Wood places particular stress upon the necessity for promptitude in any and all measures that are taken for the relief of the sufferer, and says that he believes that many lives are sacrificed by the loss of critical moments in the interval between the finding of the patient and his reaching the hospital ward. He therefore advocates the equipping of hospital ambulances during the hot weather with ice and antipyrin in order that treatment may be begun at once. Cold water must be used without stint by those finding a person suffering with heat stroke, the neighboring pump furnishing the most available means. If circumstances favor, it is better to rub the patient with ice, or place him in the cold bath, that is, a bath of the temperature of about 50°. Enemata of ice water are also generally opportune. All these measures have for their object the reduction of temperature, and if they do not have this effect, they do no good, and other means must be employed. For the ascertaining of the effect of the treatment no means can be relied upon except the use of the clinical thermometer in the mouth or rectum. Still, caution is necessary that the treatment be not carried too far, since cases have been recorded where the temperature, when reduced by the cold bath after sunstroke, continued to fall after the patient had been taken out of the water until it was far below the normal. Wood thinks that but little treatment is generally required after reduction of the temperature has been effected. Yet he cites cases where the period of insensibility having lasted too long there has been no return to consciousness, even tho there has been a return to normal temperature. Such cases he considers almost hopeless, and states that he knows of no other treatment than that of meeting the symptoms as they arise, except that good results may be expected from the application of a large blister to the whole of the shaved surface of the scalp. Occasionally, after the temperature has been reduced, and even after the return of consciousness, there is great tendency to relapse, shown by rise of temperature. In these cases Wood advises wrapping in wet sheets and resort to even more powerful measures for the reduction of temperature. He gives 10 grains of quinin hypodermically, and 15 to 30 grains of antipyrin also subcutaneously. This is also favorably spoken of by Westbrook and Horwitz". When there are severe convulsions the treatment proposed by Hutchinson of the hypodermic injection of one-fourth grain of morphia, repeated in two hours, is still used with benefit. This possibly has good effect, not only thru its hypnotic power but also because it retards tissue change. This must not, however, supersede the use of means to reduce heat, but is an adjunct to such means. Venesection seems now to be condemned by all authorities, altho it was formerly largely practised in sunstroke, and with occasional occasional excellent effects. As free bleeding lowers the temperature markedly, it can readily be understood how in some cases it might bring about a return of consciousness and yet be a very improper remedy, particularly if there be any truth in the theory that sunstroke is due to diminution of the serosity of the body. Still it may be carefully considered in cases where sthenic apoplectic symptoms persist after the lowering of the bodily temperature by the bath, Wood says that there are cases of sunstroke in which the high temperature irritates the brain or its membranes into an acute congestion or inflammation, complications especially prone to occur when the high temperature has been allowed to continue for a long time. Hence, when the patient has a tendency to excessive headache and continuous fever, bleeding may become an essential remedy, not for the cure of the sunstroke, but for the cerebral inflammation that it has produced. In such cases it may prevent the occurrence of a chronic meningitis as a sequela. Packard considers as grave the cases where the temperature reaches 106° or more, saying that in such the danger to life is imminent. He agrees with other authorities that the prompt abstraction of heat is indicated, and gives the following as his treatment while at the Pennsylvania Hospital. "As soon as a patient with heat-fever was entered, he was placed on a waterproof bed, his clothing removed as rapidly as possible, a thermometer introduced into the rectum, and ice packed about the body and extremities. Lumps of ice were also briskly rubbed over the surface of the trunk and extremities. Usually 15 or 20 minims of digitalis were administered hypodermically. The thermometer was removed every seven minutes, the icing being continued until the rectal temperature had fallen to 104°, when the patient was dried and put on a clean bed with an ice-cap to his head, and in favorable circumstances the temperature gradually fell to normal. It was found that if the icing was continued until after the temperature had fallen below 104°, there was apt to be too rapid and great a fall subsequently, so that the application of external heat and free stimulation were required, certainly an undesirable state of affairs. In but few cases were other antipyretic measures adopted "Other means of treatment were employed to meet individual symptoms in various cases. When convulsions were present, after the temperature had been lowered to a considerable extent, morphin was employed, usually with good effect. In the favorable cases respiration and pulse both improved in character with the fall of the temperature; but if they did not do so, bleeding was employed in spite of the feeble pulse, and was almost invariably followed by quieter, fuller respirations with a soft, steady pulse." Still more recently the same writer advocates, in addition to the above measures, the use of hypodermoclysis, and cites a case of recovery from a condition apparently moribund, by the employment of this measure. Lewis' suggests that all physicians carry in the pocket a watery solution of antipyrin, 1:2, for instant use during a heated term, when there is likelihood of encountering a case of sunstroke, and administer 20 minims subcutaneously so soon as the patient is seen. The value of chloroform in controlling convulsions is emphasized by Gannett and Koerfer. In a case treated by the latter death seemed imminent and the inhalation of the drug was begun while the preparations for the cold bath were being made, with the result of an immediate improvement of respiration, renewed cardiac activity, and improved pulse. Koerfer attributes the utility of the chloroform to its power to diminish the irritability of the cardiac ganglia, thereby preventing the muscular fatigue upon which fatal heartfailure depends. It also acts as a sedative to the general nervous system, controlling the convulsive tendency, thus lessening heat production, (probably also facilitating heat dissipation) and permitting the employment of other therapeutic measures directed to the reduction of temperature and supplying water to replace that lost in consequence of the pyrexia. If there is much respira tory disturbance, Gannett advocates where possible the administration of oxygen by inhalation. Spellissy reports intermittent douching of the body with ice water instead of "ironing" by ice, the douching acting especially as a respiratory and circulatory stimulant, to such extent as to be inadvisable in cases with a convulsive tendency, which it seems to aggravate. In regard to medical treatment, Packard says that the use of cardiac stimulants is generally attended with but small measure of success, probably owing to slowness of action and failure of absorption even when administered hypodermically. In connection with their use it should be remembered that the most potent cause of the feeble circulation in sunstroke is not directly attributable to the heart muscle itself. Respiratory stimulants, such as atropin and strychnin, may, according to the same author, be required in certain cases. Atropin is of value in cases presenting edema or intense congestion of the lungs, when it often causes marked improvement in the character of the respiration, with clearing up of the local signs of pulmonary trouble. There is always to be apprehended the danger, consequent upon the vaso-motor action of atropin, of increasing the peripheral resistance to an already overburdened heart. Aside from this, the checking of secretion is by no means a small advantage from the use of the drug in some cases. Strychnin is only to be used when there is a marked tendency to respiratory failure, owing to the strong convulsive tendency natural to the disorder. When the embarrassment of respiration is due to tonic convulsion, the drug would be absolutely contraindicated. Packard also states that his experience in the matter of bleeding does not conform with that of other writers, since in many cases he has observed decided amelioration of all symptoms after and even during the removal of blood from the arm. He thinks that this procedure is indicated by cyanosis and venous engorgement. The matter of great fatigue previous to an attack is, in his opinion, a contraindication to venesection. The use of the catheter must not be neglected when unconsciousness persists for any lengthy period. So far as possible the use of antipyretic drugs should be avoided, since their antithermic effect may be more than counterbalanced by their depressing influence. After the successful lowering of the temperature, a full dose of calomel-from five to ten grains-is advised by Packard. E. Hirshfield10 condemns the use of the cold bath, owing to its power of increasing the internal congestion supposed to be present. He employs baths at about 15° below that of the patient's body. Barclay" strongly recommends the use of chloroform from his extended experience in India. In one case narcosis was maintained for seventy-five minutes. Coplin has used amyl nitrite with satisfactory results, its stimulating action upon the heart and its power of dilating the peripheral arterioles aiding its beneficial influence. De Santi, in the form of sunstroke he deems due to intoxication from the products of muscular exertion, lowers the temperature by cold applications, sustains the heart by artificial respiration, and combats coma by ether hypodermically. In what he calls the asphyxial form, little is needed but rest, pure air and the recumbent position. Treatment of the malarial form includes quinin hypodermically, but the first indication is the restoration of cardiac action by artificial respiration and hypodermic injection of ether. He remarks that so important is the latter means considered in Germany that during the summer marches every military surgeon is ordered to carry upon his person a Pravatz syringe and a bottle of ether in order to be always ready for cases of sunstroke. O'Dwyer's employs the ice-cap and icepack and dashes ice water with force from dippers at a distance of eight or ten feet for thirty or forty minutes, if necessary. He finds the most efficacious stimulant, altho it can be applied only one or two minutes at a time, a fine stream of ice water poured from an elevation upon the forehead. Finally, most of his patients are given hypodermically 40 minims of digitalis at a dose, unless the sufferer is very plethoric, when he bleeds, giving digitalis later in smaller doses. Hume' reports a case in which emesis produced by three grains of ipecac, relieved the patient and put him to sleep. The sufferer presented dyspnea and depression of the heart's action, due to direct vagic inhibition. Atkeys gives iced baths, ice to head, and brandy until consciousness returns, and then gives calomel. Smyth gives ice baths and the ice cap, but gives antipyrin to keep the temperature down after it has been reduced. Sickel" gives strychnin hypodermically, ice water baths, and the ice pack, enemata to relieve the bowels, chloral, etc. Sequelæ of Acute Thermic Disorders. Possibly symptoms of meningitis may appear, and if so, Packard recommends blisters over the nucha, leeching behind the mastoid processes, and moderate but frequent doses of calomel. For the headache that ensues all attacks he recommends cold to the head, mustard over the nucha, and sodium bromid either by mouth or rectum. Wood enumerates among the sequelæ inability to bear heat without cerebral dis tress or pain, with more or less failure of general vigor, dyspeptic symptoms and other indications of disturbed innervation. Pain in the head is usually prominent, sometimes almost constant for months, but always subject to exacerbations. There is also sometimes pain in the upper spine and stiffness of the neck. With these may be vertigo, decided failure of memory, and the power of fixing the attention, and excessive irritability, with some emaciation and the look of chronic invalidism. Epileptic convulsions have been noted occasionally following sunstroke. Chronic meningitis, with its attendant train of symptoms, has also been noted. The Latest Theory of Sunstroke. In this connection the recent researches of Dr. L.Westenra Sambon,18 of Rome, into the etiology of siriasis or sunstroke as an infectious disease is of more than common interest. The paper in question was published in the British Medical Journal for March 19, 1898. In the opening paragraph the author speaks of the belief as current among the profession that heat exhaustion is an initial stage of thermic fever, and states that he believes that heat exhaustion is nothing more than syncope, and that what is generally known as thermic fever is a specific infectious disease. The fact that syncope sometimes occurs in an overheated atmosphere, he says, has given rise to the misleading appellation of heat exhaustion, but in no case is heat its primary cause. In his opinion it is really a symptom, not a disease; and occurs in persons of unsound constitution, particularly in those suffering from organic disease of the heart. The original disease may have been latent, and the sudden prostration, under the stimulus of fatigue, excitement, alcohol or heat, may be its first manifestation. Numerous necropsies, he claims, prove this statement. It is most common among stokers, who are liable to cardiac affections on account of the laboriousness of their occupation, and among soldiers, who likewise suffer from circulatory disorders. Soldiers fall unconscious from syncope at parades and even at barracks, but far more frequently on the line of march, especially when oppressed by tight-fitting clothes and heavy accouterments, marching in "close order," and breathing the foul air which surrounds a close column. He gives for heat exhaustion the same series of symptoms as other authorities : Skin moist, pale and cool; breathing easy tho hurried; pulse small and soft; temperature at or below normal; pupils dilated; loss of consciousness incomplete, and, tho death may occur, an immediate recovery is the rule. The symptoms of siriasis, as quoted by Dr. Sambon, are hyperpyrexia, profound coma, and intense pulmonary congestion. Its mortality is exceedingly high; it has a peculiar geographical distribution; it prevails in the hot season and occasionally in an epidemic form. It is usually considered as the most obvious effect of exposure to excessive heat. Some attribute it to a gradual heating of the blood to a degree incompatible with the maintenance of the nervous function. Others believe that heat paralyzes the center or centers which are supposed to regulate the distribution of the body heat, thus causing either a greater heat production or a retention of heat, either giving rise to the hyperpyrexia so characteristic. Little considered it the result of pressure exerted upon the cerebro-spinal matter by the heat expanded cerebro-spinal fluid. Laveran thought the cause might be paralysis of the ganglia of the heart. Antonini assigned an acute neurosis of the vaso-motor system as the cause of any form of heat stroke. Disorganization of the blood and accumulation of urea, a deficiency of the serosity of the body from long-continuéd sweating, coagulation of the myosin, a more or less extended liberation of carbonic acid in a blood already saturated with the gas, and interference with heat loss as a result of the suppression of cutaneous perspiration are the reasons assigned by Senfleben, Smart, Vallin, Bauer, and Baxter and Zuber respectively. It will be seen that all these explanations are based on the preconceived idea that heat is the sole efficient cause of the disease. Dr. Sambon contends that the disease is produced by a specific germ, and he brings forth a volume of evidence to prove his claim, among the facts being the geographical distribution, the endemicity, the occurrence of epidemics, the very definite lesions, the character of the symptoms, the liability to relapse. He classes it with yellow fever, dengue and certain other tropical affections universally acknowledged to depend upon specific germs for their existence, germs for whose growth and transmission to man high atmospheric temperature is necessary, but, which tho occurring in, are by no means created by the high temperature. This theory has all of the interest of novelty, and is also as probable as the other theories advanced. It has also the advantage of being logical in all of its conclusions, and susceptible of practical demonstration, since once attention has been directed to it. Meanwhile, such conclusions have not thus far operated in a revolutionizing of treatment, altho such must eventually be the result of their complete demonstration and adoption, if medicine is to be a science instead of a mere series of empirical conclusions. "La Semaine Medicale, September 16, 1891. 3 Archives General de Medicine; British Medical Journal, July 18, 1896. 'Boston Medical and Surgical Journal, June, 1864. "New York Medical Journal, July 25, 1893. Transactions of Philadelphia College of Physicians, October, 1885. 'Medical and Surgical Reporter, July 27, 1888. Boston Medical and Surgical Journal, April 20, 1893. "Deutsche medicinische Wochenschrift, July 13, 1893. 10Deutsche medicinische Wochenschrift, July 20, 1893. "Madras Quarterly Journal of Medical Science, 1860. Pennsylvania Hospital Reports. 13 New York Medical Journal, June 5, 1897. 16 British Medical Journal, January 9, 1897. Sajous' Monthly Cyclopedia of Practical Medicine. Boylston Prize Essay, "The Acute Effects of Atmospheric Heat," by H. C. Wood, Jr. Tyson's Practice of Medicine. Wilson's American Text-Book of Applied Therapeutics. Pepper's System of Medicine. What First to do in Heat Prostration. The above is the result of a couple of weeks' study and research upon thermic affections by a member of our staff in one of the best medical libraries in this country. We thought it well to present this subject in full at this time to meet your needs during the heated season. At your leisure, of course you will read all of the above deliberately and mark passages containing information which you think you will use. In approaching a patient, who has been overcome by the heat, observe the following points: The Decide if it is a case of heatstroke or sunstroke, or of heat exhaustion. first thing to do is to take the temperature. If there are obstacles to taking temperature per mouth, such as gritting the teeth, or danger of the thermometer being crushed by the teeth, take the temperature by rectum. The axillary temperature will only give the surface heat. Notice if the skin is hot and dry or cool and moist to the hand. Hot skin and high temperature indicate sunstroke or heatstroke and not heat exhaustion, whereas a cool skin and temperature near or below normal, indicate heat exhaustion. The treatment for these conditions is directly opposite. For the high temperature of sunstroke cool baths, cold to the head, the avoidance of alcohol, etc., are indicated. For the subnormal temperature of heat exhaustion the application of dry heat, moderate use of alcoholic stimulants and perhaps digitalis, are indicated. After meeting the first obvious indications, proceed cautiously and deliberately, perhaps taking time to re-read carefully and entirely the above article. The preceding circumstances surrounding the individual, as whether or not he was exposed to the direct rays of the sun, or great artificial heat, or to moderate but long-continued solar or artificial heat, and to exhaustion by long-continued muscular effort, privation or dissipation of any kind. Thus the history of the several days preceding the attack will throw much light upon the proper management of the case. Don't be hasty in giving a prognosis. Be especially careful not to promise early or complete recovery, for even in the most favorable cases absence from occupation for several weeks is frequently necessary. Accidents Produced by Electricity. The treatment of those injured by lightning and by artificially produced electricity is for all practical purposes the same, since the manner in which electricity injures is in each case the same, altho certain external phenomena may differ, as for instance, the surface markings in a person struck by lightning and the bruises, contusions, etc., that are often seen in those suffering from an artificially-produced electric shock. During the summer season electric storms are frequent, and even the most distant country practitioner may have a case of lightning stroke to treat. Hence, it may be well to consider the causes operating to produce death. This may be produced by various secondary causes, such as injuries received at the time of the accident, in the nature of fractures of the skull, internal injuries, etc., or exhaustion from prolonged suppuration from the burns produced; but in cases where the electric force is the direct agent, death always comes from cessation of respiration or of cardiac action. |