The climatic treatment of children

Preface

The present work is intended to fill a vacant place in medical literature. While a good deal has been written on the climatic treatment of adults, most of it is somewhat one-sided, referring too exclusively to the management of tuberculosis. The climatotherapy of early life has been rather neglected; it differs widely, often radically, from that of older persons, but we have nothing important or comprehensive in the English language, or bearing on American practice, concerning this division of the subject.

Treatises on medical climatology are apt to deal too largely in generalities, whereas the practitioner is called upon to prescribe a change of air with some precision. I have therefore, in the description of climates, gone into very minute detail, especially in regard to this continent. The chapter on the climatology of temperate North America is the first attempt to present, in accessible form, a large mass of material hitherto lying buried in government reports. Somewhat fewer details are given in regard to foreign climates, on which good monographs have been published in England; they are, nevertheless, not neglected on the following pages.

No work on climatotherapy can be really satisfactory, unless it partakes of the features of a ready reference manual. For this reason, I have appended a very complete index, extending to individual localities, so

VI PREFACE

that the reader may inform himself as to climatic minutiae with the smallest possible loss of time. A manual of this sort will be a useful supplement to the ordinary treatise on therapeutics, which rarely embraces more than generalized climatic recommendations.

Finally, the urgent need, in this country, of better provision for the children of the poorer classes will be touched upon. This point of view has been forced upon me in the course of preparing this volume; America has lagged very far behind Europe in this regard, and even now our awakening is but slow and unsatisfactory. Possibly this book may act as a stimulus in this very important direction; the feasibility of adequate climatic treatment of children rests largely on economic factors, to the bearings of which communal workers, as well as physicians, should rouse themselves with more energy than they have so far displayed.

The Author.

Chapter I

Physiology of climate, temperature, humidity, variability of temperature, sensible temperature, cloudiness, rain, snow, fog, winds, atmospheric pressure, physiology of high elevations, mountain sickness, phototherapy at high elevations, temperature at elevations, the seashore, classification of climates, general application, application to childhood, climate and disease, insect-borne diseases, hay-fever Pages 1-49

Chapter VI Visceral Diseases

Diseases of the uropoietic system: albuminuria, nephritis, the "surgical" kidney, diseases of the bladder. Diseases of the digestive system, acute diarrhceal diseases, chronic diarrhceal diseases, non-diarrhceal dyspepsia. Respiratory diseases : chronic bronchitis, chronic inflammation of the upper air passages, pneumonia and pleurisy, pertussis, hay-fever. Diseases of the - ear. Diseases of the heart: compensated valvular lesions, cardiac insufficiency, congenital heart disease, pericarditis. Diseases of the nervous system : nervous irritability and nervous exhaustion, enervation, insomnia, the spasmodic affections, the paralytic affections, the painful neuroses. Diseases of the skin j ' Pages 287-352

Chapter VII

Scrofulosis. Tuberculosis: surgical tuberculosis, visceral tuberculosis. Sanatoria Pages 353-381

(For practical reasons, it has seemed best to give temperatures in Fahrenheit degrees, and elevations in feet, in preference to employing the centigrade scale and metric system).

Chapter I

The practice of medicine, as distinct from surgery, employs two therapeutic methods which we may designate as chemical and physical; the former consists in the administration of drugs and the like, the latter in the application of the great natural forces. The conditions of the atmosphere, called meteorological, supply these forces in an almost infinite variety of combination, and in a most conveniently applicable form; climatic treatment therefore constitutes probably the most generally useful department of physical therapeutics, and as such merits a more thorough and detailed study than it has hitherto obtained.

We most easily appreciate the value of climatic therapy when we recall that our other physical measures, namely baths, massage, electricity, and the newer photo- and radiotherapy, generally apply but one agent at a time. Climatic treatment not only comprises the application of heat and cold, though this forms its greatest and most important part; it also employs the atmospheric pressure, sunlight, a species of massage by the winds, and the atmospheric moisture. We therefore

l have no difficulty in recognizing that its action may often be superior to that of any one physical agent, but we also see that careful study and good judgment are requisite, if we wish to present the various climatic elements in the combination most suitable to the particular individual who comes to us for relief. We must therefore introduce our subject with a statement of its general principles and an outline of its main spheres of usefulness. In acute disease, we do not often resort to climatic treatment; here its main value is prophylactic, and in this direction we may often achieve admirable, though not always demonstrable results. This end is practically accomplished by choosing a healthful climate for the permanent residence of the normal or nearly normal individual. In chronic disease, on the other hand, the judicious selection of climate is one of our most valuable resources, and an efficient adjunct to medication and the other physical remedies. Both of these aspects of the subject shall receive extended discussion as we proceed. . Special attention attaches to the climatotherapy of childhood. The young subject is far more responsive to his physical environment than the adult; he not only requires the maintenance of health for the time being, but demands, in addition, surroundings favorable to his normal progressive growth and development. On account of his relatively very active metabolism, he also affords better opportunities for checking the advance and repairing the ravages of various ailments. Thus the proper application of physical measures may be expected to yield particularly good results in infants and children, and among these measures the selection of a beneficial climate takes a high rank.

The cardinal principles of climatic therapeutics are those so aptly laid down by Hoffmann 1 for indirect therapeutics in general, namely training and rest, expressed by him somewhat better in the German terms Uebung and Schonung. Training (Uebung) is called for under such circumstances as the following. An organ, or the entire organism, may never have learned to perform a full, normal quantum of work; it may have all along either managed to shirk a certain proportion of its duties, or shown an abnormal tendency to break down under a moderate strain. In such a case, it falls to the physician gradually to train and educate the inadequately developed organ or body, not to stimulate it, as is so often done, with strychnin and the like. It would be regarded as most unintelligent to force a boy to do a man's physical work; yet, presumably competent practitioners are attempting a parallel to this every day, with their sub-normal patients as subjects, and too often as victims. •

The above aptly illustrates the difficulty involved in raising the subnormal adult to par; training often fails in later life, even though it may not always entail the potential harm of overstimulation. In the child we are dealing with a somewhat different proposition; the growth of its body is still incomplete, its later years may be managed so as to yield better results, some of the lost ground may yet be recovered. We are therefore justified in dwelling at some length on the physical, particularly the climatic, therapeutics of the approximately normal child, in addition to discussing the treatment of actually sick children.

1 Vorlesungen (iber allgemeine Therapie, Leipzig, 1888.

A seriously diseased organ or organism requires rest; not always absolute rest, which is indeed usually unobtainable, but relative rest, what the Germans call Schonung, secured by a scaling down of the normal quota of work, either by enforced inactivity, or by shifting functions into vicarious channels. This indication is usually met more successfully than that of training, but not because of greater medical skill and resources. We shall have occasion to observe, as we go on, that most of the superiority of rest-cures, in the broad sense, over courses of training, so far as achieving tangible results is concerned, is due to a combination of circumstances. This peculiarity attaches to climatic treatment in an eminent degree, and we shall avoid unnecessary digression by investigating it from this standpoint alone; a brief survey of a few climatic, anthropological and physiological facts will make this matter perfectly clear.

The Physiology of Climate. The distinction between climate and weather cannot be stated better than in Hann's introductory words: "By climate we comprehend the total of the meteorological phenomena that characterize the average state of the atmosphere at any one locality on the earth's surface. What we call weather is merely a phase, a single act, of the succession of phenomena, whose perennially more or less similar course constitutes the climate of a locality." Physiologically, we cannot maintain this distinction, for the human body must provide not only for average, but also for occasional and even exceptional meteorological conditions. Thus, medical climatology includes both climatology and meteorology within its scope, and is not an exclusive application of the former alone; it is only the mathematical accuracy of the former science, as opposed to the numerous uncertainties still obscuring the latter, that have given the branch of medical science here under discussion its present trend and consequent appellation.

Few creatures are capable of so widespread an acclimatization as is man; yet, in spite of his range over almost the entire globe, he too, like all other animals, thrives better under some conditions than others, as is readily proved by a few statistical data. The average temperature of the earth's surface is 55 degrees, or thereabout; a careful survey of the various inhabited countries shows that the majority of the human species dwell in regions warmer than this, and that the countries averaging below 32 degrees are very sparsely settled. Historical research shows that, previous to the nineteenth century, the disproportion was several times as great as now; the cooler temperate zones have only begun to be filled up within a century or two, and it is not difficult to prove that the recent change is chiefly due to modern industrialism. None of the colder countries can feed their population with their own products alone, save in such recently opened districts as our own Northwest, where the density of the population as yet rarely approaches twenty to the square mile.

Man evidently is at least as well adapted to warm as to cool climates, even with his present constitution, which is altogether acquired; he does not do very well in .climates where frost is the rule. Anthropological studies, however, go far beyond this; the hairless skin of man, as well as recent investigations as to his origin, point to the tropical regions as his aboriginal home; they are the sole abode of the anthropoid primates, as well as of nearly all the evidently primitive human tribes (pygmies, negritos). It would therefore appear that our aboriginal environment is that of a very warm and humid climate, and that only a minority of our species have become habituated to cool regions by a very gradual process of acclimatization, aided by the invention of protective clothing. Now it happens that nearly all medical research has emanated from this minority, and that the human pathology best known is that of a cool climate; indeed, until recently, most of our ailments were attributed to the vicissitudes of that climate, and this opinion probably contains more than a grain of truth. It is therefore not strange that removal to a more genial zone should always have been regarded as a most valuable remedy for disease.

We thus see why the first attempts at climatotherapy were based on the principle of sparing the diseased organism the shocks unavoidable in a harsh climate; until quite recently this phase alone was studied, hence the somewhat one-sided development of our science. The sparing indication is met all too easily, but the indication for training, with the avoidance of injury, is satisfied with far more difficulty, and has hitherto been handled rather empirically. As a consequence, the results, especially in children, have been rarely brilliant and often disastrous, although a rational method can undoubtedly be worked out with the aid of even such data as are already at hand; what we need most of all is to keep in close touch with our physiological standards, and to set out with a clear understanding of the effect of the various climates on the normal subject. We may therefore begin with a brief review of the physiological relations of the atmospheric phenomena.

Temperature. The nude body of a healthy adult, when at rest, maintains its normal warmth of 99 degrees most easily at an air temperature of about 80; this may be called the indifferent temperature, and is reduced by very light summer clothing to about 75, by heavy winter dress to about 65 degrees; under these circumstances we feel just comfortable, when lying down or otherwise inactive. At lower temperatures we are obliged to furnish an additional amount of body heat; this we accomplish by means of an accelerated oxidation of our tissues, in its turn requiring an increased supply of oxygen through augmented respiratory activity. We achieve this extra oxidation most readily by means of muscular exertion; moderate muscular exercise, such as walking at a steady gait, lowers the indifferent temperature about ten degrees more. We can indeed effect a still further reduction by violent exercise, but this is so rapidly limited by muscular exhaustion that it is available only for a brief space of time. We therefore require artificial heat in our rooms whenever their temperature falls much below 65 degrees; out of doors, when we move about freely, we can dispense with extra wraps and overcoats at a lower temperature, down to about 55. Exposure to the direct rays of the sun introduces a factor so variable as to preclude any reduction to figures; it must suffice to state that a leeway of an indefinite, but often considerable, number of degrees is thereby afforded, depending chiefly upon the clearness of the sky. Under favorable conditions a sunny and sheltered spot will feel comfortably warm at shade temperatures near the freezing-point.

In water, an excellent conductor of heat compared to the air, the indifferent temperature is very much higher, 90 to 92 degrees in adults, 95 in- young children, and 98 in early infancy. These data are entered here, in order to dispose of this subject at once; besides, as we shall see, bathing is often made to form part of a course of climatic treatment.

The resting or sparing indication is therefore fulfilled adequately in a climate affording a daylight temperature of between 65 and 75 degrees, corresponding to an average temperature considerably lower, for the night temperatures concern us relatively little so long as they are not uncomfortably high and interfere with sleep. A lower day temperature is restful only if exercise can be indulged in, therefore neither in extreme invalidism nor when walking is impossible for other reasons. At day temperatures below 55 degrees, the element of training supplants that of rest, and whenever the latter alone is desired, so cool a climate is contraindicated. We can easily see that, near this thermal border line, it is possible to introduce some very delicate gradations with regard to the relative adjustment of temperature, rest, and exercise. On the one hand, the efficiency of the locomotor apparatus may be the chief consideration; on the other, the adequacy of the respiratory, circulatory, and excretory organs may weigh more heavily. ■ We also see how precise but delicate a therapeutic measure climatic treatment becomes so soon as we have to employ it in meeting the indication of training, and how simple its application is when rest is the sole desideratum.

The generally superior efficacy of rest-cures, in actual practice, is readily understood from the above discussion; it is almost entirely due to the ease 'and certainty of their application. It is also clear, however, that we can do excellent work, with skillful management, in cases where training is the object in view. The whole secret lies in the careful adjustment to the patient of temperatures below the indifferent point, and we shall have ample occasion to return to this subject when, in the following chapters on applied climatotherapy, we refer, again and again, to the therapeutic procedure commonly called " hardening," the most important and most abused of climatic measures.

When the temperature of the air exceeds 75 degrees, the body, even though at rest and lightly clothed, produces more heat than is needed for the maintenance of its normal warmth. The disposal of its surplus heat is effected, in the first instance, by radiation, which is, however, at best, limited to a moderate amount and greatly interfered with by even a minimum of clothing. The final resort of the human organism to meet the stated condition is the production and evaporation of sweat, which is very effective under favorable circumstances. The mere production of sweat, however, calls for additional work on the part of the vasomotor apparatus, and especially an accelerated action of the heart; heat is therefore altogether a stimulant, a point frequently disregarded in therapeutics. Many practitioners consider very warm climates as generally sedative, but the confusion with the merely mild climates is obvious, the distinction involves more than a fit tie difference. In the present discussion we have set the border line at about 75 degrees; even this is, as we have seen, somewhat too high to be truly sedative whenever any amount of physical exertion is desirable; in subjects calling for the last, a lower level of temperature is quite essential to meet the indication of rest.

Humidity. The matter does not rest with the mere secretion of sweat; its rapid and complete evaporation from the surface of the body is really the chief point. In this connection an entirely new factor comes into play, namely, the relative humidity of the surrounding air. Approximate saturation of the atmosphere with aqueous vapor totally bars evaporation, which becomes more and more effective as the proportion of moisture, the relative humidity of the air, falls below the point of saturation, 100 per cent.

Inasmuch as the atmospheric humidity affects us chiefly as regards the evaporation of cutaneous moisture, it is evident that our perception of this meteorological factor is indistinct at low temperatures, becoming well defined only above the indifferent point, about 55 degrees; below this, our impressions of the atmospheric humidity are quite apt to be fallacious. We are often told, for example, that the winter' weather in New York City is damp during the cold spells; as a matter of fact, the relative humidity ranges from 60 down to 40 per cent, and less on these occasions. We are also informed that the intense cold. in the Adirondack Mountains is "dry." The truth is that the mean relative humidity is lower in winter in the seaboard region about New York Gity than anywhere else in the state, and it is likewise true that the traditional "dry cold" of Minnesota and Iowa is also five per cent, moister than that of the Middle Atlantic coast. So much for popular impressions on this subject; the fact remains that the proportion of moisture at low temperatures is practically imperceptible and immaterial, as the transpiration through the skin is, in any case, insignificant in cold weather compared to its vast importance in summer.

From 55 degrees upward, on the other hand, the effects Of moist, as contrasted with dry air, become increasingly perceptible, growing dominant when the atmospheric temperature rises into the seventies. At very high temperatures, indeed, dryness becomes absolutely essential to the mere maintenance of life. A temperature near that of the body, with the air almost saturated with moisture, will, in a very short time, cause fatal hyperpyrexia, so-called " heat-stroke," or "sunstroke," as the result of the accumulation of body heat which is continually produced without the possibility of elimination. The frequent fatalities due to the combination of high temperature and humidity are sufficiently familiar; the danger line lies very near the point indicated' by the preceding discussion; namely, at 75 degrees with 100 per cent, of moisture, equivalent to 80 degrees with 80 per cent., 90 degrees with 50 per cent., and 100 degrees with 30 per cent. ; all these combinations are quite frequent in many parts of our continent, during the warmer months. We see, furthermore, that very intense heat may be endurable and quite safe, provided the air be dry; in our semi-arid districts, a temperature of 100 degrees is often associated with only 10 per cent, of humidity; this is equivalent to saturated air at -only 70 degrees, and therefore relatively harmless if violent exertion and exposure to the far hotter direct rays of the sun be avoided. Heat-stroke is infinitely commoner in our humid East than in the far drier though often hotter West.

The sensation produced by the approach to the danger line is called sultriness; since the normal person leads a more or' less active life, this unpleasant, condition becomes perceptible in a saturated atmosphere no warmer than 65 degrees. This is the average temperature of the wet-bulb thermometer at New York in mid-June and early September, and between those dates this climate is notoriously sultry and unwholesome. It is interesting to note the agreement on this subject between the popular impression and the scientific data.

The last paragraphs abundantly illustrate the fallacy involved in the common belief that the very warm climates are restful. The unremitting stimulation of the vasomotor apparatus, that attends even a short residence in such a region, has by no means a hardening effect ; on the contrary, the main result achieved is vasomotor exhaustion/ a part of the general systemic condition called enervation, the patient returning home enfeebled and less resistant than before. This is shown most conspicuously in an extreme sensitiveness to moderate changes of temperature; a fall of ten o fifteen degrees, which we should barely notice, may entail serious consequences in an enervated subject. The same thing is observable in our northern summer: the proverbially severe and persistent "summer cold" is especially prevalent after a long hot spell, and follows a decline in the temperature that would almost escape attention in the cold season. This invariably acquired thermic hyperesthesia is alone a sufficient reason for laying down the general rule that the hot climates and seasons be excluded absolutely from our therapeutic armamentarium. Their harmfulness is, indeed, being more and more widely recognized, so that the old practice of sending invalids to such regions as the West Indies is rapidly falling into complete desuetude.

The Variability of Temperature. We usually measure the variability of the temperature by the amount of rise or fall from day to day, employing as guides either the daily means or the temperatures at a fixed hour. It is also of advantage to note the excessively rapid changes that occur more or less frequently in the more variable climates, such as that of the eastern United States. From the purely mathematical point of view, the method just stated is unquestionably correct; applied to the human organism, it gives a distinctly false impression. It is certainly not true that we feel a fall from 30 degrees to zero as much as one from 60 to 30, the reason being that we instinctively refer all our thermic sensations to the indifferent point, regardless of the actual graduation of the thermometer ; as the temperature departs farther from the indifferent point, our perception becomes pro-_ gressively less keen. A drop from 80 to 50 degrees, as sometimes occurs in spring, is felt most acutely, for the change is from above the indifferent temperature to below it. A similar fall from 50 to 20 degrees is far less trying, and one from 20 to —10 incommodes us only moderately; temperatures below zero all feel very much alike, so that travelers may honestly report that — 30 degrees in Canada seem no colder than zero in Pennsylvania.

The above sketch accounts for the popular impression of the changeableness of the temperature in spring; purely mathematical data show plainly that the winter months are very much more variable ; they do not, however, appear so to the human organism. We here have one of the many instances in which purely theoretical considerations on climatic questions are altogether misleading.

A sudden rise of temperature affects us far less than an equal fall. The former almost always takes place during the daytime, when a certain elevation is expected in any case; the latter is relatively harmless when it occurs during the night, but more serious during the day, when we are apt to be out of doors, and prepared for a rise of temperature instead of a fall. Furthermore, we must again recall that man, being essentially a tropical animal, can withstand a rapid warming better than a sudden chill.

Sensible Temperature. It was Harrington l who first popularized the idea of " sensible temperature," regarding as such the temperature indicated by the wet-bulb thermometer, to which the surface of the body is far more akin than to the ordinary dry thermometer. His method is not quite accurate, as he does not allow for the cooling effect of air currents, but the wet bulb alone far more closely represents the modification of temperature by humidity as felt by the moist human skin than any other simple means; we may therefore avail ourselves of his idea with profit. The following table gives a few sensible temperatures, by way of illustration, and for reference; low temperatures being

1 International Med. Magazine, August 1894.

omitted as unimportant for our purpose, and to save space:

Dry

Thermometer

Humidity

90%

80%

70%

60%

50%

40%

30%

20%

10% no

107 97

88 78 68 58

104 94

85 75 66 56

100 91 82 73 64 54

96 87 79 70 61 52

92 83 75 67 59 50

87 79 71 64 56 48

82 74 67 60 53 46

76 69 63 57 50 44

We see that 110 degrees in Arizona, with the humidity at 20 per cent., feel about the same as 90 degrees in New York, with 50 per cent, of moisture, but we must not carry this line of argument too far. Exposure to the sun is a very different thing in the former place from such in the latter; furthermore, the breezes at these respective temperatures feel altogether different, one being far above the body temperature, the other well below it. As stated above, Harrington's method tells only part of the story; the Arizona summer is warmer than that of New York, and the dryness of the air only partly mitigates its fervor.

Vincent 1 attacked this problem from another viewpoint. He determined the coefficient of reduction for the surface warmth of the body, at temperatures below the blood heat, and found that it amounted to 0.3; thus the temperature of the skin falls nine degrees as that of the air falls thirty. The cooling effect of breezes he calculated at about one degree F. for each mile per hour; the effect of insolation at about one-fifth of the difference between the shade and sun temperatures, the latter being read on the black bulb in vacuo.

1 Quoted from Hann, Klimatologie, Vol. I.

Thus, on a very hot summer day, with the temperature at 100 in the shade, and a ten mile breeze, the sensible temperature, according to Vincent, is 90; in the sun, with the black bulb registering 150 degrees, -it runs up to 100. On a cold winter morning, registering zero, the sensible temperature is 70 degrees if the atmosphere be calm, falls to "60 in a ten-mile breeze, but may again be raised ten points by seeking a sunny spot, where the black bulb records 50 degrees.

Vincent does not seem to recognize the importance of the relative humidity; he very wisely does not allow for clothing, whose influence 'is beyond accurate calculation. It is interesting to note that, according to Vincent's formula, the cutaneous temperature, when that of the atmosphere stands at 80, registers about 94 degrees, the indifferent temperature in water, and to observe the agreement with the empirical data set down on pages 7 and 8.

Harrington's method of determining the sensible temperature is the more generally practical of the two; it recognizes the importance of the relative humidity, and the whole subject is of relatively little interest at those low temperatures where the wet thermometer becomes less reliable unless employed by specially trained experts. For the amateur, the hair hygrometer is a sufficiently useful instrument, and in combination with the table just given is adequate to meet all ordinary requirements.

As to Vincent's methods, the determination of the sun temperature can be made only with the black-bulbin-vacuo thermometer, which requires some experience in handling; exposure of an ordinary thermometer to the sun's rays gives results that are quite worthless, for even such trifles as the thickness of the glass and the shape of the bulb affect the readings materially. The wind correction is still more difficult of application, for while measurements on the towers of the weather stations may easily be made very accurate, they give no idea of the actual air movement on the irregular surface of the earth, where alone we are exposed to the winds, and their gauging is quite impossible. Vincent's method will therefore remain of only academic interest, though its theoretical value is indisputable. A combination of both his and Harrington's would probably cover the ground most thoroughly of all. All the other plans for determining the temperature, as actually felt, are far too complicated for general use, as they invariably call for the mastering and employment of complicated mathematical formulae.