Patient 10, a 10-year-old boy, presented with a 3-month history of ataxia and clumsiness, a 6-month history of dysarthria, and a 3-month history of suboccipital headaches and vomiting. Physical exam showed secondary optic atrophy, nystagmus, left facial nerve paresis, slurring of speech, and marked ataxia. Cushing suspected a cerebellar tumor. In surgery, there was a “protruding, bleeding, cavernous angioma which burst its way (through) the left cerebellar hemisphere as soon as an incision was made [through] the dura in spite of the ventricular puncture.”[] The patient's blood pressure fell rapidly. Postmortem examination of the mediastinum was performed on the operating room table following the patient's death. Cushing reported “the whole fatty contents of the mediastinum had been completely digested away leaving the aorta exposed, the plexus of sympathetic nerves free and naked as though they had been dissected out.”[] Cushing also wrote that a 1-inch slit was found in the esophagus, allowing gastric contents to “leak out.” He reported: “I cannot believe that the perforation in this child was due to anything else than a digestive ulcer of the esophagus… the dissection appearance of the structures in the mediastinum was much more likely to have been produced by a digestive process…”[] This patient was also mentioned in Cushing's paper, “Peptic ulcers and the interbrain,” in which he discussed 11 patients suffering from both intracranial and gastric lesions.[]
Patient 7, a 58-year-old man, presented in August 1929 because of a stuporous condition following a 6-month history of headaches. On September 10, Dr. Horrax performed an exploratory procedure and enucleated a metastatic hypernephroma. The patient's condition worsened the next day. His stupor continued with a 104° fever. Dr. Cushing was concerned that a postoperative clot had formed. Despite re-elevation of the flap, the patient remained unconscious, and upon receiving a nasal feeding tube, he regurgitated a large amount of dark brown blood and died. Postmortem exam reported edema of the right cerebral hemispheres. Cushing reported “a bilateral perforation of the esophageal wall communicated with the right and left pleural cavities, each of which contained about 400 cc of brownish mucoid fluid… The margin of the digested area in the thorax showed a border of reddening suggesting that the circulation must have been in… the early stages of the process… [and that] the fundus of the stomach was highly necrotic.”[] Gastric release must have occurred for a long time before blood was regurgitated with gastric fluid.