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 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.