This case is described in Cushing's original Yale Registry[] and Cushing's article, “Peptic ulcers and the interbrain.”[] Patient 8, a 9-year-old girl, was admitted in September 1927 with an advanced cerebellar tumor syndrome. She had a 7-month history of frontal headaches, a 6-month history of projectile morning vomiting, weight loss, and ataxia. Physical exam also showed weakness of the upper branch of the left facial nerve, bilateral papilledema, and tortuous fundi vessels. Cushing suspected that a cerebellar tumor caused the increased intracranial pressure and papilledema.\nCushing proceeded with a bilateral suboccipital exposure and found the bone and dura covering the cerebellum to be thin. He inserted a needle into the left ventricle and fluid shot out of the manometer. Cushing found the tumor to have an interior cavity that contained “soft yellowish masses of degenerated tissue” and was able to separate the tumor from the fourth ventricle. Pathologist G.W. Bennett reported that the tumor “shows a pseudoadenomatous structure and a few pseudorosettes.”[] The child was found to have a median cerebellar medulloblastoma. For the next 2 years, the patient continued to vomit 2-3 times/week and experienced weight loss.\nThe patient was admitted again in July 1929 with complaints of headache, vomiting, and staggering gait, suggestive of increased intracranial pressure caused by a recurrence of the medulloblastoma. Exam showed positive Romberg, unsteady gait, nystagmus, and some forgetfulness. She improved with X-ray therapy and was discharged in August, but was readmitted in September. 10 days before admission, the patient had refused to feed herself, lost interest in her environment, and had urinary and fecal incontinence. She also was drowsy with daily vomiting and right occipital headaches. According to Dr. Oldberg, physical exam showed drowsiness, apathy, bilateral papilledema, right oculomotor palsy with diminution and/or disappearance of other deep reflexes. On October 10, 1929, an exploratory procedure was performed on the cerebellar region. The procedure was unable to show local recurrence. The first specimen showed “a mass of calcified, degenerated tissue.” Fluid from a lateral ventricular tap failed to show any tumor cells, but did show many red blood cells. On October 27, the patient fell into a coma with a temperature of 106.5° and died.\nAutopsy report notes “in the first portion of the duodenum approximately 3 cm below the pyloric sphincter, there is a small area which has a definite elevated margin with a depressed center forming more or less of a crater. The crater measures 3 cm × 4 cm in its greatest diameters… One section of the duodenum shows the ulcer… extends down to the muscularis, and its margins are deep… there is a narrow zone of dense hyalinized connective tissue… and some fibrin and red blood cells.”[]\nPostmortem examination of the patient's brain showed obstruction of the ventricular system by a recurrent medulloblastoma. Blood culture and brain base culture grew multiple colonies of Staphylococcus aureus which could indicate meningitis. Autopsy showed “very little purulent exudate over… cerebral hemispheres.”[]
This case is described in Cushing's original Yale Registry[] and Cushing's article, “Peptic ulcers and the interbrain.”[] Patient 1, a 34-year-old man, presented in June 1915 with a 6-week history of unsteady gait associated with a 4-month history of nausea and vomiting. He also reported having midline suboccipital headaches starting in December 1914. The patient was diagnosed with a subcortical angioblastoma arising from the right cerebellar hemisphere. Cushing employed a bilateral suboccipital exploration that exposed both cerebellar hemispheres. He punctured the left lateral ventricle to lower the tension. Cushing reported “the dorsum and posterior clinoid processes show signs of pressure atrophy with destruction.”[] Pathologist W. T. Councilman diagnosed the intracranial mass as a “mixed tumor, possibly glioma-hemangioma.” Postoperatively, the patient described abdominal discomfort and vomited a bile-stained fluid. His postoperative abdominal exam showed it to be “somewhat spastic and with quite marked tenderness in the epigastrium.”[] Dr. Cushing admitted that not much attention was paid to the finding given the patient's “neurotic disposition” emerging from the effects of ether.\nDuring the evening, the patient had more severe cramp-like pain in the stomach with a rectal temperature of 102.4°. Morphine was administered multiple times. By early morning, the patient's temperature rose to 104°. Cushing described the patient as “cyanotic, breathing very rapidly and shallow and pulseless.” The patient died later that morning. Cushing's impression was an acute peritonitis of unknown origin.[]\nIt appears that pathologist W. T. Councilman had difficulty explaining the abdominal pathology and described “submucosa [as] hemorrhagic and appears to have been torn by mechanical violence… the muscularis is usually intact, but in many places, this also has ruptured… It is hard to explain the condition of the stomach, both gross and microscopically, except as a result of a mechanical action tending to stretch all layers.”[] According to the postmortem exam performed by Dr. J. L. Stoddard, the peritoneal cavity showed signs of fibrinous peritonitis in the upper abdomen and three circular gastric perforations between the cardia and pylorus. He reports that the gastric interior appeared to have been affected by corrosive poisoning.[]