Case of Dysphagia Accompanied by Ascites
Authors: E. L. Fox
Journal: BMJ (1887)

the integument, also the glands in his left groin were indurated.On fuLrther inquiry it was elicited that six months previously he was knocked down backwards by a passing truck, the fall being felt chiefly on his left side, and he admitted that, from time to time since then, he had had vague aching in the left loin, which was never, however, made worse by mlovement.There was some deficient stroke- sound and breath-sound, with absence of vocal fremitus at the base of the left chest; a systolic murmur was heard at the base of the heart; his liver reached mid-way between the ensiform cartilage and the umbilicus.His temperature in the axilla was 99.8°; his pulse was 108, small, but regular ; his respirationis were 36.He had some cough, attended with scanty muco-purulent expectoration; his tongue was moderately clean; his appetite was fair; he had had no vomiting except on two occasions, shortly after the accident referred to ; his bowels were pretty regular ; his urine was acid, deposited lithates, but wvas free from albumeln.He lay on his back, shelvincr to the left, and had difficulty in sitting up straight in bed, also in fully extending his left thigh.December 22nd.His sleep had been disturbed by the pain in his left leg; he had had none elsewvherc ; the cedema of the limb was much the same.His bowels had been freely openled by castor-oil, given to remove any accumulation ; but the physical signs and the characters of the tumour remained unalterel.December 26th.With the aid of hypodermic injections of morphine and atropine at bed-time, he hacd been sleeping better.He was easier in his left leg ; his temperature had slightly risen ; his urine was of specific gravity 1018, and showed, as it had done once or twice before since his admission, a small proportioni of albumen.December 29th.The skin could barely be pinched up over the most prominent part of the tumour.The two patches of ecchymosis above the pubes had almost disappeared.The semicircumference at the level of the umbilicus mleasured, right 15-1 inches, left 16" inches- and from the anterior superior spine of the ilium to the most depend- ent part of the ribs, the distance was, on the right side 5-inches, on the left 6`inches.His temperature was 101.4°; his pulse was 108 his respirations were 36.December 31st.He hlad ha(l paroxysms of acute shooting, pain in the left thigh, relieved only by hypodermic injections of morphine.January 2nd.He had been sleeping pretty well, and was more free from pain; but his appetite was niot .sogood, and he was beginning to suffer from dyspncea.There was still deficient resonance on percus- sion over the base of the left lung, and bronchial breathing was heard at the angle of the left scapula ; at this spot vocal fremitus was present.The breathing ov-er the right lung was free.A good deal of undu- latory pulsation was observable at the epigastrium.January 5th.His cough had increased during the few precedinig days.There was dulness on percussion more or less all down the left side of the chest, with the breacling obscure and indistinct ; bronchial breathing and bronchophony were heard over the left chest posteriorly; vocal fremitus was present at certain spots.At the right base, the breathing was harsh and rhonchal.What appeared to be the de- scending colon with solid contents was observed now coursing over the upper part of the tumour in a direction downwards and inwards.His bowels were confined ; his urine contained some albumen.January 6th.At 11.30P.m. he had a severe paroxysm of pain in his left leg ; his respirations were hurried, his breathing was op- pressed.The swelling of the limb, which latterly had diminished a little, was now much as before.January 7th.He had slept very badly.His temperature was 100.8°; his pulse was 108, very small and feeble ; his respirations were 36.He had tremulous movements of his fingers at times.He lay shelving down on the left side of his bed as though he would fall out.January 8th.He had been wandering in the night.The tremulous movements continued.His bowels had acted twice after an enema;he had considerable tympanites.His puilse was 112, very small and feeble.