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Popular Science Monthly/Volume 19/June 1881/Sunstroke and Some of its Sequels

SUNSTROKE AND SOME OF ITS SEQUELS.
By Sir JOSEPH FAYRER, M. D., F. R. S.

UNDER the designations of sunstroke, coup-de-soleil, heat-apoplexy, heat-asphyxia, thermic fever, ardent fever, insolation, and others, are included certain pathological states which, though differing from each other materially, are not unfrequently confounded.

1. There is simple syncope from exhaustion caused by heat.

2. A condition analogous to shock, due to the action of the direct rays of a powerful sun on the brain and cord; the nerve-centers, especially the respiratory, are affected; respiration and circulation rapidly fail, and death may result; recovery is frequent, though not always perfect.

3. Overheating of the whole body, blood, and nerve-centers, either from direct exposure to the sun's rays, or, more frequently, to a high temperature out of them; causing vaso-motor paralysis and intense pyrexia (fever); respiration and circulation fail, and asphyxia follows. Recovery frequently occurs, but is often incomplete, owing to structural changes in the centers, giving origin to a variety of symptoms indicative of lesions of a grave character.

The cases of simple exhaustion and syncope may occur during great fatigue or over-exertion, or when there is depression of vital power from any cause during exposure to a high temperature. There is depression of nerve-force and of muscular power; the skin is pale, cold, and moist, the pulse feeble. Death may occur in this state from failure of the heart; but complete recovery more frequently occurs. Asphyxia and apnœa (stoppage of the breath) may come on after premonitory symptoms of depression and weakness, during exposure of the head and spine to the direct rays of a powerful sun, when the atmosphere is much heated, and the nervous energy is depressed by over-fatigue, illness, or dissipation. The brain and respiratory nerve centers are overwhelmed by the sudden rise of their temperature, and respiration and circulation fail.

Recovery, though frequently complete, is sometimes tedious and occasionally imperfect, ending in serious impairment of health or intellect.

The symptoms of this form of sunstroke are those of sudden and violent derangement of the nerve-centers, unconsciousness, cold shivers, feeble pulse; all the signs of depression, terminating in death by shock; or fatal reaction may result with a variety of conditions pointing to injury to the cerebro-spinal system. In another class of cases there is ardent fever, the body generally, including the nerve-centers, is heated intensely; this may occur quite independently of the direct action of the sun's rays. It comes on frequently at night, or in the shade, in a building or tent, especially in persons who are depressed by fatigue, bad air, overfeeding, alcoholic stimulants and the consequent depression, want of rest, illness, and notably when the air is impure from overcrowding, or from insufficiency of cubic space.

The temperature of the body may rise to 108°-110°; respiration and circulation fail; there are hurried, gasping respiration, great restlessness; pungently hot skin, sometimes dry, occasionally moist. The pulse varies; in some it is full and laboring, in others quick and jerking; the head, face, and neck are livid and congested; the carotid pulsation is very perceptible; the pupils, at first contracted, dilate widely before death. Coma, stertor, delirium, convulsions frequently epileptiform in character, with relaxation of sphincter, and suppression of urine—these are the precursors of death by asphyxia, and it may be that there is cerebral hæmorrhage.

Such are the cases to which the term heat-apoplexy is given; and a large proportion of the fatal attacks among Europeans in India are so caused. Recovery may partially occur, to be followed by relapse and death, or secondary consequences, the result of tissue-change, may destroy life or impair health and intellect at a later period. The premonitory symptoms of this form of the disease may appear some hours or even days before the dangerous condition just described supervenes. There may be general malaise, disordered secretions, profuse and frequent micturition, restlessness, insomnia (sleeplessness), apprehension of impending evil, hurried and shallow breathing, disturbance about the heart, gasping, giddiness, headache, occasionally nausea or vomiting, thirst, anorexia (want of appetite), feverishness, which soon amounts to fervent heat of skin; the surface may be dry or moist, the pulse varies; and these conditions gradually become aggravated and frequently are worse at night, when the patient passes into a state of unconsciousness and dies.

The symptoms point to a profoundly disturbed state of the cerebrospinal nerve-centers, and to pathological changes in the organs whose functions have been so greatly disturbed.

Death is caused by asphyxia and apnœa, and in some cases probably by cerebral hæmorrhage. Recovery is often incomplete, resulting in permanent impairment of health, and generally in intolerance of heat and of exposure to the sun. These morbid conditions being due to heat alone, are liable to occur whenever there is exposure to a high temperature, whether solar or artificial. Soldiers marching or fighting, when oppressed by weight of clothing or accoutrements, are apt to suffer either from simple heat-exhaustion or from that form of insolation which results from direct action of a powerful sun on the head and spine. Soldiers, laborers, artificers, and people in factories, heated rooms, hospitals, barracks, tents, and even ships, may suffer from heat-exhaustion, which may pass into the same dangerous condition of heat-asphyxia. People in the hay-field, or otherwise exposed to great heat, especially if they have indulged in excess of alcoholic stimulants and food, may suffer. Weak persons with defective hearts may die in this state of syncope. Soldiers or others, when exposed to great heat, may drop out of the ranks, fall in a state of syncope and die on the spot, or pass into a state of coma and die later; or they may recover, after being in great danger, with damaged nerve-centers, and are rendered quite unfit for further service, or even residence in a hot climate. These cases occur on exposure to the direct action of the sun's rays when the atmospheric temperature is also high, and especially when unusual exertion is made, or when the individual is depressed by previous illness or the exhaustion due to dissipation, intemperance, or even undue indulgence in stimulants.

But the most serious cases are those that come on under cover by night as well as by day, and apart from the direct solar rays. Heat alone, especially when the atmosphere is loaded with moisture so as to prevent evaporation from the person, is the real cause of the disease.

Vigorous, healthy persons of moderately spare frame, with sound viscera, and who are of temperate habits, if the atmosphere be pure and moderately dry, can sustain a great amount of heat. Acclimatization has also some influence in conferring toleration. Fresh arrivals in the tropics are more prone to suffer than those who have become accustomed to the climate, and have learned how to protect themselves. It is well known that a native can bear an amount of sun on his bare head and naked body with indifference, almost pleasure, that would rapidly prostrate a European. But when the temperature rises above a certain standard all succumb, and natives of India suffer and die like others in numbers every year from loo marna (hot-wind stroke).

The extent and duration of the toleration of heat depend much on the vigor of constitution and actual state of health. The refrigerating powers of the body, when in health, enable it to support a very high temperature, considerably above that of the blood. Thus, in the hot winds little inconvenience is felt so long as perspiration is free, but, when that fails, suffering soon ensues, and the danger is great.

In the fourteenth annual report of the Sanitary Commissioner with the Government of India, 1877, it is stated that two hundred and thirty-five cases of heat-apoplexy and sunstroke occurred in the army in India, of which seventy were fatal. Of those who recover, or rather do not die, many are permanently injured, and remain invalids for the rest of life, which is frequently shortened by the changes induced.

No remarkable morbid change is observed in cases where death has occurred suddenly. The heart may be firmly contracted, and the lungs and brain and its membranes congested, but not invariably, for sometimes the reverse conditions exist; and the blood is dark and clotted, its coagulability is impaired, and it is deficient in oxygen. In death from ordinary cases of thermic fever or insolation, the pulmonary system is often deeply congested; the heart is firmly contracted with coagulation of myosin; the venous system is engorged; the body may be marked with livid patches; the blood shows a tendency to a separation of its fluid and solid constituents, and may be acid in reaction; and the body retains a high temperature for some time after death. The brain and membranes may be congested, but the disease is essentially asphyxia, not apoplexy.

In cases of simple exhaustion, remove the person to a cooler place, if possible. Give a douche, but not too prolonged, or it may over-depress. A stimulant may be useful; rouse, and gently stimulate; remove tight and oppressive clothing. Treat as in ordinary fainting—apply ammonia to nostrils, etc. Let the patient rest, and avoid exposure to over-fatigue or to great heat. In the form of sunstroke where the person is struck down suddenly by a hot sun, remove him into the shade, and allow a douche of cold water to fall from a height on his head and body. This should be freely resorted to, the object being twofold—to reduce the temperature of the over-heated centers, and to rouse by reflex action. During the assault on the "White-House picket," at the capture of Rangoon in 1853, numbers of men were struck down by the fierce April sun. They were brought to me, and laid out in rows, perfectly unconscious, in their red coats and black leather stocks. They nearly all recovered—for the time, at all events—under the influence of the douche, freely applied over the head and body. In some cases rousing by flagellation with the sweeper's broom was added with great effect, especially in the case of Brigadier-General W——, who I thought must have died. All, or nearly all, recovered, except two, both of whom had been bled on the spot before I saw them.

In addition to the douche, stimulants, such as mustard-plasters, to various parts of the body, legs, abdomen, etc., and stimulating injections, which relieve the loaded bowels and at the same time rouse, may be useful.

When I say such cases recovered, I refer to the reaction at the time. In some there were consecutive symptoms of fever, headache, etc.; and, were we able to trace their subsequent history, we should probably find that complete recovery never occurred. If recovery is incomplete, and followed by indications of disordered nerve-centers or of meningitis, other treatment of a more active character will be needed, according to the conditions.

Future exposure to the sun should be carefully guarded against, and, unless recovery has been rapid and complete, the sufferer, if in India or the tropics, should be removed to a cooler climate, where he should be protected from all excitement of mind or body, and the greatest care be taken not only to avoid all errors or excesses of diet, but also of stimulants.

In the graver cases of thermic fever, or heat-asphyxia, heat being the primary cause of the disease, the object is to reduce temperature as speedily as possible and before tissue-changes have been caused. Remedies adapted to fevers may be used sometimes with advantage. Bleeding has now happily been abandoned except in rare and peculiar cases. The treatment, generally, consists in the judicious application of cold by affusion, or by ice, taking care not to reduce temperature too low. Great care should be taken not to prolong the cold application too far, as danger would attend continued depression of the temperature below the normal standard of blood-heat. The bowels should be relieved, and blisters may be applied to the scalp and neck, though I can not but say I have not much faith in their efficacy. In the epileptiform convulsions that so frequently occur, the inhalation of chloroform may be useful, but its administration must be carefully watched. The earliest and most severe symptoms having subsided, the febrile condition that follows is to be treated on ordinary principles; the diet must be carefully regulated. As improvement progresses, symptoms of intra-cranial mischief may begin to supervene; where the indications are of meningitis, iodide of potash and counter irritation may be of service; removal to a cooler climate is essential.

The sequelæ of sunstroke are often very distressing, and render the patient a source of anxiety and suffering to himself and to his friends.

Among them are, in various degrees of intensity, irritability, impaired memory, epilepsy or epileptiform attacks, headache, mania, partial or complete paraplegia (paralysis of the lower half of the body), partial or complete blindness, extreme intolerance of heat, especially of the sun's rays, rendering a person otherwise fairly healthy quite incapable of living in hot climates or of enduring any exposure to the sun; or, the attack may gradually end in complete fatuity, dementia, or epilepsy, perchance both; chronic meningitis, with thickening of the calvarium, accounting for the intense pains in the head; or, in a lesser degree, in disordered nervous condition and general functional derangement.

The less severe symptoms—those probably of the slighter forms of meningitis, or of cerebral change—occasionally pass away after protracted residence in a cold climate; they are, however, not unfrequently the cause of suffering, and of danger to and shortening of life, pointing to permanently disturbed if not structurally altered cerebro-spinal centers.—Abridged from Brain.