treated. It is needless to urge that an epileptic child should be individualized, as there is no one method of treatment that is advisable for all epileptic children.

SUNSTROKE-INSOLATION

Sunstroke is a very serious condition which may develop very rapidly, the patient becoming suddenly unconscious, and he may die within a few hours, or even within a few minutes. He may die comatose, or he may improve somewhat and die of heart weakness. If not comatose, he will complain of headache, have disturbed vision, be nauseated, dizzy, have a rapid pulse, and the temperature may be excessive.

A patient found comatose who has been exposed to intense sun rays or intense heat may not be suffering from insolation, and all other causes for the comatose condition must be excluded. On the other hand, convulsions followed by coma may be due to excessive heat. The various causes of coma and their diagnosis have been elsewhere discussed.

Disease, indulgence in alcohol, and previous attacks of insolation are predisposing causes. Exhaustion and weariness may precipitate a heat stroke, but are more likely to develop heat prostration. The excessive temperature of sunstroke may cause albumin and casts to appear in the urine.

Just what is the exact pathologic condition in insolation is doubtful except that excessive heat can cause changes in the body metabolism, and perhaps cause autointoxication. It has been suggested that heat stroke may be a form of uremia, and creatinin has been found in excessive amount in the blood.1 Post-mortem examinations have shown congestion of various organs, and edema of the lungs, brain and meninges.

Preventive treatment is a proper head protection (and that means the air-cooled, large hat), abstention from alcohol in any form, drinking of large amounts of cool, not iced, water, and a diet largely of carbohydrates, certainly without an excessive amount of meat. Patients who are diabetics and those who have damaged kidneys should be warned against over-heating and exposure to the sun.

1 Gradwohl and Schisler, Amer. Journ. Med. Sci., Sept., 1917, p. 407.

Treatment. The patient should be immediately taken to the coolest possible spot, all tight clothing should be removed, an ice cap applied to the head, the temperature taken, the pulse noted, and then active cooling treatments inaugurated. If possible, the patient should be rapidly transported in an ambulance to the nearest hospital where opportunities for the best treatment are obtainable. Ice tubbing seems too cruel, and is perhaps obsolete. Milder cold applications are advisable. An ice cap should remain on the head and a warm water bag at the feet, the breeze from an electric fan should be directed over the body, and cold water or ice sponging should be done, or sheets wet with ice water may be wrapped around the body and frequently changed. A thermometer should be placed in the rectum and frequently read. If the temperature seems to be rapidly falling, active treatment should cease. After a certain amount of temperature has been thus abstracted, rather than continue this harsher treatment, which may be opposed to nature's method of reducing temperature, it might be well to place hot water bags about the lower part of the body, cover this part of the body with blankets, and allow perspiration to occur. The dilatation of the blood-vessels of the abdomen and legs may relieve the tension on the head by promoting perspiration, nature's method of reducing temperature. If the heart is not weak, it might be well to administer a small dose of pilocarpine. As post-mortem examinations have disclosed edema of the brain and of the meningeal tissues, it might be well to do spinal puncture and withdraw a small amount of cerebral fluid. If the patient is full-blooded, flushed, and has a bounding pulse, venesection would seem indicated. Certain it is that the older methods of treatment have not been very successful, and more rational treatment must be substituted.

If the patient seems to rally but the heart begins to fail, caffeine, strychnine, and atropine injections suggest themselves; or intramuscular injections of ergot or of pituitary extract may be advisable.

If the patient recovers consciousness and the circulation is good, the after treatment is alkaline drinks, starchy foods, and prolonged rest, with the administration of plenty of water to

promote elimination of all toxic products that have accumulated in the body. Purging may be at first inadvisable on account of the weakness that it causes, but the bowels may be moved daily by an enema.

HEAT PROSTRATION-HEAT STROKE

This condition presents an entirely different set of symptoms from those of sunstroke. It is a collapse that may be fatal, and there is likely to be, on recovery, prolonged disability, the patient very slowly regaining his circulatory strength. In this condition the patient should be moved to the nearest cool spot, but should not be transported to a distant hospital; all tight clothing should be loosened. As the temperature is subnormal, hot water bags should be placed around the body, and at the feet, and gentle massage should be given. If there is no breeze, an electric fan may be placed over the patient, or some one may fan him.

The treatment is cardiac stimulation with atropine and strychnine injections, and coffee by the mouth. An epinephrine solution may be given on the tongue, or a pituitary solution may be injected hypodermatically. As soon as the patient rallies, he may be carefully transported in an ambulance, or on a stretcher, to his home, and best to a cool veranda, and he should not exert himself for days. He has suffered a circulatory collapse, and the return of his circulatory strength will be slow.

FREEZING

Frostbite is an acute condition caused by cold, while the resulting recurrent condition may be a chilblain. While any part is more or less likely to become frostbitten if the circulation is poor, still, most frostbites occur from severe chilling of exposed parts of the body. There are different degrees of frostbite, and the severity of the condition depends upon the amount of stagnation of the circulation that has occurred. Actual freezing will so interfere with the nutrition of the part that blisters will occur, and if the severity of the freezing is still greater, the tissue is destroyed and gangrene results.

The first symptom is loss of sensation, which may not be

at first noted. The appearance of the part is pale, and later, perhaps, a little bluish.

The immediate treatment of a simple frostbite should be gentle rubbing with the hands and gentle massage of the part above the frostbite, to gradually increase the circulation of the blood. It is inadvisable to apply heat to the frozen area. As soon as the circulation improves there is burning and sometimes itching, and the part feels very uncomfortable, even at times painful. If the skin has been injured and blisters occur, they should be carefully dressed and protected, much as are burns. If there is much moisture, saturated solution of boric acid applied as a wet dressing is a most efficient treatment.

If an extremity, or a part of it has been frozen, it should be kept cold or cool for some time; i.e., the rest of the patient should be kept warm, but the affected area should not be subjected to a warm atmosphere, and gentle friction with a towel wrung out of cold water is advisable. The limb should then be elevated, to encourage the return circulation. Later the room may be at the ordinary temperature, and the frozen part may be covered with gauze. Blistered skin should be treated as above suggested.

If the circulation of the frozen area does not return and gangrene develops, then the extremity should not be elevated, as absorption from the disintegrating tissue should not be encouraged. Unless there are symptoms of absorption of toxins it is well to wait before amputating until the line of demarcation between healthy and gangrenous tissue has thoroughly formed. During this gangrenous period no treatment should be used that encourages moisture; the drier the gangrene, the less danger of infection. If the gangrene becomes moistened, powders, as boric acid, should be applied to encourage dryness. The proper time to amputate must be decided by medical and surgical consultation.

SEASICKNESS

There is no one cause for seasickness. Doubtless there are several factors producing this condition, the most important of which is probably a disturbance of the lymph in the semicircular

canals of the internal ear, and an inability to establish equilibrium when the individual first leaves the steady earth for the unsteady water. Another important factor is doubtless the blood-pressure. The blood-pressure may first be increased, by the effort of the vasopressor glands to sustain the tension and prevent the disturbance. Soon, however, the blood-pressure falls, and as soon as nausea is present there is considerable lowering of the pressure and more or less weakening of the heart. Another factor in the production of seasickness is doubtless the effect on the eyes of the moving water, and moving objects cause in some people very decided reflex disturbances. Predisposing causes to seasickness are digestive disturbances due to a bad condition of the alimentary canal, or to over-eating, and to remaining in a bad atmosphere in a cabin.

Preventive treatment is to take a purgative twenty-four hours before going aboard the steamer, and during this twentyfour hours to eat very moderately of the simplest kind of food, and let the first two meals on board be very simple. If the blood-pressure is low, it is well, for two or three days before going on board to take digitalis, and perhaps a few doses of strychnine. The individual should remain on deck as much as possible, and keep his eyes (properly protected from too bright sunlight) on objects that are not moving. In other words, he should not face the water.

If nausea and a feeling of faintness develop, black coffee atropine and strychnine should be given and the patient should lie flat in the open air. If the patient is too ill to remain on deck, if possible the port hole should be open in his stateroom, so that he may receive plenty of fresh air. A tight abdominal bandage should be applied to aid in raising the blood-pressure. If needed, atropine should be given hypodermatically, ergot intramuscularly, and epinephrine solutions on the tongue. As soon as possible, warm, thin, starchy foods should be taken.

Although bromides have been lauded and suggested as a treatment for seasickness, such medication does not seem advisable, unless the individual has a high blood-pressure. In that case bromides and hot foot-baths might relieve the cerebral disturbance.