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.
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.