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 11, a 53-year-old man who presented in September 1930, reported working under stress, suffering emotional distress, and vomiting at work over a period of 6 months. Exam showed left hemiparesis, left homonymous hemianopsia, and impaired memory. Dr. Cushing took the patient to surgery to remove nodular meningioma in the right frontal lobe. Surgery was complicated by hemorrhage due to tearing of the anterior cerebral artery segments embedded in the tumor. This resulted in bilateral spastic paralysis. A nasal tube withdrew 50 cc of coffee-ground material with red blood cells evident on microscopy. 2 days after surgery, the patient's temperature dramatically rose to 107°, he “vomited a large amount of bloody fluid,”[] and died.\nOn postmortem examination, Dr. Schulz reported that in the stomach, there were “numerous flecks of the coffee-ground material suggesting changed blood.” Numerous ulcerations “very superficial and were found scattered… both in fundic and pyloric regions.”[] Microscopic exam did not show “evidence of the arterial or capillary disease or any noteworthy constriction of or thrombosis of the vessels,” unlike the previous cases.[]