A 63-year-old man was seen July 23, 1951, with complaints of bloating, gas and belching after meals and palpitation on exertion, which had been present for ten years. He had a dull ache across the upper abdomen associated with the bloating and had had diarrhoea with considerable mucus in the stool. He had had respiratory difficulty, with cough, dyspnoea and wheezing, all his life. He also had noted paroxysmal nocturnal dyspnoea for two years, orthopnoea for six months, and swelling of the ankles for two weeks.
On physical examination, he was cyanotic and dyspnoeic and had distended neck veins. Many fine rales were present in both bases, with dullness, diminished breath sounds and tactile fremitus in the left base. Expiratory wheezes were present. Blood pressure was 142/74 mm. of Hg, and pulse rate was 108. The liver was enlarged and tender three fingerbreadths below the costal margin. An electrocardiogram showed digitalis effect and nonspecific myocardial changes. Blood urea nitrogen was 84 mg. per 100 ml. The blood count, haemoglobin, urinalysis, blood sugar, plasma carbon dioxide and serology were negative or normal. Roentgen examination of the chest (figure 1) showed marked displacement of the cardiac shadow posteriorly and to the right. A diffuse opacity occupied the lower two-thirds of the left chest. Air pockets or cystic areas with fluid levels were suggested anteriorly and superiorly in the left chest. Density in the right lower chest conformed somewhat to that of the middle lobe. The patient was considered too ill for gastrointestinal roentgen examinations.
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