Tumor and Large Cyst of the 
Cerebellum, with Symptoms 
Extending over Several Years 
J. T. ESKRIDGE, M.D. 
DENVER, COL. 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE MEDICAL DEPARTMENT OF 
THE UNIVERSITY OF COLORADO; NEUROLOGIST TO THE ARAPAHOE 
COUNTY AND ST. LUKE'S HOSPITALS 
BY 
Reprinted from the Medical Record, August 17, 1895 
NEW YORK 
TROW DIRECTORY, PRINTING AND BOOKBINDING CO. 
201-213 East Twelfth Street 
1895 Reprinted from the MEDICAL Record, August 17, 1895. 
TUMOR AND LARGE CYST OF THE CERE- 
BELLUM, WITH SYMPTOMS EXTENDING 
OVER SEVERAL YEARS. 
By J. T. ESKRIDGE, M.D., 
DENVER, COL. 
PROFESSOR OF NERVOUS AND MENTAL DISEASES IN THE MEDICAL DEPART- 
MENT OF THE UNIVERSITY OF COLORADO ; NEUROLOGIST TO THE ARAPAHOE 
COUNTY AND ST. LUKE'S HOSPITALS. 
Lucy E , eleven years of age, white, of German 
parentage, was referred to me by Dr. McNaught, Feb- 
ruary 19, 1895, on account of convulsive seizures ex- 
tending over a period of several years, attended by 
almost complete blindness. Family history was nega- 
tive. The child at birth was apparently healthy, but 
when fourteen months old, while teething, began roll- 
ing the head from side to side, and when taken in the 
mother's arms the head would be retracted and turned 
from side to side. The child would frequently cry as 
if in pain. Several days after these symptoms first 
manifested themselves, she was seized with a convul- 
sion which lasted about five minutes, during which 
there was cyanosis of the face, frothing from the 
mouth, the eyes were fixed and the pupils dilated. 
One leg was flexed at the knee and thigh, but which 
the mother does not now remember, both hands were 
clinched, and she thinks the arms were extended and 
rigid. About this time, or February, 1885, a thick, 
offensive discharge took place from both ears. The 
otorrhoea continued for two or three months, and dur- 
ing most of this time the child was restless and threw 
its head from side to side. From June, 1885, to Janu- 
ary, 1888, the child was not really ill, but it remained 2 
nervous and fretful. At the latter date it had a slight 
attack of mumps and afterward remained in its usual 
condition until May, 1889, when it suffered from mea- 
sles, but recovery from this seemed to be complete. 
In April, 1891, it fell from a wagon, striking the fore- 
head, just above the right eye, against a horse's hoof. 
There was a contused wound over the eye which con- 
tinued to suppurate for about two weeks. At this time 
complaint was made of pain in the back of the head. 
After this it remained in apparently good health until 
June, 1892, when it became very nervous, and vomited 
repeatedly. The vomiting was always attended with 
pain in the occipital region. These symptoms continued 
for two weeks, when it had its second convulsion, last- 
ing about thirty minutes. This seizure began by the 
child crying loudly, " Mamma, mamma ! " the head was 
retracted, and rolled from side to side, the spine was 
arched backward, and the arms and legs were extended 
and rigid. The child remained perfectly conscious 
throughout the seizure, moaned and called its mother, 
and gave evidence of great suffering. Six hours later 
it had a second and similar attack. The convulsions 
occurred two or three times every day, and on one day 
there were fourteen, each seizure lasting from thirty 
minutes to several hours. Her condition seemed to be 
uninfluenced by treatment, and, in fact, the mother 
stated that the bromides seemed to increase the seizures. 
In December, 1892, an abscess formed in the right 
groin, which was opened a few days later, giving vent 
to a free discharge of pus. About this time the child 
became almost totally blind, remaining so for three 
months, the convulsions continuing in the meantime. 
Early in 1893 she partially regained her vision, but the 
convulsive seizures, which were nearly all of the same 
character, continued until August, 1893. From this 
date until December, 1894, she was free from convul- 
sions, but she remained nervous and vision was very 
poor. At the latter date the convulsions recurred 3 
again and were attended with increased pain in the 
back of the head and frequent vomiting. She remained 
in this condition until I saw her, February 19, 1895, 
when I placed her in St. Luke's Hospital, under a 
trained nurse, to have the convulsive seizures watched. 
Examination February 22, 1895.-She walks fairly 
well backward or forward and with eyes open or closed. 
There is no evidence of distinct ataxia in the legs, arms, 
or trunk muscles. The knee-jerks are slight, and 
ankle-clonus is absent. Plantar reflexes and tendo- 
Achillis are present. Lower abdominal, scarcely per- 
ceptible ; epigastric, about normal. Deep reflexes of 
the arms are not increased. Dyn. R. 22 ; L. 20. While 
the child is not strong for its age, there is no distinct 
paresis or paralysis of any group of muscles. The 
tongue is protruded in the median line. All the general 
sensory phenomena and the special senses, smell and 
taste, are normal. Hearing watch, R. % ; L. The 
tuning-fork is heard better in the left ear. There 
is no weakness of the external ocular muscles. She is 
able to perceive objects with the right eye, but vision 
is not sufficient to enable her to distinguish one face 
from another. In the left eye there is only slight light 
perception. There is an extreme degree of atrophy in 
both optic nerves. The retinae are unusually vascular, 
and present a red, velvety appearance. 
She remained in the hospital seven days, and during 
this time she had, on an average, from three to four 
seizures every day. Her temperature on admission 
and for a few days subsequently remained about nor- 
mal, or from a half to one degree subnormal. The 
pulse varied from 70 to 100, the respirations from 18 to 
26. During the last days of her stay in the hospital 
the temperature was about one degree above normal, 
pulse varied from 80 to 102, the respirations most of 
the time from 20 to 34. Her appetite was good, she 
was well nourished, and when not suffering from pain 
was bright and cheerful. Her bowels were obstinately 4 
constipated, requiring large enemas to effect a move- 
ment, as the ordinary purgatives were inefficient. 
The numerous seizures that were observed did not 
vary greatly in character, and a description of one, 
with a few additional remarks, will suffice for all. I 
witnessed two of these attacks. While I was talking 
with her, she seemed to be free from pain and was 
laughing, when suddenly she cried, " Oh, mamma, 
mamma ! " her face flushed, head was extremely re- 
tracted, spine arched backward, arms extended and 
rigid, right leg flexed at the knee and hip, the left 
straight, and all the muscles of the body seemed to be 
rigid. The hands were closed tightly. While in this 
condition, and apparently suffering intense agony, she 
was entirely conscious and would answer if spoken to ; 
respiration, pulse, and temperature were about normal. 
Pupils were dilated and did not respond to light. 
The spastic seizure which I observed lasted only 
two or three minutes, when the muscles began to re- 
lax. She seemed greatly exhausted and moaned for 
several minutes after the attack was over. She said 
that she was entirely conscious throughout the spasm 
and that the pain was very great, especially in the back 
of the neck and head. Several of the attacks observed 
by the nurse were twenty or thirty minutes in duration, 
and during some of them she would become almost 
frantic with the pain. On one occasion, while trying 
to bite her own hand, she begged the nurse to strike 
her head, punch out her eyes, as the pain in the front 
of the head was so intense. The prolonged spells ex- 
hausted her greatly, and the pain in the back of the 
head and neck following them would frequently con- 
tinue for several hours or until she would have another 
attack. If the pain did not continue long after a seiz- 
ure, each seizure would be followed by a period of moan- 
ing and restlessness, which would often end in sleep. 
About 8 a.m., Feburary 26, 1895, the day that I had 
promised her that her mother might take her home, 1 5 
saw her while she was eating her breakfast, consisting 
of eggs, toast, and milk, which she seemed to relish 
very much. She was entirely free from pain, said she 
felt well, and was happy at the thought of going home 
that day. The nurse reported, however, that she had 
suffered from three attacks the previous night ; that 
while all had been longer in duration and greater in 
severity than those which she had previously witnessed, 
each seizure seemed to be worse than the one which 
preceded it. She remained in about the condition in 
which I saw her until noon, when suddenly she began 
to scream at the top of her voice, " Mamma, mamma, 
mamma ! " and immediately an intense rigidity seized 
every muscle, and the head was retracted to an ex- 
treme degree, the spine was arched backward so that 
she lay on her abdomen with head and feet in the air. 
The chest muscles and diaphragm were contracted, 
respiration ceased for a time, and the face became 
deeply cyanosed. Later, respiration became irregular, 
slow, and Cheyne-Stokes in character, and the pulse 
slow and full. This seizure lasted one and a half 
minutes, but she was no sooner out of one than she 
was seized by another of greater duration and intensity 
than the first. These attacks continued in rapid suc- 
cession, each one growing more severe until the fifth 
occurred about 2 p.m., when respiration ceased. The 
heart continued to beat for several minutes while arti- 
ficial respiration was kept up. When she died the face 
was deeply cyanotic. 
The autopsy was made three and a half hours after 
death by Drs. McNaught and Hopkins. The vessels 
and membranes of the brain presented a normal ap- 
pearance. The cortex and white substances of the 
brain showed nothing pathologic. The lateral ventri- 
cles were distended by about four ounces of a straw- 
colored, watery fluid. The left hemisphere of the 
cerebellum was apparently about twice as large as the 
right. The increase in size was apparently due to 6 
fluid in the posterior portion of the left hemisphere, 
while the anterior portion seemed to be nearly normal, 
and no undue pressure appeared to be exerted on the 
pons or medulla. On cutting into the left hemisphere 
of the cerebellum a tumor was found about three- 
fourths of an inch in diameter in its extreme posterior 
tip. The growth was hard in one portion, while in 
another two or three small-sized cysts containing a 
gelatinous fluid were found. Connected with this 
growth was a large cyst two or three inches in diameter 
and extending from near the posterior portion of the 
cerebellum to within one-half or three-fourths of an 
inch of its anterior portion, containing a thin, straw- 
colored, watery fluid, with here and there, and espe- 
cially lying against the walls of the cyst, some rather 
thick gelatinous-like substance. The cyst-wall was 
quite thick, well defined, tough and apparently fibrous 
in character. 
Microscopic Appearance.1-"The tumor consisted of 
two portions-one, the external, hard and almost 
fibrous, and the other softer. The internal portion 
was toward the cyst. At the sides passing into the 
cerebellar tissue the growth was infiltrating in char- 
acter. The soft portion varied somewhat from the 
mere gliomatous and the more distinctly sarcomatous 
structure. In parts there was a marked proliferation 
both of the endothelium and the adventitia of the 
smaller blood-vessels, a new formation of capillaries, 
to such an extent as to give the appearance of an 
angioma. Many of the blood-vessels were widely di- 
lated, and there had been hemorrhages in parts, with 
breaking down of tissue and the formation of small 
cysts. The wall of the large cyst was distinctly 
fibrous in character." 
Simple non-parasitic cysts of the brain are most com- 
monly the result of acute destructive lesions, usually of 
1 By Dr. H. C. Crouch, 7 
vascular origin, such as hemorrhage or arterial occlu- 
sion ; the effused blood or disintegrated nerve elements 
having been removed, the cavity becomes a receptacle 
into which the watery portion of the blood finds access. 
Such cysts are often irregular in their outlines, and the 
wall may not be well defined. Distinct cysts of a regu- 
lar shape and with firm fibrous walls sometimes form in 
connection with traumatic injuries of the membranes- 
a beautiful example of which I have recently observed 
in consultation with Dr. McNaught. It occurred from 
a blow received on the head nearly thirty years before, 
and gave rise to headache, mental disturbance, and 
epileptic seizures, which were relieved on removal of 
the cyst. Tumor, especially the glioma or sarcoma, of 
the brain may contain several small cysts, or a large 
cyst, as in the case just reported, may be connected 
with a small tumor. Such cysts have their origin most 
probably in the results of changes which take place in 
the growth, and after they attain a certain size they 
become much larger than the tumor from the disten- 
tion of the cyst-wall by means of the watery portion of 
the blood. In the present instance careful microscop- 
ical search was made for granular and broken-down 
pus corpuscles, as trauma, distant suppuration, and 
otorrhoea, all causes of abscess of the brain, had been 
experienced by the little sufferer. 
The diagnosis was a most difficult and, as proved by 
the autopsy, an unattainable problem-for me, at least. 
The history of the seizures, preserved consciousness, 
talking, throwing the arms wildly around without dis- 
tinct clonic convulsive movements, and opisthotonus, 
at first suggested hysteria, but this was easily excluded 
by the optic-nerve atrophy and vascular changes in the 
fundi. If these had not been sufficient to enable me 
to diagnosticate an organic lesion, the attacks that I 
witnessed would have been ample evidence of organic 
change. They were typical of irritation in the pos- 
terior cerebral fossa, especially around the pons and 8 
medulla. The posterior neck muscles were as rigid as 
cords, the head was retracted, the spine arched back- 
ward, the masseters were at times firmly contracted, so 
that when she attempted to speak, her teeth, which she 
could not separate, were simply uncovered by the lips. 
The arms, rigidly extended, were thrown wildly around 
with shock-like convulsive movements. 
Three morbid processes were considered in the diag- 
nosis, viz. : abscess, tumor, and the results of an old 
basilar meningitis. The history of the bilateral otor- 
rhcea, with a very offensive discharge, occurring about 
the time of her first nervous symptoms, and attended 
by a convulsion ; the suppuration in the right groin, 
the origin of which could not be determined, as there 
had never been any further evidence of caries of the 
spine ; and a blow to the head received just previously 
to the convulsive seizure becoming frequent, from an 
etiological stand-point were about as strong evidence 
in favor of cerebral suppuration as one expects to find. 
The subnormal temperature during the first few days 
of my observation of the case was also in favor of 
chronic cerebral abscess. The otorrhcea had ceased 
for a period of nearly ten years, and during this time 
the child had never complained of pain in the ears. It 
seemed to me that if the little patient was suffering 
from abscess of the brain the probabilities were against 
the ears having been the source of the septic poison, 
as a chronic abscess from ear infection rarely runs a 
very prolonged course. Headache is common to all 
of the pathological processes under discussion. The 
optic-nerve atrophy without any swelling of the disks 
was in favor of old meningitis and against the pressure 
of a growth or an abscess. I felt inclined to exclude 
chronic suppuration, but I admitted to the physician, 
Dr. McNaught, with whom I saw and studied the case, 
that I had not sufficient reason? to be positive in my 
opinion. 
Between meningitis and tumor I could not decide. 9 
One of these morbid processes would have accounted 
for some of the symptoms, while certain ones were 
more common to the other. The almost total loss of 
sight with optic-nerve atrophy, and the seizures at- 
tended with opisthotonus, rigidity of the masseters, 
tonic extensor spasms of the extremities, especially the 
superior ones, and shock-like movements of the arms are 
found in meningitis in the posterior fossa when the sur- 
face of the pons is irritated, and not in tumor as a rule 
unless meningitis is also present. So far the symptoms 
and the theory of meningitis harmonized, but I was at 
a loss to account for the other cranial nerves than the 
optic escaping. That the child at times should feel 
quite well, be entirely free from headache or any dis- 
comfort, and that there should be no rigidity of the 
posterior neck-muscles except during the paroxysms, 
seemed to me inconsistent with an old meningeal exu- 
date in the posterior fossa. A tumor in the cerebellum 
so situated as to produce remittent pressure on the 
pons, with distinct paroxysms of increasing pressure, is 
common to the experience of everyone who has studied 
and observed cerebellar growths, but for the pressure 
symptoms to be apparently completely intermittent, 
and to return with as much regularity as epileptic seiz- 
ures, and to consist solely of epileptoid phenomena 
without mental dulness or loss of consciousness, was 
new in my experience. 
I confessed my inability to make even a problem- 
atic diagnosis, and advised the mother to take her 
child home, as I could not recommend an operation for 
her relief, but about an hour before the time the mother 
had set to leave the hospital the child was seized with 
a series of convulsions which proved fatal within two 
hours. 
While the body was on the post-mortem table I was 
asked by Drs. McNaught and Hopkins, before they 
began their examination, for my diagnosis. I said that 
a double lesion, a tumor in one hemisphere of the cere- 10 
bellum, and an old meningeal exudate would explain 
all the symptoms observed during life, but not the ab- 
sence of others. 
In the light of the autopsy which revealed the pres- 
ence of a large cyst and a small tumor in the posterior 
three-fourths of the left cerebellar hemisphere, are the 
symptoms explicable ? It is possible that, owing to 
the watery contents of the cyst, the pressure exerted 
by the cyst, after it became chronic, on the adjacent 
structures was not as great as results from a more solid 
and unyielding tumor, so that, while there might have 
been a papillitis during the early stage of the growth, 
the lessened pressure on the formation of the cyst and 
the breaking down of the growth allowed this to sub- 
side with the resulting atrophy of the optic nerves, and 
time had permitted all intra-ocular exudates to be ab- 
sorbed. We know that a growth in the cerebellum, 
from its effects upon the circulation, especially in the 
veins of Galen and adjacent veins and sinuses, disturbs 
the function of the pons and medulla, usually to a slight 
extent continuously, and when it has reached sufficient 
size to exert pressure on the respiratory and neighbor- 
ing centres, by paroxysms, threatening life by increased 
pressure which probably results in temporary oedema 
of the parts. 
In the case of a cyst with yielding contents, which 
may vary in quantity from time to time, the pressure 
symptoms probably may become intermittent. The 
peculiar tetanic spasms were, most likely, due to tem- 
porary irritation of the pons and medulla. 
With the information gained from the clinical and 
pathological observations of this case, could error be 
prevented in the diagnosis of a somewhat similar one ? 
If a large cyst of the cerebellum is attended with more 
varying pressure-symptoms than a tumor, a problematic 
diagnosis might be ventured, and it might be correct or 
it might not. The only unilateral symptom in the case 
was the tendency of the right arm to become a little 11 
more rigid than the left, with, at times, a turning of the 
head and eyes to the right, but this was inconstant and 
of no localizing value in determining which hemisphere 
of the cerebellum was affected. Had it been possible 
to localize accurately the lesions, the tumor, in all proba- 
bility, could have been removed, the contents of the 
cyst evacuated, and the life of the patient saved. 
A careful study of the case just reported demon- 
strates how meagre and unsatisfactory are the symp- 
toms of an extensive lesion in one lateral hemisphere 
of the cerebellum, and that ataxia from lesions of this 
portion of the brain probably only occur when they 
are situated so as to exert pressure on the pons, usu- 
ally through the medium of the middle lobe of the 
cerebellum.