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NATIONAL LIBRARY OF MEDICINE
        Bethesda, Maryland
 
 
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A-3-L- 
WP
610
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mi 
THERMIC    FEVER,

    l\  C   -J h I or

             SUNSTROKE./^
                                        JAN    '     "»
                                        £f jsryr-   •
BY
          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.
PRO BONO PUBLICO.
      PHILADELPHIA:

J.  B. LIPPINCOTT &  CO.

           1872. 
<^b
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
        IDE,.  S.  -WE IK,  MITCHELL,

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
Bebicateb. 
 
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
                       i*            (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:
  " 1 st. 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 coup de soleil 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  menin-
gitis or phrenitis, 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 upon
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) 
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
1 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. 1851) 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.
9
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 suigeneris, 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- 
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 
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
zvant 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 will  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
                       2 
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 1150 to
1270, and on one occasion was noted 1050 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.
IS
to moderate  excessive heat, furnished the greatest
number of fatal cases." Mr. Longmore says, " 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 
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.
  Symptoms—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 weakness 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.
17
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 
 18    THERMIC FEVER, OR  SUNSTROKE.

 accelerated, tongue  white,  thirst  intense,  bowels
 confined, the urine 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 praecordia, and, to
 use the patient's own words, 'aburning 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°-io9°  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: subsultus  tendi-
num was a very common symptom, great restless-
ness was also very often present, and sometimes 
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."
  Petechiae 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 Y.
21
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 and 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 of 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- 
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 1 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 1080 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, aet. 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 11 \ 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 1 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 1090 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 2\ 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. 
THERMIC FEVER, OR  SUNSTROKE.
  Case IV.—C. H., Englishman, over 60 years of age, was
brought to the hospital at i£ p.m. August n.  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 1090 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, set. about  33,
was brought into the wards of the hospital at 3J p.m., Au-
gust 14.  His wife  stated that on the  10th 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  1040 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 4^ 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 dark-
blue or purplish, 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
II.30  p.m.
  Autopsy, one hour after death.—No rigor mortis.  Tem-
perature in abdomen 1080 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 1090 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 hcurs  after death.—Meningeal veins gorged
with blood.  Some serous exudation in  ventricles.   Left
heart rigidly contracted.  Temperature in abdomen 1 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 50 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 e\eiy half-l.cur, and an injection of  an
ounce of turpentine was administered.  At 10.5c p.m. his pulse
had fallen to  8o, and his general condition much improved.
His medicine  was directed to be given every hour only.
  August  12, he was  entirely  conscious,  but  vciy drowsy,
and slept a great deal. 
CLINICAL  HISTORY.
27
  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-spinaland 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.
29
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, aet. 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* 
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 ardent 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
light 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 of feoris continuus
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. 
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 works 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 experimental results, although  I have gone
                       4            (37) 
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 coma.  In my own experiments
the insensibility 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  says
that occasionally life  is terminated by a  fit of con-
vulsions, but generally it ceases gradually. 
NATURE.                 39
  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 (1854), " 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 (1871), "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. 139). 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.
  ! p.m.—Temperature in rectum, 104^°.  Temperature of
box, 1200 (F.).
  1.15 p.m.—Temperature, io6|°. Respiration very hurried.
  1.30 P.M.—Temperature, 109J0. Has convulsive attacks,
in which he  jumps, and kicks with hind legs with great
fury.
  1.45 p.m.—Temperature, 1120. Seems very weak and re-
laxed;  breathing 220 a minute.   Lies on side, with every
now and then the attacks alluded to; slobbering greatly.
                        4* 
THERMIC FEVER,  OR  SUNSTROKE.
  2.10 P.M.—Temperature of box, 1200.  Rabbit on side,
exceedingly weak, gasping; squealing faintly at intervals.
  2.15 p.m.—Temperature, 1142°.  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 11.30 a.m.  Temperature, 104^°.
  12 m.—Temperature,  1090.  Temperature  of box, 1120.
  12.25 P-M-—Temperature, \\o\°.  Rabbit  weak, slobber-
ing a great deal;  breathing with great rapidity.
  1.15 p.m.—Rabbit conscious, lying  quietly on his side;
not slobbering; breathing not nearly so rapid, but deep and
labored.   Temperature, 11 \\°.
  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.
  12.11  p.m.—Anal temperature,  1050.  Just  put  in  box,
whose temperature is 1300, heated by very hot brick flues,
on which the rabbit lies.
  12.15 p.m.—Rectal  temperature, 1070. Breathing excess-
ively hurried.
  12.17 p.m.—Rectal  temperature, 1090.
  12.21  p.m.—Rectal temperature, m°.  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.
   1 p.m.—Fut in  the hot box.
   1.15 p.m.—Anal temperature, 1060.
   1.30 p.m.—Anal temperature, no0.
   1.40 p.m.—Anal temperature, 1 io|°.  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 
THERMIC FEVER, OR  SUNSTROKE.
arterial  hue.   The vessels were  carefully  examined :  no
clots were found in them.

  Experiment 5.—An adult pigeon.
  11.40 a.m.—Rectal temperature, 1090.  Just put in box;
the temperature in box,  1300; 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, 1200?.  (My thermometer
did not mark higher than 1200, 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 1300, 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. 
NA TURE.
45
  Experiment 9.
  12.36 p.m.—Anal temperature, no|°.   Pigeon  put in hot
box.
  1 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, 1300.
  12.35 PM-—Temperature of box, 1300.  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 (not by 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 
46     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 io 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 was  also interesting as
showing that the diaphragm does not lose its func-
tional power before death, nor is  always the  first
muscle in the  body to do so.
  Experiment io 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 which 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 
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  360 to 400
Cels.  (=96$° to 1040 F.) the cobwebs were lost to
sight from the muscle  becoming less transparent
(loc. cit, p. 128).
  Herrmann and Walker, who  have  recently (Pflii-
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 TURE.
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
living  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 
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 literally, for in his diagram (Fig.
ioi) the  curves  representing the loss of muscular
currents follow the law of Harless.
  Kiiline  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, Brticke (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 contractilen 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 400  C. (1040 F.)
instantly formed a large, firm, translucent coagu-
Ium.   At a temperature of 350 C. (950 F.), coagu-
lation occurred in an hour; at 380 C. (iooi° F.), in
half an hour; and at from I2°-I4° C. (533-58° F.),
at the end of six hours.
   Kiihne also performed similar experiments upon
a  rabbit with  similar  results,  obtaining  a  glairy
liquid,  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 1150 F. was reached at  once changed
color, became  whitish  and somewhat  turbid; at  116° F.
there was decided coagulation.  If 1 io° 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 (Henleund Pfeuffer's Zeitschrift fur
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 650 R. (= 178*°  F.), or for  some min-
utes in one at 300 R. (= 99^° F.).
  Schiff (Lehrbuch  der Physiologie) 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 650 R.
or 820 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 450  C. (= 1130 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. (= ioo° 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.  (= 1040 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. (= 1040 F.); and
although the circulation was perfectly re-established, 
NA TURE.
S3
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  400 C.
(=104° F.)  it instantly  coagulated;  at 30°  C.
(= 86° F.) coagulation occurred in an hour;  at
380 C. (= ioo|° 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.
(= 1040 F.), could be rendered  more rigid by a
heat of 450 C. (= 1130  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
                       5* 
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.
 101) than to  the  other albuminoids.  He  also
found  that the coagulation temperature  is in warm-
blooded animals near45° C. (= 1130 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°
 Q (=86°-iiii°  F.); in  a calf, from  45°-46° C.
 (=II3°-Ii6° F.);  and whilst in a  very old cat
450 C,  in a  newly-born  kitten it was  700  C*
 (=I58°F.)!
   He also found (p. m) that the formation of the
* This is evidently a misprint. 
NATURE.
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 iiber die Muskerstarre," 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 former, but  to a physical action
of the acid developed upon the muscular fibrillae,
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. 
56     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 1) and  Prof.
Stannius, of Rostock (Archiv fiir phys. Heilkunde, 
NATURE.
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 itiiad 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
Kiihne, 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
 bean shown  that the  myosin  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 Kiihne (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 thermic and post-mortem rigid-
ity are alike due to the 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 
NATURE.
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 450 C. (1130 F.),—" 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 
60     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 450 C. or  1130  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
440 C. to 46.1 ° C. Claude Bernard states that the
death temperature ranges from 43° C. (109^° F.)
to 450 C. (1130 F.).   Dr. Stiles says the tempera-
ture never rose above 1150 F., and was often one
or two degrees below it.
   The testimony of Vallin must  be received with
some guardedness, as he 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 1130 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 iii° to 1140 F.
   Dr. T. Lauder Brunton, in  experiments  reported
in  St. Bartholomew's Hospital Reports, vol. vii., 
NA TURE.
61
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 1130 and
1140 F., and even above.  He has seen the heart,
however, beating actively at 115 ° 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
vitiated by the fact that the animals  were  all nar-
cotized either with chloral or opium.  In  pigeons
the fatal temperature was always up to 1200 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  1150  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 1 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.
^3
 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, 1140.  At 2.14 the temperature was 117°.   The
 pigeon was now  taken out of the box very ill, unable 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 experiments viewed alone are,
then, very positive, that death does  not generally 
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:
                       6* 
66     THERMIC FEVER,  OR  SUNSTROKE.
TABLE OF TEMPERATURES.
   Place.
New Orleans.
Philadelphia.
Observer.
Dowler.
Temp. Max. observed*
 113° F.
    "        1040 after death.
    "        uo° after death.
             1060
  Levick.      109.5°
             1090
             106°
             105.5°
             112° after death.
H. C. Wood, Jr. 108°
             108° after death.
             109°
    "        104°
             106°
    "        io9°-iio° 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. 
NA TURE.
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 Physiologie 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 420 C. (107!° F.), whilst that from a similar
non-tetanized rabbit did not change until 480 C.
(u8|-0 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 30  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 1130 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  long rest  of a  muscle
diminishes the tendency of myosin to coagulate.
   It is very plain a priori that 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 
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-
tion, when it occurs before or simultaneously with 
NA TURE.
71
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
IO, 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 pathognomonic 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 
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  de soleil, the
 importance  of such investigation  must be most
 obvious.  What  is required is  the determination
 how far the  nervous symptoms  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 
NA TURE.
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 102 20.
Time.   Temp, of Water.               Remarks.
12.11     1400 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     1750 F.       A sudden, severe convulsion, followed by
                       a state of semi-unconsciousness.
 1.4      1500 F.       Rectal temperature, i04i°.
                         7 
74
THERMIC  FEVER,  OR  SUNSTROKE.
Time.	7Vw/. 0/ Water.
I.IO	1400 F.
I-I5	1800 F.
1.20	
                                       Remarks.
                          Lies  quiet,  semi-unconscious;  but the
                           corneae 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 1170
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 Temp.
12.38	1900 F.	
12.50	140° F.	103I0 F.
1.05	135° F.	
"5		104^° F.
1.20	174° F.	
1.30		
1.50     1500 F.
106° F.
Remarks.
Pupils not contracted.

 Before  this there  have been
   struggles, apparently  semi-
   convulsive, and  contracted
   pupils.   Now a  true con-
   vulsion, followed by uncon-
   sciousness and complete re-
   laxation.  1'he breathing is
   accompanied by fine, sonor-
   ous rales.
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 TURE.
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.                   Remarks.
11.15       162° F.
rl-25                     Cat  has had several convulsions not pre-
                             ceded by signs of nervous disturbance,
                             coming on suddenly and followed by
                             insensibility, with partial anaesthesia 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 1130 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	1400 F.
11.41	162° F.
"•55	1700 F.
 
THERMIC FEVER,  OR  SUNSTROKE.
  Experiment  16.—A very large, powerful tomcat was
used, and bladder fitted to head at 10.30 a.m.

Time.   Temp, of Water.               Remarks.
I°-35      175° F.
11.        1400 F.       Very hurried breathing. .
11.30      1800 F.
12.        1600 F.       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 1140 F. ;
when placed, however, so as to be in contact with the inside
of the skull, it marked 1150.   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 1130  to 1170 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.   Third. That these symptoms come 
NA TURE.
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 1130 to  1140 F. is fatal to
the brain of the cat, 1170 F. to  that of the rabbit.
  * These experiments also incidentally confirm the modern belief
that sunstroke 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.                _->■-■ - 
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 1130 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 (n-30 F.)  is sufficient in
itself to cause death in man, whose normal tem-
perature is 990 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 haemic  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.

  Nerve-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 Einfiuss 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 
NA TURE.  .
79
results were arrived at in regard to the nerve-trunks.
If a motor nerve of a frog be  gradually heated up
to 30°-32° C. (86°-89|° F.), its irritability is pro-
gressively increased, but  at 35° or 360 C. (95°-96|°
F.) the excitability is abruptly lost.  In  mammals
this loss of excitability occurs at 52° C. (125!° F.).
In birds, at 57.50 C. (133^° 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. 
80     THERMIC FEVER, OR  SUNSTROKE.
   The experiments were as follows :

  Experiment 17.—A young pup.
                      LEFT NERVE.
Time.    Temp, of Water.             Result.
 £ min.      1400 F.      Nerve transmits no impulse.
 5 "      None applied.  Has partially recovered its power.
		RIGHT NERVE.
Time.	Temp, of Water.	Result.
6 min.	120° F.	No impairment of activity; in fact, nerve more excitable than normal.
I7i"	120° F.	No impairment of activity.
5 "	1400 F.	Nerve fails to transmit the strongest im-pulse.
S "	None.	Nerve has not recovered itself.
   Experiment 18.—A  young rabbit.  Crural nerve em-
 ployed.
 Time.   Temp, of Water,                 Remarks.
 1 min.      1180 F.
 2  "       1160 F.
 2  "       1240 F.
 ii "       1220 F.        Excitability of nerve seems increased.
 2  "       134° F.
 2  "       1290 F.
 ii "       1400 F.
 3i "       !34° F.        There is not yet any distinct impairment
                          of conducting power of nerve.

   Experiment 19.—A large cat.
 Time.   Temp, of Water.                 Remarks.
 8 min.      1200 F.
4  "       i3o°F.
5  "       124° F.
5  "       1220 F.
5  "       1270 F.
 3  "       1230 F.       No  distinct impairment of conducting
                          power of the nerve. 
NA TURE.
81
  Experiment 20.—A very weak, sick cat.
                LEFT CRURAL NERVE.
Time.   Temp, of Water.              Remarks.
5 min.     1360 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 "      1340 F.      Nerve transmits impulse only with diffi-
                       culty.
g "      None.       Nerve has partially recovered itself.
                RIGHT CRURAL NERVE.
Time.   Temp, of Water.              Remarks.
6 min.    1320 to 1340 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.
Time.   Temp, of Water.            Remarks.
12.     1300 to 1700 F.
      during the hour.
 1.     1400 F.        Cat has been for some time very quiet,
                      evidently semi-comatose;  at  times
                      arousing herself.  Pupils moderately
                      contracted.
 1.15    1800 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. 
NA TURE.
B3
 Time.    Temp, of Water.              Remarks.
 1.30       1800 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.
 I.40       1700 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 107J0 F.

   For reasons before  given, it seems  irresistibly
probable that if a temperature of ic8 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- 
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 :

  I. 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 TURE.
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
ofteri 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 Qf  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-
ditions 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 glass receiver, 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  ioo cubic  centi-
metres of blood were obtained:
         Blood, ioo c. c, ( CO* 372 c- centim-
                     I  O  1.00 " 
NATURE.
87
  In a second experiment there was a momentary
exposure of blood to the air.  The result was as
follows:
                      C02 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-Slroke, Exp. i.    Heat-Stroke, Exp. 2.
  CO.) 37.26 c. c.        36.79 c. c.          35-9^ c. c.
    O  13.81  "         0.94 "           0.75  "
    N  2.62  "         3.96 "           1.70  v
    53.69 "        41.69  *'           36.41  "

After the addition of sulphuric acid to the blood:
Normal Blood.	Experiment 1.	Experiment 2.
C02 9.37 c. c.	6.42 c. c.	1.51 C. C.
O 1.12 "	Q-57 "	O.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?-0 F.) was
reached, when they became contracted and broke
up into debris and little masses of coloring matter
                       8* 
GO     THERMIC FEVER, OR  SUNSTROKE.

At  a temperature  of from  45° to 46 ° C. (113°-
114| 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  500 C. (1220  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. lxii.) and Vallin (Archives Generales,
Jan. 1872), the work 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 iiber das Maxi-
mum der Warme in  Krankheiten."   In this paper
Weikard states that one of the dangers of hio-h 
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 ) Commencement  T. + 230   T. + 430  T. + 230
  years old.   }  of coagulation, 1 minute.   Instantly.  1 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 360 to 400 C.  (96f°-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- 
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  IO 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 
NA TURE.
93
with the microscope. The capillaries were 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 anaesthesia.   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 
94
THERMIC FEVER, OR  SUNSTROKE.
secondary, not  primary, in their position.  Indeed,
the whole testimony of the facts which have been
elicited 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 
NA TURE.
95
cause of 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 io8£°, was placed in hot box (1300 F.) at 11.42 a.m. At 
96     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 ioo0.  It was now left in a basket at 1 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.
      Temp.  A nal
Time,  of box.  Temp.                Remarks.
II.40 120° F. 1050 F.
11.48 1200 F. 112° F.
11.55 1200 F. ii7°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  Ii2j°; 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, 1120.  12.53 p.m., anal temperature, 117^°. Bird
 lying on back and side, apparently dying.   It was plunged
 in cold water for several minutes, and  when taken out its
 anal temperature was 109J0.  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, 1070.
   3 minutes.—General condition growing worse.
   10 minutes.—Reviving.   Able to push itself along.
   12 minutes.—Temperature, 101J0.  On application of gal-
 vanic current,  muscles respond well.
   25 minutes.—Although pigeon has been in a warm place,
 its temperature is 960.
   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 ioo0.
   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.
   Tlieory 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 
gS     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 effi-
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 generally preceded by more
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 TURE.
99
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 1080 F., and  death  when a tem-
perature  of 1130 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; 
IOO
THERMIC FEVER, OR SUNSTROKE.
that the nerve-trunks bear a temperature  of  1250
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 soleil is a fever,
not dependent upon blood-poisoning, but upon heat,__an
ephemeral or irritative fever, if the term be preferred. 
NA TURE.
IOI
   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 990 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  1040,  and in a few hours to 1070 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* 
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
belief 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,  Thermic 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 of 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. Dowler, 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), " During the
      (104) 
                  TREATMENT.              1Q^

 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 
106    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 time, it was followed by diminution of 
                   TREATMENT.              lQ»

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, met 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 
108     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. 
TREA TMENT.
IO9
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, A vary, 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
                        10 
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 will 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.
Ill
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
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 (500 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- 
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 bathing, 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  was 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 
77?^ TMENT.
"3
 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
sponged with acetum lytt<z: . .  . increasing confi-
dence as to the  ultimate result may be indulged in
so soon as vesication  takes  place; and, in cases 
 II4   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.
"5
  As already 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 priori 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.
      (116) 
SEQUELsE.
117
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. 1865, 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 \V.  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 990 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 
SEQUELAE.
119
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 
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 
SEQUELAE.
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 allowed
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 XVII.—G. B., aet. about 35, ordinary seaman; previ-
ously well;  no syphilis.  Being in the United  States navy,
                         11 
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 : 
SEQUELAE.
123
  Case XVIII.—Mr. ----,  United States army, a sturdy,
well-made man, aet. 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  Philadelphia 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 1, 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 
SEQUELAE.
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  dysaesthetic, 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 
I26    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; bowels  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 
SEQUELAE.
127
membranes surrounding the upper end of the cervical cord,
and a like 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 soleil, 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 (loc. cit.) 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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The  Dervishes.    History  of  the  Dervishes;   or,
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New America.  By Win. Hef worth Dixon.  Fourth

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Bulwer''s  Novels.    Globe  Edition.    Complete  in

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ta"—New Orleans Times.
Zanoni..................1 voL

Pelham..................1 vol.

The Disowned...........I vol.

Paul Clifford............1 vol

Ernest Maltravers........1 voL

Godolphin...............1 voL

Alice...................I vol.

Night and Morning.......1 vol.

Lucretia.................1 vol.

A Strange Story.........1 vol

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Rcadc's Novels.  Illustrated Standard Edition of

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Foul Play...............  1.50
The Cloister and the IIearth$i.75
Griffith Gaunt............  1.50
Peg Woffington..........  1.25
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The Course of True Love
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Our Own Birds of the  United Slates.  A Familiar

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A Few  Friends,  and How  They  Amused  Them-

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     Pastimes and Games, aivd a Fancy-Dress Party.  By M. E. Dodge,

     author of " Hans  Brinker," &c.   i2mo.   Toned  paper.   Extra

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or less intellectual, all provident of mirth.
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Advice to a  Wife  on  the Management of her  own
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            LIPPIlsTOOTT'S
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Gazetteer   of the  World,
                            OR,

        GEOGRAPHICAL  DICTIONARY,

Comprising  over 2300 pages.  Giving  a  Description of nearly One
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