15 B. F. Westbrook, New York Med. Journal, July 25, 1883.
16 Orville Horwitz, Trans. College of Physicians of Philada., Oct., 1885.
In cases complicated with repeated severe convulsions, hypodermic injections of one-quarter of a grain of morphia have been very frequently given in the Pennsylvania Hospital, with excellent results. In such patients the use of anæsthetics to facilitate the giving of cold baths would be very proper, but so long as the temperature is high nothing should be allowed to substitute the external cold.
Severe headache and other evidences of cerebral inflammation, manifesting themselves directly after the recovery of consciousness, should be met by local or even general bleeding, blistering, the use of arterial sedatives, mercurials, etc.; or, in other words, by the treatment of cerebral inflammation from other causes adapted to the exigencies of the individual case.
Formerly, venesection was largely practised in sunstroke, with occasional excellent effects, but with, on the whole, very bad results. As free bleeding lowers temperature markedly, it can be readily understood that in some cases it might bring about a return of consciousness and yet be a very improper remedy. If in any instance sthenic apoplectic symptoms persist after the lowering of the bodily temperature by the bath, venesection should be carefully considered. There are cases of sunstroke in which the high temperature irritates the brain or its membranes into an acute congestion or inflammation. These complications are especially prone to occur when the high temperature has been allowed to continue for a long time. A case of this character, in which the autopsy revealed proof of the presence of an acute meningitis, may be found on p. 121 of my book on Thermic Fever. When, then, the patient has a tendency to excessive headache and continuous fever, bleeding may become an essential remedy, not for the cure of thermic fever, but of the cerebral inflammation which has been produced by that fever. The case of S. Weir Mitchell is in point. In his early manhood he had a sunstroke, and when consciousness began to return “the first sensation was that of an intense, agonizing headache, and the next was the perception of his father—J. K. Mitchell—and Mütter discussing the possibility of his recovery. As soon as he could speak, he said, ‘Bleed me.’ His father, coming to the bed, shook his head, but the son repeated, ‘Bleed me.’ He persisted in simply repeating this until they thought him delirious; but at last he mustered strength to say, ‘I am not delirious, but have a frightful headache: if you don't bleed me I will die.’ By this time his pulse had become full and bounding, and finally he sat up and was bled. Ten or fifteen ounces were taken without avail; but as more blood flowed the headache vanished, to be succeeded by a feeling of most delightful languor and rest from pain. Between twenty-five and thirty ounces were taken, and afterward recovery was a very simple matter.”
That Mitchell by the bleeding was saved from meningitis appears almost certain, but it is most probable that if he had been primarily immersed in a cold bath no bleeding would have been required.
SEQUELÆ.—Almost all persons who have had a coup de soleil suffer from after-effects. In the mildest form these are inability to bear exposure to heat without cerebral distress or pain, with more or less marked failure of general vigor, dyspeptic symptoms, and other indications of disturbed innervation. In other cases the symptoms are more decided. Pain in the head is usually prominent: it may be almost constant for months, but is always subject to exacerbations. It sometimes seems to fill the whole cranium, but not rarely is fixed to one spot; and I have seen it associated with pain in the upper cervical spine and decided stiffness of the muscles of the neck. With it may be vertigo, decided failure of memory and of the power of fixing the attention, with excessive irritability. When the symptoms approach this point in severity, there is usually marked lowering of the general health, loss of strength, possibly some emaciation, and the peculiar invalid look produced by chronic disease.
Epileptic convulsions occasionally follow a sunstroke, but, at least in my experience, are always associated with more constant evidences of cerebral disease.
A pathognomonic symptom in the sequelæ of sunstroke is the effect of heat. The glare and heat of summer are the most trying, but usually artificial heat is not well borne. It is very common for headache and severe general distress to be produced by going into a warm room even in the winter months. Where cerebral symptoms are affirmed to be the result of a sunstroke, if there be no excessive susceptibility to heat the alleged sunstroke has almost certainly been an attack of some other nature; and on several occasions I have been enabled to determine that a supposed epileptic attack or a fall followed by unconsciousness from violence was really a sunstroke by noting the extreme susceptibility to heat. The symptom I believe to be a diagnostic one.
The lesion in these cases is usually chronic meningitis, though it is possible that in some instances the gray matter rather than the membrane of the brain may be affected, and in severe cases the gray matter is of course more or less compromised. In one case occurring in the care of S. Weir Mitchell, and in one in my own practice in which death occurred from extraneous causes, severe chronic meningitis was found at the autopsy.