Lobar infiltration by squamous cell carcinoma.

A 74-year-old retired bricklayer had been followed by the res,piratory department since 1963 for chronic bronchitis. When first seen his forced expiratory volume in one second was 0-63 1, and vital capacity l*25 Il, with a slight bronchodilator response, and a normal mixed venous carbon dioxide and transfer factor for carbon monoxide. A subsequent steroid trial was negative. He had smoked 30 cigarettes a day between 1920 and 1963, when he stopped completely. Over the next 16 years the natural history of his disease was closely followed. He had three acute exacerbations requiring inpatient treatment between 1974 and 1979, developed carbon dioxide retention in 1975, and cor pulmonale in 1978. In April 1978 abdominoperineal excision of the rectum was performed for a Duke's stage A welldifferentiated adenocarcinoma; postoperative recovery was uneventful. In April 1979, the patient was readmitted to hospital with a two-week history of increasing cough, productive of foul green sputum, increasing dyspnoea, and ankle oedema. Two days previously amoxycillin, 250 mg eight-hourly, had been started. On examination, there was pyrexia, central and peripheral cyanosis, and evidence of congestive cardiac failure. Dullness to percussicn and reduced breath sounds w-ere present over the left upper and mid zones posteriorly. Clinical diagnoses of cardiac and respiratory failure, secondary to an acute infective exacerbation of chronic bronchitis were made. Investigations showed a leucocytosis of 13'8 x 109 1-1, with 93% neutrophils, and diffuse shadowing in the left upper lobe on the chest radiograph. Sputum and blood cultures were negative. Blood gas analysis confirmed the presence of respiratory failure. The FEV1 was 0-5 1, and VC 1II0 1. Treatmenft was started with controlled oxygen, diuretics, bronchodilators, physiotherapy, and the