Hx of heat stroke 2 of 2

178 Copyright © SLACK Incorporated
Historical Perspectives on Medical Care for
Heat Stroke, Part 2: 1850 Through the Present
A Review of the Literature
Douglas J. Casa, PhD, ATC, FACSM, FNATA; 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
ABSTRACT
Part 1 of this literature review provided a snapshot of some of
the important historical landmarks regarding the standards of
medical care for heat stroke from ancient times through the
nineteenth century. The second part of the manuscript contin-
ues from the mid-1800s through the current evidence-based
practice and standard of care for heat stroke.
“The profession generally have but vague and indefi-
nite ideas respecting it, and it is a matter of surprise that
medical literature is so deficient on the subject.”
~ Dr. H.S. Swift1
[Speaking of current physician
knowledge regarding heat stroke in 1854]
P
art 1 of this manuscript2
discussed accounts of
beliefs about the causes and management of heat
stroke from ancient times through the nineteenth
century. Part 2 presents an extension of these accounts
beginning in the mid-1800s through the current evi-
dence-based practice and standard of care.
Military Experiences From 1850 to 1900, with
Emphasis on the Civil War
Medical education and patient care during the mid-
1850s were lacking in comparison with today’s stan-
dard.3-6
Sunstroke (ie, all categories of heat-related ill-
nesses) was common during the Civil War, yet a fairly
small number of deaths were specifically attributed to
the condition. Sunstroke was mentioned in soldiers’
diaries, memoirs, and letters, and occasionally in of-
ficer reports.7-9
Hours of drills and marches in woolen
uniforms, carrying gear during hot summer months,
and limited access to water contributed to the cases
that occurred. Symptoms most often included head-
ache, nausea, vomiting, and faintness, followed by
convulsions and unconsciousness.10
Reports after the Civil War categorized all heat-related
ailments under the term sunstroke, regardless of severity.11
According to an 1885 report from the Adjutant General’s
Office, 313 deaths occurred among Union forces due to
sunstroke.3,5
However, it would seem likely that heat-
related problems and dehydration contributed to many
more of the 620,000 total casualties. Of the nearly 13,000
deaths reported at Andersonville Prison (Ga) between
1864 and 1865, only 52 were attributed to sunstroke.12
This relatively small number is somewhat difficult to
understand in view of the lack of shelter from the hot
Georgia sun. A newspaper account states that 7200 fed-
eral soldiers suffered some degree of this problem, yet the
mortality was low, probably due to the prompt attention
given.13
An 1888 report from the Surgeon General noted
Dr Casa and Dr Armstrong are from the Department of Kinesiology, University
of Connecticut, Storrs, Conn. Dr Carter is from the Thermal and Mountain
Medicine Division, U.S. Army Institute of Environmental Medicine, Natick, Mass.
Dr Lopez is from the University of South Florida,Tampa, Fla. Dr McDermott is from
the University of Tennessee, Chattanooga, Tenn. Dr Scriber is from Ithaca College,
Ithaca, NY.
Originally submitted August 26, 2009.
Accepted for publication December 22, 2009.
Posted online May 14, 2010.
The authors have no financial or proprietary interest in the materials presented
herein.
The authors thank Jill Livingston, Medical Librarian, University of Connecticut,
for doing all of the heavy lifting regarding locating some phenomenal sources
that made this 2-part article such a joy to prepare and write. Her efforts were
above and beyond the scope of her job, and the authors are very grateful for the
professional assistance.
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: douglas.casa@uconn.edu.
doi:10.3928/19425864-20100514-01

179Athletic Training & Sports Health Care | Vol. 2 No. 4 2010
History of Heat Stroke: Part 2
6617 cases of sunstroke among White soldiers.10
Of the
more than 400,000 pensions awarded between 1862 and
1888, approximately 1500 pensions were awarded to fed-
eral soldiers due to sunstroke and the many complica-
tions(eg,diseasesoftheliver,viscera,abdomen,heart,and
lungs, dizziness of the head, mental aberrations, epilepsy,
vertigo, loss of speech, and hemiplegia) that arose from
it.14,15
Of the 10,000 Union soldiers treated in hospitals
near Frederick, Md, after the battles in 1862, only 11 had
sunstroke listed as their chief complaint.16
Some ceme-
tery gravestone logs list sunstroke as a cause of death for
some Civil War soldiers (Figure) (J.H. Nelson, personal
communication, 2004).
First-person soldier accounts regarding sunstroke
give several interesting perspectives of this problem and
how it was treated.7
These accounts demonstrate that sol-
diers understood that direct sun and heat, combined with
heavy marches, were causative factors in sunstroke. It is
also clear that they understood the importance of shade,
rest, loosening their clothing, fanning, and drinking water
in minimizing sunstroke. Examples from some of these
accounts follow. One account5
noted:
Of those remaining, a very large number were greatly
exhausted by the last two days’ marching, some have fall-
en by sunstroke,…not more than one-third of my force
could be carried into action.
Confederate General “Stonewall” Jackson mentioned
the oppressive heat at the Battle of Cedar Mountain, Vir-
ginia, and mentioned several cases of sunstroke among
the casualties17
:
• Scores upon scores fell out, unable to proceed a
step further. Some of the poor fellows traveled as long
as they could endure the heat, and then dropped dead
in their tracks. Six of the 10th New Hampshire were re-
ported to have died that day from sunstroke…. I myself
counted over fifty cases of sunstroke in the space of a
few miles, but whether they proved fatal or not, I never
knew.7
• I never saw so many broken down, exhausted men
in my life. I was sick and as wet with blood and sweat as I
could be, and many of our men were vomiting with exces-
sive fatigue, overexhaustion, and sunstroke; our tongues
were parched and cracked for water, and our faces black-
ened with powder and smoke, and our dead piled indis-
criminately in the trenches.9
• This was a hard day owing to the scarcity of water
and excessive heat.8
• These marches are nearly as fatal as a hard-fought
battle.18
• It is very hot this afternoon. I put green leaves in
the top of my hat to protect my head from the sun and
sunstroke.12
• It first showed itself as an attack of sunstroke,
and ever since that time any exertion has found me weak
Figure. Kent Scriber, pointing out the grave marker of Civil War Soldier George Moran, 34th Massachusetts Calvary, who died of sunstroke. Antie-
tam National Cemetery, Sharpsburg, Md (Photos by Roger Eslinger).
A B

Casa et al.
and unable to endure fatigue as I used to in the old cam-
paigns.19
• Many of them faint of sunstroke, others fanning
themselves or cursing those in command.20
Although the sick and wounded in the Civil War
generally suffered greatly because of the limited medi-
cal knowledge and training during that time, there is
evidence that soldiers, as well as those who cared for
them, had a fairly good recognition of heat-related
problems and how to manage them.13,21
Physicians
also mentioned that the loads carried by soldiers not
only interfered with pulmonary expansion, but also
prevented evaporation and cooling because more of
the body’s surface was covered.10
Veteran soldiers
were less likely to experience heat-related illness than
were new recruits because they would drop out of the
march, loosen or remove some of their clothing, rest in
the shade, and drink water until symptoms resolved.21
Removing belts, equipment, and clothing; resting in
the recumbent position; moving into the shade; and
drinking water generally sufficed.22
The new recruits
were more likely to try to continue a heavy march until
they fell by the wayside, sometimes dying as a result.
As might be expected, most heat-related problems oc-
curred during the hot and humid months of June, July,
and August, during long marches or exhausting labor
such as erecting field fortifications.10,21
Many understood the need to shade the body in effort
to cool someone if they were showing signs of hyper-
thermia. Keeping the head cool was known to be particu-
larly important. Havelocks, or cloth hat covers with ex-
tensions draping down to cover the soldier’s neck, were
used early in the war but were discontinued when com-
manders realized that they increased body heat storage
because they prevented the circulation of air around the
head and neck.23
When a soldier experienced heat-related
illness, it was common practice to encourage him to
drink water and loosen his clothing. An 1866 newspaper
article10
mentioned that a favorite sunstroke treatment in
the army involved the continuous dashing of the patient’s
body with cold water until revived, and allowing him to
drink plenty of water as soon as swallowing was possible.
Another newspaper account24
after the Civil War men-
tioned that soldiers knew that sunstroke most likely oc-
curred when supplies of water were exhausted; as long as
the canteens were full, sunstroke was uncommon. Some
Civil War physicians also noted that bloodletting was
neither recommended nor used, although some medical
officers previously had used this technique to treat sun-
stroke and other maladies.10,21,25
Both medical personnel and soldiers knew to expose
the body of a stricken patient by removing clothes, and
to cool the body by using cold cloths to swab them. The
patient was moved to a cool shaded area and tight cloth-
ing was loosened, especially around the neck and chest.26
The conscious patient received cool water to drink, and
cold water was poured on the extremities; if the skin was
hot and dry, ice was wrapped in a towel and placed on the
head.26
A Massachusetts inventor patented a hat insert to
be soaked in cold water and placed under a hat to prevent
sunstroke. His invention was used by the U.S. Army and
the U.S. Navy.27
It also was known that alcoholic extracts
evaporated more quickly than water, causing a greater
degree of cooling.28
Strenuous marches in hot weather and lack of condi-
tioning contributed to the risk of heat stroke. A Union
assistant surgeon from New York watched some of his
men “fall as if they were shot and die almost as quickly,
from sunstroke” and questioned the “pointless routine
of marching and countermarching, when no rebels are in
sight or hearing.”29
In the same account, he mentioned
how the men improved after washing and bathing in the
river. Another surgeon made an interesting statement
indicating knowledge of a difference between sunstroke
and heat exhaustion, after approximately one-quarter of
the men dropped out of a march due to heat prostration.
Because internal body temperatures were not taken, “it is
not known whether the condition was sunstroke or heat
exhaustion.”30
In 1863, Dr. William King31
recognized
the need to “season new troops to their work (soldier-
ing) by a little previous training” (ie, heat acclimitization)
to prevent exhaustion and illnesses. He stated this after
many fresh troops became immediately ill and several
hospitals had to be established between Harrisburg, Pa,
and Hagerstown, Md.
Many different treatments and cures for sunstroke
can be found when examining medical and nonmedical
references from the latter part of the 1800s. These in-
clude some current standards, such as cooling the body
by applying cold water, loosening clothing, fanning the
individual, and having the individual drink water. A
medical text printed as late as 1892 mentioned bleeding
as an acceptable treatment for sunstroke and many other
conditions.25
Newspaper accounts and advertisements
described various causes and “cures” for sunstroke dur-
ing the late 1800s (Tables 1 and 2).32-40

Overall, the care provided for Civil War soldiers, who
suffered from dehydration and heat-related problems,
appears to have been more advanced than the care for
most other diseases and illnesses at that time. During a
war in which two-thirds of all fatalities were caused by
noncombat problems (eg, disease, infection, diarrhea),
deaths directly attributed to sunstroke were related to the
level and nature of available medical care.
Military Experiences Through the 20th Century
Significant advances in our understanding of exertional
heat stroke (EHS), especially with regard to its etiology
and treatment, occurred during the first half of the 20th
century (Tables 3 and 4).41-69
Much of this progress came
about as a result of military experiences. During the Span-
ish-American War of 1898, the U.S. Navy maintained
various classes of ships to accomplish a range of missions.
Battleships and monitors were the most dangerous crafts
because of the heat and humidity generated in their steam
and engine rooms (41-96°C, 105-204°F). Even though
considerable improvements in ventilation and insulation
were made during the first decade of the 20th century,
numerous cases of heat illness appeared aboard ships.
The highest incidence of heat stroke fatalities occurred
from 1900-1903, when 9 deaths and 4 military discharges
occurred among 24 hospitalized sailors.41
During a simi-
lar period (1902-1905), the British Army reported 216
heat stroke deaths.43
In a 1935 lecture presented to the Royal Society of
Medicine in London, D.H.K. Lee48
differentiated heat
stroke, heat exhaustion, and heat cramps as distinct ill-
nesses with distinct etiologies. His description of heat
stroke was similar to our current clinical understanding.
This included a great increase of body temperature with
Table 1
Interesting Items Regarding Heat Stroke in 19th Century Newspapersa
Headline Summary reference
Insanity Cured by a Sunstroke A young lady who was insane for 3 years was overcome with heat stroke
while picking berries. After recovering from fainting several times she
began to talk rationally.
TheSyracuseCourier, September 19,
189839
The Cause of Sunstroke The NYS Pathological Institute investigated and stated that they believed
virulent poisons were secreted in the blood and caused sunstroke (as
opposed to direct sunlight).
UticaDailyUnion,August 28, 189635
;
TheSyracuseDailyCourier, June 21,
187036
The Nature of Sunstroke NYS researchers felt sunstroke was an autotoxic malady where fluid secre-
tions (poisons) were created in the body and not excreted in hot, humid
weather.
RochesterDemocratandChronicle,
August 24, 189640
Theory of Sunstroke Described a theory where they believed an infectious organism in the
soil (activated/facilitated by heat and humidity) actually was causative of
sunstroke.
Bridgeport(CA)ChronicleUnion,
189537
a
All sources accessed through http://www.fultonhistory.com.
Table 2
Items Regarding Heat StrokeTreatments in 19th Century Newspapersa
Headline Summary reference
Sunstroke (Duffy’s Pure MaltWhiskey advertisement) The one remedy that has been used with continued
success since 1860
TheOswegoDailyPalladium, August
8, 191334
Combats Heat Prostration and Summer Complaints
(Vin Mariani advertisement)
Use the world famousVin Mariani body, brain, and
nerve tonic
TheEveningTelegram, August 10,
189938
Catarrh, Dyspepsia, and Sunstroke Cured (Sarsaparilla
advertisement)
After drinking 3 bottles, a gentleman claims he was
cured from sunstroke.
TheOswegoPalladium, December
26, 189133
Heat Prostration (Bovinine advertisement) A few drops of Bovinine introduced into the system
promotes vitality, without an increase in heat and is
invaluable for treating heat prostration.
RochesterDemocratandChronicle,
July 12, 189532
a
All sources accessed through http://www. fultonhistory.com.

Casa et al.
predominant nervous system involvement that may
progress to permanent nervous impairment if cooling
is not instituted. Lee48
described the key clinical char-
acteristics as irritability, nausea, headache, convulsions,
stupor, or dyspnea and stated that a patient’s response
to treatment hinged on reducing body temperature. He
considered an increase of protein breakdown products
and lactic acid in blood and urine as terminal events.
Table 3
A Snapshot of Key Moments in the Medical Diagnosis,
Predisposing Factors, and Prognosis of Exertional Heat Stroke
Year Milestone Reference
1865 The first recorded death of a U.S. Navy sailor occurred due to heat stroke. Fiske, 191341
1896 U.S. Navy reports 59 cases of heat stroke and numerous cases of heat exhaustion, due to inadequate
ventilation and high heat-humidity (105-204°F, 41-96°C) in engine rooms of ships.With improvements in
the insulation and design of ships, casualties were reduced in subsequent years.The role of exercise was
acknowledged as a contributory factor.
Fiske, 191341
1900-1903 Nine U.S. Navy sailors die of heat stroke while on duty. Fiske, 191341
1905 For the first time, J.S. Haldane established that a rise of human core body temperature correlated more
strongly with air wet bulb than dry bulb temperature.
Haldane, 190542
1913 A study of 50 heat stroke deaths identified the following predisposing factors: hot-moist air, muscular
exertion, unsuitable clothing, carrying a heavy load, and alcohol abuse.
Pembry, 191443
1914 For the first time, the incidence of military casualties in the heat was correlated with the wet bulb
temperature.
Simpson, 191444
1914-1918 More than 600 heat stroke deaths occurred in British troops stationed in Mesopotamia duringWorldWar I. Mitchell & Smith, 193145
1920 The following host characteristics were recognized as predisposing factors for heat stroke, in British
troops (see previous item): alcohol abuse, age .40 years, exertion, and febrile diseases (eg, malaria, sand-
fly fever, typhus, smallpox).
Willcox, 192046
1927 A military epidemiology study spanning 65 years showed that being born in the northern (versus south-
ern) United States involved an increased risk of heat casualties (all types).
Wakefield & Hall, 192747
1935 D.H.K. Lee distinguished heat stroke, heat exhaustion, and heat cramps as distinct illnesses with different
etiologies.
Lee, 193548
1939 Sleep loss is recognized as a predisposing factor to heat stroke in British soldiers. Nicholls, 193949
1942-1945 E.F. Adolph et al conducted field studies in California and Florida, subsequent to the United States enter-
ingWorldWar II.Their observations delineated several predisposing factors to exertional heat illness.
Adolph, 194750
1941-1945 More than 220 fatal cases of heat stroke occurred in the U.S. Armed Forces duringWorldWar II. Most
occurred during basic training in southern installations.
Haymaker et al, 195551
;
Gardner & Kark, 200152
1941-1945 British military training for hot environments emphasized provision of adequate water and salt, sleep,
and heat acclimatization.
Mellor, 197253
1957 The wet bulb globe temperature successfully predicted the incidence of Marine heat illness casualties
at Parris Island, South Carolina.This index subsequently was used to regulate the amount of strenuous
exercise during training.
Yaglou & Minard, 195754
,
Minard, 196155
1964 The book HeatStressandHeatDisorders summarized the diagnosis and predisposing factors of exertional
heat stroke.
Leithead & Lind, 196456
1976 Reviews of Israeli Defense Force medical records indicate that most exertional heat stroke cases occur in
highly motivated, healthy, young men who exert themselves beyond their physiological capacities.
Shibolet et al, 1976,57
Epstein et al, 200158
1980s The Israeli Defense Force institutes laboratory heat tolerance testing of all soldiers who experience heat
stroke to determine their fitness to return to duty.
Multiple57,59-61
1988 The Energy Depletion Model of heat stroke pathophysiology is described. Hubbard & Armstrong,
198862
2003 The book ExertionalHeatIllnesses detailed the medical diagnosis, predisposing factors, and prognosis of
exertional heat stroke in military, sport, and industrial scenarios.
Armstrong, 200363

World War II
Military training and combat operations have been a
consistent cause of heat injury-related morbidity and
mortality.70-72
During World War II, approximately 250
fatal cases of heat stroke occurred in the U.S. military,
mostly in military basic training camps in the south-
ern United States (this number likely grossly under-
estimates the number of EHS, given the toll the heat
had on the North American and South Pacific theatre
during World War II).11,51,73
After World War II, these
southern U.S. military training installations continued
to produce disproportionately high EHS incidence and
mortality rates.55
Unfortunately, many of these fatali-
ties could have been prevented with appropriate treat-
ment and vigilance by commanders and medical staff.
However, during World War II, the main goal involved
preparing a large number of troops rapidly in prepara-
tion for the challenges that existed in Northern Africa,
Europe, and the South Pacific. The Great Britain War
Office publication “Memoranda on Medical Disease in
Tropical and Subtropical Areas,”66
published in 1930
and then distributed by the U.S. Army in 1943, stated,
“The most effective means of reducing pyrexia is by
securing evaporation of water from the skin. Evapo-
ration carries .59 calories of heat per gram while the
melting of ice takes away only .08 calories per gram.”
The specifics of treatment included, “The nude patient
was placed on a table with a web or rattan top that
allowed the circulation of air under his body. He was
sprayed with water at room temperature, while large
electric fans were played over his body.” The author66
noted that “packing a patient in ice is certainly an ap-
pealing method. However, the heat loss by conduction
is minimal and the resultant water has to reach body
temperature, and the surrounding air would be agi-
tated before the maximum result could be achieved.”
We believe the treatment prescribed by the British and
U.S. military forces, and seconded by Larkin,74
would
certainly serve as a viable (although certainly not ideal)
treatment method, but we question the logic that leads
to an erroneous assumption that cold water immersion
(CWI) is not an effective treatment.
In what is commonly considered an important land-
mark toward our understanding of the influence of heat
and dehydration on exercise heat tolerance and health
issues, Adolph et al50
published Physiology of Man in
the Desert in 1947. The book was a culmination of a
4-year effort during World War II (1942-1945) to study
various components of the human response to exercise
in the heat. The ultimate goal for this research team was
to study soldiers during actual training scenarios to
enhance the health and performance of American sol-
Table 4
A Snapshot of Key Moments in theTreatment of Exertional Heat Stroke,
1917 to the Present
Year Milestone Reference
1917 British medical officers established heat stroke treatment stations, including ice for body cooling
and abundant water for drinking.Troops were relieved of duty between 1000 and 1600 h whenever
possible.
Wilcox, 192046
; Hill, 192064
1917 One of the first known applications of whole-body cooling for heat stroke via immersion in a tub of
tap water, covering the body except the head.Vigorous skin massage was performed and ice was
freely added to the water bath.
Gauss & Meyer, 191765
1930 The superiority of water evaporation (versus ice pack application) was described in terms of removal
of heat: (a) water evaporation removes 0.59 cal/gram whereas melting ice removes only 0.08 cal/
gram, and (b) evaporation of only 70 grams of water removes as much heat from the body as a 1-liter
ice water enema.
Great BritainWar Office,
1930,66
as cited in Nicholls
193949
1990 A published report described the success of ice-water immersion therapy, applied to 250 cases of
exertional heat stroke among Marine recruits at Parris Island, SC. Zero fatalities occurred.
Costrini, 199067
1996 The American College of Sports Medicine reports that cold- and ice-water immersion provide the
fastest cooling rates during heat stroke treatment.
Armstrong et al, 199668
2007 A review of the medical and scientific literature shows that cold-water immersion reduces core body
temperature faster than any other cooling modality, and provides practical guidelines for implement-
ing cold-water immersion.
Casa et al, 200769

Casa et al.
diers fighting in some of the most extreme heat condi-
tions during World War II. Unbeknownst to them at
the time, it has become a building block for the field of
thermal physiology.
Post-World War II
After World War II, much attention regarding EHS fo-
cused on prevention by instituting measures such as heat
acclimatization guidelines, work-rest cycles, and hydra-
tion intake guidelines.11,75,76
Prior to this period, com-
manders erroneously ignored the consequences of exer-
cise in the heat, and many withheld water during intense
or prolonged maneuvers and field operations because
it “toughened the troops.”75
In 1954, the Navy Bureau
of Medicine and Surgery evaluated the wet bulb globe
temperature (WBGT) as part of its heat injury preven-
tion program, and in 1956 the WBGT index was adopted
by the U.S. Marine training command at Parris Island,
SC.77
According to Minard,55
prior to the institution of
preventive measures in 1952, the incidence of heat illness
at Parris Island was 40 per 10,000 individuals. Shortly
thereafter, the use of WBGT became widespread within
the U.S. military community and heat illness rates sub-
sequently decreased. The WBGT, as a new climatic heat
stress index,77
replaced many existing indices around the
world. The British Army developed guidelines based
on WBGT78
and acclimatization strategies in the 1960s
and 1970s, in response to a large number of heat illnesses
amongtroopsdeployedtoCyprus,Malaya,andKuwait.75
The Israeli military also adopted WBGT indices of heat
stress, but incorporated minimal temperature limits that
were much lower than the U.S. and British guidelines.
The WBGT index and other heat stress mitigation
strategies led to a significant reduction in the number
of heat injury and EHS cases.77
However, the success of
decreasing mortality rates resulted primarily from the
application of whole-body cooling during military train-
ing.59,60,79
Importantly, numerous soldiers during subse-
quent conflicts such as the Vietnam War and Gulf War
(1991) benefited from the lessons learned during earlier
conflicts.80
Several cooling strategies have been investi-
gated and reviewed by military scientists; despite these
investigations, some uncertainty still exists regarding
the best therapeutic approach for EHS treatment. Cool-
ing procedures range from removal of clothing to CWI
and ice water immersion (IWI).81
Acceptable cooling
methods vary considerably across military communities
around the world.
Between 1977 and 1990, 2 laboratories evaluated prior
EHS patients by administering a standardized heat tol-
erance test. These tests (ie, 90 minutes of brisk treadmill
walking in a 38°C [100.4°F] environment) demonstrated
that some patients with heat stroke, although declared
normal on the basis of clinical standards, exhibited ex-
ercise-heat intolerance 2 to 5 years after the event.82,83
In
contrast, 10 patients with prior heat stroke were evalu-
ated 61 days after experiencing heat illness84
; 9 were able
to acclimatize to exercise in the heat normally, and only
1 patient required 11.5 months to return to normal. It is
reasonable to ask why this range in recovery times ex-
ists in patients with prior heat stroke. We believe that this
can be explained in terms of the degree of damage that is
inflicted by the initial heat illness episode. This explana-
tion is supported by the research of Shibolet et al,57
who
observed 20 “light” and 16 “severe” cases of EHS. In the
former group of patients, coma was less prolonged and
hyperthermia fell rapidly within 1 hour. Patients with se-
vere heat stroke, in contrast, were often moribund on ad-
mission and died early of central nervous system damage.
The primary difference was the degree of multi-organ
damage, which was limited when heat stroke was iden-
tified swiftly and whole-body cooling was administered
promptly.84
An alternative method of cooling developed by Kho-
gali and Weiner,85
which used evaporative cooling from
the warm skin, mainly due to concerns about negative
physiological consequences, increased core temperature
secondarily to skin constriction, in response to CWI. The
U.S. and Israeli militaries have never documented a case
of paradoxical increase in core temperature following
CWI, so this alternative technique has not been widely
used by the military community. Several pharmaceutical
strategies have been evaluated but are not generally rec-
ommended.81
The use of antipyretics in the treatment of
EHS has been suggested, but most militaries, notably the
Israeli Defense Force, are against their use in EHS treat-
ment.86
The Past 30 Years
In the past 30 years, written protocols for EHS treat-
ment have been developed and instituted by the mili-
taries of the United States, Canada, Israel, France, the
United Kingdom, and several North Atlantic Treaty
Organization countries.78
Currently, the medical guide-
lines for EHS treatment in other countries (ie, Singapore
and Ecuador) are consistent with Western countries that

contribute most to the literature and research on heat
illness. In 1982, a 7-km training run was performed on
an extremely hot and humid day; as a result, 20 of 216
Ecuadorian cadets experienced exertional heat illness,
were treated with intravenous fluids, and were cooled
by removal of clothing in an air conditioned room.87
Most of these individuals recovered over time, but with
subsequent injury. Unfortunately, 2 of the 6 soldiers
who required hospitalization died in subsequent days.
It is likely that survival rates would have been higher
with more aggressive cooling.87
The method used to treat those experiencing EHS
depends on the resources available.59,60,79
Immersion
in a tub of ice water is the most widely used successful
method. Because water has a very high specific heat, this
method results in a rapid reduction of core temperature
to less than 39°C within 10 to 30 minutes.59
In 4 mili-
tary reports that evaluated water immersion treatment
of EHS in more than 300 soldiers, no fatalities were re-
ported.59,67,71,79
Investigators affiliated with the Israeli Defense
Force57,61
historically have been leaders in studying EHS
treatmentmodalities.TheIsraeliDefenseForceadvocates
that 2 factors must be considered: availability of cooling
methods and the environment where the EHS occurs.
The Israeli military doctrine also stresses the importance
of adequate water intake for heat illness prevention. In
2000, Israeli Defense Force researchers analyzed 52 cases
of EHS and showed that placing the casualty in the shade,
removing clothing, wetting the skin with large amounts
of tap water, and fanning the skin vigorously will remove
a significant amount of heat from a patient.59
Recent in-
vestigations conducted by the Israeli Defense Force high-
light the importance of rapid treatment of heat stroke. In
“The ‘Golden Hour’ for Heatstroke Treatment,” the au-
thors evaluated a series of case reports and showed that
rapid cooling of EHS in the field has an enormous effect
on prognosis.60
In addition, the work of Rav-Acha et al88
has supported the necessity of proper triage and rapid
care to decrease the fatality rate from EHS.
In 2000, Gaffin et al89
discussed the Parris Island pro-
tocol for treating suspected EHS, emphasizing that pa-
tients with suspected EHS should be placed immediately
in a tub of ice water or cold water while rectal tempera-
ture, mental status, and other vital signs are assessed. This
protocol is widely used at U.S. Marine training sites and
has proven to be very effective in treating EHS cases. Ten
years prior to Gaffin’s work, Costrini67
published data
showing a 0% fatality rate in 250 patients with EHS at
Parris Island, SC. He attributed this success to IWI.
In 2003, the U.S. Army and Air Force published a
technical bulletin, “Heat Stress Control and Heat Ca-
sualty Management,” that outlined the current guide-
lines and procedures for the treatment of EHS, as well
as evidence-based procedures for the prevention of heat
illness among military personnel.81
The U.S. Army advo-
cates that all soldiers suspected of having heat injury or
stroke must have early initiation of cooling and rehydra-
tion in the field. The first responders (ie, medics, phy-
sicians, other soldiers) should immediately remove the
individual’s clothing and initiate body cooling using the
most practical method for the setting in which they are
situated. They emphasize that CWI has the best cooling
rates and should be used if feasible (eg, during many basic
training situations in which treatment would be readily
available).
Recent U.S. military operations in the Persian Gulf
and previously in Somalia resulted in increased reliance
on aeromedical support for the treatment of severe EHS
cases.90
During the Vietnam War, aeromedical evacua-
tions contributed to saving the lives of soldiers who
may have died as a result of severe hyperthermia.80
The
goal of aeromedical evacuations is to safely transport a
patient to a higher level of care, especially when EHS
treatment resources are lacking. Further, in preparation
for deployments to hot climates, aeromedical units are
required to adjust existing supplies of oral and intra-
venous fluids and rectal thermometers and to plan for
special EHS cooling stations that incorporate water, ice,
fans, and life support equipment.90
These ground cool-
ing stations are used when field medical treatment facili-
ties are overwhelmed.
Prevention of heat stroke is a vital issue.88,91
All efforts
should be made to minimize the risk of EHS; however,
even with these efforts, it is doubtful that all EHS cases
within the military community can be prevented, due to
the nature of military training and the numerous combat
operations that occur in hot environments. Therefore,
continued efforts to enhance effective and rapid treat-
ment are paramount within military communities to
prevent EHS fatalities. When EHS occurs, the medical
staff must be properly equipped to institute whole-body
cooling therapy that saves lives. The U.S. military has
committed a substantial amount of resources to the pre-
vention, recognition, and treatment of environmentally
related medical conditions. For more than 40 years, the

Casa et al.
United States Army Research Institute of Environmen-
tal Medicine, located in Natick, Mass, has been home to
some of the most important contributions to the scien-
tific understanding of exercise in the heat, through the
work that has been done in its Thermal and Mountain
Medicine division.92
Civilian Experiences 1900 to the Present
Modern-day treatment of EHS has progressed due to
attention given to treatment and research.65,93
As early
as 1901, recommendations stated that an individual
experiencing heat stroke should be stripped of cloth-
ing and sprayed with water while he or she is massaged
with ice.94
Others supported this treatment and offered
a recommendation that an ice bath be used for serious
cases.95
Compared with earlier treatment proposals,
these recommendations were clearly advanced. A lack
of communication between physicians, medical groups,
and research regarding EHS treatment contributed to
the perpetuation of some misconceptions regarding
certain aspects of treatment. This is evident consider-
ing a variety a medical professionals supported differing
advice regarding EHS treatment. Given that IWI has
shown to be the most effective cooling modality69
and
that some researchers dispute this fact even today, it ap-
pears that the therapeutic knowledge of the early 1900s
was lost for decades and only in recent years has been
appreciated again.
Bilik,96
aU.S.physician,presentedaneffectivestrategy
for treating sunstroke in the early 1930s—he purported
that the patient be placed in a cold bath. Other supple-
mental treatments supported were “ice to [the] head, cold
enema, and heat to [the] feet.” Bilik incorrectly posited
that heating the feet accentuated cooling somehow. In
contrast to Dr. Bilik’s recommendation, in 1940 an ath-
letic trainer explained the risks associated with consum-
ing cold fluids: “Hot drinks are given in cases of overheat,
because this stimulates perspiration, which evaporates
and cools the body by refrigeration.”97
The idea regard-
ing the body heating up from ingesting cold water and
cooling after consuming heated water is unfortunate, but
assuredly a myth at this point.
In the first direct comparison of whole-body cool-
ing modalities, Wyndham et al98
attempted to isolate the
most effective treatment for miners working deep under-
ground in oppressive heat. They reported that evapora-
tive cooling (water being splashed on subjects while being
fanned) was superior to CWI. The authors claimed that
CWI causes cutaneous vasoconstriction, delaying whole-
body cooling. This claim was perpetuated in the medical
literature and still remains a misconception regarding the
treatment of those with EHS.69
The introduction of supplemental drug treatments
came with advances in pharmaceutical research and de-
velopment during the 1950s and 1960s. Authorities rec-
ommendedthatsedativeandtranquilizingdrugsbeadded
to whole-body cooling to control shivering and seizure
muscle spasticity.99,100
These recommendations were not
based on research but rather appeared in case reports
with limited success. In those cases, treatments involv-
ing ice sheets, fanning, and ice pack applications cooled
patients slowly, despite positive results due to rapid ini-
tiation. The medications added to the treatments did not
offer an increased efficiency of whole-body cooling.
Between 1950 and 1980, a reawakening occurred in
some medical circles that EHS need not end with death.101
It was proposed again that the severity of the patient out-
come was determined by the amount of time that core
temperature remained elevated above a threshold (ap-
proximately 105.5°F-106°F).102
The goal of research and
recommendations following this time period focused on
cooling the individual as quickly as possible. For example,
in 1980 the Body Cooling Unit (BCU), designed by Kho-
gali and Weiner85
and Khogali et al,103
was a novel prod-
uct that continuously sprayed tepid water on the patient
while he or she was being fanned, maximizing convective
and evaporative cooling. The water temperature was room
temperature or warm to avoid peripheral vasoconstriction
and shivering. The $18,000 cost of the BCU also was of
concern. Comparing the cooling rates, the BCU seemed
ideal, with rates as high as 0.31ºC.min-1
, the second high-
est reported with any modality. Subsequent trials us-
ing the BCU have never replicated these results; in fact,
follow-up studies reported low cooling rates. Thus, be-
cause the BCU provided inefficient cooling in most re-
ports and was inordinately expensive, the search for opti-
mal cooling continued.
Reinforcement of the Importance of Cold-
Water Immersion
Controversies regarding EHS treatment continued dur-
ing the 1980s, as authorities were divided with regard to
CWI. Larkin74
first proposed that CWI was limited by
the constraints of conduction, providing minimal cool-
ing. Strydom et al104
supported his argument and added
that peripheral vasoconstriction insulates the body;

they believed that CWI might even result in an increase
of central body temperature. Others105-107
refuted this
concept and supported the claim that ice pack applica-
tion and CWI were superior.
As the debate continued, scientists systematically be-
gan to compare a variety of treatments for whole-body
cooling. When ice pack application, evaporative cool-
ing, and passive cooling were compared, a combina-
tion of packing the entire body in ice packs and hosing
produced the fastest cooling rates.98
This refuted claims
that extreme cold applied directly to the skin causes pe-
ripheral vasoconstriction, subsequently delaying cooling.
More recently, 3 other studies compared cooling rates of
whole-body cooling modalities.105-107
Adding credence
to claims regarding the effectiveness of CWI, all 3 report-
ed the fastest cooling rates with this modality. Exertional
heat illness patients were observed by Armstrong et al105
when comparing iced towel application versus CWI in-
side the medical tent at the end of a summer road race.
The most convincing evidence to date, which supports
water immersion as a cooling modality, involved vari-
ous water temperatures.107
Researchers found the fast-
est cooling rates when the coldest water (2ºC) was used.
These studies have led to evidence-based practice, includ-
ing CWI, for the treatment of EHS.108
Interestingly, critics of CWI still exist, despite the fact
that recent reviews have supported it as the modality of
choice.22,69,109
Opponents claim that peripheral vasocon-
striction and shivering are counterproductive and make
the patient uncomfortable.110
A recent review by Casa et
al69
refuted these and numerous other claims, and labeled
CWI or IWI as the gold standard for the treatment of
EHS.
Published case reports involving patients with heat
stroke support IWI for the treatment of both EHS and
classic heat stroke. For example, Hart et al111
reported
an EHS case involving a runner who was treated with a
cooling blanket. This technique required approximately
5 hours to decrease the individual’s core body tempera-
ture to 38ºC. The cooling times of 14 individuals with
classic heat stroke (treated with a tepid shower while be-
ing massaged) averaged approximately 1 hour.112
Three
medical publications, which involved numerous pa-
tients, reported 100% survival when CWI or dousing
was incorporated.67,113,114
One report involved runners
from the Falmouth Road Race,113
and another involved
individuals with classic heat stroke during the U.S. heat
wave of 1995.115
The only patient in the latter report who
was cooled within a safe time period (ie, 20 minutes)
was treated with CWI.115
Data from case reports of in-
dividuals treated with non-water immersion modalities
show mixed results, whereas 100% survival rates are con-
sistently shown with the gold standard (CWI) of EHS
treatment. The evidence regarding the Falmouth Road
Race since the publication of Brodeur et al116
continues to
be overwhelmingly positive regarding rapid cooling. In
the nearly 40-year history of the race and more than 400
EHS cases, there still has not been a fatality when CWI is
used as the modality immediately after collapse, reaffirm-
ing recent military findings.113
The work in future years
will be to convert the recent success at road races at mili-
tary installations that have successfully treated EHS via
immediate cooling with cold water to the playing field,
especially in American football, where the incidence of
EHS is by far the highest among the youth sport popula-
tion. High schools that sponsor American football need
tobesuretheyhaveathletictrainerspresenttoaddressthe
medical issues, and the athletic trainers need to be ready
to utilize CWI on site when EHS is suspected. Only then
can we feel secure that our youth are being appropriately
cared for when EHS presents itself.69
The current EHS treatment recommendations of
professional medical organizations include the use of
CWI.108,117,118
These recommendations represent the most
current, evidence-based, best practice for the treatment
of EHS and are supported by research data, case reports,
and epidemiological data. The main predictor of outcome
following EHS is the amount of time that core body tem-
perature remains elevated; the fastest way to limit this du-
ration is to cool the individual with CWI.102
Some medical
professionals continue to disagree with this recommenda-
tion and perpetuate the myth that peripheral vasocon-
striction and shivering limit water-immersion cooling, but
these claims soon will be past misconceptions.
Conclusion and“State of the Art”Practice in
the 21st Century
In 1976, a boy who was experiencing EHS was treated
by “immersion in a heap of fermenting horse manure
for forty minutes.”119
He subsequently died. This ex-
emplifies the variety of treatment techniques and beliefs
regarding EHS that have occurred through the years.
The historical snapshots covered in this manuscript
offer insight that sometimes medical practices of the
specific time frame were not well-suited to treat this
condition. Conversely, some of the practices of the past

Casa et al.
were highly intuitive and successful. The best evidence
known today indicates that cooling the body as quick-
ly and efficiently as possible (preferably with CWI) is
recommended. The resultant rapid reduction of body
temperature is the overwhelming factor that positively
influences outcome and facilitates recovery. n
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