PROPHYLAXIS AND TREATMENT.—The prophylaxis of sunstroke is so evident in its nature that it may be dismissed in a few words. When exposure to heat is imperative the bodily health should be maintained by avoidance of alcoholic, sexual, or other excesses, and, as far as possible, of great bodily or mental fatigue; the diet should be almost purely farinaceous, and the glandular apparatus of the bowels, kidneys, and skin kept in an active state by the use of fruit, water in abundance, and mild salines if necessary. Many persons have a very strong prejudice against the drinking of cold water during exposure to heat; and it is conceivable that large draughts of intensely cold ice-water may do harm by suddenly chilling the stomach; but when the water is taken in small quantities at short intervals, by its action in reducing the general temperature, but especially by its rendering free perspiration more easy, it must exert a most favorable influence. The addition of claret or some other local stimulant to the water is often of great service when there is a tendency to gastric or intestinal depression.
In the mild cases of continued thermic fever the basis of the treatment should be the use of the cold bath. The plan adopted by Guiteras at Key West was to wrap the patient in a dry sheet, lift him into a tub of water, having the temperature between 80° and 85°, and then rapidly cool this water by means of ice. The time of the immersion lasted from fifty to fifty-five minutes, it being regulated by the thermometer in the mouth of the patient. The patient was then lifted out upon a blanket, the skin partially dried, and the body covered. Guiteras found great advantage by giving a moderate dose of whiskey and thirty minims of the tincture of digitalis twenty minutes before the bath. He states that it is very important to avoid currents of air blowing upon the patient and to have the bath given in a small warm room. The result of the bath was invariably a lowering of the temperature, a reduction of the rate of pulse and respiration, and a refreshing sleep. After the second bath the course of the temperature seemed permanently influenced for the better. It was never necessary to give more than two baths in the twenty-four hours, but in some cases they had to be used for many days.
In the severe acute form of thermic fever it is essential that the bodily temperature be reduced at once, and no time should be lost waiting for a physician. As soon as the patient falls he should be carried into the shade with the least possible delay, his clothing removed, and cold affusions over the chest and body be practised. This must not be done timidly or grudgingly, but most freely. In many cases the best resort will be the neighboring pump. In the large cities of the United States during the hot weather hospital ambulances should be furnished with a medical attendant and with ice and antipyrin, so that when a sunstroke patient is reached he may be immediately stripped underneath the cover of the ambulance and remedial measures applied during his passage to the hospital. I believe many lives are now sacrificed by the loss of critical moments in the interval between the finding of the patient and his reaching the hospital ward.
If circumstances favor, instead of the cold affusions, rubbing with ice may be practised. The patient should be stripped and the whole body freely rubbed with large masses of ice. When practicable, a still better plan is to place the patient in the cold bath (50° F.) The employment of enemata of ice-water, as originally suggested by Parkes, may sometimes be opportune.
In using these various measures it must always be borne in mind that the indication is the reduction of temperature: if the means employed do not accomplish this, they do no good.
Relaxation of the pupil is said to be “the first symptom that shows the good of the cold affusion;”14 but as, in my experience, the pupil frequently has not been contracted, reliance cannot be placed upon this, and the thermometer in the mouth or the rectum affords the only proper guide as to the effect of the treatment.
14 Aitken, Practice of Medicine, vol. ii. p. 394.
It must be borne in mind, however, that the cold douche, cold bathing, etc. are powerful remedies, and are capable, if used too long, of doing harm. In my experiments upon animals I have seen the temperature, when reduced by the cold bath after sunstroke, continue to fall, after the animal had been taken out of the water, until it was many degrees below normal.
In the cases which have come under my own observation after the use of the cold bath but little treatment has been required. If, however, the period of insensibility has lasted too long, there may be no return to consciousness, even though the bodily temperature be reduced to the norm. Under such circumstances the case is almost hopeless, and I know of no treatment other than that of meeting the symptoms as they arise, excepting that a large blister should, in my opinion, be applied to the whole of the shaved surface of the scalp.
After the temperature has been reduced, and even after consciousness has returned, there is sometimes a great tendency to a fresh rise of temperature, and consequent relapse. This tendency may be met by wrappings in wet sheets, and, if necessary, by a recourse to the more powerful measures for reduction of temperature which have been already cited. It can be to some extent controlled by the use of quinine, ten grains of which may be given hypodermically. During the heated term of the summer of 1885 antipyrin has been used both in New York15 and in Philadelphia16 with asserted most excellent results; and the testimony is so strong that I think it should always be employed as an aid to, not as a substitute for, the direct extraction of the bodily heat. It should be given hypodermically, as soon as the patient is found, in doses of from fifteen to thirty grains.