ally such a response has no significance, for it is found in many healthy individuals. The variability of the response is dependent largely on the degree of tension of the tendon, the response being slight when the tension is lax. In some individuals a layer of fat under the tendon seems to interfere with the reaction. It is often difficult to obtain the knee jerk in infants and young children. But under some circumstances a diminished response must be looked upon with suspicion, if not considered a positive sign of disease. This is true when the knee jerk, at one time normal or even excessive, is observed to gradually lessen in degree, or when it is much less on one side than the other, and especially when it is altogether absent on one side. Such manifestations must make us suspect disease of the cord.

ANKLE CLONUS.

We have so far considered the significance of absent tendon reflexes; we must now consider the significance of these phenomena when they are excessive. We shall consider only that form of these manifestations which has the greatest clinical significance, the ankle clonus.

The ankle clonus consists of a series of rhythmical up-and-down movements of the foot, at the rate of six to ten per second, produced by its sudden dorsal flexion. To elicit it the foot is grasped firmly with one hand, while the other may support the lifted leg, and then the foot is flexed suddenly and forcibly, and held in the flexed position. The movements of the foot are caused by the contractions and relaxations of the muscles of the calf. The clonus is a series of Achilles tendon reflexes. The sudden flexing of the foot stretches the tendon and produces a contraction of the calf muscles, just as a sudden blow on the tendon would cause it; and the series of contractions is caused by a succession of the same causes. The movements continue as long as the foot is held in its flexed position.

The ankle clonus is very rarely met in healthy individuals. Berger examined 1,400 soldiers and succeeded in eliciting it only three times. Like the absence of the patellar tendon reflex, it acquires its significance in disease on account of its rare appearance in health.

The ankle clonus is found mainly in those cases where there is disease of the pyramidal tracts of the cord, in various forms of myelitis, in lateral sclerosis, and in degeneration of the pyramidal tracts secondary to cerebral lesions. But it is not found if there be,

at the same time, sclerosis of the posterior columns, or extensive disease of the anterior grey matter in the lumbar portion of the cord.

It is a question to what extent the ankle clonus will assist in differentiating between organic disease of the cord and some cases of hysteria, where loss of power, rigidity of limbs, and excessive tendon reflexes seem to indicate organic disease. Usually the presence of a decided ankle clonus may be accepted as proof of organic disease. While there may be excessive tendon reflexes in hysteria, we seldom, if ever, find the ankle clonus. There may be found a spurious ankle clonus; that is, a few clonic contractions of the calf muscles are obtained when an attempt is made to elicit the ankle clonus, but not the unbroken series of movements of the foot as long as the effort is kept up, as is true of the genuine clonus.

The tendon reflexes are often very pronounced in nervous persons; they are excessive in some cases of ordinary neurasthenia, in hysteria, in fact, wherever there appears to be excessive irritability of the nervous system,-in chronic diseases, in convalescence from severe diseases, etc.; but in none of these instances does the excess usually reach to the development of the ankle clonus.

In addition to their significance in diagnosis, excessive tendon reflexes often have great value in prognosis, in assisting us to determine whether a hemiplegia of cerebral origin will be permanent. The earlier and more pronounced these manifestations are, the more unfavorable the prognosis.

ON THE TREATMENT OF SCARLET FEVER BY CHLORAL. (J. C. Wilson, M. D., physician to the hospital of Jefferson Medical College, in Med. News.)-So soon as the patient is suspected or known to be developing scarlatina, a laxative dose of calomel is administered. Shortly thereafter chloral is given in moderate doses, at intervals of two or three hours, or longer, throughout the attack. The dose varies with the age of the child; the frequency of its administration depends largely upon its effect. To infants of two or three years, a dose of from one to two grains may be given, the dosage being gradually increased with older children; that for adolescents reaching five grains. The tranquilizing and sleep-producing effects of the drug are in most instances promptly realized, the patient falling into a condition of quietude or somnolence, in striking contrast to the

discomfort and jactitation which are so distressing in the well-developed disease.

The repetition of the dose should not be more frequent than is necessary to maintain this condition of quietude, a condition from which the patient may be easily aroused, and into which he quickly relapses, when disturbed. It is neither necessary nor desirable to push the drug to the establishment of a deeper sleep. Profound narcotism is, of course, to be avoided. The patient may thus be kept in a condition of light repose throughout the whole duration of the fever. By this means, not only is there obtained relief from the restlessness and distress of the active period of the disease, but much wear and tear of the nervous system and some exhaustion from muscular effort are prevented. Delirium is controlled; the itching and burning of the skin, due to the eruption, are allayed; in a word, the greater number of the distressing symptoms of the disease, are favorably influenced by the cautious and prolonged administration of chloral in efficient doses.

As a rule, the drug is easy of administration and well borne by the stomach. I have found its acrid after-taste best masked by the administration in Aubergier's syrup of lactucarium diluted, thus:

Sig. hours.

R-Chloralis ....

Syrup. lactucarii (Aubergier)

Aquæ

....

}

gr. xxx ǎā 3jss.-M.

A teaspoonful in iced water every two, three, or four

The administration of nourishment immediately after the medicine is desirable. The sleep-inducing properties of the drug manifest themselves rapidly, but are not prolonged; therefore, its repetition at intervals of two or three hours, is called for.

The elimination of the drug takes place chiefly by the kidneys, and to a large extent as chloral. Decomposition with the formation of chloroform does not, as Liebreich anticipated, take place within the organism. This fact is of some theoretical importance, in view of the well-recognized antiseptic properties of chloral. Chloral acts, then, as a local antiseptic, upon two tissue areas that are especially prone to the pernicious effects of the infecting principle of scarlatina. These are the throat and the kidneys. It can not be claimed that chloral, in such doses as are safe, exercises to any great degree specific antiseptic effect upon the fluids of the organism at large

Nevertheless, the continual presence of even small amounts of chloral in those fluids, may be held to exert, to some extent, an influence upon them, unfavorable, so far as it goes, to the development of bacteria.

The local action of chloral, in these doses, upon the throat in ingestion, and upon the kidney in elimination, is direct and efficacious, as shown by the lower grade of intensity of the inflammation of the palatine arches and tonsils, on the one hand, and by the almost constant absence of albuminuria, on the other. The diuretic action of chloral is almost invariably manifested, the urine being much increased in quantity, of lower specific gravity, light-colored, and faintly acid. The diuresis is sometimes enormous, reaching from fifty to eighty fluid ounces in the course of twenty-four hours. large number of cases, intercurrent albuminuria was rarely encountered, and post-scarlatinal nephritis was not observed, although the cases were kept under observation for prolonged periods.

In a

Chloral, in the doses given, appears to exercise no influence upon the primary temperature curve of the disease, defervescence taking place between the seventh and ninth days by rapid lysis, as is usual.

Otitis media, extensive adenopathy of the cervical lymphatics, the collar of brawn, and abscesses, under this treatment do not occur. Hence, troublesome secondary fever, by which the febrile movement of scarlatina is often prolonged indefinitely, is prevented.

In the above doses, chloral does not appear to be a cardiac depressant, exerting, in the earlier periods of the disease, simply a favorable influence upon the excited heart, similar to that of small and frequently repeated doses of aconite. If, during the course of the disease, especially at the beginning of defervescence, the heart flags, alcohol must be given. As a matter of fact, alcohol in the form of milk punches, wine whey, or egg nogg, forms a useful addition to the dietary throughout the course of disease.

From the beginning of the attack, the nasal passages and the throat are systematically treated by antiseptic sprays, such as weak dilutions of Labarraque's solution, Dobell's solution, Listerine, or the antiseptic tablets devised by Dr. Seiler. This is done from the beginning in all cases. I regard it as a prophylactic measure of great importance, preventing the accumulation and retention of the morbid products of the inflamed mucous membrane and diminishing

the risks of secondary mixed local infection, the cause of the throat and ear inflammations which constitute occasional complications.

From the time of the appearance of the eruption, inųnction is practiced. For this purpose freshly washed lard is employed.

If the arrangements are such as to secure thorough disinfection of the clothing before it is washed, frequent changes are permitted; otherwise, to avoid risk of contagion, the patient is allowed to wear the same night-clothes throughout the attack. After the child leaves. the room, thorough disinfection is to be practiced by sulphur fumigation in the presence of moisture.

During the convalescence, quinine, nux vomica, and iron are indicated.

A HINT FOR FACILITATING THE MICROSCOPICAL EXAMINATION OF URINE.-When attempting to examine urine under the microscope, for casts, epithelial cells, and other organic bodies, a good deal of annoyance and difficulty is sometimes caused by urates, and also, when the specimen is not quite fresh, by fermentation and putrefactive products. In order to obviate this difficulty, and with the further view of preserving the specimen, Dr. M. Wendringer advises that the urine should be mixed with a nearly saturated solution of borax and boracic acid. This dissolves the urates, and keeps the urine from fermenting, and at the same time exercises no destructive effects upon the casts and epithelial elements which it is desired to examine. The solution is prepared by mixing twelve parts of powdered borax in one hundred parts of hot water, and then adding a similar quantity of boracic acid, stirring the mixture well. It is filtered while hot. On long standing, a small deposit crystallizes out, but clings to the side of the vessel, so that it does not interfere with the transparency of the liquid. The urine to be examined is put into a conical glass, and from a fifth to a third of its bulk of the boracic solution added to and agitated with it. The urine will be found to have become clear in a short time-i. e., if there is no cloudiness due to bacteria; and it will remain unchanged for several days. If it is only wanted to clear the urine and to make it keep for a day or two, the addition of a smaller quantity of the boracic solution is sufficient. If a third of its bulk is added, no fermentation or putrefactive processes take place, even if the glass is left uncovered.