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 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.[]