This case is described in Cushing's original Yale Registry[] and Cushing's article, “Peptic ulcers and the interbrain.”[] Patient 1, a 34-year-old man, presented in June 1915 with a 6-week history of unsteady gait associated with a 4-month history of nausea and vomiting. He also reported having midline suboccipital headaches starting in December 1914. The patient was diagnosed with a subcortical angioblastoma arising from the right cerebellar hemisphere. Cushing employed a bilateral suboccipital exploration that exposed both cerebellar hemispheres. He punctured the left lateral ventricle to lower the tension. Cushing reported “the dorsum and posterior clinoid processes show signs of pressure atrophy with destruction.”[] Pathologist W. T. Councilman diagnosed the intracranial mass as a “mixed tumor, possibly glioma-hemangioma.” Postoperatively, the patient described abdominal discomfort and vomited a bile-stained fluid. His postoperative abdominal exam showed it to be “somewhat spastic and with quite marked tenderness in the epigastrium.”[] Dr. Cushing admitted that not much attention was paid to the finding given the patient's “neurotic disposition” emerging from the effects of ether.\nDuring the evening, the patient had more severe cramp-like pain in the stomach with a rectal temperature of 102.4°. Morphine was administered multiple times. By early morning, the patient's temperature rose to 104°. Cushing described the patient as “cyanotic, breathing very rapidly and shallow and pulseless.” The patient died later that morning. Cushing's impression was an acute peritonitis of unknown origin.[]\nIt appears that pathologist W. T. Councilman had difficulty explaining the abdominal pathology and described “submucosa [as] hemorrhagic and appears to have been torn by mechanical violence… the muscularis is usually intact, but in many places, this also has ruptured… It is hard to explain the condition of the stomach, both gross and microscopically, except as a result of a mechanical action tending to stretch all layers.”[] According to the postmortem exam performed by Dr. J. L. Stoddard, the peritoneal cavity showed signs of fibrinous peritonitis in the upper abdomen and three circular gastric perforations between the cardia and pylorus. He reports that the gastric interior appeared to have been affected by corrosive poisoning.[]
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.