James J. Waring G 1 7 



the complaints of marked constipation, increasing shortness of breath, "pain 

 in the stomach," enlargement of the belly, and swelling of the feet. 



About six months previous to admission he first noted difficulty in getting 

 his bowels to move. In spite of frequent cathartics, he was still troubled with 

 constipation and some distress in the upper part of the belly, which had slowly 

 but markedly increased in size for the previous five months. All this had been 

 accompanied by slight swelling of the feet and ankles, shortness of breath, 

 increasing weakness and lethargy. Past history was unimportant except for 

 the fact that in igi6 he contracted syphilis for which he took very little treat- 

 ment. 



Physical Examination. On admission the patient was comatose, answered 

 questions not at all or only after a notable pause and then in a deep, monoto- 

 nous voice and without opening his eyes. He seemed in no respiratory distress 

 while lying flat in bed. The skin was dry, brown, scaly, not cyanotic; the 

 mucous membranes of the lips were a little cyanotic. The hair was thin, espe- 

 cially on the back of the neck and above the ears. The eyebrows w^ere thin in 

 the outer thirds. The eyelashes were thin on the upper eyelids and missing 

 from the lower lids. Pubic and axillary distributions of hair were normal. The 

 face was generally swollen, the eyes narrowed to slits by edematous upper 

 and lower eyelids. The belly was much distended, with dullness in the flanks, 

 and the feet and legs were slightly edematous. The hands were dry, cold, thick, 

 the skin over the backs parchmentlike. There was some occupational der- 

 matitis. The tongue was dry, coated, thick; the mouth edentulous; there was 

 slight cervical adenopathy; the thyroid gland was not palpable. Both pupils 

 reacted sluggishly to light and diuung accommodation. 



Chest. The cardiac impulse was not visible nor could the movements of the 

 heart be felt by palpation. On percussion the area of precordial dullness ex- 

 tended from right anterior axillary line to left anterior axillary line at the 

 levels of the fourth and fifth ribs. The interspaces over this area were filled 

 out. The mediastinal dullness was about 14 cm. wide in the third interspace. 

 The heart sounds were inaudible. The veins in the neck were somewhat promi- 

 nent. The radial pulse was regular in rhythm, rate 60, temperature 97°, respira- 

 tion 28, blood pressure 150/95. The lungs were resonant in the upper lateral 

 portions of the chest and also in the upper portions posteriorly. The base of 

 the left lung was dull. Signs of pulmonary edema were absent. 



Abdomen. The abdomen was distended, tympanitic superiorly and dull in 

 the flanks. A fluid wave was present. The liver was just palpable. The spleen 

 was not felt. 



Extremities. The lower extremities showed a slight edema. The knee jerks 

 were present but sluggish, with a quick contraction and tardy recovery typical 

 of myxedema (Chaney""). 



Genitalia. Penile scar present; prostate moderately large and firm. 



Laboratory Tests. Urine: specific gravity, 1.030. No albumin, sugar, acetone, 

 or casts, but a small number of pus cells. 



