Reprint Albany Medical Annals, May, 1888. 
CLINICAL REPORTS. 
I. 
TWO CASES OF TUMOR OF THE CERE- 
BELLUM. 
By HENRY HUN, M.D., 
Professor of Diseases of the Nervous System and of Psycho- 
logical Medicine in the Albany Medical College. 
ALBANY, N. Y., 
Case I.-January 2, 1886. F. P., aet. 
48. Male. Married. Piano varnisher. 
Just before coming to this country, four- 
teen years ago, he served in the Franco- 
Prussian war, and previously in the Aus- 
trian war, and it is to the hardships suf- 
fered in these wars that he attributes his 
sickness. Since coming to this country 
he has never been well. At first he 
was troubled with hemorrhoids, for which 
he has undergone surgical operations on 
three different occasions; the first about 
ten, the last about seven, years ago, and 
since the last operation he has not been 
troubled by them at all. Ten or eleven years ago he acted strangely for a couple 
of weeks and imagined that people were 
conspiring against him. For a number 
of years past he has had occasional at- 
tacks of severe headache, vertigo, loss of 
memory, distress after eating and consti- 
pation. His head always feels worse 
when he is constipated. He has always 
been accustomed to take long walks, and 
he walks perfectly erect and straight. 
He has worked up to the present time, 
but he has been taking medicine steadily 
for the past fourteen years, and gives the 
impression of being hypochondriacal. 
He is a large, strong man. There is no 
paralysis of motion nor sensation and no 
trace of ataxia. Eyes were not examined 
ophthalmoscopically. Urine contains 
neither albumen nor sugar. Thoracic 
and abdominal examination gives nega- 
tive results. 
February 13. He grew steadily and 
rapidly worse. He was greatly troubled 
by vomiting, vertigo, and headache which 
he was unable to localize. He ate very 
little. His memory was almost com- 
pletely lost, and at times he was delirious. 
He was not confined to his bed until the 
2 3 
last week of his life, and up to that time 
he walked steadily and showed no signs 
of ataxia, even when his eyes were shut. 
Towards the end of his life he complained 
more of vertigo than of headache, and 
when compelled to sit up in bed he held 
his head with both hands on account of 
the vertigo. He became drowsy, then 
comatose, and died to-day. 
Autopsy held twenty eight hours after 
death. Head, only, examined. The 
bones of the entire skull are extremely 
thin ; the course of the arteries is marked 
by deep grooves; the pacchionian bodies 
have made such deep holes that the bone 
is almost perforated, and the roof of the 
orbit is exceedingly thin, transparent, 
and easily breaks down nnder the point 
of the knife. Dura mater and pia mater 
normal. No increased amount of sub- 
arachnoid fluid and no decided flattening 
of the convolutions. Cerebral substance 
oedematous. All the ventricles of the 
brain are much dilated and are filled with 
a fluid of normal appearance. Cortex 
and ganglia at the base of brain appear 
normal. Right hemisphere of the cere- 
bellum is larger than the left, and pre- 4 
sents fluctuation. On section the right 
hemisphere of the cerebellum is found to 
be reduced to a thin shell, its whole inte- 
rior consisting of a cyst containing clear 
light yellow fluid. The wall of the cyst 
is smooth, and the cyst-cavity is trav- 
ersed by no septa. At one edge there is 
a nodule of deeply congested tissue or a 
hemorrhage. The left hemisphere and 
the body of the cerebellum, as well as its 
peduncles, appear normal. 
A microscopic examination failed to 
reveal the exact nature of the cyst. 
Neither rhe fluid in the cyst, nor the 
cyst-wall, exhibited any thing character- 
istic of echinoccocus or cystocercus ; and 
sections through several parts of the 
cyst-wall and neighboring tissue showed 
no signs of sarcoma, glioma, or any other 
new growth. The cyst-wall was formed 
by the normal cerebellar tissue decidedly 
compressed. It appeared most probable 
that the cyst was due either to hemor- 
rhage or to an occlusion of an artery 
which had occurred a long time ago. 
In this case the appearance of the cyst, 
the general thinning of the bones of the 
skull, and the symptoms of the patient, 5 
all indicate that the lesion had been in 
existence for a long time, and it is not 
improbable that it had its origin eleven 
years ago when he acted as if he were 
insane for a short time. It shows, then, 
that an extensive lesion of a hemisphere 
of the cerebellum may be in existence 
for years and yet produce only vague and 
ill-defined symptoms. It is true that the 
cerebellum is the great co-ordinating cen- 
tre of the body, and that lesions of it 
frequently cause characteristic and exten- 
sive disturbances of co ordination, but 
these occur only when the body of the 
cerebellum is implicated, and it is well 
known that lesions of the cerebellar 
hemispheres may produce no symptoms 
whatever. Such lesions, however, very 
frequently give rise to a secondary hydro- 
cephalus, with general dilatation of the 
cerebral ventricles, as occurred in this 
case; and to this secondary hydrocepha- 
lus were probably due the the more vio- 
lent symptoms which came on during the 
last few weeks of life and which termi- 
nated in coma and death. 
Case II.-September 20, 1886. Gf. S., 
get. 16. Female. About the middle of last July the patient began to be troubled 
by severe headache, which, however, did 
not prevent her working. After the 
headache had continued several days, 
she suddenly had an epileptoid attack, 
and afterwards she was unable to walk, 
and her eyesight began to fail rapidly. 
She entered the hospital to-day. On en- 
trance her eyesight is much impaired, 
although she can recognize faces and can 
see large objects ; her manner of walking 
is awkward and unsteady, which seems 
to be due, in part, at least, to her blind- 
ness. There is no paralysis of any mus- 
cle. Sensation is everywhere perfect, as 
are also her hearing, taste and smell. AH 
the reflexes, superficial, deep and organic, 
are normal. No aphasia nor mental dis- 
turbance. The strength of her arms and 
legs is good. She can stand on either 
leg. On ophthalmoscopic examination, 
both eyes are found to present typical 
specimens of choked discs, with much 
oedema and extensive neuritis. 
October 20. Has remained in about 
the same condition, except that she has 
become somewhat weaker. She has fre- 
quent attacks of vomiting, not dependent 
6 7 
upon food, and has had a frontal head- 
ache, which has steadily grown more 
severe, and for the relief of which she 
requires constantly increasing doses of 
morphine. There is still no trace of any 
paralysis of motion or sensation, and the 
reflexes are normal. She is almost en- 
tirely blind. 
- November 20. The headache has been 
intense during the past month, so that 
she has been kept under the influence of 
morphine. Yesterday she had a general 
convulsion, the first since entrance. The 
vomiting continues. Within the past 
few days there has appeared an abso- 
lute paralysis of both abducens nerves, 
with the consequent convergent squint 
and inability to turn either eyeball out- 
ward beyond the median line. There is 
no other paralysis, except that from the 
time of entrance both pupils have been 
widely dilated and respond very slightly 
and sluggishly to light. No trace of any 
facial paralysis. The patient is so weak 
that she is confined to her bed. 
December 10. Patient is entirely 
blind. She is very weak, but she can 
move her arms and legs fairly well in bed. 8 
Hearing, taste, smell and cutaneous sen- 
sibility of all kinds are normal. There 
is no muscular paralysis, except that of 
the abducens muscles. Since the last 
record she has had little or no headache, 
and has required no morphia. She has 
had many convulsions, which are of 
short duration, are bilateral, and seem to 
consist mostly of tonic spasm. She vom- 
its frequently. Lately she has passed 
urine and fasces in bed, and during the 
past week or two there has been much 
offensive discharge from the vagina. 
December 18. During the past two 
months the patient has complained 
greatly of dizziness whenever she has sat 
up. The headache of which she com- 
plained so much was general over the 
head, and especially frontal, but she has 
not complained of it lately. There has 
been at times much spasm of the muscles 
of the neck. During the past week the 
nurse has noticed that she rubbed her 
genitals much, but previously the nurse 
had noticed nothing like masturbation. 
She has not menstruated since she has 
been in the hospital, although she said 
that she had done so previously. Lately 9 
she has failed steadily, and died this 
evening. She was conscious almost up 
to the time of her death. 
December 20. Autopsy held thirty- 
six hours after death. General emacia- 
tion. Dura mater but slightly adherent 
to scull cap. Dura mater and pia mater 
normal. Very little sub-arachnoid fluid 
on surface of brain, but an increased 
amount at base. Convolutions slightly 
flattened. Corpus callosum much thinned. 
All the ventricles of the brain uniformly 
and greatly dilated. Cortex and medul- 
lary substance and ganglia at base of 
cerebral hemispheres entirely normal, 
except for some oedema and unusual 
prominence of puncta vasculosa. The 
left hemisphere of the cerebellum is in 
great part replaced by a tumor. This 
tumor apparently commenced at the outer 
part of the cerebellar hemisphere, and 
had extended inwards, destroying the 
cerebellum ; so that now the outer half 
or two-thirds of the left cerebellar hemis- 
phere is replaced by the tumor, which is 
a hard, whitish growth. The whole inte- 
rior of the tumor is broken down into a 
soft, creamy mass, and the adjoining part 10 
of the cerebellum is softened, so that 
there is no very sharp line to be drawn 
between the softened cerebellum and the 
tumor. The body of the cerebellum is 
not involved, and there is no apparent 
degeneration of the peduncles. On the 
inner surface of the skull, pressing 
against the tumor and at the point where 
the growth probably commenced, is a 
small but very sharp osteophyte. 
Upper lobe of lungs are very anaemic, 
the lobes being the seat of hypostatic 
congestion. Heart normal, except that 
two of the semi-lunar valves are adher- 
ent at the contiguous part of their free 
edge, so that they are converted into one 
long valve. Liver, spleen and kidneys 
are normal. There are no adhesions nor 
signs of pelvic peritonitis. The ovaries 
are two or three times the normal size 
and of white color. They seem to be 
sacs with a very thick wall, and appear 
to be examples of chronic interstitial 
oopheritis. The vagina is greatly dis- 
tended by a large quantity of thin yellow 
pus. The walls of the vagina are deeply 
congested and in places slate colored. 
The cervix is also deeply congested and 11 
soft. There is no hymen. The nymphae 
are greatly elongated. 
A microscopic examination of the 
tumor showed it to be a spindle-celled 
sarcoma. 
In Case IL, as in Case I., the lesion is 
confined to one hemisphere of the cere- 
bellum ; but the symptoms are very dif- 
ferent, and this difference is due to the 
different nature of the lesion in the two 
cases. In Case I. the lesion was a cyst, 
which either did not increase in size at 
all or else did so very slowly; while in 
Case II. the lesion was a tumor which 
increased in size steadily and rapidly, 
and in so doing not only destroyed the 
hemisphere, but also exercised a strong 
pressure on the body of the cerebellum, 
and thus produced in a mild degree the 
symptoms characteristic of lesions of the 
body of the cerebellum, viz., an awkward, 
unsteady walk, a retraction of the head, 
and convulsions. Failure of the sight, 
rapidly developing into complete blind- 
ness, was one of the first symptoms of 
Case IL, and is a very common symp- 
tom in cases of cerebellar tumor. In 
such cases the blindness is probably 12 
not due to the choked disc and the con- 
secutive optic neuritis, but is generally 
ascribed to the increased pressure of fluid 
in the dilated ventricles, which increased 
pressure manifests itself in some cases in 
a bulging downwards of the floor of the 
third ventricle, and consequent pressure 
on the optic chiasm. The paralysis of 
the abducens was probably also due to 
the increased pressure within the ventri- 
cles, the nuclei of the abducens nerves 
lying so superficially in the floor of the 
fourth ventricle that they are more ex- 
posed to this increased pressure than 
most of the other cranial nerves. The 
auditory nerve and nucleus is usually 
involved in such cases, but in this case 
hearing was not affected. The irritation 
of the little osteophyte was probably the 
exciting cause of the tumor. 
Although the cerebellum is no longer 
regarded as exercising any influence on 
the sexual sphere, yet it is remarkable 
that this tumor should have been asso- 
ciated with oopheritis, vaginitis and 
greatly elongated nymphae.