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 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.