Symptomatology of Cerebellar 
Disease ; Clinical Analysis of 
a Hundred Cases, with Re- 
port of Four Personal 
Cases. 
BY 
WILLIAM C. KRAUSS, M. D., 
BUFFALO, N. Y., 
Professor of Pathology, Medical Department of Niagara 
University ; Neurologist to Erie County Hospital, etc. 
REPRINTED FROM THE 
Neb ¥orR fHeulcal journal 
for June 1, 1895. Repr inted from the New York Medical Journal 
for June 1, 1895. 
SYMPTOMATOLOGY OF CEREBELLAR DISEASE; 
CLINICAL ANALYSIS OF A HUNDRED CASES, 
WITH REPORT OF FOUR PERSONAL CASES* 
WILLIAM C. KRAUSS, M. I)., 
BUFFALO, N. Y., 
PROFESSOR OF PATHOLOGY, MEDICAL DEPARTMENT OF NIAGARA UNIVERSITY J 
NEUROLOGIST TO ERIE COUNTY HOSPITAL, ETC. 
The most important addition to our knowledge of cere- 
bellar physiology in recent times is the able monograph 
of Luciani, published in Florence in 1890. Luciani was 
first attracted to this field in the summer of 1882, he hav- 
ing in that year completely extirpated the cerebellum of a 
dog and succeeded in keeping the animal alive. 
The fact that this was a possibility, and considering the 
chaotic condition in which cerebellar physiology existed, 
induced him to make a minute study of the subject, casting 
aside all theories and hypotheses, and plunging into the very 
beginning of the work just as if cerebellar physiology had 
never been thought of. 
After eight years of observation and study, he brought 
his labor to the light of day, and a comparison of his re- 
* Read before the Medical Society of the State of New York at its 
eighty-ninth annual meeting. .,,; .. ..r-- 
Copyright, 1895, by D. Applet-ox and Company. 2 
CEREBELLAR DISEASE. 
suits with the results obtained by other experimenters, and 
a comparison of these with the symptoms of cerebellar dis- 
ease, will be the purpose of this paper. 
The pioneer of cerebellar physiology depends upon 
whether the compiler resides in England, Italy, or France. 
If in England, then Willis is considered the father; if in 
Italy, then Rolando; and if in France, then Flourens is 
considered the founder. Willis was undoubtedly the first 
to lend attention to the cerebellum, although his work was 
more anatomical than physiological or experimental. Ro- 
lando essayed the solution of cerebellar action and experi- 
mented upon animals, especially young pigeons, turtles, etc. 
His technique was faulty, and the animals experimented 
upon lived but a short time after the removal of the cere- 
bellum. As a result of his experiments he found that slight 
injuries to, or partial destruction of, the cerebellum influ- 
ences muscular movements, while complete destruction an- 
nihilates the nerve activity, the abolition of which occasions 
complete paralysis. 
Supporting these deductions he cites the clinical cases 
of Bianchi, Larrey, and Bertini. 
Tn Bianchi's case, abscess of the right lobe of the cere- 
bellum produced paralysis of the right side of the body; 
in Larrey's case, injury to the right lobe was followed by 
right hemiplegia; and Bertini's diagnosis of cerebellar dis- 
ease was based on the uncertain, irregular muscular move- 
ments of his patient, resembling the antics of a drunken 
man. 
Although mistaken regarding the presence of paralysis, 
which is nothing more than a loss of sthenic tone, Rolando 
proved that the cerebellum exerted some influence over the 
correlation of muscular forces, and that an insult to one 
side of the cerebellum was manifested by some disorders on 
the corresponding side of the body. CEREBELLAR DISEASE. 
3 
Flourens, the brilliant young French experimenter, in 
1822 addressed to the Royal Academy of Sciences a memoir 
on cerebellar physiology, which stands to day for all that is 
accurate and positive regarding cerebellar action from an 
experimental standpoint. Three of his experiments, which 
are quoted by all writers on this subject, may not be amiss 
in this paper : 
" I extirpated the cerebellum of a pigeon by successive 
layers. During the removal of the first layers only slight 
feebleness and want of harmony in the movements were 
noticed. 
" At the middle layers an almost universal agitation was 
manifested, but without convulsions; the pigeon executed 
sudden and disordered movements; hearing and vision 
remained intact. On the removal of the last layers the 
faculty of jumping, Hying, walking, and maintaining the 
erect position was lost entirely. Placed on its back, it 
was not able to recover itself, and became vainly and con- 
tinually agitated, but it never moved in a firm and definite 
manner." 
The entire removal of the cerebellum, then, in a pigeon 
results in volition, sensation, and perception remaining in- 
tact. The possibility of making general movements per- 
sists, but the co ordination of the movements in regular and 
definite acts of locomotion is lost. 
The second experiment relates to partial removal of the 
cerebellum in a young cock. The animal immediately lost 
all stability, all regularity in its movements, and its totter- 
ing and bizarre mode of progression reminded one entirely 
of the gait in alcoholic intoxication. 
Four days after, the equilibrium was less disturbed, and 
the progression was more firm and assured. 
Fifteen days after, the equilibrium was completely re- 
stored. 4 
CEREBELLAR DISEASE. 
Partial destruction of the cerebellum, then, means a tem- 
porary loss of muscular co-ordination. 
Flourens fell into an error regarding the influence of 
the cerebellum as crossed instead of direct, each hemisphere 
exerting its influence over the corresponding half of the 
body. With this exception, the experimental results of this 
astute observer remain unchallenged to this day, even though 
there may be difference of opinion as to his deductions re- 
garding the functions of the cerebellum. 
Magendie, another French physiologist, followed closely 
upon the work of Flourens, and repeated the almost forgot- 
ten experiments of Pourfour du Petits-that of cutting the 
cerebellar peduncles and observing the animal rotate on its 
longitudinal axis toward the right or left, according to the 
side on which the peduncle was cut. He also observed 
what Fodera von Palermo had previously noticed-that in- 
juries to the cerebellum were accompanied by an uncon- 
trollable inclination to lean or even fall backward. 
Serres (1826), through faulty experimentation, taught 
that the action of the cerebellum was crossed; he also ob- 
served the tendency of animals to recoil, to incline the head 
backward, and was the first to call attention to the fact 
that the cerebellum exerts powerful influence over the ex- 
tremities, more particularly the inferior or posterior. This is 
shown nicely in the experiments upon pigeons, where, after 
extirpation of the cerebellum, on being thrown into the air 
they are able to fly, but, on trying to rise from the ground, 
they are unable to use their feet, because, as Serres says, 
they are paralyzed. 
Gall, the father of phrenology, in the early part of the 
century taught that the cerebellum was the seat of the sex- 
ual desires. This doctrine was combated by Bouillaud 
(1827), who, studying many clinical cases, asserted that the 
cerebellum had no connection whatever with the sexual in- CEREBELLAR DISEASE. 
5 
stincts. Bouillaud followed Flourens's experiments, and 
tried to prove that the cerebellum presided over acts of 
equilibrium, of station, and of progression. 
Andral, in 1833, published the first series of cases of 
cerebellar disease, and was able to collect ninety-three cases, 
of which six were under his personal observation. Of these 
cases, only one, according to Andral, tended to confirm the 
opinion of physiologists that the cerebellum was the organ 
that regulated the co-ordination of muscular movements. 
Longet (1842), in his Anatomy and Physiology of the Nerv- 
ous System, says, in view of Andral's resuits, we must be 
extremely reserved in calling the cerebellum the co ordina- 
tor of voluntary muscular movements. Andral's analysis 
seems to have precipitated a merry war between the experi- 
mental school and the pathological school. The former, 
following Flourens and Bouillaud, regarded the cerebellum 
as the organ of co-ordination, while the latter lent it no 
such functions. 
Flint, in his text book on physiology, page 712, makes 
a scrutinizing analysis of Andral's cases, and comes to the 
following very sound conclusions : 
"Of Andral's ninety-three cases, eighty five may be 
thrown out altogether, leaving but eight; and of these 
eight cases, five are so imperfectly described and the disor- 
ganization of the cerebellum is so restricted that they may 
also be disregarded. The ninety three cases are thus re- 
duced to three. Of these three cases, in two it is uncer- 
tain whether or not there were deficiency of co-ordinating 
power, and in one the difficulty in equilibrium or co- 
ordination was distinctly noted." This criticism does not 
show that Andral's cases are opposed to the Flourens 
doctrine. 
Following Andral's publication, there seems to have 
been a lull in the study of cerebellar physiology, for noth- 6 
CEREBELLAR DISEASE. 
ing important was published until the year 1860, when 
Brown-Sequard, in his lectures on the central nervous sys- 
tem, taught that the inco ordination was not due to the 
loss of function of the cerebellum, but that it was due to 
irritation of neighboring parts of the brain carried through 
the cerebellar peduncles. 
Schiff studied carefully the effects of cutting the cere- 
bellar peduncles and was the first to explain one of the ele- 
ments of cerebellar ataxia-namely, that it was due to in- 
complete fixation of the vertebral column, the result of 
paralysis of the vertebral muscles. 
Wagner, Dalton, Lusanna, and Renzi, in their experi- 
ments on pigeons and birds, added little that was not 
known of cerebellar physiology, their findings taking 
more the character of negative rather than positive phe- 
nomena. 
Dalton, however, found that the greater the extirpation 
of the cerebellum the more pronounced would be the motor 
disturbances, and these would disappear, leaving nothing 
but a certain general muscular weakness. After the disap- 
pearance of the inco-ordination, the result of an irritative 
lesion, there remains the general muscular weakness, the 
result of the deficiency lesions. 
The inco-ordination he believed to be due to the sudden 
injury to the cerebellum as a whole, rather than the simple 
loss of a part of its substance. 
Renzi asserted that the cerebellum was the seat of 
memory, while Lusanna set up the hypothesis that the 
muscle sense resided in the cerebellum. 
Other observers, especially Foville and Pinel-Grand- 
champ, thought that the cerebellum stood in close relation 
with the posterior white columns, and therefore presided 
over general sensation. 
Leven and Ollivier (1862-'63) rejected the Flourens CEREBELLAR DISEASE. 
7 
doctrine, but made the same error as Flourens in thinking 
the action of the cerebellum crossed instead of direct. 
Luys (1864) undertook to resuscitate the Rolando doc- 
trine, and regarded the muscle weakness following extirpa- 
tion of the cerebellum not paralytic but asthenic. 
Weir Mitchell came practically to the same results ob- 
tained by Dalton, Leven-Ollivier, and Luys, regarding the 
weakness following extirpation of the cerebellum, and con- 
sidered it as one of the great centres of force development 
for voluntary and perhaps involuntary motion. .Its loss 
leaves finally no functional defect save some incapacity for 
prolonged muscular activity. 
Nothnagel in 1876 emitted the theory that to the mid- 
dle lobe alone belonged the functions commonly ascribed 
to the cerebellum, and that on lesion of this lobe, directly 
or indirectly, the symptoms of cerebellar disease exclu- 
sively depend. 
Ferrier, in his experiments on monkeys, found that 
when the cerebellum has been totally removed the animals 
exhibit the most tumultuous disorders of equilibrium, so 
that station and locomotion are for the time altogether im- 
possible. Gradually these tumultuous disorders subside, so 
that the animal can sit up, but is so tottering that it falls 
over on the slightest disturbance or excitement. A per- 
sistent feature is the astasia or unsteadiness of the head, 
trunk, and limbs. 
If only one of the lateral lobes is removed the sprawl- 
ing, ungraduated action of the limbs and the astasia are 
confined to the same side as the lesion. 
If the middle lobe is destroyed the symptoms are essen- 
tially of the same character as those which follow destruc- 
tion of the whole organ, but they do not affect one side more 
than the other and are more pronounced in the head and 
trunk than in the limbs. These symptoms are less persistent, 8 
CEREBELLAR DISEASE. 
and in a few months almost entirely disappear. If one of 
the peduncles is cut the symptoms have the same char- 
acter as those following destruction of the lateral lobe, and 
are confined to the limbs on the side of the lesion. 
Ferrier concludes that the cerebellum is the organ pre 
siding over the equilibrium of the body or the location of 
the body in space. 
Stefani (1877) regarded the cerebellum as Ferrier the 
organ of maintaining the equilibrium ; Bechterew is also 
of this opinion, but regards the olivary bodies, the semi- 
circular canals, and the gray matter of the third ventricle 
as associated with the cerebellum in the performance of 
this function. 
Bianchi succeeded in keeping alive for some time a dog 
which had the greater part of its cerebellum removed, 
which showed no sign of inco-ordination, but simply a 
loss of muscular power. 
The results obtained by experimental physiologists 
previous to Luciani's publication may be summed up as 
follows : 
First, as concerns the negative phenomena, all observers 
are practically agreed that the cerebellum plays no part 
whatever over the mind, instinct, intelligence, sensibility, 
or special senses ; these functions belong to the cerebrum 
alone, and remain unaffected even in the most severe of 
cerebellar accidents. 
That the sexual instinct resides in the cerebellum, as ad- 
vocated by Gall, has found no supporter, and must be dis- 
missed from further consideration. 
The teaching of Rolando, Serres, and others, that pa- 
ralysis follows cerebellar extirpation must likewise be modi- 
fied so as to mean loss of tone or simply weakness, which 
may disappear or persist according to the extent of injury 
to the cerebellum. CEREBELLAR DISEASE. 
9 
The positive phenomena following complete or partial 
extirpation are more difficult to enunciate, and any attempt 
to make generalizations will be met by stern rebukes and 
demurrers. As Vulpian has aptly said, the problem of the 
functions of the cerebellum is still far from being definitely 
solved. However, this much we do know : 
1. That lesions of one side of the cerebellum produce 
symptoms on the corresponding side of the body. 
2. That after partial removal of the cerebellum muscu- 
lar weakness follows, which disappears almost entirely after 
a lapse of a few months. 
3. That after complete removal of the cerebellum in 
animals the movements of the lower or inferior extremities 
become tangled, and they refuse to obey the impulses which 
try to guide their action. 
4. That the cerebellum has some function over the 
regulation of muscular movements, either co-ordinative or 
compensatory ; the weight of opinion seems to favor the 
former. 
5. That lesions of the middle lobe seem to affect both 
sides of the body, while lesions to the lateral lobes or pe- 
duncles affect the corresponding side of the body only. 
To Summarize.-The cerebellum, as a centre, according 
to the majority of observers up to 1890, presides over the 
co-ordination of muscular movements, the effects of which 
would be to maintain the equilibrium of the body, the 
guidance of locomotion, and the maintenance of body 
station. 
Luciani's labors in the field of cerebellar physiology de- 
serve the highest encomiums, and his views merit most re- 
spectful consideration. It is gratifying to know that which 
the cerebellum does not do, even if we dispute the things 
that it does do. Luciani has virtually decided for all time 
that complete extinction of the cerebellum produces neither 10 
CEREBELLAR DISEASE. 
partial nor general paralysis of the mind, perception, 
volition, intuition, muscular movements, or the appetites. 
Removal of the cerebellum produces, first, irritative 
phenomena; secondly, ataxic phenomena. The irritative 
phenomena follow closely upon the destruction of the cere- 
bellum, and are indicated by such symptoms as opisthotonus 
and pleurothotonus, rotation round the longitudinal axis, 
squinting, or deviation of the optic axis. The ataxic phe- 
nomenon or cerebellar ataxy is due to three principal condi- 
tions-asthenia, atonia, and astasia-due to the loss of a 
sthenic tone and static influence which the cerebellum nor- 
mally exerts on the apparatus of movements, and which is 
the essence of its function. A trophic influence is also 
exerted by the cerebellum direct on the efferent tracts 
which spring from it, and indirect on the nutrition of the 
body. 
According to Luciani the cerebellum is an end organ 
directly or indirectly related to certain peripherical sensory 
organs, and in direct efferent relationship with certain gan- 
glia of the cerebro spinal axis, and indirectly with the 
motor apparatus in general.. It is functionally homogene- 
ous, each part exercising the functions of the whole, but 
having special relations to the muscles on the correspond- 
ing side of the body. 
Now turn from the physiologico-experimental to the 
clinico-pathological and see how the facts obtained from 
experiments upon animals harmonize with the symptoms of 
cerebellar disease. 
From 1880 up to the present time, the era of greatest 
scientific progress that medicine has ever enjoyed, I have 
been able to collect ninety-seven cases * of cerebellar dis- 
* The cases reported by American observers in this list are those 
of Eskridge, JbwmaZ of Nervous and Mental Disease, 1885, No. 12; CEREBELLAR DISEASE. 
11 
ease in which the diagnosis was verified by the ne- 
cropsy. 
This does not embrace cases of mental defect or aber- 
ration with such lesions as atrophy or absence of the cere- 
bellum, but, with one or two exceptions, only those cases 
where a diagnosis was surmised intra vitam. To this num- 
ber I can add three of my own which T will report later on 
in this paper. These cases have been studied with a view 
of establishing a syndrome of cerebellar disease based upon 
the labors of clinicians the world over. 
Of these one hundred cases the pathological finding in 
the cerebellum is as follows : Sarcoma in twenty-two cases, 
tubercles in twenty-two, glioma in eighteen, abscess in ten, 
tumor (character not specified) in thirteen, cyst in seven, 
and one case each of softening, endothelioma, cyst and sar- 
coma, cancer, gumma, fibroma, and haemorrhage. The pro- 
creative faculty of the cerebellum for neoplasms of various 
kinds is here well illustrated, being particularly partial 
toward tuberculosis and the sarcomata. 
The left lobe of the cerebellum was found to be the 
seat of lesion thirty-two times, the right lobe thirty-two 
times, the middle lobe seventeen times, both right and left 
six times, right and middle lobes three times, left and mid- 
dle lobes twice. 
Turning to the clinical manifestations, we find that 
Wilkins, Canada Medical and Surgical Journal, 1886, No. 4 ; Seguin, 
Journal of Nervous and Mental Disease, 1887, No. 4 ; Preston, Journal 
of Nervous and Mental Disease, 1889, No. 4, and 1892, No. 4 ; Booth, 
Journal of Nervous and Mental Disease, 1889, No. 3, and 1890, No. 10; 
Knapp, Journal of Nervous and Mental Disease, 1892, No. 2 ; Knapp, 
Intracranial Growths ; Dercum, Transactions of the American Neuro- 
logical Association, 1893; Starr, Brain Surgery ; Amidon and Weir, 
Annals of Surgery, 1887; Wyman, Medical News, 1890; Bullard, Bos- 
ton Medical and Surgical Journal, 1890; Angell, Buffalo Medical and 
Surgical Journal, 1894, No. 9. 12 
CEREBELLAR DISEASE. 
headache was present in eighty-three cases, absent entirely 
in six cases, and in twelve cases its presence or absence was 
not reported. 
Vomiting occurred in sixty-nine cases, was absent in 
nine cases, and not reported in twenty-three cases. 
Optic neuritis was found in sixty-six cases, was absent 
in twelve, and not reported in twenty-three. 
Vertigo was present in forty-eight cases, absent in nine, 
not reported in forty three. 
These four symptoms are generally considered charac- 
teristic of intracranial growths, and their frequency in this 
series of cases shows that whether the tumor resides in the 
cerebrum or cerebellum the "big four" must ever be re- 
garded as pathognomonic, especially when all of them or 
even three are present at the same time. 
Of the symptoms which we are in the habit of desig- 
nating distinctly cerebellar, we find that occipital pain and 
tenderness were present in forty-five cases, doubtful in 
thirty-nine, absent in eight, and not reported in eight. 
Ataxia-and by this I mean the disturbances of motion, 
especially of the inferior extremities-was noted in fifty- 
eight cases, absent in nine, and not reported in thirty-two. 
Asthenia, or the lack of sthenic tone in the muscles as 
evidenced by weakness, erroneously termed paralysis or 
paresis, was present in forty-eight cases, absent in four- 
teen, and not reported in thirty-eight. It would have been 
interesting to determine whether the muscular asthenia al- 
ways occurred on the same side as the lesion, as was found 
in the experiments upon animals, but the clinical histories 
were very faulty in this particular, and hence no data could 
be obtained to form any conclusion, although it is generally 
admitted that such is the case. Convulsions, either partial 
or general, were present in thirty cases, absent in fourteen, 
and not reported in fifty-six. CEREBELLAR DISEASE. 
13 
Inclination to go to one side or the other has sometimes 
served as an index for determining the lobe affected, the 
rule being that the patient walks toward the side bearing 
the lesion. Of thirty-five cases where inclination was re- 
ported the following results were obtained : Where the 
lesion was situated in the right lobe, six inclined to the 
right, two to the left, two backward, and one forward. 
Where the lesion was situated in the left lobe, four inclined 
to the left, one to the right, and three backward. Where 
the middle lobe was affected, four inclined to the left, two 
to the right, and one backward. In eight cases there was 
no inclination either to the right or left. These results seem 
to bear out the rule enunciated that the patient moves from 
the well to the diseased side. 
The tendon reflexes were reported normal in ten cases, 
exaggerated in twelve, and diminished or absent in twelve 
cases. 
Disturbances of the general sensibility were so rarely 
noted, and the reports so incomplete, that any careful con- 
sideration is out of the question. 
The symptom astasia, so often quoted by Luciani, 
which is the counterpart of the tremors, oscillations, insta- 
bility of the body in station and motion, has been partly 
considered under the head of inclination. The tremors 
which were so often noticed in animals, sometimes com- 
pared by writers to the intention tremor of multiple sclero- 
sis, were recorded in only two or three of the one hundred 
cases collected. 
Polyuria and glycosuria were likewise so infrequent, and 
the cause so hypothetical, that they may be dismissed from 
the list of primary cerebellar symptoms. 
Another important group of symptoms arising chiefly 
from pressure of the tumor mass upon the floor of the 
fourth ventricle, producing paralysis of the fifth, sixth 14 
CEREBELLAR DISEASE. 
seventh, eighth, ninth, and tenth pairs of cranial nerves, or 
the blocking up of the venae Galeni and the consequent dil- 
atation of the lateral and third ventricles, are only second- 
ary, but concomitant with the primary symptoms help to 
localize more accurately the seat of the lesion in the cere- 
bellum. The sudden death so often observed in cerebellar 
disease may be due to the effects of pressure upon the nu- 
cleus of the vagus nerves. 
Marked changes in the sexual desire, the appetites, or 
the mental states were not discoverable. 
To summarize, the symptoms of cerebellar disease ar- 
ranged according to their frequency in this series of cases 
would be headache, vomiting, optic neuritis, vertigo, ataxia, 
asthenia, occipital pain and tenderness, inclination to turn 
toward the side of lesion, convulsions, and such secondary 
symptoms as nuclear paralyses, polyuria and glycosuria, 
tremors, and sudden death. The negative symptoms would 
comprise the disorders of the sexual desire, of the mind, of 
sensation, and the variability of the tendon reflexes. 
The following cases* of cerebellar disease have come 
under my observation. Cases I and II having been previ- 
ously published, Cases III and IV, seen by me during the 
past year, are reported here for the first time : 
Case I. Clinical Diagnosis: Tuberculosis of the Cerebel- 
lum; Autopsy; Anatomical Diagnosis: Miliary Tuberculosis, 
with Duplication of the Cerebellum.-January, 1888, Willy 
L., a child of two years, appeared for the first time in the poly- 
clinic for nervous diseases of Professor Mendel and Professor 
Eulenburg (Berlin), where I had the opportunity of studying 
the case. 
* Case I. Tuberkel Knoten des Kleinhims. Inaugural Dissertation. 
William C. Krauss, M. D., University of Berlin, August 8, 1888. Case 
II. Journal of the American Medical Association, Chicago, November 
30, 1893. CEREBELLAR DISEASE. 
15 
The child was emaciated, thin, pale, and showed, in general, 
a scrofulous disposition. The father had always been a healthy 
man. The mother, with the exception of being an alcoholic, 
had always enjoyed good health. The mother relates the fol- 
lowing history: 
For some time past the child had been subject to attacks, 
regular in appearance, occurring every five minutes. During 
these attacks, which may be regarded as epileptoid, clonic con- 
tractions appear on the right side, particularly involving the 
right arm ; the head is drawn backward and is rigid. During 
these paroxysms the patient is not in an unconscious condition, 
nevertheless the mental faculties are somewhat blunted. 
Movements of the orbits, general convulsions, tonic and clonic, 
and paresis of the sphincters are wanting. The mother reports 
that the child complains frequently of headaches, during the 
night is restless, and sleep is much disturbed. During the past 
week the child has become quiet and apathetic. The mother 
also relates that four children have died of similar attacks. 
Status Prcesens.-The child is in a state of apathy, pacing 
no-attention to surrounding objects; is indifferent during the 
examination. The head is easily moved; no rigidity at the 
back of the neck. The movements of the eyeballs are normal; 
the pupils react readily, and show no difference in their size. 
An examination of the fundus of the eye was not undertaken. 
The tongue is protruded easily, shows no deviation, shows no 
appearance of scars either recent or former. The face shows 
no dissimilarity of the two sides. An examination of the ex- 
tremities reveals no paresis or paralysis. The general sensi- 
bility is not affected. 
The child, in attempting to walk, shows a staggering gait, 
with a tendency to fall backward, so that it is impossible to 
make any progress without support. The reflexes are all 
normal. 
An examination of the lungs shows consolidation in both 
upper lobes, with fine bronchial rales. 
The heart sounds are distinct; no murmurs appreciable. 
The pulse is not retarded. The examination of the remaining 
organs gives a negative result, 16 
CEREBELLAR DISEASE. 
The diagnosis is that of an affection of the brain-or the 
cerebellum-based upon the epileptoid convulsions, headaches, 
staggering gait, dizziness, nocturnal cries, and semi-comatose 
condition. With reference to the age, constitution, and condi- 
tion of the lungs it is plausible to infer that the affection is of a 
tubercular nature. 
Ten days later death occurred, and the report of the autopsy 
is as follows: 
The body gracile, emaciated; shows a slight amount of 
rigor mortis. The cranium is easily removed ; no adhesions of 
the dura. The dura presents nothing of interest. The pia is 
clear, easily removed ; no adhesions to the cortex. Blood-ves- 
sels are not engorged. 
In attempting to remove the brain from the cranium the 
left hemisphere of the cerebellum offers resistance, being firmly 
adherent to the dura. By using some force the adhesions are 
overcome, but there remains attached to the dura a round, 
somewhat regular mass of about the size of a hazelnut. The left 
hemisphere of the cerebellum shows a cavity with irregular 
walls, corresponding to the tumor attached to the dura. 
The cerebrum presents a smooth surface, with no percepti- 
ble resistance. Cross sections reveal nothing abnormal. The 
surface of the cerebellum shows, with the exception of the cav- 
ity above referred to, nothing abnormal. A Closer examina- 
tion, however, reveals distinctly the presence of six round, 
hard tumors, the size varying from a bean to a hazelnut, and 
a number of smaller ones less distinct in the substance of the 
cerebellum. Cross sections show the tumors to be distributed 
in the superior and inferior vermiform processes and the infe- 
rior lobes of the right and left hemispheres. 
A section of the tumors shows them to be grayish white, of 
a distinct concentric formation. The centre shows a soft, de- 
generated caseous mass. The surrounding tissues are (edem- 
atous. 
The examination of the thoracic cavity reveals the pleura 
pulmonalis covered with numerous yellowish points of about the 
size of a pin's head. Sections through the lungs reveal in great 
number the same deposits, The mediastinal glands are swollen CEREBELLAR DISEASE. 
17 
and present the same caseous consistence as the tumors in the 
cerebellum. The heart shows nothing abnormal. 
By request of the parents, the examination was limited to 
the cranial and thoracic cavities. 
Anatomical Diagnosis.-Miliary tuberculosis, especially 
characterized by the formation of tubercular deposits in the 
cerebellum. 
The nodule to which I will pay special attention is a tumor 
having the size and form of a hazelnut, with a diameter of ten 
millimetres. It is situated 
in the inferior-posterior lobe 
of the right hemisphere, oc- 
cupying the greater portion 
of this lobe. A longitudinal 
section through cerebellum 
and nodule shows it to ex- 
tend upward into the region 
of the corpus dentatum. The 
grayish coloration of its ex- 
ternal layers permits it to 
be easily separated from the 
surrounding tissue, while 
its centre presents two large, 
opaque caseous masses sur- 
rounded by an amorphous structure not possessing the caseous 
character of the former, being less opaque and of a greater con- 
sistence. The central masses are surrounded by a zone having 
a concentric laminated structure of a light gray color. The 
transition into the normal tissues of the cerebellum is not a 
sharp one, the gray coloration of the external zone of the 
nodule gradually disappearing. During the section-cutting 
the nodule shows the following microscopic changes: Gradu- 
ally diminishing in size, and in the centre several small, 
opaque, irregular masses appear. Laterally another group of 
small nodules appear, increasing in size gradually, conglomerat- 
ing, forming a new nodule laterally and posterior to the one 
first described. The lobus inferior posterior of the right hemi- 
sphere, therefore, possesses two tumors of about equal size; 
2 
6 
7 
8 
Sj 
nd 
7 
3 
2 
Fig. 1.-Case I (natural size).-nd, nucleus 
dentatus ; 2, lobus cuneiformis ; 3, 4, 
lobus posterior inferior, with nodule ; 
5, lobus posterior superior ; 6, 7, 8, lo- 
bus lunatus posterior. 18 
CEREBELLAR DISEASE, 
the one situated mesad and anteriorly, the other laterally and 
posteriorly. 
Case II. Clinical Diagnosis: Neoplasm of the Right Lobe 
of Cerebellum ; Autopsy ; Anatomical Diagnosis: Cyst of Right 
Lobe of Cerebellum.-For the history of this case and the pleas- 
ure of having made the observation I am indebted to my friend 
Dr. Linus T. McAdam, of Buffalo, N. Y. 
Jacob M., aged thirty-six years; height, five feet seven 
inches; weight, a hundred and seventy pounds; complexion, 
fair; constitution, robust; well developed. Antecedents, noth- 
ing of particular note was elicited ; family history good. 
Early History.-The patient passed through infancy and 
adolescence without any serious illness; never contracted syph- 
ilis or gonorrhoea. Some years ago he suffered a slight attack 
of insolation from which, however, he seemed to have fully re- 
covered. 
Present Condition.-On October 23, 1892, the patient con- 
sulted Dr. McAdam for pain in the back of the head, dizziness, 
nausea, peculiar revolving sensations in his head, and on stand- 
ing or while walking an inclination to be drawn backward. So 
strong were these last sensations that while the patient was in 
bed he would be compelled to turn on his right side, his head 
deep in the pillow, or while working in a stooped position he 
would suddenly fall backward, and on several occasions received 
quite severe knocks on his head. Along with these symptoms 
there coexisted a subnormal temperature, slow pulse, furred 
tongue, loss of appetite, sallow complexion, discoloration of the 
conjunctivae, and constipation. The patient was given hepatic 
stimulants, but without obtaining any alleviation of the distress- 
ing symptoms. A few days after this first visit he again consulted 
his physician, and complained of great thirst and gave a history 
of polyuria. On examination, the urine was found to contain 
sugar in abundance, and on measuring the urine it was found 
that he passed sixty to seventy ounces daily. About this time 
(November 7, 1892) he experienced considerable difficulty in 
walking, and was obliged to discontinue all work and remain at 
home. With assistance he was still able to walk about the CEREBELLAR DISEASE. 
19 
house, but his gait was unsteady, staggering, with a marked 
tendency to fall backward and to the right. 
With the exception of the glycosuria and polyuria, which 
subsided under careful treatment, the remaining symptoms 
gradually became more and more severe, and a consultation was 
held. The disease was diagnosticated as of cranial origin, but 
no definite diagnosis was reached. All methods of treatment 
proving unavailing, and, Dr. McAdam being desirous of further 
counsel, the writer was called to see the case on January 17, 
1893, with his family physician. 
The patient was found lying upon a couch, complaining of 
intense occipital pains radiating toward the vertex. On sitting 
up he felt dizzy, nauseated, and as if his head w'ere being pulled 
backward. On attempting to walk his gait was staggering, 
with a desire to fall to the right and backward, and on walking 
across the room with assistance he would continually veer to 
the right. 
Psyche.-Ilis mind seemed to be clear and unaffected ; sleep, 
fair. 
Motility.-The strength of the muscles of the extremities 
was diminished, but no more than the inactivity to which he 
was subjected would warrant; the muscles of the right side 
were, however, weaker than those of the left. 
Tendon Reflexes.- The patellar tendon reflexes were slightly 
exaggerated. Other superficial and deep reflexes were normal. 
Sensation.-There existed no disturbance of the sensory 
nerves; trophic and vaso-m<>tor disturbances were likewise 
wanting. 
Special Senses.-Unfortunately, the fundus of the eye was 
not examined, due perhaps to the fact that no ophthalmoscope 
was at hand. An ophthalmoscopic examination was, however, 
promised, but failed eventually to be performed. No abnormi- 
ties whatever of the special senses were discernible; no loss of 
sexual power was admitted. 
To me it seemed clear that we had to deal with some cere- 
bellar neoplasm, but what its nature or origin I could not say. 
The characteristic symptoms of cranial tumor-such as intense 
cranial pain, obstinate x omiting, vertigo, coupled with symp- 20 
CEREBELLAR DISEASE. 
toms which we are wont to denominate cerebellar, as stagger- 
ing, ataxic gait, inclination to fall backward, occipital tenderness, 
etc.-warranted the diagnosis arrived at. 
Not receiving the desired promise of speedy and certain re- 
covery, the patient sought other advice, and the history of the 
course of the disease was unfortunately interrupted. On the 
evening of March 15, Dr. McAdam was hastily called, and ar- 
rived in time to see the fatal termination. Inquiry elicited the 
fact that for two or three weeks previous the patient had been 
attacked with a slight fever with occasional chills. No con- 
vulsions had been noticed at any time. 
An autopsy was made on the following day by the writer, 
assisted by Dr. McAdam, with the following results: The cal- 
Fig. 2, Case II.-1, opening of cyst cavity (the dotted line shows the size of the 
cyst); 2, the corpora qnadrigemina ; 3, the vermis. 
3 
varium was rather thick, dura somewhat adherent. The pia 
was clear; vessels not markedly injected; Pacchionian bodies CEREBELLAR DISEASE. 
21 
small and sparse. The convexity of the brain appeared healthy, 
the convolutions were not flattened, and the fissures were of 
usual depth. The cerebrum was removed; beginning cephalad, 
the basilar structures were carefully severed, and, on cutting the 
right side of the tentorium cerebelli, a clear, amber-colored fluid 
flowed into the cerebral cavity. The cerebellum was carefully 
removed, and in the inferior-occipital fossae was found about an 
ounce to an ounce and a half of amber-colored fluid. On closer 
examination the right lobe of the cerebellum was found to be 
flattened, boggy, and considerably smaller than the left lobe. 
This condition was quickly explained by the presence of a large 
cavity in the right lobe, the walls of which had collapsed, and 
the fluid had escaped during the removal of the cerebellum. 
The entire right lobe appeared to have been undermined, and 
virtually was nothing more than the walls of the cyst. During 
the dissection and examination of the cerebellum the under- 
taker thoughtfully and thoughtlessly sponged the cranial cavity, 
thus depriving us of any of the cystic fluid for a more careful 
microscopic examination. It is therefore impossible to say just 
what the character of the cyst was: whether it was the result 
of hydatid disease, or of inflammatory or haemorrhagic origin. 
Case III. Clinical Diagnosis: Abscess of Left Lobe of Cere- 
bellum ; Autopsy ; Anatomical Diagnosis: Abscess of Left Lobe 
of Cerebellum. -S. S., aged forty-two years, kindly referred to 
me by Dr. C. W. Bourne, of Hamburg, N. Y.; height, five feet 
five inches; weight, two hundred and eleven pounds; constitu- 
tion strong, healthy; complexion dark; married and father of 
children; occupation, salesman; family history shows no trace 
of any hereditary or constitutional disease. 
Early History.-When four years old he had an attack of 
brain fever and was sick ten days; otherwise he has always 
been a healthy, robust man, of good habits, moderate in his 
appetites, ambitious, striving to attain success in everything he 
undertook. 
During the latter part of November, 1893, he slipped on an 
icy sidewalk and struck on the back of his head. He com- 
plained of a numb feeling, but did not experience much pain. 
It only made his head " feel queer," as he stated, and in a few 22 
CEREBELLAR DISEASE. 
days he felt no further effects of the fall. The following week 
he was taken sick with the "grippe" according to his family 
physician. He complained of a general malaise, drowsiness, 
dizziness, pain in the ears, but no otorrhcea. He was not con- 
fined to his bed, but did not leave the house for two weeks. He 
returned to his work, but after a week's trial was compelled to 
abandon it because of the ear trouble, which caused him much 
pain and dizziness. He experienced a dull, heavy feeling just 
back of the ears-would tire easily. 
About February 1, 1894, he again resumed his work, and 
soon thereafter had a second fall on an icy sidewalk, striking 
the back of his head with considerable force. He was stunned 
for a few moments and complained of much pain about the 
occiput. After treating the head with liniments and applica- 
tions for a few days, he was once more able to go on the road. 
On March 17, 1894, he complained for the first time of a severe 
headache at the back of the head, and referred to it as "just 
as if something were trying to burst his head open." The pain 
was excruciating, its greatest intensity being over the left oc- 
cipital region. Pressure upon the occiput alone would relieve 
it. About midnight of the same day he began to vomit, appar- 
ently on the least exertion, without any warning; no nausea, 
and the vomited material would be forced from his mouth (pro- 
jectile vomiting). He was unable to retain anything on his 
stomach, expelling it immediately, and vomited much watery 
fluid. The least movement of his head or body would precipi- 
tate a spell of vomiting. He complained of much dizziness and 
vertigo. His gait was staggering, loggy, and he could not rise 
from the chair alone because of the dizziness and inclination to 
fall backward. Ilis condition grew gradually worse, and in a 
few days he was unable to leave his bed. His head would be 
drawn down into the pillows, and he seemed to have lost the 
power over the movements of the head. I was summoned to 
see him in consultation with his family physician on March 29, 
1894, and found the status prcesens as follows: 
A strong, well-nourished, heavily built man of about forty 
years of age, lying upon a bed with his head drawn backward, 
the posture of spinal meningitis. On hearing the history of CEREBELLAR DISEASE. 
23 
vomiting, localized headache, dizziness, associated with a fall, 
the backward displacement of the head, I surmised some cere- 
bral disorder. His mind was at times clear-always clear, the 
family reported ; but to me he appeared semi-conscious, would 
reply tardily to questions put to him, and made considerable 
effort to make known his wants. 
Motility, although impaired somewhat by the long sick- 
ness and inability to retain food, was not limited to any special 
extremity or side; face and tongue were regular on both sides; 
eyeballs moved lazily; pupils dilated and responded to light. 
The eyes were dull and heavy. I did not carry an ophthalmo- 
scope with me and so unfortunately could not examine the optic 
discs. 
The tendon and muscular reflexes were exaggerated. Patel- 
lar reflexes considerably increased, but no definite ankle-clonus. 
Apparently no disorders of sensation, although the semi-stupor 
which he was in may have influenced this examination, lie 
evinced great pain when the head was turned or when the occi- 
put was percussed, but did not feel any other painful sensa- 
tions. 
Pulse was full, regular, uniform, ranging from 78 to 85 per 
minute. 
Temperature, 98'7° F. 
Urine contained neither sugar nor albumin and was not in- 
creased in quantity. 
Bladder and rectum performed their functions normally, and 
up to March 17, 1894, there was no change in his sexual power. 
My suspicions of a cerebral growth were satisfied, and tak- 
ing into consideration the fall on the occiput, with a history of 
a preceding attack of grippe, I ventured the diagnosis of cere- 
bellar abscess. He was in no condition for an operation and 
palliative measures were resorted to. 
A troublesome hiccough set in a few days after my visit, 
also a paresis of the left arm and leg; both of these symptoms 
increasing in severity from day to day. 
Incontinence of urine, necessitating catheterism, and con- 
stipation also made their appearance. He was conscious up to 
the last, and at intervals would make inquiries about local CEREBELLAR DISEASE. 
24 
affairs. On awakening from sleep he would be flighty for a 
few seconds, then would be calm and composed. 
He died on April 11, 1894, and on the following day I was 
telegraphed for to perform an autopsy. 
The head only was examined, as it was deemed unnecessary 
to make a complete examination. 
3 
2 
w 
Fig. 3, Case III.-1, abscess, denoted by the dotted line; 2, opening of the 
abscess; 3, trigeminus nerve ; 4, pons. 
The scalp was quite thick and bound quite firmly to the 
skull. No haemorrhages or discolorations could be detected 
over the occipital region, the result of the previous falls. 
The calvaria was somewhat thicker than normal; not ad- 
herent to the dura. The sinuses were engorged with venous 
blood, and the pial vessels were markedly injected, but not ab- 
normally so. The pia was easily removable; there were no 
opacities, and the Pacchionian bodies were not enlarged. 
• The cerebro-spinal fluid was clear, amber-colored, and of the 
usual quantity. The cerebrum was carefully removed from the CEREBELLAR DISEASE. 
25 
fossa, and on cutting the tentorium and attempting to roll out 
the cerebellum so as to cut the spinal cord, a thick, creamy 
fluid burst through the lateral walls of the left cerebellar hemi- 
sphere. 
The brain was carefully placed on a platter and sections cut 
through the cerebrum, longitudinally and transversely. A small 
quantity of fluid was found in the lateral ventricles; no haemor- 
rhages, no inflammatory conditions, and no diseased condition 
of the cerebral arteries could be detected. The cerebellum, 
however, was of more interest. 
The right side was firm and elastic to the touch, while the 
left hemisphere was boggy, and on the slightest pressure a 
thick, creamy pus exuded from a large longitudinal opening in 
the lateral wall of the lateral lobe. The opening was perhaps 
one inch in length, and opened into an irregular cavity about 
the size of a small hen's egg. The walls of the abscess cavity 
were roughened, irregular, and had a reddish haemorrhagic ap- 
pearance indicative of a former congestion or capillary haemor- 
rhage. The pus was not examined bacteriologically and its 
bacterial contents can not therefore be given. 
Analyzing this case briefly, we find present the three car- 
dinal symptoms of brain disease: localized headache of the 
bursting variety, dizziness, and cerebral vomiting-i. e., vomit- 
ing without nausea, without warning, and forced from the 
mouth (projectile). The other cardinal symptom of brain dis- 
ease-tumor, choked disc, or optic neuritis-was unfortunately 
not sought for, and must therefore be left out of consideration. 
The history of two severe falls upon the occiput, with symp- 
toms of pain and numbness for a few days following, the stag- 
gering gait, tenderness and rigidity of the neck muscles, with 
head drawn backward, pointed to some cerebellar affection. 
The gradual implication of the left side of the body, semi- 
paresis, consciousness up to the end, and the behavior of the 
reflexes, strengthened the theory of cerebellar disease. The 
diagnosis of abscess was made upon the theory that as, prior to 
the falls, he had been sick with an infectious disease, and as 
septic processes are liable to be lighted up consequent to such 
injury, the idea of abscess seemed to me both plausible and pos- 26 
CEREBELLAR DISEASE. 
sible. Trauma is recognized as one of the most prolific setio- 
logical factors of brain abscess, the shock seeming to tear and 
bruise the tissues directly under the seat of injury, causing 
haemorrhage, inflammation, disintegration, and finally necrosis 
of the nerve elements. The presence of pyogenic bacteria in 
the system, and the cordial invitation which such a focus of 
softening and dissolution extends to the gallant germs, results in 
the speedy formation of a suppurating abscess. 
Case IV. Clinical Diagnosis: Tuberculosis; or else Abscess 
of Cerebellum.-L. L., female, unmarried, aged twenty-three 
years: height, five feet four inches and a half; weight, one 
hundred and twenty-four pounds; complexion, dark; constitu- 
tion, delicate. 
Antecedents.-Father and mother both living and healthy, 
aged forty-six and thirty-eight years respectively; three broth- 
ers and two sisters likewise healthy. 
Paternal grandparents: Grandfather living and healthy, aged 
seventy four; grandmother died of typhoid fever, aged sixty- 
one years. 
Maternal grandparents: Grandfather died of paralysis, aged 
seventy-two; grandmother died of cirrhosis of the liver, aged 
fifty-seven years. 
No history of tuberculosis among near or distant relatives 
could be elicited. 
Early History.-When a child she had measles, chicken- 
pox, diphtheria, scarlet fever, and malarial fever. When nine 
years of age she fell over suddenly and injured her back, a 
large bunch appearing over the lumbar region a little to the 
right of the spinous processes. She was unconscious for twenty- 
four hours, and suffered great pain. Curvature of the spine 
developed, and for a year she was unable to walk about. Was 
vaccinated when fourteen years old, and immediately her back 
grew worse, the deformity increasing until a right scoliosis was 
well marked. She wore braces for some time and improved in 
general health, so that the spinal irregularity was scarcely 
noticeable. When nineteen years of age she had a severe at- 
tack of pneumonia, and every winter since then has had heavy 
colds with cough, expectoration, symptoms of fever, and periods CEREBELLAR DISEASE. 
27 
of extreme weakness. At the same time she began to notice a 
dull, heavy ache over the occiput extending down the spine, 
accompanied with vomiting spells and dizziness; was taken 
with fever which ended suddenly, and began to improve and 
increase in weight (winter of 1891). The following winter she 
again had the occipital headaches, but without vomiting or 
dizziness. In January and February, 1893, the same familiar 
headaches reappeared and as quickly subsided, leaving her in 
comparatively good health for the remainder of that year. On 
July 4, 1893, she weighed one hundred and thirty-six pounds. 
The week before Christmas of 1893 she was taken with a 
slight attack of the then prevalent grippe. 
Iler present sickness she dates back to January 1, 1894, when, 
without any warning whatever, she would vomit forcibly a wa- 
tery, stringy fluid. She narrates that while going through the 
figures of a quadrille one evening in January, 1894, a convulsive 
act of vomiting overtook her on the dancing floor. Headaches, 
confined mostly to the occipital region and extending down the 
spine to the middle of the back, made their appearance, sharp 
and piercing at first, then would gradually wear away. Along 
with the headaches she would have dizzy, staggering spells, and 
on rising from a chair would feel like falling backward. On 
walking she would constantly pitch to the left side, and would 
put out her left hand to save herself. On several occasions her 
left knee and leg would give way, precipitating her to the 
ground. Accompanying these symptoms she would experience, 
two oi' three times daily, a feeling of extreme heat come over 
her which would be followed by light chills. Iler face would 
redden, flush, perspiration would break out, and in a short time 
she would complain of the room being too cold. The head- 
aches, vomiting, and vertigo growing more intense, she was re- 
ferred to me by Dr. C. C. Frederick on April 21, 1894, for 
special treatment. 
Status Prcesens.-April 21, 1894, I found her a fairly well 
developed, bright, intelligent, and active girl, with no indica- 
tions of any mental disturbance. 
Head.-Not painful on percussion except over the occiput, 
and when pressure is exerted over the left occipital region she 28 
CEREBELLAR DISEASE. 
coinplains of severe pain, just as if something were crushing 
her head, or as if the back of her head were falling out. Her 
hair, which is long and beautiful, is coming out rapidly, and 
many gray hairs have appeared within the past year. Her face 
when she entered the office was cold, pale, and anaemic, and 
before leaving it was hot, flushed, and feverish. 
Eyes.-No disturbances of motility, but when they are fixed 
to the right or left she experiences a pain over the occiput. 
Pupils react to light and accommodation, and are dilated. No 
nystagmus and no appearance of any optic neuritis (choked 
disc). 
Ears.-A buzzing noise has been heard at times, and she 
has sometimes experienced an itchy feeling in both ears. No 
deafness. 
Nose and Mouth.-Nothing abnormal about the sense of 
smell or taste. The tongue protrudes without deviation and is 
not coated. 
Appetite poor. 
Motility.- A staggering, uncertain gait is manifest, and her 
mother reports an inclination of wheeling to the left, and has 
repeatedly chided her for the unladylike way in which she 
walks. Standing with her eyes closed, she tends to fall back- 
ward. Inco-ordination of the hands or legs can not be de- 
tected. 
Right-hand grip, as measured with the dynamometer, 50 ; 
left, 48. Muscles are rather flabby. 
Sensation.-No distinct abnormities of sensation can be 
detected. 
Reflexes.-Somewhat, though slightly, increased, especially 
the patellar tendon; no ankle-clonus. Superficial reflexes not 
exaggerated. 
Internal Organs.-Heart and lungs appear undisturbed. 
Pulse, 80, regular and uniform ; temperature, 37'8° C. 
Bowels regular. Urine, high specific gravity; no albumin, 
but shows presence of sugar. 
General Symptoms.-She sleeps very poorly because of the 
pulsation in her head. When she turns over she feels as if 
something heavy had turned over in her head with a thump. CEREBELLAR DISEASE. 
29 
Menses irregular; flows profusely for eight or nine days. 
She has lost much in weight since January 1, 1894, her clothes 
all becoming too loose and baggy. Iler hands and feet are 
generally very cold and covered with cold perspiration, and yet 
her face will be hot and flushed. 
The severe headaches, projectile vomiting, and vertigo, 
along with occipital pain and tenderness, inclination to fall 
backward, and of veering to the left, the sudden giving way of 
the left leg, ataxic gait, with general sensibility and reflexes but 
little if at all disturbed, indicated some cerebellar growth, seated 
in all probability in the left lobe. The slow growth, previous 
history of the patient, and fever phenomena suggested to me 
the presence of a tubercular nodule undergoing softening and 
disintegration. 
Without disclosing my diagnosis to the patient or her par- 
ents, I put her on a palliative and constructive treatment, 
which seemed to relieve and benefit her for about five weeks. 
The symptoms became suddenly more severe, and feeling pretty 
confident that if an operation could be secured an abscess cav- 
ity would be found, I entreated the parents to yield to what 
seemed the only procedure that would offer any hope of saving 
the daughter's life. Consent was obtained provided the opera- 
tion would not be performed unless it was reasonably certain 
that it would bring relief, and the patient was transferred to 
the Sisters of Charity Hospital. A thorough examination 
made June 19, 1894, revealed the following additional facts: 
She feels as if her chin were being elevated and the head 
drawn backward. At night the head digs deep into the 
pillows. Pressure over the occiput provokes a feeling of 
nausea. 
Sensation.-Some slight disturbances of sensation have pre- 
sented themselves, as delayed sensation over the forehead and 
areas of hyperesthesia about the face and hands, which per- 
haps arise from the state of mind occasioned by her surround- 
ings. Her eyes were tested to-day by Dr. A. A. Hubbell, whose 
report is here appended: 
" R. and L. hypermetropia, 0'75 D.; no optic neuritis; eso- 
phoria, 3° ; abduction, 8°; adduction, 25°, one trial, which can 30 
CEREBELLAR DISEASE. 
be brought up to 40° or 45°. There is nothing here to account 
for symptoms." 
Measurements of the arms and legs give the following re- 
sults : 
Circumference of Distance from internal Circumference of 
left arm : condyle of humerus : right arm: 
9 inches. 9 inches. . 9 inches. 
8$ " 6 " 8$ " 
8$ " 3 " 8$ " 
Left forearm : Right forearm : 
8 inches. 3 inches. 8 inches. 
6$ " 6 " 6$ " 
5| " 9 " 5$ " 
Circumference of Distance from internal Circumference of 
left thigh : condyle of femur : right thigh : 
15$ inches. 6 inches. 15$ inches. 
13$ " 3 " 14 " 
Left leg: Right leg : 
12| inches. 3 inches. 12$ inches. 
12$ " 6 " 13$ " 
12$ " 9 " 13 " 
Strength of hands: Right, 40; left, 40. The strength of the 
legs, as measured with the pedo-dynamometer, shows: Right 
leg, 30; left, 36. 
The temperature has ranged from 38'5° C. to 40° C. Pulse, 
70 to 85 a minute. Urine shows now no trace of sugar. 
The surgeon in charge, Dr. II. Mynter, desired to keep her 
in the hospital for a few days before operating and to watch 
her closely, so that in case she should fail rapidly an operation 
could be performed at once. To our surprise, instead of failing 
she seemed to improve, the vomiting was less frequent, the head 
less painful, appetite improved, the fever symptoms were less 
marked, and her general health was gaining. Encouraged by 
this change in her symptoms, the parents removed her to their 
home and all thoughts of any operation are now relegated to 
dreamland. 
My diagnosis and mode of relief, so nicely planned and 
specified, have provoked some twitting remarks, but neverthe- CEREBELLAR DISEASE. 
31 
less I am positive that the diagnosis was correct, and the 
operation would have sustained me. 
I have seen the patient several times since she left the hos- 
pital, and still find left occipital tenderness, unsteadiness of 
gait, vomiting and vertigo. Her general physical condition is 
below par; she is pale, anaemic, and still complains of feelings 
of heat and cold. 
I have at no time observed any manifestation of hysteria or 
any type of malarial fever, and am confident that her cerebellum 
harbors a latent tubercular nodule. The New York Medical Journal. 
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