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This case is presented for two reasons: (1) the bizarre roentgenologic picture, and months, and pain in the right chest. Anorexia had been apparent for three months. A month previous to the examination, the patient had had an attack of pain in the right chest which had lasted a week. This pain had later become constant. It was exacerbated by breathing and by lying on his left side. He had lost 15 pounds in the 3 months preceding examination.

The man gave a history of the usual infectious childhood diseases, malaria for a period of three years in early manhood, and an attack of irregular, rapid heart action in 1922. Careful questioning did not reveal a history of an acute febrile illness that might have been regarded as a pneumonia, pleuritic effusion, influenza, or other serious respiratory infection. Nocturia two or three times nightly had been present for six or seven years, with increased frequency and difficulty in starting the stream for two or three years previous to this report.

Physical Examination.—Temperature, normal. Pulse, from 75 to 80. Respiration, 20. Blood pressure, 132/94. All teeth had been removed. The head and neck were otherwise negative.

The left chest was emphysematous and hyperresonant throughout. Percussion note over the right chest was dull below the fifth rib in the posterior axillary line and the fourth rib anteriorly. Over this area, breath sounds were absent except along the border of the sternum, and vocal and tactile fremitus were greatly decreased. The right chest showed very little respiratory movement. The left border of the heart was at the anterior axillary line, with the maximum impulse sharply localized just to the left of the midclavicular line. The A2 was sharply accentuated, but there were no thrills or murmurs. The abdomen was apparently normal. Rectal examination showed a moderately enlarged prostate, smooth, and not unusually firm.

X-ray Examination.—Roentgenograms of the chest (Figs. 1 and 2) showed a dense opacity occupying the lower two-thirds of the right lung field, obliterating all lung detail, and completely obscuring the right diaphragm. The upper third of the right lung and the entire left lung were clear. The ascending aorta and the horizontal arch were distinctly outlined above the shadow, on the lateral view; the descending aorta was entirely obscured. Diagnosis was a probable tumor involving the right lower and middle lobes. The condition was also considered as possibly due to either encapsulated pleural fluid or aneurysm of the descending aorta with atelectasis of the lower and middle lobes.

The patient refused hospitalization, stating that he felt better when ambulant and that he did not consider himself really ill. Although it was advised, thoracentesis was not done.

On Jan. 4, 1931, the man was re-admitted to the hospital with a greatly distended bladder and complete urinary suppression which had lasted for 24 hours.

Article History

Published in print: Jan 1933