276 DISEASES OF THE PLEURA. 



tioii of the effusion, inspection will often show that the heart beats fat 

 to the left, and even as far as the axillary line. The cause of this is 

 that the heart, which at first was pushed to the right by the pleuritic 

 effusion, upon reabsorption of the latter, is now drawn as far into the 

 left pleural cavity, in order to fill up the vacant space caused by the 

 disappearance of the liquid. 



We may finally observe that the restoration of the normal dimen- 

 sions of the chest, and even the secondary contraction of a chest pre* 

 viously distended by effusion, is not, by itself a sufficient proof of the 

 complete absorption of the exudation. A compressed lung occupies 

 very little space, and, even after the pleural cavity has been greatly 

 reduced in size, there is always room for a considerable quantity of 

 liquid effusion. Upon palpation, a sensation of friction is perceptible 

 in a large number of cases of pleurisy. The characteristics and pecu- 

 liarities which distinguish this sensation from other sensible signs, as 

 well as the conditions under which it arises, will be discussed while 

 treating of the auscultatory phenomena. 



Palpation, moreover, often furnishes important diagnostic signs of 

 pleurisy with profuse effusion, from the peculiar character which the 

 vocal fremitus exhibits in cases of pleuritic exudation. In general 

 terms, it may be asserted that the pectoral fremitus is much weakened, 

 or entirely suspended, wherever 'a liquid pleuritic effusion is in contact 

 with the thoracic wall ; but, above the limit of the effusion, where the 

 compressed lung touches the side of the chest, the fremitus is intensi- 

 fied. It is quite manifest that a profuse liquid effusion will impede 

 the conduction of sound-waves to the thoracic wall, and that it will 

 also act as a powerful damper upon the vibrations of the latter, and it 

 is equally plain that the retracted pulmonary tissue forms a better con- 

 ductor for the passage of the vibrations to the chest-wall, and disturbs 

 them less, than does the normal unretracted lung. As, under normal 

 conditions, the vocal resonance is more plainly felt upon the right side 

 of the chest than upon the left, feebleness or absence of pectoral fre- 

 mitus upon .the right side is of greater diagnostic importance than the 

 occurrence of the same symptom upon the left side. In the anterioi 

 and lateral regions of the chest, the abrupt transition from absence to 

 exaggeration of the fremitus is a valuable means of determining the 

 limit of the exudation. Posteriorly, however, the signs change in a 

 more gradual manner. According to some very accurate observations 

 of Seitz, when the exudation is slight, the fremitus is only more or less 

 weakened ; when it is extensive, the fremitus is lost over the lower 

 portion, but over the upper it is merely lessened, and even this dimi- 

 nution decreases gradually toward the level of the liquid. When the 

 patient has a weak, high-pitched voice, whose wave-sounds hardly 



