tending to become more and more continuous and profound until merged
in fatal coma, is encountered among the negro inhabitants of the
Atlantic coast of tropical Africa. Similar cases have been
occasionally reported in other regions of the world, but it is among
the Africans that they have been principally observed. For our
knowledge of this disease we are chiefly indebted to the writings of
Clark,[29] an English surgeon residing at Sierra Leone, and of
Guérin,[30] a surgeon in the French navy, who enjoyed unusual
opportunities for its study among the laborers recently brought from
Africa to the island of Martinique. According to these observers, the
onset of the malady is gradual, commencing with a slight frontal
headache. Very soon a disposition to sleep after meals is remarked.
This becomes increasingly urgent, and the paroxysms of sleep are
prolonged, until at length the patient becomes continually soperose.
The wakeful intervals are marked by a sluggish state of the
intellectual faculties. The pulse is not accelerated, but remains full
and soft. The veins of the sclerotic become turgid and the eyeball
seems unusually prominent. The temperature does not increase, but
rather tends to diminish its figure. The skin becomes dry and
moderately cool. The tongue continues moist, and is covered with a
white fur. The contents of the bowels and of the bladder are regularly
voided, and the appetite persists with considerable vigor. Finally,
the patient becomes completely comatose and dies quietly. Sometimes,
however, the evolution of the disease is less tranquil. Epileptiform
convulsions, followed by {384} progressively deepening paroxysms of
coma, interrupt its course, until a continuous muscular tremor marks
the closing period. At the same time the pulse grows weaker and more
frequent, until its movements cease in death. Recovery is almost
unknown, though the duration of the disease often varies from three
months to a year or longer. Examination of the body after death has
thus far yielded very negative results: the sinuses and larger vessels
of the brain are engorged with blood, but no evidence of inflammation
is anywhere apparent. The other organs present no pathological
alterations whatever. These observations seem to indicate that the
disease originates in some form of general blood-poisoning rather than
in any local inflammation or degeneration, and Clark has called
attention to an enlargement of the cervical glands as a feature of the
malady. According to G. H. Bachelder,[31] the native physicians cure
the disease by extirpation of the affected glands. He has also
observed an initial lesion in the nasal mucous membrane. If this be
confirmed, the malady will take its place among the forms of coma
produced by septic poisoning.
[Footnote 29: _Transactions of the London Epidemiological Society_,
vol. i. p. 116.]
[Footnote 30: _De la Maladies du Sommeil_, 1869.]
[Footnote 31: _The Medical Record_, July 1, 1882, p. 23.]
Lethargy.
A pathological variety of sleep, in which the repose of the body is
even more complete than in coma. The victim of coma often presents a
countenance suffused with blood; the pulse beats vigorously, and
respiration may become stertorous. But in lethargy the abolition of
bodily movements is almost total. In the milder forms of this disorder
the patient may be partially roused, so as to attempt an answer when
addressed, appearing like a person in very profound sleep; but in the
majority of cases he remains insensible, unconscious, and utterly
irresponsive to ordinary forms of irritation. Respiration and
circulation are reduced to a minimum, even becoming for a time
imperceptible. Uncomplicated with hysteria, the disorder is rapidly
fatal, but according to Rosenthal[32] hysterical lethargy is never
mortal.
[Footnote 32: _Real Encyc. der ges. Heilkunde_, vol. viii. p. 276.]
Many examples of this disorder have been furnished by the records of
apparent death.[33] I am well acquainted with a lady who in early
childhood was laid out for burial at the supposed termination of some
infantile disease. Her mother alone insisted that the child was still
alive. After some time spent in weeping and expostulation, she applied
a blister to the thorax of the babe, who at length began to exhibit
signs of consequent irritation, followed by a complete recovery. Still
more instructive is the case related by Rosenthal[34] of a young woman
twenty-four years of age who in consequence of violent emotional
excitement became unconscious and presented no sign of life, though
tested with a mirror before the mouth and by dropping melted
sealing-wax upon the skin. On raising her eyelids the pupils gave no
response to light; the limbs remained perfectly placid and the radial
arteries were motionless. Careful auscultation, however, detected a
very feeble and intermittent sound in the cardiac region. The thorax
exhibited no movement, but the lateral surfaces of {385} the abdomen
presented a slow and almost imperceptible oscillation. Gentle
faradization of the muscles and nerves of the face and hand aroused
definite muscular contractions. By these observations Rosenthal became
satisfied that, although the patient had remained for thirty-two hours
in this condition, she was only apparently dead. In fact, after
continuing forty-four hours in a state of suspended animation she
awoke spontaneously, made a rapid recovery, and enjoyed as tolerable
health as an excitable nervous temperament would permit.
[Footnote 33: See article “Mort apparente,” _Dic. Encyc. Sci. méd._,
2d Series, vol. ix. p. 598.]
[Footnote 34: _Loc. cit._, p. 272.]
Apparent Death.
Certain authors make a distinction between lethargy and apparent
death. But, leaving out of view the cases of so-called lucid lethargy,
a variety of the trance state, the difference is rather one of degree
than of kind. The movements of respiration and of circulation, though
greatly diminished, are readily observed in ordinary forms of
lethargy, while in apparent death the pulse can no longer be
discovered, and only the faintest sound can be distinguished in the
region of the heart. It therefore becomes imperative to have within
reach a crucial test of the persistence of general vitality. Such a
test, according to Rosenthal, exists in the faradic current. Within
two or three hours after genuine death the muscles cease to be
excitable by the induced current, but in a case of apparent death this
form of electro-muscular contractility never disappears. Every other
test that has been proposed has failed under certain circumstances.
This alone gives uniformly positive indications.
Lucid Lethargy.
In certain cases of apparent death the patient presents the external
phenomena of suspended animation, but the power of conscious
perception does not cease. The senses of sight and hearing remain, and
are perhaps intensified by inhibition of the power of projecting
cerebral volitions into space. The sufferer hears and sees;
perception, memory, reasoning, judgment, emotion, volition, all
persist. The possibility of centrifugal projection from the sphere of
consciousness into the realm of space seems to be the only thing that
is wanting.
The victims of this form of apparent death are usually women, or men
who are characterized by a feminine nervous organization. Great mental
excitement, fatigue, semi-starvation, and exhausting diseases are the
principal proximate causes of the event. The following case, which was
observed by my friend P. S. Hayes of Chicago, illustrates all these
facts: A female physician, about thirty years of age and consumptively
inclined, after a long and wearisome hospital service was attacked
with typhoid fever. After a period of great prostration the hour of
death seemed to have arrived. In the presence of her physician and
surrounded by her relatives she ceased to breathe and the pulse
stopped. Bottles of hot water were applied to the limbs, and other
methods of restoration were employed, but a number of hours elapsed
before these efforts yielded any result. At last she began to breathe
once more; life was resumed and {386} a gradual recovery followed.
During all this time of apparent death consciousness had been
preserved. She seemed to be looking down from above her bed, by the
side of which she could see the physician holding her wrist, and she
felt grief at witnessing the sorrow of her friends. Ordinary sensation
was suspended, for she did not feel the scalding heat of the bottles
that were applied to her limbs. Borne upon the wings of a liberated
imagination, she thought she beheld the celestial city, but might not
enter within its gates. In this exaltation the reasoning faculties
also shared, so that certain philosophical problems which had long
baffled her intellect were now perfectly comprehensible, and the
memory of their interpretation persisted after recovery.
Many similar narratives have been duly authenticated, but the limits
of the present article will not permit a discussion which properly
belongs to an investigation of the phenomena of trance. The important
fact for present consideration is the persistence of conscious life
despite the appearance of death. In this preservation of
consciousness, notwithstanding temporary suspension of certain forms
of sensibility, together with loss of the power of voluntary motion,
may be discovered a relationship between the events of lucid lethargy
and various somnambulic modifications of sleep which have been
previously passed in review.
{387}
ACUTE AFFECTIONS PRODUCED BY EXPOSURE TO HEAT.
BY H. C. WOOD, M.D., LL.D.
There are two distinct diseases—or, more correctly, conditions—of the
human body which are produced by exposure to heat, and which have a
certain similarity in their symptoms, but are very different in their
immediate pathology and require directly opposite methods of
treatment. Although their individuality was pointed out as long ago as
1851 by the late D. F. Condie of this city,[1] yet they have been
frequently confounded by writers upon the subject, and the terms
heat-exhaustion and sunstroke have not rarely been used as strictly
synonymous. In the present article it is proposed to consider them as
separate affections under the respective names of heat-exhaustion and
thermic fever.
[Footnote 1: _Amer. Journ. Med. Sci._, Jan., 1852.]
Heat-Exhaustion.
Any one who has been long exposed to a high temperature under
circumstances requiring physical exertion must have noticed the
feeling of general weakness and relaxation which results. Thus far
reaches our every-day experience, but cases in which acute symptoms
are severe enough to cause alarm occur, although somewhat
infrequently. The attack may come on slowly, but may be as abrupt as
that of true sunstroke, and the severest cases may happen in those who
have been in robust health as well as in the weak and feeble. The mind
is usually clear, the pulse rapid and feeble, the surface cool, the
voice very weak, muscular strength greatly lessened, and the feeling
of exhaustion extreme. If this condition be intensified, syncope may
be developed with its usual symptoms. In all this there is nothing
peculiar and little that is necessary to notice here; but there is a
form of heat-exhaustion in which the heart does not seem to suffer
principally, but in which there is collapse with palsy of the
vaso-motor system, great fall of the bodily temperature, and marked
general nervous symptoms. At the International Exhibition of 1876 a
very powerful man, whilst working in an intensely hot, confined space,
fell down without giving warning, and was brought into the hospital.
He was in a state of restless, delirious unconsciousness, incessantly
muttering to himself, and when shaken and shouted at responding only
by a momentary grunt. The pulse was rapid, fluttering and feeble. The
{388} surface was covered with a very heavy sweat and exceedingly
cold. The muscular relaxation was extreme. The facies was that of
collapse, and the temperature, as taken in the mouth, 95.25° F.
The PATHOLOGY of heat-exhaustion is best discussed in conjunction with
that of thermic fever, and will therefore be for the present
postponed.
The TREATMENT of heat-exhaustion is a very obvious one. The
indications are to stimulate the circulation and warm the body by
external heat with an energy proportionate to the severity of the
attack. In mild cases the exhibition of a whiskey punch or similar
beverage may suffice, but in severer attacks alcohol acts too slowly
and is not capable of filling all the indications. It may re-excite
the flagging heart, but it is probably not a vaso-motor stimulant, and
if given too freely may even increase the vaso-motor depression.
Digitalis is an excellent stimulant of the heart, and probably also of
the vessels. It acts, however, comparatively slowly even when
hypodermically injected, but in severe cases it should always be
employed. The tincture is the most eligible preparation, and when
injected under the skin in doses of fifteen drops causes no local
irritation. Ammonia would be a very valuable remedy did not its use
offer so many difficulties of administration: injected into the
cellular tissue, it causes great pain and usually sloughing, and its
intravenous use is by no means always easy. As a vaso-motor stimulant
atropia is an excellent remedy, and, as it has also a very powerful
influence in arresting the secretion from the skin and in raising the
animal temperature, it should produce very good results in the
peculiar form of collapse under consideration.
When the bodily temperature is below normal the most important measure
of treatment is the use of the hot bath: the water should be from 100°
to 120° F.—_i.e._ as hot as can be borne—and the whole body should be
immersed in it until the mouth temperature becomes normal.
Thermic Fever.
SYNONYMS.—Coup de soleil, Sunstroke, Heat apoplexy, Heat asphyxia,
Heat fever, Sun fever, Thermohæmia, Erethismus tropicus, Insolation.
The immediate cause of thermic fever is always exposure to excessive
heat in some form. As the body can cool itself much more readily in a
dry than in a moist atmosphere, it is able to resist the influence of
a dry, overheated air much better than when there is also moisture. It
is for this reason that sunstroke is so much more infrequent upon the
high table-lands of Abyssinia or in the dry belt of our Texan prairies
than in the lowlands of India or upon our own seacoast. For the same
reason it is especially prone to attack indoor workers in confined,
moist factories, and especially in laundries and sugar-refineries. At
one time it was thought that exposure to the direct rays of the sun
was the chief cause of the disease, but there is now abundant clinical
testimony to the fact that such exposure is in no sense necessary.
Without occupying space in giving detailed references, it suffices, as
an illustration of the fact that the most complete darkness is no
protection, to allude to the epidemic upon the French man-of-war
Duquesne, as recorded by M. Boudin, in which a {389} hundred cases of
sunstroke occurred in a short time, most of them at night when the men
were lying in their bunks. Bonniman[2] 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 unusual for men to go to bed in
apparent health, and to be seized during the night; and patients in
hospitals who have been confined to bed for days previously are
frequently the subjects of attack.”
[Footnote 2: _Edinburgh Med. Journ._, vol. xiv. p. 1029, 1864.]
Although the immediate cause of the attack is excessive heat, there
are certain conditions which act as predisposing causes by lessening
the power of the system to resist the heat, or, in accordance with the
theory of sunstroke which I believe established, by so weakening the
inhibitory heat-centre that it is readily exhausted. The chief of
these predisposing causes are race, excessive bodily fatigue, and
intemperance. It is true that males are much more frequently affected
than females; thus, in an epidemic occurring in St. Louis, Missouri,
in 1878, there were 115 deaths in males and 39 in females. This is
due, however, not to one sex being predisposed to the attacks, but to
the habitually greater exposure of males than of females to heat. The
much greater frequency of sunstroke in the laboring than in the upper
classes has similar explanation.
Those races which are least accustomed to a tropical climate are most
apt to be attacked; thus, both in this country and in India, Europeans
suffer far more than do the natives. No race is, however, absolutely
exempt. Even the negro and the Hindoo inhabitant of tropical India are
occasionally prostrated.
The general experience in the United States shows that habitual excess
of alcohol very strongly predisposes to attack, but some of those who
have had widest experience in India are inclined to deny this. It has
been especially noted in India that persistent bodily fatigue greatly
weakens the resisting power of the European. As an instance of this
may be cited the case of the Forty-third regiment of the line during
the Sepoy rebellion, as recorded by its surgeon, Barclay. It had 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 the regiment rested some
eight days, and then started again, arriving soon in a narrow ravine
in the Bisramgunge Ghat, with precipitous walls nearly a mile in
height. During the day the thermometer in the tents ranged from 115°
to 127°, and on one occasion was noted 105° at midnight. The number of
cases of insolation now became very great, and, although most of them
recovered, 2 officers and 11 men were lost in the four days during
which the regiment remained encamped. The air became cooler as the
command emerged from the hills, yet 7 more fatal cases occurred in
three days.
SYMPTOMS.—Under the name of ardent continued fever, or febris
continuis communis, has been described in India an affection which may
be considered as representing a mild form of thermic fever. In C.
Morehead's clinical work _On the Diseases of India_ the following
account of the symptoms is given: “The attack is generally sudden,
often without {390} much chilliness. The face becomes flushed; there
are 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
continues unabated, the headache increases, and is often accompanied
with delirium. If symptoms 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.”
Until very recently the existence within the United States of this
class of cases has not been recognized. But in a very able article in
the _Therapeutic Gazette_ of March 16, 1885, John Guiteras shows that
the so-called typhoid fever of Key West is the disease described by
Morehead.
In the _Philadelphia Medical Times_, vol. v. p. 664, C. Comegys calls
attention to the cases of entero-colitis which are so abundant in the
young children of our cities during the hot months. The immediate
enormous rise of the mortality-rate among children which always
accompanies a marked rise of temperature during July or August
indicates very strongly that excessive heat is the chief factor in the
production of the disorder. The symptoms may be summed up as high
fever, dry tongue and mouth, rapid pulse and respiration, intense
thirst, vomiting, purging of greenish, watery, fecal or serous matters
with undigested particles of food, and more or less pronounced
evidences of cerebral disturbance, such as insomnia, headache,
contracted pupils, delirium, and finally coma. In some cases the
bodily temperature rises before death to a point comparable with that
it reaches in sunstroke of the adult. As pointed out first by Comegys,
these cases are almost uniformly relieved by cold water used either,
as Comegys himself employs it, in the form of cold affusions practised
until the temperature of the child becomes normal, or, as, according
to my own experience, is preferable, simple cold baths administered
every two to three hours, with just sufficient vigor to produce the
desired effect.
Thermic fever in the adult and in this latitude is usually first seen
by the physician after the stage of insensibility has been reached. In
many cases this condition comes on with great suddenness, but in other
instances there are distinct prodromata, such as inaptitude and
disinclination to exertion, vertigo, headache, confusion of ideas,
great oppression or distress at the præcordia or epigastrium, and
disturbances of the special senses. Swift has noticed a peculiar
chromatopsia, the sufferer seeing everything of a uniform color, in
most cases blue or purple, but in others red, green, or even white,
and W. H. Kesteven[3] has reported a case in which a man, after
exposure to an excessively hot sun, was seized with severe headache,
saw everything red or green, and had for some days a distinctly
impaired color-sense.
[Footnote 3: _Trans. Clin. Soc. of London_, 1882, xv. 101.]
At one period I saw a large number of advanced cases of sunstroke in
{391} the hospital, and the symptoms were quite 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 accompanied by the rattle of mucus in the trachea. The face was
usually suffused, sometimes, with the whole surface, deeply cyanosed.
The conjunctiva was often injected, the pupils various, sometimes
dilated, sometimes nearly normal, sometimes contracted. 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 108°-109° F., but it
sometimes reaches 112° 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 tendinum was a very common symptom;
great restlessness was also very often present, and sometimes 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 motor system
suffered paralysis, the patient moving neither hand nor foot.
This extreme motor relaxation, which in my observation is rare, seems
to have been very common in the epidemic described by Barclay,[4] as
he states that in a large proportion of the cases, from the
commencement of the attack until its termination in death, the patient
never moved a limb or even an eyelid. Petechiæ and ecchymoses, the
evidences of broken-down blood, were present in some of my cases, and
there was in one or two instances a fetid hemorrhagic exudation from
the nostrils during life. A symptom which has almost escaped the
attention of authors was a peculiar odor, which was most marked in
patients who had involuntary passages, but was very distinct 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
recognition of a case by the sense of smell alone. The discharges from
the bowels were liquid and very often involuntary. None of my cases
passed urine whilst under observation.
[Footnote 4: _Madras Quarterly Journal_, 1860, 364.]
It is plain that the symptoms of coup de soleil, as usually seen, may
be summed up as those of intense fever, accompanied by profound
nervous disturbance (as manifested by insensibility with or without
delirium, and by motor symptoms, such as convulsions or paralysis), by
arrest of glandular action, and by changes in the blood. In this
ordinary form of sunstroke death takes place by asphyxia or by a slow
consentaneous failure of both respiration and cardiac action. It very
rarely occurs in less than half an hour after the first decided
symptoms, and usually is postponed for a much longer period.