average appearance of the normal thorax. Changes in outline of the heart, aorta, lungs, and other structures predicate some abnormal condition. In fluoroscopic or screen examinations, the patient bares the upper portion of the body, and is placed eight inches from the tube convexity, the lead glasscovered screen or fluoroscope being applied close to the skin, the target of the tube being directed over the centre of the region to be examined. This cathode target should be changed as the screen ascends or descends (preferably by means of a rachet arrangement) as the best penetration is obtained in a central line with the target. But a few minutes are required for careful examination, the anterior and posterior aspect of the thorax being thoroughly mapped out and, if preferred, sketched on a glass plate fastened over the anterior surface of the screen. The tube for these examinations should always be a tested one of high vacuum to secure penetration and detail.

For securing permanent skiagraphic records of thoracic examinations, some special practice and skill are required. With present perfected apparatus the chest can be skiagraphed in from one to thirty seconds by means of a 16-20 inch spark gap coil, and from three to eight minutes with a large static apparatus. The coil is preferable as rapid exposures are necessary in order to prevent interference with the image through respiratory action. To secure the skiagram, the apparatus, including the tube, is carefully tested, the patient placed in a recumbent position with arms extended over the head. A suitable table is employed and a special, rapid X-ray plate, size 14x17, or 11x14, depending on the size of the patient, is placed in the plate-holder below the parts to be skiagraphed. In important cases it is always desirable to take two exposures, or an anterior and posterior skiagram. The length of the exposure depends on the character of the tube and the apparatus and the depth of tissue to be penetrated. The more corpulent the patient the longer the exposure. Plates after exposure should be carefully marked with the case number, date, subject, etc., and developed and fixed, lege artis, as promptly as possible. If required, prints can subsequently be made from the finished plates, or the latter alone may be stored away as permanent records of the case. The skiagraphs can be taken from time to time, and the progress of the case noted. In tuberculosis of the lung the clearing up of a former hazy zone predicts a favorable

termination of the lesion at that site, showing resolution of tissue to normal conditions. On the other hand, increased shadows or haziness indicate a spread of the consolidation with less favorable prognosis.

FLUOROSCOPIC AND SKIAGRAPHIC APPEARANCE OF THE THORAX.

If we examine a normal thorax, Fig. 1., we note a central opacity of both sides of which the lattice work produced by the ribs will be seen, between which is the clear or diaphanous space. The central opacity is caused by the vertebral column, the sternum, the large blood vessels and the heart. The shadows of the latter are noted sometimes to the right, but generally to the left of the median line, and in close contact with the diaphragm. By placing the arms of the patient over the head, the scapulæ are rotated outward and the lung space in the respective regions appears clear. In screen or fluoroscopic examinations the motion of the diaphragm can be closely studied. This is an important part of the examination as limited excursion of the diaphragm (Williams' sign) is now recognized by all radiologists as an early sign-if not the earliest-of involvement of the lungs. The diaphragm can be best studied by placing the fluoroscope or screen at the back of the patient about the sixth to eighth dorsal space. In health, with normal respiration, the diaphragm moves one-half to three-quarters of an inch on either side; in forced respiration the right leaflet of the diaphragm moves 23 inches, the left but 2 inches. In the study of many normal cases the average difference of one-quarter inch between the right and left leaflets has been amply corroborated, showing increased mobility on the right side, due, as is recognized, to the position of the heart and blood-vessels. Williams (Roentgen Ray in Medicine and Surgery, 1902) was, we believe, the first to emphasize the fact that in incipient tuberculosis of the lung, one of the first signs noted was lack of excursion of the diaphragm of the side affected. This has been verified so frequently and is so valuable a diagnostic point. that Williams' sign should be looked for in all cases of persistent cough, and an early tentative diagnosis of tubercular invasion will be warranted if this sign is present, and the symptoms of other well-known lesions are eliminated and differentiated.

Tubercular invasion can be diagnosed by this method of precision much earlier than by the finding of Koch's tubercle

bacillus in the sputum-for in the latter case there is already purulent decomposition and breaking-down of tissue, indicating a lesion of some standing. Percussion and auscultation, even the percussion method of Kroenig, appear much later in the disease as a positive factor than the fluoroscopic or skiagraphic signs. When the lung is primarily attacked, even before marked changes in temperature are noted, the diaphragm will be found less active on the affected side. Observation of its increasing immobility or its return to normal mobility will assist the observer in rendering judgment as to improvement or aggravation.

FIG 2.

dated areas will be noted.

In tuberculosis, the fluoroscope or skiagraph shows a mottled or grayish appearance of the parts involved: Fig. 2. This haziness will, wherever consolidation supervenes, become darker; if on the contrary, improvement takes place, the normal clear or diaphanous. space will reappear. If cavities are formed, a white, clear, usually rounded but slightly irregular space, surrounded bydark spaces of consoli

In some cases when the cavity contains pus or exudates, the diagnosis is impossible, owing to the fact that the shadows will harmonize more or less with the surrounding consolidation. Records of these fluoroscopic surveys are valuable for purposes of prognosis, as the progress of the disease can be accurately determined.

The technic in the examination of a suspected case of pulmonary tuberculosis consists in the diaphragmatic survey

already discussed, this being followed by the examination of the side of the chest, which the diaphragmatic examination points out as the affected one. Comparisons of both sides are then in order to make sure of conclusions. Different degrees of haziness will be noted: slight haziness, marked haziness, and a black shadow indicative of consolidation. In most cases it is best to examine the chest anteriorly and posteriorly.

DIFFERENTIAL DIAGNOSIS

In EMPHYSEMA of the lung, excursion of the diaphragm is limited especially in the upper area, the normal rise of the dome of the diaphragm being absent. We find, in addition, usually the characteristic barrel-shaped thorax, the ribs being in a horizontal position during forced inspiration. The heart is usually in a vertical position due to the lowering of the diaphragm and increased pressure of the lungs. Portions of the lung present a whitish, absolutely transparent appearance of the parts affected, surrounded by an area of less transparency or even slight opacity.

In PNEUMONIA, an accurate diagnosis of a central lesion can be made--the area showing a dark shadow of distinct consolidation. This lesion, central pneumonia, has theretofore been diagnosed usually by exclusion. The history of the case, with the rapid appearance of dark or hazy interspaces between the ribs will not make differentiation difficult. The diaphragm is, of course, limited in its excursion on the affected side-if the lesion is bi-lateral total immobility of the diaphragm will be present.

In PLEURISY with effusion, the outline of the opaque shadow of the fluid is well defined, the opposite side showing normal transparency. In this disease restriction of breathing, instead of hyperactivity of the well side as noted in pneumonia, is a feature.

In MILIARY TUBERCULOSIS, the lung presents a characteristic disseminated mottled appearance, which, when once seen, can be instantly recognized.

In conclusion it can be stated that in the Roentgen ray method of examination we have a means for the early detection of tuberculosis with its invaluable importance for early treatment; are able to watch the progress of the disease and render valuable prognostic service through the frequently changing but reliable picture presented on examination.

REST AND EXERCISE IN THE TREATMENT OF TUBER

CULOSIS.

BY JOHN EDWARD WHITE, M.D.

(Medical Director of Nordrach Ranch, Colorado Springs, Colo.)

The intelligent prescribing of rest and exercise is the first and most important thing in the treatment of tuberculosis, and the success of all future treatment will depend upon it. We certainly cannot hope to effectually arrest the disease in a large percentage of cases unless this rest and exercise are under control. How very few physicians understand the great importance of each, and the simple rules that govern their application. It is very difficult for a physician in private practice to regulate the rest and exercise, owing to the difficulty of controlling the patient. One day he is feeling badly and will take too much rest, the next he is feeling better and perhaps he will ride horseback for many hours, upsetting days of actual gain. In this way the patient is constantly see-sawing back and forth until he reaches a point where nothing can be done.

It seems so strange that we did not recognize the value of rest years ago. We employed it in the treatment of nearly every other disease, especially in surgery; but why did we neglect to enforce rest in the treatment of tuberculosis? The advice heretofore has been to take exercise, get out and walk, ride horseback, etc. Now we make our patients take a maximum amount of rest until the disease is arrested, and then begin with our exercise.

The thermometer should guide us in advising rest or exercise; an accurate temperature and pulse record should be kept of every case, for it is only when we know the daily range of each that we can intelligently prescribe either. It is very hard in private practice to keep an accurate record, owing to the difficulty of making the patient see the necessity of doing so; and again we find many patients who ought not to know their daily temperature, as it keeps them constantly in a worry. Tuberculosis is, in a majority of cases, a direct result of overwork, either mental or physical, or both; and the first thing to accomplish is to regain this lost vitality by enforcing a rest, complete rest, too, in bed if temperature indicates the necessity. If one wishes to get well of this almost incurable disease, there can be no compromise in regard to rest. It must be complete and absolute; all work for the present and plans for the future must stop.