Clinical Pathological Conference

complaining of pain in the abdomen. During the previous four months his appetite had been poor and he had lost some weight. His bowel movements had been regular, except for an occasional attack of diarrhea. There had been no nausea or vomiting. Four days before admission he complained of dull steady pain in the epigastrium and both flanks. Simultaneously he became constipated and was unable to take anything by mouth except liquids. During this period he felt feverish at night and had occasional chills during the day. The patient had lived in New Britain all his life with the exception of a short trip to Italy in infancy. His father is currendy ill with carcinoma of the rectum. There has been no history of jaundice. The temperature on admission was 99.4, pulse 100, respirations 20, and blood pressure 130/90. Physical examination revealed a well-developed and well-nourished, acutely ill white male. The skin was smooth and slightly icteric. The tongue was coated. The teeth were in good repair and the tonsils and pharynx were negative. There were no enlarged peripheral lymph glands. The lung fields were clear. The heart was not enlarged to percussion, and the cardiac sounds were dear; murmurs were absent. The peripheral vessel walls were normal, the abdomen was distended and tympanitic, with shifting dullness in the flanks. The liver was palpated three finger-breadths below the right costal margin, with moderate tenderness in this area. The spleen was not palpable. There were no joint changes. The neurological examination was negative. On admission the R.B.C. was 3.8 million, hemoglobin 12.0 gm., the W.B.C. 7,400 with 81 per cent neutrophils, 11 per cent small lymphocytes. The urine was essentially negative except for the presence of bile. Stool examinations on several occasions during his hospital stay were negative for ova and parasites and for occult blood, but on two different days a few ova of Ascaris lumbricoides were seen. The prothrombin time on many different occasions varied from 17 to 19 seconds. On December 27, the cephalin flocculation test was negative. On January 3 it was again negative, but on January 28 it was reported as one-plus positive. On December 28 the NPN was 30 mg., the cholesterol 176 mg., the CO2 combining power 48 per cent, plasma chlorides 590 mg. The van den