Selections and Translations.

SUNSTROKE, OR THERMIC Fever.

Before entering upon the discussion of the clinical aspects of the subject, it may be allowable to call attention to the confirmation afforded by post-mortems recently made in the Philadelphia Hospital, as well as by recent German research, of the observation first made by myself in 1863, namely, the characteristic hardening or contraction of the heart found after death from coup de soleil. The results of experiments show that the early coagulation of the cardiac myosin, to which the hardening of the heart is due, is dependent upon the high temperature. The "cardiac spasm" is therefore not to be expected when the patient dies from the after-results of the heightened temperature, the excessive heat having been artificially removed from the body during life, whether by the use of external cold or by free venesection. Moreover, putrefactive changes occur so rapidly after death from thermic fever, that, unless the post-mortem is made very soon, the heart which has been contracted may be found relaxed. In these two factors, rather than in incorrect observations, probably exists the reason that the heart, in the accounts of autopsies upon sunstroke, has so often been reported as relaxed.

The result reached in my monograph was that there are two distinct classes of cases which have been confounded under the name of sunstroke. In the one the patient is collapsed; in the other the bodily temperature is excessive. At the Centennial grounds there have been under treatment a number of cases of the collapsed form of the disease, almost the first which I have ever seen. The severe cases occurred chiefly among persons who had been doing hard work in confined and excessively hot apartments. As a type of them may be noticed the instance of a very powerful man, who without warning fell over unconscious

in the Machinery Department. After about fifteen or twenty minutes he was carried into the hospital, still unconscious, in a state of muttering delirium, out of which he could be aroused just sufficiently to respond with a sort of grunt. The skin was wet as possible; the pulse very rapid and feeble; the breath strikingly cold, the temperature in the mouth being 95 ° F. Contrasting with this case was one of a Scottish harbor-master, also a very large, powerful man, who fell over unconscious in the Main Building, and was brought to the hospital with muttering delirium, rapid, feeble pulse, a dry skin, and a mouth-temperature which was certainly 108° or higher, since it was still 1071⁄2° after he had been some minutes in the ice bath. It certainly is proven that in the true sunstroke the direct action of the heat is the cause of the unconsciousness. The patient just alluded to was plunged into a full bath of ice and water in nearly equal amounts, and great chunks of ice were piled about his head and neck, so that the first dawning of consciousness was the impression that he was a corpse packed away in the ice-box. As his temperature fell, consciousness was regained pari passu. There is a source of fallacy in the study of the action of temperature upon the brain which is worthy of mention here. A patient is brought into a hospital senseless from coup de soleil. The burning temperature is reduced by a cold bath, but consciousness is not regained. It seems a natural inference that the excessive temperature was not the fons et origo mali. It is plain, however, that there are two sets of results caused by the caloric, -the immediate and the secondary effects. The excessive heat produces at once unconsciousness, but if it continue in action long it also causes changes in the nerve centres, which are themselves sufficient to prevent intelligence. The hospital case may have been under the influence of the intense fever for several hours before entering the ward, and, though the temperature be reduced, unconsciousness and death may be the only possible outcome of the mischief already wrought.

In the two cases just described as occurring at the Centennial

grounds, unconsciousness was developed with equal suddenness, and was accompanied by a similar delirium. It seems probable that in the collapse there is more than simple syncope,-that lowered temperature, like elevated temperature, paralyzes the nervous matter, which has been so constituted as to perform its functions upon a certain caloric level.

Finally, how.

In my experiments upon animals, it was possible to produce every degree of fever by external heat. In examining the clini cal literature of the subject, I was for a long time surprised not to find any discussion of mild cases of sunstroke. ever, in examining the writings of the India practitioners I found that they recognized very clearly mild cases of the disorder, in which the patient suffered no loss of consciousness, only fever of greater or less degree, and in which the termination might be health, or might be sudden coup de soleil. This summer, especially upon the Centennial grounds, I have seen an abundance of such cases,―men and women complaining usually of headache and always of wretchedness, with an accelerated pulse, and a temperature of 102°, 103°, 104°, or 105°. It was found that these patients were relieved at once by the cold bath. Such cases must be frequent during long spells of excessive heat, and their true nature has, no doubt, in this country, often been overlooked. This appears to be especially the case with children. There can be little doubt that many of the cases reported as cholera infantum, enteritis, etc., are really instances of thermic fever, and are curable by treatment as such. Especially does

this seem to be true of those cases in which the disease is popu larly said to "go to the head." Cases of this character usually owe their cerebral symptoms either to intense exhaustion, to be treated by stimulants, or to intense fever, to be treated by cold baths. In the Philadelphia Medical Times, vol. v. p. 664, may be found a most valuable paper, by Dr. C. G. Comegys, cerning the cold bath treatment of infantile "summer complaint." Any one who has seen, as I have this summer, the child on whom drugs had ceased to act, and who was seemingly doomed to die,

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relieved in twelve hours by enforced cold bathing every three or four hours, will grant to Dr. Comegys the credit of having introduced one of the most life-saving improvements in modern infantile therapeutics. The sudden sweet sleep, replacing, after the bath, the fretful nights and days of unrest, is a thing never to be forgotten when once seen, and the arrest of diarrhoea is certainly no less remarkable.

The diagnosis of thermic fever in the adult usually offers no difficulty. But on an intensely hot day a malarial paroxysm without chill may readily be mistaken for it. In one case I had to hold my decision; and I have seen others make the error. The malarial fever occurring on a very hot day may be greatly intensified by the heat, and the temperature, as I have seen it, mount so high as to become perilous and to call imperatively for the use of external cold.

The treatment which I have found at once successful in every case of collapse which has come under my care, consists in the use of the hot bath to restore caloric, and in the administration of moderate doses of whisky and ammonia internally, and especially the hypodermic injection of from 10 to 15 minims of the tincture of digitalis to restore the cardiac action. Rubbings with warm cloths dipped in tincture of capsicum, followed by the application of dry heat and wrapping in blankets, may replace the hot bath, but probably are less efficient.

In thermic fever the chief treatment is a simple one. Success depends upon its early and efficient use; the most efficient means of abstracting heat is the ice water bath. I have found in hospital practice a tendency to a routine use of this, the patient being put in always for so many minutes. This must be strenuously guarded against, every case being a study of itself, and the bath being used just long enough to reduce the mouth or rectal temperature to 100°, and no longer. After the cold bath I have found hypodermic injections of quinine seemingly of great service in preventing a rise of temperature. There is one further point to which I desire to call special attention. Af

ter the subsidence of the first symptoms, headache, slight elevation of temperature, general distress, and sometimes decided mental hebetude, come on. These delieve to be due to a low

grade of meningeal or even cerebral inflammation. Certainly I have found them to yield, in some cases very rapidly, to free blistering of the back of the neck and head, aided by small repeated doses of mercurials. In some cases a disordered condition of the abdominal viscera follows sunstroke; in this also small doses of mercurials are of great service.

One great cause of the excessive mortality of sunstroke in hospital practice is the length of time that elapses between the onset of the disease and the use of the bath. In the Philadelphia Hospital this has been in some measure remedied by supplying the ambulance with ice, and causing the patient to be stripped as soon as placed in it, and, under the superintendence of thc ambulance physician, rubbed with ice.

H. C. WOOD, In Philadelphia Medical Times.

[The remarkable results following the sub-cutaneous injection of quinine, as noticed in Indian practice, would seem to justify something more than the casual reference to this means made by Dr. Wood. "If there is anything in the practice of medicine which may be described as magical, it is the effect of the sub-cutaneous injection of quinine in sunstroke," are the words of one who has witnessed its action. Five grains dissolved in five minims of dilute sulphuric acid, to which is added fifty minims of water, are injected in different places about the shoulders.-ED.]

ARSENIC IN SKIN DISEASES.

Dr. L. Duncan Bulkley sums up an article in the N. Y. Medical Journal on the "Use and Value of Arsenic in the Treatment of Diseases of the Skin" as follows:

1. Arsenic, when administered in medicinal doses, has quite another action from that manifested by poisonous doses; the average dose of the former is one twenty-fourth of a grain of arsenious acid, while the smallest toxic dose is stated at two grains.