ducing ill-effects. By many it is thought that the extra amount of heat produced is met, as a rule, by a corresponding increase in the amount of heat loss, so that the resultant body temperature is but little, if at all, raised, and that should any great increase take place a number of characteristic symptoms ensue. This view is probably due to the method of taking the temperature. It has been shown by Pembrey and Nicol that mouth and axillary temperature readings are unreliable, particularly in cold weather and after muscular exercise. The most reliable method is per rectum. Observations made by the writer and Hill at the London Hospital and Inter-Hospital Sports of 1907, when the weather was bleak and moist, with cold winds blowing, showed that the longer the effort on the part of the athletes the higher the temperature rose. One subject, after a 220-yard race, in which he finished first, had a rectal temperature of 100.85° F. Another, finishing first in the mile race, showed a temperature of 102.6° F., the temperature reading being taken one minute after the race. A number of other observations were made at this time, all showing a rise of temperature after body exercise.

A second tabulated series of cases was compiled from the temperature readings taken on the members of the winning team at the Inter-Hospital Rugby Final, on March 12, 1908. The afternoon was sunny, fresh and cool, with but little wind blowing. The subjects, when their temperatures were taken, felt "quite cool," yet they all showed temperatures ranging from 101.6° to 103.4° F. None showed any signs of warmth or dyspnea. These temperatures were taken with a thirty-second thermometer, allowing it to remain in the rectum fifty seconds, and the record was made from ten to twenty-eight minutes after the match was over.

It is well known that many factors, such as food, age, sex, race, external temperature, besides muscular work, are held to play a part in determining the body temperature. It would appear, however, that muscular work is the most important.

On the Proper Employment of Milk, Especially in Certain Diseases of the Skin.

eases.

L. Duncan Bulkley (The Dietetic and Hygienic Gazette, May, 1908) contributes an interesting and important paper upon the proper employment of milk in general medicine, as well as in the treatment of skin disHe demonstrates that the general inability of patients to go on and maintain a "milk diet" because it makes them "bilious," is due to no special fault of the milk itself being indigestible, but is rather due to a lack of proper appreciation of the physiology of digestion, and the administration of the milk at the wrong phase of stomach digestion. He shows the similarity of milk, in many ways, to chyle (formerly called "milk juice"), and asks, therefore, why can not milk be absorbed without the process of coag

ulation, caseation and subsequent digestion? As a matter of fact, at one time the intravenous injection of milk was recommended, whereby milk, like other digested components of the blood, was swept directly to the lungs. The problem, therefore, of proper milk administration, is to give it at such a time and in such a manner as to escape the acid and fermentative changes in the stomach during the process of digestion, and so avoid being curdled before it can be absorbed. It is definitely known that the stomach does not secrete gastric juice, except under the stimulation of food. After the stomach digestion has gone on for a certain period, the stomach is found empty, it loses its turgid color, becomes pale and flaccid, and its surface is bathed with more or less of an alkaline fluid, forming what is known as the "alkaline tide." This alkaline tide occurs. at varying periods of time after the ingestion of food, dependent upon many circumstances; it may begin an hour or so after a very small amount of digestible food, or it may be delayed four, five, or even many more hours, after a very heavy or unusually indigestible meal, or with very weak or sluggish digestion. It is only when this "alkaline tide" is perfectly secured and utilized that the method of giving milk, to be here recommended, can be carried out.

The idea, therefore, is to give the milk alone, pure or diluted with boiling water, at the body temperature, just after the "alkaline tide" has set in, or during its continuance, and to avoid any food or substance that will call forth gastric secretion until after the milk absorption has occurred. Therefore, give no crackers, whisky, egg, etc., with the milk. The milk should be gently warmed to 100° F., never boiled, cream should never be added. Occasionally, if the digestion is sluggish, it is necessary to give pepsin or other digestives freely. In other cases, Bulkley gives full doses of bicarbonate of soda, half hour before taking the milk.

In eczema, particularly, the writer has seen the greatest gain from the right use of milk. Give the milk, at times, when the patient is in bed, an hour before breakfast, also one hour before the noon and evening meals. Milk is also serviceable taken later in the night, if wakeful or restless from itching, provided, no food or medicine will interfere with the exact operation. Acne cases do well on this milk dietary. The same can be said of cases with other cutaneous diseases, even in such a matter as excessive loss of hair, where there is a nutritive fault to be repaired; frequently, good effects are seen in severe or malignant syphilis.

Milk, when taken successfully on the plan advocated by this writer, does not interfere with the appetite for the following meal; on the contrary, it seems to stimulate the appetite, on physiological grounds: the process of secretion from the glands of the stomach and cther organs depends largely upon osmosis and blood pressure. By the quick absorption of the milk, the pressure in the capillaries is increased, and a richer blood is also offered for the production of gastric juice, while a certain amount

of nervous relief is also given, enabling a more adequate supply of nerve energy to the digestive organs.

Kernig's Sign in Infancy-A Study of 2,000 Cases.

John L. Morse (Archives of Pediatrics, No. 3, 1908) reports his observations on the presence of Kernig's sign in various conditions in 2,000 babies (infants under two years of age) in his private and consultation work during the past five years, also patients seen in his hospital practice at the Infants' Hospital during the same period of time. He says that Kernig read the paper in which he called attention to this sign before the St. Petersburg Medical Society, in 1882, but it was not published until 1884. Almost no attention was paid to it, however, until Netter published his paper in 1898. Many articles were written on the subject during the past few years, but interest has somewhat diminished in it lately. It was at first supposed that this sign was not only pathognomonic of meningitis, but that it occurred so much more frequently in the cerebro-spinal than in the tuberculous form that it was of value in the differential diagnosis between the two. It was soon found, however, that it was in both forms, and that it was sometimes absent, also that it was found in other diseases of the nervous system, sometimes in the acute infectious diseases, notably typhoid fever and pneumonia. It was noted in cerebral hemorrhage, meningeal hemorrhage, chronic encephalitis, hemiplegia, cerebral abscess and hysteria. It has also been found in uremia.

Kernig's sign consists in the inability to extend the leg fully on the thigh, when the thigh is at a right angle with the trunk, or to flex the thigh to a right angle with the trunk when the leg is extended on the thigh. Kernig originally made the test by having the patient sit on the edge of the bed with the legs overhanging, and then attempting to extend the legs. Others modified the test by attempting to have the patient sit up straight in bed, with the legs extended on the thighs. Osler, in 1899, called attention to the fact that the sign could be elicited as well with the patient lying on his back, by flexing the thigh and leg on the trunk. Kernig did not consider the sign positive unless the angle was 135 degrees or less. Others have placed the limit at 120 degrees, or even at 115. The measurement of the angle of the leg on the thigh is the most satisfactory. This sign is an involuntary manifestation, and is not due to pain. It should not be confused with the inability to extend the thigh, which is seen in sciatica. Sainton and Voisin claim that the sign is a reflex phenomenon resulting from the action of the excito-reflex cells of the spinal cord, under various influences.

Five hundred and seven of the babies examined by Morse were normal. No one of them showed a Kernig's sign. The others were suffering from a great variety of diseases, a list of which would be too long to publish

in this abstract, numbering among them, however, typhoid fever, rickets, otitis media, adenitis, whooping-cough, etc. It was found that Kernig's sign is almost never found in infancy, either in health or disease, except in meningitis. It is found so rarely in other diseases at this age that its presence in an acute disease justified, as far as any one sign can, the diagnosis of meningitis. It is never present, however, in some cases, and in many others it is present only intermittently. It occurs with equal frequency at all stages of the disease. It has no apparent connection with the degree of intracranial pressure. It is more often present when the kneejerk is increased than when it is diminished. It is of no value in the diagnosis between the tuberculous and the cerebro-spinal forms.

The Blood Changes in Meningitis Cerebrospinalis Epidemica, Meningitis Tuberculosa and Meningitis Purulenta Non Epidemica.

G. Zand (Virchow's Archiv, Band 192, Heft 1, 1908) was influenced to make a study of the blood in various kinds of meningitis for the purpose of determining what aid can be obtained from such examinations in making the diagnosis and prognosis of the several varieties of infection of the meninges. There has been published already a considerable literature upon the blood changes in epidemic cerebrospinal meningitis, the chief contributors being Williams, Altman, Rieder, Struempell, Von Jaksch, Koplik, Spill, Grawitz, Foster and Goeppert. For instance, Williams found in 32 cases 12 instances where there was a decrease in the number of leucocytes-an observation considerably at variance with the other observers. Altman and Rieder found a considerable increase in the number of leucocytes. Spill found 10,000 leucocytes to the c.c. in one case, and 15,000 in another case of epidemic meningitis, and 20,000 each in two other cases. Goeppert found leucocytosis in his series of ten cases, as did Foster. Koplik found an increase in the number of leucocytes in his 21 cases, ranging from 12,000 to 55,000 per c.c. So did Osler. Presser and Jez studied the blood from a qualitative point, as well as from a quantitative; they found that the polymorpho-nuclear neutrophiles preponderated, with a diminution in the lymphocytes, with a marked diminution. in the eosinophiles. Tuerk claims that the leucocytosis of epidemic cerebrospinal fever is due almost altogether to the increase in the polymorphonuclear neutrophiles.

The writer gives the following literature on the blood picture in meningitis tuberculosa: Rieder found the blood normal in one case of tuberculous meningitis, a leucocytosis of 14,000 in a second case. Zappert noted leucocytosis of 11,000, with 1.5% of eosinophiles in a tuberculous meningitis case without fever. Limbeck counted leucocytes to 6,000 and 8,000 in his cases. G. Pick failed to find leucocytosis in two cases. Koplik, who studied cases of tuberculous meningitis in children, found a leu

cocyte count ranging from 20,000 to 25,000; a higher count in but one case; he claims that a higher count than 25,000 indicates some other kind of meningitis than the tuberculous. Tuerk notes a leucocytosis up to 20,000 in tuberculous meningitis.

The writer's cases number 10 cases of epidemic meningitis, in which the diagnosis was confirmed by the finding of the diplococcus intracellularis meningitidis of Weichselbaum; 2 cases of purulent meningitis which were not epidemic cases; 2 doubtful cases, where no lumbar puncture was made, but a provisional diagnosis of epidemic meningitis was in order, and 6 cases of meningitis tuberculosa. Of the 10 epidemic cases, 6 died; of the tuberculous cases, 6 died, and of the 2 doubtful cases, I died. These blood examinations were made at the same time every day, between II a. m. and 12 noon, shortly before meal time. Therefore, no question of digestion leucocytosis can enter here. The blood was taken from the lobe of the ear, which was cleaned with ether and punctured with a Franke needle. The red cells were diluted with Hayem's solution, and the white cells with a 1% watery solution of gentian violet, I part; glacial acetic acid, I part, and water, 100 parts. The stained specimens were prepared with Jenner's stain, with Ehrlich's triacid, and with Ehrlich's hæmatoxylineosin solution. It may be mentioned, also, that the percentage of hæmoglobin was estimated in these cases with the Gower's instrument.

These examinations showed that in both epidemic cases (due to the diplococcus of Weichselbaum), and in sporadic cases (due to the streptococcus), there is a leucocytosis up to 26,000 per c.c. during the height of the disease, with a leucopenia supervening towards the lethal termination of the case. The grade of the leucocytosis seems to have no importance as indicating the severity of the infection. This leucocytosis is a neutrophile increase, with especial increase of the polymorpho-nucleated neutrophile cells. In meningitis epidemica, streptococcica and diplococcica there is also an increase in the multinuclear neutrophiles, as in other acute infections, scarlatina, etc. It was noted, in the epidemic cases, that there was a decrease in the amount of hæemoglobin, as well as in the number of red-blood cells to the c.c.

In the tuberculous cases, it was found that the count of the white-blood corpuscles ranged from below normal up to 11,400 per c.c. This corresponded to the observations of Rieder, Zappert, Limbert and Pick. The lymphocytes showed a great increase in the differential count, as well as the transitional forms and the uninucleated cells. The count of the red cells was normal, or slightly above normal. The hæmoglobin estimation showed a diminution below the normal.

Of what value are these observations from a diagnostic or prognostic viewpoint? Simply this, that a high grade of leucocytosis, in a disputed. case, would tend to rule out the possibility of the case being tuberculous. Again, leucocytosis in epidemic cases, followed by a decrease in the num