent in the cerebellum 
 than in the cerebrum, and especially in the cere- 
 bellopontile angle. This has been better recog- 
 nized within the last few years, because of the 
 relatively successful surgical removal of tumors 
 growing in this area. 
 
 A fibroma invading the cerebellopontile an- 
 gle may be only a part of a general neurofibroma- 
 tosis ; this, however, is rare, or, what is more 
 common, it may be the only expression of this 
 process, a central neurofibromatosis. The growth 
 is slow, and generally is unilateral, although in 
 rare instances it may be present on both sides. 
 Henneberg and Koch pointed out that these tu- 
 mors are more often found on the left side in the 
 ratio of three to two. In the cases reported by 
 Dr. Mills, the pathological reports of which are 
 here given, the neoplasms were on the left side. 
 In an examination of the tumors situated in the 
 pons, medulla oblongata and the cerebellum, we 
 found that the majority were on the left side. It 
 seems, therefore, that tumors of these areas are 
 more prone to grow on the left side. 
 
 The fibroma may be as small as a cherry or 
 
149 
 
 the size of a large egg. The growth is firm, hard, 
 nodular, and has a distinct capsule surrounding 
 it. It is loosely attached to the brain by an 
 atrophic nerve trunk, a few blood vessels or a 
 meningeal process, and these attachments may 
 be easily ruptured. These tumors are in organic 
 relation, especially with the acoustic nerve, and 
 more rarely with the trigeminus and facial nerves. 
 They nearly always grow from the endoneurium 
 and rarely from the peri- or epineurium. Conse- 
 quently we may find medullated nerve fibres either in 
 the periphery of the tumor or in its centre. As 
 a rule, if the process involves the other cranial 
 nerves, we have a general neurofibromatosis 
 
 The fibroma may undergo a cystic, fatty, or 
 myxomatous degeneration. Very often in its ad- 
 vanced stages it may assume a sarcomatous tend- 
 ency. Histologically we find a connective tissue 
 structure with entire absence of nerve elements, 
 except sometimes a few medullated nerve fibres 
 either in the periphery or its central part. These 
 are remnants of the nerve on which the fibroma 
 grows and should not be mistaken for a part of 
 the new growth. Most writers persist in call- 
 ing these tumors neurofibromata. The best ex- 
 ample of a true neurofibroma is the amputation 
 neuroma, therefore, a fibroma would be a better 
 term for these growths. 
 
150 
 
 In a number of cases of fibroma of the acous- 
 ticus there were associated cortical changes. 
 Henneberg and Koch reported hyperplasia and 
 hypertrophy of the glia cells of the cortex, espe- 
 cially of the deeper layer, and in another case en- 
 dothelioma and psammomata of the dura mater. 
 Fraenkel and Hunt made a similar observation. 
 In another case reported by these authors there 
 were protrusions and minute hernise attached to 
 and sometimes perforating the dura. Histolog- 
 ically, these consisted of large cells of the spin- 
 dle type and of glia cells. 
 
 At times the fibromatous process may involve 
 the whole of the intracranial portion of the acous- 
 ticus. In a case of Alexander and v. Frankl- 
 Hochwart, an anatomical examination of the 
 labyrinth showed a degenerative atrophy of the 
 cochlear nerve, the spiral ganglion, the organ of 
 Corti, and the striae vasculares. 
 
 These tumors compress greatly the lateral 
 lobes of the cerebellum, the pons, and the medul- 
 la oblongata. In one of Dr. Mills's cases the 
 temporal lobe was compressed. Because of the 
 slow growth and the nature of the tumor, clinical 
 symptoms may not appear at all, or only late in 
 the disease. In one of Dr. Mills's cases there 
 were no symptoms of such a growth, the tumor 
 being found at necropsy. 
 
154 
 
 discussed when speaking of sarcoma. Other tu- 
 mors, as fibroma and carcinoma, are prone to un- 
 dergo cystic change, but more rarely. Some au- 
 thors believe that the whole tumor may disap- 
 pear and only a cyst remain. In other cases only 
 a microscopical examination will detect a small 
 tumor mass in the walls of the cyst. Spiller has 
 pointed out that the wall of a congenital cyst 
 may be the starting point for a neoplasm, and 
 this possibility should not be ignored. 
 
 The most common cystic changes found in 
 the brain are due to parasitic growth, the cysti- 
 cercus cellulosae and the ecchinococcus. These, 
 however, are so rare in this country that they will 
 not be here discussed. 
 
 Cysts due to traumatism are recorded, but 
 their genesis is by no means clear. Congenital 
 cysts are rare. They are probably offshoots of 
 the primary cerebral vesicles. Dermoid cysts 
 have been recorded as occurring in the cerebel- 
 lum in several instances. 
 
 Carcinoma. — Carcinoma of the cerebellum is 
 rare. This form of neoplasm is always second- 
 ary and grows from the dura or in the substance 
 of the brain. Saenger recorded infiltration of the 
 cerebral pia with cancer cells. The possibility 
 of toxic changes must be considered, as it is not 
 improbable that through intoxication caused by 
 
Fig. 3. — Fibroma growing in the left cerebellopontile angle com- 
 pressing the lower surface of the cerebellum and the left 
 side of the pons. 
 
157 
 
 a carcinoma elsewhere in the body, symptoms of 
 brain tumor may be present. 
 
 Osteoma. — In several instances an osteoma has 
 been described as occurring in the cerebellum. 
 It is probable that these growths are not pri- 
 marily of bone formation, but are the result of cal- 
 cification of such tumors as tuberculoma, fibroma, 
 sarcoma, and even lipoma. Other neoplasms, 
 as adenoma, lipoma, angioma, psammoma, and 
 cholesteatoma are hardly ever found in the cere- 
 bellum, so they will not be discussed. It must 
 also be remembered that aneurysm of the verte- 
 bral or basilar artery may give symptoms of cere- 
 bellar growth. 
 
 The Influence of Cerebellar Growths. — At the 
 operation when the dura is removed there is 
 nearly always increased tension and the parts 
 may bulge. The surface of the cerebellum is 
 flat and the fissures may be abolished. The pia 
 covering the neoplasm is generally poor in its 
 blood supply. The tissues near the growth may 
 be softened. If the tumor is in the lateral lobe of 
 the cerebellum it may compress the fifth, seventh, 
 and eighth cranial nerves. The occipital lobes 
 may even be compressed through the tentorium. 
 If the cerebellar tumor is large it may compress 
 the corpora quadrigemina, pons, and the medulla 
 oblongata, and these structures may be flattened 
 
158 
 
 or deformed. Pressure may also be exerted upon 
 the cranial nerves at the base of the brain. The 
 influence of cerebellopontile growths upon sur- 
 rounding structures has already been discussed. 
 
 The cerebrospinal fluid is almost always in- 
 creased in cases of cerebellar tumor, because 
 pressure is exerted upon the communication be- 
 tween the lateral ventricles and the fourth ven- 
 tricle, or upon the veins of Galen, which convey 
 the blood from the choroid plexus to the sinus 
 rectus. Because of this internal hydrocephalus 
 undue pressure is brought to bear upon the differ- 
 ent cranial nerves, as the optic and olfactory. 
 The optic chiasm may be directly compressed 
 through pressure from the third ventricle. 
 
 Alterations in the posterior roots and the pos- 
 terior columns of the spinal cord have been re- 
 corded as occurring in conjunction with tumors 
 of the brain. Such changes have been also found 
 by Dr. Spiller. According to Batten and Collier 
 they are especially present in cerebellar growths, 
 and are due to the increased pressure. Dinkier 
 and Becker believe that toxic or nutritional 
 changes are at fault. 
 
 Tumors of the Fourth Ventricle, Medulla Oblon- 
 gata, Pons, and Choroid Plexus. — It is not in the 
 province of this paper to consider in extenso neo- 
 plasms of these areas, but inasmuch as these 
 
159 
 
 growths sometimes give symptoms of cerebellar 
 involvement, they will be briefly considered. 
 
 Tumors of the fourth ventricle and of the me- 
 dulla oblongata may give no appreciable clin- 
 ical symptoms. They may either be cystic or 
 hard, and may grow in the substance of the me- 
 dulla oblongata. This is especially true of para- 
 sitic and congenital cysts. Hunt recorded two 
 congenital cysts of the fourth ventricle in which 
 the cerebellum was greatly compressed and yet 
 there were no cerebellar symptoms. 
 
 Neoplasms growing within or upon the cor- 
 pora quadrigemina nearly always compress the 
 middle or the lateral lobes of the cerebellum. 
 They also cause internal hydrocephalus. Two 
 such specimens are in our collection. 
 
 Tumors of the pons may cause pressure symp- 
 toms upon the cerebellum, or the growths may 
 involve the middle cerebellar peduncles. Growths 
 of the chorioid plexus, as in a case of Arnold's, 
 where a psammoma of the size of an apple was 
 found, may compress the pons, medulla oblon- 
 gata, and the cerebellum. 
 
 Tumors in the Cerebrum Giving Symptoms of 
 Cerebellar Growth. — Ascherson recorded an in- 
 stance in which a sarcoma was found in the cen- 
 trum ovale of the left side in the upper motor area. 
 This neoplasm measured i^ by 2^ inches, and 
 
160 
 
 could easily be enucleated. It caused a compres- 
 sion of the lateral ventricle in the same side. 
 This author cites Raymond as having recorded 
 an almost similar case. Ascherson is of the opin- 
 ion that the cerebellar symptoms were due to 
 pressure exerted through the lateral ventricle, 
 and he emphasizes the importance of early symp- 
 toms before those of pressure are apparent. In 
 this connection the fact that tumors of the post- 
 parietal cortex or subcortex, may give unilateral 
 ataxia should be borne in mind. The diagnosis 
 between post parietal and cerebellar tumors is 
 given in the paper of Dr. Mills. 
 
 Abscess. — Chronic otitis media is the most fre- 
 quent cause of abscess in the cerebellum. It 
 may be due to such other causes as traumatism 
 or may be a part of a general pysemic process, 
 but these instances are uncommon. The abscess 
 occurs mostly in the anterior outer part of the 
 cerebellum, and is generally single. It may in- 
 volve also the adjoining temporal lobe. The ab- 
 scess may be encapsulated or it may keep on 
 forming pus. Surrounding it, oedema and soft- 
 ening of the brain substance are found. Pus may 
 travel along the facialis and acousticus, and cause 
 extradural abscesses. Hydrocephalus, sinus 
 thrombosis, and thrombophlebitis are frequent 
 complications. 
 
161 
 
 Internal Hydrocephalus. — This condition is most 
 often caused by a brain tumor, but it may be 
 congenital or acquired. Spiller recorded an in- 
 stance in which the symptoms were those of 
 cerebellar tumor, and at the necropsy the cere- 
 bral ventricles were much distended, but the 
 fourth ventricle was of normal size. The aque- 
 duct of Sylvius was almost entirely occluded 
 when examined, and the occlusion must have 
 been congenital or have occurred early. Byrom 
 Bramwell recorded a similar case, but here a 
 localized meningitis caused a closure of the fora- 
 men of Magendie. The possibilty of internal 
 hydrocephalus should always be kept in mind 
 when a cerebellar growth is considered. 
 
 Symptoms of Cerebellar Tumor Without Lesions. 
 — In a very important paper, Nonne called atten- 
 tion to those cases in which the majority of the 
 symptoms of brain tumor were present, and in 
 which either spontaneously or under mercurial 
 treatment the symptoms disappeared, leaving, 
 perhaps, a partial optic nerve atrophy. There 
 was no reason in any of the eight clinical cases 
 he reported to suspect syphilis. 
 
 He also records three similar cases with ne- 
 cropsy, in two of which symptoms of a tumor in 
 the posterior cranial fossa was diagnosticated. At 
 the necropsy in the first case, internal hydro- 
 
162 
 
 cephalus was found. On the floor of the fourth 
 ventricle, opposite the posterior medullary velum, 
 there was a hard, long, yellowish white struc- 
 ture, which obstructed the flow of the cerebro- 
 spinal fluid. Microscopically this was found to 
 be a fibroma. In his second case, internal hydro- 
 cephalus was also found, this being caused by a 
 sarcoma of the ependyma of the floor of the 
 fourth ventricle. 
 
 He further records three cases with necropsy 
 in which there was no internal hydrocephalus. 
 Nonne also reports cases of internal hydro- 
 cephalus which gave largely basal symptoms due 
 to various causes, and which terminated either 
 in death or recovery. He leaves us in doubt as 
 to what is the cause of such a condition. 
 
 Dr. Spiller has very kindly given me the rec- 
 ords of such a case occurring in his service. 
 
 Woman, 44 years of age, domestic, past his 
 tory unimportant. Two and one half years age 
 the patient began to have violent headache in 
 the left cerebellar region. This headache became 
 more severe and became localized in the left 
 parietal region, where there was also great ten- 
 derness to pressure. She had an ataxic, drunken 
 gait, and would fall to the left or backwards 
 when walking. Extreme vertigo was also pres- 
 ent, especially when she was lying on her left 
 side or walking. Power was diminished in the 
 
163 
 
 lower limbs and sensation was also somewhat 
 impaired. The patellar jerks were absent. There 
 was no albumin in the urine. 
 
 Dr. Roberts operated at the point of great ten- 
 derness in the left posterior parietal region. 
 There was nothing abnormal found and the 
 brain appeared to be in a healthy condition. 
 
 The patient's symptoms steadily disappeared, 
 the pain in the head became better and in a 
 short time she seemed almost well. 
 
 Another case was studied by me repeatedly. 
 
 This woman was in the nervous wards of the 
 Philadelphia General Hospital in the service of 
 Dr. Spiller. She was 52 years of age, denied 
 venereal history, and her past history was unim- 
 portant. Five years ago she began to have vio- 
 lent vertical headache, which has persisted more 
 or less since. One year ago she began to have 
 objective vertigo, and convulsions, Jacksonian in 
 type, which always involved the left side of the 
 face, and the left arm and leg. Sight also became 
 poor at that time, and her memory was not as 
 good as formerly. In my examination she 
 showed a paresis of the left arm and leg, these be- 
 ing spastic, and the reflexes were exaggerated. 
 The Babinski sign was present on this side. 
 There was also a paresis of the lower distribu- 
 tion of the left seventh nerve, and a paralysis 
 of the left abducens and the left fifth nerve, both 
 in its motor and sensory distribution. Optic 
 neuritis was present in both eyes. 
 
164 
 
 On protruding her tongue she had a clonic to 
 and fro movement which became apparent on 
 talking or moving the tongue. She became stead- 
 ily worse and finally was comatose. The urine 
 examination was negative. She rallied, however, 
 her symptoms steadily disappeared and she was 
 discharged from the hospital four months after- 
 wards, the only remaining symptom being a 
 dimness of vision. 
 
 These two cases are similar to those recorded 
 by Nonne. No adequate explanation for them 
 can be given. 
 
 Lesions of the Cerebellum Without Symptoms. — 
 These lesions may be either congenital, acquired 
 early in life, or may be tumors. It is not sur- 
 prising that injuries to the cerebellum early in 
 life or that tumors of slow development which 
 occur in the same period give no appreciable 
 symptoms, because the functions of the cerebel- 
 lum in such cases have probably been assumed 
 by other parts of the brain. Lesions of the lat- 
 eral lobes of the cerebellum are less liable to 
 cause symptoms than when the)'' implicate the 
 entire cerebellum. Spiller recorded three cases 
 of lesion of the cerebellum in which there were 
 no symptoms, and he also reviewed the litera- 
 ture upon this subject. In his first case one cere- 
 bellar lobe was smaller than the other, and it was 
 sclerotic. In the second case there was a tumor 
 
165 
 
 upon the corpora quadrigemwia in which the lat- 
 eral lobe of the cerebellum was compressed. The 
 third was one of tumor within the vermis. 
 
 Cases are recorded in which tubercles in- 
 volved an entire lateral lobe and gliomata and 
 cysts occupied the middle lobe, and yet there 
 were no symptoms. Oppenheim refers to a case 
 of Putnam's, where the only symptom for years 
 was an optic nerve atrophy, in which at necropsy 
 a cyst of the cerebellum was found. He also re- 
 fers to Bramwell's case, where in a thoroughly 
 studied case no symptoms were apparent, while 
 at necropsy four tumors were found. 
 
 It can readily be understood why symptoms 
 may not be apparent in a gliomatous tumor, be- 
 cause of its infiltrating character, and in tuber- 
 cles, in which the axis cylinders are retained ; but 
 it is difficult to explain the absence of symptoms 
 in the other instances. 
 
 The notes of the case of cerebellopontile tumor, 
 as shown in the illustration. Fig. 3, and Case II of 
 this paper, were furnished by Dr. Mills. The pa- 
 tient was seen by Dr. Mills in consultation with 
 Dr. W. W. Keen ; she was also examined in con- 
 sultation by Dr. W. G. Spiller. The tumor sprang 
 from the eighth nerve, and the chief focal symptoms 
 were one sided deafness, tinnitus, facial monospasm, 
 hypsesthesia of one side of the face, nystagmoid 
 
166 
 
 movements, slight paresis of right abducens, and 
 vasomotor and cardiac disturbances. Severe 
 headache, nausea, vomiting, and optic neuritis 
 were also present. 
 
 This patient was a married woman, 30 years 
 of age, five of whose maternal relatives had died 
 of cancer. Four years before coming under ob- 
 servation the ossicles of her left ear were re- 
 moved, on account of an annoying tinnitus, but 
 without the desired result. About one year later 
 she began to suffer from severe headache. The 
 next year slight optic neuritis was observed in 
 both eyes, the neuritis going on to atrophy and 
 blindness, which was complete in less than two 
 years. Headache, nausea, vomiting, and depres- 
 sion were recurring symptoms, and taste and 
 smell were impaired. During two or three years 
 she was treated for various complaints as anaemia 
 and neurasthenia, and both Graves's disease and 
 interstitial nephritis were suspected. About six 
 months before coming under observation she 
 had a convulsion with loss of consciousness, this 
 being followed by several others of a similar 
 kind. 
 
 The patient was having at somewhat frequent 
 intervals attacks beginning with pain in the head, 
 which was referred to the forehead and eyes.. In 
 these she became nauseated and then vomited, 
 becoming pale or even cyanosed, with loss of 
 consciousness. The vomiting was preceded or 
 accompanied by marked facial monospasm, in 
 
167 
 
 which the mouth was drawn forcibly to the left 
 and the eyelids were drawn together. Only the 
 left side of the face was involved in the seizure. 
 Examination showed that she had no ataxia of 
 station or gait. Hearing on the right side was 
 good, on the left side it was abolished. The 
 mouth deviated slightly to the left when opened 
 widely. Hypassthesia to pain was present on the 
 left side of the face and head, and sometimes ap- 
 peared to be present in the left hand. The pa- 
 tient was not mentally impaired, but was easily 
 exhausted mentally, and was at times irritable 
 and depressed as the result of her sufferings. 
 During the time she was under observation she 
 had frequently recurring headaches, usually se- 
 vere, sometimes accompanied with nausea or even 
 vomiting, and sometimes with the facial spasm 
 already described. Irregular nystagmoid move- 
 ments occurred when the patient turned the eye- 
 balls to the extreme right or left. She had com- 
 plete loss of smell, and loss of taste on the left 
 side of the tongue. On one occasion it was 
 thought that the facial spasm was accompanied 
 by some spasmodic movements of the left hand, 
 but this was doubtful, and even the observer 
 thought it may have been a voluntary movement. 
 The question of the existence of exophthalmic 
 goitre was one which arose for diagnostic dis- 
 cussion several times during the history of this 
 case. The diagnosis of this affection was first 
 made a year or two before coming under our ob- 
 servation. It was also considered and favorably 
 regarded by some of those who saw her in con- 
 
168 
 
 sultation late in the case. Her eyes had some- 
 what the staring expression of the blind; they 
 were rather large, but her relatives stated that 
 she had always had prominent eyes, and the ex- 
 ophthalmos was apparent rather than real. The 
 enlargement of the thyreoid was so doubtful as 
 to cause some disagreement among those who 
 examined her as to its existence. A slight en- 
 largement of the gland on one side seemed some- 
 times to be present. Her pulse frequently, per- 
 haps usually, was between loo and no, and some- 
 times rose above the latter point. It was a pulse 
 such as is not infrequently seen in the late stages 
 of an exhaustive intracranial disease. Graves's 
 disease was finally excluded. In the light of the 
 post mortem findings, it is not improbable that 
 some of the symptoms simulating this affection 
 were due to the tumor, from its position, causing 
 vasomotor and cardiac disturbances. 
 
 Ocular and ophthalmoscopic examinations 
 were made by Dr. W. C. Posey, who reported 
 as follows: Ocular movements good in all direc- 
 tions, except externally to the right, where there 
 is a slight limitation of movement, the right eye 
 not being brought as far as normal into the ex- 
 ternal canthus. On fixation in the median line 
 and below, the eyeballs are quiet. Marked lat 
 eral nystagmic movements appear, however, as 
 soon as the eyes leave these primary positions, 
 the nystagmus being most marked on extreme 
 outward rotation to the right and to the left. 
 The pupil in the right eye is round, and is 5 mm. 
 in size; that in the left eye is oval, 3 by 4 mm., 
 
169 
 
 with its long axis at 50°. The irides do not 
 respond to light or accommodation stimuli. The 
 ophthalmoscopic examination reveals clear media 
 in each eye, with the signs of regressive optic 
 neuritis. The swelling of the nerves, however, 
 is still very marked, both papillae projecting into 
 the fundi to the extent of 2 or 3 mm. The 
 nerves are gray and succulent looking, and the 
 retinal arteries and veins are tortuous and cord 
 like. One nerve is not more swollen than the 
 other. There are no extravasations or haemor- 
 rhages, or traces of either of these in the fundi. 
 The patient is totally blind. 
 
 Other examinations were made by Dr. Posey, 
 but they did not demonstrate anything different 
 from what is above recorded. 
 
 Eventually an operation was performed in this 
 case by Dr. W. W. Keen, by whom the patient 
 was seen in consultation with Dr. Mills. Al- 
 though a tumor at the base was considered, it was 
 thought for several reasons that the lesion was 
 probably in or beneath the facial centre. In the 
 first place sufficient consideration was not given 
 to the tinnitus and deafness. Owing to the fact 
 that a peripheral operation had been performed 
 early for the relief of the latter, it was supposed 
 that the impairment and disturbance of hearing 
 were due to causes which were at least in part 
 peripheral. The facial monospasm was much like 
 that which is observed in the case of subcortical 
 or cortical growth. It is interesting to note that 
 some disease of the cortex was present at the 
 position of the trephining, as demonstrated at 
 
170 
 
 the necropsy, but no tumor was found here. The 
 patient died a few hours after the operation. 
 Bibliography. 
 
 Schuster. Psychische Storungen bei Hirntumoren, Stutt- 
 gart, 1902. 
 
 Raubitschek. Wiener klin. Wochenschrift, September 29, 
 1904. 
 
 Oppenheim. Die Geschwiilste des Gehirns, Wien, 1902, 
 page 6. 
 
 Spiller. American Jour, of the Med. Sci., February, 1904, 
 page 16. 
 
 Spiller. American Jour, of the Med. Sci., July, 1903. 
 
 Mills. University of Pennsylvania Med. Bulletin, May, 
 1904. 
 
 Henneberg and Koch. Archiv. f. Psychiatric, Vol. 
 XXXVI, No I, page 51. 
 
 Fraenkel and Hunt. Medical Record, December 26, 1903. 
 
 Alexander and v. Frankl-Hochwart. Obersteiner's Ar- 
 beiten, Vol. XI, 1904, page 385. 
 
 Spiller. University of Pennsylvania Med. Bulletin, June, 
 1901, page 13. 
 
 Saenger. Neurolog. Centralblatt, 1901, page 188. 
 
 Batten and Collier. Brain, 1899. 
 
 Dinkier. Zeitschrift fUr Nervenheilk., Vol. VI. 
 
 Hunt. American Jour, of the Med. Sci., March, 1904. 
 
 Ascherson. Lancet, September 10, 1904, page 759. 
 
 Spiller. American Jour, of the Med. Sci., July, 1902. 
 
 Bramwell. Brain, Spring, 1899, Vol. XXII, page 66. 
 
 Nonne. Deutsche Zeitschrift fUr Nervenheilk., Vol. 
 XXVII, Nos. 3 and 4. 
 
 Spiller. University of Pennsylvania Med. Bulletin, June, 
 1904. 
 
 Oppenheim. Loc. cit., page 156. 
 
THE FUNCTIONS OF THE CEREBELLUM. 
 By EDWARD LODHOLZ, M. D., 
 
 PHILADELPHIA, 
 DEMONSTRATOR OF PHYSIOLOGY, UNIVERSITY OF PENNSYLVANIA. 
 
 Probably there is no part of the nervous system 
 that differs more in size and functional importance, 
 in closely allied species, than the cerebellum. Its 
 development depends to a great extent upon the 
 means of orientation of the animal. Reptiles pos- 
 sess a cerebellum functionally less active than 
 swimmers, and in these it is less developed than in 
 birds. Indeed in this animal which is capable of 
 going through the most complicated movements of 
 all animals the cerebellum is relatively enormous. 
 However, the size is not always proportionate to 
 the variety of movements. In the frog, which is 
 capable of complex coordination, the cerebellum is 
 relatively small. It is an unexplained anatomical 
 fact that in birds the lateral lobes are absent, where- 
 as in apes and man they are quite large. 
 
 Possibly no one has given so much impetus to 
 the study of this part of the nervous system as 
 Flourens ( i ) , Practically all his experiments were 
 performed upon pigeons, animals which show 
 marked effects following the removal of parts of 
 the cerebellum. Many of the phenomena here ob- 
 
172 
 
 served can be of but comparative interest to the 
 student of human physiology. For this reason the 
 work of Luciani has done much to further our 
 knowledge of the function of the human cerebellum. 
 He experimented upon dogs and monkeys, animals 
 in which the cerebellum is more closely allied to the 
 human cerebellum than that of pigeons. 
 
 So early as 1809 Rolando (2) removed portions 
 of the dog's cerebellum, and several other physiol- 
 ogists studied the mammalia previous to Luciani's 
 time, but none was able to surmount the tremen- 
 dous technical difficulties necessary, for instance, to 
 remove the whole cerebellum and keep the animal 
 alive for a considerable period after the opera- 
 tion. 
 
 Luciani (3) showed the immediate symptoms 
 differed very much from those which subsequently 
 developed. If the narcosis is not too deep, and the 
 loss of blood inconsiderable, the more important 
 symptoms which immediately follow removal of the 
 cerebellar cortex, are extreme restlessness ; pleuro- 
 thotonos, the concavity being toward the operated 
 side; tonic stretching of the fore extremity on the 
 homonymous side ; clonic contractions of the other 
 three extremities ; and spiral twisting of the neck 
 with the head turned toward the well side. Nystag- 
 mus and strabismus are present, the eye of the 
 side operated upon being drawn down and inward, 
 
173 
 
 that of the well side up and out. If the animal at- 
 tempts to stand, he falls to the side of the lesion 
 and rolls in the same direction. 
 
 When the whole cerebellum is removed there is 
 marked restlessness and irritability of the animal; 
 the head is drawn back, and the animal tends con- 
 stantly to move or fall backwards. There is con- 
 vergence of the eyeballs. If the wound remains 
 aseptic these symptoms last from eight to ten days 
 when they generally ameliorate, the tonic spasms 
 become clonic or oscillatory, the animal is able 
 to walk with less difficulty, and the tendency to roll 
 from side to side or fall backward is less marked. 
 Long before the animal learns to walk he is able to 
 swim. This fact, first described by Luciani, has 
 great physiological importance. The last symptom 
 to disappear is opisthotonos. 
 
 The symptoms which occur with constancy after 
 removal of the cerebellum give us but little infor- 
 mation as to the exact role this part of the nervous 
 system plays in the intact cerebrospinal axis. 
 Wundt states that " the functions of the cerebellum 
 belong to the darkest part of the central nervous 
 system." The truth of this statement becomes more 
 apparent when the multitudinous connections of the 
 cerebellum with other portions of the brain and 
 spinal cord are considered. 
 
 The old idea that the cerebellum has distinct 
 
174 
 
 functions independent of its connection with the 
 rest of the cerebrospinal axis is rapidly disappear- 
 ing. 
 
 The centre for coordination has been located in 
 the cerebellum by Flourens, and the symptoms 
 which follow ablation of a part, or the whole of the 
 cerebellum seem to substantiate this assertion. How- 
 ever, cases have been recorded in which a large 
 portion was congenitally absent associated with 
 normal ability to execute coordinate movements. 
 
 Total ablation in animals is always followed by 
 an amelioration of the symptoms after varying in- 
 tervals of time, and eventually incoordination en- 
 tirely disappears. 
 
 When the cerebellum is inactive it appears that 
 cells in other parts of the nervous system are 
 capable of performing the functions normally as- 
 signed to the cerebellar cells. The experiments of 
 Ewald (4) and Luciani confirm this statement. 
 They demonstrated that if compensation was com- 
 pletely established after partial cerebellar destruc- 
 tion, a return of symptoms would appear if certain 
 cerebral motor areas were destroyed. The symp- 
 toms never reappear after the second operation. 
 
 A close functional relation has been found to exist 
 between the semicircular canals and the cerebellum. 
 Total destruction of the canals is followed by symp- 
 toms identical with cerebellar ablation. Stef ani ( 5 ) 
 
175 
 
 found degeneration of Perkinje's cerebellar cells 
 after removal of the semicircular canals. From 
 this the inference may be drawn that the canals are 
 the peripheral organs and the cerebellum is the 
 centre. Lange, a student of Ewald, found when 
 the semicircular canals were removed from a de- 
 cerebellarized animal, in which full compensation 
 had been established, that the characteristic symp- 
 toms appeared such as are observed in a normal 
 animal following destruction of the canals. Stefani 
 concludes that the semicircular canals functionate 
 not only through the cerebellum, but also through 
 other parts of the nervous system. Luciani thinks 
 these, and other experiments, disprove the belief of 
 Magendie (6) that the cerebellum is the centre of 
 static and dynamic equilibrium. He believes it does 
 play an important role in the maintenance of equili- 
 brium, and agrees with Galio (7) that we move in 
 space by the aid of impulses coming from the special 
 senses. 
 
 The results obtained from excitation of the cere- 
 bellar surfaces have added to some extent to our 
 knowledge of the influence of the cerebellum upon 
 nervous activity. It is a mooted question whether 
 ablation produces symptoms the result of stimulation 
 consequent to the trauma of the operation, or pa- 
 ralysis due to destruction of the cells. Ferrier (8) 
 showed that unilateral burning of the cerebellum 
 
176 
 
 produced symptoms on the opposite side of the 
 body to those following ablation. But this method 
 is unscientific, for it is impossible to determine 
 whether symptoms are due to stimulation or de- 
 pression. 
 
 Electrical stimulation properly applied eliminates 
 depression as a factor. A recent work by Lewan- 
 dowsky (9) has shown that the electrical current 
 produces results differing from those following 
 ablation. When weak currents were applied to the 
 cerebellum the following symptoms were noted: 
 Restlessness; evidences of vertigo; lateral move- 
 ments of the head ; or the animal assumed a recum- 
 bent position and placed the head between the front 
 paws. Strong currents caused curvature of the 
 spinal column, when the left side was stimulated 
 the concavity was toward the right side, the dog 
 always fell toward the right. Occasionally nystag- 
 mus was observed. When the current was broken 
 the movements occurred on the other side, but were 
 decidedly weaker. It will be noticed, as Lewan- 
 dowsky states, that the symptoms following stimu- 
 lation are on the opposition side of the body to that 
 produced by ablation. 
 
 Sherrington (10) reports a very interesting 
 phenomenon following stimulation of the cerebellum. 
 He discovered in decerebrate rigidity, a condition 
 of long maintained muscular contraction following 
 
177 
 
 removal of the cerebral hemispheres, that inhibition 
 can be produced by excitation of the anterior (cere- 
 bral) surface of the cerebellum. He demonstrated 
 that faradaization caused a relaxation of the muscles 
 of the neck, head, and lower limbs, especially on the 
 same side. He concludes that stimulation of the 
 cerebellum " cannot only excite contraction of the 
 muscles, but can inhibit contraction." However, 
 the exhaustive studies in cerebellar ablation and 
 stimulation have not given us very satisfactory 
 knowledge of how this organ normally functionates, 
 although many errors have been corrected and new 
 facts added. 
 
 The teaching of the Gall school that the cerebel- 
 lum has a sexual function has been disproved by 
 Bouillaud, Luciani, and others. These investiga- 
 tors demonstrated that impregnation and birth of 
 offspring would occur in an animal from which the 
 whole cerebellum was removed. 
 
 Flourens was the first to locate in the cerebellum 
 the centre for coordinated movements. 
 
 Luciani demonstrated that coordinated move- 
 ments returned in animals from which the cerebel- 
 lum had been removed. 
 
 The teaching of Rolando that the cerebellum was 
 essentially motor has been modified by Dalton ( 1 1 ) , 
 Luys (12), Mitchell (13), and Luciani. These au- 
 thors consider it an organ in which motor impulses 
 
178 
 
 are strengthened. Removal of the organ causes 
 muscular weakness, which was described by 
 Luciani as due to three factors: Asthenia (weaken- 
 ing of muscular energy), atonia (lessening of mus- 
 cular tone), and astasia (uncertain and unsteady 
 movements). 
 
 That asthenia is present is shown by the fact that 
 animals with unilateral ablation swim toward the 
 crossed side, but walk toward the same side. 
 Astasia is represented by the intention tremor which 
 develops at varying lengths of time after removal 
 of either part or whole of the cerebellum. Atonia 
 can be readily detected by the feebleness of the 
 muscles which becomes manifest after the disappear- 
 ance of the primary spasm. 
 
 Many physiologists have defended the theory of 
 Lussana (14) that the centre for muscle sense is 
 located in the cerebellum. The vertigo frequently 
 present suggests a sensory function. But human 
 beings with atrophy of the cerebellum still possessed 
 a normal amount of muscle sense. Luciani's care- 
 ful work has gone far to disprove the existence 
 of such a centre in the cerebellum. The the- 
 ories advanced to explain the normal func- 
 tions seem too inadequate to account for all the 
 phenomena. It appears conclusive that the cere- 
 bellar cells are continually exerting an influence 
 upon other nerve centres, but with reference to the 
 
179 
 
 true nature of this action nothing is known with 
 
 certainty. 
 
 References. 
 
 1. Flourens, Recherches experimentales sur les proprie- 
 tes et les fonctions du systeme nerveux, Paris, 1824 and 
 1842. 
 
 2. Rolando, Saggio sopra la vera struttura del cervelle, 
 Turin, 1823. 
 
 3. Luciani, Ergebnisse der Physiologie (Asher and 
 Spiro), 1904, 2 Abth, s. 260. 
 
 4. Ewald, Untersuchungen uher den Endorgan des N. 
 octavus, Wiesbaden, 1892. 
 
 5. Stefani, Arch. ital. di biol., XXX, 2, page 235. 
 
 6. Magendie, Precis elementaire de physiologie, Paris, 
 1823. 
 
 7. Galio, Arch. ital. di biol., XXXVIII, 3, page 383. 
 
 8. Ferrier, see Luciani, Biol. Zentralbl, XV, 9 and 10. 
 
 9. Lewandowsky, Arch. f. Anat. und Phys., phys. Abth., 
 1903, page 132. 
 
 10. Sherrington, Jour, of Phys., Vol. XXII, page 319. 
 
 11. Dalton, Amer. Jour, of the Med. Sci., 1861, page 83. 
 
 12. Luys, Arch, gener. de mid., 1864, page 385. 
 
 13. Weir Mitchell, Amer. Jour, of the Med. Sci., 1869, 
 page 320. 
 
 14. Lussana, Jour, de la physiologie, 1862, page 418. 
 
 A complete bibliography of this subject is given by 
 Luciani, Ergebnisse der Phys. (Asher and Spiro), 1904, 
 s. 210. 
 
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 Xmaors of the cerebellum.