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.”[]
Patient 9, a 25-year-old man, presented in June 1929 with suboccipital headaches associated with vomiting. The patient reported that in May 1929, while fatigued from a long car drive, he endured a severe suboccipital headache and vomiting. He also experienced seizures that consisted of neck retraction, dizziness, sweating, eye protrusion, and arm flexure. Cushing wrote that the patient was reportedly taken to the hospital in late May for “gastric symptoms.”[] On examination, the patient had a rigid neck, bilateral abducens palsy, bilateral Babinski reflex, hyperreflexia, and a choked disc of 4 diopters. Ventriculograms showed some evidence of obstructive hydrocephalus at the foramina of Monro and a filling defect of the third ventricle. He was given four radiation (X-ray) treatments and the pressure symptoms subsided for 1 year.\nIn 1931, his gastric symptoms returned, and a recurrence of the tumor was suspected. He received three additional radiation treatments, and the symptoms disappeared. However, the symptoms recurred again in January 1932. These symptoms were more indicative of a duodenal ulcer. He received radiation at the third ventricle, and he improved. However, several weeks later on March 3, barium studies confirmed the presence of a healed duodenal ulcer following the radiation therapy.[]