i6o 



T/ie Per it ~(ir< fin in 



middle line and compressed, respiration is embarrassed, and the patient 

 is hardly able to move himself in his bed. 



When the effusion is excessive the lower two-thirds of the sternum, 

 and the left cartilages, from the second to the seventh, are prominent, 

 the intercostal spaces are widened, and the area of cardiac dulness is 

 increased. In the young subject, with pliant chest-walls, the bulging 

 is more marked than in the adult. 



As the patient lies in bed the effusion does not at first increase the 

 area of dulness, because it gravitates to the back of the sac collecting 

 behind the heart ; but as the distension increases the lungs are pushed 

 aside, and the ascitic pericardium bulges against the chest-wall, giving 

 rise to a dull percussion-note as high, perhaps, as the first space, and 

 extending widely behind the right and left cartilages, and the xiphoid. 



Effusion into pericardium ; lungs pushed aside ; .slight effusion into right pleura, v, vi, vn, 

 ribs in section. (BRAUNE.) 



The diaphragm, liver, and stomach are, at the same time, thrust 

 downwards. In acute inflammation the sac may contain from twelve to 

 eighteen ounces of serum, but when the disease is chronic the fluid may 

 amount to three pints. In the latter case the left lung would be pushed 

 far out, and the tumour would bulge so much towards the abdomen 



