CEREBELLAR TUMOR. 
Operation; Hemorrhage from Defect 
of Occipital Bone; Death; 
General Remarks. 
BY 
W. N. BULLARD, M.D., and E. H. BRADFORD, M.D. 
Reprinted from the Boston Medical and Surgical Journal 
of April go, i8gi. 
BOSTON: 
DAMRELL & UI'HAM, Publishers, 
283 Washington Street. 
1891. S. J. PARKHILL & CO.( PRINTERS 
BOSTON CEREBELLAR TUMOR; OPERATION; HAEM- 
ORRHAGE FROM DEFECT OF OCCIPITAL 
BONE; DEATH; GENERAL REMARKS.1 
BY W. N. BULLARD, M.D. AND E. H. BRADFORD, M.D. 
The patient, a girl, six and one-half years old, was 
first seen at the Out-patient Department of the Chil- 
dren’s Hospital in April, 1890. At this time the 
mother gave the following history. The family history 
was entirely negative, except that an uncle on the 
mother’s side had died when ten years old of brain 
fever. 
For a year the patient has been subject to attacks of 
yomiting preceded by dizziness, when she runs to some 
piece of furniture or something which she can hold to 
for support. These attacks occur on an average, three 
times a week, but sometimes come as often as twice a 
day. Last Christmas (1889), she had the grippe and 
since then she has never seemed as well as previously. 
For six weeks, has been gradually losing power in the 
right lower extremity. No pain. No incontinence. 
No other symptoms. 
The condition found at that time was as follows: 
Muscular development, fair, head appears rather large. 
The measurements were: circumference 50.25 cm.; 
glabella to inion 36 cm.; antero-posterior diameter, 
taken by pelvimeter, 18.50 cm.; biparietal diameter, 
taken by pelvimeter, 15.75. The chest circumference 
was 56 to 57.50 cm. Pupils dilated somewhat; react 
to light. Heart negative. Spine normal. Lower 
1 Read before the Boston Society for Medical Improvement, Feb- 
ruary 9, 1891, 2 
extremities seem alike. No atrophy. No vaso-motor 
disturbance. Sensation normal. Knee-jerks good. 
Gait unsteady, staggering. 
Was recommended for admission to the hospital. 
April 28th. Mother now states that three weeks 
ago patient began to lose use of the right upper extrem- 
ity, but that this varied somewhat from day to day. 
Yesterday, began to lose use of the left upper extrem- 
ity, and for the first time could not feed herself. Two 
weeks ago began to have pain in the back, and at times 
could not bear to have her back touched. Passes 
very little urine, and that with great difficulty. To- 
day passed only about a wineglassful, and that took 
ten minutes. 
Present condition. Can move both upper extremi- 
ties ; grasp fair; nothing abnormal in their appearance. 
Admitted to hospital, service of Dr. Bradford. 
May 1st. Has shown no decided evidence of affec- 
tion of the upper extremities. Urine scanty; 1,015; 
acid; very slight trace of albumen ; abundance of cells, 
some with one nucleus, some with two or three, single 
or in clumps. 
May 3d. Had an attack of vertigo this morning, 
and fell. Inco-ordination of lower extremities; can- 
not move foot in a circle. 
May 9th. Examination of the eyes by Dr. Wads- 
worth. Hypermetropia ; papillitis o. u., worse right. 
Another attack of vertigo this morning. 
No arsenic or lead in the urine. 
May 17th. Nausea; staggering; almost totally 
blind. Transferred to medical department for treat- 
ment with mercury. 
June 10th. Returned to surgical department. Iodide 
of potassium, gr. i, t. i. d. 
June 13th. Iodide of potassium, gr. x, t. i. d. Had 
slight trouble in ear while on medical side. Complains 3 
much of paiu, which is sometimes seated in the back of 
the head, sometimes in the ears, sometimes in the 
throat; worse at night and wakes her. Cheeks to-day 
are swollen, but not cedematous. Pupils widely dilated, 
equal. Can stand if supported, but sways; cannot 
walk. (Is now almost totally blind.) Knee-jerks in- 
creased and ankle-clonus on both sides. 
June ‘20th. Memory good. Sings songs when 
asked. Tongue protruded straight. Great variability 
of pulse. Ataxia not well marked in upper extremi- 
ties. Right lower extremity weaker than left. Can- 
not sit up in bed or stand without much support. 
June 21st. For past week has wet bed occasionally ; 
now complete incontinence for a day or two. Cannot 
perceive light. 
June 25th. Record much as previous. Left eyelid 
droops a little more than right. There is now marked 
paresis of both upper extremities, but more right than 
left. Touches nose fairly well with right forefinger, 
less well with left. Right triceps reflex a little stronger 
than left. Considerable paresis right lower extremity, 
less of left lower extremity. Ankle-clonus right more 
marked than left. 
June 27th. Operation by Dr. Bradford. 
After the operation was decided upon, the usual 
steps were taken in preparing the patient, and in secur- 
ing complete asepsis. The child’s general condition 
was excellent, and appeared to justify an operation. 
After anaesthesia (ether having been administered with 
a previous subcutaneous injection of morphia and 
atropia) the child was placed upon her belly, and the 
face turned slightly to the left. The incision usually 
recommended in cases of cerebellar tumor was made; 
namely, a curved incision with convexity upwards, ex- 
tending from one mastoid process to the other, reaching 
upwards as far as the superior line. The flap was 4 
rapidly dissected downward; an attempt being made 
to remove not only the flap, but any of the pericranium 
that adhered to it. Not more than the usual amount 
of bleeding was met with, until the median line was 
neared, when a jet of blood was noticed issuing from 
one of the small foramina occasionally seen in the skull. 
This bleeding was checked by the insertion of a splin- 
ter of wood, cut from a match, which had been prepared 
for such emergency. A second jet from another fora- 
men was also met, and the bleeding checked in the 
same way. As the flap was drawn from the median 
line, a slight amount of fibrous tissue was found to ad- 
here to the skull, and bleeding was noticed to come 
from this region. The amount of bleeding was at first 
small, but afterwards became copious, and a third 
opening, of considerable size, was discovered. On ex- 
amination the diameter of this opening was much larger 
than that of any foramen, and no match could control 
the bleeding. The finger was placed over this imme- 
diately, and a piece of cork inserted. The amount of 
bleeding which had taken place was ‘considerable, 
though not more than is seen in an ordinary amputa- 
tion, yet it seemed to cause great collapse, and in a 
few moments the patient was found to be dead. Arti- 
ficial respiration was employed, but to no advantage 
After death the trephine was applied directly over the 
opening, and the button of bone removed. On the 
inner surface the skull was found to be perfectly nor- 
mal ; but the opening, which could be distinctly seen, 
and which was smooth on the inside except in one spot 
was found to communicate directly with the sinus at 
the junction of the lateral and median sinuses, the spot 
known as the torcular Herophili. The dura was per- 
fectly healthy, and there was no evidence of disease 
either in the dura or in the bone. The opening was 
enlarged by means of forceps, and on the right side at 5 
the projection of the posterior lobe of the cerebellum, 
a large, cheesy mass was easily recognizable. This 
was removed by the finger, and found to extend to a 
considerable depth forward and to the left, constituting 
evidently a tubercular mass. 
The existence of this surgical anomaly could in no 
way have been foreseen. Its existence should serve 
as a surgical warning, that in operations of this sort, 
the pericranium should not be too fully stripped up in 
removing the skin flap in a region over the median 
line or over the occipital protuberance. How common 
such an anomaly as this may be, of course, there is no 
means of determining; as no such case has come to 
my notice, after investigating the subject with some 
care. I shall not attempt to define the nature of the 
opening, except that it was apparently a congenital 
one, and not due to the presence of disease. The ope- 
ration could probably have been carried out to the end 
successfully, if this opening had been avoided. At 
least there was no reason to judge that there was any 
cause of death except the loss of blood. 
Little need be said of the technique in operations on 
cerebellar tumors, as they differ in no way from what 
has been so carefully described in the details for the 
removal of cerebral tumors elsewhere. The question 
is simply one of the locality for insertion of the tre- 
phine, that is an anatomical one. The lines of indi- 
cation for the place of trephining are clearly marked 
by natural limitations, namely, the foramen below, the 
median line on one side, the mastoid process on the 
other, and above, the superior line of the occiput, 
which marks the course of the lateral sinus. 
The advisability of an operation on cerebellar tumor 
has been questioned, as until recently all cases were 
fatal. Messrs Maudsley and Fitzgerald of Australia, 
however, had reported a successful case; and Mr. 6 
Horsley writes me that he has recently met with 
another successful trephining for the relief of pressure, 
from a growth on the middle cerebellar peduncle. As 
diagnosis becomes more readily made, and cases pres- 
ent themselves for operation at an earlier stage, the re- 
sults will in all probability be more favorable than those 
which have been as yet recorded. The present case 
illustrates a hitherto unforeseen danger, fortunately one 
which can, in future cases, be avoided. 
No autopsy was permitted. The mass of the tumor 
removed through the opening, was three-quarters of an 
inch in depth, and from half to three-quarters iii 
width. The material was hard and cheesy, and on 
microscopic examination by Prof. W. F. Whitney, 
there was found a narrow exterior zone of small round 
cells, with here and there a number grouped into 
minute rounded nodules ; irregularly scattered about 
were large multi-nucleated bodies, giant cells, but the 
greater part of the specimen showed cheesy degenera- 
tion. No tubercle bacilli were found. The anatomi- 
cal appearances were those found in large tubercles of 
the brain. 
Professor Whitney reports in regard to the bone as 
follows : The specimen is a circular piece of bone 
measuring 3.5 centimetres in diameter. The inner 
surface is marked by ridges of bone meeting at a cen- 
tral point similar in appearance to the point on the 
occipital bone (named) the torcular Herophili. At 
this place is an irregularly oval opening, about 1.0 
by .50 centimetres, passing obliquely through the bone 
to open outside by an irregularly oval opening .75 by 
.50 centimetres, with a thin and slightly everted edge. 
The bone lying between these two openings has a 
worm-eaten look as if vascular sinuses had been found 
there. Into this space pass one or two large arterial 
foramina. When first seen the space was lined with 7 
a perfectly smooth tissue in which there was no evi- 
dence of any granulations or tubercles. It is probably 
External and Internal Surfaces of Bone, from Photographs. 
a series of dilated blood sinuses with erosion of th& 
bone. 
TUMORS OF THE CEREBELLUM IN CHILDREN. 
General Remarks. — The relative frequency of 
intracranial tumors in children is considerable, about 
fifteen per cent, out of all intracranial tumors, exclud- 
ing specific, being found in children of ten years of 
age or under. Cerebellar tumors are relatively more 
frequent in children than in adults; that is, the per- 
centage of tumors situated in the cerebellum to that 
of all intracranial tumors, is greater in children than 
in adults. 
Out of 445 cases of intracranial tumors reported 
by Bernhardt in which the ages were given 68 (15 
per cent.) were in children of ten or under. Stelfen 
considers that the third year of life contains the 
largest proportion of children thus affected, and in 
the years following the number is diminished by one- 
half up to the age of ten. Out of a hundred cases of 
intracranial tumor collected by Mills and Lloyd, ten 8 
were under ten years of age, twelve between ten and 
twenty. Gowers says : “ The first twenty years (of 
life) furnish one-third of the cases of cerebral tumor. 
The proportion in the first decade is 18.5 per cent. 
If tubercular growths be excluded, the proportion in 
the first twenty years of life falls to one-fifth.” Hale 
White from one hundred autopsies of intracranial 
tumor at Guy’s Hospital finds that more than half of 
those dying from cerebral tubercle were under ten 
years of age (f $). 
Relative Frequency. — The relative frequency of 
cerebellar tumors as compared with all intracranial 
tumors in children is marked. Out of one hundred cases 
of intracranial tumors in children of ten years of age 
or under, taken at random, I find that in nearly fifty 
the cerebellum was affected. Some of these were 
cases of single tumors, in many the tumors were mul- 
tiple. Starr, out of three hundred cases in persons 
under nineteen years of age, found ninety-six (thirty- 
two per cent.) cerebellar. Out of the one hundred 
cases of Mills and Lloyd of intracranial tumors at all 
ages, only nine were cerebellar. 
Bernhardt, out of four hundred and eighty-five intra- 
cranial tumors at all ages, gives ninety cases (18.5 per 
cent.) of tumors of the cerebellum, but in addition to 
these there are a considerable number in which the 
cerebellum was affected although it was not the princi- 
pal seat of the tumor. 
Forms of cerebellar tumor.— The relative frequency 
of the various forms of cerebellar tumor in children 
has been referred to by various authors. Starr has 
found the following results from ninety-six cases of 
cerebellar tumor in persons under nineteen. We have 
obtained our results as seen in the table from one 
hundred and twenty-three cases in children of ten 
years of age or under. 9 
Starr. 
Bullard and Bradford, 
No. 
Per cent. 
No. 
Per cent. 
Tubercle 
48.96 
85 
69.10 
Glioma 
16.62 
11 
8.94 
Sarcoma 
10.42 
10 
8.13 
Glio-sarcoma . . . . 
1.04 
1 
0.81 
Cyst 
9.37 
4 
3.26 
Carcinoma 
3.12 
2 
1.62 
Myxoma 
. . 0 
2 
1.62 
Gummata 
1 
0.81 
Unknown . . " . . 
11.46 
7 
5.69 
96 
123 
As to the portion of the cerebellum affected in our 
cases: In thirty-two the tumors were situated wholly 
or largely in the right lobe, thirty-two were in the 
left lobe, and twenty in the middle lobe or centre. In 
seven cases both lobes were affected and in six the whole 
cerebellum. In seventeen cases there seems to have 
been more than one tumor in the cerebellum. 
Symptomatology.— Tumors of the cerebellum may 
be wholly latent, although this is rare. They are 
usually accompanied by marked general, that is, non- 
localizing symptoms, headache, vomiting, vertigo and 
optic neuritis, followed by atrophy of the optic nerve, 
and frequently, also, mental depression, apathy and 
gradual mind-failure. There is almost invariably a 
considerable ventricular effusion, internal hydrocepha- 
lus, on the presence of which these symptoms largely 
depend. The hydrocephalus and the general symp- 
toms above mentioned are apt to be specially marked 
in tumors of the cerebellum, because the position of 
the latter is frequently such as either to compress the 
vena Galeni or other efferent blood-vessels, or to dimin- 
ish or occlude the communication between the ventric- 
ular cavities and the cerebro-spinal canal, in either 
case causing an excessive accumulation of fluid in the 
ventricles and the prominence of the symptoms thereby 
produced. 10 
In addition to these general symptoms there also 
occur in cerebellar tumors certain others, which, while 
not so usual an accompaniment of intracranial irrita- 
tion and compression, yet can hardly be considered as 
having any definite localizing value. Such, for exam- 
ple, is nystagmus. General clonic convulsions also 
sometimes occur, but are not especially common. Tremor 
on voluntary movement, resembling that of cerebro- 
spinal sclerosis is of doubtful localizing value. 
Of more importance as a symptom of the position 
of the tumor is the presence of general tonic convul- 
sions, opisthotonos and tetanoid contractions. When 
these occur to a marked extent and form a prominent 
feature, they have a certain localizing significance. Aside 
from these the true localizing symptoms of cerebellar 
tumors are few. They may be stated briefly as cere- 
bellar ataxia, rotary movements, and the symptoms 
produced by the pressure of the tumor on the adjacent 
or neighboring parts, the pons Varolii, the medulla 
oblongata and the adjacent nerve trunks. Cerebellar 
ataxia and rotary movements are the only symptoms 
due to the affection of the cerebellum itself. 
Of- the symptoms produced by pressure on other 
organs, the most important is the presence of paraly- 
sis due to pressure on the pyramidal tracts. We shall 
not, however, enter into the question of indirect or 
pressure symptoms. 
Headache is, as we have said, a usual accom- 
paniment of tumors in the cerebellum. It may be situ- 
ated in the occipital region and in this case it may be 
of some slight value when taken with other symptoms 
as pointing to an affection below the tentorium. Fre- 
quently, however, it is situated elsewhere, for example 
in the supra-orbital region, hence its presence in 
another region than the occipital and its absence from 
that region does not contraindicate tumor in the cere- 
bellum. 11 
Vomiting, which occurs in many intracranial tumors 
and hence is classed as a general symptom, is said to be 
especially frequent in tumors in this vicinity and may 
be due in part to pressure on the medulla oblongata. 
Double optic neuritis followed by double optic atro- 
phy is an almost invariable symptom in any large 
tumor in this region. So long as this symptom were 
wanting, the diagnosis of cerebellar tumor would be a 
very uncertain one. This symptom is probably largely 
dependent on the hydrocephalus. 
Vertigo, although occurring in many other intra- 
cranial affections and being frequently present in 
tumors in other portions of the cranial cavity, bears an 
especially prominent part in the case of cerebellar 
tumors. When considered in connection with the 
cerebellar ataxia and the rotary movements, of which, 
however, it is entirely independent, it seems possible 
that it may have a direct origin in the cerebellum it- 
self, apart from any general cause. Of itself it is not 
a localizing symptom, but taken in connection with 
rotation and ataxia it would be of value as tending to 
confirm the diagnosis. In many young children its 
presence is naturally difficult to detect and it may 
easily be overlooked. 
The mental conditions are probably, largely second- 
ary to the hydrocephalus, either through compression 
or otherwise. 
Of general tonic convulsions, opisthotonos and teta- 
noid spasms we can only say that they too, like vertigo, 
tend to confirm the diagnosis when other symptoms 
are present. They are supposed to be due in a general 
way to irritation of the medulla and should probably 
be classed among the indirect or pressure symptoms. 
Cerebellar ataxia and rotary movements, with per- 
haps, certain forms of vertigo, are the only symptoms 
so far as we yet know, which are directly caused by 12 
irritation or destruction of the cerebellum. These, 
however, are distinctly characteristic and when they, 
or either of them exist, we have a definite localizing 
agent. It is not our purpose here to enter into the 
cause of these motions, so far as this is at present 
understood, but we can say that it is not a simple inco- 
ordination. Cerebellar ataxia is the term used to 
denote a peculiar reeling gait, resembling that of a 
drunken man and totally distinct from that so common 
in sclerosis of the posterior columns of the cord, the so- 
called locomotor ataxia. In cerebellar ataxia true in- 
co-ordination of the muscles does not occur, at least in 
many cases. There is no loss of muscular sense. The 
upper extremities are frequently not affected (with 
inco-ordination) even in the latest stages. The diffi- 
culty seems to be, not in the transmission of the cen- 
tral influences to the muscles, causing an imperfect and 
irregular passage thereof, but a direct affection of 
certain nervous centres, very possibly of a sensory 
character. In the so-called locomotor ataxia the diffi- 
culty seems due, largely, at least, to the irregular and 
imperfect transmission of motor influences, possibly in 
part to the affection of unconscious co-ordinating nerve 
centres in the cord. In cerebellar ataxia the dyskine- 
sis is due to impeded or imperfect action of the sense 
of equilibration. From affection of the sensory centres 
or other cause, the normal sense of equilibrium becomes 
perverted, abnormally increased or abnormally dimin- 
ished in one or more directions, and this produces in 
the first place a sensation of general unsteadiness, often 
enhanced by the vertigo, which it probably also causes in 
part, and secondly, a sensation of leaning or falling in 
a special direction. This latter produces a tendency 
to compensate the supposed inclination or leaning and 
thus the patient is forced to bend or incline to the 
opposite side in order to feel himself in equilibrium. 13 
When the affection is severe the patient may fall to the 
side opposite to that on which he feels himself weak, 
that is, he may overbalance through mistaken sense of 
compensation. The direction of the fall, however, has 
only a doubtful significance, as there often seems a 
certain paresis on the affected side which causes the 
patient to fall on the side which seems to him weak. 
(By the affected side we mean the side of the lesion 
and the motor impairment connected with the ataxia 
is on this side.) 
In severe cases or in those in which the loss of the 
balancing sense is very marked, there is sometimes 
found, in addition to simple want of balance and 
tendency to fall in a special direction, an impulse 
to rotation around a vertical axis. This seems to 
be due simply to an exaggerated loss of the sense of 
lateral equilibrium and the direction of rotation would 
appear to be from the affected to the sound side. This 
is present especially in cases where a lateral lobe or 
one of the middle peduncles is affected. 
It was stated by Nothnagel and the view is still 
largely accepted, that the ataxic gait (cerebellar) exists 
only in those cases in which the middle lobe of the 
cerebellum is either directly or indirectly affected. It 
is certain, however, that the presence of this symptom 
does not necessarily imply any direct involvement of 
the middle lobe and in some cases it has existed to a 
very marked degree where such involvement did not 
occur. 
The indirect symptoms due to irritation or pressure 
of the neighboring parts may be of essential aid in 
forming the diagnosis. We shall not discuss these 
symptoms here as they belong more properly in the 
consideration of functions of neighboring organs and 
are more or less self-evident. We will only note that 
the paralysis produced by pressure on the pyramidal 14 
tract is usually a late symptom, and that it is hemi- 
plegic in form. It is generally permanent and is on 
the side of the body opposite to that of the lesion, thus 
differing from the cerebellar weakness which is on the 
same side as the lesion. We would also note a fact, 
which seems thus far largely to have escaped remark, 
and that is, the presence of temporary pareses of the 
extremities due to irritation of the pyramidal tracts. 
These were especially noticeable in our case. 
Another symptom to which little attention has thus 
far been drawn is the presence of a swelling of the face 
ccdematous in appearance, but not pitting on pressure. 
( This has been especially noted lately in two cases 
which have come under our observation) and lasting a 
few hours to a few days. It is possibly due to some 
vaso-motor disturbance of the lymph vessels and is 
quite distinct from the flushings due to a similar dis- 
turbance of the superficial blood-vessels. This affects 
principally the cheeks and the middle portion of the 
face. The eyelids in our cases were not affected. 
SURGICAL INDICATIONS ; SURGERY OF THE CERE- 
BELLUM. 
The first question which arises is, What proportion 
of these tumors, if any, can be helped or cured by 
operation, and how far is operation in these cases 
justifiable? The latter question must be largely de- 
termined by the personal equation of the operator. I 
shall not enter into it at all, but shall only give the 
facts as far as they can be determined, and leave the 
conclusions to be drawn by each, according to his best 
judgment. 
Hale White thought that out of one hundred 
autopsies of all intracranial tumors ten to fourteen 
were susceptible of operation. This means that, if as 
much had been known in regard to the tumor before 15 
death as could under the circumstances have been 
known, these cases were operable. 
Starr, out of his three hundred cases of intracranial 
tumors in children thinks sixteen would have been 
successful if operated on. He also thinks that in 
cerebellar cases, one-third of the tumors can be reached 
by the surgeon. 
These are general considerations. For the special 
problem of cerebellar tumors in children of ten jears 
of age or under, we must consider special data. In 
the first place we have already stated the immense 
preponderance of tubercular disease, about seventy 
per cent. This being the case we have always to con- 
sider the probability that a given case is due to tuber- 
cular disease, unless there is special cause to suppose 
the contrary. 
The three special conditions on which we determine 
the operability of any cerebellar tumor are its size, its 
exact position, and its nature (pathological formation). 
Dependent on these are several factors of much im- 
portance : (1) Its duration and the rapidity of its 
growth; (2) its vascularity; (3) its infiltration; (4) 
the involvement of neighboring structures, the medulla, 
etc. ; (5) the probability of disease elsewhere, which 
would cause the removal of the tumor, even if success- 
ful, to be of doubtful permanent benefit to the patient. 
Many of these elements cannot be determined. We 
will consider them separately. 
Size. — The only method we have of in any way 
estimating the size of a cerebellar tumor, except in 
rare cases of growth through the bone, is from what 
we can judge of its nature and duration and from the 
pressure symptoms. Although tumors of the same 
nature grow with varying degrees of rapidity, if we 
can determine the nature, we can in some measure 
estimate its probable size in relation to the time of 1G 
growth. As in most cases, however, the nature of 
the tumor is somewhat doubtful, we depend largely 
for our estimate of size on the pressure symptoms 
when they are such as to afford us any information. 
We do not include under this head the amount of 
hydrocephalus, as although this probably depends 
largely on pressure on the venous channels and the 
communications between the general ventricular cav- 
ity and subarachnoid space, such pressure may be 
exerted by a comparatively small growth situated in 
a favorable locality, while a much larger one in an- 
other position would exert less influence. It is evi- 
dent, however, that if there exist evidences of pressure 
iu structures some distance apart and not supplied by 
the same blood-vessels, or otherwise so connected that 
pressure on the connecting links may affect them, the 
tumor must either be a large one or we have to deal 
with multiple tumors. The diagnosis between these 
conditions is often very difficult, owing to the fre- 
quency of multiple tumors in the cerebellum. 
Position. — The exact position of the tumor can 
rarely be determined. This is due largely to the 
absence of localizing symptoms within the cerebellum 
itself. The only symptom referable to the cerebellum 
itself which can be of service in determining the por- 
tion of the cerebellum affected is the direction in which 
the patient falls or rotates. The rotation is iu many 
cases absent, but when present would seem to be of 
value. The direction in which the patient falls or 
towards which he inclines, when lateral, is of but 
doubtful value, as in some cases patients fall towards, 
and in others away from the side of the lesion ; where 
the tendency is forwards or backwards this symptom 
may have more value. 
The presence of reeling or staggering can hardly 
be considered to have much weight in the determina- 17 
tion of the position of the tumor within the cerebellum, 
because although it is generally considered to be due 
to irritation or affection of the middle lobe, it is fre- 
quently found in tumors which do not involve the 
middle lobe directly at all; and Bramwell states that 
in his experience this symptom has been more marked 
in cases where the tumor has been confined to a lat- 
eral lobe. If the diagnosis of cerebellar tumor could 
be made without the presence of this symptom, its 
absence would suggest that the tumors were small and 
situated laterally. 
More definite localization within the cerebellum 
may sometimes, however, be obtained by the effects 
of pressure on the neighboring organs, the pons, the 
medulla and the subjacent nerves. In many cases, 
however, localizing symptoms of this character, espec- 
ially those due to pressure on the pyramidal tracts, 
only appear in the later stages. 
Pathological Character. — In regard to the patho- 
logical character of the tumor little can be determined 
from its direct symptoms. The general rule that 
fluctuations and rapid changes in the blood-pressure 
and general condition of the patient are more liable to 
occur in vascular than in non-vascular tumors, prob- 
ably holds good here, but in these cases we are espec- 
ially likely to find these changes affected and compli- 
cated by the conditions of the hydrocephalus, which is 
influenced by other factors than the vascularity of the 
tumor. Our principal means of determination, there- 
fore, lie in the history of the case, the duration of the 
tumor, the apparent rapidity of its growth, the evi- 
dence of the presence of other tumors either intra- 
cranial or in other organs, or the presence of tubercu- 
lar disease elsewhere. It goes without saying that, 
where tubercular disease exists elsewhere or where 
there is a strong family history of tuberculosis, the 18 
probabilities in favor of the tubercular nature of the 
tumor are much increased. In like manner the pres- 
ence of sarcoma, of carcinoma or of gumma elsewhere, 
would suggest the probability that the cerebellar tumor 
was likewise of this character. 
Where no evidence is obtainable from the history or 
condition of the patient, we must still remember that 
the large percentage of tubercular tumors always 
causes a probability in favor of the tumor being of 
this nature. Multiplicity of intracranial tumors also 
points on the whole to their tubercular character; 
though many other tumors are also multiple, sar- 
comata and carcinomata, gummata. If a tumor be of 
extremely slow growth or appears to have become 
passive, we may suspect a growth from the dura or 
from the bone. 
The rapidity of growth of a tumor affects its opera- 
bility in two ways. In the first place, indirectly, as 
the operation to be performed must be performed as 
soon as possible in order to deal with as small a 
growth as we can. Secondly, as a means of diagno- 
sis of the character of the tumor. On the whole 
sarcomata, carcinomata and gummata grow quickly, 
while tubercular tumors, gliomata, cysts and myxomata 
are slow. Sarcomata from the membranes and osteo- 
mata may be very slow. 
The vascularity of a tumor affects its operability to 
a certain degree, and should when possible, be taken 
into consideration. In cerebellar tumors it seems to 
be often indeterminable. Pseudo-apoplectic symp- 
toms and fluctuations in the blood-pressure point to it. 
The question of infiltration can only be determined 
from the pathological character of the tumor. Except 
the long duration in some gliomata we have no intrin- 
sic data. 
The question of the multiplicity of tumors is very 19 
important. Where evidence of the presence of tumor 
in other parts of the body exists, or where tubercular 
or syphilitic disease manifests itself elsewhere, the 
case is simple. The same may be said where we 
have evidence of multiple intracranial tumors. In 
the latter case certainly one would hesitate long before 
considering any operation justifiable. 
But the important question is, What are the chances 
in the case of any given cerebellar tumor in children of 
ten or under, that we have to deal with a simple tumor, 
and not with either multiple tumors or with dyscrasic 
manifestations such as tubercular meningitis, miliary 
tuberculosis, or in the case of gummata with syphilitic 
lesions of another character ? 
These questions can only be settled by statistics. 
We find out of 121 tumors that 48 (39.6 per cent.) 
are single and uncomplicated. (This number is prob- 
ably too large as we have counted here all those in 
which no special mention of multiplication or compli- 
cation was made.) Fifty-six (46.2 per cent.) were 
multiple, and in addition to these 17 (14 per cent.) 
showed disease, usually tuberculosis, elsewhere in the 
body. Out of 84 tubercular tumors we find 48 
(57 per cent.) multiple and 17 (20 per cent.) compli- 
cated by tuberculosis or other trouble elsewhere, and 
only 19 (22.6 per cent.) reported single and uncom 
plicated. It must be remembered, however, in con 
sidering these figures that these results are all obtained 
at autopsies, and that it is very probable that in earlier 
stages many more of these cases were uncomplicated 
and single. 
Of our gliomata, two were multiple; ten, including 
a glio-sarcoma, were single; no lesions elsewhere 
reported. Sarcomata, single, nine, including two 
angio-sarcomata; and multiple, two, one melanotic. 
Carcinomata are probably always secondary. Gum- 
mata are frequently complicated or multiple. 20 
Of surgical operations for tumors of the cerebellum, 
we can find but four up to the present date. Of 
these, three were fatal and one successful. These 
cases are: 
(1) May. Male, seven. Tubercular tumor, right 
lobe of cerebellum. Death in a few hours, from shock. 
(Lancet, 1887, I, 768.) 
(2) Suckling. Female, twelve. Glioma, left lobe 
of cerebellum. Death in forty-eight hours, from 
shock. (Lancet, 1887, II, 656.) 
(3) Horsley. Male, eighteen. Tubercular tumor, 
chiefly in right lobe of cerebellum. Death in nine- 
teen hours. (British Medical Journal, 1887, I, 863.) 
(4) Maudsley. Male, twenty-eight. Tumor press- 
ing on left lobe of cerebellum. Not removed. Re- 
covery from operation, and improvement. (Trans- 
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