Portal de Periódicos da CAPES

Historical Perspectives on Medical Care for Heat Stroke, Part 1: Ancient Times Through the Nineteenth Century: A Review of the Literature

2010; Volume: 2; Issue: 3 Linguagem: Inglês

10.3928/19425864-20100428-07

1942-5872

Douglas J. Casa, Lawrence E. Armstrong, Robert Carter, Rebecca M. Lopez, Brendon P. McDermott, Kent Scriber,

Thermal Regulation in Medicine

Original Research freeHistorical Perspectives on Medical Care for Heat Stroke, Part 1: Ancient Times Through the Nineteenth Century: A Review of the Literature Douglas J. Casa, PhD, ATC, FACSM, FNATA, ; , PhD, ATC, FACSM, FNATA Lawrence E. Armstrong, PhD, FACSM, ; , PhD, FACSM Robert Carter III, PhD, MPH, FACSM, ; , PhD, MPH, FACSM Rebecca Lopez, PhD, ATC, ; , PhD, ATC Brendon McDermott, PhD, ATC, ; and , PhD, ATC Kent Scriber, EdD, ATC, PT, , EdD, ATC, PT Douglas J. Casa, PhD, ATC, FACSM, FNATA Address correspondence to Douglas J. Casa, PhD, ATC, FACSM, FNATA, Department of Kinesiology, University of Connecticut, 2095 Hillside Road, U-1110, Storrs, CT 06269-1110; e-mail: E-mail Address: [email protected]. , Lawrence E. Armstrong, PhD, FACSM , Robert Carter III, PhD, MPH, FACSM , Rebecca Lopez, PhD, ATC , Brendon McDermott, PhD, ATC , and Kent Scriber, EdD, ATC, PT Athletic Training & Sports Health Care, 2010;2(3):132–138Published Online:April 28, 2010https://doi.org/10.3928/19425864-20100428-07Cited by:10AbstractPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInRedditEmail SectionsMoreAbstractExertional heat stroke has affected an untold number of people throughout history. These people were often forced to exert themselves physically or sustain themselves in hot weather for a prolonged period of time. This literature review provides a window into the multitude of different viewpoints regarding what was thought to cause and alleviate the associated effects of this medical condition. The purpose of this literature review is to provide a snapshot of some of the important historical landmarks regarding the standards of medical care for heat stroke from ancient times to the present.IntroductionHeat stroke (sunstroke) has been described as the oldest known medical condition.1 Although it may seem a stretch to make this statement regarding any specific condition, Osler's findings1 lend support to the fact that this condition has occurred and been treated for as long as recorded history; Table 1 provides various heat stroke terminology used throughout history. Exertional heat stroke (EHS) is the most life threatening of the heat-related injuries. Exertional heat stroke occurs as a result of the body's thermoregulatory systems being overwhelmed during and after physical exertion. Core temperature increases to above 40°C (approximately 104°F) and is associated with signs of central nervous system dysfunction.2 Heat stroke is unique from other medical maladies in that it does not require the transmission of a virus or bacteria from one carrier to another, nor does it need the violence of physical trauma that may occur from a gunshot, knife, or fall. Someone who is in perfect health and participating in what seem to be normal activities may die from EHS within 1 hour. Unlike most medical conditions, it is as likely to influence a person in the peak of health as it would a person who is weak or infirm. Exertional heat stroke may manifest without bias among those who dare to tempt the thermoregulatory limitations of the human body while existing or exercising in hot conditions. The following quote summarizes this idea: But sunstroke gives no such warning. It strikes down its victim with his full armor on. Youth, health, and strength oppose no obstacle to its power; nay, it would seem, in some instances, to seek out such as these, as if boldly to flaunt its power, and in the very glare of day to deal its final blow.3Table 1 Common Terms for Heat Stroke Through the AgesHeat strokeHeatstrokeHeat-strokeExertional heat strokeClassic heat strokeSun strokeSun-strokeSunstrokeSiriasisThermic feverIctus solisCoup de soleilHeat exhaustionIctus calorisProstratio thermicaCoup de chaleurColpo di caloreHitzchlagWarmschlagHeat-apoplexyHeat-asphyxiaHeat-dyspneaThermal feverThermic feverArdent feverPhrenitis aestivaPhrenitis calentureErthismus tropicusInsolationClassic heat stroke (CHS) is different than EHS in that its onset generally occurs over a period of hot, humid days and is most likely to affect the elderly, young children, or those with preexisting illnesses. Exertional heat stroke has a sudden onset and often affects healthy young adults, athletes, laborers, or soldiers.4 It can cause sudden and fatal consequences due simply to the element of having to exercise in warm or hot conditions. Exertional heat stroke has existed for thousands of years in humans who had to survive and sometimes attempt to thrive under an unforgiving sun. Through centuries of history, appropriate prevention and management for heat-related problems has affected the difference between success and failure on the battlefield.A wide variety of recommendations have existed regarding proper heat stroke prevention and treatment methods. Over the years, cold water has received rave reviews as the treatment of choice for hyperthermic individuals, although the idea that cold water should be avoided due to potential harm has also existed (and still does in some circles). Recently, laboratory and clinical evidence has provided insight into the critical importance of rapidly reducing the core body temperature of hyper-thermic individuals to maximize the likelihood of survival from heat stroke. The current standard of care tells us that cold water immersion (CWI) seems to provide the fastest cooling rates, but unfortunately, this cooling modality is not universally practiced for reasons that will be discussed later.The purpose of this article is to provide a historical snapshot of past and present beliefs about the causes of, and the medical care for, heat-related problems. We hope that an examination of past practices will point out important factual information that has led us to current thinking and best practices in the 21st century. It should also remind us that current recommendations for management providing rapid whole-body cooling will result in maximizing survival rates for individuals who experience EHS.Ancient Times Through 1500 ADThe effects of heat stroke, or sunstroke, date back thousands of years. Several historical accounts have made reference to the dangers of the heat from the sun. The Bible acknowledged several sunstroke deaths both in farmers and in fighting men.5 Judith's husband, Manasseh "got sunstroke and took to his bed and died" after being out on the fields supervising the barley.6 Reference has been made to the connection between sunstroke and the dog star Sirius, hence the phrase "dog days of summer."6,7 Ancient Greeks, Romans, and Egyptians described how Sirius was responsible for bringing fever to men, explaining the occasional use of the term siriasis to describe heat illness.7 In approximately 400 BC, Hippocrates' Aphorism XIII (from The Aphorisms of Hippocrates)8 described how the violent heat from the sun could result in fevers and convulsions as a result of "too profuse a perspiration." The doctrines of Galen regarding bloodletting were obediently practiced by doctors for more than 1,000 years (Table 2). In general, the rationale for bloodletting was that it extracted the "bad" blood of the body, taking with it the illness, heat, and so on. The body then restored blood volume and homeostasis without illness.9,10Table 2 The Medical Practice of Bloodletting9–11Definition: The practice of restoring equilibrium to the body by releasing blood. This could be used to release disease, plethora (historically meant to infer overfulness; overeating with too little exercise), fever, poison, pneumonia, or excessive excitement.Purpose: The "bad" blood of the body can be extracted, taking with it the illness, heat, etc. The body then restores blood volume and homeostasis without illness. Other beliefs included the possibility that excess blood caused illness and removing it restored equilibrium.Specific practice: Applying a tourniquet to the arm so the veins become exposed, a sharp knife or needle was used to open the vein. The blood was collected in a bowl or cup; sometimes saved as a family heirloom. Some descriptions include the application of leeches to the wound to facilitate blood loss. Others would vigorously rub the skin to the point of bleeding (friction).The cephalic vein in the arm was considered well adapted for bloodletting. Often much importance was placed on the specific choice of the source that was to be exposed.Interesting facts: Practiced by doctors for over 1000 years, thought to be legacy of Arabian medicine. Profoundly decreased overall blood volume. Patients were treated with Iron after blood-letting to correct anemia. No known survival rates reported following treatment (for any illness).Also known as bleeding, cupping, venesection.Many military men were reported to have died as a result of the combination of exposure to the sun and the use of heavy armor. Also in approximately 400 BC, Herodotus described how the Spartans and Athenians were affected by the sun and extreme thirst as a result of combining environmental heat with protective clothing and heavy loads.7 Preventive measures for heat stroke date back to Alexander the Great in 332 BC, when military advisees cautioned on embarking on a long march without sufficient water supplies.7 In 24 BC, the governor of Egypt, Aelius Gallus, lost a large part of his army as they marched through the desert under a scorching sun.12 It is evident that heat stroke has been acknowledged as a cause of death for thousands of years. However, the numerous treatments for heat stroke used in ancient times through 1500 AD are not as obvious.Throughout the literature, the treatment of heat stroke varies substantially. Although early reports of treatment for heat stroke include the use of cold water or cold baths, the use of these modalities seems to have been lost in translation throughout history. One of the first reports of heat stroke treatment dates back to 400 BC in Hippocrates' document The Aphorisms of Hippocrates.8 In Aphorism XXI, he refers to treating "bodies in the middle of summer" by pouring cold water on them to extract heat. According to Hippocrates, the pouring of cold water was used to cure "over-heating." He believed that a sudden contraction of the fibers throughout the body forces liquid movement throughout, to restore obstructed sweating and to cool the body.8 Although the physiological explanation for the effectiveness of this treatment may be better understood today, Hippocrates was on the right track.Hundreds of years later, Aelius Gallus' sunstruck army suffered fatal consequences in the desert and sun. The only treatment used by these Egyptians consisted of a mixture of olive oil and wine that was either ingested or used as an ointment.12 The evidence indicates this treatment was not effective in treating heat stroke, and it is uncertain whether the olive oil and wine needed for the treatment were readily available. Apparently, previous recommendations of Hippocrates (pouring cold water onto the individual) were not available to them either, nor did they likely have access to cold water.Thoughts From the 10th to 15th CenturiesNearly 1000 years later, The Canon of Medicine of Avicenna from the year 1020 included precautions against thirst, preventive measures for traveling in the heat, and various treatments for sunstroke. Protecting the body from the sun and heat consisted of protecting the chest via the application of purslane juice or mucilage of flea-wort.13 Further, applying ointments of rose oil and violet, or swimming in cold water were recommended to alleviate the effects of traveling in the heat. One of the more logical remedies included staying in a cool place and throwing cold water over the limbs and face. The pouring of cooling rose oil, willow oil, and cold juices over the head also was believed to be a viable treatment, whereas sexual intercourse was contraindicated. On the other hand, additional recommendations for sunstroke treatment included ingesting salted fish, diluted wine, and sour buttermilk.13The Canon of Medicine may be one of the first documents to imply that drinking cold water might hinder recovery from heat stroke. According to Gruner,13The Canon stated that a patient of sunstroke should only rinse the mouth with cold water if thirst was present: "Water should not be swallowed to repletion, because of the risk of sudden death [from shock] thereby." Therefore, it was advised that rinsing of the mouth with water should only be done so in moderation, and the first ingestion of water should be accompanied with rose oil. Unfortunately, some medical professionals retained this theory regarding cold water even into the 20th century.The Catalan medical doctor Arnau de Vilanova, personal physician to James II of Aragon as well as Popes Boniface VIII and Clement V in the 1290s, used the seal of the lion when treating various diseases of the stomach and back, as well as sunstroke and acute fevers.14 This golden seal was stamped in the shape of a lion. Exactly how this seal was intended to alleviate the symptoms of heat stroke is unclear, and success rates were not reported.1500 AD Through the 19th CenturyTrying to cope with the heat was an enormous challenge to colonists in the southeastern United States during the 17th through 19th centuries. Kupperman15 wrote an exquisite account of the issues that settlers faced during the brutal summer heat and humidity. Ironically, they believed that profuse sweating caused the "inner parts" to become cold, especially the stomach, thus causing loss of appetite and problems with digestion. To cope with this perceived paradoxical hypothermia, they warmed the inner organs by hydrating with "strong spirits" (alcohol) and eating hot peppers. Although many recommended that water should be avoided during exertion in this era, others encouraged hydration. For example, Parkes16 stated "The restriction of water by trainers is based on a misapprehension: a little water, and often, should be the rule."The prevailing medical advice at this time is noted by Motherby in a 1775 medical dictionary.17 The book used common terms of the time to define heat stroke, such as insolatio, ictus solaris, and coup de soleil. The definition provided was "given to disorders that arise from too violent an influence of the sun's heat, particularly on the head. A long exposure to a hot sun often produced an inflammation that was speedily fatal." The recommended treatment was to: First bleed as freely as the strength will admit; after this the legs, or if the disorder is violent, the whole body may be put into a warm bath, which should not be hotter than new cow's milk. Emollient clysters (gelatinous and oily articles) should be frequently injected, almond emulsion, lemonade, and such like demulcent cooling drinks should be freely given; linen cloths wrung out of vinegar and water may be applied on the face and scalp.17The combination of substantial bloodletting and a warm bath assuredly helped to speed the fatal outcome of the EHS. The lemonade and almond emulsion, while sounding spa-like, likely offered little relief in the final moments.A telling account of managing and treating heat stroke occurred during the Lewis and Clark expedition in 1804–1806. Dr. Peck provided an account of the medical issues faced during this journey in his book, Or Perish in the Attempt: Wilderness Medicine in the Lewis and Clark Expedition.18 In one account, Clark is quoted as saying this about one individual who likely experienced heat stroke: "one man very sick, struck with the sun, Captain Lewis bled him and gave him niter [saltpeter, potassium nitrate] which has revived him much." The treatment of bleeding a sick individual was common in that era but did quite a disservice to this patient by further decreasing blood volume (Table 2). Wakefield and Hall6 beautifully summarized the medical practice of the value of bloodletting in 1927: "bloodletting, the therapeutic sheet-anchor through all the ages…has been a favorite treatment in the past and even now in selected cases." Not surprisingly, the use of therapeutic iron supplementation became a popular accoutrement after blood letting, since the unlucky patients were now also anemic due to blood loss.6 Niter was commonly used in this era as a mode to increase urination (ie, diuretic), another treatment that would decrease blood volume. In addition, it was common to recommend opiates to treat heat stroke (originally described by Rush19).So, imagine being a hyperthermic, dehydrated, exhausted member of the Lewis and Clark expedition, and your treatment consisted of taking a diuretic and bloodletting, yet you believe that these methods were helpful. We believe the temporary recoveries following these cases and similar ones provide powerful examples of the extraordinary ability of the placebo effect (maybe explained by the opiates). Patients thought they were being helped, so they were almost obligated to feel better, but this recovery was short-lived and the hyperthermia eventually cooked vital organs to the point of destruction and, ultimately, they succumbed to the condition.In 1858, Beatson20 noted his lack of belief in this standard practice of bloodletting and wrote the following regarding a series of heat stroke cases he had treated as a military surgeon: "I believe that bloodletting in this disease, as a general rule, is a most injudicious and injurious practice." He also noted, quite intuitively from his successful outcomes, that heat stroke cases should be treated as follows after removing the uniform: "Get him, if possible, under the shade of a bush, raise head a little, and commence the affusion of cold water from a bheestie's [water-carrier] sheep-skin bag, continuing the affusion at intervals over head, chest, and epigastrum, until consciousness and the power of swallowing returned."20 The writing of Levick3 probably best summarized the feeling of many physicians regarding heat stroke treatment in the late 1800s about the evolving thoughts regarding blood-letting: "Without quoting separately each author, let me here state that nearly all our American writers agree that bleeding, so far from advantage, generally hastens a fatal termination." The questioning of the efficacy of the common practice of bloodletting was noteworthy and reaffirmed Forestus' very early (1562) disbelief regarding the usefulness of this technique in many of these cases.3A treatise published by James Currie in 1798 deserves special attention in an article discussing the historical aspects of EHS.21 The document, titled Medical Reports on the Effects of Water, Cold and Warm, as a Remedy in Fever and Other Diseases, was groundbreaking for numerous reasons. First, it was one of the first to document the physiological influences of the human body in various water temperatures. The initial period of no change (or even a paradoxical very slight increase) in body temperature due to shivering and peripheral vasoconstriction when a normothermic individual was subjected to CWI was termed the Currie effect in 2007 by one of the authors (D.J.C.).4 Currie also refuted the thinking of the time regarding the ingestion of cold water causing heat stroke and offered other useful foundations from which many paradigms were built.21 The greatest line of thinking to emanate from his early findings was the notion that a severely hyperthermic person will cool rapidly in cold water due to the powerful cooling properties of water.In the 1800s, some thought that drinking cold water caused heat stroke. These speculations were first ascribed to Dr. Rush and his preachings of this point in the years that followed.19 Patients received the following diagnosis: Hurt by drinking cold water. Three circumstances generally concur to produce disease or death from drinking cold water: 1) The patient is extremely warm, 2) The water is extremely cold, 3) A large quantity is suddenly taken into the body. The danger is in proportion to the degree of combination of the three circumstances cited.19The author went on to give specific recommendations regarding how to warm the water prior to pouring it into a cup for ingestion or to wash the hands and face prior to drinking to dissipate the shock of ingesting cold fluid. In 1814, the Philadelphia Humane Society posted signs on public pumps warning against the risk of sudden death from drinking cold water.22 Because some patients were too hot for the cold water to provide noticeable relief, the cold water was inaccurately believed to cause heat stroke. Much to their credit, some medical professionals of that generation argued against the belief that the cold water was the cause of affliction and argued rather that high body temperature was the cause of physiological compromise.3In an elegant account of the evolution of these thoughts from the rhetoric of Rush to the beliefs through the 1800s, Spellissy22 wrote "A Review of the Study and Treatment of Heatstroke at the Pennsylvania Hospital and Elsewhere, 1751–1870." This is one of the finest accounts of heat stroke from a historical perspective that has been produced to date. The highlights run the gamut of all things relevant to this condition. He covers the cause (and hence a great attention to discounting the claims of ingestion of cold water by Rush and points toward the act of seeking cold water as a result of the extreme hyperthermia, not the cause of the hyperthermia), proper recognition, treatment strategies (and gives great attention to the evolution of practice toward the use of cold water), pathophysiology (including the current thoughts of the time regarding heating and cell damage), and epidemiological results of different treatments (most forms had extremely high levels of mortality). The reader is encouraged to obtain this text to fully grasp the quality of its offerings and to catch a glimpse of the road to our current understanding.Some of the first in-depth descriptions in medical literature of the beneficial use of cold water and ice to treat patients with heat stroke is likely attributed to Darrach23 and Levick3 in the late 1850s. Darrach described numerous cases in which the treatment included stimulants, sinapisms (ie, plasters) to the extremities and body, and ice to the head.23 The description of the type of stimulant and the composition and extent of sinapisms is lacking, but the article purports the benefit of cold water and ice.Much of Levick's writing's seems to be well ahead of his time, and certainly many of the concepts that become dogma in later years can be traced back to this seminal work. He offered contributions across the gamut of this condition3: Cause: "unacclimation I believe to be a strong predisposing cause."Recognition: "when however an individual, and still more so when a number of persons in ordinary health exposed to a temperature approaching 90°F in the shade, are suddenly seized with these symptoms (speaking of unconsciousness, labored respiration, and extreme sweating), for a moment perhaps preceded by thirst, vertigo, and a confused perception of colours, there can be little doubt that the attack is that of sunstroke."Treatment: "I believe this to be, with some modifications, the treatment called for" (speaking of using cold water affusions over entire body). Levick3 stated, "I can readily conceive there may be instances in which the powers of life may be so spent, as to fail to respond to the shock of the cold, and the existing depression be this increased." It is possible that Levick, while noting the importance of cold water, was still hanging on to some preconceived notions regarding its use. It is likely that most of the ill patients he described would most benefit from this aggressive treatment. However, those who had a severe condition and delayed treatment likely did not respond to the treatment because the damage had already been done and no treatment could have helped at that time.During the same time frame, Merrill24 provided commentary on the classic heat stroke paper by Levick.3 Merrill noted that the differences in the successes of various treatments is due largely to "time, and manner, rather than upon a want of adaptation."24 This statement emphasized the importance of rapid treatment once hyperthermia occurs, and that even the best treatments may not have value if treatment is delayed. However, Merrill demonstrated the characteristic lack of evidence-based medicine of that time when he stated that "opiates, bloodletting, and cold bathing have all been used successfully in these affections by many physicians, and by as many, perhaps, unsuccessfully."24 The combination of all of these treatments into the same sentence suggests that they provide equal benefit, whereas the medical evidence of that era could offer no support. He advocated the use of chloroform and stated it is "far superior to any or all of these, for this dangerous condition of the system," but later stated "my experience has not been sufficient to determine its true value in such affections, or the proper method of administration."24 Merrill's advice was not based on medical evidence and clearly could have misled unknowing practitioners.One of the most unique and, in retrospect, impractical treatments of the 1800s was described by Edwin Babbit in The Principles of Light and Color.25 He prescribed using the color blue for sunstroke (and other conditions such as sciatica, meningitis, nervous headache) and red for physical exhaustion (as well as constipation and paralysis). Babbit developed a funnel-shaped device that used color filters to focus light on specific body parts. Our question, with a hint of sarcasm, is, if an individual was experiencing EHS, would Babbit have recommended both red and blue simultaneously? Similarly, in 1914, Colville also wrote about using light and color in the treatment of sunstroke, stating that an individual's sunstroke "was quickly relieved by simply wearing a blue band or lining inside his customary hat."26A final synopsis of this era offered in 1895 what may be considered one of the most intuitive observations of the time. Wilson et al27 showed the importance of rapid cooling by being the first (we believe) to state that you should cool first and transport second. In addition, they prescribed the use of ice or cold water and the measuring of temperatures in the rectum. They eloquently stated27: From the experience of several physicians it must be remarked that for the treatment of insolation (thermic fever) every ambulance should carry ice, sprinkler, and pail, and the patient should be treated on the spot until the ambulance surgeon feels it is safe to move him. It is essential to have the patient's clothing removed, and it is best to take thermometric observations with the thermometer in the rectum.The concept of on-site cooling is a doctrine that is still struggling to find traction currently, but the evidence indicates immediate, on-site cooling could be the single biggest factor to assure survival, or the death knell, for those experiencing heat stroke on whom it is not practiced. Kudos should be offered to Wilson et al27 for recognizing 3 critical concepts that are the key to EHS treatment. First, get an accurate temperate via the rectum. Second, use cold water and ice to rapidly cool the patient. Third, treat on-site if at all possible. These are concepts that were, when taken as a whole, completely innovative and unheard of during this era of medical care regarding EHS. But all was not perfect with their recommendations; they did encourage the use of bloodletting "if the circulation and respiration do not improve with the fall in temperature."27 Upwards of 16 ounces of blood were recommended to be withdrawn—a substantial amount of blood for a likely dehydrated person to lose during the acute stress of EHS.Hazzard28 similarly offered some of the earliest observations regarding the differences between sunstroke (EHS) and heat exhaustion in his 1901 treatise, "The Practice and Applied Therapeutics of Osteopathy." He especially emphasized the differences in severity (heat exhaustion being less serious) and the need for rapid cooling for sunstroke28: It must be treated promptly. The patient should be laid in the shade, the clothing be loosened, and the applications of cold water to head, spine and surface of the body are made. Ice may be rubbed over the surface of the body, or the patient may be put in an ice-bath (ice in the water).ConclusionIt is evident from this review that beliefs related to the causes and management of heat-related problems have continually evolved over centuries. Although medical opinion and management has changed over the years, many current treatment concepts were in place as early as 400 BC, when Hippocrates recommended cooling the body with cold water, and have progressed through the 19th and into the 20th centuries.Part 2 of this literature review, to be published in the next issue of Athletic Training & Sports Health Care, extends the discussion about the causes and management of heat stroke, beginning in the mid-1800s and progressing through the current evidence-based practice and standard of care.1.Osler W. Principles and Practice of Medicine. New York, NY: Appleton and Company; 1892. > Google Scholar2.American College of Sports Medicine. Exertional heat illness during training and competition. Med Sci Sport Exerc. 2007; 39:556–569. > CrossrefGoogle Scholar3.Levick JJ. Remarks on sunstroke. Am J Med Sci. 1859; 37:40–45. > CrossrefGoogle Scholar4.Casa DJ, McDermott BP, Lee EC, Yeargin SW, Armstrong LE, Maresh CM. Cold water immersion: The gold standard for exertional heat stroke treatment. Excers Sport Sci Rev. 2007; 35:141–149. > CrossrefGoogle Scholar5.Pandolf KB, Burr RE, Wenger CB, Pozos RS. Medical Aspects of Harsh Environments. Washington, DC: