. Physical diagnosis . actile fremitus, andabsence of Littens phenomenon, but the tactile fremitus is usuallymore diminished when fluid is present than in simple pleural thick-ening and atelectasis. An area of dulness which shifts with changeof position points to pleuritic effusion. The presence of frictionsounds over the suspected area speaks strongly in favor of pleuralthickening, but it is possible to hear friction sounds over fluid, 352 PHYSICAL DIAGNOSIS. probably because they are conducted from, a point higher up in thechest at which no fluid is present. In doubtful cases the diagnosisca
. Physical diagnosis . actile fremitus, andabsence of Littens phenomenon, but the tactile fremitus is usuallymore diminished when fluid is present than in simple pleural thick-ening and atelectasis. An area of dulness which shifts with changeof position points to pleuritic effusion. The presence of frictionsounds over the suspected area speaks strongly in favor of pleuralthickening, but it is possible to hear friction sounds over fluid, 352 PHYSICAL DIAGNOSIS. probably because they are conducted from, a point higher up in thechest at which no fluid is present. In doubtful cases the diagnosiscan and should be cleared up by puncture. (3) In two cases I have known enlargement of the liver due tomultiple abscesses to be mistaken for empyema. In both condi-tions, one finds in the right back dulness on percussion as high asmid-scapula, with absence of voice sounds, breath sounds, andfremitus. These conditions are due in one case to the presence offluid between the lung and the chest wall, and in the other case to. Fig. 175.—Area of Dulness in Solitary (tropical) Abscess of the Liver. the liver which pushes up the lung together with the physical signs alone I do not see how this diagnosis is possible,though Littens sign may be of use, since the shadow is absentin empyema and sometimes present in moderate-sized subdia-phragmatic accumulations. Some of the symptoms, such as chills,sweating, and irregular fever, are common to both conditions. Acareful consideration of the history and the associated signs andsymptoms may help us to decide. Large solitary abscess of the liver, occurring as it almost in-variably does in the posterior portion of the right lobe, produces anarea of flatness on percussion, which rises to a much higher level in DISEASES AFFECTING THE PLEURAL CAVITY. 353 the axilla and back than in front or near the sternum (see Fig. 175),and may be in this way distinguished from empyema; but when theliver contains many small abscesses, as in suppurativ
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