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 5, a 44-year-old man, presented in January 1930 with headaches and declining vision for the previous year. Blood pressure was 210/145 and on exam, there was evidence of long-standing papilledema. Ventriculograms did not show any evidence of a tumor. On February 10, the patient vomited a total of 1300 cc of blood over the course of 2 days. On February 17, the patient experienced intense epigastric pain warranting exploratory surgery. Dr. John Powers found “a perforation in the posterior wall of the stomach 1 cm in diameter and 8 cm proximal to the pylorus.”[] This ulcer was surgically closed. The patient died on February 22 with a rectal temperature of 104°. Postmortem exam showed “peritonitis restricted to the lesser peritoneal cavity with terminal septicemia from a gas-producing bacillus… The sutures closing the perforation had been dissolved away, and the stomach was in shreds from autodigestion.”[] No tumor was found.