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THERMIC FEVER, 
 
 OR 
 
 SUNSTROKE. 
 
 BY ^y---,:,. (%^y 
 
 H. C. WOOD, Jr., M.D., ■ 
 
 Professor of Medical Botany, and Clinical Lecturer on Diseases of the Nervous 
 
 System in the University of Pennsylvania ; Physician to the 
 
 Philadelphia Hospital. 
 
 BOYLSTON PRIZE ESSAY. 
 
 PHO BONO PUBLICO. 
 
 PHILADELPHIA: 
 
 J. B. LIPPINCOTT & CO. 
 
 1872. 
 

 Entered according to Act of Congress, in the year 1872, by 
 
 J. B. LIPPINCOTT & CO., 
 In the Office of the Librarian of Congress at Washington. 
 
TO 
 
 id:ei. s. -v^eii^ nyniTOKCELXi, 
 
 Not only as a tribute to his high renown as an original investigator, 
 and an offering of personal attachment ; but also as a grate- 
 ful acknowledgment of practical sympathy and 
 generous aid to the author in his early at- 
 tempts at medical research, 
 
 THIS BOOK IS RESPECTFULLY 
 
 Icbicafeb, 
 
PREFACE. 
 
 About ten years ago my attention was directed 
 very forcibly to the subject of sunstroke by the 
 cases which I witnessed at the Pennsylvania Hos- 
 pital, when resident physician. At that time I 
 noted the peculiar rigidity of the heart after 
 death, about which so much is said in this essay. 
 The great interest excited in me by the disease, 
 and the fact that my observations were rather de- 
 rided in certain quarters, long since determined 
 me to make at some time an experimental study 
 of the subject. The present essay is the result of 
 this determination. 
 
 Although my effort has been awarded the 
 Boylston Prize of the Harvard University, yet 
 with some hesitation I place it before the med- 
 ical public, claiming only that I have endeavored 
 simply to find the truth, and asking that any 
 
 (5) 
 
6 PREFACE, 
 
 shortcomings may be pardoned, because my work 
 has been honest in its intentions and desires. 
 
 The following is extracted from the minutes of 
 the Boylston Medical Committee : 
 
 ** By an order adopted in 1826, the Secretary was directed 
 to publish annually the following votes ; 
 
 ** 1st. That the Board do not consider themselves as ap- 
 proving the doctrines contained in any of the dissertations 
 to which premiums may be adjudged. 
 
 " 2d. That in case of publication of a successful disserta- 
 tion, the author be considered as bound to print the above 
 vote in connection therewith." 
 
PART I. 
 
 CLINICAL HISTORY. 
 
 Introductory. — There can be no doubt that under 
 the name of sunstroke or conp de j<?/^// sudden cases 
 of severe illness of very different natures have been 
 described by authors. Such of these cases as have 
 really been dependent upon exposure to excess- 
 ive heat can be classified under two, or perhaps 
 three, heads, to which the names of acute meni7t' 
 gitis or phreititis^ heat exhaustion^ and thermic fever 
 or true sunstroke^ may be respectively applied, as 
 more or less expressive of the pathological condi- 
 tions existing. 
 
 Acute meningitis or phrenitis, due to exposure 
 to the sun and the direct action of its rays i^on 
 the head, must be a very rare affection. In fact, I 
 have no positive evidence to offer of its existence 
 in nature, having never seen or read an unequiv- 
 ocal record of such a case, and therefore will pass 
 this theoretical class by without further allusion. 
 
 Simple exhaustion, due to excessive labor in a 
 
 (7) 
 
8 THERMIC FEVER, OR SUNSTROKE. 
 
 heated atmosphere, is an affection so very distinct 
 from true sunstroke, that it is strange it should 
 ever have been confounded with the latter. It 
 does not differ in its pathology or symptoms from 
 other forms of acute exhaustion, offering like them, 
 as its chief features, a cool, moist skin, and a rapid, 
 feeble pulse, associated with great muscular weak- 
 ness, and a tendency to syncope. The following 
 case is the only one I have seen ; the notes are 
 from memory, and therefore not so full as might 
 be desired. 
 
 Case. , set. about 50, was brought into my office at 
 
 I P.M. of a hot July day. He appeared to be a man of feeble 
 physical organization, and, after rallying, stated that he had 
 been feeling exceedingly weak and ill for several days. He 
 was in a semi-unconscious, syncopal condition, with an ex- 
 ceedingly rapid, fluttering pulse, a cool, damp skin, and 
 pale face. I had him laid flat upon his back, and brandy 
 administered very freely. Under its use the pulse soon be- 
 came much steadier and slower ; half an hour afterwards 
 he was able to walk with assistance to a carriage ; and I 
 heard of him no more. 
 
 Some years ago the late Prof Wm. Pepper 
 (American Journ. Med. Sci., Jan. 185 1) reported 
 to the College of Physicians certain cases of sun- 
 stroke, in which on post-mortem examination he 
 found the heart very much softened and relaxed. 
 As he distinctly states that the surface during life 
 was cool, there can be but little doubt that his 
 
CLINICAL HISTORY, g 
 
 cases really belonged to the affection now under 
 consideration. 
 
 In the discussion that followed the reading of 
 his paper, Dr. Condie described very clearly the 
 two classes of sunstroke cases, and was, so far as I 
 know,*the first American writer who clearly rec- 
 ognized the distinction. He evidently believed 
 Dr. Pepper's patients to be suffering simply from 
 exhaustion. 
 
 As there is nothing peculiar in these cases, I do 
 not think that they should have any especial name. 
 The term heat-exhaustion might be applied to them 
 had it not been used to signify true sunstroke. The 
 main point to be borne in mind is, however, that 
 such cases should not be called sunstroke, as they 
 have not the slightest affinity with that disorder. 
 
 Causation. — It is the third class of cases, then, to 
 which I would restrict the name of sunstroke, and 
 which alone offer a disease jr///^^;^mi", as well marked 
 and distinctive in its clinical history and anatomical 
 lesions as any affection at present known. 
 
 Although this paper has for its chief object the 
 discussion of the pathology of sunstroke, yet a 
 sketch of the clinical history is an evident neces- 
 sity to its completeness. 
 
 In the first place, in regard to the etiology of the 
 disease, my own experience is, that the only abso- 
 
lO THERMIC FEVER, OR SUNSTROKE. 
 
 lutely necessary, and the ever-present, immediate 
 cause, is heat, solar or artificial. It was formerly 
 believed that exposure of the head to the direct 
 rays of the sun was requisite, but this is now well 
 known not to be true. One of my own cases origi- 
 nated in a sugar refinery. 
 
 Dr. Longmore tells us that out of sixteen cases 
 seen by him in one epidemic, thirteen originated 
 in barracks or hospital. 
 
 M. Boudin, as quoted by Dr. W. C. Maclean 
 (Reynolds's Syst. of Med., vol. ii. p. 157), states that 
 one hundred cases of sunstroke occurred on the 
 French man-of-war Duquesne, most of them at 
 night, when the men were lying in their bunks. 
 
 Dr. Morehead (Researches on Diseases of India, 
 vol. ii. p. 583) says that direct exposure to the sun, 
 although a frequent, is not a necessary condition 
 to the production of the disease. 
 
 Dr. Geddes (Clinical Observations on Diseases of 
 India, London, 1846) details a case which occurred 
 in the hospital in the person of a man convalescent 
 from measles. 
 
 Dr. Barclay says (Madras Quarterly Journal, 
 No. 2, i860), ''The attacks of insolation came on, 
 with very few exceptions, when the men were in 
 the tents, — generally during the day, but in several 
 instances during the night, — never, except in one 
 instance, along the line of march. The patient 
 had generally been lying down, and often seem- 
 
CLINICAL HISTORY. 
 
 II 
 
 ingly asleep, or, as it would probably be more ac- 
 curate to say, attempting to induce sleep. Some- 
 times the attention of his comrades was first directed 
 to him by his hurried and heavy breathing, and on 
 attempting to arouse him he was found insensible." 
 
 Dr. Bonnyman (Edinburgh Med. Journ., vol. xiv. 
 p. 1029, 1864) says, **By far the greater number of 
 cases that yearly occur in India are of men who 
 have not been exposed to the sun. It is not un- 
 usual for men to go to bed in apparent health, and 
 to be seized during the night; and patients in hos- 
 pital, who have been confined to bed for days pre- 
 viously, are frequently the subjects of attack." 
 
 Dr. Swift (p. 47) asserts that the same affection 
 may be caused by exposure to artificial heat, and 
 that eleven of his cases were attacked in the laundry 
 of a hotel, and several were brought from sugar re- 
 fineries. 
 
 These quotations could be very much increased 
 in number, but they are surely sufficient to show 
 that exposure to the direct rays of the sun is in no 
 degree necessary for the production of coup de soleil. 
 The testimony of authors, and that of common 
 experience, that sunstroke occurs only in a highly- 
 heated atmosphere, are indeed so concordant, that 
 it is certainly allowable to take this point for granted 
 as long ago proven. 
 
 There has, however, prevailed in certain quarters 
 an idea that intemperance, and even malaria, were 
 
12 THERMIC FEVER, OR SUNSTROKE, 
 
 necessary factors in the production of coup de 
 soleil. 
 
 There can be no doubt that in this country a 
 large number of the cases occur in the persons of 
 habitual drinkers ; but the most temperate are not 
 exempt. 
 
 In India, among the European soldiery, the tem- 
 perate would seem at times to afford even the 
 larger proportion of victims, because the vagabond 
 drunkard soldiers are notoriously shirkers of duty. 
 Thus, of eight fatal cases in the 71st Highlanders, 
 occurring on the 7th of May, 1858, six were sober 
 men, one a '' tolerably free liver," and one a '* free 
 liver" (Crawford, Madras Quarterly, No. 2, p. 30, 
 i860). Dr. Crawford also says (p. 315), "I can 
 point to many soldiers whose lives are spent in an 
 unvarying round between the canteen, the guard- 
 room, and the prison, and yet they do not die of in- 
 solation at a time when our best non-commissioned 
 officers are victims to the apoplectic form of ardent 
 fever." Both he and Dr. Barclay also insist that 
 malarial poison is in most instances of insolation 
 not present, and does not when existent strongly 
 predispose to attacks. 
 
 The real and sole producing cause of the disease 
 is, therefore, Heat. There are, however, various pre- 
 disposing causes, which greatly aid the exciting 
 cause probably by lessening the powers of resist- 
 ance to it. First in importance among these is a 
 
CLINICAL HISTORY, 
 
 13 
 
 want of acclimatization. Foreigners are always at- 
 tacked in much larger numbers than natives of the 
 tropics. It must be remembered, however, that no 
 amount of acclimatization w^ill afford certain pro- 
 tection, as even the Hindoo, born and bred in the 
 stifling atmosphere of Bengal, is occasionally at- 
 tacked. 
 
 A second important predisposing cause is habit- 
 ual intemperance, all or almost all authorities co- 
 inciding in the assertion that habitual drinkers 
 afford a much larger proportion of victims than 
 temperate men when the exposure is the same. 
 
 A third predisposing cause is debility, and espe- 
 cially that debility or exhaustion which has been 
 brought on by fatigue, and in the highest degree 
 by fatigue in a heated atmosphere. The most 
 frightful epidemics on record have had this pre- 
 disposing cause for their ground-work. 
 
 A very marked instance of such an epidemic 
 is that recorded by Dr. Barclay (loc. cit.). The 
 43d Regiment, to which he was attached, made a 
 most extraordinary march of over eleven hundred 
 miles, chiefly through the lowlands of India, and 
 at the hottest season of the year. This march 
 was continuous, with the exception of a few brief 
 halts. No cases of sunstroke occurred until nine 
 hundred and sixty-nine miles had been traversed, 
 and the men had become thoroughly exhausted, 
 and even markedly emaciated. Shortly after this 
 
14 THERMIC FEVER, OR SUNSTROKE. 
 
 the regiment rested some eight days, and then 
 started again, arriving soon in a valley in the Bis- 
 ramgunge Ghat, a narrow ravine, with precipitous 
 walls nearly a mile in height. During the day 
 the thermometer in the tents ranged from 115° to 
 127°, and on one occasion was noted 105° at mid- 
 night The number of cases of insolation now be- 
 came very great, and although most of them recov- 
 ered, two officers and eleven men were lost in the 
 four days during which the regiment remained en- 
 camped. Although the air became cooler as the 
 regiment emerged from the hills, yet seven more 
 fatal cases occurred in three days. The further 
 following of Dr. Barclay's account is not necessary 
 for our purpose. It certainly shows that exhaus- 
 tion from severe labor at a high temperature is a 
 powerful predisposing cause of sunstroke. 
 
 Another predisposing cause, according to the 
 testimony of Indian observers (especially Dr. Bar- 
 clay, p. 378), is a febrile state. Some have deemed 
 that malaria was especially active in this respect, 
 but, as Dr. Barclay states (loc. cit, p. 378), *'at 
 the season when insolation prevails, malaria is 
 never present in the air in any quantity." 
 
 Still another predisposing cause appears to be 
 crowding in badly-ventilated barracks. Dr. Butler 
 says, as quoted by Maclean, '' Assuredly those 
 barracks the most crowded, least ventilated, and 
 worst provided with punkahs and other appliances 
 
CLINICAL HISTORY, 
 
 15 
 
 to moderate excessive heat, furnished the greatest 
 number of fatal cases." Mr. Longmoresays, "Nearly- 
 half the deaths occurred in a single company of the 
 regiment quartered in the barrack which was man- 
 ifestly the worst conditioned as to ventilation, and, 
 indeed, in every sanitary requirement.'* 
 
 A predisposing cause, which in the past has 
 added to the mortality list of sunstroke among 
 British soldiery, has been improper clothing, 
 ** The buttoned-up, tight-fitting coats, the leather 
 stocks, as stiff and unyielding as horse-collars, the 
 heavy cross-belts, so contrived as to interfere with 
 every movement of the chest, the heavy felt shakoes 
 mounted with brass ornaments, with wide, flat, 
 circular tops, ingeniously contrived to concentrate 
 the sun's rays upon the top of the head," no doubt 
 very seriously interfered with the soldier's power 
 of resisting the high temperature. 
 
 In reviewing these various predisposing causes, 
 it will be found that all of them either render the 
 nervous system more sensitive to the morbific 
 agent, — heat, — or else interfere with the glandular 
 system, so weakening it that it is unable to afford 
 the proper secretions whose evaporation shall 
 enable the body to resist the external heat, or 
 perhaps act in both of these ways. 
 
 Thus, want of acclimatization means simply an 
 unaccustomed condition of the nervous system to 
 the stimulant, heat, and also, probably, that the 
 
1 6 THERMIC FEVER, OR SUNSTROKE. 
 
 glandular system, from want of training, so to speak, 
 is unable readily to produce the requisite amount of 
 secretion. Again, intemperance causes the same 
 results in a slightly different form : organically 
 weakened nervous system and organically altered 
 glandular apparatus are unable to cope with the 
 morbific agent. 
 
 Syrnptovis — Course, — The idea that sunstroke 
 attacks its victims instantaneously certainly obtains 
 among the people, and to some extent even among 
 the profession. 
 
 The truth seems to be, however, that in most in- 
 stances the affection gives abundant warning of its 
 approach, although in others it attacks very sud- 
 denly. The histories of nearly all the cases herein 
 reported were very imperfect, yet in one (Case 5) the 
 wife of the sufferer gave a very distinct statement 
 that the man had had severe headache, vomiting, 
 and Aveakness previously to the attack. An exam- 
 ination of clinical records shows much more posi- 
 tively that prodromes, or symptoms preceding 
 unconsciousness, are very common, and, indeed, 
 generally present. 
 
 Dr. Morehead, in his work on the Diseases of 
 India, clearly recognizes their existence. He says, 
 p. 583, ''In this degree there is much headache, 
 with intolerance of light, and contracted pupils, 
 succeeded by suffused eyes and drowsiness or quiet, 
 
CLINICAL HISTORY, 1 7 
 
 delirium, or convulsions, — followed by coma with 
 dilated pupils." 
 
 Dr. Longmore (London Lancet, March, 1859) 
 calls attention to excessive irritability of the blad- 
 der as a symptom preceding attacks of sunstroke. 
 
 Dr. Bonnyman (loc. cit.) says, " Where premoni- 
 tory symptoms show themselves, they are some- 
 times well marked. Those usually observed are, 
 — inaptitude and disinclination for any exertion, 
 drowsiness, or a desire to sleep, vertigo, headache, 
 and slight confusion of ideas ; the patient feels 
 weak, sighing frequently; the appetite is gone, 
 thirst is increased, and the bowels are constipated ; 
 the symptoms become aggravated, and the patient 
 either passes into the state of profound coma, 
 or symptoms of the first or progressive form of the 
 malady are complained of, viz., distressing head- 
 ache, with a feeling of weight and heat in the 
 occiput, tightness, distention, and throbbing in the 
 forehead and temples, anxiety at the praecordia, 
 nausea, and a disposition to vomit. A sensation 
 of sinking or of insupportable weight, or uneasi- 
 ness, is referred to the pit of the stomach, and a 
 feeling of horror or of impending calamity, with a 
 tendency to weep, is experienced. The breathing 
 is natural, or slow and sighing. The face is gen- 
 erally natural or somewhat flushed, eyes bright, 
 pupils either natural or somewhat contracted. 
 The skin is very hot and dry ; the pulse is full and 
 
1 8 THERMIC FEVER, OR SUNSTROKE, 
 
 accelerated, tongue white, thirst intense, bowels 
 confined, the iiriiie suppressed. If these symptoms 
 persist, tetanic convulsions suddenly appear, and 
 the patient lapses into the second or severe form 
 of the disease." 
 
 Dr. J. R. Taylor says ('' On Erethismus Tropi- 
 cus," London Lancet, 1858, vol. ii. p. 355), ''The 
 symptoms in these cases were, weakness, pains in 
 the limbs, great oppression at the prsecordia, and, to 
 use the patient's own words, ' a burning pain inside.' 
 An indefinite pain in the head was always admitted 
 upon inquiry, and sometimes, but not in many in- 
 stances, was the most prominent cause of com- 
 plaint." 
 
 Dr. Swift states that premonitory symptoms were 
 wanting in the majority of his cases, but that the 
 insensibility was very generally preceded by pain in 
 the head, disordered vision, a sense of weight in 
 the epigastrium, and sometimes nausea and vomit- 
 ing. Surrounding objects appeared of a uniform 
 color, in most cases blue or purple, in some red, 
 green, or even white. 
 
 Dr. Staples (British Army Reports, 1868) states 
 that as seen by himself prodromes were always 
 present, the disease appearing in fact to come on 
 gradually, there often seeming to be no line of 
 demarkation between the prodromatous stage and 
 the stage of complete insensibility, the latter 
 coming on gradually. 
 
CLINICAL HISTORY. 
 
 19 
 
 All the cases of sunstroke which have come 
 under my observation have been in the hospital, 
 and therefore represent only the severe, fully-formed 
 disease. The symptoms have been very constant. 
 Total insensibility was always present, with, in 
 rare instances, delirium of the talkative form, and 
 still more rarely the capability of being roused by 
 shaking or shouting. The breathing was always 
 affected, sometimes rapid, sometimes deep and 
 labored, often stertorous, and not rarely accompa- 
 nied by the rattle of mucus in the trachea. The 
 face was often suffused, sometimes, with the whole 
 surface, deeply cyanosed. The conjunctiva was 
 often injected, the pupils various, sometimes di- 
 lated, sometimes nearly normal, sometimes con- 
 tracted. The skin was always intensely hot, and 
 generally, but not always, dry ; when not dry, it 
 was bathed in a profuse perspiration. The intense 
 burning heat of the skin, both as felt by the hand 
 and measured by the thermometer, was one of the 
 most marked features of the cases. The degree of 
 heat reached during life was, in my cases, mostly 
 io8°-i09° F. The pulse was always exceedingly 
 rapid, and early in the disease often not wanting 
 in force and volume; later it became irregular, 
 intermittent, and thready. The motor nervous 
 system was profoundly affected : sitbsiiltus tendi- 
 num was a very common symptom, great restless- 
 ness was also very often present, and sometimes 
 
20 THERMIC FEVER, OR SUNSTROKE. 
 
 partial spasms or even violent general convulsions. 
 The latter were at times epileptiform, occurring 
 spontaneously, or they were tetanoid and excited 
 by the slightest irritation. Sometimes the spinal 
 cord appeared to be paralyzed, the patient abso- 
 lutely not moving. 
 
 Dr. Barclay also notes this difference in cases in 
 regard to the motor apparatus. He says (p. 364), 
 ** In a large proportion of cases, from the commence- 
 ment of the attack till its termination in death the 
 patient never moved a limb or even an eyelid. A 
 comparatively small number of cases, however, 
 were from the first attended with convulsions. 
 These generally began in the upper extremities, 
 and in some cases they did not extend farther, 
 the patient either becoming rapidly insensible 
 or recovering ; but in other instances they ex- 
 tended to the whole of the voluntary muscles, 
 and were of the most violent description, — ceasing 
 frequently for from two to three, to fifteen or 
 twenty minutes, and recurring again with increased 
 severity." 
 
 Petechise and ecchymosis, the evidences of 
 broken-down blood, were present in some of my 
 cases, and there was, in one or two instances, even 
 a fetid hemorrhagic exudation from the nostrils 
 during life. A symptom which has pretty much 
 escaped the attention of authors was the peculiar 
 odor. This was most marked in those patients 
 
CLINICAL HISTOR V. 2 1 
 
 who had involuntary passages, but was very dis- 
 tinct from any fecal odor. The stools emitted it 
 very strongly, but so did the skin and breath. It 
 was so distinctive as to render possible the recog- 
 nition of a case by the sense of smell alone. The 
 discharges from the bowels were liquid and very 
 often involuntary. None of the cases passed urine 
 whilst under observation. 
 
 These symptoms agree very well with the de- 
 scriptions of most authors. Dr. Barclay (loc. cit), 
 however, says that in his cases ^' the eyes were 
 fixed anjd slightly turned upwards, becoming grad- 
 ually more and more glassy, as if from the forma- 
 tion of a film over the cornea ; the pupils greatly 
 contracted ; the conjunctiva pinky, the color grad- 
 ually becoming deeper; the congestion at first 
 being deep-seated. The face was invariably pale, 
 never in any instance bloated or flushed, as has 
 been described by others. The heart's action was 
 very rapid and sharp, the impulse and the pulsa- 
 tions in the carotid being perceptible to the eye 
 from a considerable distance." 
 
 The truth seems to be that all the minor symp- 
 toms vary, — that the important characteristic and 
 always-present symptoms of this variety oi coup de 
 soleil may be summed up as intense fever with 
 profound disturbance both of the cephalic and 
 spinous nervous system ; the disturbance manifest- 
 ing itself in the form of insensibility, with or with- 
 
22 THERMIC FEVER, OR SUNSTROKE. 
 
 out delirium, and with restlessness, convulsions, or 
 paralysis of the motor tract. 
 
 The following notes of cases were all taken 
 during my residency in Pennsylvania Hospital, 
 and, having been made before I was conversant 
 with the literature of the subject, or had thought 
 much about it, are unfortunately not so full on 
 certain points as is desirable: 
 
 Case I. — T. B., Irishman, aet. about 30, was brought 
 into the ward at i P.M. August 2, 1863. He was said to 
 have fallen whilst walking in the street a few minutes 
 before. He was perfectly unconscious, with very labored 
 breathing. His pupils were not markedly dilated or con- 
 tracted, and yielded sluggishly to light. His skin was 
 cyanosed and very hot and dry. He had vomited and 
 passed his feces unconsciously. His pulse was no, quick 
 and moderately strong. He could scarcely swallow. Tur- 
 pentine injections and brandy were exhibited; but the man 
 died at 5 p.m. 
 
 Autopsy, two hours after death, — Rigor mortis marked. 
 Venous trunks of the meninges of the brain loaded with 
 dark blood. Brain substance normal. Lungs congested. 
 Heart rigidly contracted. A thermometer in thorax indi- 
 cated 108° F. Blood very dark-colored, with a slightly acid 
 reaction ; not coagulating. Blood-corpuscles under the 
 microscope normal, but very dark-colored. 
 
 Case II. — Irishman, set. 64, a moderately stout, muscular 
 man, was brought into the ward about 7 p.m. August 10. 
 His skin was very hot, belly tympanitic, pulse 177, not 
 intermittent, but very weak. He had had involuntary dis- 
 charges from the bowels. The face was very much con- 
 
CLINICAL HISTORY. 23 
 
 torted by spasms, repeated pretty regularly 130 times a 
 minute. He was treated with turpentine injections, brandy, 
 aromatic spirits of ammonia, etc. He died quietly at 1 1 J p.m. 
 Autopsy, one hour after death. — Venous trunks of the me- 
 ninges of the brain loaded with blood. Brain substance nor- 
 mal, not congested. No bloody or serous effusion. Heart 
 rigidly contracted. Kidneys normal. Blood very dark and 
 fluid ; of a slightly acid reaction. 
 
 Case III. — German. A discharged soldier; very intem- 
 perate ; a large, fat man, weighing about 200 pounds. He 
 was brought into the wards at i p.m. August 10. Those who 
 brought him in stated that he had fallen suddenly whilst 
 loading a dray, about an hour and a half previously. His 
 skin was^ of a dark-reddish color, the capillaries refilling 
 very slowly when they were emptied by pressure with 
 the finger, it requiring several seconds for them to do so. 
 His pulse was 170 and upwards, very irregular and intermit- 
 tent, but not excessively weak or thready. He was perfectly 
 unconscious, but lay absolutely still, without even subsultus 
 tendinum. His pupils were contracted. The conjunctiva not 
 sensitive, and very much congested. His skin exemplified 
 calor mordax. A thermometer placed in the axilla indi- 
 cated 109° F. His breathing was slow, very labored, and 
 irregular. He had involuntary discharge of feces. He 
 gradually grew worse, and before death bloody, dirty foam 
 trickled from the nose and mouth. Death occurred at 2J p.m. 
 
 Treatment. — Frictions with ice ; brandy and ammonia, as 
 much as could be forced down him. Turpentine injections. 
 
 Autopsy, one hour after death. — Cadaver intensely hot, 
 very fat, no rigor mortis. Meningeal venous trunks en- 
 gorged. Brain substance normal. Left heart slightly con- 
 centrically hypertrophied, very firmly contracted. Kid- 
 neys normal. Blood very dark-colored, fluid, coagulating 
 slightly, forming not more than a grumous mass. 
 
24 
 
 THERMIC FEVER, OR SUNSTROKE. 
 
 Case IV. — C. H., Englishman, over 60 years of age, was 
 brought to the hospital at \\ p.m. August 11. He was said 
 to have fallen in the street one or two hours previously. He 
 was very restless, almost convulsive ; breathing labored 
 and noisy; pulse 170, and slightly intermittent; skin burn- 
 ing hot ; temperature in axilla 109° F. His pupils were con- 
 tracted, the conjunctiva dry, non-sensitive, and injected. 
 There was some, but not strongly pronounced, stasis in the 
 capillaries of the skin. 
 
 Treatment. — Brandy, aromatic spirits of ammonia, tur- 
 pentine injections, and rubbing with ice. He died in half 
 an hour. 
 
 Autopsy, one hour after death. — Cadaver very fat. Menin- 
 geal venous trunks engorged. Brain substance very slightly 
 congested, the ventricles distended, with slightly reddish 
 serum ; no effusion of blood. Left heart slightly hyper- 
 trophied, firmly contracted. Liver very fatty. Kidneys 
 normal. Spleen very much enlarged, and softened. Blad- 
 der empty, rigidly contracted. Blood very dark ; coagu- 
 lating, but not firmly. 
 
 Case V. — ^J. B. An intemperate Irishman, aet. about 33, 
 was brought into the wards of the hospital at 3-j p.m., Au- 
 gust 14. His wife stated that on the loth he had been so 
 exhausted by the heat, so sick at the stomach, and had 
 suffered so much from headache, as to be forced to give up 
 work until the morning of the 14th. When he entered the 
 ward the skin was very moist, but intensely hot, and cov- 
 ered with a rubeoloid eruption. A thermometer placed be- 
 tween the thighs indicated 104° F. The pupils were slightly 
 contracted, the conjunctiva injected and very sensitive. 
 There had been no discharges. The pulse was 140, and 
 rather feeble. He was entirely unconscious, but was con- 
 tinually muttering unintelligibly, and was very restless. He 
 vomited freely. 
 
CLINICAL HISTORY. 
 
 25 
 
 Treatment. — Cold water poured by the bucketful over the 
 head and breast, and turpentine injections. At 4 o'clock 
 his restlessness was replaced by convulsions, with very 
 marked opisthotonos. These convulsions lasted some five 
 or six minutes each, and were somewhat epileptiform ; but 
 as the secretion of saliva was entirely dried up, he did not 
 foam at the mouth, although his jaws worked violently. 
 His breathing was for the most part very hurried, shallow, 
 and irregular, but at times labored and slow. He passed a 
 few drops of urine, and his bowels were moved by an in- 
 jection. Brandy was put in his mouth, but its exhibition 
 produced immediately fearful convulsions, probably owing 
 to the difficulty of deglutition. 
 
 The cold affusions lowered the temperature of the skin, 
 but did not resuscitate him in the least. At 47 o'clock the 
 douche was repeated, but this time produced violent spasms, 
 with vomiting and great congestion of the face. From this 
 time his symptoms deepened, his body became very d.irk- 
 blue or purphsh, and he died quietly at 5.15 p.m. No post- 
 mortem was allowed. 
 
 Case VI. — An Irishman, middle-aged, robust, and muscu- 
 lar, but not fat, was brought into the wards at 8 p.m., Au- 
 gust 14. He was said to have fallen about 3 p.m. He was 
 perfectly unconscious, somewhat restless, with muscular 
 twitchings and subsultus tendinum. His tongue was very 
 dry ; his skin dry, harsh, and hot. The temperature in 
 the axilla was 104° F. His pupils were slightly dilated, his 
 conjunctiva injected ; pulse 150, weak, not intermittent, but 
 somewhat fluttering ; breathing 48 per minute, and very 
 laborious. He could swallow only with difficulty. He 
 was treated simply with brandy, and died quietly about 
 11.30 P.M. 
 
 Autopsy, one hour after death, — No rigor mortis. Tem- 
 perature in abdomen 108° F. Brain, with its large venous 
 
 3 
 
26 THERMIC FEVER, OR SUNSTROKE. 
 
 trunks, engorged, and ventricles containing an abnormal 
 amount of serum. Left heart rigidly contracted. Liver 
 very fatty. Blood very dark and fluid, with a decided acid 
 reaction. 
 
 Case VII. — C. B., German, a large, muscular man, was 
 brought into the hospital at 12.30 p.m., August 15. The 
 skin was very hot and dry, axillary temperature 109° F. ; 
 pupils almost normal, conjunctiva injected, mouth moist, 
 deglutition almost impossible. He had a severe convulsion 
 immediately after his entrance, and died in a very few min- 
 utes. There was a large ecchymosis in one axilla. He was 
 said to have fallen whilst working in a sugar refinery, and 
 to have been brought at once to the hospital. 
 
 Autopsy, two hours after death, — Meningeal veins gorged 
 with blood. Some serous exudation in ventricles. Left 
 heart rigidly contracted. Temperature in abdomen i io|° F. 
 Blood decidedly acid, very fluid, without a sign of coagu- 
 lation. Under the microscope the red corpuscles were ap- 
 parently darker than normal. 
 
 Case VIII. — An Irishman, only a few days in the country. 
 He was said to have fallen during the latter part of the after- 
 noon, whilst wheeling coal. When brought in at 9 p.m. he 
 was semi-unconscious, but could scarcely speak intelligibly ; 
 his pulse was 90 per minute, moderately strong ; surface dry, 
 but not inordinately hot ; he had no pain, but complained of 
 great weakness ; he had not had involuntary discharges. 
 
 Treatment. — Ten grs. of muriate of ammonia and f § ss of 
 brandy were given every half-hour, and an injection of an 
 ounce of turpentine was administered. At 10.30 p.m. his pulse 
 had fallen to 80, and his general condition much improved. 
 His medicine was directed to be given every hour only. 
 
 August 12, he was entirely conscious, but very drowsy, 
 and slept a great deal. 
 
CLINICAL HISTORY, 2/ 
 
 August 14, well. He now states that previously to his 
 attack he had been drinking freely of ice-water, but had not 
 been sweating at all, and that he had no premonitory symp- 
 toms, no signs of exhaustion, no optical derangement, no 
 headache, etc. 
 
 In many of the cases which have come under 
 the notice of the author of this memoir, the evi- 
 dences of asphyxia were quite marked some time 
 before death; but at the same time there was gen- 
 erally a consentaneous failure of the heart's action, 
 so that the immediate cause of death was not merely 
 failure of respiration, but also of the heart's action. 
 
 These cases, I think, represent the ordinary va- 
 riety of the disease seen in our large cities. 
 
 According to Maclean, Dr. Morehead* has di- 
 vided insolation into three varieties : the cardiac, 
 the cerebro-spinal, and the mixed. " In the cardiac 
 variety, although it is probable that the sufferer is 
 himself conscious of some premonitory symptoms, 
 there is seldom time for their full development, so 
 as to attract the attention of bystanders, before the 
 patient falls, gasps, and, in some severe cases, expires 
 
 * Dr. Maclean gives no reference, and I have not been able to 
 find where the classification is made. As the Royal Society's 
 catalogue does not ascribe to Dr. Morehead the authorship of any 
 especial paper on sunstroke, it seems probable the classification 
 was proposed in his work on the Diseases of India. If so, it must 
 be in a later edition, for the first contains no reference to any 
 such division. 
 
28 THERMIC FEVER, OR SUNSTROKE, 
 
 before there is time to do much or anything for 
 his recovery, death taking place by syncope." 
 
 This variety I have never seen an instance of, 
 and further discussion of it will be postponed to a 
 later part of this paper. 
 
 The distinction between cerebro-spinal and mixed 
 cases is certainly not so evident as the separateness 
 of the cardiac variety. If the pathology hereafter 
 developed be, as it seems, true, there can be no 
 mixture between the cerebro-spinal and the car- 
 diac. Leaving out of view the cardiac, it is true 
 that cases of insolation may be divided into those 
 in which death takes place purely through paraly- 
 sis of respiration, and those in which the heart also 
 suffers a gradual weakening; but as these cases 
 are not practically — i.e. therapeutically — distinct, I 
 cannot see any advantage to be gained by such a 
 separation, especially as cases in which the heart 
 does not suffer more or less are so very rare, that 
 I have not only never seen a case, but do not know 
 of an unequivocal account of more than one or two. 
 The nearest approach to such that I can call to 
 mind is the following by Dr. Crawford (Madras 
 Journ., No. 2) : 
 
 Case IX. — A. B., aged 24, a soldier, was heard at mid- 
 night moving, and his comrades, thinking the noise strange, 
 cried out, and, not receiving a reply, got up, and found him 
 muttering incoherently about a drink. He became quiet, 
 then comatose, and when I [Dr. Crawford] saw him about 
 
CLINICAL HISTORY. 20 
 
 a quarter-past one o'clock, I found him moribund ; respira- 
 tions short, quick, and stertorous ; pulse full and bounding; 
 face flushed, eyes suffused, pupils contracted to a point, and 
 skin hot. I had scarcely completed my examination, when 
 all the sphincters relaxed ; the contents of his stomach, 
 chiefly water, welled from his throat; a frothy mucus 
 tinged with blood ran from his nostrils ; his pupils dilated 
 to their utmost extent ; a slight tremor crept over his frame, 
 and he was dead. 
 
 In contrast with this, as representing a typical 
 ** mixed" case, may be cited the following from 
 Dr. Barclay's paper (loc. cit, p. 368) : 
 
 Case X. — R. C, set. 26 ; not intemperate ; was attacked 
 with fever, while on guard, on the 26th of May, and came 
 into the hospital the evening of the same day. On the 
 morning of the 27th he was quite free from fever, but 
 rather weak, and was detained in consequence. He lay on 
 his cot during the forenoon without making any complaint. 
 About noon was observed to be in a state of insensibility, 
 and breathing heavily. He was removed at once to the 
 coolest veranda in the hospital, the cold douche applied 
 over his head, chest, and back, and eight leeches applied to 
 his temple by the apothecary then on duty. 
 
 At 1.2 P.M. I saw him. He was then completely insensible, 
 his face paler than usual, his eyes fixed and slightly turned 
 upwards, the pupils somewhat contracted, but much less so 
 than was usual in the cases in the field. His skin felt burn- 
 ing to the touch. His pulse was frequent and rather full. 
 The pulsation in the carotid was very strong, and could be 
 seen at a distance. He had no convulsions, nor could the 
 slightest movements of his limbs or eyelids be observed 
 for hours. On stethoscopic examination, loud subcrepitant 
 rales were heard all over the chest. The first sound of the 
 
 3* 
 
30 THERMIC FEVER, OR SUNSTROKE. 
 
 heart was natural, the second indistinct. The leeches, which 
 had drawn very little blood, were removed, and there was 
 scarcely any bleeding from the bites. The cold douche was 
 applied assiduously for some time, but without any good 
 result, and had to be discontinued on account of failure of 
 the pulse. An attempt was made to give a stimulant, but 
 nothing could be swallowed. A purgative enema was given 
 at once, and a considerable quantity of thin feculence was 
 brought away with it. Enemata of brandy-and-water, with 
 from fifteen to twenty minims of chloroform, were given re- 
 peatedly, but they were never retained for more than a few 
 minutes, and no effect seemed to be produced by them. A 
 blister was applied to the nape of the neck, sinapisms to the 
 chest and feet, and ammonia to the nostrils. His head and 
 the whole surface of the body were kept wet, and his face 
 assiduously fanned. During the afternoon he became gradu- 
 ally worse. His pulse became imperceptible, his conjunc- 
 tiva pinky, his hands and feet livid. His head continued 
 for a couple of hours firmly bent backwards, and his hands, 
 forearms, and toes flexed. By evening the blister had risen 
 well, and he then improved considerably. The spasm dis- 
 appeared, the lividity of his hands became less, his pulse 
 returned, and he regained a certain amount of conscious- 
 ness, and was able to swallow with difficulty. A small 
 quantity of brandy-and-water was then given every half- 
 hour ; and, the bronchial tubes being evidently loaded 
 with mucus, he was occasionally turned over on his face, 
 his head projecting over the edge of the cot. This change 
 of position was generally followed by efforts to vomit, by 
 which his breathing was greatly relieved. About midnight 
 he began to sink again. The insensibility became more 
 profound, and the breathing more stertorous and oppressed. 
 A blister was applied to the vertex without any relief. The 
 pulse gradually failed, and he died at 3.20 a.m. on the 28th. 
 
CLINICAL HISTORY, 
 
 31 
 
 Whether the division into mixed and cerebro- 
 spinal insolation be accepted or not, I think it must 
 be allowed that, in the majority of cases of the dis- 
 ease, death is induced by asphyxia, especially when 
 it comes on quickly but not instantaneously. The 
 general concurrence of authors in this is indicated 
 by the frequent use of the name '' heat'' or '' solar 
 asphyxia." To corroborate my own observation 
 further, I will make one or two quotations. 
 
 Dr. Dowler, of New Orleans, who has watched 
 a very large number of cases from immediately 
 after the fall until death, says (New York ^Medical 
 Gazette, 1842, pp. 214, 215), '' The cause of death 
 begins, continues, and ends in the breathing appa- 
 ratus. . . . After the death of the lungs or the 
 cessation of the respiration, the heart and arteries 
 will, in some instances, continue to act." 
 
 Dr. Pirrie says (London Lancet, May, 1859), 
 '* The symptoms are distinctly those of that mode 
 of dying in which the disease commences at the 
 lungs." Dr. Crawford (loc. cit.) goes further, be- 
 lieving even the coma to be secondary upon the 
 asphyxia. 
 
 The conclusion seems logically inevitable that, 
 even in very many rapidly fatal cases, death occurs 
 from paralysis of the respiratory centres by the 
 excessive heat or other causes. 
 
 There is an affection which is rarely, if ever, seen 
 in this country, but which appears to be very com- 
 
32 THERMIC FEVER, OR SUNSTROKE, 
 
 mon in India, where it is known as arderit continued 
 fever. This disease is really scarcely worthy of 
 a distinct place in the nosological catalogue, but 
 is a variety, or rather degree, of insolation, arising 
 from the same cause, presenting a similar but 
 less violent array of symptoms, and often passing 
 into the fully-formed coup de soleil. One of the 
 earliest, and at the same time clearest, accounts of 
 this fever which I have met with is that in More- 
 head's work on the Diseases of India. After 
 stating that, although mental excitement, intem- 
 perance, etc. are often factors of importance in the 
 production of the disease, elevated temperature is 
 the necessary condition, Dr. Morehead gives the 
 following account of the symptoms: 
 
 " The attack is generally sudden, often without 
 much chilliness. The face becomes flushed ; there 
 is giddiness and much headache, intolerance of 
 b'ght and sound. The heat of skin is great; the 
 pulse frequent, full, and firm. There is pain of 
 limbs and of loins. The respiration is anxious. 
 There is a sense of oppression at the epigastrium, 
 with nausea and frequent vomiting of bilious 
 matters. The bowels are sometimes confined ; at 
 others, vitiated discharges take place. The tongue 
 is white, often with florid edges. The urine is 
 scanty and high-colored. If the excitement con- 
 tinues unabated, the headache increases, and is 
 often accompanied with delirium. If symptoms 
 
CLINICAL HISTORY. 33 
 
 such as these persist for from forty-eight to sixty 
 hours, then the febrile phenomena may subside, the 
 skin may become cold, and there will be risk of 
 death from exhaustion and sudden collapse. In 
 most cases the cerebral disturbance is greater in 
 degree, and in these death may take place at an 
 earlier period in the way of coma." 
 
 Whether Dr. Morehead has confounded two or 
 more fevers somewhat, I do not know ; but Sir J. 
 R. Martin certainly says (The Influence of Tropi- 
 cal Climates on European Constitutions, p. 208), 
 '*We have not here the tendency to collapse 
 so characteristic of the true Bengal remittent 
 fever." 
 
 A reference to the quotation from the paper of 
 Dr. Bonnyman, already given, will show that he 
 has evidently seen cases of fever, excited by heat, 
 some ending, others not ending, in insolation. 
 
 Dr. Barclay (loc. cit., pp. 365, 367, 368) states 
 very plainly that during the hot season of 1858 
 there were very many cases of men whose systems 
 were in a state of feverish excitement from the heat, 
 others which were more serious and were entered 
 upon the hospital roll as cases o{ febris contiintus 
 communis, and others which were marked as inso- 
 lation. 
 
 The line which he drew between the last two 
 affections he asserts to have been a purely arbitrary 
 one. Those cases in which insensibility or con- 
 
34 THERMIC FEVER, OR SUNSTROKE, 
 
 vulsions were present, were called insolation ; 
 others, common continued fever. 
 
 This evidence might be increased by further 
 quotations, but is certainly sufficient to show that 
 very often insolation is preceded by an acute 
 ephemeral fever, and that this fever is caused by 
 exposure to heat, and may exist either with or 
 without inducing the symptoms ordinarily known 
 as sunstroke : the difference between the affections 
 is therefore simply one of degree, not of kind. 
 
 Pathology, — The post-mortem appearances, after 
 sunstroke, are mostly negative : there is scarcely 
 any constant lesion whatever of the solids, nor is 
 congestion of the brain, or serous or haemic effu- 
 sion into its ventricles or substance, of frequent 
 occurrence. All authors appear to agree in stating 
 that the right heart and the pulmonary arteries, 
 with their branches, are gorged with dark fluid 
 blood. In my cases the lungs did not present at 
 all the appearance of congestion of their minute 
 capillaries, but when they were cut the blood 
 poured from them abundantly, seemingly from 
 their larger vessels. Not only do the lungs suffer 
 from venous congestion, but the whole body also. 
 The blood appears to leave, as it were, the arterial 
 system, and collect in the venous trunks. The 
 arterial coats are often stained red, apparently from 
 the altered haematin of the blood. 
 
CLINICAL HISTORY, 
 
 35 
 
 In my autopsies I was astonished to find the 
 heart, especially the left ventricle, rigidly con- 
 tracted. It had been previously stated by some 
 observers that the heart was soft and flaccid, whilst 
 most had not reported at all the condition of the 
 viscus. There was no room for doubt in the ob- 
 servation ; in every case the heart was rigid and 
 hard to a degree which none of us had previously 
 seen. The question at once arose, How is this to 
 be reconciled with testimony? The observations 
 of Dr. Pepper have already been shown not to be 
 applicable to the subject. But there remain those 
 of Levick, who failed to find any rigidity. The 
 cause of this failure is, however, sufficiently obvi- 
 ous. The post-mortems were made from thirteen 
 (Levick, Pennsyl. Hosp. Reports, 1868) to thirty 
 hours after death. As the temperature of the body 
 remains above 100° for hours, it is evident that 
 putrefactive changes, often already entered upon 
 before demise, must go on very rapidly, and that 
 probably even three or four hours would afford 
 sufficient time for the relaxation of commencing 
 decomposition to follow the heat rigidity. More- 
 over, direct evidence of the truth of this is not 
 wanting. It has been experimentally demonstrated 
 (see Boston Journal of Med., vol. x. p. 350) that in 
 animals rigidity of the heart is found directly after 
 death from excessive heat, but that in a very few 
 hours it disappears. 
 
36 THERMIC FEVER, OR SUNSTROKE. 
 
 There can be no doubt that the blood suffers 
 in sunstroke very similarly to what it does in low 
 fevers. Its coagulability is always, so far as my 
 experience goes, impaired, but not always de- 
 stroyed ; and it is probable that in the very rapid 
 cases it may not be decidedly affected. Generally, 
 the blood appears after death as a dark, often thin, 
 sometimes grumous fluid, whose reaction is very 
 feebly alkaline, and in some of the cases herein 
 reported was even decidedly acid. Dr. Levick (loc. 
 cit., p. 373) appears to assert that the blood disks, 
 as seen by the microscope, were shriveled and 
 crenated, and showed very slight tendency to ad- 
 here in rouleaux. In several of my cases the blood 
 was carefully examined by the microscope, but 
 nothing abnormal was found. 
 
PART II. 
 
 NATURE. 
 
 Sufficient of authority and reason has been 
 brought forward to make it at least probable that 
 heat is the sole exciting cause of sunstroke. This 
 being so, it is to be expected that the lower animals, 
 as well as man, should suffer from the affection, 
 and experience fully corroborates this a priori 
 reasoning. We are able, therefore, to induce sun- 
 stroke in animals, and, by varying its conditions, 
 study its nature much more thoroughly than can 
 be done at the human bedside. A discussion of 
 the nature of coup de soleil must, I conceive, rest 
 largely upon such basis of experimentation. 
 
 Of the various experimenters upon the effect of 
 heat upon animals, I have had access to, and have 
 used especially, the w^orks of Dr. Vallin, Dr. Stiles, 
 and Claude Bernard. The observations of these 
 gentlemen, in so far as they cover the same ground, 
 are in close agreement ; and I myself have attained 
 similar exp^rirnental results, although I have gone 
 
 4 (37) 
 
38 
 
 THERMIC FEVER, OR SUNSTROKE, 
 
 further and have read the phenomena somewhat 
 differently. 
 
 The symptoms produced by exposing an animal 
 to excessive heat do not appear to differ save in 
 degree, whether the heat be artificial or due to the 
 direct rays of the sun, or whether it be moist or 
 dry. The animal is at first excited, trying to get 
 away from the cage in which it is confined. This 
 period of excitement sooner or later, according to 
 the intensity of the heat, gives place generally to 
 a second stage of profound muscular prostration 
 and quietude. From the beginning the respiration 
 has been exceedingly hurried, and now very often 
 it cannot be counted. The beat of the heart keeps 
 pace with the respiration, and panting and ex- 
 hausted the animal lies quiet, with the saliva pour- 
 ing from its open mouth. This second stage soon 
 yields to that of com^a. In my own experiments 
 the insensibihty has generally come on gradually, 
 not suddenly, and has not been accompanied by 
 convulsions. In one case, however, the animal 
 was attacked by coma and fatal convulsions with 
 absolute abruptness. 
 
 According to Dr. Vallin's experience, convul- 
 sions are very commonly present. 
 
 Claude Bernard recognizes them as sometimes 
 present, sometimes absent ; whilst Dr. Stiles sa3^s 
 that occasionally life is terminated by a fit of con- 
 vulsions, but generally it ceases gradually. 
 
NATURE, 3g 
 
 The resemblance between these symptoms and 
 those of coup de soleil of man is very marked. 
 There is in many cases of the latter the same 
 stage of feverish excitement, the same condition 
 of weakness, the same gradually approaching coma . 
 In other cases in man the nervous symptoms come 
 on suddenly, as they do sometimes in animals. The 
 chief difference appears to be, that whilst in animals 
 sudden onset of the nervous symptoms is rare, in 
 man it is common, the reason evidently being that 
 the cephalic nervous system of man is much more 
 delicate and more easily disturbed than that of 
 animals. The post-mortem appearances are very 
 similar to those seen in man. The arterial sys- 
 tem is comparatively empty, and there is abso- 
 lute engorgement of the large venous trunks 
 with blood, whose crasis is more or less broken 
 down. 
 
 The muscular system offers the most obvious 
 lesion, and it is to this I shall first direct attention. 
 Dr. Stiles says (1864), " When the thorax is opened 
 (just after death) the ventricles of the heart are 
 found rigidly contracted, or become so in five or 
 ten minutes, both auricles distended with blood, 
 and manifesting fibrillar movements. The cut sur- 
 face of the ventricles is acid to litmus-paper; under 
 the microscope the muscular fibres of the heart 
 have lost their transverse striae." 
 
 Dr. Vallin says (1870), '' At the moment of death 
 
40 THERMIC FEVER, OR SUNSTROKE, 
 
 the ventricles are contracted upon themselves, glob- 
 ular ; the left ventricle in especial has a ligneous 
 hardness. Its cavity is effaced, and does not con- 
 tain a trace of liquid blood, nor of clot. The auri- 
 cles — the right especially, and sometimes the right 
 ventricle — are full of black liquid blood, or con- 
 fluent clots. The ventricles instantly after death 
 are insensible to every kind of stimulus. The au- 
 ricles have for a very few minutes spontaneous 
 rhythmic movements, but in a little while these 
 cease, and cannot be reprovoked; all the muscu- 
 lar tissue is strongly acid." 
 
 Claude Bernard says (i 871), "In opening the 
 cadaver immediately after death there is found 
 generally an arrest of the beating of the heart, a 
 black coloration of the blood in the arteries, some- 
 times ecchymosis under the skin, and lastly cada- 
 veric rigidity comes on with great rapidity" (loc. 
 cit, p. 1 39). Claude Bernard and Vallin, then, agree 
 in stating that the voluntary muscles are affected 
 similarly to the heart, and that the muscles directly 
 after death either do not react at all to the stim- 
 ulus of galvanism, or do so very feebly and imper- 
 fectly, and that post-mortem rigidity comes on 
 almost immediately after death. Vallin says, " The 
 diaphragm is, after the heart, the muscle which 
 loses its irritability most quickly : generally at 
 the moment of death it fails to contract under any 
 stimulus. Certain muscles of the trunk commence 
 
NATURE, 41 
 
 to become rigid even during the agony, and in 
 about half an hour this rigidity is generally com- 
 plete for the whole body. A constant accompani- 
 ment of the muscular rigidity is an acid reaction." 
 There can be no doubt that in some instances 
 this rigidity is almost consentaneous with death. 
 Dr. Stiles, however, states that in his experiments 
 on rabbits post-mortem rigidity did not come on 
 until between one and two hours after death. 
 
 As a study of the subject, the following experi- 
 ments were performed. The first two of them were 
 made in the last week of September, when the sun 
 had already waned in power, without the aid of 
 artificial heat. A box was constructed rudely with 
 a slanting glass lid, like a miniature green-house. 
 It was simply placed upon a brick pavement, when 
 used, in such a way that the sun could exert its 
 fullest power upon it. 
 
 Experiment i. — Exposed a two-thirds-grown rabbit in a 
 box covered with glass. 
 
 I P.M. — Temperature in rectum, 104^°. Temperature of 
 box, 120° (F.). 
 
 I.I 5 P.M. — Temperature, io6J°. Respiration very hurried. 
 
 1.30 P.M. — Temperature, 109^°. Has convulsive attacks, 
 in which he jumps, and kicks with hind legs with great 
 fury. 
 
 1.45 P.M. — Temperature, 112°. Seems very weak and re- 
 laxed; breathing 220 a minute. Lies on side, with every 
 now and then the attacks alluded to ; slobbering greatly. 
 
42 THERMIC FEVER, OR SUNSTROKE. 
 
 2.IOP.M. — Temperature of box, 120°. Rabbit on side, 
 exceedingly weak, gasping; squealing faintly at intervals. 
 
 2.15 P.M. — Temperature, 114^°. Perfectly unconscious; 
 lies relaxed and motionless on the cool ground in the shade. 
 
 2.20 P.M. — Only gasping at long intervals ; heart still 
 beating, although laboredly, and somewhat irregularly, yet 
 pretty steadily, and with some force. 
 
 2.21 P.M. — Dead. 
 
 Autopsy. — Heart : right side and left auricle full of blood; 
 left side, containing blood, not contracted. The heart made 
 a few very imperfect and feeble attempts at beating when 
 it was cut across. Blood coagulating with great rapidity 
 and firmness ; alkaline. Brain not congested. Muscles 
 all failing to show the slightest sign of contraction under 
 the strongest faradaic current, except some of the leg mus- 
 cles, which contracted very feebly, and only at all when the 
 current was very intense. 
 
 Experiment 2. — Two-thirds-grown rabbit. Put in a box 
 at 1 1.30 A.M. Temperature, 104^°. 
 
 12 M. — Temperature, 109°. Temperature of box, 112°. 
 
 12.25 P-M. — Temperature, iio}°. Rabbit weak, slobber- 
 ing a great deal ; breathing with great rapidity. 
 
 I.I 5 P.M. — Rabbit conscious, lying quietly on his side; 
 not slobbering ; breathing not nearly so rapid, but deep and 
 labored. Temperature, iii^^^. 
 
 1.35 P.M. — Rabbit found dead. Temperature, 112°. 
 
 Autopsy. — Heart : left ventricle empty, very firmly con- 
 tracted, with a very evident white spot at apex. Galvanic 
 (induced) current very strong, giving rise to no muscular 
 movements whatever, either of heart or voluntary muscles. 
 Blood coagulating slowly and imperfectly ; reaction neutral, 
 or at least so feebly alkaline as to be uncertainly so. Mus- 
 cular reaction very decidedly acid. Spinal cord not con- 
 gested. Right side of heart gorged with blood. 
 
NATURE. 43 
 
 Experiment 3. — A large adult rabbit. 
 
 12. 1 1 P.M.— Anal temperature, 105°. Just put in box, 
 whose temperature is 130°, heated by very hot brick flues, 
 on which the rabbit lies. 
 
 12.15 P.M. — Rectal temperature, 107°. Breathing excess- 
 ively hurried. 
 
 12.17 P.M. — Rectal temperature, 109°. 
 
 12.21 P.M.— Rectal temperature, 111°. Had a moment 
 since what was apparently a convulsion, and has had nu- 
 merous convulsive twitchings since. Appears semi-uncon- 
 scious. 
 
 12.25 P-M- — Dead. Temperature in abdomen after death, 
 111°. Respiration ceased some time before heart. The tho- 
 rax was opened, and the heart was felt with the finger to be 
 pulsating. It was then further opened, and the heart was 
 seen to be very distinctly pulsating, and gradually becoming 
 filled with dark blood. It was punctured, and blood allowed 
 to escape ; it made one or two pulsations, and then at once 
 became rigid. After this the diaphragm was tried with the 
 galvanic current, and responded to it. The muscles of the 
 hinder extremity failed to do so, those of the fore legs did. 
 Peristaltic action of the intestines was moderately active 
 when the body was opened, and on galvanic excitation be- 
 came very active. 
 
 Experiment 4. — A moderate-sized dog. 
 
 I P.M. — Put in the hot box. 
 
 I.I 5 P.M. — Anal temperature, 106°. 
 
 1.30 P.M. — Anal temperature, 110°. 
 
 1.40 P.M. — Anal temperature, iio|°. Just dead. 
 
 Autopsy. — As soon as respiration ceased, the body was 
 opened. Heart still beating, gorged with dark blood. 
 Veins full of dark blood. Blood on being shaken in test- 
 tubes rapidly clotting, and slowly changing its color to an 
 
44 
 
 THERMIC FEVER, OR SUNSTROKE. 
 
 arterial hue. The vessels \vtre carefully examined : no 
 clots were found in them. 
 
 Experiment 5. — An adult pigeon. 
 
 1 1 40 A.M. — Rectal temperature, 109°. Just put in box; 
 the temperature in box, 130"^; besides, the pigeon was in 
 direct contact with the very hot brick flue. 
 
 11.45 A.M. — Respirations very weak. 
 
 12 M. — Has been unable to stand for some time ; has been 
 semi-unconscious. Just had a convulsion, followed by per- 
 sistent opisthotonos. 
 
 * 12.2 P.M. — Anal temperature, 120°?. (My thermometer 
 did not mark higher than 120^, to which the mercury rose; 
 the hand could hardly bear the heat of the flesh.) Dead. 
 Respiration certainly ceased before the heart's action. 
 Rigidity came on almost before heart ceased beating. 
 Thorax opened as soon as heart ceased action. The 
 heart was found rigidly contracted like a board. Muscles 
 acid. 
 
 Experiment 6. — Precisely like last in conditions and re- 
 sults. Death temperature the same. 
 
 Experiment 7. — Precisely like last in all respects. Death 
 temperature the same. 
 
 In none of these experiments was the thorax 
 opened before the heart ceased to beat. 
 
 Experiment 8. — A young pigeon, put in box at 130°, and 
 taken out some time afterwards dying. 
 
 The heart being felt to be beating after respirations had 
 ceased, the body was opened and the pulsations were watched 
 for some time. 
 
NATURE. 
 
 45 
 
 Experiment 9. 
 
 12.36 P.M. — ^Anal temperature, iio|°. Pigeon put in hot 
 box. 
 
 I P.M. — Anal temperature, 113!°. 
 
 1.30 P.M. — Pigeon found dead; on its being opened, the 
 heart was found to be beating, although irregularly and 
 very feebly. 
 
 Experiment 10. — Cat. 
 
 12.16 P.M. — Temperature of box, 130°. 
 
 12.35 P.M. — Temperature of box, 130°. The cat ever since 
 having been put in the box has been struggling violently 
 and savagely, and for the last five minutes has been evi- 
 dently growing weaker, but perfectly conscious. Just seized 
 with a sudden tetanic convulsion, which instantly arrested all 
 respiration, and persisted with absolute rigidity for about five 
 minutes (notby actual timing). When the cat was taken from 
 the box the pupils were widely dilated, the heart beating 
 strongly and regularly. She was plunged into cold water, 
 but never made an effort at breathing, although perfect 
 relaxation of the muscles soon came on. The body was 
 opened ; heart found to be still beating and distended with 
 blood ; after a considerable time it was seen to gradually 
 stop beating, and the left side contracting expelled all the 
 blood from it, and became rigid under our eyes. The dia- 
 phragm responded, though somewhat feebly, to the gal- 
 vanic current fully fifteen minutes after respiration had 
 ceased. 
 
 These experiments confirm in many respects the 
 results of previous observers, but they also show 
 that the rigidity of the heart and of the muscles is often 
 not ante mortem^ but post mortem^ occurring some- 
 times at the moment of death, at other times not 
 
40 
 
 THERMIC FEVER, OR SUNSTROKE. 
 
 until some minutes after it. In all those cases in 
 which an especial observation of the point was made, 
 respiration ceased before the heart's action. In Ex- 
 periment 8, the pigeon was opened directly after 
 death, and the pulsations of the heart watched for 
 some time. In Experiment lo the same thing was 
 done upon a cat. In this case, the heart under- 
 went the process of hardening beneath my view. 
 The change was a quick but not instantaneous 
 one ; the viscus appeared gradually to shorten 
 itself, and to become at the same time less broad, 
 and put on a very rigid look, — the whole process 
 taking perhaps about half a minute to complete 
 itself This experiment w^as also interesting as 
 showing that the diaphragm does not lose its func- 
 tional power before death, nor is aKvays the first 
 muscle in the body to do so. 
 
 Experiment lO was of great interest on account 
 of the sudden seizure resembling so closely certain 
 forms of sunstroke in man. The symptoms were 
 evidently not of muscular origin, the heart per- 
 sisting in its regular beat long after respiration had 
 been arrested by a tetanic spasm, from w^iich the 
 muscles after a time completely relaxed, and the 
 diaphragm responding to electricity fully fifteen 
 minutes after the cessation of respiration. 
 
 Muscular System, — As the very rapid post-mortem 
 rigidity of the voluntary and involuntary muscles is 
 
NATURE. 
 
 47 
 
 certainly among the most prominent and character- 
 istic lesions of sunstroke, it is evident that a study of 
 the causes or nature of post-mortem rigidity is most 
 vital to a discussion of the nature of the affection. 
 
 Three theories have been advanced to explain 
 this rigidity. The first is, that it is a sort of 
 vital contraction, allied to the normal contraction, 
 which has become permanent. This vitalistic idea 
 has been recently placed in its most definite, tan- 
 gible form at the hands of Chas. Bland Radcliffe, 
 who has formulated the following proposition : 
 '* Rigor mortis, like ordinary muscular contrac- 
 tion, would seem to be caused by the elasticity 
 of the muscular fibres being allowed to come into 
 play by the disappearance of the electrical charge 
 which had previously kept these fibres upon the 
 stretch, the contraction in rigor mortis being per- 
 manent simply because this disappearance is final." 
 Another vitalistic theory, essentially different from 
 that of Radcliffe, is the so-called idio-muscular 
 theory of Schiff, according to which an acrid acid 
 juice is developed by a commencing decay of cer- 
 tain portions of the muscles, and acts upon the 
 remaining sound portion as a stimulant, causing 
 persistent contraction. 
 
 It would be digressing too widely to discuss 
 the general theory of Radcliffe as to muscular con- 
 tractility. It suffices for my purpose to deduce 
 the following objections, which, in the absence of 
 
^8 THERMIC FEVER, OR SUNSTROKE. 
 
 any proof in favor of it, seem to me fatal to a 
 theory which associates normal vital contractility 
 and post-mortem rigidity. 
 
 The physical conditions of the contracted muscle 
 are very different from those of the rigid one. Thus, 
 the elasticity of the two is entirely different : the 
 contracted normal muscle stretches, the rigid one 
 breaks. Kiihne has shown, and Harless (Unter- 
 suchungen an der Muskelsubstanz ; Sitzungsberichte 
 derbayer. konigl. Akad., i860) has confirmed, that 
 whilst the tetanized muscle is translucent, the rigid 
 one is turbid and opaque, and the turbidity has been 
 proven to come on pari passu with the rigidity. 
 Dr. Harless experimented so as to show beyond 
 cavil the simultaneous occurrence of opacity and 
 rigidity, in the following way. A piece of frog's 
 muscle was tightly placed between the compresso- 
 rium plates under a microscope, and a stream of 
 light thrown through it just sufficient in power to 
 bring out distinctly the lines of a cobweb microm- 
 eter in the eye-piece. It was found, on heating 
 the fragment of tissue, that at from 36° to 40° 
 Cels. (=96^° to 104° F.) the cobwebs were lost to 
 sight from the muscle becoming less transparent 
 (loc. cit, p. 128). 
 
 Herrmann and Walker, who have recently (Pflu- 
 ger's Archiv, ii. 182, 195) called attention to the 
 difference in the contraction of post-mortem rigidity 
 and that of living muscle, state that whilst the living 
 
NA TURl 
 
 49 
 
 muscle will raise a weight much higher than occurs 
 during post-mortem hardening, during the latter 
 process a heavier weight will be lifted than the 
 most powerful electrical stimulation will induce the 
 livn'ng muscle to elevate. 
 
 The second objection to the theory of identity 
 of rigor mortis and muscular contractility was first 
 urged, I believe, by Dr. Harless (Untersuchungen 
 iiber die Muskelstarre, Sitzungsberichte derkonigl. 
 bayer. Akad., i860, p. 456.) It is as follows: If 
 the loss of irritability of a separated muscle be 
 expressed by a curved line, the curve at first sinks 
 gradually and towards the close abruptly, or, in 
 other words, the irritability at first lessens very 
 slowly, afterwards very rapidly. Now, if, as the 
 vitalistic theory contemplates, the irritability and 
 post-mortem rigidity are, as it were, complementary, 
 a curved line expressing the growth of the latter 
 ought to be similar to that expressing the growth 
 of the former, — i.e. a curve at first gradual, after- 
 wards sudden. This, however, does not happen^ 
 but from the beginning the muscular currents, 
 which are an inverse index of the post-mortem 
 rigidity, lessen with decreasing rapidity. It would 
 appear at first as though Morgan (Electro-Phys- 
 iology and Therapeutics, p. 327) expressed a 
 different belief from this of Harless as to the re- 
 lations spoken of, for he says, *' The diminution 
 of the muscular current is directly as the de- 
 
 5 
 
CO THERMIC FEVER, OR SUNSTROKE. 
 
 crease of the irritability of the muscle." It appears, 
 however, that Dr. Morgan does not mean this to 
 be construed too hterally, for in his diagram (Fig. 
 lOi) the curves representing the loss of muscular 
 currents follow the law of Harless. 
 
 Kiihne also found by experiment that the ex- 
 pressed acrid juice of dead frog muscle has no 
 power to cause contraction of living frog muscle. 
 Evidently a coup de grace to Schiff's theory. 
 
 As early as 1842, Briicke (Ueber die Ursache des 
 Todtenstarre, Muller's Archiv, 1842) accounted for 
 the occurrence of post-mortem rigidity by the co- 
 agulation of a plasma in the muscle ; he, however, 
 failed to prove his supposition. The difficulty he 
 met with was, that whenever he attempted to press 
 out the plasma from the muscle, the change would 
 take place whilst the latter was in the press, and he 
 would obtain only rigid muscles and an acid juice. 
 
 In 1859 Kuhne took the matter in hand (Un- 
 tersuchungen iiber Bewegungen und Veranderun- 
 gen der contraction Substanzen, Reichert und Du 
 Bois Reymond's Archives, 1859, p. 564), and suc- 
 ceeded in overcoming the difficulty by the use of 
 salt and cold, both of which agents have the power 
 of retarding muscular rigidity. He first washed the 
 blood out of the muscles of frogs by injecting 
 through the arterial system of the animal just killed 
 a one to two per cent, solution of salt ; then cut the 
 flesh into small pieces, washed it with salt water. 
 
NA TURE. 
 
 51 
 
 and put it in a cold press. By this means he ob- 
 tained a glairy fluid, which near the freezing tem- 
 perature remained liquid, but at 40° C. (104° F.) 
 instantly formed a large, firm, translucent coagu- 
 lum. At a temperature of 35° C. (95° F.), coagu- 
 lation occurred in an hour; at 38° C. (iOo|-° F.), in 
 half an hour; and at from I2°-I4° C. (531-58° F.), 
 at the end of six hours. 
 
 Kiihne also performed similar experiments upon 
 a rabbit with similar results, obtaining a glairy 
 h'quid, which coagulated after standing three or 
 four hours at an ordinary temperature. 
 
 I have repeated the experiment of Kiihne on a 
 rabbit, with results similar to his. 
 
 Experiment i i . — November 15,1871. A full-grown rab bit 
 was killed by a blow on the back of the neck. It was opened 
 immediately, and salt water was thrown into the descending 
 aorta so as to come out of the vena cava ascendens. The 
 muscles were then cut into small pieces, thrown into salt 
 water, and put immediately into a press. The liquid first 
 obtained was rejected ; it was thin and pinkish ; afterwards, 
 under strong pressure, a clear, slightly pinkish viscid fluid 
 was procured. The reaction of this was neutral ; but on 
 exposure of the wet litmus-paper to the air, the acid re- 
 action was soon developed. This fluid was gradually 
 warmed, and when 115° F. was reached at once changed 
 color, became whitish and somewhat turbid; at 116° F. 
 there was decided coagulation. If 110° F. was maintained, 
 in the course of a very few minutes coagulation took place. 
 After coagulation the reaction was decidedly acid. 
 
52 THERMIC FEVER, OR SUNSTROKE. 
 
 Dr. Pickford (Henle und Pfeuffer's Zeitschrift fiir 
 ration. Medicin, Neue Folge, i.) was, I believe, the 
 first to notice that a frog's muscle would become 
 rigid when placed for a few seconds in a liquid 
 heated to 65° R. (= 1781° F.), or for some min- 
 utes in one at 30° R. (= 99^° P.). 
 
 Schiff (Lehrbuch der Physiologic) and Mundt 
 (Die Lehre der Muskelbewegung) confirmed this, 
 but to Kiihne belongs the credit of having first 
 thoroughly investigated the subject, in the paper 
 already quoted. He found (loc. cit., p. 789) that a 
 muscle of a frog plunged into a liquid of 65° R. 
 or 82° C. (= 178^° F.) for twenty-five seconds be- 
 came permanently rigid; and that if a muscle were 
 left for a whole minute in a liquid at the temperature 
 of about 45^ C. (= 113° F.) the same result fol- 
 lowed. Further, that if the muscle were immersed 
 for some minutes in quicksilver at a temperature 
 of 37.5° C. (= 100° F.) it lost its power of con- 
 tracting under the influence of the strongest gal- 
 vanic stimulus, and yet remained limp, and with 
 an alkaline reaction. By a still longer immersion 
 it became perfectly rigid. M. Kiihne also states 
 that immersion of a frog's muscle in quicksilver at 
 a temperature of 40° C. (= 104° F.) produced 
 almost instantaneous rigidity. This was also found 
 to take place in a living frog when the legs were 
 placed in quicksilver at 40^ C. (= 104° F.); and 
 although the circulation was perfectly re-established, 
 
NA TURK, 
 
 53 
 
 and the frogs kept alive, the muscles never in any 
 sense recovered themselves, — never regained any- 
 contractile power. The lowest temperature by pro- 
 longed exposure to which the frog's muscles lose 
 their functional ability is between 35° and 37° C 
 (=95° and 99^ F.). 
 
 On the other hand, an exposure of the frog's 
 muscles to a low temperature protracted the period 
 of sensitiveness to stimuli, so that under such con- 
 ditions the muscles would remain active for days. 
 
 With these facts the coagulability of the muscle 
 fluid was found in complete accord. Near 32° F. 
 it remained clear and liquid for days ; at 40° C. 
 (=104° F.) it instantly coagulated; at 30° C, 
 (=86° F.) coagulation occurred in an hour; at 
 38° C. (= loof^ F.) in half an hour. The reac- 
 tion of the heated muscle was acid, and it was 
 also found that a frog's muscle which had under- 
 gone spontaneous rigidity, or one that had become 
 rigid by the sudden application of a heat of 40° C. 
 (= 104° F.), could be rendered more rigid by a 
 heat of 45° C. (=113° F.). Kuhne also found 
 that, even if the frog's muscle had commenced to 
 decay, it was changed (by a heat of 45 ° C.) into a 
 hard, whitish mass, and also that he could press 
 out from thoroughly rigid muscles an acid juice, 
 which had no tendency to coagulate at ordinary 
 temperatures, but which does undergo immediate 
 coagulation at 45° C. These facts certainly seem to 
 
54 
 
 THERMIC FEVER, OR SUNSTROKE. 
 
 show that whilst the rigidity produced by a tem- 
 perature of 40° C. (= 104° F.) in a frog's muscle 
 is the same in nature with post-mortem rigidity, 
 that produced by a temperature of 45° C. (= 113° 
 F.) is of a different nature, and depends upon the 
 coagulation of a distinct albuminoid substance. 
 
 In the Sitzungsberichte der konigl. bayer. Aka- 
 demie der Wissenschaften, June, i860, Herr E. 
 Harless published the elaborate paper which I 
 have already quoted (see page 48), in which 
 he corroborates in the main the statements of 
 Kuhne. He succeeded without trouble in ob- 
 taining the muscle plasma musculin in quantity, 
 and found it a nitrogenous substance more closely 
 allied to casein in its behavior with reagents (p. 
 lOl) than to the other albuminoids. He also 
 found that the coagulation temperature is in warm- 
 blooded animals near 45° C. (=113° F.), and that it 
 varies in different animals, and in the same species 
 under different circumstances (p. 100). Thus, in 
 different rabbits he found it ranged from 42^-48^ 
 C. (= io7f°-ii6|° F.); in frogs, from 30^-44° 
 C. (=86^-1 1 1 i° F.); in a calf, from 45^-46° C. 
 (=113°-! 16° F.) ; and whilst in a very old cat 
 45° C, in a newly-born kitten it was 70° C* 
 (=I58°F.)! 
 
 He also found (p. in) that the formation of the 
 
 ■^ This is evidently a misprint. 
 
A' A TURK, 
 
 55 
 
 acid precedes the commencement of coagulation, 
 taking place 4^-5° Cels. (8°-io° F.) below the 
 temperature that the latter occurs at, and occur- 
 ring sooner when the fluid is allowed to coagu- 
 late spontaneously. When the acid forms it alters 
 very materially the color of the liquid, and by set- 
 ting the latter aside in a glass vessel in a cool room 
 he was enabled to watch the change into a deep 
 reddish-brown liquid, occurring in from twelve to 
 twenty-four hours, whilst not a trace of turbidity 
 existed. This change of color I myself have noted 
 as occurring just before coagulation, and think 
 therefore that Morgan (loc. cit., p. 329) is mistaken 
 when he says the coagulation of the muscle fibrin 
 precedes this acidity; a mistake which might very 
 well have been a mere slip in the manuscript, and 
 it is well known he did not live to read the proof. 
 In a second paper in the Sitzungsber. der k. bay. 
 Akad. d. Wissensch., i860, entitled '' Untersuch- 
 ungen uber die Muskelstarre," Harless attempts to 
 establish the theory that although coagulation of 
 the myosin and post-mortem rigidity occur at the 
 same temperature and consentaneously, the latter 
 is not due to the form.er, but to a physical action 
 of the acid developed upon the muscular fibrillse, 
 shrinking them up. I do not think, however, he 
 succeeds in establishing this, and believe that it is 
 disproven by the facts that in some muscles the 
 acidity does not develop (see Morgan, loc. cit., p. 
 
eg THERMIC FEVER, OR SUNSTROKE. 
 
 329), and that washing the acid out of a muscle by 
 an alkaline solution will not restore its contractility 
 when rigidity has fully set in. There can be no 
 doubt, however, of the close connection between 
 the acidity and the coagulation of the myosin. 
 A circumstance illustrating this, mentioned by 
 Morgan (loc. cit, p. 333), is the action of a ten per 
 cent, solution of common salt on a rigid muscle. 
 This dissolves out the myosin, and leaves the 
 muscle limp and translucent, and at the same time 
 free from acid reaction. 
 
 The only objection to the coagulation theory 
 worthy of notice is found in the circumstance that 
 muscle which has become rigid after the cutting 
 off of the circulation from it, can be made to- regain 
 its pliability and contractility by removal of the 
 arterial ligature, or that muscle which has become 
 rigid after the death of the animal can be restored 
 by the injection of warm blood. As early as 1834, 
 Dr. Jno. P. Kay (Treatise on Asphyxia, p. 143) 
 noted that if the circulation was arrested in a limb, 
 the muscles soon lost their power of contracting 
 under the influence of galvanism, but recovered it 
 when the obstruction to the passage of the blood 
 was removed. 
 
 His experiments have been repeated and ampli- 
 fied by various observers, especially by Brown- 
 Sequard (Comptes Rendus, June, 185 i) and Prof 
 Stannius, of Rostock (Archiv fiir phys. Heilkunde, 
 
NA TURE, 
 
 57 
 
 1852). The experiments of the first of these ob- 
 servers were made both on man and animals; the 
 details it is needless here to speak of, but the results 
 arrived at were, that cadaveric rigidity in animals 
 could be overcome after it had lasted from ten to 
 twenty minutes, and in man a muscle which had 
 been rigid for nearly two hours could be restored. 
 I have not seen the original account of Prof. Stan- 
 nius's experiments, but, as quoted, they are very 
 similar to those of Brown-Sequard, and the results 
 arrived at only differ in so far that Stannius suc- 
 ceeded in restoring the hind legs of a puppy which 
 had been stiff and cold for one hour. It is this 
 possibility of restoration which has been urged as 
 an objection to the plasmic theory. As stated by 
 Kuhne, however, it does not seem to be a fatal ob- 
 jection. The first coagulation of the muscle plasma 
 does not necessarily imply the immediate death of 
 the fibre. And it is conceivable that while in a 
 condition of partial coagulation, as it were, the 
 plasma might yield to the solvent powers of the 
 warm alkaline blood and the renewed activity of 
 the surrounding life forces, and be brought into 
 such a state as to be removed, especially as it has 
 been shown that the miyosin can be washed out 
 and the muscle rendered limp by a strong solution 
 of salt. In Brown-Sequard's experiments it was 
 found that the blood changed its color from arte- 
 rial to venous during its passage through the arm, 
 
58 THERMIC FEVER, OR SUNSTROKE. 
 
 showing that vital action was recommenced. Fur- 
 ther, it is implied by the experiments both of Brown- 
 Sequard and Stannius, and definitely proven by 
 those of Kijhne (loc. cit.), that there does come a 
 time when the rigid muscle cannot be restored, 
 although through the unbound artery the blood 
 courses into the capillaries and veins with steady, 
 free, persistent current. If the contraction were a 
 vital phenomenon, this could not be, because the 
 muscle should relax as soon as dead, and, not 
 being dead until relaxed, whilst still rigid ought to 
 be capable of restoration. In this view, then, the 
 assumed objection is rather a confirmation than a 
 valid objection to the plasmic theory. 
 
 This being so, I feel forced to accord assent to 
 the proposition, that tJiennic and post-mortem rigid- 
 ity are alike due to tlie coagulation of a plasma in the 
 muscles. 
 
 This proposition being acceded, the question 
 naturally presents itself. Is death in sunstroke due 
 to the coagulation of the plasma by heat? 
 
 It is evident that in determining this question at 
 least two lines of approach are open, — the one, 
 that of absolute ocular and palpable examination, 
 determining whether or not the heart does stop 
 before respiration, and whether the muscles are 
 absolutely dead before general death; the other, 
 the comparative study of the temperatures at which 
 
NA TURK. 
 
 59 
 
 coagulation of myosin occurs, and of the death 
 temperature in fatal heat or sunstroke. 
 
 Along the last of these roads I shall first ap- 
 proach. Vallin (loc. cit., p. 143) believes that co- 
 agulation of the myosin is the cause of death. 
 He says, — after detailing the fact that muscles 
 always become rigid at 45° 0.(113'' R), — ''The 
 death has always taken place at the precise mo- 
 ment that the temperature of the blood attains 45° 
 C, and a thermometer introduced into the cavity 
 of the heart did not vary more than some tenths 
 of a degree above or below this point; so that it 
 affords, as it were, a sort of natural realization of 
 the coagulation of a muscle by plunging it into 
 water at 45° C. The diaphragm, after the heart, 
 is the muscle which becomes rigid the most quickly, 
 and all the world acknowledges, after Claude Ber- 
 nard, that the point of greatest heat in the body is 
 where the vena cava traverses the diaphragm. It 
 is easy, then, to understand why at death the heart 
 and diaphragm are rigid, whilst the muscles of the 
 trunk preserve their contractility. Coagulation com- 
 mences with the left ventricle, which becomes rigid 
 and immovable; its cavity is effaced, and hence is 
 explained the relative arterial anaemia which all the 
 organs present. The right ventricle becomes rigid 
 more slowly and irregularly, and preserves in some 
 cases for a time its activity, so that the blood of 
 the pulmonary circulation, not finding access to 
 
6o THERMIC FEVER, OR SUNSTROKE. 
 
 the left ventricle, accumulates in the lungs, pro- 
 ducing an enormous congestion, and sometimes 
 rupture. Further, the inertia, or, to speak more 
 accurately, the rigidity, of the diaphragm interferes 
 with the respiration, and adds the effects of asphyxia 
 to those produced by stoppage of the heart." 
 
 The temperature at which myosin coagulates 
 has already been shown to vary, but to be in warm- 
 blooded animals often above 45° C. or 113° F. 
 The testimony of Vallin, that the death tempera- 
 ture agrees with this, has just been cited, and in 
 another place in his memoir (p. 139) he says the 
 temperature at the moment of death varies from 
 44° C. to 46.1° C. Claude Bernard states that the 
 death temperature ranges from 43° C. (109!^ F.) 
 to 45° C. (113° F.). Dr. Stiles says the tempera- 
 ture never rose above 115° F., and was often one 
 or two degrees below it. 
 
 The testimony of Vallin must be received with 
 some guardedness, as lie is so fully committed to the 
 support of a theory. It will be seen that the experi- 
 ments of both the other authorities indicate that 
 whilst in some cases 113° F. is attained, in many 
 others the death temperature is much below it. 
 My own experiments, already detailed, confirm 
 this testimony, the rectal temperature at death 
 varying from 1 11° to 114° F. 
 
 Dr. T. Lauder Brunton, in experiments reported 
 in St. Bartholomew's Hospital Reports, vol. vii., 
 
NATURE. 6 1 
 
 states that the upper limit at which the heart, when 
 heated, stands still varies in different cases, but 
 that in the stronger animals it is between 1 13^ and 
 114° F., and even above. He has seen the heart, 
 however, beating actively at 1 1 5° F., and still under 
 the influence of the vagus nerve. These tempera- 
 tures, however, he remarks, were taken in the 
 rectum, whilst the arrangement of the heating 
 apparatus was such that the probabilities are the 
 temperature was somewhat less in the thorax than 
 in the abdomen. His results, I think, are further 
 vitiatedby the fact that the animals were all nar- 
 cotized either with chloral or opium. In pigeons 
 the fatal temperature was always up to 120° in my 
 experiments; but there can be no doubt that the 
 coagulation point of myosin in these birds is higher 
 than in mammals, as their normal temperature is so 
 much higher. They must therefore be left out of 
 consideration in discussing the question in regard 
 to mammals. 
 
 From these different views of the subject it may 
 be safely inferred that in some cases where an 
 animal is killed by overheating, the temperature 
 reached during life is that at which myosin removed 
 from the body coagulates, but in others it is a de- 
 gree or two below the point. 
 
 Further, it seems very probable that the myosin 
 influenced by life forces, and by the steady alkaline 
 current of the blood, would resist a heat in living 
 
 6 
 
62 THERMIC FEVER, OR SUNSTROKE, 
 
 muscle which would coagulate it instantly under 
 other conditions. Confirmatory is the statement 
 of Dr. Brunton, already cited, that he has seen the 
 heart beating fairly and still under the influence of 
 the vagus when the thermometer in the rectum in- 
 dicated 115° F. 
 
 Looking at the question under consideration 
 solely from this point of view, the answer is some- 
 what doubtful, but appears to be that in some cases 
 it is very possible that death of the animal may be 
 due to direct coagulation of the cardiac myosin 
 by heat, whilst in other cases it is most improbable. 
 
 It is very possible that the mode of applying the 
 external heat, and especially the intensity of the 
 latter, may affect the result. Certainly my own ex- 
 perience is much opposed to the idea that a bodily 
 temperature of 115° F. is often attained in killing 
 cats and rabbits by heat. 
 
 The second means of deciding the question leads 
 in a more positive manner to a definite conclusion. 
 My own experiments were carefully made with a 
 view of determining the matter, and were very uni- 
 form in the result. 
 
 In no case that was closely studied did the heart 
 cease to beat before arrest of respiration. In Ex- 
 periment I the heart beat very feebly and imper- 
 fectly after the opening of the cadaver; in Experi- 
 ment 2 the animal may have been dead fifteen 
 minutes before the autopsy. In Experiment 3 the 
 
NA TURE. 
 
 63 
 
 heart was found beating quite actively after death, 
 and was seen to become suddenly rigid. In Ex- 
 periments 4, 5, and 6, on pigeons, the pulsations 
 of the heart could be felt continuing after the cessa- 
 tion of respiration. In Experiment 7 the thorax 
 was opened and the regular beat of the heart 
 ocularly demonstrated after respiration had ceased. 
 In Experiment 8 death took place from a centric 
 convulsion, and the heart went on for some ten 
 minutes with a strong, vigorous beat. 
 
 Further, if it be true that an animal dies from 
 coagulation of the myosin of the heart, it is very 
 apparent that if, by any artificial means, it can be 
 cooled before such coagulation has occurred, whilst 
 the heart is still beating, recovery must result, or 
 at least death be averted for the time. 
 
 That an animal may, however, be cooled down 
 to its normal temperature, whilst the heart is beat- 
 ing, and yet the fatal result be in no very perceptible 
 degree postponed, is shown by the following experi- 
 ment: 
 
 Experiment 12. — Pigeon put in hot box at 1.53 p.m. 
 Temperature, 114°. At 2.14 the temperature was 1 17°. The 
 pigeon was now taken out of the box very ill, imable to 
 stand, but with the heart beating regularly. It was plunged 
 into cold water, and the temperature reduced to 105°. It 
 did not, however, revive any, and died in some ten minutes. 
 
 The results of my experim.ents viewed alone are, 
 then, very positive, that death does not generally 
 
64 THERMIC FEVER, OR SUNSTROKE. 
 
 occur from coagulation of the cardiac myosin, but 
 from arrest of respiration. 
 
 Claude Bernard (loc. cit., p. 134), on the other 
 hand, says, " It appears still very possible, at least 
 probable, that there is a coagulation of the myosin, 
 and that this is the cause of the death of the mus- 
 cles, and of the heart in particular. The manner 
 in which heat causes death is, then, perfectly ex- 
 plained. However, as the animals can be taken 
 from the stove a few moments before the fatal issue 
 and not die for many hours, or even for many days, 
 it seems necessary to admit that there are many 
 other grave alterations produced by the heat." 
 
 Modifying my own results by those of Claude 
 Bernard and Vallin, I think the following proposi- 
 tion expresses the truth : 
 
 Death in the lower animals from sunstroke or 
 heat fever, not produced by a sudden intense heat, 
 occasionally is the result of coagulation of the 
 cardiac myosin ; but in many instances, and prob- 
 ably in the majority of cases, is not so produced, 
 but is the result of arrest of respiration. 
 
 If it be true that when an animal is kept in the 
 intensely heated atmosphere until death, it suc- 
 cumbs often from other causes than the coagulation 
 of the muscular plasma of the heart, it would seem 
 that much more frequently would man suffer and 
 die from these other causes. His nervous system, 
 
NA TURE. 
 
 65 
 
 especially the cephalic, is so much more susceptible 
 that it would be expected to suffer more than that 
 of the animal. More than this, in the experiments 
 I have detailed, the external heat is steadily kept 
 up until death, and hence the body of the animal 
 attains the maximum temperature. Not so with 
 man; very generally the external heat is removed, 
 but death takes place nevertheless. 
 
 It is necessary, therefore, to study the effects of 
 heat on man separately from that on animals, to 
 determine whether death does result from coagula- 
 tion of the myosin of the heart; and I shall ap- 
 proach the subject as before. 
 
 First, then, what temperature is attained in cases 
 of insolation or coup de soleil ? 
 
 Unfortunately, very few close clinical records 
 have been kept which can throw light on this point. 
 In India, especially, the suddenness and epidemic 
 nature of the affection, the fact that it mostly occurs 
 during the most laborious and trying periods of 
 campaigns and marches, and the circumstance that 
 the doctor is himself generally on the border of an 
 attack, all combine to prevent any clinical work 
 beyond what is necessary for the safety of the 
 patients. 
 
 The following table, taken from Dr. Levick's paper 
 in the Pennsylvania Hospital Reports for 1868, 
 represents, however, sufficiently the disease as it 
 occurs in the United States: 
 
66 
 
 THERMIC FEVER, OR SUNSTROKE. 
 
 TABLE OF TEMPERATURES. 
 
 Case. 
 I. 
 
 Place. 
 New Orleans. 
 
 Philadelphia. 
 
 Observer. Te7np. Max. observed.* 
 
 Dowler. 113° F. 
 
 109° 
 *' 104° after death. 
 
 " 110° after death. 
 
 106° 
 Levick. i09-5° 
 
 109° 
 106° 
 105.5° 
 " 112° after death. 
 
 H. C. Wood, Jr. 108° 
 
 108° after death. 
 109° . 
 «♦ 104° 
 
 106° 
 " 109°-! 10° after death. 
 
 An examination of this table will show that in 
 no case was a temperature anywhere near 115° F. 
 reached, either before or after death ; and that in 
 the large majority of cases the highest point at- 
 tained was not within six degrees of that degree; 
 although it is very probable that the temperature 
 given does not always represent the actual maxi- 
 mum, yet the evidence seems irresistible that in the 
 majority of cases of insolation in man the bodily 
 heat does not become sufficient to coagulate the 
 cardiac myosin. The results of observation are in 
 close concord with this conclusion. Earlier in this 
 
 ■^ Proof seems wanting that the temperatures noted were actually 
 the highest attained in all cases. 
 
NATURE. 
 
 67 
 
 paper I discussed the modes of death in sunstroke, 
 and it was, I think, clearly proven that in the gen- 
 erality of cases death is immediately produced by 
 a failure of respiration, or by a gradual consenta- 
 neous failure of respiration and circulation. 
 
 The conclusion seems to follow inevitably that 
 in the ordinary forms of human sunstroke death is 
 not due to the coagulation of the cardiac myosin, 
 and that the latter change and consequent hard- 
 ening of the heart is a post-mortem phenomenon, 
 occurring directly after death. 
 
 In the discussion of the clinical history of sun- 
 stroke, it was ^stated that there is a distinct class of 
 cases in which syncopal death occurs suddenly. 
 A study of these cases is evidently here in order. 
 
 It is a fact well known to sportsmen that rigor 
 mortis comes on with extraordinary rapidity after 
 severe muscular exertion. A rabbit or hare which 
 has been run for several miles by a dog will, on 
 being shot, perhaps, roll over once or twice and 
 be picked up perfectly stiff. The same thing has 
 been observed in the tetanus produced by strychnia, 
 the spasmodic muscles being said to sometimes 
 become rigid even without relaxation. Of these 
 facts there can be no doubt, as they are testified to 
 by every investigator. (See Hermann, Grundriss 
 der Physiologic des Menschen, Berlin, 1870, p. 228.) 
 
 The explanation of this, if the theory of post- 
 mortem rigidity herein advocated be correct, is 
 
68 THERMIC FEVER, OR SUNSTROKE. 
 
 that the myosin under such circumstances under- 
 goes some peculiar change by which its tendency 
 to coagulation is increased. 
 
 Dr. Harless (loc. cit.) has experimentally proven 
 this to be the case, for he found that myosin pre- 
 pared from a rabbit tetanized with strychnia coagu- 
 lated at 42° C. (i07|-° F.), whilst that from a similar 
 non-tetanized rabbit did not change until 48° C. 
 (ii8|° F.) was reached. 
 
 Certain experiments which I have performed 
 would seem to illustrate this fact by its opposite. 
 In Morgan's work (loc. cit, p. 332), the following 
 method of preparing myosin in large quantities is 
 given : '* Enough common salt in powder is mixed 
 with snow in a cold vessel to form, when thawed, a 
 one per cent, solution, and this mixture rubbed up 
 intimately with one-fourth of its weight of shavings 
 of frozen frog's muscle is, while still at 3° C, 
 thrown on a piece of linen ; then the liquid is 
 filtered several times through paper wet with a 
 cold one per cent, solution of common salt set in a 
 cold glass funnel, and each time the filter clogs 
 a new one is substituted for it." 
 
 I followed this process, but not so closely, per- 
 haps, as I ought, straining only through the linen, 
 and perhaps having the salt in excess ; and got a 
 thick, syrupy liquid, which did not undergo distinct 
 instantaneous coagulation at a lower temperature 
 than 1 13° F. The frogs I used were frozen almost 
 
NA TURE. 
 
 69 
 
 stiff, and had been absolutely torpid for months, 
 and to this circumstance I attribute the slight tend- 
 ency of the myosin to coagulate, so that the propo- 
 sition may be stated that lo7ig rest of a muscle 
 dimmislies the tendency of myosifi to coagulate. 
 
 It is very plain a priori \k\dl these facts must be 
 true of man, if of animals; and clinical observation 
 certainly confirms them. 
 
 As a proof of this it is only necessary to refer 
 to a paper on ''Instantaneous Rigor as the Ac- 
 companiment of Sudden and Violent Death," by 
 Dr. Jno. H. Brinton, in the American Journal of 
 Medical Sciences, 1870, p. 1870. In this exceed- 
 ingly interesting memoir the sudden occurrence of 
 such instantaneous rigor is very clearly proven by 
 the testimony of the author and other eye-witnesses 
 as being frequently seen on battle-fields. Under no 
 circumstances is the excitement more intense, or 
 the muscular system more strained, than on the 
 field of battle ; so that the evidence is certainly 
 complete that both in man and animals excessive 
 exertion predisposes to coagulation of myosin, 
 and renders it liable to alter at a temperature 
 decidedly below the normal point of change. 
 
 The cardiac variety of sunstroke is said by the 
 Indian authorities to occur especially in action, 
 rarely during marches, never in barracks. As an 
 example of it may be cited the account given by a 
 witness to Dr. Parkes, and incorporated in his work 
 
70 
 
 THERMIC FEVER, OR SUNSTROKE. 
 
 on Hygiene (Pract. Hygiene, 2d edit., p. 360), of 
 an occurrence during the first Chinese war. The 
 98th Regiment was marching on a very hot day, 
 and the surgeon who was with the rear-guard 
 stated to Dr. Parkes that the men fell suddenly 
 on their faces, as though struck with lightning, 
 and, on running up and turning them over, many 
 of them were already dead. Dr. Maclean, who 
 was present at this occurrence, confirms the ac- 
 count given by Dr. Parkes, but states that it was 
 at the attack on Chian-Kiang-Foo. The men 
 were thickly clothed, with tight accoutrements and 
 tight, rigid stocks, and were charging up a very 
 steep hill. A great number of them were stricken 
 down, and fifteen died instantly, falling on their 
 faces, and giving merely a few convulsive gasps. 
 
 The points worthy of note in this history are, — 
 first, that the men were making violent exercise 
 going up-hill, so that the heart must have been in 
 exceedingly active exertion, increased by the im- 
 pediment to the circulation afforded by the tight 
 accoutrements ; second, that the attacks were in- 
 stantaneous and syncopal in their character. To 
 my mind the conclusion is irresistible that death 
 was produced by sudden coagulation of the myosin 
 of the cardiac muscle, and consequent rigid arrest 
 of the heart's action. 
 
 Vallin seems to think that the arrest of respira- 
 tioit, when it occurs before or simultaneously with 
 
NATURE. yi 
 
 the cessation of the heart-beat, is due to a coagu- 
 lation of the myosin of the diaphragm. I think, 
 however, that the disproof of this, except as a mere 
 possible rarity, is so plainly contained in what has 
 been said about the heart, that it is not necessary to 
 dwell upon it. I will merely refer to Experiment 
 lo, in which, although the cat died of sudden arrest 
 of respiration, the diaphragm distinctly reacted to 
 the stimulus of galvanism fifteen minutes after 
 death, and also to the fact that is shown in my 
 clinical records, that in man general muscular rigid- 
 ity is often not developed within the first hour after 
 death from insolation. 
 
 The prolonged study of the muscular system in 
 insolation has, then, produced the following conclu- 
 sions : 
 
 1st. Excessive rigidity of heart, due to a coagu- 
 lation of its myosin, is a very pathognomionic lesion 
 of sunstroke. 
 
 2d. That in most cases it is a post-mortem, rather 
 than an ante-mortem, phenomenon, occurring di- 
 rectly after death. 
 
 3d. In certain cases, the so-called cardiac variety 
 of sunstroke, death is probably due to a sudden 
 ante-mortem coagulation of the cardiac myosin, 
 and consequent instantaneous arrest of the heart's 
 action. 
 
 4th. That the muscles after death from heat 
 fever very soon become rigid, sometimes do so 
 
72 THERMIC FEVER, OR SUNSTROKE, 
 
 instantly, and that such rigidity is of the same 
 nature as ordinary post-mortem rigidity. 
 
 5th. That while it is conceivably possible that 
 death from asphyxia may occur from coagulation of 
 the myosin of the diaphragm and other respiratory 
 muscles, it is exceedingly probable that in man 
 death never does actually occur from such cause. 
 
 Nervous System. — Having completed the study 
 of the action of heat upon the muscles and their 
 pathology, so to speak, in sunstroke, it seems next 
 in order to take up the nervous system. To any 
 one who has witnessed a case of coup dc soleil, the 
 importance of such investigation must be most 
 obvious. What is required is the determination 
 how far the nervous symptom.s are produced di- 
 rectly by the heat, and how far they are the result 
 of antecedent changes in the blood. The first step 
 in such inquiry must logically be the endeavor to 
 find out whether the degree of heat manifested in 
 sunstroke will of itself produce nervous symptoms; 
 and if so, how these will compare with those of 
 coup de soleil. 
 
 This endeavor also naturally divides itself into 
 two parts : first, the study of the action of heat on 
 the nerve-centres ; second, the investigation of its 
 action on the nerve-trunks. 
 
 There is no difficulty in applying heat directly 
 to the brain of the cat and rabbit by surrounding 
 
NATURE. 73 
 
 the head with a double bonnet of india-rubber, or, as 
 I have used, of pig's-bladder, and allowing hot water 
 to run through this. Vallin is, so far as I know, the 
 only observer who has made any such experiments. 
 It is evident that there are two points especially to 
 be determined in this inquiry: first. How do the 
 symptoms produced compare with those of ordi- 
 nary coup de soleil? second. What is the tempera- 
 ture at which the functional power of the brain is 
 lost? In only two instances did Vallin succeed in 
 causing death by the hot-water bonnet, and in 
 neither of these cases was any attempt made to 
 measure the temperature of the brain. The symp- 
 toms are not described by Vallin as closely as is 
 desirable, but appear to have been insensibility, — 
 whether coming on gradually or suddenly is not 
 stated, — with convulsions. 
 
 My own experiments are as follows : 
 
 Experiment 13. — A full-grown rabbit. Rectal tempera- 
 ture I02j°. 
 
 Time. Temp, of Water. Remarks. 
 
 1 2. 1 1 140° F. 
 
 12.49 1750 F. Puffiness and great swelling of the scalp, 
 
 with very hurried respiration and ex- 
 ceedingly rapid pulse, with violent 
 struggles, constitute the only effects as 
 yet produced. 
 
 12.51 175° F. A sudden, severe convulsion, followed by 
 
 a state of semi-unconsciousness. 
 1.4 150° F. Rectal temperature, 104^°. 
 
 7 
 
Time. 
 
 Te7np. of Water. 
 
 I.IO 
 
 140° F. 
 
 1. 15 
 
 180° F. 
 
 1.20 
 
 
 74 THERMIC FEVER, OR SUNSTROKE, 
 
 Remarks. 
 Lies quiet, semi-unconscious ; but the 
 
 corneas are very sensitive. 
 Convulsions. 
 Died in a stupor, a gradual deepening 
 
 of the previous semi-unconsciousness. 
 
 The respiration ceased before heart's 
 
 action. 
 
 Autopsy. — Skull opened instantly, just sufficiently to allow 
 a thermometer to be plunged in the brain ; it indicated 1 17° 
 F. The heart was soft and flaccid ; the right side full of 
 blood, the left empty. The muscles responded well to gal- 
 vanic stimulus, but rigor mortis set in in a few minutes. 
 
 Experiment 14. 
 
 Time. Temp, of Water. Anal Te7np. Remarks. 
 
 12.38 
 
 190° F. 
 
 
 12.50 
 
 140° F. 
 
 103I0 F. 
 
 1.05 
 
 135° F. 
 
 
 1. 15 
 
 
 104^0 F. 
 
 1.20 
 
 174° F. 
 
 
 1.30 
 
 
 
 Pupils not contracted. 
 
 Before this there have been 
 struggles, apparently semi- 
 convulsive, and contracted 
 pupils. Now a true con- 
 ^^~~ — ~ vulsion, follov^ed by uncon- 
 
 sciousness and complete re- 
 laxation. The breathing is 
 accompanied by fine, sonor- 
 ous rales. 
 1.50 150° F. 106° F. The rabbit has lain for some 
 
 time in a perfectly comatose 
 state, with occasional con- 
 vulsions. The hot-water 
 bonnet was now removed 
 from the head, and cold 
 water poured over the latter ; 
 almost immediately the ani- 
 
NA TURK. 
 
 75 
 
 mal showed signs of recover- 
 ing, and after awhile did so 
 - , perfectly. The next day, ex- 
 
 cepting in regard to the local 
 trouble in the scalp, etc., the 
 rabbit seemed well. 
 
 Experiment 15. — A young, half-grown cat. The hot- 
 water bonnet was adjusted to its head, and the water al- 
 lowed to run through it. 
 
 Time. Temp, of Water. Rei7tarks. 
 
 II. 15 1620 F. 
 
 11.25 Cat has had several convulsions not pre- 
 
 ceded by signs of nervous disturbance, 
 coming on suddenly and followed by 
 insensibility, witii partial anassthesia of 
 cornea. 
 
 There have been repeated convulsions, 
 during which pupils would dilate some, 
 although the eye was in the full blaze 
 of sunlight. Almost constant convul- 
 sive trembling, affecting very markedly 
 even the eye-muscles. The cat is all 
 the time absolutely unconscious. Cat 
 died at 11.57, the respiration ceasing 
 at least four minutes before the heart 
 ceased to beat. On opening the body 
 the right heart was gorged with blood, 
 and, on being cut, the ventricle pul- 
 sated again. The brain was opened 
 as soon as possible after death. Its 
 temperature was 113° F. The muscles 
 responded to galvanism not so actively 
 apparently as might be, and rigor mor- 
 tis came on in about fifteen minutes 
 (not timed with watch) after death. 
 
 11.40 
 
 140° F. 
 
 II.4I 
 
 162° F. 
 
 11-55 
 
 170° F. 
 
Time. 
 
 Temp, of Water. 
 
 IO-35 
 
 175° F. 
 
 II. 
 
 140° F. 
 
 11.30 
 
 1800 F. 
 
 12. 
 
 160° F. 
 
 75 THERMIC FEVER, OR SUNSTROKE. 
 
 Experiment 16. — A very large, powerful tomcat was 
 used, and bladder fitted to head at 10.30 a.m. 
 
 Remarks. 
 
 Verv hurried breathinsr. 
 
 Cat is now unconscious ; the unconscious- 
 ness came on in a very short space of 
 time, but not with absolute abruptness ; 
 no convulsions ; respiration slower. 
 12.15 1750 F. Cat just dead. The respiration certainly 
 
 ceased before the heart some seconds, 
 or probably a minute or two. No con- 
 vulsion. 
 
 Autopsy. — Brain opened instantly. The thermometer 
 plunged directly into the substance rose above 114° F. ; 
 when placed, however, so as to be in contact with the inside 
 of the skull, it marked 115^. There was decided, but not 
 extraordinary, congestion of the brain. 
 
 As these experiments are painful ones, I have 
 not repeated them further. They seem sufficient 
 to establish the following conclusions : First, A 
 temperature of the brain of from 113° to 117° F. 
 is sufficient, if maintained, to produce death in a 
 short space of time in mammals by arrest of the 
 respiration. Second. That the chief symptoms in- 
 duced are insensibility and convulsions, preceded 
 by exceedingly rapid respirations and action of the 
 heart, and unaccompanied by any general rise of 
 temperature. Tliird. That these symptoms come 
 
NA TUKE. 
 
 77 
 
 on very quickly in all cases, at times with absolute 
 abruptness.* 
 
 A point to be borne in mind in comparing these 
 temperatures with those fatal to the muscle, is that 
 the death is produced by paralysis of the respira- 
 tory centres, and that these centres being at the base 
 of the brain are farthest from the heat, hence it is 
 very probable they may have been one or more 
 degrees below the temperature of the cerebrum as 
 represented by the degree noted. The resem- 
 blance of these symptoms, induced by the local 
 application of heat to the head, to the nervous 
 phenomena of sunstroke, is very striking, both in 
 regard to the symptoms themselves and also to the 
 suddenness of their onset. A reference to the ac- 
 count of the exposure of cats to a general high 
 heat, will show that in these animals the nervous 
 symptoms are much more sudden and severe than 
 in rabbits ; in fact, approaching what is seen in man. 
 A study of the experiments just detailed will show 
 that a temperature of 113° to 114° F. is fatal to 
 the brain of the cat, 117° F. to that of the rabbit. 
 
 * These experiments also incidentally confirm the modern belief 
 that smistroke is not due so much to the direct heating of the head 
 by the sun, as to the heating of the general body, for the symptoms 
 induced outside of those arising directly from the cerebrum were 
 not those of true insolation. The importance of these experiments 
 in the interpretation of the nervous symptoms of fever, it would 
 be out of place here to dwell on. 
 
 7* 
 
78 THERMIC FEVER, OR SUNSTROKE, 
 
 The nervous system of the cat is much more ex- 
 citable, and much more impressible, than that of 
 the rabbit, and consequently feels the abnormal 
 temperature more acutely. The brain of a man is 
 much more highly organized, and no doubt cor- 
 respondingly more sensitive, than that of a cat; 
 and if a temperature below 113° F. is fatal to the 
 brain of a cat, whose normal temperature is 102^° 
 F., it seems very certain that the temperature of 
 some cases of insolation (113^ F.) is sufficient in 
 itself to cause death in man, whose normal tem- 
 perature is 99° F. 
 
 As will be shown hereafter, death in coup de 
 soleil is frequently due in a great measure to a 
 slow, gradual deterioration of nerve, muscular, 
 and hsemic organization; and in such cases the 
 fatal result may be brought about without being 
 immediately caused by the temperature, without, 
 in other words, the lethal nerve heat point being 
 reached. 
 
 Nei've-Trunks. — According to Vallin, E. Harless 
 published some years since in Henle und Pfeuffer's 
 Zeitschrift, 3d B. viii. pp. 122-185, a paper entitled 
 *' Ueber den Einfluss der Temperaturen und ihrer 
 Schwankungen auf die motorischen Nerven." I 
 have not had access to this memoir, but Vallin 
 states that no study of the effect of heat upon 
 nerve-centres was made, and that the following 
 
NATURE, 
 
 79 
 
 results were arrived at in regard to the nerve-trunks. 
 If a motor nerve of a frog be gradually heated up 
 to 3o''-32° C. (Se^'-Sgl" F.), its irritability is pro- 
 gressively increased, but at 35° or 36° C. (95^-96!^ 
 F.) the excitability is abruptly lost. In mammals 
 this loss of excitability occurs at 52° C. (l25|° F.). 
 In birds, at 57.5° C. {i33}4'' F.). At precisely the 
 degree at which in the different species of animals 
 the irritability is lost there is also a molecular 
 change in the nerve-substance, the myeline fusing 
 so that the nerve-fibre becomes softer and more 
 transparent, and its diameter greater. If a heated 
 nerve be allowed to cool, it regains its functional 
 power ; but on a second or third repetition of the 
 heating, its functional ability is finally totally lost. 
 My own experiments have not been directed so 
 much to the close physiological study of the action 
 of heat on nerve-trunks as to the answering of the 
 question. Does the highest temperature reached in 
 insolation affect seriously the conducting power of 
 the nerves? They were made by exposing for sev- 
 eral inches the sciatic nerve, passing underneath it 
 a strip of india-rubber cloth, so as to isolate it 
 from the muscles, and pouring water of a known 
 temperature over it. At irregular intervals the 
 conducting power of the nerve was tested by 
 touching it with the poles of an induction battery 
 above the heated portion. The animals were kept 
 throughout in a state of complete anaesthesia. 
 
8o 
 
 THERMIC FEVER, OR SUNSTROKE, 
 
 The experiments were as follows : 
 Experiment 17. — A young pup. 
 
 LEFT NERVE. 
 Time. Temp, of Water. Result. 
 
 \ min. 140° F. Nerve transmits no impulse. 
 
 5 " None applied. Has partially recovered its power. 
 
 RIGHT NERVE. 
 
 Result. 
 
 No impairment of activity; in fact, nerve 
 more excitable than normal. 
 
 No impairment of activity. 
 
 Nerve fails to transmit the strongest im- 
 pulse. 
 
 Nerve has not recovered itself. 
 
 Time. 
 
 Temp, of Water. 
 
 6 min. 
 
 120° F. 
 
 I7i" 
 
 120° F. 
 
 5 " 
 
 140° F. 
 
 None. 
 
 Experiment 18. — A young rabbit. Crural nerve em- 
 ployed. 
 
 Time, Temp, of Water. 
 
 1 mm. 
 2 
 2 
 
 2 ' 
 2 ' 
 
 3i' 
 
 118° F. 
 116° F. 
 124° F. 
 122° F. 
 134° F. 
 129° F. 
 140° F. 
 134° F. 
 
 Rejnarks. 
 
 Excitability of nerve seems increased. 
 
 There is not yet any distinct impairment 
 of conducting power of nerve. 
 
 Experiment 19. — A large cat. 
 
 Time. Teiiip. of Water. 
 
 8 min. 120° F. 
 
 4 " 130° F. 
 
 5 " 124° F. 
 5 '• 122° F. 
 5 " 127° F. 
 3 " 123° F. 
 
 Remarks. 
 
 No distinct impairment of conducting 
 power of the nerve. 
 
NATURE. 8 1 
 
 Experiment 20. — A very weak, sick cat. 
 
 LEFT CRURAL NERVE. 
 
 Time. Temp, of Water. Re-marks. 
 
 5 min. 136° F. The nerve was not tested for five min- 
 
 utes after heat was applied. The con- 
 ducting power was then good, but 
 somewhat lessened. 
 
 3 " 134° F. Nerve transmits impulse only with diffi- 
 
 culty. 
 
 5 " None. Nerve has partially recovered itself. 
 
 RIGHT CRURAL NERVE. 
 Time. Temp, of Water. Remarks. 
 
 6 min. 132° to 134° F. Some slight impairment of the conduct- 
 
 ing power of the nerves. 
 
 As far as they go, these experiments certainly 
 confirm the statements of Henle and Pfeuffer, and 
 demonstrate that the highest temperature ever 
 reached in sunstroke is not sufficient to sensibly 
 affect the conducting power of the nerves. 
 
 Coma. — It is very evident from the experiments 
 which have been detailed, that heat exerts a much 
 more deadly influence upon the nerve-centres than 
 upon the nerve-trunks, and that a temperature not 
 higher than that reached in most cases of sun- 
 stroke in man, not only induces symptoms similar 
 in many respects to the nervous phenomena of 
 insolation, but will also cause death by paralysis, 
 from over-stimulation, of the respiratory centres. 
 It becomes, therefore, a matter of grave interest to 
 decide, if possible, what is the lowest degree of 
 
82 THERMIC FEVER, OR SUNSTROKE. 
 
 heat which is sufficient to produce coma and con- 
 vulsions. 
 
 At first I was somewhat at a loss to invent an 
 experiment which should settle the point. It is 
 manifestly impossible to have the bulb of a regis- 
 tering thermometer in the brain so as to mark the 
 point at which convulsions come on. 
 
 I finally determined, as the best method at my 
 command, to apply the hot-water bonnet to the 
 head of an animal, and immediately after the in- 
 duction of decided nervous symptoms to open the 
 skull and plunge a thermometer into the brain. 
 When the coma comes on gradually, so that it is 
 impossible to determine the time exactly when it 
 commences, this method is very imperfect, but under 
 favorable circumstances is sufficiently accurate. 
 
 The following experiments were performed in 
 this way, and I think the results yielded are 
 sufficiently accurate for practical purposes : 
 
 Experiment 21. — A full-grown cat.^ 
 
 Remarks. 
 
 Time. 
 
 Temp, of Water. 
 
 12. 
 
 130° to 170° F. 
 
 
 during the hour. 
 
 I. 
 
 140° F. 
 
 Cat has been for some time very quiet, 
 evidently semi-comatose ; at times 
 arousing herself. Pupils moderately 
 contracted. 
 1. 15 180° F. Cat was so comatose that an attempt 
 
 was made to open the head. The first 
 incision was not noticed ; but the sec- 
 ond aroused her. 
 
NATURE. 
 
 83 
 
 Tune. Temp, of Water. Remarks. 
 
 1.30 180° F. The pupils have been strongly con- 
 
 tracted, and cat quiet and semi-coma- 
 tose. Suddenly pupils at once dilated 
 widely, and a severe convulsion came 
 on. This was so severe that I think 
 the cat would have died in it. In the 
 midst of the fit, however, the skull was 
 opened and the thermometer plunged 
 into the brain. It indicated 108° F. 
 
 Experiment 22. — A young kitten. 
 
 Time. Temp, of Water. Remarks. 
 
 1.40 170° F. 
 
 1.55 Kitten has been semi-comatose, with 
 
 strongly contracted pupils, for some 
 time. Suddenly its pupils dilated, 
 and a general epileptiform convulsion, 
 commencing in the muscles of the 
 jaw, set in. In the midst of this the 
 thermometer was plunged into the 
 brain. It indicated 107^° F. 
 
 For reasons before given, it seems irresistibly 
 probable that if a temperature of 1 08 F. in the brain 
 of a cat will produce these serious symptoms, it will 
 induce no less in man. 
 
 The conclusion is apparently unavoidable that 
 the nervous symptoms of sunstroke may be, and 
 probably are, due to the direct action of the heat 
 upon the cerebro-spinal axis, and that death itself 
 by asphyxia is often brought about by the same 
 influence. 
 
 The only objection of any force which I can 
 imagine capable of being raised against the conclu- 
 
84 THERMIC FEVER, OR SUNSTROKE. 
 
 sion just drawn from the previous experiments, is 
 that the results were not really due to the imme- 
 diate action of the heat, but to a determination of 
 blood to the head and consequent congestion of the 
 brain. 
 
 The want of validity of this objection is appar- 
 ently demonstrated by the following facts : 
 
 1. Sudden epileptiform convulsion is not gen- 
 erally the result of congestion of the brain. 
 
 2. Opening the skull through the longitudinal 
 sinus, although necessarily affording immediate 
 relief of any existent congestion, did not stop the 
 convulsion. 
 
 3. Abstraction of the heat by the pouring of cold 
 water over the head, sufficed to produce immediate 
 cure. 
 
 Dr. Richardson, of London, in a lecture pub- 
 lished in The Medical Times and Gazette, takes a 
 different view of sunstroke. He says, ^^ There is 
 little difficulty in explaining the cause of the coma 
 of sunstroke : it is due to the contraction of the ves- 
 sels which supply the brain with blood, and to the 
 subsequent changes in the nervous system incident 
 to withdrawal of blood." 
 
 Unfortunately, Dr. Richardson does not deem it 
 necessary to prove this explanation, and it there- 
 fore rests merely upon his ipse dixit. The experi- 
 ments herein detailed certainly show that whatever 
 
NA TURK. 
 
 85 
 
 may be the immediate method through which it 
 acts, high temperature within the brain causes the 
 nervous phenomena, and to invoke the aid of the 
 capillaries in explanation of this fact seems to me 
 to be unnecessary, and, in the absence of proof, 
 gratuitous. I think the more direct and therefore 
 more logical supposition is, that the heat overstim- 
 ulates the nerve-cells themselves. More than this, 
 what little evidence there is points strongly towards 
 the latter conclusion. It is impossible to believe 
 that during the comatose stage of coup de soleil 
 there is a state of general vaso-motor excitement, 
 because in both animals and man the general, if not 
 absolute, rule is, that during the coma the pupils 
 are minutely contracted. This is equally true 
 whether the applied heat be general or restricted to 
 the encephalon. 
 
 As a part of the convulsion, there is no doubt 
 often vaso-motor spasm, with sudden, abrupt, wide 
 dilatation of the pupil ; but all these appear to 
 be secondary, not primary, phenomena, preceded, 
 not followed, by changes in other nerve-centres 
 than the vaso-motor. 
 
 In order to prove that what is the possible and 
 also probable cause of any effect is the absolute 
 cause, it is often necessary to disprove other as- 
 serted causes, and therefore the full establishment 
 of the fact that heat is the real primary and imme- 
 diate cause of the nervous disturbance of sun- 
 
 8 
 
86 THERMIC FEVER, OR SUNSTROKE. 
 
 stroke, must be put off until the pathology of the 
 blood is considered. 
 
 The Blood. — As has already been stated under the 
 head of Pathology, the blood in sunstroke suffers 
 very markedly. In man it is always black, or very 
 dark, semi-fluid, with its alkalinity impaired, — in a 
 word, presenting largely the appearances and con- 
 ditioYis which exist in it in cases of low fevers. In 
 my experiments in animals, it has partaken of these 
 characters to a degree, but not so obviously as it 
 appears to have done in the experience of Claude 
 Bernard and Vallin. Both of these observers, 
 struck by the dark color of the blood, have made 
 researches as to its gases. 
 
 The method which Claude Bernard employed 
 was substantially as follows: By means of a syringe, 
 blood was drawn from the vena cava of an animal 
 just dead of sunstroke, and passed without expo- 
 sure to the air into a glassreceiver, previously fitted 
 to a mercury-pump. The gas, which was obtained 
 from the blood by the latter, passed immediately 
 into a graduated measure. It of course consisted 
 of oxygen, nitrogen, and carbonic acid. The last 
 having been absorbed by means of potash, and the 
 first by the use of pyrogallic acid, what was left 
 represented the nitrogen. From lOO cubic centi- 
 metres of blood were obtained: 
 
 Blood. loocc. 1^^2 37.2 ccentim. 
 i O i.oo •" 
 
NATURE. 
 
 87 
 
 In a second experiment there was a momentary- 
 exposure of blood to the air. The result was as 
 follows : 
 
 CO2 27.9 c. centim. 
 Blood, 100 c. centim. O 3.8 " " 
 N 9.4 " - 
 
 Normal venous blood, treated in the same way, 
 yields, according to Claude Bernard, from 12 to 15 
 c. cent, of oxygen per 100. 
 
 The analyses given by Vallin (p. 150) yielded 
 the following results. Gas obtained in 100 volumes 
 of venous blood : 
 
 Normal Blood, Heat-Stroke^ Exp, x. Heat-Stroke^ Exp. 2. 
 
 CO2 37-26 c. c. 36.79 c. c, 35-96 c, c, 
 
 O 13.81 •• 0.94 " 0.75 " 
 
 N 2.62 " 3.96 " 1.70 •* 
 
 53.69 " 41.69 " 36.41 " 
 
 After the addition of sulphuric acid to the blood : 
 
 Normal Blood. 
 
 Experiment i. 
 
 Experiment 2. 
 
 CO2 9-37 c.c. 
 
 6.42 c. C. 
 
 1. 51 c. C. 
 
 1. 12 " 
 
 0.57 '* 
 
 0.38 " 
 
 N 1.25 " 
 
 3.21 '* 
 
 0.38 " 
 
 11.74 " 10.20 " 2,27 ** 
 
 These analyses, having been made by different 
 investigators, and being entirely in unison, and 
 also in accordance with the pointings of all the 
 other facts of the case, must, I believe, be accepted 
 as demonstrating that after death of animals from 
 
88 THERMIC FEVER, OR SUNSTROKE. 
 
 heat the proportional amount of oxygen in the 
 blood is only a fractional part of what it normally 
 should be, and that the dark color of the blood 
 is largely owing to this absence of oxygen. 
 
 The question which presents itself is, To what is 
 this absence due ? That it is not due, as might be 
 at first supposed, to such a destruction of the life 
 of the blood as to prevent the absorption of oxygen, 
 is shown by the fact that if the blood be drawn 
 from the vein during life, or directly after death, and 
 be shaken in the air, it rapidly assumes the arterial 
 tint. Claude Bernard (loc. cit., p. 185) explains pov- 
 erty in oxygen by stating that when blood has its 
 temperature elevated it has a very great power of 
 changing oxygen into carbonic acid, and that the 
 phenomenon is really a post-mortem result; for if 
 the ''body be opened instantly after death, and the 
 arrest of the heart's action, the blood is still red in 
 the arteries, especially in cases where death has 
 been produced simply by the breathing of the hot 
 air, the body of the animal remaining outside of the 
 stove/* As to the latter class of cases I cannot 
 speak, having had no experience. The conditions 
 are so artificial, so unlike those of genuine sun- 
 stroke, that it has not seemed necessary to make 
 the experiment. I have, however, examined a 
 number of cases of heat-stroke in animals, and in 
 all of them the blood was everywhere dark, even 
 when the animal was killed before the appearance 
 
NA TURE. 
 
 89 
 
 of any indications of immediate death. To me the 
 explanation of the small quantity of oxygen in the 
 blood in sunstroke, both before and after death, 
 is very simple. Oxidation under the stimulus of 
 the high temperature must go on with intense 
 rapidity ; and, no doubt as a direct result of this, the 
 respiration very early in the affection becomes im- 
 mensely accelerated, and for a time this rapidity 
 serves to maintain more or less fully the balance of 
 demand and supply. But by-and-by the respira- 
 tion begins to fail ; although no less rapid, it grows 
 shallower and less perfect, and the constantly in- 
 creasing demand is met by a constantly diminish- 
 ing supply, until, in many cases, death results from 
 gradual asphyxia, and long before life is extinct, 
 the livid, purple surface, the dark, stagnant capilla- 
 ries, indicate what is taking place. 
 
 The fact that the red globules are generally able 
 to absorb oxygen after death, would indicate that 
 the blood has not lost its vitality : that it is not 
 dead. 
 
 This indication receives very strong corrobo- 
 ration from the experiments of Max Schultze 
 (Schultze's Archiv, i.), who found that when blood 
 was heated in a moist chamber, under the micro- 
 scope, no alteration took place in the red globules 
 until a temperature of nearly 52° C. (125!° F.) was 
 reached, when they became contracted and broke 
 up into debris and little masses of coloring matter 
 
 8* 
 
90 
 
 THERMIC FEVER, OR SUNSTROKE, 
 
 At a temperature of from 45° to 46'' C. (113'^- 
 1 14I F.) the amoeboid movements of the white cor- 
 puscles became more active, and continued so for 
 a greater or less length of time. When the tem- 
 perature was raised to 50° C. (122^ F.) they stiff- 
 ened, as it were, retaining permanently the condi- 
 tion or shape in which the heat found them. 
 
 Eulenberg and Vohl, according to Vallin, have 
 advanced the theory that death from sunstroke is 
 the result of the sudden liberation of gases in the 
 blood. According to both Hermann (Virchow's 
 Archives, t. Ixii.) and Vallin (Archives Generales, 
 Jan. 1872), the w^ork of these authors is a most re- 
 markable mixture of all that is bad in scientific 
 treatises. Vallin gives at some length the reasons 
 of Eulenberg and Vohl, and, as their proofs do not 
 amount to anything whatever, and the whole theory 
 is very unreasonable, I am content to simply refer 
 my readers to the reviews by Hermann and Vallin. 
 
 A more plausible theory is one originally pro- 
 posed by Weikard and recently supported by Dr. 
 Richardson, of London. (St. Bartholomew Re- 
 ports, vol. vii.) I have not seen the paper of the 
 former of these authorities, but according to Vallin 
 (Archives Generales, Jan. 1872), the memoir ap- 
 peared in the "Archiv der Heilkunde," 1863, p. 
 193, under the title of *' Versuche liber das Maxi- 
 mum der Warme in Krankheiten." In this paper 
 Weikard states that one of the dangers of high 
 
NATURE, 
 
 91 
 
 temperature is an augmentation of the coagulability 
 of the blood and consequent formation of clots in 
 the vessels. As quoted by Vallin, the principal 
 proof brought forward is that the coagulation of 
 blood occurs more rapidly outside of the body 
 when it is heated than when cold. The following 
 table expresses one of his experiments : 
 
 123 
 
 Man, 20 to 30 1 Commencement T, + 23° T. + 43° T. + 23° 
 
 years old. \ of coagulation, i minute. Instantly. i minute. 
 
 Apoplexy. j Firm coagulum, 20 " 12 minutes. 18 " 
 Separation of 
 
 serum, 12 ** 8 " 10 '• 
 
 Diameter of clot 
 
 after 2 hours, 34 cent. 33 cent. ? 
 
 The result reached by Weikard was, that by a 
 temperature of from 36° to 40° C. (96|^-i04°F.) 
 the coagulation is retarded, below and above that 
 it is accelerated. 
 
 Dr. Richardson, of London, in the lecture in The 
 Medical Times previously alluded to, expresses a 
 similar belief He says, ''At this stage there may 
 be slower motion, gradually falling temperature, 
 and collapse. These changes indicate in nearly 
 every instance that there has been separation of 
 fibrine in the heart. The separation has stopped 
 or arrested the current of the blood at the main, 
 and virtually all is over. In the human subject 
 we recognize by external signs this condition con- 
 
g2 THERMIC FEVER, OR SUNSTROKE. 
 
 stantly ; in the inferior animals we produce it syn- 
 thetically, and determine it with precision. 
 
 '* Here, in illustration, is the dead body of a cat. 
 In this animal there was, during life, an induced 
 increment of heat or fever. The fever progressed 
 until the mean temperature of the animal had 
 reached an increment of nearly lO degrees; then 
 the animal began to sink. She might have strug- 
 gled on hopelessly for hours, as human bodies do; 
 but we could in her case put her to death, in sleep, 
 by making her inhale the vapor of ether. We did 
 so, and at once laid bare the heart. See what has 
 happened. The right cavities are almost filled with 
 a firm separation of fibrine." 
 
 Coagulation of the blood in the heart is certainly 
 not a common occurrence in animals killed with 
 heat. I have examined a large number of such 
 hearts and have never seen any coagula. I have 
 also examined all of the arteries of some cases, 
 without finding thrombi. As will be shown here- 
 after, if a pigeon be revived after having been 
 nearly killed by heat, it recovers consciousness, but 
 remains partially paralyzed, and finally dies. It oc- 
 curred to me that possibly this might be due to 
 coagulation of the blood in the small capillaries, 
 and, to test the matter further, the following experi- 
 ments were instituted : 
 
 Experiment 23. — Two pigeons were killed by the hot box. 
 Two hours afterwards their brains were carefully examined 
 
NATURE. 
 
 93 
 
 with the microscope. The capillaries Avere almost all of 
 them empty ; a few contained masses of blood-corpuscles, 
 none of them, however, firm clots. 
 
 Experiment 24. — Pigeon was put in hot box, and when 
 dying, its head was cut off. In the examination of the brain 
 capillaries I failed to detect any thrombi. 
 
 Experiment 25. — A pigeon was partially revived from 
 heat-stroke, and its head then cut off. A careful microscopic 
 study of the brain gave the same negative results as in the 
 other cases. 
 
 As the results of my experiments, I am forced 
 to refuse assent to the idea that coagulation of the 
 blood in the living body is a factor in the history 
 of sunstroke, and to explain the single experimental 
 result deduced by Richardson as due to the slow 
 death of ansesthesia. Clinically viewed, the matter 
 appears even more definite. Loss of coagulability 
 of the blood is the one great lesion of human coup 
 de soleil, to whose existence all observers bear wit- 
 ness ; and in the absence of all evidence of real 
 weight, it seems most illogical to conclude that death 
 is ever due to the formation of coagula during life. 
 
 In my experiments upon animals, I have never 
 witnessed the profound breaking down of the blood 
 often seen in human sunstroke. Other experiment- 
 ers have had different experience ; and, after all, the 
 difference is one of degree, not of kind. The ab- 
 sence of these blood changes in many of the cases, 
 especially in the most rapid and when the nervous 
 symptoms are the most severe, shows that they are 
 
g4 THERMIC FEVER, OR SUNSTROKE. 
 
 secondary, not primary, in their position. Indeed, 
 the whole testimony of the facts which have been 
 eHcited in regard to sunstroke is in accord with this 
 view, for in rapid cases there is, as already stated, 
 comparatively little deterioration of the blood. In 
 slow cases, the vital fluid suffers the same degra- 
 dation that is seen in other fevers with high tem- 
 perature. When once these changes have been 
 set up, it cannot be doubted that they react upon 
 the nervous system, and possibly at times serve 
 to keep up the disease. In human sunstroke, 
 running a course mayhap of many hours or even 
 days, the secretions are largely arrested, whilst tissue 
 changes are vastly accelerated; more effete matter 
 than normal is thus poured into the blood, and the 
 avenues of discharge are choked up ; so that both 
 directly and indirectly the vital fluid is degraded, 
 until at last it in some cases no doubt becomes 
 incapable of sustaining life. 
 
 Before making a general review of the subject, 
 it remains to establish the proposition already 
 given, — that heat is not merely a possible and 
 probable, but the absolute and only cause of the 
 primary nervous symptoms of sunstroke. 
 
 It is not requisite, after what has been said, to 
 go much into detail, for it is an almost absolutely 
 necessary conclusion from what has been demon- 
 strated, that the changes in the blood are not the 
 
NATURE. 
 
 95 
 
 cause oi coup de soleiL It is, however, comfortable 
 to have this conclusion experimentally verified. 
 
 It has been shown that the life of the blood is not 
 destroyed, and that there are no embolic arrests of 
 circulation. There remains only the possible, but 
 exceedingly improbable, supposition, that a specific 
 poison is developed in the blood. Dr. Stiles (loc. 
 cit.) has proven that the injection of the blood of 
 an animal dead of heat-stroke into the veins of a 
 second animal, is not productive of harm to the 
 latter. Surely I am justified in believing that it 
 has been shown that all possible causes (except 
 heat) of the primary nervous disturbance have no 
 real existence as such, and in asserting the truth of 
 the proposition that abnormal temperature is the 
 only poison present. 
 
 If this be so, withdrawal of the heat before too 
 much damage has been done, ought to be followed 
 by immediate relief of the symptoms. The follow- 
 ing experiments show that this is the case : 
 
 Experiment 26. — A young rabbit was put in a glass box 
 set in the sun ; in twenty minutes he was apparently totally 
 unconscious, having passed through all the ordinary symp- 
 toms. He was now taken out, and put in a bucket of water. 
 The temperature of his body rapidly fell to normal, that of 
 the water rising two degrees, and consciousness was re- 
 stored at once. He was very weak, but in a few minutes 
 was able to walk some, and the next day was as well as 
 ever. 
 
 Experiment 27. — A pigeon of full age, with anal temper- 
 ature io8J°, was placed in hot box (130° F.) at 1 1 .42 a.m. At 
 
q6 thermic fever, or sunstroke. 
 
 12 M. it had a convulsion, followed by persistent opisthotonos, 
 with complete unconsciousness, which indeed had been 
 nearly complete before the convulsion. 12.2 p.m. the pigeon 
 was taken out, utterly unconscious, and at one time I thought 
 it was dead : there were only a few gasps at long intervals. 
 I plunged it into a tub of cold water, and kept it there. 
 Its respirations slowly improved ; but after it had been in 
 some three or four minutes it had a violent convulsion, after 
 which for awhile it again appeared to be dead. It, how- 
 ever, slowly got better again, and in about fifteen minutes 
 was taken out of the water and put in the air. It was now 
 perfectly conscious, and breathing slowly and regularly, 
 but was not able to walk. In two or three minutes it was 
 able to push itself rapidly forward with its feet, on its breast, 
 but was unable to raise its body from the ground. Its anal 
 temperature was 100°. It was now left in a basket at i p.m., 
 apparently improving. At 2 p.m. it was found dead, still 
 warm. I saw the body at 4 p.m. There was general rigidity, 
 and the blood was not coagulated anywhere. 
 
 Experiment 28. 
 
 Tei7ip. A nal 
 
 Tune, of box. Temp. Remarks. 
 
 11.40 120° F. 105° F. __ 
 
 11.48 120° F. 112° F. 
 
 11.55 120° F. 117° F. The pigeon had previously struggled violently, 
 but its struggles were apparently voluntary. 
 It was so weak as not to be able to walk, 
 and was now taken out of the box. It was 
 unable to stand at all. 12.8 P.M. the anal 
 temperature 112^°; pigeon is now able to 
 push itself along, although not to stand. 
 12.30 P.M. pigeon apparently all right, but 
 not disposed to fly, and its feathers seem 
 ruffled. Pigeon died some time between 2 
 and 5 P.M. Autopsy made twenty-four 
 hours afterwards showed that the blood was 
 fluid, and very dark. 
 
NA TURE. 
 
 97 
 
 Experiment 29. — Adultpigeon. Anal temperature, 109^°. 
 At 12.29 P.M. it was put in hot air chamber. 12.39 P-M., anal 
 temperature, 112°. 12.53 p.m., anal temperature, 117^°. Bird 
 lying on back and side, apparently dying. It was plunged 
 in cold Avater for several minutes, and when taken out its 
 anal temperature was 109^°. It was unable to make any 
 effort; with very irregular, jerking breathing, so that I mo- 
 mentarily expected it to die. It was not again put in water. 
 
 2 minutes (after taking out of water). — Temperature, 107°. 
 
 3 minutes. — General condition growing worse. 
 
 10 minutes. — Reviving. Able to push itself along. 
 
 12 minutes. — Temperature, ioiJ°. On application of gal- 
 vanic current, muscles respond well. 
 
 25 minutes. — Although pigeon has been in a warm place, 
 its temperature is 96°. 
 
 2 hours. — Pigeon much better; lies quiet all the time, but 
 can walk, though constantly falling ; still, is better. It has 
 been dry and in a warm place for two hours, but its temper- 
 ature is only 100°. 
 
 3 hours. — Left as before. 
 
 5 hours. — Found dead, cold and rigid. Blood as first 
 taken out dark and fluid, but on standing in a test-tube 
 forming into a firm coagulum. 
 
 These experiments certainly demonstrated what 
 has been claimed. The after-death of the pigeons 
 is probably explainable as the result of permanent 
 damages done to the nervous system, due to the 
 intense heat. 
 
 Theory of Disease. — Sufficient progress has now 
 been made in this memoir to render necessary a 
 short review of the facts that have been developed, 
 preparatory to a final sketch of the nature of coup 
 
 9 
 
q8 thermic fever, or sunstroke, 
 
 de soleil. It will be called to mind by my readers, 
 no doubt, that it has been shown that the sole efifi- 
 cient, always present, cause of sunstroke is excess 
 of temperature ; that whilst circumstances of the 
 degree of moisture in the air, or of the condition 
 of the patient, as race, acclimatization, temperance, 
 health, and so forth, have great influence, yet they 
 possess such influence only in so far that they 
 render the heat more penetrating or efficient, on the 
 one hand, or the patient less capable of resisting the 
 heat by the natural methods of self-cooling, on the 
 other; that the disease is generallyprecededbymore 
 or less marked prodromes, and that when it is fully 
 developed the symptoms consist simply of intense 
 fever, with great nervous disturbance, as shown by 
 unconsciousness, paralysis, convulsions, etc., and 
 that in most cases death results from gradual 
 asphyxia or a simultaneous failure of circulation 
 and respiration ; that there are cases whose course 
 is almost like that of lightning -stroke, — instant 
 death, — the patient suddenly falling forward in a 
 condition of fatal syncope, and that these cases al- 
 ways occur during active exercise ; that the most 
 obvious lesions found after death are, a condition 
 of the blood similar to that seen in low fevers, and 
 great rigidity of the heart. 
 
 In the second or experimental portion of the 
 memoir it was shown, — 
 
 That sunstroke may be produced in animals as 
 
NA TURK, gg 
 
 readily as in man, either by natural or artificial 
 heat; that the symptoms are similar to those seen 
 in man ; that death takes place ordinarily by as- 
 phyxia ; that after death the characteristic lesions 
 are alteration of the blood and rigidity of the heart, 
 with immediate or quickly appearing post-mortem 
 rigidity of the general muscular system ; that this 
 rigidity of the heart comes on in most cases after^ 
 not before, death, and is a result, not cause, of 
 death ; that post-mortem rigidity is dependent 
 upon coagulation of myosin, and that the rigid- 
 ity of the heart is of similar origin, coagulation of 
 the muscle plasma occurring almost instantane- 
 ously at 115° F., a degree almost attained in sun- 
 stroke; that when a muscle has been in great 
 activity immediately before death, the myosin co- 
 agulates at a much lower temperature, and that 
 the cases of sudden cardiac death occurring in bat- 
 tle among the East Indian English troops were no 
 doubt due to the coagulation of the heart's myo- 
 sin ; that heating the brain of a mammal produces 
 sudden insensibility, with or without convulsions, at 
 a temperature of 108° F., and death when a tem- 
 perature of 113° F. is reached; that this effect 
 of the local application of heat is not due to in- 
 duced congestion, but is the result of the direct 
 action of the heat upon the cerebrum, and that 
 consequently the nerve-centres are as perniciously 
 affected by high temperature as the muscles are; 
 
100 THERMIC FEVER, OR SUNSTROKE. 
 
 that the nerve-trunks bear a temperature of 125° 
 F. without their conducting power being imme- 
 diately affected ; that whilst the general symp- 
 toms induced by heating the brain of a rabbit are 
 very different from those of sunstroke, the nervous 
 symptoms are exactly similar; that the life of the 
 blood is not destroyed by any temperature reached 
 in sunstroke, the amoeboid movements of the white 
 blood cells and the absorption power of the red 
 disks not being injured ; that the amount of oxygen 
 of the blood is greatly lessened, as the result of 
 gradual asphyxia combined with abnormal con- 
 sumption of oxygen; that there is no reason for 
 believing that capillary thrombi are common in sun- 
 stroke ; that there is no specific poison developed 
 in the blood; that the deterioration of the vital 
 fluid is due to the rapid tissue changes induced by 
 the fever, and the more or less complete arrest of 
 excretion ; that such deterioration is secondary^to 
 the nervous symptoms, not primary ; that if the 
 heat be withdrawn before it has produced perma- 
 nent injury to the nervous system, blood, or other 
 tissues, the convulsions and unconsciousness are 
 immediately relieved, and the animal recovers. 
 
 As a postulate from these facts and deductions, I 
 think it follows that the nature of sunstroke is that of a 
 fever ^ or, in other words, that coup de soleilis a fever ^ 
 not dependent upon blood-poisonings but upon heat, — an 
 ephemeral or irritative fever, if the term be preferred. 
 
NATURE. jQI 
 
 It is well known that certain lesions of the 
 nerve-centres will cause fever without the super- 
 vention of inflammation or blood-poisoning ; such 
 a lesion is section of the spinal cord in the neck. 
 Indeed, it is apparently inconceivable that inflam- 
 mation itself can cause fever in any other way 
 than by a reflex action upon the nervous system. 
 Further, every practitioner has seen fever, and 
 even ''the fevers," produced or developed largely 
 through the nervous system. Very recently I 
 have had a patient convalescent from severe ty- 
 phoid fever, in whom the temperature for a week 
 had not been over 99° F. She, contrary to orders, 
 got out of bed, and made considerable exertion, 
 and within fifteen minutes had a slight rigor, fol- 
 lowed by intense fever, the temperature rising at 
 once to 104°, and in a few hours to 107° F. At 
 the same time, grave nervous symptoms were de- 
 veloped, and the pulse rose above 150, so rapid 
 and thready that it could not be counted. There 
 are two explanations of these facts, either of which 
 is conformable to our present knowledge : 
 
 First. That fever depends simply upon paralysis 
 of the vaso-motor nerves. 
 
 Second. That there is in the medulla or higher 
 up a controlling centre, which influences through 
 the vaso-motor or other nerves the heat production 
 in the body. 
 
 Which of these be the truth it is not necessary 
 
 9* 
 
I02 THERMIC FEVER, OR SUNSTROKE. 
 
 for our purpose to be determined, the theory of 
 sunstroke being plain in either case. When a 
 man is exposed to heat beyond his powers of re- 
 sistance, there is a gradual slow rise of temper- 
 ature, until the stimulus of the heat becomes so 
 intense as to paralyze either the heat centre or the 
 vaso-motor nerves, as the case may be, and then 
 there is probably a sudden intensifying of the oxi- 
 dation processes, and a further rise in temperature, 
 preceded, accompanied, or followed by an over- 
 whelming of the cerebrum; in other words, intense 
 fever, with its accompaniments, is developed. 
 
 That sunstroke is of the nature of a fever was 
 dimly seen by Sir J. Randall Martin and other 
 Indian writers, but not distinctly postulated by 
 them, at least that I know of, and the standard 
 authorities of England to-day do not consider sun- 
 stroke among the fevers. 
 
 It is said that Dr. Gerhard formerly taught in 
 his clinical lectures that sunstroke is a fever; but I 
 am not aware that he has put such opinion on 
 record 
 
 In a paper in the American Journal of the Medical 
 Sciences, Jan. 1859, Dr. J. J. Levick makes an elab- 
 orate comparison between the post-mortem results 
 of typhus fever and sunstroke, and says, " These 
 facts would seem to indicate that there is in sun- 
 stroke, as there is in typhus fever, a poisoned con- 
 dition of the blood, and that it is to this that we 
 
NA TURE. 
 
 103 
 
 are to refer the various morbid phenomena of the 
 disease. I cannot, however, divest my mind of the 
 behef that in sunstroke this unnatural condition of 
 the blood is a secondary affection, not the primary 
 one ; that there is, in the first place, an exhaustion 
 or depression of the nerve-forces which regulate 
 nutrition, respiration, circulation, and the other 
 acts of organic life." 
 
 In 1863 I published a paper in the American 
 Journal of the Medical Sciences, in which I insisted 
 strongly upon the claim of this disease for a place 
 among the fevers, and gave it a name as such, 
 namely. The nnic Fever. I believed at that time that 
 the nervous symptoms were due to the development 
 of a poison in the blood, not perceiving that the 
 heat itself was the poison. 
 
 In the last edition of his Practice of Medicine, Dr. 
 George B. Wood allowed the claim of sunstroke 
 for a place among the fevers. He says, '' Heat is 
 a universal stimulant to the organs ; and excessive 
 stimulation, or rather the high degree of irritation 
 that attends it, has a tendency first to derange, and 
 in the end to diminish or suspend, the functions of 
 these organs." In accordance with these views, Dr. 
 George B.Wood proposed the name oi Heat Fever 
 for the disease. Since the difference between the 
 two names seems to be very slight, I have retained 
 Thermic Fever, as having the priority. 
 
PART III. 
 
 TREATMENT. 
 
 The treatment of sunstroke has been very various 
 in the past, just as the ideas as to the nature of the 
 affection have been so diverse. By the first observ- 
 ers it was looked upon as the result of rush of blood 
 to the head, and the quick, often full and hard pulse, 
 the hot skin, suffused face and eyes, the sudden 
 unconsciousness, the convulsive startings, all seemed 
 to them to call most imperatively for bleeding. Ac- 
 cordingly, they practiced venesection, and for a time 
 believed they derived advantage from it; but the 
 frightful mortality which attended this practice 
 soon forced the abandonment of the lancet, and 
 latterly venesection appears to be condemned as a 
 general practice both by American and Indian sur- 
 geons, the testimony of some of whom I subjoin. 
 
 Dr. Dow^ler, of New Orleans, has occasionally 
 
 seen bleeding apparently do good, yet, as a general 
 
 measure, he unqualifiedly condemns it. He says 
 
 (New York Medical Gazette, 1842), '* Doiring the 
 
 ( T04) 
 
TREA TMENT. 
 
 105 
 
 last five years I have been called to see a very con- 
 siderable number of sunstruck persons, within five 
 or ten minutes after they fell in the streets. For- 
 merly, I used to bleed them, and though the great 
 heat of the body is thereby suddenly diminished, 
 the pulse becoming soft as air, yet by the time the 
 arm is tied up (which is done for form more than 
 for necessity), the patient is suddenly choked, and, 
 to appearance, by a dense tenacious mucus, the 
 breathing not ceasing gradually, as in other dis- 
 eases, but instantly, the face turning livid, and even 
 its veins, especially upon the forehead, becoming 
 at the moment distended. Bleeding hastens the 
 strangulation, though it is always desired by 
 friends." 
 
 Dr. Swift (New York Medical Journal, 1854) con- 
 demns bleeding, and also the indiscriminate use of 
 affusions. Looking on the cases as instances of cold 
 collapse, he advises that the patient be put in a hot 
 bath, rendered stimulant by capsicum or mustard, 
 and that general stimulation be used. 
 
 Surgeon Thos. Longmore, of the Indian army 
 (London Lancet, 1859), condemns venesection, ex- 
 cept in rare cases, and extols cold affusions, with 
 purgative enemata, and mustard-plasters along the 
 spine. 
 
 Dr. Wm. Pirrie, of the same service, says, '* I 
 have been told by many who had had ample 
 means of observation, that venesection always 
 
T06 THERMIC FEVER, OR SUNSTROKE. 
 
 seemed to hasten a fatal termination." He com- 
 mends cold affusions to head and chest, with dili- 
 gent use of frictions and heat to legs and arms. 
 
 Crawford says (The Madras Quarterly, Oct. 
 i860, p. 330), ''I have never seen any advantages 
 derived from venesection in such cases, and I am 
 satisfied that the reverse is often the case. It is 
 worthy of remark that its strongest advocates 
 admit 'that blood-letting kills, if it does not cure 
 the disease,' and that * to deplete with good re- 
 quires care and discrimination, aided by a calm 
 judgment.' " 
 
 Dr. G. S. Beatson (Med. Times and Gazette, Dec. 
 1857) condemns bleeding very strongly. He states 
 that, in an epidemic which he witnessed, four cases 
 were treated by venesection, with three deaths, 
 whilst of eight cases treated by repeated cold affu- 
 sions to head, chest, and epigastrium, all recovered. 
 
 Dr. A. E. L. Longhurst (Lancet, Jan. 1869) com- 
 mends treatment by pouring cold water freely on 
 the head, and the internal use of croton oil in small 
 quantity, with the free administration of brandy. 
 He gives three cases, all of which recovered under 
 this treatment. He believes the cold water to act 
 by exciting the nervous system, and states that in 
 his cases the immediate effects were raising of the 
 pulse and forcible contractions of the voluntary 
 muscles ; but if the douche were continued too 
 long at one tim.e, it was followed by diminution of 
 
TREA TMENT. 
 
 107 
 
 the volume of the pulse and marked depression. 
 He condemns venesection. 
 
 Mr. J. R. Taylor, Deputy-Inspector of Hospitals, 
 India, says, after describing a severe epidemic of 
 the disease, " Had I fortunately before the epi- 
 demic at Gozupore, 1843, ^^^ with the records to 
 which I have referred, I should have been more 
 moderate in the employment of venesection." He 
 then speaks of an epidemic which he witnessed in 
 1852, in which ''numerous" severe cases were 
 treated simply by continuous cold affusions with- 
 out one death. 
 
 Further testimony might be adduced as to the 
 impropriety of bleeding in sunstroke ; yet it can- 
 not be gainsaid that occasionally whilst the blood 
 has been flowing the patient has become conscious. 
 Dr. Dowler appears to admit this freely, although 
 condemning venesection. The truth appears to be 
 that whilst, in some cases, blood-letting may do 
 good, in by far the majority of instances it does 
 absolute harm. There can be no doubt of the great 
 refrigerating power of bleeding. Dr. Dowler ex- 
 pressly states that the skin grows cool when it is 
 practiced in coup de soleil^ I conceive that when 
 
 * Since this memoir has gone to press, on re-reading Dr. Wm. 
 Pepper's account of sunstroke (referred to in the early part of this 
 work), I find that all his cases had been freely bled before he saw 
 them. The cases were very probably true sunstroke, not simply 
 heat-exhaustion, as I have suggested, and the cool skin was the 
 
I08 THERMIC FEVER, OR SUNSTROKE. 
 
 venesection does good, it does so generally, if not 
 always, by reducing the temperature ; and since 
 other simpler and infinitely less exhaustive means 
 of doing the same thing are so available, bleeding 
 is generally exceedingly bad practice, even if the 
 patient does recover. 
 
 In order, however, to allow the other side of the 
 question to appear somewhat, I append the follow- 
 ing from a report in the Medical Times and Gazette ^ 
 October, 1870 : 
 
 Case XI. — Dr. J. H. Salter was called to a lad 16 years 
 of age, who before the attack had been in perfect health. 
 Dr. Salter, on arriving half an hour after the lad fell, found 
 him "insensible, and wriggling in convulsions like an eel." 
 
 He says, "The muscles of the trunk, neck, and legs were 
 rigid, the countenance suffused, the eye directed backwards 
 and fixed, the breathing snatchy and stertorous. 
 
 "On closer examination, I discovered the pupils were 
 contracted to a minimum, the conjunctivae were injected, 
 and the teeth were firmly clinched together. The temper- 
 ature of the body was abnormally high, with the surface 
 dry and rough. The heart beat tumultuously, and the 
 throbbing of the carotid was very energetic. 
 
 "At the wrist the character of the pulse was small, quick, 
 sharp, and wiry ; there was a lack of volume, not of pro- 
 pelling force. I watched him carefully for some minutes, 
 and his symptoms increased in severity, so that I considered 
 him in extremis. I then took several ounces of blood from 
 
 result of the bleeding. The soft, flaccid hearts were found because, 
 the temperature not being high at the time of death, the cardiac 
 myosin did not coagulate. 
 
TREATMENT. lOg 
 
 his arm without delay. The effect was most striking. The 
 convulsions were quickly relieved, and gradually ceased as 
 the blood continued to flow ; the pulse became slower and 
 fuller, the breathing less labored and snatchy, and the 
 venous congestion of the face subsided ; the pupils relaxed 
 a little, and by the time I had bound up his arm he lay in 
 a heavy, oppressed sleep. 
 
 " He was then removed to a neighboring house and put 
 into bed. Cold applications were used to his head, and his 
 extremities, which were now hot, were artificially warmed. 
 ^A dose of castor oil was given as soon as he could swallow, 
 and through the night small quantities of weak beef-tea and 
 brandy. 
 
 "The next day the patient was much better and partially 
 conscious. The following day he was able to be taken 
 home." 
 
 In remarking on the case, Dr. Salter says, " The 
 immediate effect seemed to be to relieve the gen- 
 eral venous congestion; to render the breathing 
 calmer and less labored; to diminish the frequency 
 and alter the character of the pulse ; to lessen the 
 spasms and arrest the convulsions." 
 
 The Indian treatment of sunstroke appears to 
 be almost uniform of recent years, having the cold 
 douche for its basis. Barclay, Aiken, Maclean, 
 Morehead, Avary, and others, might be cited, but 
 further quotation seems scarcely necessary, and 
 would be cumbersome. At the same time, whilst 
 experience has taught the Indian surgeons the 
 value of the cold douche, it appears evident that 
 most of them consider that it acts chiefly by rousing 
 
 lO 
 
no THERMIC FEVER, OR SUNSTROKE. 
 
 up the nerve-centres : a false theory, which must 
 impair in practice the efficiency of the employment 
 of the remedy. 
 
 In America, no such uniformity of treatment has 
 as yet prevailed, although in the last five years the 
 drift of the professional teaching seems to be more 
 in that direction. 
 
 In 1859 (American Journal of the Medical Sci- 
 ences, vol. xxxvii. p. 55), Dr. B. Darrach recom- 
 mended that ice be applied to the skin, and also 
 rubbings with ice, in sunstroke; and this treatment 
 has subsequently been employed quite largely and 
 been generally approved, especially by Dr. Levick 
 (Pennsylv. Hospital Reports, 1868). 
 
 In the same Reports for 1869, Dr. Jas. H. Hut- 
 chinson details a number of cases in which hypo- 
 dermic injections of morphia were employed. Six- 
 teen were so treated, and all recovered but four: 
 a result which certainly is much better than my 
 own experience in the same hospital. At the same 
 time, it is to be noted that in most or many of these 
 cases the '' ice treatment" was more or less effi- 
 ciently employed, so that the results cannot fairly 
 be attributed solely to the morphia. 
 
 It wull be noted that I have avoided making any 
 statistical comparisons of results of treatment. I 
 have done this from the belief that such inquiry 
 would be worse than useless. The condition of 
 the patient before the attack, the severity and form 
 
TREA TMENT. I j j 
 
 of the latter, and the time at which treatment is 
 begun, are so rarely noted, and are so diverse and 
 so important in affecting the results, that all statis- 
 tical comparisons seem futile. 
 
 In concluding this essay, the final, practical 
 question is, What is the best method of treating 
 J sunstroke ? And I shall now attempt the answer 
 of this. 
 
 If there be any truth in the views of the nature 
 of thermic fever taken in this memoir, it is self- 
 evident that the chief indication in every case is 
 the abstraction of heat. An excess of the latter 
 agent is the materies morbi ; and if it can be re- 
 moved before too much harm has been wrought, 
 the patient will assuredly recover.' 
 
 As soon, therefore, as a man falls, he should be 
 carried into the shade with the least possible delay, 
 his clothing removed, and cold affusions over the 
 chest and body practiced. This must not be done 
 timidly or grudgingly, but most freely. In many 
 cases the best resort will be the neighboring pump. 
 In the hospital, probably, a better method of re- 
 ducing temperature than the cold affusion is to 
 place the patient in the cold bath (50° F.), or rub- 
 bings with ice may be practiced, and, as originally 
 suggested by Dr. Parkes, enemata of ice-water may 
 be given. 
 
 In using these various measures, it must always 
 be borne in mind that the indication is the reduc- 
 
112 THERMIC FEVER, OR SUNSTROKE. 
 
 tion of temperature : if the means employed do 
 not accomplish this, they do no good. 
 
 Relaxation of the pupil is said to be ''the first 
 symptom that shows the good of the cold affusion" 
 (Aitken, Practice of Medicine, vol. ii. p. 394); but 
 as, in my experience, the pupil frequently has not 
 been contracted, too much reliance cannot be 
 placed upon this; and I think the thermometer in 
 the axilla, or better the rectum, affords the best 
 guide as to the effect of the treatment. 
 
 After the temperature has been reduced, and 
 even after consciousness has returned, there is 
 often a great tendency to a fresh rise of tempera- 
 ture and consequent relapse. This tendency may 
 be met by wrappings in wet sheets, and, if neces- 
 sary, by a recourse to the more powerful measures 
 for reduction of temperature, which have been 
 already cited. 
 
 It must be borne in mind, however, that the 
 cold douche, cold battling, etc. are powerful rem- 
 edies, and are capable, if used too long, of doing 
 harm. 
 
 In my experiments upon animals, I have seen 
 the temperature, when once reduced by them after 
 sunstroke, continue, notwithstanding their with- 
 drawal, to fall until it w^as many degrees below 
 normal. It needs no argument to establish the 
 harmfulness of such reduction, and, whilst the possi- 
 bility of its occurrence should not intimidate us in 
 
TREATMENT, II3 
 
 the use of the measures, it should temper our bold- 
 ness with caution. 
 
 The evidence adduced by Dr. Hutchinson in 
 favor of the hypodermic use of morphia, as first 
 suggested by Dr. Herbert Norris, is certainly suffi- 
 cient to justify its further trial. 
 
 Dr. Hutchinson has stated to me, in conversation, 
 that the effects of the remedy were most apparent 
 in 'the convulsive form of the affection, and that, 
 indeed, the power which it exhibited in allaying 
 the spasms was most surprising. 
 
 Moreover, theory seems rather to favor than dis- 
 favor the practice, as it has been shown by Prof 
 Binz that morphia has the power of checking 
 tissue changes, and thereby lowering the tempera- 
 ture. It seems impossible that the moderate use 
 of morphia can do harm : it may do great good ; 
 and I would, therefore, advise the hypodermic in- 
 jection of a quarter of a grain of the sulphate every 
 four to six hours, especially in the convulsive cases. 
 
 After the first violence of the attack has been 
 subdued, a blister may- be applied, as recom- 
 mended by some English authorities. Aitken says 
 (loc. cit, p. 394), '' The hair is to be cut short so soon 
 as possible, and a blister applied to the nape of the 
 neck, the surface having previously been first well 
 ^^ovi^^AW\\}i\ acetuvilyttce: . . . increasing confi- 
 dence as to the ultimate result may be indulged in 
 so soon as vesication takes place ; and, in cases 
 
 10* 
 
114 THERMIC FEVER, OR SUNSTROKE. 
 
 where insensibility recurs, after an interval of ten 
 or twelve hours it may be removed by the applica- 
 tion of a second blister to the vertex." 
 
 While I would personally use a blister in this 
 way, from deference to authority and in the hope 
 it might do good, I would not rely too much 
 upon it. 
 
 Many of the Indian authorities advise a mild 
 purgative; in most of the cases that I have seen, 
 there was already diarrhoea; a dose of Rochelle 
 salt would, however, do no harm, but in bad cases 
 could hardly be swallowed early enough to do 
 much good. 
 
 Both Drs. Barclay and Maclean speak of a class 
 of cases in which every attempt to administer the 
 cold douche produces such violent convulsions 
 that it is inadmissible. It seems probable that the 
 cold baths, or rubbings with ice, would be borne 
 by some of these cases; if so, they no doubt would 
 be of inestimable value. 
 
 The authorities alluded to have never tried these 
 measures, but have used chloroform by inhalation. 
 
 Dr. Maclean says, " In India I have saved the 
 lives of many by acting on this advice" {i.e. giving 
 chloroform). Dr. Barclay, in like manner, found 
 chloroform useful ''in the convulsive form of the 
 disease attended with extreme nervous irritability : 
 ... in some instances life was saved by the 
 remedy ; in all it was prolonged." 
 
TREATMENT. 
 
 IIS 
 
 As alread}^ stated, it is especially in these cases 
 that Dr. Hutchinson has found the hypodermic 
 use of morphia of service. The best treatment of 
 the convulsive form of the affection would, there- 
 fore, seem to consist in the use of morphia and 
 chloroform, with the cold bath, or ice rubbings ; the 
 latter measures being practiced, if necessary, whilst 
 the patient is in a state of anaesthesia, 
 
PART IV. 
 
 SEQUELS. 
 
 It* is a piiori very improbable that an affection 
 which produces so rude a shock to the nervous 
 system as does thermic fever, should not frequently 
 be followed by grave after-effects. 
 
 Experience confirms such probabilities, for in 
 many cases, after recovery from the acute disease, 
 various symptoms of deranged innervation mani- 
 fest themselves. 
 
 Comparatively little has been written upon the 
 sequelae of the affection, but among Indian authori- 
 ties, Maclean states that the least serious of these 
 after-effects is " incapacity for service in India, or 
 any hot climate, without at least a more or less 
 prolonged stay in a cold climate." This inability 
 to endure heat in some degree almost universally 
 
 * This portion of the monograph has been added since the 
 Boylston prize was awarded. 
 
 ("6) 
 
SEQUELAl, y\J 
 
 follows sunstroke. It generally, with care, wears 
 off, sometimes in a year or so, sometimes not till 
 after a period of years. 
 
 Persistent headache, very severe and very in- 
 tractable, is spoken of by Maclean as a more 
 serious sequela. 
 
 Whilst serving in our army hospitals during the 
 rebellion, I saw quite a number of men who had 
 been disabled from duty by coup de soleil, and this 
 cephalalgia, often associated with giddiness, was 
 a very common, almost universal, symptom. 
 
 Unfortunately, I kept no notes of cases ; but, 
 through the kindness of Dr. Harrison Allen, I am 
 allowed to publish the following brief notes, taken 
 by him during his service. From the fact that the 
 hospitals he had charge of were well towards the 
 front, but few of such chronic cases remained for 
 any length of time under his care, so that complete 
 clinical histories were not obtainable ; but the ab- 
 stracts given are sufficient to show the general 
 symptoms. 
 
 Case XII. — Wm. L. received a sunstroke May 6, 1864, 
 during the battle of the Wilderness. Lay unconscious one 
 hour and a half On recovery, had severe headache, and 
 has suffered from it very much since. He had, previous to 
 the attack, convergent strabismus of left eye, which has been 
 much worse since. He also lost the sight of the eye at the 
 time of the accident. Jan. 186$, he had his first convulsion ; 
 has had three altogether. 
 
 Tongue at present furred; pulse small, thready; sleeps 
 
Il8 THERMIC FEVER, OR SUNSTROKE. 
 
 well ; bowels not costive. He suffers from persistent frontal 
 headache. 
 
 Case XIII. — David L. received a sunstroke in July, 1862, 
 which was followed by drowsiness, headache, and vertigo. 
 He was ill for several months. Up to present time, July, 
 1863, has not been able to do duty. 
 
 At present time is anaemic, with a calm pulse of 72, a clean 
 tongue, slight epigastric tenderness, and some dyspeptic 
 symptoms ; bowels regular. There is loss of memory, and 
 at intervals there are attacks of vertigo and weakness, last- 
 ing several days. 
 
 Case XIV. — George W. Sunstroke one year ago. Before 
 this time the patient had never had headache. Since the 
 occurrence has had it constantly. There is marked loss of 
 memory. Bowels constipated. Has attacks of vertigo and 
 weakness on taking even gentle exercise. Exposure to sun 
 produces intense headache and vertigo. He sleeps but very 
 poorly. Mouth temperature 99° F. Pulse 95. 
 
 Case XV. — B. L., about a year since, during a march 
 after the battle of Gettysburg, fell senseless, and remained 
 unconscious one hour. Since this he has suffered from 
 constant intense headache and obstinate constipation. The 
 bowels are never moved except by the aid of medicine. He 
 sleeps poorly, and suffers from decided loss of memory. 
 Exposure to the sun increases the headache very greatly. 
 Reading causes dizziness and great pain in the eyes. Pulse 
 95. Exercise produces great palpitation of the heart. 
 
 Intense, fixed headache, with or without other 
 serious indications of brain lesions, is often the most 
 prominent symptom in these cases. The fixedness 
 and obstinacy of the pain would seem to indicate 
 
SEQUELM. IIQ 
 
 that it is more than functional, an indication con- 
 firmed by the frequency with which other and 
 more serious symptoms of brain-trouble are finally 
 manifested. Thus, Dr. Pepper, in the paper previ- 
 ously quoted, states that out of twenty cases treated 
 in the Pennsylvania Hospital, three of the ten re- 
 coveries resulted in chronic brain diseases, eventu- 
 ating in insanity. 
 
 In order to treat these cases intelligently, it is of 
 very grave importance to decide what is the real 
 nature of the trouble. 
 
 Some time since, Dr. S. Weir Mitchell expressed, 
 in conversation, the belief that in many, if not all, 
 of the serious cases the after-lesion of thermic 
 fever is meningitis ; and reflection has convinced 
 me of the truth of his position. 
 
 There can be no doubt that in many cases of 
 sunstroke, after the subsidence of the original dis- 
 ease, there is manifested a marked tendency towards 
 the development of inflammation of the meninges 
 of the brain. This has been noticed by several 
 observers : thus, Bonnyman (Edinb. Medical Jour- 
 nal, 1864) speaks of reaction sometimes setting in 
 strongly, and requiring the application of leeches 
 to the temples. 
 
 Some years since. Dr. Mitchell, after walking 
 about the city for nearly the whole of an intensely 
 hot August day in the sun, went out of town a few 
 
I20 THERMIC FEVER, OR SUNSTROKE. 
 
 miles, and climbed a steep hill in the intense blaze 
 of the afternoon sun. At this time his carotids 
 were throbbing tremendously, and he had an in- 
 tense, bursting headache. He sat down to dinner 
 a few moments after this, and shortly fell forward 
 upon the table, entirely unconscious. 
 
 He says that he has a dim remembrance of being 
 helped up-stairs ; but beyond this is an absolute 
 blank, in his memory, of ten days. During this 
 period he is said to have had an intense fever, with 
 delirious unconsciousness, and a rapid, feeble pulse. 
 
 He was treated with cold applications, and at 
 the end of the period named, after a prolonged 
 mustard foot-bath, recovered his consciousness. 
 
 The first sensation was that of an intense, agoniz- 
 ing headache, and the next was the perception of 
 his father— Dr. J. K. Mitchell— and Dr. Mutter dis- 
 cussing the possibility of his recovery. 
 
 As soon as he could speak, he said, " Bleed me.'* 
 His father, coming to the bed, shook his head; but 
 the son repeated, "' Bleed me." He persisted in 
 simply repeating this, until they thought him de- 
 lirious ; but at last he mustered strength to say, 
 *' I am not delirious, but have a frightful headache: 
 if you don't bleed me I will die." By this time his 
 pulse had become full and bounding, and finally he 
 sat up and was bled. Ten or fifteen ounces were 
 taken without avail; but as more blood flowed the 
 headache vanished, to be succeeded by a feeling of 
 
SEQUELy^. 121 
 
 most delightful languor and rest from pain. Be- 
 tween twenty-five and thirty ounces were taken, 
 and afterwards recovery was a very simple matter. 
 That Dr. Mitchell, by the bleeding, was saved 
 from meningitis appears most probable, especially 
 in the light of the following case, reported by Dr. 
 J. J. Levick in the Transactions of the College of 
 Physicians of Philadelphia : 
 
 Case XVI. — A lad, aet. 17, had been engaged during the 
 morning in unloading coal at a wharf in New York. While 
 doing so, he complained of pain in the head, and fell over 
 in a convulsion. He remained in a state of stupor, and 
 was brought to Trenton in the canal-boat, unprotected, 
 and thence by railway to Philadelphia. 
 
 At the time of his admission he was in a semi-stupid state, 
 but could be roused with some exertion. He had at that 
 time ptosis of the right eye, with occasional delirium and 
 other symptoms of inflammation of the brain, for which 
 latter affection he was put upon the use of calomel, in small 
 and repeated doses, blisters to the nape of the neck, etc. 
 After death there was found extensive inflammation at the 
 base of the brain. 
 
 Dr. S. Weir Mitchell has generously allow^ed 
 me to publish the following cases, which have oc- 
 curred in his practice. They are strongly corrob- 
 orative of the opinion already advanced as to the 
 nature of the sequelae of sunstroke. 
 
 Case XVH. — G. B., aet. about 35, ordinary seaman ; previ- 
 ously well ; no syphilis. Being in the United States navy, 
 
 I T 
 
122 THERMIC FEVER, OR SUNSTROKE. 
 
 he was exposed to prolonged sun-heat on the African coast, 
 while on some duty connected with overseeing a party of 
 natives who were watering the ship. He came on board 
 suffering from headache, which grew worse in the hot tropic 
 night. The next day he fell on the deck, and soon became 
 insensible. He thinks he was treated with purgatives, and 
 cold to the head, but can recall little of what passed during 
 three weeks, when he became well enough to be on deck. 
 He was told that he had had sunstroke, and not the coast 
 fever. Save rare headaches, he had no permanent evil re- 
 sults, but the least exposure to sun made him suffer with 
 parietal pain and with weakness. Two years later, in Nor- 
 folk, a long exposure to heat produced general feebleness 
 and headache, which lasted a month or more. Thencefor- 
 ward his headaches were frequent and severe in summer, 
 but less common and more mild in cold weather. He en- 
 tered my wards at St. Joseph's Hospital two years after his 
 last stroke, and had then great general weakness and con- 
 stant headache, with buzzing in the left ear. As well as I 
 remember, the senses were otherwise unaffected, and the 
 lungs, heart, and kidneys healthy. There was, however, 
 slight acid dyspepsia, and intense constipation. A great 
 variety of treatment had failed to relieve his pain, which 
 was severe, was worst during the day, and was only eased 
 by heavy doses of opiates. A few days after he entered, he 
 became sluggish and inattentive. This was followed by 
 lessened complaints of headache, and somewhat later by 
 stiffness in the muscles at the back of the neck, with con- 
 tracted pupils, coma, and death. On examination we found 
 a remarkably extensive meningitis, some of it old, and some 
 new. The later trouble lay chiefly at the base, and there 
 was no other brain lesion proper. 
 
 The following case seen very recently offers 
 many points of likeness to that just related : 
 
SEQUELS, 123 
 
 Case XVIII. — Mr. , United States army, a sturdy, 
 
 well-made man, set. 30, married four years, but childless, was 
 in perfect health until August, 1869, when serving in Texas 
 he contracted ague, which proved very persistent. While 
 still liable to rare attacks of this disease, he was called upon 
 to ride a long distance in a very hot sun. On his return he 
 dismounted, and, while standing by his tent, he began to 
 feel headache, very suddenly. In addition to this he had 
 true vertigo, external objects turning around him, and vio- 
 lent throbbing of the head, especially behind his ears, and 
 also in the arteries of the neck. His face was deeply flushed, 
 and I presume from his statement that he must have felt just 
 such symptoms as follow a full inhalation of nitrite of amyl. 
 He staggered into his tent, and lay down, feeling weak and 
 confused. An illness of six weeks ensued, with headache, 
 delirium, much worse at night, and high fever. On recov- 
 ering it was thought unwise to keep him on duty, and he 
 was most imprudently sent back on horseback to San An- 
 tonio, — a four days' ride. A relapse occurred, and he was 
 again ill, with like symptoms, during two weeks, when he 
 gradually recovered, the headache becoming by degrees 
 more rare, until in the summer of 1870, after exposure to 
 sun-heat, the cephalalgia became again more frequent and 
 more severe. The winter which followed alone gave full 
 relief. In April, 1871, in New Mexico, the great heat re- 
 newed his pain, and before July he fell twice, owing to sud- 
 den weakness with vertigo. During this summer he had 
 frequent headaches, with many dizzy spells, which at length 
 were accompanied with loss of consciousness without spasm. 
 At this time also he suffered from sense of choking, and 
 there was also steady pain high up in the right side of the 
 neck, with buzzing in the right ear, tenderness of the mas- 
 toid process, and stiffness of the muscles below and back of 
 this region. The attacks lessened with cooler weather, and 
 in November and December there were none. I should 
 
124 THERMIC FEVER, OR SUNSTROKE. 
 
 add that from July he had had, when excited, tremor of the 
 right arm, but, notwithstanding these grave symptoms, had 
 remained on duty. January i, 1872, when much annoyed 
 and angry, a sudden spell of giddiness came on, with numb- 
 ness of the right arm, and twitching of the right hand. From 
 thence forward he dragged the leg a little in walking. He 
 came to Philadelfhia in March, 1872, and in the interval 
 had several attacks, which were alike, and began with a 
 sudden increase of the post-aural pain, which he properly 
 says is a sense of numbness with pain. The pain seems to 
 him to ascend above and behind the ear, and to run for- 
 ward on to the forehead. Meanwhile, the head feels full, 
 vertigo comes on, objects seem to rotate from left to right, 
 and loss of consciousness, without spasm, follows, after 
 which he sleeps, or is dull and drowsy. Until he came to 
 this city the leg and arm were increasingly feeble, the tremor 
 easily excited, and the headaches frequent. The palsy was 
 not, however, always the same, and in a time of excitement 
 and danger, during his homeward journey, he suddenly 
 seized the reins of a pair of unruly horses, and then discov- 
 ered that for some days after he could walk with ease. Per- 
 haps, feeling his weakness, he had not before this ventured 
 so much, and this seeming return of power was only a dis- 
 covery of a capacity always existing. 
 
 Mr. had no new attack until June i, 1872, at which 
 
 date he was free of headaches, and was rapidly gaining 
 strength. The first attack in June was preceded by pain 
 down the right neck, shoulder, and arm. A second fit fol- 
 lowed, June 9, and it then appeared that all his symptoms 
 had darkened. 
 
 When seen by me in consultation, June 12, 1872, this was 
 his condition : The mind said to be unimpaired ; memory 
 unaltered, or, if at all changed, it is so in regard to names ; 
 temper as usual ; questioned closely, he thinks that an hour 
 before an attack his memory of dates and names becomes 
 
SEQUELS, 125 
 
 much obscured ; hearing unaffected, but at times has had 
 buzzing in the right ear ; taste and smell as usual. I detected 
 no lesion of either eye bearing on the case. After the attacks 
 he has seen double for an hour, but now there is no squint, no 
 difficulties as to the accommodation. The field of vision is 
 entire, the acuteness of vision normal, and the pupils, alike 
 in size, play readily under changes of light. Dr. Wm. 
 
 Thomson was kind enough to see Mr. with me, and he 
 
 also found no changes in the disks of either eye, and no 
 evidence in them of past or present mischief. The sensi- 
 bility of the neck and face was examined with care, and 
 with these curious results : The entire distribution of the 
 fifth nerve was dyssesthetic, while also over the eye and in 
 front of the ear the sense of touch was lost altogether. The 
 ear and cheek and lips were least affected, but there was 
 still more complete loss of touch over the whole back of the 
 neck and head to the middle line. A needle-prick was felt 
 anywhere in the face, but not at all below the ear, or at any 
 point of the neck from the third cervical vertebra to the 
 occipital bos. 
 
 The mastoid process feels at times painful, and is slightly 
 tender on pressure. Deep pressure on the muscles below 
 and behind the right ear causes some pain, and he is never 
 free from some sensation in this region, which ranges from 
 annoyance to intense pain. The state of tactile sensation 
 in the right hand varies, and has varied so as that at times 
 he has slight loss of feeling, at others much more. When 
 first examined by me, the localizing power and the sense of 
 pain and temperature were all lessened. The compass- 
 points could not be separated widely enough to be felt as 
 two on the fingers of the right hand. The feeling of the 
 right leg was rather less disturbed. 
 
 There were no motor-palsies of any of the cerebral nerves. 
 The muscles of the right side of the neck were said to be 
 at times stiff, and were always sore. Speech normal. The 
 
126 THERMIC FEVER, OR SUNSTROKE. 
 
 right hand had, by the dynamometer, one-quarter the power 
 of the left. The right hand was in a state of tremor, in- 
 creased by the examination. During perfect rest it did 
 shake. When he made voluntary motions with the hand 
 it ceased to shake. The limb had every movement, but 
 each was feeble. He could walk with only a slight shuffle 
 in the gait. 
 
 Heart, lungs, abdominal organs, healthy ; appetite good ; 
 digestion natural ; bov/els regular ; urine, two specimens, 
 specific gravity 1024, no deposit, no albumen or sugar. 
 
 The treatment consisted of iodide and bromide of potas- 
 sium, with corrosive sublimate. The post-aural region was 
 leeched four times. When the first leeches were applied he 
 did not feel them, but before they fell off he felt them. The 
 second leeching was felt at once, and the effects were mani- 
 fest in the almost entire return of feeling in the fifth nerve 
 and its partial restoration in the cervico-occipital region. 
 The pain also disappeared, and the head felt lighter and 
 better. From thence the gain in other respects has been 
 steady and remarkable. 
 
 June 29, 1872. — The leeching was repeated yesterday, and 
 three ounces taken. A previous dry-cupping afforded less 
 relief; that from the leeching is notable, and what is thus 
 gained is also kept. He thinks the sensation of the hand 
 better, but it is still so dull that the width of the fingers is not 
 space enough to enable me to separate the compass-points 
 so that they shall seem to be two. On the neck and face 
 the sense of touch is still improving, and everywhere alight 
 contact is felt, save at the centre of the cheek, over a space 
 a half- inch in diameter; even here a deep pressure or 
 
 rough touch is felt. Mr. ordered to the seaside, and to 
 
 continue treatment. 
 
 This case is one of general interest. There was no sus- 
 picion of specific disease. It was clearly due to sunstroke. 
 In all probability there was some inflammatory state of the 
 
SEQUELS. 127 
 
 membranes surrounding the upper end of the cervical cord, 
 and a Hke state of the basal cerebral membranes. Both cen- 
 tres of disturbance must have been on the right side. The di- 
 agnosis, although not altogether satisfactory, seems to accord 
 pretty well with the results of treatment, which have been 
 decided and satisfactory. Many of his symptoms might 
 lead one to suspect the presence of a tumor, but I do not 
 see how a mass could be so situated as to occasion all the 
 troubles, while the careful and repeated studies of the eye 
 leave no doubt as to the absence of the usual ocular signs 
 of basal tumor. 
 
 I think the evidence now brought forward is 
 sufficient to establish the frequency of meningitis 
 following sunstroke, and that the fixed, intense 
 headache so often complained of is probably due 
 to such cause. 
 
 Whether the epilepsy and insanity which occa- 
 sionally follow sunstroke are really due to chronic 
 meningitis or not, I cannot say. 
 
 Maclean states that the epileptic fits usually 
 subside when the patient is removed to a cool 
 climate. 
 
 There is often, however, after coup de soldi ^ a 
 condition of simply deranged innervation, with 
 headache, dyspepsia, etc., in which there is no suf- 
 ficient reason to believe that actual inflammation 
 of the meninges exists. Such cases are readily dis- 
 tinguished by the headache being irregular and 
 shifting, sometimes absent, sometimes present, 
 sometimes frontal, sometimes occipital, etc. 
 
128 THERMIC FEVER, OR SUNSTROKE. 
 
 Treatment, — If the view here taken be correct, 
 the indications for treatment are very plain. First 
 and most important among them is the avoidance 
 of exposure to heat, it being evident that every 
 renewal of the original irritation will add fresh fuel 
 to the fire. This being borne in mind, the treat- 
 ment resolves itself into that of chronic meningitis, 
 which it is not necessary here to discuss. It is, 
 however, interesting to note that at Netley, Eng- 
 land, without apparently any definite idea as to the 
 true pathology, they have, as the result of clinical 
 observation, settled upon a good plan of treatment; 
 for Maclean (Joe. eit.) says, " When the pain is fixed 
 and severe, long-continued counter-irritation to the 
 nape and a course of iodide of potassium some- 
 times permanently relieve.'' 
 
 In the milder forms of the after-affection, the 
 physician's duties may often be limited to simple 
 hygienic measures and treatment of symptoms. 
 
 In these cases, as well as in the more serious, 
 Dr. Maclean lays stress upon the necessity of at- 
 tending to the functions of the skin, which he states 
 always to be profoundly perverted. 
 
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