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 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.