Case 17241

Abstract

This case is that of a fifty-two year old American laborer who came into the Emergency Ward on the night of March 10. He was at that time very dull and unable to give a good history. His chief complaints were a vague dull pain through his epigastrium and stomach trouble for the previous four weeks.His past history showed that he had been here in 1909 with acute rheumatic fever and in 1911 for appendectomy. He had an uneventful convalescence and was discharged feeling quite well. In the interval of twenty years he had been quite well, working regularly, and had had no attacks of abdominal pain and no discomfort of any kind until four weeks before admission, when there was a gradual onset of what he called "stomach trouble". This consisted of dull pain in the epigastrium and over the umbilicus radiating towards the sternum, not to the shoulders or down the arms. It was relieved by food, milk and soda. About three weeks before admission his urine became quite dark and his skin became jaundiced. This had grown progressively worse until entrance. At that time he was quite jaundiced and had anorexia and occasional nausea and vomiting. He had lost twelve pounds in weight.He was first seen in the Emergency Ward by the East Medical service.He was found to be fairly well developed and nourished and jaundiced. He had signs of recent weight loss. His teeth were carious. The glands were normal. The heart and lungs were negative. The abdomen was quite distended with gas and was difficult to palpate. No fluid wave was obtained, but on percussion it seemed that the liver dullness was quite diminished and there was dullness in the flanks.Sounds of peristalsis were heard. They could percuss the liver dullness only on a small band between the sixth and eighth ribs on the right. *The following report gives the essentials of two discussions, one in Dr. Cabot's Third Year class, one at a conference of the hospital staff. **Recently senior interne on the West Medical service. a > • i.s •_ '.Rectal examination showed some internal hemorrhoidal tabs.When he arrived in the ward the following morning he was quite comfortable lying in bed, although he was dull and lethargic. He had only a little abdominal pain. He felt better than he had. He showed no change until four o'clock in the afternoon, when the student taking the history noticed that it was becoming more and more difficult for the patient to focus his attention on the history and that he complained of increasing abdominal pain. This progressed rapidly, and he was really in distress after an hour and had signs then of a rather typical surgical abdominal condition with diffuse tenderness on release of pressure. The liver dullness was not obliterated. About five o'clock, when I saw him, the surgical service was called immediately.He was in the ward such a short time that the laboratory findings are rather scanty. The urine showed much bile. The red blood count was 4,400,000, the hemoglobin 70 per cent, the white blood count 3,900. The smear was interesting in that it showed 4 per cent...