H. C. (Horatio C.) Wood.

Thermic fever; or, Sunstroke online

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reaction ; not coagulating. Blood-corpuscles under the
microscope normal, but very dark-colored.

Case II. — Irishman, set. 64, a moderately stout, muscular
man, was brought into the ward about 7 p.m. August 10.
His skin was very hot, belly tympanitic, pulse 177, not
intermittent, but very weak. He had had involuntary dis-
charges from the bowels. The face was very much con-



CLINICAL HISTORY. 23

torted by spasms, repeated pretty regularly 130 times a
minute. He was treated with turpentine injections, brandy,
aromatic spirits of ammonia, etc. He died quietly at i li p.m.
Autopsy, one hour after death. — Venous trunks of the me-
ninges of the brain loaded with blood. Brain substance nor-
mal, not congested. No bloody or serous effusion. Heart
rigidly contracted. Kidneys normal. Blood very dark and
fluid ; of a slightly acid reaction.

Case III.- — German. A discharged soldier ; very intem-
perate ; a large, fat man, weighing about 200 pounds. He
was brought into the wards at i p.m. August 10. Those who
brought him in stated that he had fallen suddenly whilst
loading a dray, about an hour and a half previously. His
skin was of a dark-reddish color, the capillaries refilling
very slowly when they were emptied by- pressure with
the finger, it requiring several seconds for them to do so.
His pulse was 170 and upwards, very irregular and intermit-
tent, but not excessively weak or thready. He was perfectly
unconscious, but lay absolutely still, without even subsultus
tendinum. His pupils were contracted. The conjunctiva not
sensitive, and very much congested. His skin exemplified
calor mordax. A thermometer placed in the axilla indi-
cated 109° F. His breathing was slow, very labored, and
irregular. He had involuntary discharge of feces. He
gradually grew worse, and before death bloody, dirty foam
trickled from the nose and mouth. Death occurred at 2 J p.m.

Treatment. — Frictions with ice; brandy and ammonia, as
much as could be forced down him. Turpentine injections.

Autopsy, one hour after death. — Cadaver intensely hot,
very fat, no rigor mortis. Meningeal venous trunks en-
gorged. Brain substance normal. Left heart slightly con-
centrically hypertrophied, very firmly contracted. Kid-
neys normal. Blood very dark-colored, fluid, coagulating
slightly, forming not more than a grumous mass.



24



THERMIC FEVER, OR SUNSTROKE.



Case IV. — C. H., Englishman, over 60 years of age, was
brought to the hospital at \\ p.m. August 11. H,e was said
to have fallen in the street one or two hours previously. He
was very restless, almost convulsive ; breathing labored
and noisy; pulse 170, and slightly intermittent; skin burn-
ing hot ; temperature in axilla 109° F. His pupils were con-
tracted, the conjunctiva dry, non-sensitive, and injected.
There was some, but not strongly pronounced, stasis in the
capillaries of the skin.

7reaimen/.-^—Bra.nAy, 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 loth he had been so
exhausted by the heat, so sick at the stomach, and had
suffered so much from headache, as to be forced to give up
work until the morning of the 14th. When he entered the
ward the skin was very moist, but intensely hot, and cov-
ered with a rubeoloid eruption. A thermometer placed be-
tween the thighs indicated 104° F. The pupils were slightly
contracted, the conjunctiva injected and very sensitive.
There had been no discharges. The pulse was 140, and
rather feeble. He was entirely unconscious, but was con-
tinually muttering uaintelligibly, and was very restless. He
vomited freely.



CLINICAL HISTORY. 35

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
11.30 P.M.

Autopsy, one hour after death. — No rigor mortis. Tem-
perature in abdomen 108° F. Brain, with its large venous

3



26 THERMIC FEVER, OR SUNSTROKE.

trunks, engorged, and ventricles containing an abnormal
amount of serum. Left heart rigidly contracted. Liver
very fatty. Blood very dark and fluid, with a decided acid
reaction.

Case VII. — C. B., German, a large, muscular man, was
brought into the hospital at 12.30 p.m., August 15. The
skin was very hot and dry, axillary temperature 109° F. ;
pupils almost normal, conjunctiva injected, mouth moist,
deglutition almost impossible. He had a severe convulsion
immediately after his entrance, and died in a very few min-
utes. There was a large ecchymosis in one axilla. He was
said to have fallen whilst working in a sugar refinery, and
to have been brought at once to the hospital.

Autopsy, two hours after death. — Meningeal veins gorged
with blood. Some serous exudation in ventricles. Left
heart rigidly contracted. Temperature in abdomen i io|° F.
Blood decidedly acid, very fluid, without a sign of coagu-
lation. Under the microscope the red corpuscles were ap-
parently darker than normal.

Case VIII. — An Irishman, only a few days in the country.
He was said to have fallen during the latter part of the after-
noon, whilst wheeling coal. When brought in at 9 p.m. he
was semi-unconscious, but could scarcely speak intelligibly ;
his pulse was 90 per minute, moderately strong ; surface dry,
but not inordinately hot ; he had no pain, but complained of
great weakness ; he had not had involuntary discharges.

Treatment. — Ten grs. of muriate of ammonia and f § ss of
brandy were given every half-hour, and an injection of an
ounce of turpentine was administered. At 10.30 p.m. his pulse
had fallen to 80, and his general condition much improved.
His medicine was directed to be given every hour only.

August 12, he was entirely conscious, but very drowsy,
and slept a great deal.



CLINICAL HISTORY. 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-spinal and mixed
cases is certainly not so evident as the separateness
of the cardiac variety. If the pathology hereafter
developed be, as it seems, true, there can be no
mixture between the cerebro-spinal and the car-
diac. Leaving out of view the cardiac, it is true
that cases of insolation may be divided into those
in which death takes place purely through paraly-
sis of respiration, and those in which the heart also
suffers a gradual weakening; but as these cases
are not practically — i.e. therapeutically — distinct, I
cannot see any advantage to be gained by such a
separation, especially as cases in which the heart
does not suffer more or less are so very rare, that
I have not only never seen a case, but do not know
of an unequivocal account of more than one or two.
The nearest approach to such that I can call to
mind is the following by Dr. Crawford (Madras
Journ., No. 2) :

Case IX. — A. B., aged 24, a soldier, was heard at mid-
night moving, and his comrades, thinking the noise strange,
cried out, and, not receiving a reply, got up, and found him
muttering incoherently about a drink. He became quiet,
then comatose, and when I [Dr. Crawford] saw him about



CLINICAL HISTORY. 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, set. 26 ; not intemperate ; was attacked
with fever, while on guard, on the 26th of May, and came
into the hospital the evening of the same day. On the
morning of the 27th he was quite free from fever, but
rather weak, and was detained in consequence. He lay on
his cot during the forenoon without making any complaint.
About noon was observed to be in a state of insensibility,
and breathing heavily. He was removed at once to the
coolest veranda in the hospital, the cold douche applied
over his head, chest, and back, and eight leeches applied to
his temple by the apothecary then on duty.

At 1.2 P.M. I saw him. He was then completely insensible,
his face paler than usual, his eyes fixed and slightly turned
upwards, the pupils somewhat contracted, but much less so
than was usual in the cases in the field. His skin felt burn-
ing to the touch. His pulse was frequent and rather full.
The pulsation in the carotid was very strong, and could be
seen at a distance. He had no convulsions, nor could the
slightest movements of his limbs or eyelids be observed
for hours. On stethoscopic examination, loud subcrepitant
rales were heard all over the chest. The first spund of the
3*



30 THERMIC FEVER, OR SUNSTROKE.

heart was natural, the second indistinct. The leeches, which
had drawn very little blood, were removed, and there was
scarcely any bleeding from the bites. The cold douche was
applied assiduously for some time, but without any good
result, and had to be discontinued on account of failure of
the pulse. An attempt was made to give a stimulant, but
nothing could be swallowed. A purgative enema was given
at once, and a considerable quantity of thin feculence was
brought away with it. Enemata of brandy-and-water, with
from fifteen to twenty minims of chloroform," were given re-
peatedly, but they were never retained for more than a few
minutes, and no effect seemed to be produced by them. A
blister was applied to the nape of the neck, sinapisms to the
chest and feet, and ammonia to the nostrils. His head and
the whole surface of the body were kept wet, and his face
assiduously fanned. During the afternoon he became gradu-
ally worse. His pulse became imperceptible, his conjunc-
tiva pinky, his hands and feet livid. His head continued
for a couple of hours firmly bent backwards, and his hands,
forearms, and toes flexed. By evening the blister had risen
vfell, 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 bUster 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. jj

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. 2o8),
" 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 oi febris 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 ioo° for hours, it is evident that
putrefactive changes, often already entered upon
before demise, must go on very rapidly, and that
probably even three or four hours would afford
sufficient time for the relaxation of commencing
decomposition to follow the heat rigidity. More-
over, direct evidence of the truth of this is not
wanting. It has been experimentally demonstrated
(see Boston Journal of Med., vol. x. p. 350) that in
animals rigidity of the heart is found directly after
death from excessive heat, but that in a very few
hours it disappears.



36 THERMIC FEVER, OR SUNSTROKE.

There can be no doubt that the blood suffers
in sunstroke very similarly to what it does in low
fevers. Its coagulability is always, so far as my
experience goes, impaired, but not always de-
stroyed ; and it is probable that in the very rapid
cases it may not be decidedly affected. Generally,
the blood appears after death as a dark, often thin,
sometimes grumous fluid, whose reaction is very
feebly alkaline, and in some of the cases herein
reported was even decidedly acid. Dr. Levick (loc.
cit, p. 373) appears to assert that the blood disks,
as seen by the microscope, were shriveled and
crenated, and shoyved 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,
arc in close agreement ; and I myself have attained
similar experimental results, although I have gone

4 (37)



38 THERMIC FEVER, OR SUNSTROKE.

further and have read the phenomena somewhat
differently.

The symptoms produced by exposing an animal
to excessive heat do not appear to differ savfe 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,


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