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.[]
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.[]