Chronic pulmonary failure.

About 15 years ago I was asked to report on the cardiovascular state of a man of 48, almost crippled for want of breath, in whom no adequate reason for the disorder could be found. This man had passed unscathed through the First World Wrar, and since then had farmed successfully a sheep station of so,ooo acres. His land bordered what is called the 'back country.' It is a land of richness in good seasons, but subject to prolonged and terrible droughts. It is a dry and healthy climate. Until he reached the middle forties, he never spared himself and never recalled being ill. Gradually thereafter he became vaguely aware that all was not well and he was easily exhausted. So rapidly had this feeling increased over the last 12 months that as I watched him, he was painfully distressed at the mere effort of removing his shirt. Yet had I turned away, I would have been unaware of this distress for the dyspnoea was almost noiseless. He stood there stripped, over 6 feet in height, and gaunt almost to the point of emaciation. His neck muscles tugged at his upper chest and his abdomen caved in with the inspiratory effort. Not only did his chest seem fixed but the skin was so tautly stretched as scarcely to obscure the outlines of the pectoral and intercostal muscles. A light percussion was enough to set these muscles into action like the spread of ripples in a pond. Not only was one aware of the silent nature of the dyspnoea, but on auscultation there w,as silence or a near approach to it. It was as though the fetch of wind had ceased before it reached the alveoli. On fluoroscopy one saw the small heart within large lung fields, the lowN, disphragm immobile except for slight further flattening when instructed to blow his stomach out, so typical of advanced emphysema. An X-ray film of the chest showed nothing other than emphysema. Here then was a man whose illness began with shortness of breath; who had never been subject to bronchitis or asthma; who had no history of pneumonia; whose days were passed in an outdoor occupation in ani exceptionally healthy climate. This clinical study is based on the observation Fi(I.i-H.A., aged 63, has a history of progressive dysnpnoea for twelve years. Note the anxious facies and the tenseness of the accessory muscles of respiration. The limbs and body are 'wasted to the point of enmaciation. He had heen confined to hed for manv months wvith the mistaken diaglnosis of cardiac failure. Note the intranasal catheter. He had long been addicted to oxygen.