life, especially one given to mental, emotional, venereal or alcoholic excess, should at once excite a suspicion of the development of paretic dementia.

Sunstroke.

What are the symptoms of sunstroke?

Sunstroke, heat-stroke, insolation, of which there are at least two principal varieties, heat-fever or thermic fever and heat-exhaustion-is an affection of the heated term. It occurs in persons exposed to intense heat, solar or artificial, in whom the respiratory and cutaneous transpiration is checked.

Crowding and defective ventilation predispose to the occurrence of heat-stroke. The onset may be abrupt or gradual, the symptoms severe or mild (incomplete). While most often coming on during active muscular exertion, as in the case of laborers and marching soldiers, the attack not infrequently follows the mid-day meal. It usually but not invariably happens during the period of maximum heat of the day.

There occur increased frequency of micturition, headache, vertigo, nausea, vomiting, delirium, loss of consciousness, dysphagia, stertorous breathing and coma, associated in the febrile form with a hot, often flushed, skin, frequent pulse and high temperature. The pupils may be dilated or contracted, or contraction and dilatation may be present at different times in the same There may be rectal and vesical incontinence, sometimes partial suppression of urine. The duration of the symptoms varies from a few minutes to several hours.

case.

Death may occur early or late; recovery may be speedy or tardy. Persistent headache, vesical irritability, choreoid movements of the upper extremities, mental impairment, epilepsy, and in rare instances hemiplegia, or other paralysis, usually transient, may supervene as sequelae. Anhydrosis, with headache and elevation of temperature, annually recurring near the anniversary of the attack, has been observed.

General paralysis of the insane (paretic dementia) has been attributed to sunstroke.

What are the principal points of differentiation between heatexhaustion and heat-fever, or sunstroke proper?

In heat-exhaustion the skin is pale, cool or cold, moist or clammy; the temperature is low, even subnormal; there is syncope rather than coma; the pupils are usually dilated; the pulse is feeble; convulsions are absent; and rapid relief follows the use of warmth and stimulants.

How does cerebral hemorrhage differ from sunstroke?

The coma of sunstroke, unlike that of cerebral hemorrhage, does not set in unannounced; nor is it as lasting or as profound; while dysphagia may be greater, stertor is less.

The symptoms of sunstroke are symmetrical; the pupils and the reflexes are equal; hemiplegia is not an ordinary sequel. The temperature rises much higher in insolation than at any time in hemorrhage. The pulse is frequent, often feeble; that of cerebral hemorrhage is commonly slow and full.

It must, however, not be forgotten that cerebral hemorrhage may occur amid circumstances favorable for the development of sunstroke.

With what other conditions might sunstroke be confounded?

Sunstroke might be mistaken for acute alcoholism, meningitis, uremia or narcotic poisoning. Alcoholic excess may bring on an attack, so that the phenomena of both might be intermingled. The history and the symptoms detailed should prevent error in other cases.

In uremia, too, convulsions usually precede coma.

Delirium Tremens.

What are the symptoms of delirium tremens?

The continued ingestion of excessive quantities of alcohol sometimes gives rise to a condition in which with impaired appetite and gastric irritability are associated inability to sleep, tremor and delirium. The temperature is likely to be elevated. The urine may contain albumin. The patient is restless and evinces a tendency to talkativeness; he is always busily engaged with his delusions. Sometimes the delirium is

more violent. The victim is terror-stricken by hideous illusions and hallucinations. The figures of the wall-paper, and articles of furniture are converted into crawling reptiles; attendants, into demons. The patient is unable to sleep. Hypnotics may prove futile. There is little desire for food. That which is taken may be rejected. If recovery is to take place, sleep is gradually restored; else the patient is worn out and succumbs to exhaustion. Pneumonia, especially of the apices, is not an uncommon complication of alcoholism. The use of tobacco during convalescence is sufficient to renew the attack.

How is delirium tremens to be distinguished from acute mania?

The delirium of alcoholic intoxication may be maniacal, but it is associated with a history of alcoholism, while acute mania usually develops in a person with a psychopathic family history, and has probably been preceded by a prodromal period characterized by a change in manner, in disposition or in behavior. The character of the illusions and hallucinations differs in the two disorders. Delirium tremens usually subsides after sound sleep for a number of hours consecutively, and recovery is complete. Evidences of insanity persist after the attack of acute mania is at an end.

How are delirium tremens and cerebral meningitis to be differentiated?

The distinction between delirium tremens and cerebral meningitis depends upon a knowledge of the cause, the history, the course, the symptoms and the termination of the two affections respectively. Delirium tremens is preceded by a history of alcoholism; meningitis, by a history of traumatism or infection. Delirium tremens lasts from a few days to a week; meningitis for a much longer time. In meningitis there are, and in delirium tremens there are not, muscular spasm, convulsions and sensory disturbance, followed by paralysis. The delirium and tremor of alcoholism are peculiar and characteristic. The temperature may be slightly elevated above the normal in delirium tremens, but meningitis is distinctly a febrile disease.

Plumbism,

What are the clinical manifestations of lead-poisoning?

Lead may gain entrance into the system and give rise to toxic manifestations under diverse circumstances. Thus saturnine intoxication occurs in those who work with the metal, as miners, color-grinders, painters, plumbers, type-founders, compositors. Lead may also be introduced into the system by means of drinking-water conveyed through lead-pipes, or with food prepared in leaden vessels, or by the use of hair-dyes, of cosmetics, or of snuff packed in lead-paper, or by the medicinal administration of lead in some form. The most common manifestation of plumbism is multiple neuritis.

FIG. 51.

ness.

Wrist-drop from lead poisoning. (Gowers.)

The symptoms vary in kind, degree, distribution and acuteThe more common and the more characteristic are obstinate constipation, abdominal colic, wrist-drop, and a blue line on the gums. In addition, the nutrition is impaired and there

is anemia. Among other symptoms are cramps in the legs, tremor, headache, convulsions, delirium and coma. The paralysis of the extensors of the wrist and fingers upon which the wrist-drop depends is bilateral, but does not involve the supinator longus. Sometimes, the intrinsic muscles of the hand atrophy; at times, too, the lower extremities are paralyzed. The knee-jerks may be enfeebled or lost; station may be unsteady; coordination may be deranged. Occasionally, symptoms of sensory derangement, laryngeal palsy, mental failure, melancholia, inequality of the pupils and impairment of vision are observed. The pupils may be small and fail to react to light. The optic nerve may undergo atrophy. Paralyzed muscles display the reaction of degeneration. Cardio-vascular-renal changes are of strikingly common occurrence. Arthritic manifestations and deposits indistinguishable from those of gout are not rare. If potassium iodide be administered, the urine may respond to chemic tests for lead.

How may lead-poisoning be confounded with cerebral tumor, and how is the differentiation to be made?

When the system has been impregnated with lead, there may be optic neuritis, headache, convulsions, delirium and palsy; but there are also a blue line on the gums; a history of exposure to the toxic metal; of intestinal colic; of obstinate constipation; and the palsy gives rise to wrist-drop.

What is torticollis ?

Torticollis.

Torticollis or wry-neck is a condition in which, from shortening or from spasm of one or more muscles of the neck, the head is maintained in an abnormal position.

What are the varieties of torticollis ?

There are two types of wry-neck. In one, as a result of traumatism, or of defective development, the muscle, usually the sterno-mastoid upon one side, is atrophied and shortened. The head is rotated to the side opposite to that of the affected