diaphragm shadow; is seen to be altered early in pulmonary tuberculosis.

It is a diminution of the excursion of the diaphragm, or, in other words, consists in a limiting or shortening of the normal shadow on the affected side.

This sign is important and should always be sought for in suspected cases.

Palpation.-Palpation may be negative in the incipient stage, as it is difficult to estimate slight increase in conduction.

As condensation or infiltration progresses vocal fremitus is increased. If, however, vocal fremitus is equal on the two sides indicates an increase on the left, or if it is greater on the left side than the right, the fact is significant. (Remember normal vocal fremitus is somewhat greater on the right side.)

Percussion.-In the earliest stage percussion may be negative or uncertain. There are not sufficient tubercles at this stage of the disease to help very materially. The effect of these small areas of consolidation upon the percussion note is more than counterbalanced by the resonance of the surrounding healthy portions of lung tissue.

Later on the dulness observed is usually very slight, often requires much experience to detect it, and particularly if at the apex is of immense significance.

Still later, when infiltration has increased, due to sufficient deposits of tubercles, moderate dulness is readily detected.

Hypersonous note at the apex, if unilateral, is a valuable sign of an incipient involvment.

Auscultation.—This is the most important physical method of examination. The first of procedure is to have the patient breathe naturally, and carefully compare the corresponding portions of the two sides before having the patient taking long and deep breaths or to cough.

The earliest auscultatory sign is, generally speaking, feeble breathing, owing to a diminution in the amount of air entering the bronchioles and air cells of the affected area. Make a careful comparison between the two sides during quiet breathing. Inspiration on the affected side may be inaudible.

Next in order of sequence is a prolongation of the expiratory murmur. About the same, or little later the inspiratory sound

grows harsher, rougher. The rhythm often becomes very jerky, occurs chiefly during inspiration and is described as cog-wheel respiration. If cog-wheel respiration is confined to one apex it is suggestive and suspicious sign, but if found throughout both lungs, as is often the case in nervous individuals, it is of no value. (As the disease progresses the type of breathing becomes broncho-vesicular.)

Adventitious sounds.-Râles may be absent for a considerable period in the incipient stage. When râles are detected on quiet breathing the case is no longer in the incipient stage. In the very early and true primary stage we have no râles, but at a later period, but still in the early stage, fine uniform crackling râles are heard only during forced inspiration, especially at the end of inspiration following cough, and limited to apex of one lung. As the presence of these fine râles is a valuable sign I will explain the method used for their detection. Direct patient to cough at the end of expiration and the deep inspiration following cough the râles are most likely to be heard. As we frequently meet patients who do not know how to take a long breath I tell them to blow out all the air they have in chest and hold their breath, and the full inspiration which follows is of value in eliciting râles; or have them. count 1, 2, 3, several times.

DIAGNOSIS AND RECAPITULATION.-Every effort should be made to arrive at an early diagnosis, before the disease is advanced and without depending on the finding of tubercle bacilli in the sputum.

There are cases in which expectoration is absent, or, if present, does not contain tubercle bacilli, and we are compelled to depend on other means. The physician who declines to make a diagnosis on account of the absence of the tubercle bacilli is making a grave mistake and assumes a great responsibility.

In some early cases there may be no recognizable physical signs, and we must remember some lesions are deeply situated and covered by healthy lung tissue, and it is in such cases the diagnosis may be established only by the history, clinical symptoms, and tuberculin injection.

A history of possible infection as living in the same room with consumptives, working in the same office, workshop or any association with consumptives.

Personal history as regards to dusty and confining occupations, unhygienic mode of life, living in dark, damp rooms, alcoholism, previous history of pleurisy.

Gradual loss of weight and strength, and fatigue after slight exertion, loss of appetite, dyspeptic symptoms are important. Light, dry, hacking cough, especially in the morning.

A persistent temperature without apparent cause.

Tachycardia, pulse frequent and low tension. Hemoptysis rarely profuse, usually being only streaked with blood.

The recognition of early physical signs as slight flattening below the clavicle on affected side, deficient apical expansion of affected side, diminution of excursion of diaphragm on affected side.

Moderate impairment apical resonance on affected side. Slight changes in the breath sounds at apex of affected side as feeble breath sounds, prolongation of expiratory sound. Harsh and rough inspiratory sounds, and may have the noisy, jerky respiration. Fine crackling râles heard only during forced inspiration, as by coughing.

We must not expect to find all the above symptoms and physical signs in all cases of suspected or early tuberculosis. Some cases present many of the above symptoms and others only a few. Three or more of these signs combined are sufficient to subject patient to treatment. Example: Disturbance of nutrition, loss of weight, associated with cough.

Remember, cough and hemoptysis are more valuable signs than the loss of weight and strength and rapid pulse.

If the clinical history and physical signs are not sufficiently diagnostic, and where there is no sputum, or if present, there are no bacilli on repeated examination, we should then resort to the tuberculin test.

Tuberculin has its advocates and its bitter opponents. Formerly I used tuberculin frequently with most satisfactorily results, but of late years I have been able to arrive at a positive diagnosis with clinical and physical methods in almost every case, therefore employ it very seldom, and use it only as a last resort.

Ophthalmo-Tuberculin Test.-Calmette has shown tuberculin as a diagnostic agent by dropping it into the conjunctival sac. At first one drop of one per cent is used, and if no reaction occurs two drops may be employed after a few days.

X-Ray. It is said the skilful use of the fluoroscope throws much light upon the condition of the lungs in incipient tuberculosis. I have no personal experience with this method of diagnosis. My colleagues, Drs. Amédée Granger and Adolph Henriques, who are experts in this method of examination, have made extensive studies and obtained valuable information, and regard it important in early diagnosis.

Special Comment.-Certain points are absolutely essential to the proper examination and early diagnosis of tuberculosis.

The technic and methods of procedure are of vital importance. Example: The technic and method of percussion requires more perseverance in acquiring manipulative skill than any other method of physical examination.

The knowledge of the sounds produced by the various maneuvres in the normal chest, etc.

Unilateral variations are infinitely more important than bilateral ones in early cases.

Remember, the disease usually begins at the apex; more frequently in the suprascapular region.

Finally, in short, the important areas are the apex, posteriorly and anteriorly the inner lung borders and the region of the interlobar fissure posteriorly, as roughly indicated by the scapular border when the arms are placed on the opposite shoulder.

Louisiana State Medical Society
Proceedings.

(EDITED BY PUBLICATION COMMITTEE).

P. L. Thibaut. M. D., Chairman.

Electricity in Medicine.

By DR. NARCISSE F. THIBERGE, New Orleans, La.

Before introducing the subject, I wish to offer a few words of apology and explanation. As my experience in this extensive branch covers a space of only four years, it is comparatively so meager that I have deemed it advisable to add to it the crystallized opinions of the electro-therapeutists of to-day. I claim little of

originality for this paper except its method of arrangement. The information that it carries, however, will prove of interest and be useful in our choice of method. Many times electricity is blamed for failure because the selection of current has been injudicious. This agent is a powerful adjuvant to internal medication. The general practitioner should clearly interpret what this form of current will do for one case and what this other form will do for another case with opposite indications. Take for instance an overexcited nerve keeping a patient awake-apply positive galvanism and the nerve will be soothed; when that same nerve is meshed in cicatricial tissue the pain will be more quickly dispelled by the absorbing negative electricity; tachycardia is relieved by the anode to the vagus, while the cathode is a circulatory stimulant. Transfer the poles, the symptoms are increased and electricty is blamed as a harmful agent. Here it is not the application but the physician, who, unequipped with a proper idea of the exact effect that a special current causes, is dangerous to the patient.

Innumerable are the indications possible to be met by electricity either in the form of electro-magnetic, sinusoidal or high frequency, galvanic or faradic, or as the X-ray and electro-cautery, or as a generator of heat, light, ozone or vibration. So vast is the field, so multiple and dissimilar the effects that we can considerately forgive the over enthusiast for looking upon it as a panacea. Metabolism in general is aroused by it and a better nutrition of the body functions is assured, especially as this effect is directed towards the nervous system and the circulatory apparatus. We can re-establish communication between the muscle and its nerve, and reconnect the center with the periphery; raise or lower the blood pressure; re-animate functions of organs disturbed by disease; destroy parasites; expel toxins from the system; and destroy new growths.

I will now invite you to review briefly the local and systemic effect of each variety of current separately and to draw their therapeutic indication therefrom.

As a diagnostic help for fracture, dislocation, inflammation of the osseous system, location of urinary calculus or other foreign body, the study of deformity, pelvic diameters or heart area, we cannot value the X-ray too highly. The skiagraph with its exten