REPORT OF A CASE
The following case is worthy of reporting not because it is at all unusual, but more for the reason that it illustrates certain problems of diagnosis and also, the just limitations of the law of similars. Hence its publication in the Journal.
Mr.C.W.J., age 67, first came for treatment on June 29, 1942. He complained of “indigestion” stating that he had a sensation of a heavy lump in the stomach and that for some time, his bowels had been costive, with hard, lumpy stools requiring pressure of the fingers on the perineum to facilitate their passage. His tongue was rather heavily coated, grayish-white; he had always been a small eater and was rather thin, wiry and tall; he was accustomed to smoke four or five pipefuls a day, but had fifteen years ago given up the chewing of tobacco, a habit which he had acquired as a railroad trainman.
He urinated freely, without difficulty any kind. An occasional aperient had apparently relieved the constipation. He slept well, though at times talked in his sleep, as reported by his wife. His face was thin and his complexion florid. He was fond of sweets but had no special cravings. With the exception of the lump sensation in the epigastrium, he had no outstanding symptoms. The past history was negative, though he spoke of an attack of quinsy sore throat during his forty fifth year.
Physical examination revealed normal heart sounds, with somewhat rapid rate which corresponded with a pulse of 84. The blood pressure was 128/68. The abdomen showed nothing abnormal and there was no tenderness anywhere. As he formerly at least, had been sensitive to cold and was inclined to be irritable, he was given one dose of Silicea 1000 and the customary placebo of saccharum lactis. This remedy was repeated in a single dose of the 10m Skinner, on July 22nd, and again on September 10th. On December 9th the previous improvement under the action of Silicea ceased; examination showed tenderness on pressure over the right lower abdominal quadrant.
He stated that eating was apt to relieve his stomach distress and that his bowels had again become costive. Anacardium orintale 10m Skinner, one dose, was given December 9, 1944, but with no particular improvement. Later, Carbo vegetabilis 200 and still later, Sulphur 1000, were given with symptoms strongly marked enough to lead to these remedies. The last named remedy was given on December 23rd and the patient was not again heard from or seen until January 11, 1945 when he stated that he still was troubled with the lump sensation. Reexamination showed no enlargement of the liver or of the spleen, though there was some tenderness on pressure over McBurneys Point; the heart and pulse were normal; he complained of some burning in the epigastrium, relieved at times by taking food, then again, not relieved by eating.
A single specimen of the urine showed a specific gravity of 1.012 but no albumin. He now stated that he was obliged to urinate once or twice at night, thought there was no difficulty in doing so. At eight oclock in the evening of this same days, while in the bathroom, he had fainted and was carried to the bedroom and placed upon his bed. When seen, he was in a state of complete collapse, face deathly pale, no pulse to be felt at the wrist, cold sweat, yet he did not complain of feeling cold.
The heart sounds were very feeble, the patient was fully conscious, but said little. Camphor 200, a dose very ten minutes, brought him out of the collapse within twenty minutes and he was given three more doses at half hourly intervals. On the following morning he had a rather large, black stool which visual examination showed to be blood; there was no abdominal tenderness, but he was having colicky pains, without distension of the abdomen, Colocynthis 200, one dose, relieved the colic. The next day he received a single dose of Nux vomica cm, but without visible effect on his general condition.
A complete gastro-intestinal X-ray examination was now undertaken, the report of which read as follows: “Esophagus-no defect noted. Stomach-the stomach is moderately enlarged and no lesion defect noted in the fundus or pars media. There is noted persistent irregularity in the region of the pylorus and duodenal cap indicative of lesion. 6 hour film-there is still noted a delay in the region of the pylorus and duodenal cap with barium scattered throughout the small intestines. 24 hour film-Barium is noted scattered throughout the colon from the cecum to the rectum. 48 hour film-Barium is noted scattered throughout the colon from the cecum to the rectum.