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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