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 6, a 47-year-old man, presented on January 11, 1926, with a 7-year history of suboccipital headaches, a 4-year history of bilateral tinnitus, a 1-year history of ataxia, and a 2-3 months history of right facial palsy and constipation. Exam showed papilledema, nystagmus, moderate bilateral deafness, cerebellar ataxia, and absent gag reflex. Blood pressure was 140/80. A tumor was suspected, but exploration found none. During the surgery on January 26, the patient experienced vomiting and a fall in blood pressure. Cushing noted the absence of cerebellar tonsillar herniation, and he also noticed evidence of upward herniation of the spinal cord.\nOn postoperative day 3, the patient's temperature rose to 104°. Lumbar puncture revealed mildly blood-tinged fluid. The patient's lungs filled with fluid, and he became cyanotic, eventually leading to his death on postoperative day 4. The autopsy reported an aneurysm of the basilar artery that displaced the brainstem, arteriosclerosis, bronchopneumonia, and gastromalacia. A postmortem exam found “the peritoneal cavity [near] the spleen contained 500 cc of brownish dirty fluid containing small masses of mucus. The fundus of the stomach and lower esophagus was found to be completely disrupted and in shreds.”[] The gastric perforation was found to be 15 cm in diameter, extending to the cardia of the stomach and entering the esophagus.[] The presence of brown fluid showed that gastric secretions had been released for some time, allowing for perforation of the stomach.