On Diseases of the Cerebellum
Article V.- ?On Diseases
of
the Cerebellum.
Shearer.
(Read at the
Medical Institution,
Liverpool,
on
23d
By
Dr Geokge
January 18G2.)
Case 1.
Summary.?Cephalalgia; vertigo ; amaurosis ; deafness ;
; impaired balancing or co-ordinating power ;
automatic or involuntary cries; indications of crossed motor paralysis ; convulsion fits ; intellect clear. Tumour growing into cerebellum from meatus internus of right ear. Waxy kidneys.
divergent squint
set. 37, admitted to Liverpool Workhouse Hospital, under the
Gee, on 10th November 1860.
Patient is a thin, emaciated woman, complaining "of pain in her forehead, of
blindness (amaurosis with dilated pupils), and of rheumatic pains in her
limbs. She is quite helpless, and has been bed-ridden for four months; so that
bed-sores have formed over the sacrum and trochanters. She has marked
Mary Bradley,
care
of Dr
"
She appears to have suffered from frontal headache and
for at least twelve months ; gradual loss of vision, amounting at length
to complete
amaurosis, for eight months; loss of hearing for four months, partially
recovered from during the last month, and now confined chiefly to the right ear;
loss of power to walk or sit erect for five months. When propped up in bed,
there is a constant tendency to fall over to one side or other. She can, however, draw up her legs in bed; but there seems to be less power in the left than
in the right
leg. At one time the arms are said to have been paralyzed; but
this is not now the case.
divergent squint.
vertigo
1038
DE SHEARER ON DISEASES OF THE CEREBELLUM.
the fortnight this patient was under observation, she was a source of
annoyance both to her own and the adjoining wards, from an uncontrollable tendency to shout and scream in the most vociferous manner, suddenly and without
any apparent reason breaking out into the most piercing and piteous waitings,
which she continued at short intervals throughout the night, and carried on
occasionally also during the day. Of course she slept little, and only during
the daytime. Her noisiness appeared to be utterly beyond voluntary control.
Repeated expostulations and warnings were vainly tried, and even threats of
confinement in the asylum failed to entail silence upon lier. The loudness of
her cries seemed to bear no relation to the intensity of her sufferings, for she
afterwards declared that she did not cry out because of the pain, but because
she could not help doing so. Frequently she denied the existence of pain
altogether. Her cries, in short, were automatic rather than voluntary, and
closely resembled the long-continued piercing cries or wailings which are
extorted from animals whose nervous ganglia are irritated or cut into by the
knife of the vivisector. She had been habitually intemperate, and had been
subject to frequent epileptiform convulsions during the last four months. It
was observed that she was quite ready and clear in answering questions when
loudly spoken to,?in fact, there was no impairment of the intellectual faculties.
She gradually wasted and pined away, and died a fortnight after admission.
Post-mortem examination revealed a tumour of the size of a walnut growing from the internal meatus of the right ear, slightly attached to the auditory
It had formed a nest for itself amongst the folia of the right hemisnerve.
phere of the cerebellum, which it had, by pressure, opened out and somewhat
softened. The right side of the pons bore also a visible concave impression;
but none of the nerves arising at this part appeared to have been seriously
incommoded. The tumour presented, on section, a few hsemorrliagic-looking
spots, and near the surface a small cyst. It was fibro-plastic in structure, consisting of numerous cells of small size interspersed amidst meshes of fibres.
The kidneys were waxy, but the urine had not been examined : there was no
dropsy. No other diseased organs were found.
N.B.?The greater enfeeblement of the left lower extremity observed in this
case was doubtless owing to the pressure of the tumour upon the right side of
the pons.
During
Case 2.
Summary.?Cephalalgia; temporary paralysis
of
right
side, of sphincters, and of speech, without loss of consciousness.
Recovery from paralytic symptoms. Supervention of comatose
symptoms, but intellect only in abeyance; vision perfect. Deepening insensibility; loud and distressing, almost incessant, automatic
moanings. Death. Post-mortem.?Large clot in left lobe of cerebellum, composed of two portions,?a recent central portion, con-
sisting of recently effused blood; and a lighter coloured circumferential portion, containing compound granular corpuscles, and
crystals of heematin.
Neil Macneile, aet. 62, shoemaker, admitted to the Edinburgh Royal Infirmary,
under the care of Dr W. T. Gairdner, on 12th March 1860.
Patient had enjoyed good health up to 2d March, ten days before admission, on which evening, at the hour of 10i p.m., he was seized with a severe
pain in his left temple, which soon spread all over his head. An hour later
it was observed that he had lost the power of his right arm and leg: his left
side also was affected in a minor degree, and he passed his water and stools in
bed. He was quite conscious at this time, and complained of pain in his head
and back.
At 2 a.m. his speech was so much affected that what he said could
not be made out.
On 6th March, i.e., the fourth day of liis illness, he had completely regained
DR SHEARER ON DISEASES OF THE CEREBELLUM.
faculty
of
recovering tlie power of the palsied side (the
soon passing off), and was able to keep his
"owels and bladder under
control.
voluntary
On the 12tli his
progress was arrested by the supervention of comatose
symptoms, and he was taken to tlie hospital. State on admission.?Patient
seems to be in a
deep sleep, from which, however, he can be roused so as to
answer questions addressed
specially and emphatically to himself. Respirations slow, but without stertor; countenance and surface
very pale and cool;
puffing of cheeks; pulse, small and irregular, about 90. Moves left arm about,
kees and can count
correctly the number of objects held up to him. Vespere.
T-Tongue seems protruded to right side. When asked, is able to move his
fight arm up to his head, and can lay hold of a hand presented to him, though
the
grasp is feeble. Can pull up either leg, and sensibility in both is evinced
satisfactorily on scratching them. Intelligence not abolished,?only in abeyance, requiring stimulation.
?in much the same state. Pulse 72. On being roused, patient replies
enough to simple questions, but relapses into somnolence the moment
j'eadily
he is left
alone, to be roused again by a new question, but only if put to him
s
speech,
and
1039
-was
!ghter affection of the left side
sharply,
and in
a loud tone of voice.
not now respond to stimuli of any kind. His moanings, which
are
very loud and distressing to his fellow-patients, are continued, with per-
14th.?Does
haps twenty
however,
successive
respirations,
and then
they
cease
for
a
little?only,
during the night.
Post-mortem examination.?A large clot, of the size of a pigeon's egg, occupied the substance of the left lobe of the cerebellum, which was much softened
around the clot. The clot had partially interposed itself between the cereto be recommenced.
He died
_
bellum
and the dura mater. The lateral ventricles were distended by three oz.
The clot consisted of two portions?a central, which rolled out
easily, was of a deep jet colour, and the consistence of jelly, and which, under
the microscope, consisted of an immense mass of blood globules; and a circumferential portion, which adhered to, or was incorporated with, the surrounding
hrain substance, was of a brownish colour, and under the microscope contained
numerous compound granular corpuscles and pigment masses?black, brown,
pink, and yellow. Some tetrahedral crystals of a pinkish colour were also seen.
of serous fluid.
The twofold character of the clot corresponds with and explains
the main features of the case. It is plain from the history that this
patient
underwent two distinct apopleptic seizures?the first on 3d
twelve days before death; the second on 12th March, two
days before the fatal event. The clot, in the first instance, doubtless underwent, during the twelve days of the man's existence,
partial absorption, and such transformation of its elements as yielded
the pigment masses of various colours, and tetrahedral crystals of
haimatin. Its irritative influence upon the surrounding cerebellar
substance was also indicated by the abundance of inflammatory or
exudation globules, which were seen in the outermost zone of
softened brain. The second and fatal hemorrhage was composed
entirely of blood globules, which appeared to have undergone no
perceptible alteration in form or colour; it must, therefore, have
been very recently effused.
March,
Case 3. Complicated with cerebral disease. Summary.?Dementia; impairment of co-ordinating power. Injury of the head six
years before; convulsion fits, unrelieved by trephining; temporary
motor and
sensory paralysis of right side; Death. Post-mortem.?
1040
Fungus
DR SHEARER ON DISEASES OF THE CEREBELLUM.
cerebri.
Purulent accumulation in
hypertrophy of falx cerebri, and of
rounding and enclosing the cerebellum.
hyaline cyst in right corpus striatum.
mense
Imsac of arachnoid.
all the membranes surOld apopleptic clot or
James Matthews, set. 44, a sailor, a patient under the care of Mr Fletcher, at
the Workhouse Hospital, Liverpool, with signs of dementia of three months'
duration, combined with slight paraplegic (?) symptoms.
Loss of memory, and chiefly of names, is the most important symptom.
He is tolerably deaf, but can articulate in a slow, deliberate manner. He
frequently raises his hand to his head, and pulls down his eyebrows, as
if he suffered from pain in his" head.
He is very insecure on his legs
and unsteady in his gait, and complains of a feeling of numbness in his feet.
He appears to drag the foot partially when walking,?in fact, he has very
much the " carry" of a flat-footed person; yet there is no real paralysis,
for by a strong effort of the will, inspired by prompting, he can plant his
foot firmly upon the ground. He received an injury to the right side of
the skull near the vertex, six years ago, which has left a considerable hiatus
in the outer table of the skull, to which the scalp is very firmly bound
down, and which at first sight led to the opinion that there was a depressed
portion of bone pressing upon the brain and causing the convulsions. Shortly
after he first came under my notice he was seized with a general convulsion fit
at the hour of 5 p.m. on 8th November, which passed off in an hour, leaving
him in a quiescent state, insensible and moaning. Pulse 144 ; respirations 32;
pupils natural; spasm of eyelids induced by efforts made to open them ; cheeks
puffing out with eveiy breath; eyes directed to the left. Right arm and
leg palsied, but limber; no response whatever to pricking or tickling the
Muscles of
cutaneous surface, sensibility as well as motion being paralyzed.
left arm and leg firm ; sensibility easily excited in the whole of the left side.
At 8 p.m. the temporary paralysis of the right side had passed off, but the
patient lay insensible and snoring.
The operation of trephining was performed over the depressed spot, but no
depression of bone was found to exist, neither was there any osteopliytic growth
at the site ; the depression being caused by an exfoliation of a portion of the
outer table of the skull.
The man Avas therefore not relieved by the operation;
and, after lingering in an insensible state from twenty-four to thirty-six hours,
he died.
Post-mortem examination revealed a considerable mass of the right cerebral
hemisphere fungating, ready to slough, and exhaling a most intense pungent
fetor. A quantity of laudable pus, amounting probably to two or three ounces,
was found in the sac of the arachnoid.
From the quantity and quality of the
exudation when contrasted with the patient's low state?the shortness of the
time since the operation, and the opposite state of the exposed brain (sloughing)
?it had evidently been formed prior to the operation.
The falx cerebri was
much thickened, to the extent of not less than a quarter of an inch, and seemed
The falx
to contain some firm nodules of fibrous matter in its substance.
cerebelli and the membranes above and below the organ were also very considerably thickened and opaque. In short, it was evident that there had been
a slow and gradual growth or hypertrophy of these membranes, extending
A small cavity, large enough to lodge a
very probably over many months.
filbert, and containing a clear fluid, was found in the substance of the right corpus
striatum. It was probably the seat of a hyaline cyst. Its development was
probably very slow and gradual, and it certainly was not accompanied by any
special symptoms. The surface of this little ulcerated (?) spot was somewhat
uneven, of a greyish aspect, and somewhat softer than the rest of the brain.
Under the microscope numerous granular bodies resembling the exudation
globules of Bennett were seen, and much plastic lymph upon the vessels.
The above is
a
complicated
and
important
case.
I
desire,
how-
DR SHEARER ON DISEASES OF THE CEREBELLUM.
1041
which it may
of
with
cases
cerebellar
disease.
the
other
comparison
The dementia is readily explained by the state of the greater falx.
1 he occurrence of convulsion-fits
shortly before death appears to have
depended upon the development of purulent fluid in the sac of the
arachnoid. The temporary motor and sensory paralysis of the right
Slde, and the cyst-like cavity in the substance of the right corpus
striatum are both enigmas to me. But I may state in one word
that I consider that the hypertrophied condition of the membranes
^vesting and enclosing the cerebellum, which must have caused
pressure upon that organ, and the patient's altered gait and impaired
Diode of progression, were connected in the relation of cause and effect.
ever,
bear
solely
to fix attention upon tliose features in
Case 4.
Disorganization of posterior cerebellar lobes in a case of
with amaurosis, in which, for many days before
death, the extraordinary symptom was observed in the patient of
suddenly and without apparent cause, bursting out into the most
piercing cries and wailings," which closely resembled those uttered
chronic mania,
by
the lower animals when their
have been injured
The case is recorded
Perth Royal Asylum
minor lesions affecting the cerebrum.
nervous
ganglia
by the knife of the experimental physiologist.
by Dr Lindsay in his Annual Report of the
for 1861.
There
were
Case 5. Abscess in substance of right lobe of cerebellum, in
which loss of balancing or regulating power over the lower
extremities was particularly observed. Other particulars of the
case not known.
Case 6. A living illustration of the main symptoms observed in
the foregoing cases, and in which there are the strongest presumptive
proofs
of the existence of morbid
growths
inferior occipital fossa. The patient was shown
the Institution when the paper was read.
in the
posterior
to the members of
Summary of Symptoms.?Cephalalgia for ten months ; single convulsion fit at
commencement of illness; history of syphilis and of nodes on forehead and
scalp; immense node in right temporal fossa; double facial palsy and paralysis of
both auditory nerves; incessant and most piteous involuntary cries and wailings
throughout the night. When asked why he kept on so, he said " I was not
conscious of my moanings ; it's more like a habit than anything else." Intelligence unimpaired throughout. Tottering or drunken gait. Vast relief and
improvement under four weeks' treatment with Plummer's pill and hydriodate
of potash.
Diagnosis.?Two or more tumours of syphilitic origin,?intracranial nodes, in
short,?growing
upon or behind the posterior surface of the petrous portion of
both temporal bones, and from their contiguity to the hemisphere of the cerebellum, determining pressure upon that organ.
The following is an enumeration of the symptoms presented in
cerebellar diseases in the order of their importance. The first three
take the position of
leading symptoms, and a concurrence of the first
five might (in the writer's opinion) lead to a certain inference of
disease in the cerebellum :?
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