OBSERVATIONS 
ON 
<2B#austioii from t|e (Effects of Scat. 
(COUP DE SOLIELL 
BY H. S. SWIFT, M.D., 
RESIDENT PHYSICIAN OP THE NEW YORK HOSPITAL. 
(PROM THE NEW YORK JOURNAL OF MEDICINE). 
NEW YORK: 
HOLMAN, GRAY & CO., PRINTERS, CORNER CENTRE AND WHITE STREETS. 
1 8 5 4. OBSERVATIONS 
ON 
(Erjjattstion from % (Effects of ujeat. 
Owing to tlie oppressive and long-continued hot weather 
of the past summer, an unusually large number of cases 
were admitted to the New-York Hospital of what is 
called coiiy de soldi, or, as now regarded by the profes- 
sion, extreme prostration produced by exposure to excessive 
heats, combined, perhaps, with the effect of receiving large 
draughts of cold water into the system, when overheated. 
So prevalent, indeed, was this disease, that at one time it 
was regarded almost as an epidemic, not only in this, but in 
neighboring cities. Several cases occurred in the country, 
where, heretofore, it has seldom appeared. It will be recol- 
lected that a large per cent, of the cases were fatal. The 
report of the City Inspector of this city alone shows 260 
deaths from coup dc soldi, without including many cases 
designated as “ congestion of the brain ” and the “ effects 
of cold water.” 
It is now only five or six years since the nature of this 
disease was pointed out, and yet the profession, generally, 
have but vague and indefinite ideas respecting it, and it is a 
matter of surprise that medical literature is so deficient on 
this subject. A few short monographs, and a few reported 
cures, are all that can be found in regard to it. Cases are 
not so infrequent, nor is this affection so devoid of interest, 
as this silence would seem to indicate. 4 
Swift on Exhaustion from Heat. 
I have no new theories to propose, or any new light to 
throw upon the pathology or the treatment of this disease ; 
the object of this paper is simply to call the attention of the 
profession to this subject, more especially as the season is 
now approaching in which we may reasonably expect a re- 
turn of this “ calamity.” 
The term coup de soldi as applied to this disease, is a 
misnomer. It is a popular rather than a professional appella- 
tion. All our authors agree that “cerebral apoplexy” is oc- 
casionally produced by exposure to the direct rays of the 
sun. This I regard as true coup de soldi. The subject 
now under consideration is an entirely distinct affection. It 
is now almost universally admitted to be mere nervous ex- 
haustion produced by protracted and violent exercise in an 
over-heated atmosphere. 
Of the large number of cases observed by me, none were 
strictly apoplectic, and no lesions were noticed in those which 
proved fatal, sufficient to account for death. Those two op- 
posite conditions—the “cerebral congestion” and “ nervous 
debility”—require opposite modes of treatment, and should 
be carefully distinguished from each other. 
The subjects of this affection are usually laborers who 
have been exposed several hours during the day to the direct 
rays of the sun, the thermometer being over 90°. A great 
majority of the following cases were foreigners, many of 
whom had but recently arrived in this country, and who, 
after the deprivations of a long passage, were ill-adapted to 
endure great fatigue in so high an elevation of temperature. 
The same condition may result after exposure to artificial 
as well as solar heat. Eleven patients were attacked one 
morning in the laundry of one of our principal hotels ; several 
were brought to us from a sugar-refinery, where, after working 
several hours in a close and over-heated apartment, they fell 
down suddenly in a state of insensibility ; and we had an op- 
portunity of comparing their symptoms and lesions with 
those who became exhausted after laboring in the sun, but 
were unable to satisfy ourselves of any distinction. Swift on Exhaustion from Heat. 
Whatever tends to enfeeble the vital powers must be re- 
garded as the predisposing cause. This may result from 
muscular debility or preexisting disease. Heat acts as the 
exciting cause. One patient had suffered for several weeks 
from an obstinate diarrhoea. He had eaten nothing on the 
morning of the attack, and, after imprudently walking only 
a short distance in the sun, fell down insensible. Another 
patient was suffering at the time of the attack, as we after- 
wards learned, from the usual malaise of fever, and after 
convalescing from this disease, passed through the ordinary 
attack of petechial typhus. Still another was in a cachectic 
condition from the influence of malaria. He wars also picked 
up in the street, and brought to hospital in an insensible 
condition. These cases were not included in our Report, 
though they were evidently suffering from this disease at the 
time of their admission to the hospital. 
An attempt has been made to distinguish those cases which 
are the result of exhaustion merely, and those who have been 
suddenly seized after drinking large draughts of cold water 
when over-heated either from exposure to the sun or by vio- 
lent exercise. If such a distinction exists, by far the greater 
number of cases which fell under my observation would be 
included in the latter class, though only in a single instance 
were we able to trace any immediate connection. A 
seaman had been employed, during the day, in the rigging 
of a vessel, exposed to the direct rays of the sun. At 3 p. m., 
he complained of a severe pain in the head and a “ sense of 
sinking within him.” After drinking very freely from a bucket 
of hydrant-water, he plunged his head into it, and imme- 
diately fell down insensible. Most of the patients had been 
drinking water freely during the day,—some moderately,— 
while others had scrupulously avoided it. But a large ma- 
jority of them were attacked immediately after dinner, when 
probably large draughts of water were employed. 
For this reason I am inclined to believe that the effect of 
the cold water in these cases is merely to hasten the de- 
velopment of the disease, and that a majority of the cases 6 
Swift on Exhaustion from Heat. 
reported as deaths from “ drinking cold water,’’ are really 
occasioned by “ solar exhaustion.” Nearly all the patients 
were exhausted by severe labor, and at their dinner they 
were in just the condition to suffer from the shock of receiv- 
ing a large quantity of water suddenly into the system. 
Deaths from the effects of cold water are not so frequently 
met with as is generally supposed. Dr. Dickson, of Charles- 
ton, S. C., says: “ I have never seen a death from drinking 
cold wTater, nor have I been able to obtain any authentic 
account of such an event having occurred since I have been 
engaged in the practice of medicine in this city. Yet here, 
if anywhere, such accidents should occur. Immense quan- 
tities of ice and iced fluids are daily consumed here by per- 
sons subjected to the several conditions which are regarded 
as calculated to favor the morbid influence of the agent in 
the highest degree. The cases described by Rush I believe 
to have been generally cases of insolation, and that, being 
sensible of rapidly approaching disease, and at the same time 
feeling an internal heat, the patients were just procuring 
relief when overtaken by sudden death.” Such, undoubtedly, 
was the case of the sailor above referred to. 
The disease is usually stated to be confined to patients of 
irregular habits ; but only a small proportion—at least less 
than one-half of the following cases—could be regarded as 
intemperate, and many of these had restricted themselves 
during the day to a single glass of ale or brandy. 
The premonitory symptoms are usually slight, and of short 
duration. A laborer may, perhaps, have been employed 
until a late hour the previous night, and the next morning 
complains of a slight headache and a general feeling of lan- 
guor. He takes his breakfast with less relish than usual, but 
resumes his ordinary duties. But, in the great majority of 
cases, even these slight symptoms are wanting. They are 
suddenly seized, while in the performance of their labors, 
with pain in the head, and a sense of fulness and oppression 
in the epigastrium, occasionally nausea and vomiting, general 
feeling of weakness, especially of the lower extremities, vcr- Swift on Exhaustion from Heat. 
7 
tigo, dimness of vision, and insensibility. Surrounding ob- 
jects appear of uniform color. In a great majority of 
cases, this was, so far as could be ascertained, blue or purple. 
In one instance, everything appeared red; in another, green; 
and in another, white. One stated that objects retained their 
natural color, but expressed them as being very beautiful, 
while to another everything appeared greatly magnified. 
This may be regarded as the first stage of the disease. It 
is usually of short duration. In the milder forms of the dis- 
ease, the stupor is only momentary. The patient is at first, 
perhaps, aroused with difficulty, but he gradually regains his 
consciousness. If, however, the attack is severe, the patient 
shortly passes into a state of coma. The skin is hot and 
pungent to the touch, and by actual experiment, according 
to the observations of Dr. Dowler, the temperature is elevated 
ot 112° Fahr. The pupils are dilated and insensible 
to light; the breathing hurried and labored ; the pulse is 
sometimes slow and full—sometimes frequent and feeble, 
though the action of the heart may continue inordinately 
strong up to the last moment of life. 
In the third stage, the symptoms are those of collapse. 
The pulse becomes more frequent and feeble ; the respiration, 
which at first was hurried and labored, now becomes ster- 
torous, and accompanied with sighing and moaning ; the 
skin cool, or the surface of the body may retain its natural 
temperature, though the head may be hot ; the sphincters 
become relaxed ; extremities cold; the countenance swollen 
and livid; the pupils may be dilated, but are often firmly 
contracted; tracheal rales appear; either the patient is quiet, 
as if completely paralyzed, or else convulsions, often violent 
in character, supervene, and he dies suddenly, or he may re- 
main in this condition for several hours. 
The first stage corresponds very nearly to that condition 
described by Southern writers as “ solar exhaustion.” Dr. 
Dowler makes a distinction between this “ solar exhaustion ” 
(the couj) dc soldi of northern latitudes) and what he 
calls “solar asphyxia.” The former he regards as “a mere 8 
Swift on Exhaustion from Ilcat. 
fainting, in which the face is pale, skin cool, or not above 
the natural standard, while, in the latter, the skin is burning 
hot, face flushed, and the mind and body are utterly insensi- 
ble to impressions.” It runs its course rapidly, and often 
proves fatal in 30 minutes. Dr. Cartwright says, the cases 
of “ asphyxia are often incurable from falling into an incura- 
ble state before medical aid can be obtained ” ! while those 
of exhaustion simply, if properly treated, will yield as readily 
as a case of common intermittent, and almost as fatal as 
“ solar asphyxia” if improperly treated. 
The second and third stages, described in the progress of 
the disease, are so intimately connected that it may seem an 
unnecessary division ; but it is more convenient to regard 
them separately. They differ usually in the mode of attack, 
and for this reason some have regarded them as a distinct 
condition. The stage of collapse is most frequently noticed 
in those who are seized late in the afternoon, “ without the 
signs of apoplexy,” after exposure to the heat and fatigue of 
the day. But the same condition may occur in those who 
have been seized suddenly “ with the signs of apoplexy,” 
and yet pathologically there may be no difference. 
Of 60 cases which came under my observation during the 
past year, 44 were insensible at the time of admission, and 
16 were either stupid or sensible. The pupils were dilated 
in 30, contracted in 19, and natural in 11. The temperature 
of the body was hot in 34, warm or natural in 14, and cool 
in 12 ; while that of the head was elevated in 31, warm in 
11, and cool in 18. 
The respiration was hurried in 14 ; I he pulse was uniform- 
ly accelerated, varying from 100 to 160, and even more per 
minute. Convulsions were present in 24, delirium was noticed 
in only a few. 52 of the patients were males. The average 
duration of the fatal cases was about 4 hours. 
The time of the at’ckin 3 cases was between 8 and 11 a.m. 
“ “ “ “ “ “40 “ “ “ 11 A.M.and 4 p.M. 
“ “ “ “ “ “17 “ “ “ 4 and 9 p.m. 
Convalescence is usually speedy, after the severity of the Swift on Exhaustion from Heat. 
9 
disease has passed, arid reaction is fully established, varying 
from a few minutes to five or six hours ; the patient sinks 
into a deep slumber, and awakes somewhat exhausted, and 
the cerebral functions disturbed ; but this soon disappears. 
Two patients only complained of severe pain in the head, 
and at intervals exhibited great forgetfulness for nearly a 
week ; and one was occasionally delirious. 
A case wTas reported to me in which delirium supervened, 
resembling that of delirium tremens. I can conceive that 
such a condition may exist, but this patient was intemperate, 
and had been drinking to excess previous to the attack. 
Dr. Pepper reports 20 cases, 10 of which died, and 3 re- 
sulted in insanity. This termination was not noticed in over 
100 cases received at the New-York Hospital. In the re- 
ports of lunatic asylums, however, few cases of insanity are 
referable to an attack of coup Je solid. One patient was 
delirious, and with the greatest difficulty restrained. 
The statistical reports are too inaccurate to furnish any 
satisfactory data for the mortality of this disease, as no at- 
tempt has been made in the reports to distinguish it from 
“ cerebral apoplexy ” ; but this latter class is, I believe, less 
frequently met with than was formerly supposed; and that 
their number will somewhat diminish as the facilities for post- 
mortem examination are furnished, and that by far the greater 
number of cases included under the head of coup de soldi 
are nothing more than “ nervous prostration.” About one- 
half of the cases are usually fatal. The mortality of the 
past year will, however, be above this estimate. 
The total number of cases admitted to this Hospital since 
1845, is 150, of which 78 died. The mortality of the cases 
admitted in 1853 is 33 in 67. 
The mortality of hospital practice must be greater than 
that in private, as very many were admitted in a moribund 
condition, and died before any treatment could be adopted, 
while others were rendered hopeless by being brought a long 
distance, several hours after the attack. 
The prognosis will depend on the stage of the disease. In 10 
Swift on Exhaustion from Heat. 
the first stage, the prognosis is usually favorable; much, 
however, will depend upon the treatment adopted. The 
symptoms indicating collapse are always unfavorable. 
In 33 fatal cases, the pupils were contracted in 20, moder- 
ately dilated in 7, and markedly so in 6 ; while, in the suc- 
cessful ones, the pupils were dilated in 19, and nearly na- 
tural in 15. No case recovered in which the pupils were 
contracted. Mere stertorous breathing is not necessarily 
fatal ; but after the respiration becomes sighing and moaning, 
the prognosis is very unfavorable; only two patients re- 
covered after this character of the breathing was present. 
To these two symptoms—the condition of the pupil and 
the character of the respiration—I attach much value; and if 
other observations shall confirm this, they will furnish the 
most reliable basis for prognosis. 
The respiration was sighing or moaning in 31 of the 33 
fatal cases ; convulsions were noticed in 24. This is a grave 
symptom, but 6 recovered after they were present. The 
pulse alone is no safe criterion of the actual condition of the 
patient, for it may continue of fair strength throughout the 
whole course of the disease, with no perceptible alteration 
either in force or frequency, though the patient may be under 
the free use of stimulants. This will frequently surprise 
those who are unaccustomed to observe it. 
A fatal relapse occurred in one instance. This patient was 
attacked suddenly while at his work, and lost all conscious- 
ness. As soon as he had sufficiently recovered, he walked a 
long distance to the Hospital, exposed to the direct influence 
of the sun. This exertion, combined with his previous pros- 
trated condition, probably induced another attack. He again 
partially convalesced, but immediately sank into a comatose 
condition, from which he did not rally. 
The pathology of this disease is uncertain. We have as 
yet failed to discover any satisfactory lesion to account for 
the phenomena noticed before death. It is now, however, 
generally admitted to be merely “ exhaustion ” produced by 
fatigue—either in the sun, or, less frequently, in a close 
and over-heated apartment. Swift on Exhaustion from Heat. 
11 
The post-mortem appearances, though of a negative char- 
acter, are precisely opposite those found in “ congestion ” of 
the brain or apoplexy produced by insolation—in other words, 
coup de soleil. And it is of great importance that this 
relation should be correctly understood, for they obviously 
require an opposite course of treatment. Unfortunately these 
two conditions are too indiscriminately called coup de soldi. 
Our nomenclature, in this respect, is imperfect, and calcu- 
lated to mislead those who are unaccustomed to observe it. 
But we must not infer, simply because a disease has been 
erroneously called coup de soldi, that we have apoplexy to 
contend with. “It is debility we have to meet, and not 
repletion.” Depletion, which is essential in the one, is almost 
necessarily fatal in the other. 
In some cases we have apoplectic symptoms with those 
which properly belong to the opposite condition. And we 
may perhaps be puzzled to know to which class they belong. 
But even in these cases, we rarely find any lesion. Sometimes 
there will be found a moderate congestion of the brain, but 
no more so than we often find in cases where we suspect no 
lesion of that organ. 
The following case may perhaps be interesting, as illustrat- 
ing this: 
An unknown woman was picked up in the street in a state 
of exhaustion, and brought to the Hospital at 8 p.m., Aug. 
14th. Nothing could be learned of her previous history. 
She was completely insensible, pulse frequent (120) and 
feeble ; respiration hurried and labored ; skin burning hot ; 
temperature of head elevated; pupils contracted and insensi- 
ble. The prognosis was unfavorable. Our ordinary treat- 
ment was adopted. Sinapisms were applied to the calves of 
the legs and abdomen, ice to the head. Stimulating enema 
of spts. tereb., brandy, and tr. capsici were administered 
moderately. Frictions with mustard were also ordered. Four 
hours after her admission, her condition became decidedly 
worse. The slight convulsive movements of the body, which 
were noticed at the time of her admission, were more marked 12 
Swift on Exhaustion from Ileat. 
and violent, and it was only with the greatest difficulty that 
she could be confined to the bed. The breathing was ex- 
ceedingly labored, and accompanied with sighing and moan- 
ing—pupils dilated ; the pulse very frequent, and scarcely 
perceptible at the wrist ; the countenance swollen and 
livid ; extremities cold ; the stomach refused to retain the 
stimulants. The bronchial tubes became clogged with an in- 
crease secretion of mucous; and deglutition was very difficult. 
The slightest attempt to swallow threatened almost immedi- 
ate asphyxia. She was ordered injections of brandy and 
carb. ammonia. 
On the following morning reaction, was fully established. 
The pulse 130, but fair strength. The head and surface of 
the body hot; eyes suffused, red and injected, fixed and 
motionless ; pupils contracted to a point and inactive ; face 
flushed; countenance swollen and turgid ; respiration deep 
and stertorous ; and the patient was completely comatosed. 
The quantity of stimulants was diminished, and an aloetic 
enema repeated ; ice reapplied to the head, and sinapisms 
to extremities. 
The physician in attendance now regarded these symptoms 
sufficiently indicative of cerebral congestion to warrant deple- 
tion. Ordered a moderate abstraction of blood from the 
temples by cupping, and the treatment adopted during his 
absence to be continued. She died 21 hours after admission. 
Autopsy 18 hours after death. No marked congestion of 
the brain or lungs was observed. The heart was flaccid 
and filial with fluid blood. The liver was much congested 
—other organs healthy. 
This case was, doubtless, one of “ nervous exhaustion ”— 
a condition so often mistaken for, and associated with, “cere- 
bral apoplexy,” and it was the only one in which reaction 
ran sufficiently high to indicate depletion. But even in this 
the post-mortem disappointed us. I have only seen a few, a 
very few cases, of insolation verified by a post-mortem exami- 
nation,—certainly not one during the past year, although 
examinations were made in all the cases in which we sus- 
pected any cerebral lesion. Swift on Exhaustion from Heat. 
13 
The diagnosis of those cases, which simulate apoplexy is 
often difficult. The remarks of Dr. Condie, though inappli- 
cable to the case just given, may perhaps be generally useful. 
He says : “In those cases requiring depletion, the head partic- 
ularly, and often the entire surface of the body, is hot. The 
eyes injected; pupils contracted; pulse small, quick, and 
corded. Tongue red and dry. Patients are delirious, rest- 
less, and in a constant state of agitation ; and if not speedily 
relieved by prompt and active treatment, coma ensues, and 
the patient dies as in acute meningitis.” 
The true pathology of this disease, like those cases of 
death produced by lightning, will probably never be cor- 
rectly explained, unless, perhaps, the microscope may aid in 
removing the veil of mystery which surrounds it. But it 
must be remarked en passant, that there are many points of 
resemblance in the appearance of those who have died from 
the effects of heat, and the cases reported of death from 
lightning. 
Does the heat produce death by destroying the “ vital 
principle,” as Hunter supposed was the effect of lightning ? 
Does it produce some chemical change in the blood itself, 
so that it can no longer subserve the purposes of innervation ? 
or does it produce its effect primarily upon the nervous sys- 
tem ? This is the most plausible theory. The vital powers, 
already enfeebled by fatigue and the heat of the atmosphere, 
are unduly stimulated. The natural balance of the circula- 
tion is destroyed, and the heart contracts with a “ morbid 
activity.” The lungs are engorged with blood, and the heart 
labors to overcome the increased obstacle, until at length it 
is exhausted by this “ morbid activity,” and passive congestion 
takes place in the capillaries throughout the body. 
The pathology of this disease is too obscure and uncertain, 
and observation too limited, to arrive at any satisfactory con- 
clusions in regard to the treatment. It is at best empirical. 
We regard the disease as one of debility, and we partially 
treat it as such. 
The great practical point to be regarded in the treatment 14 
Swift on 'Exhaustion from Ileat. 
is, that this affection is entirely distinct from coup de 
soldi, as generally understood by the term. It is a disease of 
“ debility,” and not one of u repletion.” Depletion is gene- 
rally contra-indicated, and stimulants are usually required. 
In cases of Insolation, the lance is often employed. But 
these are very rare. During the summer of 1818, there 
were 13 cases admitted into the Hospital. These were 
largely bled ; 60 ounces were taken from the arm by repeated 
bleedings ; and in one case as many as 80 ounces. And the 
“ recovery in this one was much more marked and speedy.” 
Three of these died, and the post-mortem appearances were 
precisely those of “ cerebral congestion.” But in cases of 
exhaustion, I have never seen a patient recover after he had 
been bled. 
This practice is now nearly abandoned. Formerly, nearly 
every case treated before admission to the Hospital had 
been bled. But not a single patient had been bled of those 
admitted during the past summer. They do not bear well 
even the local abstraction of blood by cupping. 
The plan of treatment usually adopted is to place the 
patient in a hot bath, rendered stimulating perhaps by 
mustard or capsicum—or counter-irritation to the whole 
body by means of mustard ; a stimulating enema of tr. 
aloes c., or, what is preferable, spts. terebinth ; ice to the 
head when the temperature is elevated ; brandy and tr. capsici, 
or even carb. ammonia if required. 
The indiscriminate use of cold affusions is productive of harm. 
Injurious and often fatal effects result from them. It is a 
popular and erroneous idea that a patient, as soon as he is 
attacked, should be completely deluged with cold water. 
To employ it in every case would be as absurd as in cases of 
collapse from any cause. 
Another important consideration in the treatment of the 
earlier stages is rest. In crowded cities, to which this 
disease is mostly confined, this caution is too much disre- 
garded. As soon as a patient is attacked, he should be 
placed in a horizontal position, in as cool a place as possible, and perfect rest required. Nothing can be more serious for 
a patient in this condition, to be carried, as is too often the 
case, upon an ordinary cart for a long distance, or allowed 
to remain exposed to the influence of the sun. 
The length of this paper will prevent any detailed account 
of the cases themselves. They were admitted during the 
attendance of Drs. Joseph M. Smith and H. D. Bulkley, and 
the treatment adopted during their absence was approved of 
by them. In conclusion, I desire to express my special ac- 
knowledgments to my senior assistant, Dr. John B. Chapin, 
for his valuable assistance, not only on this, but other 
occasions. 
New York Hospital, March lath, 1854. 
Swift on Exhaustion from Heat.