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.”[]
Described in Cushing's original Yale Registry[] and Cushing's article, “Peptic ulcers and the interbrain,”[] Patient 2 was a 34-year-old man who presented with cerebellar signs and symptoms in November 1927. This was Dr. Cushing's second case of postoperative duodenal ulceration with perforation, 12 years after patient 1. Patient 2 reported a 5-year history of pain in the posterior neck and dizziness on bending over with diplopia, and said he had experienced weakness, numbness, and loss of control of his right arm and leg for about 10 months. He also reported four seizures, loss of consciousness, and a 3-year history of intermittent vomiting.\nOn exam, the patient had bilateral papilledema, ataxia, and sustained nystagmus. The patient was found to have a right partially cystic cerebellar astrocytoma. According to Dr. Cushing's operative note, the tumor could be easily separated from the cerebellar hemispheres via electrosurgery. A few days later, the patient experienced intense epigastric pain, and rectal temperature elevated to 102.4°. By the following morning, his temperature had risen to 106.2°. No vomiting had occurred, and he died 4 days postoperatively.\nAccording to Dr. G. A. Bennett, postmortem exam demonstrated a “residual mass of nonadherent tumor deeply indenting and flattening the medulla.” The peritoneal cavity had 1100 cc of a dark red-brown fluid and two irregularly-shaped perforations in the duodenal wall 3 cm from the pylorus. Microscopic examination of the tissue near the perforated areas demonstrated an acute inflammatory process and “showed a completely destroyed mucosa… replaced by an exudate of fibrin, inflammatory cells, and blood.”[] According to Bennett, these destructive lesions were the result of vascular thrombosis, commonly believed to be the cause of duodenal ulcers.[]