The

years since the disease was really described, and it is quite well-known now among the skin men throughout the country, it is a little surprising About a year ago saw the first case I have ever seen in my life of this disease, which is so thoroughly described in the late text-books on dermatology that I could not make a mistakeat least, I thought I could not. The clinical aspects of this disease may be mistaken for three skin troubles-tuberculosis verrucosa cutis, fungous syphiloderm, and lupus vulgaris. I believe the differential diagnosis can be easily made between tuberculosis verrucosa cutis and this disease by the very slow growth in cases of tuberculosis. The blastomyces seem so me to be much more rapid. Not only that, but it has a peculiar appearaace. The lesions of tuberculosis, as we all know, are of a pale, or livid color, more bluish. A blastomycetic affection of the skin is decidedly red. In tuberculosis the lesions have a tendency to ulcerate, whereas in blastomycetic dermatitis they appear more like a carbuncle. The disease leaves large folds, like worm-eaten wood. This is characteristic of the disease. In differentiating it from fungous syphiloderm, we consider the history, infection of the lymphatics in the early stage, and the rapid acute condition. From lupus vulgaris I will say that lupus vulgaris has a tendency to form scar tissue or hardened scar cicatrization. Lupus, of course, is a slow process. It is very slow in its destruction; while blastomycetic inflammation is rapid. The lesion starts as a pimple or papulo-pustular eruption, and in a week or a few days the lesions may be the size of a dime. case that I saw, a man, had lymphangitis of the arms about five years previous to the blastomycetic dermatitis. He said that the disease had existed about two months when he came to me. It had the characteristic appearance of blastomycetic dermatitis. Sometimes people were led to think that it was ringworm; there was peeling in the center. In this case, when I removed the crusts, I found little papules under them, not a complete return to normal, but that peculiar condition we find exhibited in blastomycetic dermatitis. I thought I would try the antiseptic treatment by giving iodide of potash, with iodide of sodium internally. The man lived in Nebraska. I sent him home after a few applications of pure carbolic acid, followed by the application of alcohol afterwards, and then applied bichloride of mercury, 1-2000, in the form of wet packs. Under this treatment he improved markedly up to about the third week, so much so that he thought he was well. But I wrote him to again apply the carbolic acid. He did so. He came back at the end of six weeks from the time of the first application very much improved, and I told him that I thought after one or two more applications he would entirely recover. About a month ago he came back with a new infection. He said he had gotten entirely well, only there was a peculiar crust formation on the surface of the arms. There was no soreness, no elevation, and the color had returned to normal. This new infection was about the size of a quarter, quite elevated, and there were a number of foci of suppuration over the surface-maybe a dozen-which were exuding characteristic muco-purulent discharge. I told him the only thing to do was to excise it. I removed it, and told him if he had any further trouble to come back. I have not heard anything from him since he left. I believe generally we will hear a great deal more of this disease in future years. It is surely an affection that we should be careful about in diagnosing it early. I believe after the system has become impregnated, treatment will do little, if any, good. So early diagnosis and early, proper treatment are very important. The histopathological condition is peculiar to itself, and I am very sorry that the author of the paper is not able to present the specimens he has and the microscopic slides while the paper is being discussed. I want to congratulate the author on bringing this subject before the society, as it is one that is comparatively new.

DR. FRICK, in closing the discussion, said: I have not much more to add to what I have already said in my paper. I had hoped that Dr. Lyle would be here to discuss my paper, because one of these cases has been reported more fully by him before. Dr. Geiger spoke on the pathology of the disease. As I remarked before, while it is considered a very rare disease now, my opinion is that it is not as rare as it would seem to be, as the number of cases is increasing, and reports are coming in from all over the country. Once in a while we see a report in the literature of a case from Texas or some other State. We are getting reports of cases of blastomycosis from Germany and other foreign countries. The pathology of the disease is so well worked out and so characteristic that we can differentiate the disease from tuberculosis, carcinoma and syphilis. The large number of giant cells

found in blastomycetic dermatitis are similar to what they are in tuberculosis. Some of the characteristics are very much like those of carcinoma. There is increased proliferation of epithelium, the interpapillary plugs extending deep into the corium and sometimes distorted; also there is the presence of whirls as seen in epithelium holds together and is not found down in the connective tissue structures, cut off from the epithelial layer, as in cancer. If we can rely on any one thing as being characteristic of the pathology of this disease, it is the miliary abscesses, both clinical and microscopical. In the course of the disease the appearance of the surface varies. These miliary abscesses are not always apparently near the surface; but they are diagnostic when they are present. Indeed, it seems that we can make the diagnosis from them alone. We have a number of these minute abscesses. with a peculiar, sticky sort of pus that comes from them. But sometimes we do not see them right on the surface: they have been crusted or scabbed over. Dr. Geiger has said that the disease is usually found in man. The reason it is found in man is because men are generally exposed to the infection. Again, the infection usually takes place at the point of trauma. In the case I spoke of, the boy struck his head against something, and fell, and at that point the infection took place, showing that these infections occur at some point in the skin, and it is quite reasonable to presume that when there is trauma or a break in the skin it permits the fungus to gain entrance. There are some cases, however, especially systemic cases of blastomycosis, which cannot be traced to trauma, but may be traceable to the repiratory tract. The patient may be out and around where there is a mole fungus, and he is more apt to get this infection than a woman. That is a natural inference. The mole fungus is found in grain. The first patient I spoke of was a man, who was in the habit of handling feed for the cattle, and the fungus may have gained entrance through an abrasion of the skin. The disease is very apt to occur in those who work on a farm. In one case reported by Dr. Montgomery, of Chicago, the patient was a farmer, and according to the history of the case there was smut on the grain, and it is believed that he received his infection from an abrasion of the skin.

TUMORS OF THE CEREBELLUM, WITH REPORT OF A CASE.

F. E. Coulter, M. D., Omaha, Neb.

ERHAPS a more befitting title for this paper would be the "Symptoms and Diagnosis of Growths Found in the Posterior Fossa of the Skull."

It is not our purpose at this time to give an exhaustive resume of all that has recently been written upon the subject of cerebellar tumors, but rather to cull out a few principal signs and symptoms of diagnostic value and formulate them, if possible, into a working basis. Tumors found in the cerebellum or in that immediate vicinity occur with sufficient frequency to justify every physician in making a study of the subject. Of recent years there has been an adequate number of such cases reported, in which the diagnosis has been verified by operation, autopsy or both to warrant the establishing of certain classical symptoms with which every one should become familiar, and mistakes in diagnosis need not occur so frequently as heretofore. Of course we all understand that a certain number of cases are always to be found that do not conform to any stereotyped group, and under these conditions one must make a tentative diagnosis until the case is farther advanced or has been more fully observed. The case which we shall report latter illustrates this point to some extent.

Starr (1 and 2) recently reports two lists aggregating 965 cases of brain tumor, and of this number 157 were cerebellar, thus demonstrating that the cerebellar variety existed in a little more than 1 to 5 in all cases of intracranial neoplasms in this collection. Gowers (3) reports a list of 718 cases of all kinds of growths in the brain, of these 179 were of the cerebellar variety, thus making the proportion in his list just about 1 to 4. Recently Stewart and Holmes (4) of the National Hospital analyzed 40 cases of cerebellar tumor, 22 of which came to autopsy or operation. The lists above referred to when combined from a respectable number from which to deduct conclusions, and shall be referred to again in the present paper. When we take into account the fact that the cerebellum, at last so far as avoirdupois is concerned, is in the proportion to the rest of the encephalon as 1 to 9, we recognize the fact that tumors are more frequently found in this subdivision of the brain than in any other.

Etiology. As to the etiology of cerebellar growths it is conceded that the causative factors are in the main of a very similar nature to those found producing tumors in other portions of the brain, especially the cerebrum, for the histological elements of the two structures differ but little other than in arrangement, hence for all practicable purposes the causative factors we may say are essentially the same.

All authors agree that the male is more likely to be effected than the female, and this in the proportion of about 2 to 1. This is true of all forms of growth, excepting the sarcomatae, which effect both sex about. equally. No period of life is found exempt, but during the first six months and old age they are not so frequent. Constitutional conditions, either inherited or acquired, are potent factors in the production of brain tumors, in the former (the inherited condition) tubercular growths are most prominent, while the latter (the acquired condition) syphilis heads the list. Trauma is supposed to be a factor, but not nearly so important as those already mentioned, and as to the cause of the other neoplasms found, we are still in the dark quite as much concerning their cause here as in other locations of the body.

As to the nature of the growths themselves in the lists already referred to, they are given in the following order as to frequency of occurrence: Tubercles, sarcoma, glioma, glio-sarcoma, cysts, gumma, angioma, hydatid-cysts, endithelioma, neuro-glioma, and there is recorded a few cases of melamo-sarcoma, cysto-sarcoma, epithelioma, carcinoma, fibroma and osteoma, cholesteatome, lipoma, psammoma, and of the parasitic growths the echinococcus and cysticercus have been found.

Symptoms.-The symptoms of cerebellar tumor are usually divided into two principal divisions. The first embrace those that are indicative of an intracranial growth in the abstract, and the second those that are of a localizing nature. The first group of symptoms are in the main, quite similar to those encountered when the growth is in other portions of the brain, but if carefully studied they are found to differ to some extent in nature, being as a rule generally more sudden in onset, having greater intensity and are more persistent in duration when the tumor is located in the cerebellum than when it is found in other regions of the brain. rule these general symptoms appear first, but like all rules there are exceptions.

As a

Headache usually leads the list just as it does in growths elsewhere in the cranial cavity, but when the cerebellum is the seat of the growth it often is referred to as located in the occipital region, and frequently on the same side as the tumor, but this is not invariably the rule.

Optic neuritis is present in about 80% of all brain tumors, but when the growth is located in the posterior fossa, generally it is unusually intense and occurs early in the course of the disease.

Vomiting is often present in cerebellar growths and is persistent if the central lobe is involved, being perhaps on the whole more persistent than when the growth is found in other locations.

Mental alterations are often found and are of an asynesic character when present, but of course afford no indication as to location.

Vertigo is a very important sypmtoin in cerebellar growths, and is as a rule more severe in these cases where the central lobe or the middle or upper pedicles are involved, and when taken with the symptoms already mentioned it will give much weight to the diagnosis.

Convulsions may occur in cases of cerebellar tumor, but are seldom of the Jacksonian type, and are not as a rule followed by paralysis.

Given a case of severe persistent headache,, located in the occipital region, together with uncontrollable vomiting, especially of the projectile type, vertigo marked and persistent, intense early optic neuritis, together with mental hebetude, other evidence being negative one would be justified in making a tentative diagnosis of cerebellar tumor, but would not be justified in advising an operation for its relief upon this basis alone, excepting to relieve the optic neuritis and headache.

The cerebellum being located in the posterior fossa and practically enclosed, above by the tentorium, and below by the base of the skull, symptoms of compression appear early, this is supposed to account for the early headache, optic neuritis, and an increase in the ventricular contents by the occlusion of the foramen of Monroe which produces an internal hydrocephalis that masks many of the other evidences of cerebellar tumor. The second group of symptoms, those that relate more definitely to the cerebellum as the seat of the lesion afford us some evidence of a localizing nature, but they vary more or less in character, and depend upon the particular part of the cerebellum involved for their coloring. When the lateral hemispheres or inferior pedicles are involved the clinical picture is somewhat different from that present when the central lobe or middle or superior pedicles are the seat of the growth.

Ataxia probably stands at the head of these focal signs, it is peculiar in character and is considered almost pathognomonic of the condition, though not invariably present during the entire stage of the disease, it is seldom found absent during the whole course, especially if the vermiform process is implicated. This symptom is noted frequently in all of the muscular operations of the individual. The gait of such a patient may readily be mistaken for that of a drunken person, or he may invariably go to one side only, the side of the lesion, but this is not always true, it is most pronounced in the extremities as a rule. Patients may be aware of this condition, but are totally unable to prevent it (Stewart and Holmes (4). It is most apparent in the very acute cases and is one of the last signs to

disappear after an operation. In chronic cases it is not so characteristic, the muscles most frequently and markedly involved are those on the same side as the lesion, but if the vermis be invaded it is generally bilateral in distribution to some extent.

Diococinisia first referred to by Babinski and considered pathognomonic of cerebellar tumor by this author, has not been confirmed by other observers.

Position of the head by some authors has also been considered pathognomonic, but Battin (5) made a careful study of this particular symptom in a number of cases, and his conclusions are as follows: "A definite attitude of the head is not infrequently seen in cases of cerebellar disease of man, that position being with the ear approximated to the shoulder on the opposite side to the lesion, and with the face turned up to the side of the lesion; this position is sometimes found present in cases in which there is no gross lesion of the cerebellum, and is a further reason for not attaching too great an importance to the position assumed by the head." The same author refers to six cases he examined pathologically, and in three this position of the head was present, and in three it was not. He also states this symptom may be present a portion of the time, and then it may disappear entirely, and in summing up says, "the position assumed by the head is of value, but too much importance should not be attached to its presence alone, or when opposed to symptoms which have been shown to possess greater diagnostic value.

The cranial nerves seldom escape in this disease, the external recti and the auditory are among those most frequently involved, conjugate lateral movement of the eyes toward the side of the lesion is usually impaired, but not frequently entirely lost.

Nystagmus is generally present at some time in the course of the disease, and is usually of a slow, jerking character most marked toward the side of the lesion.

Auditory symptoms may be found of every grade from a slight tinnitus aurum to complete deafness, and when the latter is present it is usually found to exist on the same side as the lesion. The facial nerve is frequently involved upon the same side as the lesion, but a complete paralysis is seldom present. The remaining cranial nerves are not involved so frequently as those mentioned, yet one should always keep them in mind when he has reason to suspect a growth in the posterior fossa, for any of them may be implicated in a given case, the result of direct or indirect pressure.

Hypotonia, this condition is usually found in patients suffering from cerebellar tumor, even when the reflexes are increased, in such conditions the extremities are flail-like and flaccid in character, the muscles becoming soft and flabby, this symptom is most pronounced in the acute cases.

Sensory changes have not been noted in cerebellar tumor, excepting in those cases where the fifth nerve is involved, or the pressure is so great as to involve the pons, or pedicles of the cerebrum.

The reflexes are most variable in this disease, being found present or absent during short intervals. The plantar response is not found to be