Class JSMi^L Book , -_ Copyright N°_ COFWtlGHT DEPOSIT. THE CLIMATIC TREATMENT OF CHILDREN THE CLIMATIC TREATMENT OF CHILDREN BY FREDERICK L. WACHENHEIM, M.D. Chief of Clinic, Children's Department, Mount Sinai - Hospital Dispensary, New York NEW YORK REBMAN COMPANY 1123 BROADWAY LIBRARY of CONGRESS Two Cooles Received ^AY 16 190r *. CoDyntf* Entry CLASS « /\ XXC, N6, dopv 'b: Copyright, 1907, By REBMAN COMPANY New York 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 some- what one-sided, referring too exclusively to the manage- ment of tuberculosis. The climatotherapy of early life has been rather neglected; it differs widely, often radi- cally, 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 accessi- ble 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. CONTENTS CHAPTER I GENERAL PRINCIPLES Physiology of climate, temperature, humidity, variability of tem- perature, sensible temperature, cloudiness, rain, snow, fog, winds, atmospheric pressure, physiology of high elevations, mountain sickness, phototherapy at high elevations, temperature at eleva- tions, the seashore, classification of climates, general application, application to childhood, climate and disease, insect-borne diseases, hay-fever Pages 1-49 CHAPTER II THE CLIMATOLOGY OF TEMPERATE NORTH AMERICA Topography, atmospheric pressure and prevailing winds, tempera- ture, cloudiness and humidity, precipitation Pages 50-138 CHAPTER III HEALTH RESORTS North American resorts; foreign resorts: western Europe, central Europe, the Mediterranean region; sea voyages, sea bathing, Pages 1-39-206 CHAPTER IV THE CLIMATIC MANAGEMENT OF THE NORMAL CHILD General considerations, warming and ventilation, housing, cloth- ing, " catching cold," hardening, summer resorts, seashore resorts, inland resorts, elevations, winter resorts, spring resorts, autumn resorts." Pages 207-249 vii Vlll CONTENTS CHAPTER V CONSTITUTIONAL DISEASES The errors of nutrition and development : simple malnutrition, rickets, anaemia.- Systemic diseases: rheumatism and the rheumatoid diseases, the hemorrhagic diseases, amyloidosis, congenital syphilis, malaria Pages 250-286 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 AND TUBERCULOSIS Scrofulosis. Tuberculosis: surgical tuberculosis, visceral tuber- culosis. 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). THE CLIMATIC TREATMENT OF CHILDREN CHAPTER I GENERAL PRINCIPLES The practice of medicine, as distinct from surgery, employs two therapeutic methods which we may desig- nate 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 treat- ment 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 meas- ures, 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 great- est and most important part; it also employs the atmos- pheric pressure, sunlight, a species of massage by the winds, and the atmospheric moisture. We therefore l 2 THE CLIMATIC TREATMENT OF CHILDREN 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 ele- ments in the combination most suitable to the particular individual who comes to us for relief. We must there- fore 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 ac- count 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. GENERAL PRINCIPLES 3 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 per- form 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 compe- tent 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. 4 THE CLIMATIC TREATMENT OF CHILDREN A seriously diseased organ or organism requires rest; not always absolute rest, which is indeed usually unob- tainable, 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 digres- sion 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 compre- hend 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." Physio- logically, we cannot maintain this distinction, for the human body must provide not only for average, but also for occasional and even exceptional meteorological con- ditions. Thus, medical climatology includes both cli- matology and meteorology within its scope, and is not GENERAL PRINCIPLES 5 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 accli- matization 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 ap- proaches 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, 6 THE CLIMATIC TREATMENT OF CHILDREN 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 inven- tion 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 indi- cation for training, with the avoidance of injury, is satisfied with far more difficulty, and has hitherto been handled rather empirically. As a consequence, the re- sults, 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 GENERAL PRINCIPLES 7 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 tem- perature 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 tem- perature 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 8 THE CLIMATIC TREATMENT OF CHILDREN sheltered spot will feel comfortably warm at shade tem- peratures 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 aver- age temperature considerably lower, for the night tem- peratures 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 exer- cise. 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 excre- tory 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. GENERAL PRINCIPLES 9 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 tempera- tures 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, pro- duces 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 circum- stances. The mere production of sweat, however, calls for additional work on the part of the vasomotor appa- ratus, and especially an accelerated action of the heart; heat is therefore altogether a stimulant, a point fre- quently 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 10 THE CLIMATIC TREATMENT OF CHILDREN about 75 degrees; even this is, as we have seen, some- what 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 GENERAL PRINCIPLES 11 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 abso- lutely 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 "sun- stroke," as the result of the accumulation of body heat which is continually produced without the possibility of elimination. The frequent fatalities due to the com- bination of high temperature and humidity are suffi- ciently 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 12 THE CLIMATIC TREATMENT OF CHILDREN 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 be- comes 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 mod- erate changes of temperature; a fall of ten o fifteen degrees, which we should barely notice, may entail seri- ous consequences in an enervated subject. The same thing is observable in our northern summer: the pro- verbially severe and persistent "summer cold" is especially prevalent after a long hot spell, and fol- lows a decline in the temperature that would almost escape attention in the cold season. This invariably acquired thermic hyperesthesia is alone a sufficient GENERAL PRINCIPLES 13 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 com- plete 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. 14 THE CLIMATIC TREATMENT OF CHILDREN 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, how- ever, 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 ani- mal, can withstand a rapid warming better than a sudden chill. Sensible Temperature. It was Harrington l who first popularized the idea of " sensible temperature," re- garding 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 illus- tration, and for reference; low temperatures being 1 International Med. Magazine, August 1894. GENERAL PRINCIPLES 15 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 70 100 63 90 58 80 53 70 47 60 42 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 view- point. 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. 16 THE CLIMATIC TREATMENT OF CHILDREN Thus, on a very hot summer day, with the tempera- ture at 100 in the shade, and a ten mile breeze, the sensi- ble 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 calcula- tion. It is interesting to note that, according to Vin- cent'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 tem- perature 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 ex- perts. 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-bulb- in-vacuo thermometer, which requires some experience in handling; exposure of an ordinary thermometer to GENERAL PRINCIPLES 17 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 sta- tions 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. Cloudiness. Excessive cloudiness is an objectionable climatic factor; it is not only a psychical depressant, but cuts off much of the beneficial effect of sunlight, to be noted presently; a ratio of cloudiness exceeding 70 per cent, of the possible total impairs a climate very seriously. So high a proportion is not uncommon in many parts of the temperate zone during the winter months; just then, however, the shortness of the day renders sunshine none too abundant even in fine weather, so that any loss through cloudiness is an important mat- ter. Apart from this aspect of the case, which is largely psychical, we must devote a few lines to a discussion of the widespread belief that a lack of sunshine favors the dissemination of infectious diseases; there is probably some justification for this opinion, but the influence of 18 THE CLIMATIC TREATMENT OF CHILDREN cloudiness on disease has been exaggerated. Ruhemann* seemed to present a strong case, when he attributed the prevalence of influenza in Berlin in January, 1900, to the almost total absence of sunshine, there having been only ten hours during the entire month, 2J per cent, of the possible total, whereas the normal proportion for that place is 14 per cent. This last allowance is assured- ly little enough, and exceeded almost everywhere in temperate North America, save perhaps at a few points on the south shore of Lake Ontario. Yet , if Ruhemann's contention were sound, our Middle Atlantic Coast, with an average allowance of 135 hours of sunshine in Janu- ary, 45 per cent, of the possible total, should be almost immune to epidemics of this disease. Anders, 2 more- over, in a comprehensive analysis of this subject for Philadelphia, showed clearly that cloudiness and influ- enza bear no intimate relation to each other. It is also a recorded fact that our first and most violent outbreak of this disease took place in the phenomenally mild, sunny and almost spring-like winter of 1889-90. Thus no true point of contact can be proved, and the effect of cloudiness on epidemic disease remains indetermin- able. Still, sunshine is of indisputable value in winter in elevating the temperature during the day, and giving the individual basking in it the benefit of direct heat and light radiation; its germicidal usefulness will be touched upon presently. There is a reverse side to this question, little appre- ciated, but not hard to understand. There is, particu- larly in summer, such a thing as .too much sunshine; 1 Berliner klinische Wochenschrift, February 26, 1900. 2 Journal of Balneology and Climatology, October 1902. GENERAL PRINCIPLES 19 during the warm season, a little relief through the inter- vention of clouds is often grateful. We shall have occa- sion to return to this subject, and mention here only that the almost cloudless climates are quite as irritating as the gloomy ones are depressing; an excess of every- thing, even fine weather, ceases at last to be either attrac- tive or healthful. We may refer again to the psychical effect of cloudi- ness and its absence, which may be ignored in a healthy person, but is of some account in an invalid. A clear sky is distinctly stimulating, a cloudy one as positively sedative ; the mixed conditions characterizing our east- ern spring and summer seem to be the most generally beneficial. This matter is of relatively little importance in such sections as our Atlantic Coast, where the seasons differ but slightly in this respect; in most regions, how- ever, they are unquestionably of great moment, and well worth consideration, as any one can convince himself by spending a year in our lower Lake Region or in central Europe. Rain, Snow and Fog. An ample rainfall, if not too frequent, and well distributed through the year, is al- ways a good climatic feature, as it purifies the air and checks the formation of dust. The amount of rain on any one occasion is almost immaterial, provided it be sufficient to fulfill this purpose; its duration is more important, since an excess of rainy weather interferes with outdoor exercise, and acts as a psychical depressant even more than mere cloudiness. Most cool climates have a relatively small precipita- tion during the winter; as little moisture is required a,t low temperatures, owing to the small amount of 20 THE CLIMATIC TREATMENT OF CHILDREN evaporation, this is of no consequence and perhaps even advantageous, for a wet winter is invariably productive of mud and slush. More important is the consideration of such regions as have a dry summer. If rain be totally absent, the air and dust undergo a certain amount of sterilization by drying; the annoying clouds of pulverized matter, that penetrate through the finest crevices, are at any rate shorn of some of their power for mischief. A hot and merely dry summer, however, is an almost unmitigated evil, for the amount of moisture is insuffi- cient to lay the dust on the one hand, and ample for the maintenance of- bacterial life and development on the other; such a summer climate is almost always unwhole- some. In cold climates, a permanent winter snow-sheet is in every way desirable; it facilitates travel and an outdoor life, and keeps the air pure by making dust impossible. This winter snow-sheet has but one drawback; it is apt to melt rather suddenly in early spring, turn the coun- tryside into a quagmire, and render the air exceed- ingly damp and chilly. Where the winter temperatures fluctuate about the freezing point, and the cold weather is intermittent, such sloppy and damp conditions may be expected during a considerable portion of the cold season; it is therefore best to avoid this type of winter climate altogether, if the total precipitation is at all large; the steadier, if more severe, cold farther north is in every way preferable. There are two kinds of fog. The first comes in from the sea, is relatively mild in winter and cool in summer; as it creeps inward it grows denser in the former season, but becomes dissipated in the latter. This type of fog GENERAL PRINCIPLES 21 is wholly objectionable, if at all frequent, and mars many an otherwise desirable seaside resort. The fog that forms over valleys and plains on calm nights is perhaps less harmful, for, even in winter, the accompanying absence of wind partly compensates for the dampness. In cities like .London, however, where the cold winter fog becomes so loaded with soot as to be impenetrable and suspend all traffic, it is injurious in a high degree, regularly causing an upward leap in the death-rate. Winds. Steady and moderate air currents are essen- tial to a wholesome climate, but a good deal depends on the season, and strong winds that might be agreeable in summer become most unpleasant and even harmful in winter. Calms are not very desirable, being the chief cause of the second species of fog, as well as of frost, both of which are due to rapid radiation from the earth's surface on clear and quiet nights. •The temperature, on such occasions, rapidly falls to the dew-point, and. the atmospheric moisture is condensed. We can under- stand that such mists and fogs form most readily in sur- face depressions and mountain-bordered valleys; such sites are therefore to be shunned, and hillsides to be chosen in preference. Frequent and violent storms are objectionable in every way, and regions subject to cyclones, tornadoes or nu- merous thunderstorms are utterly unsuited to invalids. Thunderstorms, in particular, act as a powerful mental and physical excitant, and are extremely trying to many neurotic subjects. Even aside from true storms, con- tinuous high winds are very injurious to invalids, though often merely bracing to robust persons; the cold winds of the mistral type, that prevail on a hilly coast with a 22 THE CLIMATIC TREATMENT OF CHILDREN cold hinterland, are the worst of all, but the high dust- laden winds of summer on the Great Plains are nearly as bad. An important exception may, however, be made in favor of the summer sea breeze; even if occa- sionally violent, it nevertheless brings with it the even temperature and pure air of the ocean, and is therefore tolerable and even salutary, unless it attains the force of a gale, as often happens on our North Pacific Coast. Hot winds are a direct excitant, and altogether harm- ful. It is customary for the dwellers in the desert or semi-arid West to laud the dryness of the heat, but much of the advantage conferred by the low humidity is neutralized by the furnace-blasts that make such regions a veritable inferno whenever the thermometer rises toward 100 degrees in the shade. It also is not true that these conditions are perfectly safe; the con- trary is evidenced by the frequency of heat-stroke in India during the very dry hot season, which closely resembles the summer of our own extreme Southwest. It is, of course, hardly necessary to warn invalids, especially if neurotic, against taking up their abode in regions where every spell of sultry weather leads the natives to scan the western horizon for funnel-shaped clouds, and think of their tornado-cellars; one might as well ask a patient to choose a residence on the side of an active volcano, and expect him to do well in spite of the constant nervous strain to which he will necessarily be subjected. The Atmospheric Pressure. The fluctuations of the atmospheric pressure at any fixed level, ranging as a rule within two or three inches of mercury, are of little physi- ological importance, but the variations according to GENERAL PRINCIPLES 23 altitude are sufficiently great to call for extended discus- sion. Removal of an individual to a higher or lower level furnishes an effective method of applying so-called pneumatotherapy, though its range is here somewhat limited, and its value eventually lost by acclimatization. The inhabitants of regions near the sea level can, of course, avail themselves of higher levels only, for the purpose of breathing rarefied air. Those who have dwelt at medium altitudes may either ascend or descend, in the latter event obtaining such benefits as may be afforded by the respiration of compressed air. The latter aspect of this subject has hardly been studied at all, and the transfer of patients from the mountains to the seaside has hitherto been employed but rarely, and with little definite purpose. The average air pressure at various levels, reduced to the temperature of 32 degrees, is as follows : Elevation, Feet Pressure, Inches of Hg. Elevation, Feet Pressure, Inches of Hg. 2,500 5,000 7,500 30.0 27.3 24.8 22.4 10,000 12,500 15,000 20.3 18.3 16.5 Thus, removal to the elevation of 5,000 feet deprives the individual of one-sixth of his normal supply of air, and an additional 5,000 feet cut off another sixth. So great a change must necessarily entail important physi- ological consequences, which it will be worth our while to study with some minuteness. The Physiology of High Elevations. Viault, 1 in the course of a scientific tour in the Andes, was the first to 1 Comptes rendus de l'acadeuiie des sciences, Vol. 111. 24 THE CLIMATIC TREATMENT OF CHILDREN demonstrate the remarkable blood changes at high ele- vations; he found that the dwellers at an altitude of 14,400 feet exhibited an increase in the number of red blood cells from 5,000,000 to $,000,000 to the cubic millimeter. Egger 1 made similar examinations at Arosa, in the Alps, 5,900 feet above the sea; his observations showed a gain of only 2,000,000 red blood cells. Wolff and Koeppe 2 then proceeded to examine their patients at Reiboldsgriin, 2,300 feet high; they reported an increase of only 1,000,000. These observations, which have obtained ample confirmation by other investigators, show an inverse ratio between the air supply of the individual and the number of erythrocytes in his blood. For a time, certain critics made claim that this increase was only apparent. Grawitz 3 asserted that concentra- tion of the blood through increased transpiration of the body fluids fully accounted for the relative numerical increase of the suspended corpuscles at high elevations, the actual change being a diminution of the plasma. It is not difficult to offer a. simple and final objection to Grawitz's explanation; no loss of body weight or fluid takes place at high levels, as would be inevitable in case of increased transpiration; as a matter of fact, the lower temperature at elevations tends to check perspiration, not increase it. Gottstein 4 urges that the apparent increase in the number of erythrocytes rests on a fallacy, and that the Thoma-Zeiss apparatus, the one regularly employed, is adapted only to use at the sea-level. It is not easy to follow Gottstein's train of 1 Correspondenzblatt fur schweizer Aerzte, 1892, p. 645. 2 Mtinchener med. Wochenschrif t , 1893, No. 11. 3 Berliner klin. Wochenschrif t, 1895, Nos. 33 and 34. 4 Allgemeine med. Centralzeitung, 1897, No. 74, GENERAL PRINCIPLES 25 thought, but if he supposes that the density of the blood serum is materially affected by the atmospheric pressure, he exhibits a strange ignorance of the laws of hydraulics, for liquids are so slightly compressible, that the error at 10,000 feet does not amount to more than 0.001 of one per cent, for a watery fluid like blood-serum; in other words, it is infinitesimal. It is difficult to avoid the conclusion that the whole matter is merely a compensatory hypertrophy of the blood tissue, in response to the extra work imposed upon it. The first point sustaining this view is the almost exact inverseness of the ratio of air to blood-cells, but the best evidence in favor of the hypertrophic theory is furnished by the gradual development of the cellular increase, and the concomitant, but somewhat tardier, in- crease in the. amount of haemoglobin. The observations made by K undig 1 at Davos give the following result : Amount of Increase of Erythrocytes Haemoglobin 11.1% 16.3% 21.3% 7 4% 14 1% 20.5%, It is clear that removal to a considerable elevation acts also as a general stimulant to metabolism, for so extensive an hypertrophy of the most important tissue of the body, namely, the blood, must inevitably react upon the entire organism. It necessarily follows that a sudden and extreme change of level is not suited to every constitution; the strain imposed during the first three weeks may be too great for a person suffering from impaired general vitality; on the other hand, it is plain 1 Correspondenzblatt fur schweizer Aerzte, 1897, p. 2. 26 THE CLIMATIC TREATMENT OF CHILDREN that a gradual ascent will frequently obviate this diffi- culty. After a four weeks' stay, it is possible to decide definitely whether the locality selected is or is not salutary to the individual under observation. A circumstance, noted by Weinzirl, 1 and hitherto unexplained, is an excess of about 500,000 erythrocytes in winter, as compared with summer; the place of ob- servation was near Albuquerque, N. M., at about 6,000 feet elevation, but, somewhat curiously, higher in the summer camp than in winter quarters; we should have expected exactly the opposite change. We cannot, how- ever, entirely exclude errors of observation, and his report is somewhat fragmentary. Observers seem to agree that high-level residents show as a permanent condition a somewhat increased oxygen inhalation and carbohydrate metabolism. The former is in accord with the increased amount of haemo- globin, the latter is an inevitable consequence of the former; both become especially marked when vigorous exercise is indulged in (Biirgi). 2 Mountain Sickness'. An excessively abrupt and ex- treme transfer from a low to a high level brings on the symptoms characteristic of an acute anaemia, precisely similar to that resulting from a profuse haemorrhage. It affects individuals to a varying degree, those previously anaemic naturally suffering more readily and acutely than the robust. At the height of 16,000 feet, where the supply of air is just one-half of that at the sea-level, even the most sturdy person will succumb, if he ascends to this height rapidly and by means of the arduous 1 Amer. Journ. of the Med. Sciences, August, 1903. 2 Archiv fur Anatomie und Physiologie, 1900, No. 506. GENERAL PRINCIPLES 27 exertion of climbing. Whymper, 1 seasoned as he was by the most strenuous Alpine tours, practically collapsed at the stated level in the course of his first ascent of Chimborazo, having approached that mountain rather rapidly from the Pacific Coast; after a rest of some days, he accomplished the final climb to the summit (21,000 feet), but with difficulty. Later on, being then quite accustomed to the rare atmosphere of the Ecuador plateau (10,000 feet), he climbed the same mountain, as well as others, without any noteworthy distress. It is now generally agreed that Egger 2 is right when he claims that mountain sickness is nothing more than the expression of a relatively acute anaemia; as this anaemia disappears in the course of the hypertrophy of the blood elements, the distressing symptoms gradually vanish. Phototherapy at High Elevations. Nowadays, when the study of radiant energy and its therapeutic application is so much in the foreground, we cannot discuss high altitudes without referring to the peculiar modification of the solar rays at these levels. The radiant emana- tions — or undulations — from the sun, in passing through the terrestrial atmosphere, encounter a highly absorptive medium; their absorption is partly due to the fact that air is a complicated and not uniform gaseous mixture, not a pure gas, but is caused chiefly by the presence in the air of a large and unevenly distributed amount of watery vapor. All the solar rays are affected to some degree, but the ultra-violet most of all; as the ultra- violet rays just now occupy the center of the stage, we shall consider them first. The following table, after 1 Travels among the Great Andes of the Equator, New York, 1892 2 Loc. cit. 28 THE CLIMATIC TREATMENT OF CHILDREN Bunsen and Roscoe, 1 shows the proportion of chemically active rays reaching the surface of the earth, at various levels and sun altitudes, in percentages: Elevation, Feet Altitude op Sun 70 deg. 50 deg. 30 deg. o 42% 47% 53% 59% 34% 39% 46% 53% 19% 24% 30% 37% 4 000 8,000 12,000 Saake 2 showed, in a recent communication, that the atmospheric radioactivity at Arosa (5,900 feet) is three times that in the lowlands, and points to a possible relationship between this circumstance and certain therapeutic results in tuberculosis, one of the many affections now being subjected to radiotherapy. It is also more than likely that the excess of ultra-violet rays, at high elevations, is responsible for the liability to sun- burn to which mountain-climbers are exposed. It is, at any rate, certain that the reflection from snowfields, formerly regarded as the exciting cause, is not essential, for Langley 1 suffered severely from sunburn in his ascent of Mt.. Whitney (14,600 feet), though his route led entirely over rocks. More apparent, and therefore more striking, is the proportion of solar heat that escapes absorption at high altitudes. The sun-thermometer gives higher readings in the upper Alps, than at their foot, though the shade temperature is much higher below. This advantage is enhanced in winter by the coincidence that the high valleys suffer less from clouds and mist than the foothills. We can readily understand from this how visitors to the 1 -Quoted from Hann, Klimatologie, Vol. I. 2 Miinchener medizinische Wochenschrift, 1904, No. 1. GENERAL PRINCIPLES 29 Engadine and Colorado can go about in the sun quite lightly clothed at shade temperatures well below the freezing point. The field for the application of a mild photo- and radiotherapy at high elevations is therefore quite exten- sive, and well worth further development. Little has, however, been done so far, as the more powerful and tangible forms of radiant energy have hitherto almost monopolized the interest of the scientific world. The Temperature at Elevations. In theory, the fall of temperature in ascending from the sea level is governed by a well-defined law; practically, however, modifying factors step in. The chief exception is due to what is called the inversion of temperature, in rugged regions where intense cold may reign in the deep valleys while the mountain-sides are basking in a mild sunshine. In some districts this phenomenon is quite temporary; in others it is apt to prevail for days at a time during the presence of a persistent high barometric area, especially when the ground is snow-covered. The effect of altitude on the daily range of tempera- ture varies. On towers or isolated peaks, the daily range is very much diminished, for much of the diurnal radiation from the earth is lost; the reduction amounts to as much as four degrees on fine days on the roofs of our loftiest sky-scrapers. The temperature does not continue to rise until three or four o'clock, but begins to fall as early as two or even one p.m. On high plateaus the case is quite different; the radiation from the earth's surface is even greater than on low plains, because of the rarer atmosphere, and, as stated before, the solar radiation is also relatively great ; the result is ah absolute 30 THE CLIMATIC TREATMENT OF CHILDREN , increase of the daily range as compared with the lower situations. The seasonal range regularly diminishes with the alti- tude, very rapidly in rugged districts, where the deep valleys are the seat of frequent inversion of temperature in winter; more slowly on continental elevations, where inversion is not conspicuous. At the height of only a few miles the difference between summer and winter becomes quite insignificant. We may here append a few figures. On mountain peaks the fall of temperature is about three degrees per thousand feet, measured from the sea level. Plateaus are relatively warm, the temperature then falls with increased rapidity to the surrounding summits. Inver- sion of temperature often causes a marked diminution of the fall upward, especially in winter, when the mountain slopes may be warmer than the valleys for weeks at a time. The dynamic warming and cooling of the air currents in descending and ascending, respectively, amount to five degrees per thousand feet, and the pre- dominance of one or the other flow materially affects local averages. As descending currents are common in winter, but infrequent in summer, the fall o*f tempera- ture as one goes upward averages very much greater in the latter season. The Seashore. I shall here refer only briefly to the peculiarities of marine climates, as the various details will receive ample illustration later on. The seaside is damper than the interior in summer, owing to the fre- quency of sea breezes ; it is often a little drier in winter, but only relatively, because the air is warmer and less readily saturated. ' This distribution of humidity is GENERAL PRINQIPLES 31 directly responsible for a similar one of cloudiness; to a lesser extent, this is also true of the precipitation, but here so many other factors step in that any rule would present numberless exceptions. The extremes of tem- perature are invariably modified by the presence of large bodies of water, an expanse of even thirty or forty miles producing a considerable effect; much depends on the prevailing wind direction. The summer is invariably retarded along the coast, still more on islands; the winter is sometimes retarded even more, sometimes very little, local factors modify- ing the rule in many instances. For example, mid- summer falls on the 20th of July on the Delaware River, on the 25th at New York City, on the 1st of August on southern Long Island, and on the 5th at Block Island; in winter, however, the retardation is barely a week in all. At Bermuda the mid-seasons fall on the middle of February and August respectively, whereas the Farallone Islands, off California, give February 1st and September 15th as the corresponding dates. The average annual temperature at the seaside is ele- vated northward, depressed southward; the annual and daily ranges are very much reduced, especially where sea breezes predominate. It will be of interest to glance at a comparison of Baltimore (suburban) and Atlantic City, which lie on the same parallel, for the same period. Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec Yr. Baltimore . Atlan. City 32.8 32.5 34.9 33.9 40.1 37.6 51.6 46.8 62.6 57.2 71.8 66.8 75.6 71.9 73.4 71.8 66.5 66.7 55.6 56.3 44.2 44.7 36.4 36.4 53.8 51.9 Difference . -0.3 -1.0 -2.5 -4.8 -5.4 -5.0 -3.7 -1.6 +0.2 +0.7 +0.5 0.0 -1.9 Atlantic City is only semi-oceanic, as land breezes 32 THE CLIMATIC TREATMENT OF CHILDREN prevail at all seasons, except occasionally between April and August; the reason for giving suburban data for Baltimore will be stated in the next chapter. In this semi-southern latitude (39.4) the ocean already lowers the annual average materially; the daily range is seven degrees less at Atlantic City from April to October, only three from November to March, the transition in spring and autumn occurring quite abruptly. The annual range is 37 degrees at Nantucket, Mass., and 45 at Scranton, Pa., on the same parallel. Farther north we find a range of 43 degrees in Nova Scotia (only 33 on Sable Island) and 56 in the St. Lawrence Valley. The wind velocity is about 50 per cent, greater on the coast than inland, two or three times as great on flat and small islands. This feature should never be dis- regarded in recommending marine climates; it is mark- edly diminished only a few leagues inland, unless the coast be exceptionally flat. The number of rainy days agrees quite well with the percentage of cloudiness, and does not correspond with the total amount of precipita- tion; some coasts are therefore subject to drizzling rains, others to torrential downpours: The saline constituents of the sea air are minute in quantity, and of more than doubtful medical importance ; we shall have occasion to recur to this subject later on, and here mention merely the widespread exaggeration of its value. The Classification of Climates. For therapeutic pur- poses we may classify climates, first, according to the temperature ; secondly, according to the relative humid- ity; thirdly, according to the altitude. GENERAL PRINCIPLES 33 A convenient classification according to temperature is that of Koppen, 1 here slightly modified: 1. Hot climates. Every month averages higher than 68 degrees. 2. Warm climates. Every month averages higher than 50 degrees, one or more exceed 68. 3. Truly temperate climates. All months average between 50 and 68 degrees. 4. So-called temperate climates. The monthly aver- ages range from below 50 to above 68 degrees. A better name would be " extreme climates." 5. Cool climates. All months average below 68 de- grees, one or more below 50. 6. Cold climates. Every month averages under 50 degrees. The fourth group is so very extensive in point of terri- tory covered, as well as so rich in minor variations, that it may. advantageously be sub-divided as follows : 4a. Warm temperate. Averages below 50 degrees are limited to the winter months. 4b. Middle temperate. The most extreme of all. More than three months both fall below 50 and exceed 68 degrees. 4c. Cool temperate. Averages above 68 degrees are limited to the summer months. If we classify climates according to the relative humidity, we may form the following divisions : 1. Desert climates. Humidity under 40 per cent. 2. Dry climates. Humidity between 40 and 60 per cent. 3. Moderately moist climates. Humidity between 60 and 80 per cent. 1 Meteorologische Zdtschrift, 1884. 34 THE CLIMATIC TREATMENT OF CHILDREN 4. Very moist climates. Humidity over 80 per cent. We must not forget that many localities vary according to the season, belonging to one class in winter, and to another in summer. As a rule, spring and summer are the driest seasons, but at many marine stations summer is much damper than winter. The tendency to a dry spring and moist autumn is almost universal in the temperate zones. The third classification, according to elevation; is the one on which there is most nearly a universal agreement; it has been settled to designate as low levels all those under 1,000 feet; those up to 3,000 feet may be called moderate elevations ; above that, high levels. The summary of these three methods of classification gives an array of varieties that is almost bewildering; even though some combinations do not actually occur, still the total is very great. We cannot attempt to unravel this apparent tangle until we have given an outline of the climatic types that have a definite value in therapeutics; when this has been done, a systematic grouping will present no special difficulty. General Application. With the above immense variety of climates at our disposal, we nevertheless realize at once that their applicability lies within readily defined limits. We have already excluded the hot climates from the field of therapeutics, and some of the others are also objectionable at certain seasons, or useless for par- ticular purposes. We must, furthermore, regard the previous habituation of the individual applying for treat- ment ; for changes of climate are, to a certain extent, relative. The general proposition may be concisely stated as follows : GENERAL PRINCIPLES 35 Residents of hot and warm regions may profitably avail themselves of a measure of climatic training by removal to a cooler region; it is impossible to spare their organs by the employment of a warmer climate; this involves no appreciable change for them, and they are apt to come to us already somewhat enervated. The inhabitants of temperate regions may avail them- selves either of sedative treatment in a warm climate, or of bracing conditions in a cool one; they thus enjoy more extensive opportunities. In the climates that I .have designated as truly temperate, the very evenness is likely to cause some enervation; here a visit to a cool region is sure to do good. The same treatment is often also desirable in the summer months of the extreme climates; the residents in many extreme climates have in fact two bad seasons to contend with, namely, a hot and enervating summer, and a winter that keeps the less robust indoors much of the time; here the field of climato therapy may be very extensive indeed. So far as temperature goes, the only climatic treatment that the inhabitant of a cool region is likely to require is removal to a mild winter resort. This may be chosen so as to have either a sedative or a training effect, and here a high degree of professional skill will be well rewarded, whereas mere routine management may do no end of harm. The residents of cold climates are largely excluded from the benefits of climatotherapy. Change of climate necessarily means to them increased warmth; this inevi- tably involves the dangers incident to at least relative enervation, which will make a return to their former homes perilous. The risks of permanent removal from 36 THE CLIMATIC TREATMENT OF CHILDREN' a cold to a mild region are illustrated by the sad fate of the Cape York Eskimos in the far from genial climate of New York City; the results are even worse than those attached to a transfer from New York to the tropics. Thus the inhabitants of cold countries must seek health within their own climatic range. On the other hand, the benefits often derived from a higher elevation are not limited to the inhabitants of any zone; such limitations as exist are strictly individual, and will be pointed out later on. The effect of a dry, as opposed to a moist climate, has been gone into so fully as to require no repetition here. Application to Childhood. The above rules require material modification in adapting them to infants and children. First and foremost, children are far more sensitive to cold and temperature changes than adults; we all know that their extremities become cold and even cyanotic at temperatures that are quite congenial to older persons. This difference must be regarded as normal, and is due to the following causes: In the first place, the protective accumulation of adipose tissue, aside from that peculiar to the milk-fed and inactive infant, does not usually- become extensively developed until well after puberty. Secondly, the child's meta- bolism is so largely devoted to the building up of new tissue, that a relatively small caloric surplus remains to meet adverse external conditions. Thirdly, the city child is, as a rule, deficient in that combination of resist- ing powers which we commonly call robustness; but here I must admit that my experience, though somewhat limited, does not speak for any universal superiority in this respect among country-bred children, compared with GENERAL PRINCIPLES 37 those raised in large towns under reasonably good hygienic conditions. Urban sanitation is becoming so far superior to that of rural districts, in a number of respects, that the advantages of the latter, conspicuous some decades ago, are now less in evidence. Recently collected data seem to show, in addition, a marked physical deterioration in the rural population of some of our eastern states, which does not apply equally to most western sections. In later childhood, some of the sensitiveness to low temperatures, just outlined, is compensated by a greater physical activity and relatively elastic metabolism, shown by the enormous possibilities of the juvenile appetite. These reserve forces, however, can be drawn upon only intermittently, and are often gravely abused. Excessive strains in childhood are fertile sources of various organic weaknesses in later life; for an example I need not go further than to refer to the premature degenerative processes that follow the strenuous pursuit of" athletic sports by growing boys. In infancy the stated compensations are not at all available, and the same is true, in a gradually diminishing degree, up to about the seventh year. Until the age of one-and-a- half to two years, exercise cannot, of course, be counted on at all, and after that, for some years more, its role increases only very slowly; in this direction there is fortunately no great danger of injury from trying to overdo matters. On the other hand, any attempt to stimulate the metabolism of young children to abnormal activity by forced feeding is certain to result in disaster ; the digestive functions break down at once in infancy, more slowly, but just as surely, in young children; thus 38 THE CLIMATIC TREATMENT OF CHILDREN this resource, valuable as it often becomes in later life, is absolutely barred in infancy and early childhood. Later childhood would probably present a gradual transition from the extreme sensitiveness of early life to the greater hardiness of maturity, if new adverse factors did not come into play in the seventh year. A child of that age may have become quite sturdy and robust, and able to resist unfavorable external conditions fairly well, when it is suddenly deprived of the best part of its time for outdoor play by the demands of the school. This matter would not be so bad if the trying school regime, with its severe physical discipline, were made to act on the youthful organism gradually, beginning with two and three hour sessions during the first year or two. Here, however, the child's physical welfare obtains scant consideration; iron-clad school regulations, as well as the desire of selfish or busy parents to have their children out of the way, are paramount; so we see fairly hearty children rapidly becoming flabby and anaemic as their best time is spent indoors, the care of their bodies being entirely sacrificed to an ostensible zeal for intellectual development. As a matter of fact, most of the time spent in school during the first year or two is wasted in the worst possible way; with the customary unwieldy classes a child spends the whole day in acquiring but a small modicum of knowledge. The young mind con- fessedly can grasp but few facts at a time, yet, to instill that minimum, the greatest part of the day is spent in a stuffy- schoolroom. It is only too well known that, in our great cities, the early acquirements of school-chil- dren consist chiefly of one or more of the infectious diseases, besides vicious habits of eating in the form of GENERAL PRINCIPLES 39 the bolting of food and the ingestion of portentous masses of cheap and harmful confectionery, usually sup- plied by a dealer conveniently located next door to the school. School life thus implies a distinct set-back in the physical condition of the child, the progress that would be expected with advancing years is not realized. We have seen the disadvantages under which children labor in the effort to adjust themselves to low tempera- tures; the net result is an elevation of the indifferent temperature as compared with adults. We must there- fore modify materially the general scheme of climatother- apy in applying it to children, and, in almost all cases, select warmer regions for the very young than would be either required or desirable in treating older persons. Above the indifferent point, the variations due to age are equally marked; children, especially young infants, tolerate great heat very badly. Older children, to be sure, indulge in lively play in the sun, at temperatures quite unendurable to their elders, but we have no reason to regard this sort of exposure as harmless. It is true that typical heat-stroke is rare in children, but this is chiefly because the heart and kidneys, which are charged with the duty Of combating the tendency to hyperpy- rexia, are still undamaged by the accumulated wear and tear of many years, and by chronic intoxications such as alcoholism. Still, everything considered, even if we make allowance for the elevation of the indifferent point in early life, we may safely assume that prolonged and violent exercise at a shade temperature of 95 degrees, and a sensible temperature of 80, both of which are com- mon during our hot spells, is very injurious to young as well as older children. 40 THE CLIMATIC TREATMENT OF CHILDREN It is well known, that children of white parentage do very badly in the tropics near the sea level; the regions bordering on the temperate zone, having a somewhat lower temperature in the dry season, as well as elevated sites, are often very much less dangerous, but, at their best, deprive the children, as they grow -up, of the physical training afforded by cool weather. In all cases that do not succumb in early life, there is marked enerva- tion and a low power of resistance to morbific influences of all kinds. . ' . As to elevations, there is some diversity of opinion. European observers discountenance the sending of chil- dren under six or eight years of age to the higher Alps; as the July temperature there averages only in the fifties, their attitude is quite correct, for young children and infants require a much warmer summer climate. In our Rocky Mountains this objection does not apply, and fairly robust children, even those of tender years, accommodate themselves quite readily to the consequent blood changes and heightened metabolism. As to mid- dle elevations, there is more agreement; an altitude of 1,500 to 2,000 feet is certainly beneficial to all save a few greatly enfeebled children. It is worth mentioning that stimulation of the digestive functions is a much safer procedure in the pure, cool and somewhat rarer atmosphere of our eastern hills than at lower levels; a burdening of the stomach and intestines that would be hazardous at the seashore is well borne and even advan- tageous in the mountains. Climate and Disease. Many diseases are more or less uniformly distributed over the globe, and but slightly, if at all, influenced by climate; a considerable number GENERAL PRINCIPLE* 41 are more or less modified by atmospheric conditions; a few are almost entirely subject to them, being absolutely limited to certain zones and seasons. The frequency and severity of digestive disorders in children are almost in a direct ratio to the temperature, more accurately, perhaps, the sensible temperature. They are relatively mild and uncommon in cool weather, but increase suddenly as the season grows warm, assum- ing an alarming distribution and seriousness when the indifferent temperature is passed. Chart I (see oppo- site), modified after Seibert, 1 illustrates this- point in telling fashion. It gives the number of deaths from diarrhceal diseases in New York City among children under the age of five years, and the mean temperature, by months. I have taken the liberty of adding the sensible temperature. The reader will observe that the rate of mortality remains uniformly low until the average sensible tem- perature reaches 55 degrees (middle of May); then a rapid rise occurs as the temperature goes up. A fairly rapid and continuous fall takes place as the season turns (end of July), but there is no complete remission until the mean sensible temperature again falls below 55 (early October). Some of the slight excess in October is probably due to the eventual death of severe and chronic cases holding over from the summer. That the summer temperature of New York is very far above the danger point is also shown by the data for Berlin 2 , where the summer is about eight degrees cooler; July in Berlin having exactly the temperature of 1 Med. Record, March, 1888. 2 Berliner klinische Wochenschrift, 1904, p. 1163. CHART I 1£ Jj « M I 8 » > S < f > s i 3 Vi > J ? 1 ?i u M i i \ i R Pr ■ *5»V J v rT j v / / \ ?'J 7y s \ y \ X / \ 7J, 7* it ,-* * \ ' k N \ 7* li V \ s_ \ v / *'' f 9 ft s / \ / / $ •7 Of \ f O fj-j ■ / 00 A. itts f*T M.i 4f\C O+0 "*} e£Lr •V "-J3 o3 a; T3 3 "Si a o h3 >> u 03 3 £ 03 ►"5 >> 03 3 (- V fa o u 03 9 ft < >> 03 c 3 i-a 3 gg 3 5t 3 < u 33 S & ft QQ 0/ c e C o 1 Z 0/ -C e P 03 64.2 56.6 51.7 61.7 14 -6 14 -5 17 +7 26 20 35 32 40 41 44 47 43 49 37 41 30 31 24 18 19 6 28 6 23 4 The winter in southern Greenland resembles that of Maine, but the summer is no warmer than the Maine October; it is somewhat warmer than the above figures back in the fjords, where the maximum temperature has reached 74 degrees. The winter is sometimes quite arctic;' in other years rather mild, with frequent thaws. The mean monthly range is about 45 degrees in winter and only 25 in summer; temperatures under -20 are as rare as a summer-like warmth. Labrador lies ten degrees to the south of Greenland, but the climate is decidedly worse, being but little warmer in summer, and very much more severe in winter. The temperature is the lowest known for the latitude, which corresponds to that 'of the British Isles; Nain is 43 degrees colder than Aberdeen in January, and 11 in July. The influence of the ice drift on the climate of the Labrador coast is shown by the retardation of the sum- mer warmth, August being warmer than July. The ordinary .annual range of temperature at Nain is from 77 to —36 degrees; exceptionally 80 and —45 have been observed. Both winter and summer are very erratic, as land and sea breezes alternate with great frequency, particularly at the latter season. Little is known of the climate of interior Labrador, but the more luxuriant vegetation points to a warmer 64 THE CLIMATIC TREATMENT OF CHILDREN summer, averaging about 55 degrees in July. The aver- age for January is probably not much lower than on the coast, say about 10 below zero. The Maritime Provinces and Newfoundland. In and about the Gulf of St. Lawrence, the climate is interme- diate between those of Labrador and our northeastern states. The summer remains remarkably cool for the latitude, and the winter is still quite raw,- so that the temperature as a whole resembles that of Sweden, ten to fifteen degrees farther north. The following table will illustrate this more fully: St. John's, N. F Charlottetown . Sydney Halifax Yarmouth St. John, N. B. . Chatham) Father Point . •. 47.6 46.2 46.2 44.6 43.8 45.3 47.0 52.7 63.3 60.2 63.6 66.0 66.1 65.5 68.3 35 43 35,46 40.4 40.8 41.1 42.7 43.0 41.1 38.4 34.6 The extremes and daily range in this district are as follows : Average Absolute Daily Range Max. Min. Max. Min. January July St. John's .... 84 - 6 92 -21 17—29 51—67 Sydney 85 -15 90 -25 13—27 53—71 Halifax '. 89 - 8 93 -17 15—30 54—72 Yarmouth . . . 78 + 1 83 - 2 21—34 52—67 Chatham .... 92 -27 98 -33 1—19 54—76 Father Point . • 81 -26 87 -31 0—16 49—67 We see that steady freezing weather is the rule in winter, and that the summer days are fairly warm in the CLIMATOLOGY OF NORTH AMERICA 65 interior of New Brunswick, but very cool at exposed coastal stations. Among the hills of New Brunswick the temperature may rise to 100 and fall below - 40. The St. Lawrence and Ottawa Valleys. In this district, forming a sort of wedge between the maritime provinces and the Lake Region, we find an extreme continental climate. Chicoutimi Quebec . . . Montreal . Ottawa . . . Rockliffe . 48.4 46.8 45.5 45.4 46.2 71.1 71.2 73.6 75.8 77.9 a 150 100 90 330 560 65 53 40 24 9 35 . 2 56 43 29 16 38 58 4531 67;57|43 29 64 55142 28 18i41.6 1640.4 14138.0 * The extremes and daily range are as 'ollows : Average Extreme Daily Range Max. Min. Max. Min. January July Quebec Montreal Ottawa Rockliffe 89 89 92 93 -25 -21 -29 -38 96 94 98 100 -32 -26 -33 -46 3—17 7—20 2—19 -5—18 57—75 61—78 59—80 53—80 In the Ottawa Valley, - 50 degrees have been reached on * exceptional occasions. At the July isothermal of 68 degrees we encounter the vanguard of the flora of the middle temperate zone, as- represented by the hickory and grape-vine; elsewhere the vegetation is of the type commonly called Canadian. The intense cold of the winter at Montreal and Ottawa sets no limit to the growth of the more southerly forms, for their only requirement is a sufficient warmth in midsummer. The North Atlantic States. From Maine to Virginia there prevails a remarkable climatic uniformity, the 66 THE CLIMATIC TREATMENT OF CHILDREN differences due to latitude, elevation, and proximity to the ocean can be reckoned mathematically to within a fraction of a degree; this makes it uncommonly easy to pick out the "city temperatures" in this district, and also enables us to estimate pretty closely the tempera- ture for a station, for which no actual observations are recorded. The table that follows is not too long when we consider that this region includes very many of our largest cities and most popular resorts. New England Kineo, Me Bethlehem; N. H Northfield, Vt. .. Eastport Bar Harbor. Portland (C) Boston (C) , New Haven 45.7 44.2 44.2 44.9 44.3 43.6 42.4 41.3 69.7 71.7 72.7 67:0 68.2 70.2 71.1 72.9 1000 1480 880 80 50 100 120 110 37.3 39.2 41.2 41.5 43. P 45.7 48.6 49.4 Islands Nantucket Block Island Southampton, L. I. 41.3 41.2 40.9 70.1 20 31 71.5 30 31 72.4 30 31 52 61 53 62 56 65 70 48.8 49.1 50.1 New York Albany (C) . . . Poughkeepsie New York (C) Saranac Lake Cooperstown . Liberty 42.7 41.7 40.7 44.3 42.7 41.8 73.8 74.0 74.0 74.1 75.0 74.8 100 120 90 1550 1300 1470 69 48.2 48.6 52.0 39.1 43.5 44.7 New Jersey Lakewood . . . Atlantic City 40.1 39.4 74.2 74.4 100 50 57 54 43 56145 51.2 51.9 CLIMATOLOGY OF NORTH AMERICA 67 Eastern Pennsylvania Scranton Harrisburg .... Philadelphia (C) 41.5 40.3 40.0 75.7 76.9 75.2 800 370 90 4557 66 48 60 69 5062!72 70 68 73 71 76174 -Z > o o 50 39 53 42 56 45 29 47.6 33 50.8 36 53.5 Maryland and Virginia Baltimore (C). Washington . Richmond (C) Norfolk Lynchburg Wytheville 39.3 38.9 37.5 36.8 37.4 36.9 76.6 77.0 77.5 76.3 79.2 81.1 9034 3642 11033 35 42 140J38 40 46 90l40 43147 680'37^40|46 2290 33 36 42 53 64 53 64 5767 56 66 56! 66 5261 73 77| 75 '68 57 73;7775i68 56 75 79 77 70 60 75 79 7771 61 74 78 76 697270 68 57 64 54 55.3 54.7 58.4 59.0 56.9 52.7 The following table gives the extremes and daily range at a number of stations : Average Extreme Daily Range Max. Min. Max. Min. January July Northfield . . . Eastport .... Portland .... Boston Nantucket. . . Albany New York. . . Atlantic City Philadelphia . Washington. . Norfolk Lynchburg . . 91 85 93 •96 84 95 95 92 97 98. 98 98 -25 -13 - 9 - 5 2 -10 2 3 3 2. 13 5 98 93 97 - ■ 102 89 100 100 96 103 104 102 102 -32 -21 -17 -13 - 4 -24 - 6 - 7 - 6 -15 3 - 6 7—25 14—26 15—29 20—34 26—37 16—31 25—38 27—40 25—40 25—42 32—48 28—46 54—78 53—68 60—76 63—80 62—73 63—83 67—82 66—78 68—85 68—87 70—88 67—89 On Nantucket and Block Island the climate, is oceanic, in the interior of Virginia quite continental; the seasons are three weeks earlier in the latter. Lynchburg is 14 degrees warmer than Nantucket in May, whereas there is practically no difference in November. The daily variability of the temperature is as follows : 68 THE CLIMATIC TREATMENT OF CHILDREN Winter, Degrees Spring, Degrees Summer, Degrees Autumn, Degrees Year, Degrees 6.0 8.2 5.2 5.7 " 3.4 4.2 4.6 5.7 48 Interior New England 6.0 The latter figures are as high as any on the continent. Inversion of temperature is not sufficiently common in the Alleghanies to affect the averages very materially, because the cold waves rarely halt in this section for even a day or two at a time. It occurs only when the actual crest of a high-pressure area overlies the moun- tain belt on a quiet night, and is usually aided on such occasions by a snow covering, which favors radiation. Altogether, the winter uniformly grows colder with in- creased elevation. The fall of temperature in ascend- ing may be studied conveniently by comparing the summit of Mt. Washington with Bethlehem, not far from its base : Elev., Feet Jan., Degrees Apr., Degrees July, Degrees Oct., Degrees Year, Degrees 6290 1480 5 14 21 , 36 47 64 29 ■ 42 ► 25.5 39.2 Difference Difference per 4810 1000 9 1.9 15 3.1 17 3.5 13 2.7 13.7 2.8 This rate prevails generally throughout the eastern mountains, and may be used to calculate the tempera-, ture for-all elevated situations in this half of the continent. In northern New York and New England the monthly range of temperature averages 70 degrees in winter, and 50 in summer; in the interior of Virginia these figures are reduced to about 60 and 40 respectively, so that the winter months, at least, are very variable throughout. CLIMATOLOGY OF NORTH AMERICA 69 On the Middle Atlantic Coast the corresponding figures are only about 50 and 35. The enormous difference in temperature between northern Maine and southeastern Virginia, only 800 miles apart, is plainly shown by the vegetation, which ranges from arctic types on the mountain summits of New Hampshire, through a Canadian flora in the far- northern valleys, to the five oaks and red bay trees about Norfolk. A trip from Moscow to Madrid affords •a smaller climatic change than one from the lakes of Maine to Cape Henry. Thus, despite the great annual range at the individual stations, cool summers and mild winters are within quite a short distance of each other. The Hudson River, at Albany, is regularly frozen from December 15th to March 20th, but exceptionally severe seasons may add two weeks or more at either end. Only once in more than a century has it remained open; this occurred in the abnormally mild winter of 1889-90. The freezing of the Hudson is accelerated somewhat by its sluggish current, and occurs with the first fall in tem- perature to near the zero mark. The Lake Region. The climate of the Lake Region is far less uniform than that just described. Considerable subdivision is necessary properly to group the very diverse and apparently somewhat irregularly distributed variations in this section. The key to the problem lies almost entirely in the respective situation on the wind- ward or leeward sides of the different lakes, for, in win- ter at least, the opposite shores have comparatively little in common, owing to the prevailing west winds at that season; we may therefore group the stations accordingly. 70 THE CLIMATIC TREATMENT OF CHILDREN Lake Ontario Kingston .... Toronto Oswego Rochester (C) 44.2 43.6 43.5 43.2 76.5 79.4 76.5 77.7 280 290 300 520 70 66 42.9 44.0 46.5 46.8 Lake Erie Port Stanley Buffalo (C), Erie (C) . . . . Cleveland . . Toledo (C) . 42.7 81.2 620 22 22 28 41 53 63 68 66 59 48 36 27 42.9 78.9 640 25 25 30 42 55 65 70 69 62 51 39 30 42.1 80.1 620 27 28 33 45 57 67 71 70 64 53 41 32 41 .5 81 .7 630 27 28 34 46 58 6X 72 70 64 53 41 31 41.7 83.5 630 26 28 35 48 59 69 73 71 64 52 40 30 44.4 47.0 49.0 49.3 49.6 Southern Michigan Detroit (C) 42.3 83.0 630 25 27 33 46I58I68 I I 72 70 63 51 39 29 48.4 Lake Huron Saugeen .... Parry Sound Port Huron . Alpena 44.5 45.2 42.9 45.1 81.4 80.0 82.5 83.5 630 610 610 610 65 65 42.3 40.1 45.3 41.3 Lake Michigan Grand Haven Mackinaw . . . Chicago (C) . . Milwaukee . . Green Bay . . 43.1 45.8 41.9 43.0 44.5 86.2 630 84.4: 610 87.7 620 87.9 620 87.9 620 54164 48|59 5767 54 63 55 65 46.3 41.3 48.6 45.2 42.7 Lake Superior Marquette. . Duluth White River Port Arthur 46.6 87.4 640 16 17 24 38 49 59 65 64 57 45 32 23 46.8 92.1 640 11 15 24 38 48 58 66 65 56 45 30 18 48.4 85 . 3 1250 -1 2 12 31 45 56 61 59 51 37 20 7 48.4 89.2 640 3 6 16 33 45 56 62 60 53 40 24 12 40.8 39.5 31.7 34.2 CLIMATOLOGY OF NORTH AMERICA 71 The distribution of temperature is thus far more irregular in the Lake Region than on the Atlantic Coast; this is sufficiently evident from the above table, but is illustrated even better in the following list giving the extremes and daily range : Average Extreme Daily Range Max. Min. Max. Min. January July Kingston .... Toroilto Rochester .... Port Stanley. Buffalo Cleveland. . . . Saugeen Parry Sound. Port Huron . . Alpena Detroit Grand Haven Chicago Milwaukee . . . Green Bay. . . Marquette . . . Duluth White River . Port Arthur . . 88 91 94 89 89 93 89 89 94 92 94 88 95 94 94 94 92 88 89 -20 -13 - 5 -14 - 5 - 6 -14 -31 -10 -16 - 7 - 6 -13 -17 -24 -17 -29 -52 -34 93 98 99 94 95 99 94 95 99 98 101 94 103 100 99 108 99 94 95 -32 -23 -14 -27 -14 -17 -30 -38 -25 -27 -24 -25 -23 -25 -36 -27 -41 -58 -40 9—25 14—29 17—31 15—30 19—31 21—34 12—28 5—24 15—29 12—25 19—32 18—31 18—31 14—27 7—22 10—22 4—19 - 14—12 - 7—13 60—76 58—78 61—79 59—78 63—78 64—80 56—74 56—77 60—78 57—74 63—81 60—78 65—80 61—78 60—80 57—74 59—74 48—75 52—72 The daily variability in the Lake Region is less in winter, but greater in summer, than in the Atlantic States; the lakes never freeze over, and therefore temper the former season; in summer, the alternation of land and lake breezes causes frequent and rapid fluctuations. The averages are : Winter, Degrees Spring, Degrees Summer, Degrees Autumn, Degrees Year, Degrees 6.8 6.0 4/4 5.2 5.6 We can best appreciate the influence of these great bodies of fresh water, by following a parallel of latitude, 72 THE CLIMATIC TREATMENT OF CHILDREN for example, the 43d, from west to east. In the fol- lowing table all temperatures have been reduced to a 600-foot level, and all "city temperatures" corrected: . Jan. April July Oct. Year Average Max. Min. 20 24 22 24 43 44 42 41 69 69 69 68 49 50 49 50 45.2 46.4 45.3 45.7 94 89 94 90 -17 Grand Haven Port Huron Buffalo - 6 -10 - 8 The July averages are hardly at all affected, the maxima decidedly more; the January means are raised as much as four degrees by exposure to the winds from the lakes, and the minima are as much as 10 degrees milder. Marquette is 13 degrees milder than Port Arthur in January, whereas the difference should be only about 6; the difference of the average minima is 17 -degrees. Similar but smaller contrasts may be noted between Port Stanley and Cleveland, Toronto and Oswego. The cool summer in. the Upper Lake Region causes the vegetation to be of a more northerly type than we find either to the east or west. The important July isothermal of 68 degrees, which rises from southwestern Maine to the Ottawa River, dips down into central Michigan, to rise again, after reaching Wisconsin, into northern Minnesota. The moderating influence of the lakes has therefore bad as well as good sides, for certain crops cannot be successfully raised in northern Michigan, that thrive in similar latitudes in Minnesota and eastern ' Ontario. For our purposes, however, this climatic peculiarity is of the greatest value, since it affords a great number of cool summer resorts in latitudes that would otherwise be unpleasantly warm; but for the CLIMATOLOGY OF NORTH AMERICA 73 lakes, the inhabitants of the central states would be obliged to travel to. the Atlantic Coast for a breath of cool air in hot summers. The Ohio Valley. The Ohio Valley is intermediate in climate between the Atlantic States and the Mississippi Valley, but nearer the latter; it differs widely from that of the Lake Region. Little description in detail is necessary, for the following table supplies all the required data : a) +3 o3 +3 '3d a . o el "o! >> C >. S -5 O >> 93 a; C _>. 3 s +3 ft s C o .a £ u £ ■ Pittsburg (C) 40.5 80.0 840 31 33 39 51 62 71 75 73 67 55 43 35 52.9 Parkersburg 39 3 81 5 640 32 35 41 52 63 71 75 73 66 55 44 35 53 5 40.0 39.1 83.0 84.5 820 570 28 33 32 36 39 42 51 55 62 65 71 74 75 78 73 76 66 68 54 56 41 44 33 37 5? 1 Cincinnati (C) Louisville (C) 55.3 38,2 85 6 530 34 38 45 56 66 75 79 77 69 58 45 38 56 7 Indianapolis (C) 39.8 86.2 760 28 32 40 53 64 72 76 74 66 54 42 33 52.9 The seasons are considerably earlier inland than on the lakes; note that Columbus is five degrees warmer than Cleveland in April, and only one degree in October. The following table gives the extremes and daily range : Average Extreme Daily. Range (Max. Min. Max. Min. January July Pittsburg .... Columbus . . . Cincinnati . . . Louisville. . . . Indianapolis . 97 97 96 98 96 - 4 - 7 - 3 - 1 -10 103 104 105 107 106 -20 -20 -17 -20 -25 24—39 20—36 26—41 26—42 21—36 65—85 65—86 68—88 69—90 66—86 Observe the great heat of the summer afternoons and the low minima in winter, which may fall below -30 in rural districts, lower than at most points on the lakes; Indianapolis has more severe cold than Grand Haven, 200 miles to the north. 74 THE CLIMATIC TREATMENT OF CHILDREN The daily variability in the Ohio Valley is remarkably great for the semi-southerly latitude: Winter, Degrees Spring, Degrees Summer, . Degrees Autumn, Degrees Year, Degrees 7.1 5.4 3.2 4.9 5.2 The rise of temperature from Moose Factory on James Bay to Parkersburg, 800 miles to the south, is the most rapid in' the world for the distance; for each degree of latitude it amounts to 3.2 degrees in January, 1.3 in July, and 2.1 for the year. The total equals that be- tween the North Cape and Naples, which are 2,000 miles apart, 30 degrees in latitude as compared with 12. The Upper South. The most natural division between tjie upper and lower South is marked by the vegetation. In the upper South the forest growth is similar to that of Ohio and Virginia, being composed almost entirely of deciduous hard woods, only in somewhat greater variety; in the lower South we have vast forests of long- leaved pine, intermingled with a few broad-leaved deciduous and evergreen trees; toward the coasts the broad-leaved evergreens gradually become more con- spicuous, and the characteristic plants are the live oak and palmetto. The dividing line runs from Cape Henry, at first near the coast, then inward to central South Carolina and Georgia, dropping almost to the 32d parallel in Alabama, Mississippi and Louisiana. We therefore expect to find, in the upper South, a climate similar to that of the Ohio Valley, only of course warmer, in proportion to the difference in latitude; we shall see that the extremes are relatively much the same in both districts. CLIMATOLOGY OF NORTH AMERICA 75 I give the following table : Nashville (C) Knoxville . . Raleigh .... Asheville . . . Charlotte . . . Memphis . . . Little Rock . Atlanta .... 36.2 35.8 35.8 35.5 35.2 35.1 34.8 33.8 86.8 83.8 78.6 82.5 80.7 90.1 92.3 84.4 550 1000 .380 2250 770 340 360 1110 45.52 59.3 57.2 59.1 54.6 59.9 61.3 61.5 61.4 The following table gives the extremes and daily range : Average Extreme » Daily Range Max. Min. Max. Min. January July Nashville .... Knoxville .... Charlotte .... Memphis Atlanta 97 96 98 98 96 +3 +3 +9 +8 +9 104 100 102 104 100 -13 -16 - 5 - 9 - 8 30—47 29—48 32—51 33—49 35—52 70—90 65—87 68—88 72—91 69—87 In January the days nowhere average really mild, and the nights range mostly about the freezing point; the summer days* are uniformly hot. The extreme minima are phenomenally low for the latitude, corres- ponding to that of Algeria, and the absence of subtrop- ical vegetation is thus easily accounted for; the daily variability is also excessive, at least in winter. Winter, Degrees Spring, Degrees Summer, Degrees Autumn, Degrees Year, Degrees 6.5 4.9 2.6 4.3 4.6 Even Atlanta has less than eight months relatively free from killing frosts, and the entire region is sure to 76 THE CLIMATIC TREATMENT OF CHILDREN prove disappointing to such as seek a really mild winter climate. That season is, indeed, rather trying, for spring days alternate with zero, weather, such monthly ranges as 75 degrees being far from uncommon. The summer in the lowlands is nearly as hot as in the extreme south, only shorter; the finest months are March, April, October and November, above 1,500 feet also May and September; but only southerners would call the summer at such places as Asheville comfortably cool, for its mean temperature is higher than that of Boston or Chicago, the nights being somewhat cooler, the days considerably warmer. The Lower South. This section is much milder in winter, the conditions becoming those of the warm tem- perate zone. Two subdivisions may be distinguished by their characteristic vegetation, namely, the pine and palmetto belts; in the former the subtropical flora is only partially developed, for the winter minimum still regu- larly falls to- about 15 degrees, and occasionally to zero. The Pine Belt Augusta .... Montgomery Vicksburg . . T3 ' '5b a O •-1 > >> a G a >> ci u o S-i 3 ft < £ § 0) a < S a V O o O -a S 1 s s 33.5 32.4 32.4 '81.9 86.3 90.6 180 220 250 47 48 48 50 52 53 56 58 59 64 66 66 72 73 73 78 79 79 81 81' 81 79 80 80 74 75 75 64 65 65 54 55 55 48 50 50 63.9 65.2 65.3 The Palmetto Belt Hatteras Wilmington Charleston ..".... Savannah Jacksonville Mobile New Orleans (C). 35.2 34.2 32.8 32.1 30.3 30.7 30.0 75.5 78.0 79.9 81.1 81.6 88.0 90.1 586269 54 59 57 62 67 76 1 67 61.3 63.1 65.8 66.4 69.0 66.7 68.8 CLIMATOLOGY OF NORTH AMERICA 77 The following figures will give an idea of the extremes and daily range in this region : Average Extreme Daily Range Max. Min. Max. Min. January July Augusta Montgomery . Vicksburg . . . Hatteras Wilmington . . Charleston . . . Jacksonville. . Mobile New Orleans . 100 99 98 89 97 98 98 98 95 + 16 + 16 + 16 + 18 + 17 + 20 + 24 + 20 + 25 105 107 101 92 103 104 104 102 102 + 3 - 5 - 1 + 8 + 5 + 7 + 10 - 1 + 7 37—57 38—58 39—57 41—52 38—56 43—58 46—65 43—60 47—62 71—91 71—91 72—90 73^-82 73—88 76—88 74—90 73—89 75—90 The winter days average mild throughout, but these figures are most deceptive, for the extreme minima pre- sent a very different picture; the combination of gen- erally spring-like conditions with occasional frosts of great severity makes the southern winter rather danger- ous as well as trying. Even in New Orleans the tem- perature fell below the freezing point in 24 winters out of 30; the minimum of —1 at Mobile in February 1899, is one of the most remarkable events in the history of that city; in the pine belt zero weather occurs about once in a decade. The variability of the temperature is as great, in winter, in Georgia as in New Jersey, but the summer is much steadier; the average figures for the lower south are: Winter, Degrees Spring, Degrees Summer, Degrees Autumn, Degrees Year, Degrees 5.8 3.9 2.0 3.6 3.8 The remarkable eccentricity of the southeastern winter ] unique in so low a latitude, is due to a moderate number of cold waves, accompanying the descent of a high- 78 THE CLIMATIC TREATMENT OF CHILDREN pressure area from Montana to Texas, in the wake of a storm crossing the Gulf S tat es . The " high ' ' travels south in 24 to 36 hours, causing a severe " norther " in Oklahoma and Texas, followed within another 24 hours by severe frost as far south as central and even southern Florida. The very severe spells occur at long intervals; the temperature has gone as low as 20 degrees at Jackson- ville on seven occasions in thirty years; no severe freeze occurred in the eight winters from 1887 to 1894, but two took place in the subsequent season, ruining the citrus- fruit industry for years to follow. Florida. The peninsula of Florida marks the transi- tion from the temperate zone to the tropics. - The vegetation of the latter, having made only the feeblest beginning in extreme southeastern Georgia, becomes dominant south of Titusville and Tampa, though the tenderest types cannot withstand the occasional sharp frosts of even the southern end of the peninsula, and are found only on the outermost keys. The temperature at various points is as follows: Tampa Jupiter Key West (C) 28.0 27.0 24.6 82.5 80.0 81.8 71.6 72.9 77.1 The extremes and daily range are : Average Extreme Daily Range Max. Min. Max. Min. January July Tampa Jupiter Key West .... 94 93 91 + 30 + 36 + 50 96 96 94 + 19 + 24 + 41 50—70 58—72 66—75 74—91 76—87 80—88 CLIMATOLOGY OF NORTH AMERICA 79 Killing frost occurs in three winters out of four at Tampa, and in one out of three at Jupiter; it is unknown at Key West. From May to October the climate is about as enervating as can be imagined. The reader will have observed that, from Cape Hatteras southward, the daily range is greater in winter than in summer; this is due to the change in direction of the prevailing winds, outlined at the commencement of this chapter. The South Atlantic Coast has, in fact, a well-developed monsoon system of winds, which is associated, as we shall see, with corresponding peculiarities in the seasonal distribution of humidity and rainfall; the land winds, that prevail from November to April, give way to sea winds during the warmer months. North of Norfolk west winds predominate throughout the year, south of Jupiter the northeast trade winds blow perennially; the northward movement of the latter begins in April, pro- gresses slowly until the northern limit is reached late in August, is followed by a stationary period until late October, and a rapid retreat during November. They do not in any case extend beyond the foothills of the Alleghanies or west of Alabama. The rise of temperature, from Parkersburg to Key West, for each degree' of latitude, is 2.5 degrees in January, 0.3 in July, and 1.4 for the year, therefore much less than in the north, especially in summer, but still considerable for the warm temperate zone. Before quitting the southeastern regions, We must take a passing glance at certain insular localities, that belong, 'in a measure, to this section. The Bermudas and Bahamas. These groups of small 80 THE CLIMATIC TREATMENT OF CHILDREN islands are of no little interest to the medical climatol- ogist, and merit considerable attention. We have the following data from the Bermudas : 'So c o i-5 c o £ >> u a 3 G •-a >> OS S 0) J3 o ft < 69 0) c 1-5 74 78 02 a O Z 68 s s u 0) Q 64 5 S 32.4 64.7 50 62 61 62 64 69 3 Though opposite Charleston, the winter is very much warmer, the summer but a trifle cooler, the usual range of temperature is from 90 to 48 degrees; frost is ex- tremely rare, as are temperatures above 92. The course of the seasons is oceanic, midwinter falls as late as the middle of February, and midsummer well on in August; the uncomfortable heat lasts until late October, whereas May is still very tolerable. Our data from the Bahamas are scanty; the tempera- ture at Nassau averages 71 degrees in January, and 82 in July and August, with an annual mean of 76.5; the chief difference from Miami, Fla., directly opposite, is a somewhat warmer winter, with the total absence of frost. Cuba is outside of our field, but as Havana lies only twenty miles within the tropics, I give a set of .figures, for the sake of comparison. Havana 23.1 82.4 60 71 72 73 75 78 80 81 81 80 77 74 71 76.1 The relatively cool summer is due to the exposure of the city to the northeast trade winds. The lowest CLIMATOLOGY OF NORTH AMERICA 81 temperature in a fairly long series of observations was 49 degrees, the mean minimum being 55 degrees, a tem- perature felt severely in this enervating climate. The average maximum in summer is 94 degrees. The Mississippi Valley, etc. We may begin our study of the middle and upper Mississippi Valley, and the regions lying to the north and west, as far as the 100th meridian, with a list of tabulated data. The outlying sections have been entered here because their type of climate is precisely similar. Cairo St. Louis (C) Kansas City. Des Moines . . La Crosse (C) St. Paul (C) . Moorhead. . . Wichita. Omaha Huron, S. D. Winnipeg . . . 37.0;89.2 38.6 90.3 39.1 94.6 41.6 93.6 43.8 91.2 45.0 93.0 46.8 96.8 37.7'97.4 41.3 96.0 44.4 98.2 49.9 97.1 360 470 960 86t> 710 840 940 1360 1100 1310 770 39 47 36 43 32 40 23 34 20 31 1628 520 35*43 25 35 1426 59 67 75 56166 75 54 64 73 5061 71 47 59 69 4557 67 4l'53|64 56J65 73 51 62 71 445767 36 52162 - K - s £ a. _ > ELL c 70 59 46 39 70 58 44' 36 68 56 41 32 64 51136:26 62 49 33 23 60;47,30il9 57j43 2410 6757143 35 65 53l37;27 59 46|29il7 52 39 171 3 57.7 55.9 53.2 48.5 46.0 43.3 37.6' 54.7 49.6 42.3 32.9 The extremes and daily range in this region are as follows : Average Extreme Daily Range Max. Min. Max. Min. January July 96 98 100 98 95 95 96 101 100 101 93 - 5 -11 -19 -25 -27 -35 - 5 -18 -30 -43 106 107 106 109 104 104 102 106 106 108 103 -16 -22 -22 -30 -43 -41 -48 -22 -32 -43 -54 28—43 24—38 . 19—34 10—26 8—23 4—19 -9—+ 9 ■ 20—38 11—27 - 1— + 19 -17—+ 4 70—88 St. Louis ...... Kansas City . . • Des Moines. . . . La Crosse St. Paul Moorhead Wichita Omaha Huron Winnipeg 70—89 . 67—88 64—86 62—84 61—82 56—80 66—90 66—87 58—84 53—79 82 THE CLIMATIC TREATMENT OF CHILDREN In February 1899 —63 degrees were observed at Norway House in latitude 54; within a few days —29 were recorded at Springfield, Mo., and —1 at Mobile, Ala. In Manitoba, frost is common in early June, and not very rare in the latter part of August. North of latitude 45, the January nights regularly have temperatures be- low zero, but occasional brief spells of thawing weather may occur in midwinter at Winnipeg and beyond. The weather is exceedingly changeable everywhere, and nearly as much so in Missouri as in Manitoba, the average variability being: Winter, Degrees Spring, Degrees Summer, Degrees Autumn; Degrees Year, . Degrees 8.3 5.8 3.8 5.6 5.9 At Winnipeg the mean monthly range is 72 degrees in January and 47 in July, and at St. Louis the correspond- ing figures are only about eight degrees less. The South Central States have the same type of climate, only warmer. Oklahoma. . . . Shreveport . . . Galveston (C) San Antonio. . Corpus Christi 0> A 35.4 32.5 29.3 29.4 27.8 4> 73 3 1 97 5 93.6 94.8 98.5 97.5 a _o > 9 m \ 1210 250 50 700 20 >) c3 3 a c3 | -i 36 46 53 51 56 s 3 In .a 0) 41 51 57 56 59 -a o o3 49 58 63 62 64 ft < 60 66 70 70 70 >> 03 m 68 73 76 76 76 d •-» 75 80 82 81 80 >> 1-3 79 83 84 83 82 < 77 81 83 82 81 S ft a? w 70 75 79 77 79 S3 O O O 60 65 72 70 72 B o 48 55 63 60 64 ■s o Q 41 49 56 ■54 58 58.7 65.2 69.8 68.5 70.1 The extremes and daily range are: Average Extreme Daily Range Max. Min. Max. Min. Jan. July 100 101 94 102 95 - 1 + 15 + 25 + 18 + 25 104 107 98 108 98 -17 - 5 + 8 + 4 + 11 26—46 37—55 48—58 41—62 50—62 68—90 Shreveport 73—94 80—89 San Antonio Corpus Christi 73—94 77—87 CLIMATOLOGY OF NORTH AMERICA 83 All the absolute minima date from February 1899, when the thermometer fell to 31 degrees at Tuxpan, Mexico, in latitude 21, the farthest recorded southward extension of the frost line on our continent, at the sea level. Along the 98th meridian, the rise of temperature for each degree of latitude is as follows: January, Degrees July, Degrees Year, Degrees 3.0 2.2 1.2 0.0 1.9 1.2 It will be seen that these figures are somewhat smaller than those given for the 81st meridian on pages 68 and 74. The mean variability of temperature in the South Central States is : Winter, Degrees Spring, Degrees Summer, Degrees Autumn, Degrees Year, Degrees 6.3 5.1 4.4 2.6 2.3 1.3 4 3.2 4.3 Texas Coast . 3.0 The Texas Coast would enjoy a most even climate but for the occasional cold snaps (northers) which bring killing frost nearly every winter to the Rio Grande and beyond. The subtropical flora, as the minimum tem- peratures at Shreveport would suggest, barely reaches the 32d parallel in Texas, and tender plants, such as the Magnolia grandiflora, endure the winter better at Rich- mond, Va., than at Fort Worth, five degrees farther south. Westward the subtropical vegetation gradually assumes the character of the so-called chaparral, con- sisting of partly evergreen thickets of live oak, mesquite 84 THE CLIMATIC TREATMENT OF CHILDREN and aromatic shrubs, resembling the macchie of the Mediterranean region; this floral type characterizes the semi-arid subtropical regions of both hemispheres. On the lower Rio Grande we find the beginnings of the tropical flora of the Mexican lowlands, despite occasional freezing weather; it will be remembered that analogous conditions appear in Florida, only there the somewhat milder winter permits an extension a few degrees farther north. The Great Plains and the Rocky Mountain Slope. The Great Plains, while apparently level, nevertheless rise gradually westward, abput four feet to the mile on the 50th, and eight on the 40th parallel. Slight as is this slope, it seems to be intimately connected with the cli- matic peculiarities of this region, which consist essen- tially in a rise of temperature, as we ascend. Thus, in Canada, Medicine Hat is 14 degrees warmer than Win- nipeg in winter, and 1 in summer, although it lies 1,400 feet higher; similarly, Cheyenne is 6 degrees warmer than Omaha in winter, although its elevation is 5,000 feet higher; its summer, while cooler, is far less so than the difference in altitude would 'call for, averaging only 9 degrees lower, instead of at least 15. Near the moun- tains, this may, of course, be attributed to "foehn" winds, but the increase is so gradual, beginning as far east as the 96th meridian, that the above explanation does not cover the ground perfectly; we cannot see, for example, why the winter at North Platte, in the midst of the plains, should also be warmer than at Omaha, in spite of a rise of 1,700 feet. The following table gives the temperature data for this region: CLIMATOLOGY OF NORTH AMERICA 85 Abilene, Tex Amarillo Dodge City Denver .". North Platte Cheyenne Lander Rapid City Pierre Yellowstone Park Helena Bismarck , Williston Havre Medicine Hat. . . . Regina. Banff Prince Albert Edmonton 32.4 35.2 37.7 39.8 41.1 41.1 42.8 44.1 44.4 44.8 46.6 46.8 48.2 50.0 50.4 51.2 53.2 53.2 101.7 100.0 105.0 100.7 104.8 108.6 103.2 100.3 110.5 112.1 100.8 103.6 109.7 110.6 104.6 115.6 106.0 113.5 1,740 3,680 2,510 5,290 2,820 6,090 5,370 3,230 1,570 6,200 4,110 1,670 1,880 2 500 2,160 1,880 4,540 1,430 2,160 46 35 32 32 26 27 21 23 17 • 20 22 10 8 15 12 -1 13 -3 73 *-l-° III «i o C 2 64 52 45 56 43 35 62.7 54.2 53.1 49.3 47.8 44.4 41.7 45.3 44.7 38.1 43.1 39.6 38.2 40.4 40.1 32.5 34.6 30.5 35.7 The prairies extend only as far north as the Saskatche- wan, farther on we enter the great subarctic forest which extends northwestward almost to the mouth of the Mackenzie River. The extremes and daily range on the Great Plains are as follows : Average Extreme Daily Range Max. Min. Max. Min. Jan. July 102 97 102 100 97 94 100 105 ' 95 100 99 98 88 92 + 6 - 4 -12 -20 -14 -19 -24 -25 -26 -34 -36 -49 -46 -54 110 105 108 107 105 100 106 113 103 106 108 92 96 - 6 -16 -26 -35 -29 -38 -40 -40 -42 -44 -55 -57 -70 31—52 19—42 14—38 8—32 16—40 15-36 8—30 2—23 10—25 -5— + 16 0—21 -16—+ 4 - 6— +12 -17—+ 1 71 — 93 64 — 88 Dodge City North Platte 65—91 60—87 58 87 Cheyenne Rapid City 53—81 58—83 62 -86 56 — 79 Bismarck 57—81 54—81 50—- 78 Edmonton Prince Albert 49—73 50—75 86 THE CLIMATIC TREATMENT OF CHILDREN The reader will note the relatively warm days and cold nights. In January, Denver has the day tem- perature of Baltimore and the night temperature of Albany; in July we find the days as hot as at Washington and the nights as cool as at Quebec, the heat of the day being tempered by a phenomenally low humidity. The winter minima are astonishingly low. In Janu- ary, 1885, —63 degrees were registered at Poplar River, in northeastern Montana, and in February, 1893, there was a record of —70 at Prince Albert. There is no doubt that figures as low as —75 and —80 occur in far northwestern Canada, where —65 is quite frequent. The different seasons vary exceedingly from the normal temperature; thus, at Edmonton, within fifteen years, the average for November has been as high as 40 degrees and as low as zero ; for January, the figures for the same period are 22 and —13. At Winnipeg, February has averaged 24 (1878) and —16 (1875) degrees; similar climatic eccentricities have been repeatedly noted at Havre and other points at the foot of the Rockies. A succession of the winter storms of the first type, passing through the Canadian Northwest, causes. frequent Chi- nook winds and a high mean; the stagnation of high- pressure areas over this region, which is less frequent, produces the intense cold noted above. Changes of 30 degrees in an hour when the wind shifts from southwest to north, and vice versa, are not at all rare on the moun- tain slopes, even so far south as western Texas; Greeley reports a rise of 47 degrees in 8 hours at Denver, and for Abilene there is on record a fall of 63 degrees in 16 CLIMATOLOGY OF NORTH AMERICA 87 hours. The mean monthly range at Willis ton is 74 degrees in winter, and 57 in summer. The daily variability for this region is quite uniformly : Winter, Degrees Spring, Degrees Summer, Degrees Autumn, Degrees Year, Degrees 7,5 5.8 '3.6 5.4 5.6 In winter there is little difference between Montana and Texas, but the summer is much steadier south- ward. Before leaving the Great Plains, we may glance briefly at the distribution of a few of their more striking meteor- ological phenomena. Among these, the tornado easily ranks foremost, but is not altogether peculiar to this portion of the continent, being, in fact, rather uncommon west of the 100th meridian, and diminishing in force and frequency only gradually as the Atlantic Coast is ap- proached. Tornadoes are commonest in Missouri, Kan- sas, Iowa and Nebraska; then follow Illinois, the 'lower Mississippi Valley, Oklahoma and Texas; finally, the Ohio Valley, southern Minnesota and South Dakota. In the Atlantic States they are much less frequent and destructive. Hot winds are not so frequent as is often supposed, and only exceptionally, as in the unusually dry and hot July of 1901, reach so far east as the Mississippi River. Toward the Rocky Mountains they become common, but even here are rarely so hot and dry as in Arizona, Cali- fornia, and the Snake River Valley. Temperatures above 105* degrees are quite rare, save at such localities as Pierre, which is situated to the north of a plateau, 88 THE CLIMATIC TREATMENT OF CHILDREN where the south winds, already warm, are still further heated and dried dynamically in descending. The third specialty of the Plains is the blizzard. It has recently become the fashion to call every violent snow- storm a blizzard, but the true blizzard, with fine dust-like snow, a fierce gale, and a temperature rapidly falling to zero and below is almost entirely confined to this region, prevailing in the Dakotas, Montana, Nebraska and the eastern halves of Wyoming and Colorado, less often Kan- sas. In the far north, it attracts less attention, chiefly perhaps because the inhabitants are pretty thoroughly accustomed to severe weather. The heavy snowstorms east of Nebraska and the Dakotas hardly partake of the irresistibly fatal character of the true blizzard. For a more minute description of the above phenom- ena, the reader is referred to works on meteorology; it would be out of place in a book of this kind. We have now completed our survey of the temperature conditions east of the continental divide, and may begin the consideration of the West with 'The Western Plateau. Our knowledge of this region is less complete than might be desired, good records being absolutely wanting north of the 53d parallel, and scattered and scanty elsewhere, especially in the less settled districts. The southwestern plateau is excluded from consideration here, its climate differing from the region north of the 37th parallel in many respects. The following averages have been corrected as carefully as possible by comparison with the long-established ones, which number only about eight, even if a few just outside of the district are included : . CLIMATOLOGY OF NORTH AMERICA Carson City Salt Lake City... . Winnemucca Leadville Grand Junction. . Durango Pocatello Boise" City Baker City Walla Walla Spokane Kalispell Kamloops Barkerville 39.2 40.7 41.1 119.8 111.9 117.7 103.3 108.6 107.9 112.5 116.2 117.8 118.3 117.4 114.4 120.5 121.9 4720 31 35 40 ! 47 o4 ! 6l!6766 59 5040 34 48 . 7 4370 128 34 42 50 58 67 75 74 64 52 40 32 51 .3 4340 27 33 40 47 55 63 71 70 60 49 37 31 '48 .6 10220 4610 6550 4480 2740 3470 1000 1940 2960 1190 4180 913120 24J30I41 24 28 36 28:37|45 52163 71 45154 61 30|38|4654 5l!59 52 61167 5763 52 58 5764 43 51 50 42 76 65 66J58 7059 71 61 64J56 72 64: 68159 63|54 68 58 5547 322014 523729 473428 4735 27 50 3S 32 46 35i26 54 42 35 1 4938J30 44 31 24 48^5 28 38,26121 30.2 51.5 45.7 47.0 50.7 44.2 52.5 47.8 41.9 47.1 36.2 The relatively high temperature of this region will be best appreciated by. reference to maps of isothermal lines; it will be noticed,- how T ever, that the winter at first grows somewmat colder, when we cross the continental divide, so that western Colorado and Wyoming, also eastern Idaho and adjoining Montana are colder than the regions on either side. The distribution of temperature is in any case less uniform than on the eastern side of the continent, and there are many local warm and cold climatic islands, according to the situation of the indi- vidual localities. In western Colorado it is of interest to note the rapidly increasing heat in summer from Durango to Grand Junction, due to descending air cur- rents from the southeast. The following records afford an idea of the extremes and daily range of temperature : Average Extreme Daily Range Max. Min. Max. Min. Jan. July Carson City Salt Lake City, . . . Winnemucca Boise" City Walla Walla Spokane 94 98 97 104 104 99 - 5 - 3 -10 - 6 - 4 -12 100 102 104 111 113 104 -22 -20 -28 -28 -17 -30 19—43 * 21—36 17—37 22—37 24—36 18—30 51—83 62—88 55—88 58—89 60—86 56—82 90 THE CLIMATIC TREATMENT OF CHILDREN The most marked difference between the two slopes of the Rocky Mountains is in the variability of the temperature, which is less than two-thirds as great in winter on the west as on the east side; the following figures prevail quite uniformly throughout : Winter, Degrees Spring, Degrees Summer Degrees Autumn, Degrees Year. Degrees 4.5 . 4.0 3.3 3.9 3.9 It is therefore all the more surprising to note the occa- sional intense cold at stations so mild as Salt Lake City and Walla Walla, not to speak of — 28 degrees at Boise City. These cold waves are very exceptional, and the usual minima barely touch zero; they are due to the very uncommon stagnation of a high-pressure area over the northern plateau, while the Great Basin itself is snow covered. The same phenomenon occurs in Central Europe under analogous conditions. The daily range in winter is relatively small, as this is the rainy season west of the divide; in summer the range is enormous, the nights are cool and the days very hot, this season being almost rainless. As we ascend the mountains, the fall in temperature is very rapid, as seen on Pike's Peak, for example. Elev., Feet Jan., Degrees April, Degrees July, Degrees Oct., Degrees Year, Degrees Summit Colorado Springs. . . 14130 6060 3 27 13 46 39 70 22 48 19.2 47.8 Difference " per 8070 1000 24 3.0 33 4 .1 31 3.8 26 3.2 28.6 3.5 We see how greatly this rate exceeds that in the Alleghanies; it is, however, very much less on the CLIMATOLOGY OF NORTH AMERICA 91 western slope of the Rockies, at least in winter, when inversion of temperature is quite frequent on that side. The tree line is remarkably high for the latitude in Colorado, 11,500 feet; the snow line is touched only by the highest peaks, and there are no glaciers of any con- sequence south of the Canadian border, until we ap- proach the Pacific Coast. The Southwest. Extreme southern Utah and Colorado, with the adjoining portions of Arizona and New Mexico, form a vast high plateau, deeply grooved by the canon of the Colorado. Passing southward from this table- land we enter a region geographically, as before 1846 also politically, belonging to Mexico. This relation is shown by both the flora and the climate; as we descend, the temperature rises very rapidly, and the distribution of moisture, as we shall see later, becomes quite different from that prevailing farther north, east, and west. The Upper Rio Grande Valley and Arizona first claim our attention, and the following table will supply suffi- cient and reliable data as to the temperature : Santa Fe El Paso. . Prescott . Phoenix . 35.7 31.8 34.5 33.5 106.0 106.5 112.5 112.0 7010 3760 5390 1110 54 47 56:65 68 66 60 50 38 31 48.3 64 73 ! 80 82 79 73 63 52 46 63.4 59 67 75 83 73 71 90 88 63 54 81 70 42 35152. 2 59 52J69.1 The climate of the Mexican plateau is so similar that we may most conveniently refer to it here; Mexico City, though situated in the tropics, is rendered temperate by the altitude, and may therefore likewise be added. 92 THE CLIMATIC TREATMENT OF CHILDREN d h3 3 '&) a o h4 4) >> 3 3 Eh J3 o 'E >> CD a >> on a M s CO u a o o O CD £ 1 u CD .a s 4) Q 1 Chihuahua Saltillo Mexico City 28.6 25.6 19.4 106.5 100.5 99.1 5400 4670 7470 50 51 54 54 54 57 61 60 60 69 66 64 76 71 65 79 75 64 79 71 62 73 71 62 71 69 61 65 63 59 57 56 56 52 51 54 65.5 63.2 59.7 At El Paso, August is cooler than June, south of Chihuahua July also becomes cooler, and in central Mexico May becomes the warmest month. This shift- ing of the period of greatest heat is connected with the development of the rainy season. The following table gives an idea of the extremes and daily range: Average Extreme Daily Range Max. Min. Max. Min. Jan. July Santa Fe 90 102 95 113 85 - 2 + 11 + 1 + 24 + 33 97 108 100 119 -13 - 5 -18 + 12 18—38 31—58 20—45 37—64 41—67 57 — 79 El Paso £9 — 95 Prescott Phoenix Mexico City 58— 89 76—105 May 52— 78 The summer days are hot, but in the upland sections the nights are always comfortably cool; in the lowlands high temperatures prevail both day and night. The winter weather resembles that in the Great Basin, but is drier and has a greater daily range, with of course also a rapid rise of the average temperature as we go south and descend into the deeper valleys of the Gila and Rio Grande rivers. The daily variability is quite small, as follows : Winter, Degrees Spring, Degrees Summer, Degrees Autumn, Degrees Year, Degrees 4.0 3.8 2.4 3.1 3.3 CLIMATOLOGY OF NORTH AMERICA 93 In the low valleys the summer temperature is very steady, with a maximum around or above 100 degrees every day for months. The lower Gila Valley marks the transition to the deserts of southeastern California; for the latter section we have official records for Yuma and Independence. I have corrected the semi-official data for Salton to the Yuma standard, and the resulting figures are at least approximately correct; while apparently altogether too high in summer, they agree very closely with the results obtained by the U. S. Government's Death Valley expedition. as 3 '5b a o h1 a > >. 3 a >-5 >> 3 (-. X> » 0) c 1-9 13 »-3 03 3 bO 3 0) XI S E 8 Q i-. V Yuma Salton Independence .... 32 6 33.5 36.8 114.6 115.9 118.2 140 -250 3910 54 52 40 58 57 44 64 65 50 70 75 57 77 85 65 85 95 73 92 102 80 91 100 78 84 92 70 73 80 60 62 67 48 56 58 43 72.2 77.3 59.0 In the depression at Salton, the summer is the hottest known in the world; 128 degrees have been recorded and 120 occur for days at a time. Death Valley averages only about two degrees cooler at all seasons; at Yuma the ordinary extremes are 114 and 28 degrees, the absolute extremes 118 and 20, the daily range is from 41 to 68 in January, and from 77 to 108 in July, when the afternoon maximum almost invariably exceeds 100. Salton is only ninety miles from the coast, where the July temperature is 35 degrees lower; this is the great- est contrast of temperature known, but the transi- tion is not very uniform, being gradual and moderate 94 THE CLIMATIC TREATMENT OP CHILDREN from the coast to the Coast Range of mountains, on the east side of which the increase of heat is very sudden. On the west coast of Mexico we have trustworthy figures only from Mazatlan, just within the tropics. 0> I 1 O- Hi d > 1 3 u J3 O <1 >> a 1-5 +3 DO a a ft CO s-< o U O U o h I 5 Q S3 23 2 106.4 30 68 68 70 73 77 81 83 84 84 81 76 71 76 3 Topolobampo, in latitude 25° 3', averages about 64 degrees in January, and 86 in August; Guaymas, in latitude 28°, about 60 in January and 90 in August. The interior of Sonora resembles southern Arizona, but is a little warmer in winter. No part of northwestern Mexico has as yet advanced sufficiently in civilization to attract the health-seeker and ordinary tourist. The Pacific Coast. We may begin our consideration of the climate of the Pacific Coast with southwestern California. As mentioned above, this section presents a most striking contrast to the desert behind the Coast Range. The temperatures for southwestern California are: 3 1 © 1 o a o 1 p c >-> 1 3 u J3 o a < >> 0) a 3 >> •-5 CO 1 a $ a u O z S E o a 32.7 33.4 34.1 34.4 36.6 117.2 118.4 118.2 119.7 122.0 90 50 340 130 100 54 54 53 53 50 55 54 55 54 51 56 55 57 55 52 58 56 59 56 54 61 57 62 59 56 64 59 66 62 58 67 60 69 64 60 69 61 70 66 61 67 60 68 64 60 63 59 64 61 57 59 57 59 56 55 60 7 Santa Catalina Island. 57.2 61 4 Santa Barbara 58 55 54 52 58.9 55.4 August is everywhere the warmest month, and Sep- tember is often as warm as July. Owing to the hilly character of the country, the sea breeze does not CLIMATOLOGY OF NORTH AMERICA 95 penetrate freely into the interior, and we find there an increased warmth in spite of a considerable elevation. On the other hand, the hot winds, in a modified form, sometimes reach the coast itself, as shown in the follow- ing table of extremes: Average Extreme Daily Range Max. Min. Max. Min. Jan. July San Diego Los Angeles 90 100 + 37 + 33 101 109 + 32 +.28 46—62 43—64 63—72 58—81 The outer islands are, however, entirely exempt from very warm weather; they enjoy an eternal spring, in win- ter they resemble early May in New York, in summer the latter part of May, of course in temperature only. Toward the middle Californian region, the climate also becomes singularly even, as at Monterey, where we find a transition to the San Francisco district. Lower California seems to have a uniform climate in winter, January averaging about 55 degrees in the north, and 65 in the extreme south; in summer the west coast is cool, ranging from about 70 degrees in the north to 75 in the south, but the east coast grows very hot toward the head of the Gulf of California,, with a July average of 90 degrees. All these figures are, of course, mere estimates, as no accurate records are extant. As a striking contrast to the coast and deserts just described, we may note the rather severe mountain climate in the Sierra Nevada. At Lake Tahoe, 6,200 feet high, January averages about 26 degrees and July 62, with annual extremes of about 90 and — 15. Frost is not very rare in midsummer; nevertheless, in warm sum- mers after dry winters, nearly all the snow disappears 96 THE CLIMATIC TREATMENT OF CHILDREN from the very highest peaks. In northern California, the snow line drops to about 11,000 feet, and Mt. Shasta is capped with ice fields and glaciers. About San Francisco Bay we find a most remarkable distribution of temperature, altogether unique; the fol- lowing table will serve as an introduction : SE. Farallone San Francisco (C) . Oakland (C) Mt. Tamalpais. . . . 37.7 37.8 37.8 38.0 123.0 122.5 122.3 122.7 W 30 100 70 2370 53.3 56.0 56.7 57.1 On the Farallone Islands there is an annual range of only seven or eight degrees, September being the warmest month, and October being warmer than July; the same type of climate prevails at San Francisco, save that the range has increased to eleven degrees. This curious course of the temperature is due to the suppression of the normally increasing summer warmth by the violent and continuous sea breeze; when this begins to abate, in the autumn, the mean temperature rises, and an occasional hot wind reaches the coast from the interior. Hot weather may occur in May, June, September and October; it is extremely rare in July and August. The following table will illustrate this curious anomaly: May, Deg. June, Deg. July, Deg. Aug., Deg. Sep., Deg. Oct., Deg. Average maximum, 30 years 80 82 79 78 85 82 At Oakland, across the bay, but only five miles from San Francisco, conditions are quite different; the warmest month is no longer September, but August, as CLIMATOLOGY OF NORTH AMERICA 97 elsewhere in California, and a few hot days are not so uncommon in midsummer. Oakland begins to grow warmer than San Francisco in April and May, is five degrees warmer in summer, but has the same tempera- ture in and after October. In ascending to the siimmits of .the Coast Range, as at Mount Tamalpais, we find that the sea breeze has dis- appeared, for it does not reach to this height. The sum- mer is proportionately much warmer than even at Sacra- mento; San Francisco people ascend the mountains in summer for the sake of greater warmth, instead of cool weather, as elsewhere. Localities under the lee of the Coast Range, as San Rafael, are also relatively warm in summer, but I have not been able to secure reliable data concerning this popular resort. The average extremes at San Francisco are 90 and 36, the absolute extremes 101 and 29 degrees; killing frost is even rarer than hot weather. In January the daily range is from 45 to 56 degrees, in July from 52 to 64, and in September from 55 to 68. The coast of northern California has a very similar climate, but the Coast Range is sufficiently high and con- tinuous to cut off all hot winds. August is the warmest month, though September still equals July. The annual range is exceedingly small for the latitude. The follow- ing data for Eureka will give ample information ; 0) 01 'I o G O ! >> u Z a >> u rt 3 c ■- 1 p, < >> 0) = 3 03 s < 8J s 0Q a £1 a o O o o ,£1 £ 8 Q o3 40.7 124.2 60 46 47 48 50 52 54 56 57 56 53 50 4S 51.4 The ordinary extremes are only 75 and 28 degrees, 98 THE CLIMATIC TREATMENT OF CHILDREN the absolute extremes 84 and 20; the daily range in January is from 40 to 53 and in August from 52 to 62. It is interesting to compare these figures with those of New York, in exactly the same latitude on the Atlantic Coast, the annual means being almost identical. Along this entire coast, the summer actually appears colder than the winter, on account of the penetrating winds and damp fogs at the former season. The interior of California has a climate that partakes of some of the features of the deserts. '-5 o 3 a o •J 1 >> !-. o3 S3 C 03 •-s El, a u a G !"5 s> s 0Q u 1 O £ > o OJ X! g a) o '5b a o Eh P 4 >> 83 Eh X, o u 3 ft < >> 83 C >"3 3 *-> +a p M 3 Eh B V ft 0Q Eh > eg 13 u ■ a 3 0. > G ^5 "3 »-3 1 < s ft w 09 O Xi O s ! h i> S 4) O & $ >* Dawson.. .... 64.1 139.3 1200 -21 -12 3 29 46 58 62 56 43 23 -3 -13 22.8 The average extremes are 88 and— 56, the absolute 102 THE CLIMATIC TREATMENT OF CHILDREN extremes 95 and— 68. The climate resembles that on the Saskatchewan, 1,200 miles to the southeast, but the winter is about ten degrees colder. The Yukon breaks up only about two weeks later than the St. Lawrence, but freezes a month earlier. GLOUDINESS AND HUMIDITY There are two recognized methods of calculating the percentage of clouds. One consists in judging the pro- portion of the sky that is covered, repeating this process at stated intervals during the day, and averaging the results. This method is apt to yield rather high percent- ages, because the apparent banking of clouds toward the horizon is included in the observer's estimate, and over- rated; in addition there is the element of the personal equation, which also has a tendency to overestimation. The second ; jglan consists in employing an automatic sunshine recorder of either the thermographic or photo- graphic type, and deducting the number of hours of sunshine observed from the total time between sunrise and sunset. The defect of this method is the ignoring of the night hours, which form the majority during half the year; this demerit is, however, not very important from the standpoint of medical climatology, which is not in any way interested in the ratio of cloudiness at night, but only in the actual proportion of sunshine. Throughout our territory, the first method gives a ratio of cloudiness from six to ten per cent, higher than the second; in our tables full details shall be given according fcrthe former, supplemented by the somewhat scantier, data afforded by the latter, in all cases by small districts, CLIMATOLOGY OF NORTH AMERICA 103 so as to eliminate the personal equation as far as pos- sible. The relative humidity will be similarly stated, accord- ing to small districts. We have already explained that these figures, by themselves, are almost meaningless, and are really valuable only when referred to the tempera- ture prevailing at the time; it has therefore seemed worth while to go to the trouble of calculating the sensible temperature for the warm months at a large number of stations, in order to render this statistical material really useful. Under this sub-heading, the stations are thrown together into physiological groups, with reference to the indifferent temperature, and we believe that the tables will thus graphically show which places have, respec- tively, a hot, warm, cool or cold summer, in a way superior to anything of the kind hitherto published. In the more southerly districts similar data are given for the colder seasons; this feature is unnecessary where the thermometer averages below 55 or 60 degrees, as explained in the preceding chapter. Subarctic North America. Southern Greenland has a pretty uniform ratio of 65 to 70 per cent, of cloudiness throughout the year; Labrador more nearly resembles the arctic regions, having the lowest proportion, about 55 per cent, in spring, and the highest, about 70 per cent, in autumn. In both regions the humidity is high; our data are very scanty, but 75 per cent, in the spring, and 85 per cent, in the fall, will not be far from the truth. The distribution of fogs is quite strictly in accordance with the factors just mentioned. The Northeastern States and Canada. In this district the distribution of clouds is as follows : 104 THE CLIMATIC TREATMENT OF CHILDREN Newfoundland, Nova Scotia New Brunswick, Quebec New England, Middle Atlantic Coast Northern Alleghanies 63% 56% 51% 57% The coast is almost as clear in winter as in summer, August is the finest month northward, October south- ward. The inland districts are relatively very cloudy from November to March, a phenomenon as common as it seems paradoxical; in New York the cloudiness in December increases steadily from 55 per cent, on the coast to 85 on Lake Ontario; in summer these two sec- tions differ little, but the intervening mountains are about five per cent, cloudier. Along the coast, from New England to Virginia, we find an average of 2,620 hours of sunshine annually (60%), whereas among the interior highlands the total diminishes to 2,190 hours (50%); these figures correspond quite closely to those for southern and northern Italy respectively. The distribution of the relative humidity is quite different in summer, though somewhat similar in winter, as follows : & >> 3 JS • m I * B .Q ft 3 1 ft 1 77 'u a < 76 >> o3 81 3 82 >> 3 83 • si 3 < 84 a 82 o o o 79 ft o 525 78 8 Q 77 1 Atlantic Coast 77 76 79% 73% Atlantic Plain 74 73 70 f>5 71 72 73 75 77 7o 75 74 Northern Alleghanies .. 79 77 76 69 71 73 75 78 79 80 80 80 76% The effect of the sea fog from May to September, of the cloudy conditions inland in winter, and of the CLIMATOLOGY OF NORTH AMERICA 105 mountain-valley fogs of autumn, is very apparent. The lowlands away, from the coast are relatively dry at all seasons, but especially in winter and spring. In regard to sensible temperatures, we need consider the warmest three months only, and group the localities as follows : Summer cold, Summer cool, 54—56 56—58 58—60 60—62 62—64 Summer warm, 64 — 66 66—68 68—70 70—72 52 — 54 deg., Father Point, St. John's. Yarmouth, Eastport. Chatham, Sydney, Rockliffe. Halifax, Charlottetown, Quebec, Northfield. Montreal, Ottawa, Portland. Boston, Nantucket, Block Island. Harrisburg, Albany, New Haven, Atlantic City. New York, Philadelphia. Baltimore, Washington, Lynchburg. Norfolk. The Lake Region. The distribution of cloudiness in the Lake Region is as follows : • 1 >> 3 (-. £> V Pn 71 67 57 ■a § 65 62 55 'C P. < 55 54 54 >> 52 52 51 p 1-3 49 48 50 46 44 43 +3 GO a < 47 44 45 S3 £ 4) ft , b <3 43 43 H I a I 1 1 < & S a s •-8 ! i 77 ■♦J a 0) 78 1 o O 80 a o 82 a 8 82 Northern Lake Region. . 83 82 79 74 72 73 73 78% Southern Lake Region. . 81 81 77 71 71 72 70 72 74 74 77 79 75% The winter is damper in the Lake Region than in the northeast, the summer is nearly the same, and fairly dry for the location. The sensible temperatures for the warmest three months are : Summer cold, 52 — 54 < Summer cool, 56 — 58 58—60 60—62 62—64 White River, Port Arthur. Marquette, Alpena, Saugeen, Duluth. Parry Sound, Toronto, Port Stanley, Kingston. Milwaukee, Grand Haven, Port Huron, Rochester, Buffalo, Oswego, Green Bay. Erie, Detroit, Chicago, Cleveland. The Ohio Valley. In this section the cloudiness and humidity are as follows : >> 1 ft < * 3 a 4 >> 43 EC a u 43 a « ft 0) 43 O O o 43 a > o 1 8 o3 a) 66 77 64 75 63 72 55 64 53 66 51 68 45 66 44 69 44 70 50 71 61 74 64 75 55% 71% The cloudiness is great for so continental a situation, higher than at many places farther north and east; there are 2,320 hours of sunshine (52%). The humidity in the summer months is the lowest east of Kansas; Cincinnati and Louisville having an CLIMATOLOGY OF NORTH AMERICA 107 annual average of only 68 per cent. All places in this region have a warm summer : 66 — 68 deg., Indianapolis, Pittsburg, Columbus, Parkersburg, Cincinnati. 68 — 70 " Louisville. The Upper South. The cloudiness in the upper South follows two types, on the eastern and western slopes of the Alleghanies respectively. >> 3 G 1-8 >> 3 3 t. £i XI a 5 a 1-3 >. 3 1-3 GO 1 = ft 43 c e O u £ ! S 43 S e O North Carolina to Georgia (uplands). . . 57 59 54 59 48 52 45 48 46 47 51 47 52 45 53 44 44 42 38 38 44 49 50 55 48% 49% The eastern slope has a relatively cloudy summer, whereas the west side of the Alleghanies and the Missis- sippi Valley are quite cloudy in winter, and have a bright summer; both sections have a very sunny Octo- ber. The proportion of sunshine in this region averages 2,650 hours, 60 per cent, of the possible total. As regards humidity, the entire region is so uniform that but one statement will be required. Upper South. >> u 42 42 3 3 a eg >-3 I -a 3 < & § G 3 1-3 •"8 00 3 ft » GO O O O S o s 01 o 5 74 72 70 65 68 72 75 77 75 72 73 74 72% Only in northern Tennessee is the summer a trifle less moist than the winter, otherwise it is the dampest season of the year; the result appears in the very high sensible temperatures for the summer: Summer warm, 68 — 70 deg., Knoxville. 70—72 " Raleigh, Charlotte, Nashville, Atlanta. 72 — 74 " Memphis, Little Rock. 108 THE CLIMATIC TREATMENT OF CHILDREN At the last two stations the summer is almost trop- ical. In the South it is also worth while to give the sensible temperatures of spring and autumn, these being really the best seasons for visitors. I have taken April and October as the representative months for those seasons. April cool, 52 — 54 deg., Raleigh, Charlotte, Nashville. April mild, 54 — 56 " Atlanta, Memphis, Little Rock. The October temperatures are just four degrees higher throughout. The Lower South. In the lower South, we may also distinguish two types of cloudiness, the Atlantic States having a fine winter, and a moderately bright summer, whereas the Gulf States are quite cloudy in winter; both have a fine spring, and a wonderfully bright autumn. • >> a l"3 u 3 u A o u s3 < >> 3 p 1-3 >> 3 1 3 < u A a ft QQ J-r Xi o o O S a) > o u A S £ A North Carolina to Georgia (lowlands). . 51 56 51 55 46 47 43 46 43 43 50 49 49 51 51 48 48 43 39 36 44 44 47 52 47% 48% There are about 2,750 hours of sunshine, 62 per cent, of the possible total. The distribution of relative humidity varies chiefly according to the distance from the coast, but the summer is very moist at all stations, the chief difference being in spring and autumn. 3 1-3 3 A o In s ft > 1 § ■ 3 •-3 "-3 03 < A a o o O u 0) A a > o u 0) S o> u a A 1 80 75 80 73 78 69 76 67 77 68 80 73 81 77 83 80 81 76 79 73 80 74 80 75 80% 73% CLIMATOLOGY OF NORTH AMERICA 109 At Cape Hatteras the humidity ranges between 81 and 84 per cent, throughout the year. The sensible temperature, in summer, is everywhere between 74 and 76 degrees, and therefore quite tropical. The spring (April) temperature is as follows: Mild, 54 — 56 deg., Augusta. 56—58 " Wilmington. 58 — 60 " Vicksburg, Montgomery, Charleston, Savannah. 60 — 62 " Jacksonville, Mobile. 62—64 " New Orleans. The autumn (October), on account of the greater humidity, has higher sensible temperatures than the spring, even where the dry thermometer ranges no higher. Mild, 58—60 deg. , Augusta. 60 — 62 " Mobile, Montgomery, Vicksburg, Wilmington. 62 — 64 " Charleston, Savannah. Warm, 64 — 66 " Jacksonville, Mobile. 66—68 " New Orleans. In the eastern states, the usual duration of the uncom- fortably warm season is as follows, varying, of course, in different years : New York, Pittsburg, Omaha: June 15th to September 1st. Washington, Cincinnati, St. Louis: June 1st to September 15th. Raleigh, N. C, and Nashville: May 20th to September 25th. Charleston, Montgomery, and Vicksburg: May 10th to October 10th. Jacksonville and New Orleans: April 20th to October 20th. Middle Florida: April 1st to November 10th. South Florida: March 10th to December 1st. The best months for health-seekers and tourists are: New York, Pittsburg, Omaha: May, September and October. Raleigh and Nashville: April, October and November. Jacksonville and New Orleans: March, November and December. South Florida: the winter months. In the first three of these the last-named month is sub- ject to cold often sufficiently severe to make wraps and artificial heat necessary for comfort. Florida. The cloudiness and humidity are as follows in the Florida peninsula: 110 THE CLIMATIC TREATMENT OF CHILDREN Cloudiness Humidity. £ >> 3 ^3 02 u a id 3 4 03 a »-9 1 si a o u O > o 5 0) Q 47 47 41 40 44 54 49 51 53 46 46 46 81 80 78 74 76 80 79 80 82 80 80 81 47% 79% The cloudiness closely follows the distribution of the rains; the finest season is in spring, just before the sum- mer deluge begins. Key West has 3,060 hours of sunshine, 68 per cent, of the possible total, and only about 55 cloudy days in the year; the figures for the peninsula proper are- nearly as favorable; there is a marked tendency in the rainy season to a clear sky in the daytime and clouds at night. The sensible temperatures are : Winter, Degrees Spring, Degrees Summer, Degrees Autumn, Degrees 56 61 66 66 67 70 77 76 77 69 71 Key West 73 The Mississippi Valley, etc. There are several types of cloud distribution in the Mississippi Valley, also westward and northward; we may form the following groups : Missouri, Illinois, Iowa Wisconsin, Minnesota East Kansas and Nebraska East Dakotas and Manitoba. 54 52 55 54 49 49 49 50 ! 51 51 I I 43 49% 52% 44% CLIMATOLOGY OF NORTH AMERICA 111 In the Mississippi Valley the brightest season shifts from October to July, as we go northward, while De- cember is the cloudiest month throughout. Farther westward there are two clear and two relatively cloudy seasons, but they are unequal in degree. There is everywhere a tendency for the autumn to become less pleasant as we go north. The more southerly portions of this region represent that part of the continent where the Indian summer is most typically developed. The amount of sunshine varies between 2,600 and 2,800 hours, 58 to 62 per cent, of the possible total. The relative humidity is distributed so uniformly through this region, that any division into subdistricts is difficult; we shall do best by throwing all our records together, as follows : >> 3 C c3 I Eh a 3 < >> e3 3 a> a >> 3 DO 3 < s S3 o « O u o - .2 s ft c3 CO 78 77 73 67 67 70 68 70 70 70 74 78 72% These figures are decidedly high for the center of a con- tinent; 62 per cent, in April and May, on the western edge of this region, is the lowest recorded. The sensible temperatures for the summer are as follows : Cool, 56 — 58 deg., Winnipeg. 58—60 " Moorhead. 60—62 " St. Paul, Huron. 62—64 " La Crosse. Warm, 64 — 66 " Des Moines, Omaha. 66—68 " Kansas City, Wichita. 68—70 " St. Louis. 70—72 Cairo. The South Central States. In the South Central States the distribution of cloudiness is as follows : 112 THE CLIMATIC TREATMENT OF CHILDREN 1 a >> En ,4 o u 1 a < >> eS 3 0) a CO 5 S3 a a 0) 0) O o O u a o a >* 46 54 51 55 43 52 42 51 45 48 38 43 36 38 35 42 33 43 30 37 39 46 45 51 40% East and South Texas 47% Note the suggestion of a July drought in Texas, as shown by the low percentage of clouds; and the clearness of October throughout. The amount of sunshine ranges from 2,800 hours on the coast of Texas to 3,100 in Oklahoma (62 to 69%). The humidity is excessively high on the coast, but moderate even a short distance inland. >> 1 § 1-5 o3 03 43 o a <; >> 03 S 1-5 1 a a; +j a 43 o o o 1 > o 03 43 a 8 P 1 84 73 84 71 83 68 83 68 81 72 81 73 79 71 80 71 79 71 77 69 81 71 82 71 81% 71% The sensible temperatures are as follows : Summer warm, 68 — 70 deg., Oklahoma. Summer hot, 74 — 76 " Shreveport, San Antonio. 76 — 78 " Galveston, Corpus Christi. Spring (April) mild, 54—56 58—60 62—64 Spring warm, 64 — 66 Oklahoma. Shreveport. San Antonio. Galveston, Corpus Christi. The fall ranges about two degrees higher than the spring. Over the whole area so far discussed the climate is either moist or of medium humidity, never dry; the lowest monthly humidity, even in spring, has in no case fallen under 62 per cent., and we have met with this as far east as Cincinnati and even Baltimore. The lowest CLIMATOLOGY OF NORTH AMERICA 113 proportion of clouds has been about 40 per cent, for the year, in Kansas and Oklahoma, but this figure, also, is not much below some records on the Atlantic Coast, where 46 per cent, is noted at several stations. West of the 98th meridian, we encounter a great and rapid change, and we find a very different state of things on. The Great Plains. The ratio of clouds is not so very greatly diminished on the Great Plains, which we may subdivide in the same manner as we did in discussing the temperature. Colorado and Western Kansas. . . Wyoming and Western Nebraska Montana and Western Dakotas . . Saskatchewan and Alberta 39 39 37 39 38 38 41 36 29 34 36 36% 40 45|48 51 140 43 40 33 35 i 36 40 41% 52 53'54 53 52 40 37 41 48 49 51 48% 56 57 5553 56 44 40 48 54 54 55 52% These figures are only a few per cent, lower than in the well-watered region eastward. On the middle slope, the cloudiness follows the rainfall closely; this is not the case farther south or north; in the former direction the rainy season is unduly clear, and in the latter the almost rainless winter is quite cloudy and, as we shall see, also damp. The amount of sunshine is, indeed, large, but not phenomenal for so dry a region, ranging from 2,700 hours (60%) on the upper Missouri to 3,200 (71%) at Denver; thus Colorado is not far ahead of Kansas and Oklahoma in this respect; still, Denver has 190 clear and only 55 cloudy days in the year, whereas New York City has about 130 of each. 114 THE CLIMATIC TREATMENT OF CHILDREN The humidity, in general, decreases with the altitude, that is, with the proximity to the mountains. There is, however, a considerable difference according to lati- tude, the dividing line being at about the 42d parallel, north of which the winters are as damp as in the eastern states, while the summers are dry. Our records are: Western Kansas and Nebraska Western Dakotas Texas Panhandle to Black Hills Colorado and Wyoming Montana 65% 68% 59% 50% 57% The most remarkable feature of this table is the May humidity of 52 per cent, at Denver, in association with abundant rains. The sensible temperatures for the summer are, as will be seen, exceedingly low in com- parison with the readings of the ordinary thermometer previously given. Cold, 50 — 52 deg., Edmonton, Prince Albert. 52 — 54 " Lander, Helena. Cool, 54 — 56 " Regina, Medicine Hat, Cheyenne, Havre. 56—58 " Williston, Rapid City, Denver. 58—60 " Bismarck. 60—62 " Pierre, North Platte. Warm, 64— 66 " Amarillo. 66—68 " Dodge City. 70—72 " Abilene. The Western Plateau, Here we encounter- an ap- proach to absolute clearness for the first time, the pro- portion of clouds for the summer and early autumn becoming very low indeed. The figures for the winter are fairly high even in the Great Basin, and become very high northward, so that the wet season in those parts becomes quite gloomy, recalling the least favored CLIMATOLOGY OF NORTH AMERICA 115 portions of the eastern states, without attaining the high percentages of certain parts of the Lake Region. >> u d 09 •"3 >> ■~ a d A ■- oa ft o3 d d 1-3 d »-3 00 So 3 < - E cT X O _: c o C JS B '> o z u % 5 8 q o3 o 48 66 48 61 49 56 45 55 41 49 30 47 20 26 22 21 25 34 32 47 36 54 51 67 37% Idaho, East Oregon and Washington . . 49% The amount of sunshine declines from 3,000 hours (67%) in Utah and Nevada to 2,600 (58%) in eastern Washington. The distribution of the relative humidity is similar, the winter being moderately moist, the summer exceed- ingly dry and even desert-like. > u 1 .8 u a 3 d 1-3 03 3 -2 u 03 "3 < s © d 3 >. d 1-3 r. 3 3 < z Q X) X u Si o C 5 z 5 8 P ca Utah and Nevada 70 64 55 45 46 38 32 33 38 48 58 70 50% Idaho, East Oregon and Washington . . 79 74 66 56 56 5, 41 42 51 62 74 79 61% The resemblance of this region to Central Asia is remark- able ; the vegetation of the two regions is also very similar, presenting many types that are uncommon in other portions of the globe. The sensible temperatures of the summer are ex- tremely low; the difference between shaded and sunny situations is enormous; the former are unfortunately hardly obtainable except in the towns, for, southward at least, the country is almost bare of trees, though there are fine forests in the northern parts. The figures are: 52 — 54 deg., Carson, Winnemucca, Baker City. 54 — 56 " Spokane. 56—58 " Boise City, Salt Lake City. 58—60 " Walla Walla. 116 THE CLIMATIC TREATMENT OF CHILDREN The Southwest. The proportion of clouds in the South- west is very small, with minima in spring* and autumn, and maxima in winter and midsummer. Toward the east the midsummer maximum leads, in the desert the winter maximum, but in the latter this ■" cloudy" season is clearer than any month east of the Missouri River. b 1-3 >> 2 w "3 >> c >-3 1-3 +3 CO 1 s 9) ft | u O 4) a > o to 30 19 21 1 o Q 32 30 30 1 Western Texas and New Mexico. ...... 32 31 27 35 32 29 34 30 29 31 23 22 32 18 19 32 17 11 41 42 16 42 41 20 34 21 14 26 18 17 33% 27% 21% Santa Fe has 3,400 hours of sunshine (76%), Phoenix 3,730 hours (83%), Yuma about 4,000 hours (89%). Yuma has 308 clear and only 12 cloudy days in the year, and is probably not surpassed in this respect by any spot on the globe. The humidity is generally lowest in spring, but very low at all seasons. >> >> O) 8 u s3 3 A 00 d « a a I •-3 u ■8 £ § ft >> •-3 "3 >-3 Ei a 02 o u O 1 to 8 a- c3 West Texas to Arizona. . . 51 47 37 30 29 27 43 45 44 44 45 47 41% 35% Southeastern California . . 48 39 35 30 30 27 30 35 32 37 39 44 In Death Valley the average for the summer is 20 per cent., and for the year barely 30 per cent., rivaling the interior of the Sahara. The sensible temperatures are relatively very low, but here we note the inadequacy of this method of CLIMATOLOGY OF NORTH AMERICA 117 recording our perception of heat in the desert. As a matter of fact, the fearful noon heat in the lowlands, with the sun almost vertical, is quite unendurable. Summer cool, 52 — 54 deg., Santa Fe\ 54 — 56 " Independence. Summer warm, 64 — 66 ' ' El Paso. 68—70 " Phoenix. 72—74 " Yuma. At Yuma, the summer is almost tropical in its sensible temperature, in spite of the very great dryness; it is therefore ridiculous to say that the heat is not felt; at best, in the shade, it feels almost as hot as on the South Atlantic Coast; in the sun it is an inferno. The Pacific Coast. In reviewing the ratio of cloudiness on the Pacific Coast, we must bear in mind the four main factors that determine it. They are: first, the tendency to increase northward; secondly, the summer drought in the interior; thirdly, the summer sea fogs on the coast; fourthly, the tendency in winter to clearer weather on the coast than inland. In the following table the relation of these elements is evident : >> >> u 3 3 a oj a 3 - . a < © a 3 •-s >> »"9 00 5 3 < fa $ ft x> GO £ i. B ■~ - ft u South California Coast . . . 38 40 43 46 50 44 42 39 34 35 31 39 40% 47% Middle California Coast . . 51 49 51 52 51 44 47 45 40 41 39 49 North California Coast . . . 64 64 66 66 64 60 56 52 52 53 56 65 60% 64% Oregon Coast 70 68 69 67 65 6tt 59 54 58 59 65 71 Washington Coast 76 73 1 72 69 66 64 62 56 64 66 74 78 68% The northwest coast has the gloomiest climate in North America; the ratio of clouds continues to increase north- westward, reaching 82 per cent, on Unalaska Island. Inland the figures are : 118 THE CLIMATIC TREATMENT OF CHILDREN Great Valley of California Western Oregon, interior Western Washington, interior 29% 55% 61% The clearness of the summer of interior California is so great as to be monotonous, and it is considerable even on Puget Sound. In winter there is a rapid transition from the very bright weather of southern and central California to the gloomy conditions northward; the change takes place rather suddenly, at about the 40th parallel, both on the coast and inland. In summer the increase northward is gradual everywhere, but the sky clears abruptly on crossing the Coast Range eastward. Tatoosh Island has only 1,560 hours (35%) of sun- shine, Seattle and Portland have 1,980 hours (44%), Eureka has 2,070 hours (46%), the southwest coast 3,200 (71%), and the Great Valley 3,400 (76%). On the coast itself the humidity steadily rises from moderate proportions in the south to extraordinarily high figures northward, the summer or autumn being the dampest season. In the interior the winter is moist, and the summer is very dry in the south and moderately so northward. The following table will show this more fully ; >i >t u CD .8 8 £ a .£ CO d % ti B 3 u JO CD ft V a < * a J3 >-> < ft' 02 o -s O > o 8 P • <3 CD South California Coast... . 69 69 72 72 75 75 75 76 73 74 68 65 72% Middle California Coast . . 80 78 78 78 79 80 84 86 81 79 77 80 80% North California Coast . . . 86 85 84 86 86 86 88 90 89 89 87 85 87% Oregon Coast 88 87 87 88 89 88 89 90 91 92 90 88 89% 92% Washington Coast 90 89 90 91 92 91 91 92 93 94 94 92 CLIMATOLOGY OF NORTH AMERICA 119 The dampest month gradually shifts from August to October. The figures inland are : Great Valley (except Sacramento) . Sacramento West Oregon, interior West Washington, interior .a a 51 Z Q 80 7066 58 53 41 33 35 42 54 65 81 57% 80:73 70 65 66 59 58 58 57 62 69 81 66% 85 81 75 70 69 68 63 65 70 : 79 84 87:74% 84 79 75 71 71 70 67171 176181 184|84 76% The relative dampness of Sacramento in summer is due to the same cause as the only moderately high tempera- ture, namely, a slight remnant of the sea breeze blowing in through the Golden Gate; this place is, however, no cloudier than the other interior points, the sea fog does not penetrate nearly so far, The sensible temperatures range as follows; they are quite low at the inland stations, but the remarks made in reference to the near-by deserts apply here equally well. As the spring and later autumn are pleasantly cool everywhere, we shall consider the summer data only. ■52 — 54 deg., Victoria. 54 — 56 " Tatoosh Island, Eureka, Seattle. 56 — 58 " Portland, Roseburg, San Francisco. 62 — 64 " Fresno, Red Bluff, Sacramento, Los Angeles, San Diego. We may close this division of our subject with the fol- lowing brief summary: In winter there are maxima of cloudiness in the far Northwest and the Lake Region, both exceeding 80 per cent. ; there is a minimum of 42 per cent, at Key West, and one of 24 at Yuma. In summer the farthest Northwest and Northeast have each about 60 per cent., whereas we find 32 per cent, in Oklahoma, and less than 10 per cent, in Central 120 THE CLIMATIC TREATMENT OF CHILDREN California. For the year, we have over 70 per cent, on the Alaskan Coast, and only 18 per cent, at Yuma. The winter maxima of humidity are 82 per cent, over the upper Lake Region and the Texas Coast, and 90 in the far Northwest; the two latter persist in summer, but the first shifts to the islands off the Atlantic Coast. The eastern minima are 74 per cent, in the Atlantic Plain in winter and 66 per cent, in the Ohio and Missouri Valleys in summer; westward the lowest figures are reached on the southeastern slope of the Rocky Mountains and in the southwestern deserts. The average amount of sunshine is 2,600 hours in the eastern half of the United States, and 2,950 in the west, the absolute extremes being attained at Tatoosh Island and Yuma, respectively. PRECIPITATION The Gulf of Mexico is the chief source of moisture for eastern North America. During the colder months, the southwest winds in the southern quadrant of the trans- continental storms bring abundant moisture to the terri- tory lying east of a line running from the mouth of the Rio Grande to Lake Michigan. In summer, the well- defined storms are less important, but the barometric depression in the Southwest causes a steady indraught of warm and moist southeast winds; the rains are therefore carried northwestward as far as the Continental Divide. East of the Alleghanies, there is an additional supply of moisture from the Atlantic Ocean, brought to the land by northeast winds; this source of rain is, however, subordinate to the preceding, except in the upper Lake CLIMATOLOGY OF NOKTH AMERICA 121 Region and from there to the northeast coast. These rains are of most account in the autumn and winter. In the subarctic regions we have the minimum in spring and the maximum in fall; that is common to almost all far northern localities. The entire East may therefore be subdivided as follows : I. The subarctic regions; precipitation as above. II. The Northeast, including the : Lake Region; a fairly even distribution throughout the year, with a tend- ency to an autumn maximum far northward, a winter maximum far eastward, and summer maximum inland and toward the south. III. The Southeast; summer rains everywhere, winter rains in the mountains, but a dry winter on the Atlantic Coast and in Florida. IV. The Mississippi Valley and the Great Plains; sum- mer wet, winter moderately dry in the south, very dry in the north. The Pacific side of the continent depends chiefly on the Ocean for its moisture, a little comes to the far Southwest from the Gulf of California. The rains follow the common rule of falling only when the land is cooler than the sea, and the cool months are therefore the wettest. The total falls off rapidly as we go south from Puget Sound, and southward the summer becomes absolutely rainless. The arid Southwest gets practically no rain, except in summer in # the uplands, where warm Southwest winds from the Gulf of California deposit some moisture in ascending; this rainy season is a mere remnant of the tropical rains of Mexico, and limited to the hottest months. 122 THE CLIMATIC TREATMENT OF CHILDREN We may therefore divide the western region as follows : V. The Western Plateau (north of latitude 37°) ; some rain in winter and spring, very little in summer and autumn. VI. The Southwest; rain in midsummer in the moun- tains, otherwise perennial drought. VII. The Pacific Coast; similar to district V, but wetter in winter and drier in summer, with an extreme difference between the north and south. Our tables will embrace only long records, which have been grouped according to states and districts, both to compensate for local errors, and because precipitation is more a regional than a local phenomenon. Owing to large annual variations, data of rainfall cannot pretend to the accuracy of those given for temperature or humid- ity; the probable error in the annual means for even twenty-five years varies from two per cent, on the Atlantic Coast to more than five on the Pacific, and is over three times as great as this for the monthly means. It is also important for us to know the number of wet days, the amount and frequency of snow, and the rain intensity. The number of days with thunderstorms is also useful. All these matters, with other serviceable data, will be referred to frequently as we go on. I. Subarctic North America.- Southern Greenland and the coast of Labrador are so much alike that they may be thrown together; they agree with the other subarctic climates throughout the world in having the heaviest precipitation from July to October. CLIMATOLOGY OF NORTH AMERICA 123 >> 03 3 1 >> • o3 3 1 o ol 't- >> S3 3 3 < a 0> ■g O 1 s 0> JS s 0> n 1.6 1.6 1.8 1.6 '2.1 2.4 3.0 3.5 1 4.0 I 3.0 2.2 1.6 28.4 There are 160 to 200 wet days, about half of them with snow, which, may fall even in midsummer, and attains a total depth of ten to fifteen feet. Owing to the cold- ness of the summer, thunderstorms are quite uncommon. II. The Northeastern States and Eastern Canada. As before stated, this extensive region is notable for a cer- tain uniformity in precipitation; we may, however, recognize a number of subdivisions, which present mod- erate differences. In the farthest Northeast nearly all the months are quite wet, but there is a decided excess in the six months from October to April; June and September are regularly a trifle drier than the others. Newfoundland, Nova Scotia, E. New Engl'd . >-. >> 0> o3 3 a o3 i-s e3 5 1 o u 03 - >> 03 8 3 1-9 >> a 3 < 0> o a O s s 0> o Q 4.6 4.2 4.4 3.4 3.8 3.4 3.8 3.8 2.8 4.8 4.6 4.4 48.0 Immediately to the west of this district the summer is somewhat in excess, but the winter remains very moist. >, & 1 8 u 03 3 3 >-» o3 5 ,3 O 03 - >> 03 O) 1 >> 3. CQ 3 M 3 <4 3 O) 0. 0) Oi O O O d 0> > o S 8 o> CO New Brunswick, Que- ) bee, W. New En- f gland, E. New York, f 3.43.0 3.4 2.6 3.2 3.24.24.0 3.2 3.2 3.4 3.2 40.0 New Jersey ) ■ 1 124 THE CLIMATIC TREATMENT OF CHILDREN ' In the Lake Region the autumn months lead in the north and east, and the summer months in the south and west; early spring is dry everywhere, and the winter also, except eastward. >, & ^3 OJ s I o8 S ■8 ■s a >> 'a >> 1 02 'fa ■ta a GO 01 O « O 0) o a 00 E. Lake Region 2.9 2.7 2.7 2.1 2.9 3.0 3.0 2.6 3.1 3.3 3.5 3.2 35.0 N. Lake Region S.W.Lake Region 2.0 1.6 1.8 1.6 2.6 2.8 3.0 2.8 3.8 3.2 2.6 2.2 30.0 2.0 2.1 2.2 2.4 3.5 3.8 3.2 3.0 3.2 2.8 2.6 2.2 33.0 The greater part of the Middle Atlantic States and the Ohio Valley have maxima in summer and winter, and a minimum either in spring or autumn, but moderate in either case. S. New York, Pennsyl vania, Maryland, Vir- ginia, W. Virginia, Ohio, Indiana ia, l" b §3 .2 $5 a eS 08 s r® 1 a < £ s a •-3 GO s 3 d a 0Q OJ O O o a a 01 « o> 3.4 3.4 3.4 3.2 3.8 4.0 4.0 3.8 3.2 2.8 3.0 3.0 ;*£ 41.0 The tables given will render the detailing of minor variations superfluous. The number of wet days ranges from 120 on the Middle Atlantic Coast, the Ohio River and the southern tip of Lake Michigan to 160 in the extreme Northeast and 170 in the northern and eastern Lake Region. Snow falls on 10 to 20 days in Virginia, 20 to 30 from Long Island to Indiana, but as many as 40 to 60 in the northern Alleghanies and 80 to 90 in the northern sections that have a wet winter. The number of thunderstorms gradually increases from ten per annum in the far Northeast to forty in Virginia and Ohio. The CLIMATOLOGY OF NORTH AMERICA 125 depth of snow, only about a foot for the entire season in southern Virginia, increases rapidly northward to a maximum of ten or twelve feet in the St. Lawrence Valley and certain localities in the Lake Region; few points north of the 42d parallel have less than four or five feet in all. In the Lake Region, we invariably find the heavier snowfall on the milder shore, the northwest winds are warmed on crossing the lakes and become loaded with moisture, which is promptly condensed on reaching the cold bank opposite; the remarkable phenomenon is then presented of a heavy precipitation with a rising barom- eter on the lee side of the lake, while the windward shore enjoys fine and cold weather. In summer, these differences almost disappear, owing to the more uniform barometric and thermometric conditions ; they are also far less marked in mild than in severe winters; in the latter the climate of such places as Oswego, Buffalo and Grand Haven is exceedingly disagreeable, though not nearly so cold as at the stations across the respective sheets of water, "it must be remembered that the Great Lakes do not freeze over even in the severest seasons. The duration of the snowy season naturally varies widely according to the latitude. In the coldest sec- tions, only July and August are free from snow, which falls frequently in late September and not so very exceptionally in early June; the ground is permanently covered from November until April in ordinary years, and the usual depth on the first of March is from three to five feet on the level. Along the southern border of this region, from Cape Cod to Cincinnati, snow is 126 THE CLIMATIC TREATMENT OF CHILDREN uncommon in October, and very rare indeed in May except in New England; the ground is rarely covered continuously for more than a month, and may be bare for weeks at a time in the dead of winter, as in 1906. III. The Southeast. This region is decidedly more heterogeneous than the preceding, and requires consider- able subdivision. In the Cape Hatteras region and on the Bermudas all the months are wet, but the late summer and early autumn lead. Hatteras . . Bermudas . I o9 1 1 ft < >> 3 05 § 3 ►-a a 3 < h JS a 4) +^ ft 0) O O O u o> ,£5 a o S3 a A 5.9 4.5 6.1 4.7 4.6 4.6 6.4 6.4 6.4 6.2 5.2 5.5 4.8 4.4 5.6 4.5 4.8 5.9 4.6 6.1 5.5 8.3 4.2 4.3 .5 63.2 On the South Atlantic Coast and in Florida, also in southern Texas, we have the dry and cool and wet and warm seasons of the West Indies and Central America. 1 3 % >> § e Xi r° ■a ft >> o> 3 3 >> 3 CO 3 M 3 a V ft o O u a a > o ■ 1 a 0) ft- CO N Lowlands of N. O., S. 0„ Ga., and Florida South Texas 3.8 1.9 3.2 1.7 3.8 1.5 ■3.4 1.8 4.2 3.0 5.6 2.7 6.2 1.8 6.8 3.3 6.8 4.8 5.0 2.0 3.0 2.0 3.2 1.5 55.0 28.0 A peculiar feature is the midsummer drought that appears at Galveston and becomes extreme in southern- most Texas. In the southern Alleghanies, along the lower Mississippi and on the middle Gulf coast there is more rain in winter; October is quite dry everywhere. CLIMATOLOGY OF NORTH AMERICA 127 South Alleghanies . . Middle Gulf Coast . . Lower Mississippi Valley.. >J b — u 03 C o3 1-3 03 g ^3 o ol "u a <5 >> 03 c >> '-5 3 «1 fa Q, XI O a O 55 g g Q 4.8 4.6 5.2 4.0 3.8 4.2 4.6 4.6 3.4 2.8 3.2 3.8 4 6 4 4.4 4.0 4.2 5.6 5.4 6.4 5.6 3.6 4.0 4.2 4.8 4.6 5.0 5.0 4.8 4.2 3.6 3.2 3.2 2.8 4.6 4.2 49.0 56.0 50.0 A few explanatory remarks are indispensable. The October maximum of Bermuda also occurs at Jupi- ter, Fla., and affects the figures for Hatteras, as we have seen; the cause of this peculiarity, which these points share with the more easterly Antilles, lies in the course of the autumn hurricanes along the Gulf Stream, near all these stations. In the southern Alleghanies we find the rare phenomenon of a maximum precipitation in winter far inland; this peculiarity also affects their western foothills as far as Nashville and Montgomeiy, and is due to the condensation of warm and moist south- west winds from the Gulf of Mexico. Southern Texas, as noted, has a very dry winter and suffers from severe drought in midsummer, so that this section becomes almost desert-like in July. The Atlantic Coast from Cape Fear southward, including the whole Florida pen- insula has a distribution of rainfall precisely like that of the West Indies; the year consists of well-marked dry and rainy seasons, the former from October or November to May, the latter embracing variously four to six months; thus visitors to this section are sure of much fine weather at the very season when the upper South, especially among the hills, is almost drowned in torrential rains, with occasional snow. It will be noted that the summer is wet almost everywhere ; this circumstance, in com- bination with the high temperature and humidity noted 128 THE CLIMATIC .TREATMENT OF CHILDREN in previous paragraphs, fully accounts for the insalubri- ous character of the four warmest months south of the 37th or 38th parallel. The remaining peculiarities of the southeast require but cursory mention. Glancing at this region as a whole, we note three centers of especially heavy pre- cipitation, each exceeding sixty inches per annum, sit- uated respectively in the highest Alleghanies, on the middle Gulf coast, and near the Gulf Stream. We have no good records for the first of these, but the others are well displayed in the preceding tables; Jupiter, Fla.,also, has a total of 58 inches, 19 of which are equally divided between September and October. The number of rainy days is almost everywhere in the ratio of one to each 0.45 inch of rain, being 100 at Key West, 150 at Bermuda, 120 to 130 at almost all other stations east of the Mississippi, 100 to 110 west thereof as far as Galveston and Palestine, Tex., 80 at San An- tonio and Corpus Christi, and only 50 to 60 on the lower Rio Grande. The amount for each rainy day is thus seen to be very great, and so-called cloudbursts are rather frequent throughout the South. A precipitation of two inches within an hour is common in many parts of the United States, and three inches in an hour have been recorded at places so far apart as Rio Grande City, Jacksonville, Philadelphia and Dodge City, Kan. A fall of ten inches in twenty-four hours is not very un- common in the South, but rare in the North, where even six inches in a day are quite infrequent. Snow is common in the southern states only in the Alleghanies and Kentucky, where about two feet fall on fifteen days; in Arkansas, western Tennessee, and CLIMATOLOGY OF NORTH AMERICA 129 the Cape Henry district some six to twelve inches fall on about seven days; at Wilmington, Montgomery and Vicksburg an inch or two on a day or two. In the extreme South snow falls about once in two years, and lies on the ground about once in a decade, and in the Florida Peninsula snow is a very great rarity, though a few flakes have been observed as far south as Punta Rasa; the same is true of the Bermudas. Thunderstorms average 40 to 70 per year, the latter in Florida, where they are common at all seasons, except the latter part of autumn. Tornadoes are quite frequent and destructive in the lower Mississippi Valley, less so east of the Alleghanies; southward they are commonest from February to May, northward from April to June; the weather is too steady for their development in mid- summer and thereafter. IV. The Central States. Northwest of a line drawn from Indianapolis to San Antonio, Texas, from Lake Michigan to the crest of the Rocky Mountains, we have a wonderfully uniform and typically continental dis- tribution of precipitation. The maximum regularly falls in June— occasionally May or July — and the period from October to March is relatively very dry. Careful study shows that this region is saved from absolute drought only by the great southwestern depression and the resulting southeast winds, both of which conditions are prevalent only from April -to August or September; extension of the depression toward the Mississippi, as in July, 1901, causes a shifting of the winds to southwest with serious drought far eastward. Owing to the mentioned remarkable uniformity of precipitation, one table will suffice for nearly the entire 130 THE CLIMATIC TREATMENT OF CHILDREN central region. It is of interest to note a gradual decline from south to north, especially in the winter months, and a falling off' from east to west, also most marked in the colder season. In eastern Nebraska only 8 per cent, of the total falls in winter, but 43 per cent, from May to July. >> 3 a 03 b 3 u Oi X! 8 oi a < >> 03 a 3 »-5 "3 a 3 < o> a o> CO 1 o o O .8 s ? o s- 01 X! a CD O 0) O s'l Upper Mississippi Valley . Plains, East 1.4 1.0 0.8 0.4 0.6 1.6 1.2 0.8 0.6 0.8 2.0 1.8 1.0 0.8 0.8 2.8 3.0 1.8 1.6 0.8 4.0 4.2 2.6 2.2 1.8 4.6 4.2 3.4 2.0 3.0 3.e 3.6 2.4 1.6 2.6 3.2 3.0 2.0 1.4 2.2 3.0 2.6 1.4 0.8 1.4 2.4 1.8 1.2 0.8 0.8 1.8 1.4 0.8 0.4 0.6 1.6 1.2 0.8 0.4 0.6 32.0 29.0 19 Rocky Mts., East. Slope. . N.W.Canada 13.0 16.0 In western Montana the type is somewhat mixed, Helena has a little more precipitation in winter, coming from the Pacific Ocean across the watershed,* which is somewhat lower in Montana than farther south; this is shown by the following data : Helena. ►, >> o> ^2 0) X! a; 3 a 03 03 s 1 o 'u a < >> o3 01 a 3 •-3 CO a 3 < fa • 01 Q. o> GQ X! O O o | o a. o> u 0> Q 1.4 0.8 0.6 1.1 1.6 2.4 1.1 0.6 1.2 0.9 0.7 0.9 ><£ 13.4 In the above extensive region it will be noted that, toward the south and west, there is a tendency for the maximum precipitation to occur in May, while north- westward there is a tendency to a July maximum. The decrease westward is very marked, occurring rather abruptly in the 200-mile strip between the 96th and 100th meridians. This belt does not, however, repre- sent a constant dividing line, but an area of uncertain CLIMATOLOGY OF NORTH AMERICA 131 rains, being dry in one year and moist in another; farther east drought is exceptional, occurring possibly once in a decade, farther west it is common, indeed almost certain, so that the farmer learns to depend chiefly on irrigation. Among minor matters we may note a tendency to autumn rains in the Upper Mississippi Valley, coming from the upper Great Lakes, and associated with the rainiest season in that section; also, on the southern slope, a small proportion of the late summer rains of the southwestern Rocky Mountain Region. Neither of these features, however, obscures the general type to any marked degree. The number of wet days ranges from 120 along the middle Mississippi River to 65 in Wyoming and Colorado ; it snows on 10 days in Oklahoma, 30 to 40 in Colorado and Wyoming, and 40 to 50 in the north, the total depth of snow ranging similarly from one to six feet. The Great Plains have much less snow than the north- eastern mountains and the Lake Region, contrary to the popular belief; the ground is sometimes bare in January and February almost tp the international boundary, for the heavy blizzards and general snowstorms occur only at long intervals, and are commoner in autumn and early spring than in midwinter. Thunderstorms are common everywhere, occurring on 20 days annually in the northwest and 50 days in the southeast of this territory. The eastern and southern portions of this region are peculiarly subject to the most destructive kind of tornadoes; these whirlwinds seem to .be especially frequent in Missouri and eastern Kansas, but rare north of South Dakota and west of the 100th 132 THE CLIMATIC TREATMENT OF CHILDREN meridian. The occurrence of hot winds has been dealt with sufficiently on page 87. V. The Western Plateau. Here the type of precipita- tion is almost exactly the opposite of that described above in discussing the eastern slope. Strictly speaking, however, this is true only between the 37th and 49th parallels; the section farther south will be dealt with separately, that farther north has a distribution of moisture resembling that of the Atlantic states. In the Great Basin and Idaho intense drought pre- vails from July to September, reducing the country to the condition of an absolute desert, except along the few water courses; the spring is a little moister than the winter in the east of the plateau, and drier in the west, where the conditions on the Pacific Coast are much in evidence; the differences are, however, so slight that one table will suffice: 3 1-3 >> c3 g -8 o S3 a < e a 3 1-3 >> 1 < u % .0 S a o> CO O u V Xi B u B 8 00 2.0 1.5 1.6 1.4 1.4 1.2 0:4 0.4 0.6 1.0 1.4 2.0 15.0 These figures comprise a minimum annual precipitation of 9 inches in central Nevada and a maximum of 18 on the upper Columbia River; the number of wet days is 60 in the former district and 120 in the latter, so that only about 0.15 inch falls on each day; apart from the rare cloudbursts, the precipitation consists chiefly of light drizzles and mere flurries of snow. The number of days with snow varies similarly from 25 to 50 per year, the relatively large number being due CLIMATOLOGY OF NORTH AMERICA 133 to the wet period occurring in winter; the depth of snow is from 2 to 4 feet. Thunderstorms are uncommon, because the summer is too dry; they number from 4 to 12 per annum. In interior British Columbia the type is evidently mixed, but our records are still short, and embrace but few stations. The total rises from 12 inches in the river valleys to 30 and more in the mountains; one- third falls in summer and about a fourth each -in autumn and winter, the spring being relatively dry; the conditions thus resemble those in the North Atlantic States. The winter snows in the British Rocky Mountains attain a depth of 15 feet, exceeded only in the California Sierra. VI. The Southwest. The rain-shed between the Gulfs of Mexico and California does not correspond to the sur- face drainage, but lies on the crest of the Guadalupe Mountain range, west of the Pecos River. The dividing line is not very sharp, because moisture seems to cross over, at times', in either direction, and because the wet and dry seasons are nearly the same on both sides; the July drought is, however, characteristic of the eastern slope, and absent in the west. In western Texas and in New Mexico more than half of the total precipitation is crowded into July,. August and September, with an evenly distributed and very light rainfall during the remainder of the year. In Arizona there is a little rain in winter, coming from the Pacific Ocean, but April, May and June are almost rainless. The totals, exceeding *20 inches in parts of the mountains, fall below 10 at El Paso and 7 at Phoenix, where the truly desert conditions of the southwestern lowlands become manifest. I give the following table: 134 THE CLIMATIC TREATMENT OF CHILDREN W. Texas and New Mex... Arizona >, >> u u u 2 o a <3 >> a »-9 *-9 1 fa S a JO o « O > o 0.6 0.6 0.6 0.6 1.0 1.2 2.8 3.0 2.0 1.2 0.6 0.8 1.2 1.2 1.2 0.6 0.4 0.4 2.8 2.8 1.4 0.8 0.8 1.4 it 15.0 15.0 In northern Mexico the rains arrive a month earlier and are more abundant ; Chihuahua has about 25 inches, three-fourths of which fall from June to August; in the city of Mexico 70 per cent, of the total (23 inches) fall from June to September; at Mazatlan 25 out of 35 inches fall from July to September, whereas February to May are almost rainless. In the upper Colorado Valley, in Colorado, southern Utah and Nevada, the type is mixed, with no well- marked annual period; the rains of the Southwest as well as those of the Great Basin almost disappear, so that the total is phenomenally small for the elevation and rugged topography. Jan. Feb. Mar. April May June July Aug. Sep. Oct. Nov. Dec. Year 0.8 0.4 0.6 1.0 0.8 0.4 0.8 1.2 0.8 0.8 0.8 1 0.6 9.0 ins. There are 90 wet days at Santa Fe, and only 45 at Phoenix; the combination of usually very light rains with rare cloud-bursts characterizes this section as well as the northern Plateau. There are about 30 days with three feet of snow in the higher uplands, three days with as many inches at El Paso, and a few flakes about once in two years at Phcenix. As the rainy season occurs in midsummer, thunderstorms are relatively common, 20 to 40 per year. Tornadoes are quite unknown, and general storms of the usual description are rare, for the CLIMATOLOGY OF NORTH AMERICA 135 great barometric depressions rarely pass through this district; some recent winters have, however, proved exceptional in this regard. The terrific dust storms, which are especially common in spring, more than make up in discomfort for the absence of the wet spells of the eastern states. VII. The Pacific Coast. We may begin the review of this region with a glance at the deserts near the Colorado River. Here the winter rains, such as they are, already predominate, and but little moisture strays in during the summer from the Gulf of California ; the total precipita- tion is very small throughout, as follows : >> u o3 3 C o3 >-5 >> s- o3 2 u e3 a, < >> 03 c 3 on a 3 < u £ OJ 0) O o O u S > o S5 a Q DO Southeastern California . 0.6 0.6 0.4 0.2 0.0 0.0 0.2 0.2 0.1 0.2 0.2 0.8 3.5 At an elevation of even 3,000 feet, the total is but little higher; in the great depressions below the sea level, it is barely two inches. Almost- infinitesimal as are these amounts, they even so are chiefly due to cloud-bursts, occurring at long intervals ; thus, Yuma had three inches of rain in February, 1901, of which 2.6 fell in twenty- two hours; the three- preceding years, added together, had yielded but little more, 1899 only 0.6 inch. Yuma has only 13 rainy days in the year, 8 of them with thunder, and a few flakes of snow are seen about once in a decade. California has a singularly uniform type of precipita- tion. The greatest amounts fall in the northwest corner and the Sierra Nevada, 50 to 60 inches; the total declines 136 THE CLIMATIC TREATMENT OF CHILDREN rapidly as we go southward, and becomes insufficient for agriculture at the 35th parallel on the coast and at the 38th inland. We may glance at the following table: South California Coast. Middle California Coast North California Coast . Fresno Sacramento Valley. 3 s a >> 3 u > 0) 3 3 02 1 3 a a CO u n> -Q o o O u O) S > o a O o Ol Q 2.4 4.8 7.6 1.4 4.2 2.8 3.8 6.8 1.2 3.6 2.2 3.0 6.2 1.2 3.2 1.2 2.0 4.2 1.2 2.2 0.4 0.6 2.8 0.4 1.2 0.1 0.2 1.2 0.2 0.4 0.0 0.0 0.2 0.0 0.0 0.0 0.0 0.2 00 0.0 0.1 0.2 1.4 0.2 0.6 0.6 1.2 2.8 0.4 1.2 1.2 2.4 5.2 1.2 2.6 3.0 4.8 7.4 1.6 4.8 14.0 23.0 47.0 9.0 24.0 Seventy per cent, of the total falls during the four coldest months, practically none at all during the four warmest. The number of rainy days ranges from 35 in the extreme southwest to 130 in the northwest corner; snow is almost unknown in the lowlands, except to the north of latitude 40, where a trifle falls about once a year; in the northern high Sierra the amount of snow locally exceeds thirty feet, probably the highest figure on our continent; the reason being, of course, that most of the very heavy precipitation falls in winter. Thunderstorms are very rare, numbering only about two a year and usually occurring in winter. The local proverb, that earth- quakes are more destructive than lightning, has unfor- tunately obtained only too ample verification. . In Lower California, as we approach the tropics, sum- mer rains appear once more, the winter rains continue to fall off, so that the southern tip of that peninsula pre- sents a distribution resembling that noted ior Mazatlan, only in smaller quantity; exact data are not extant. The worst feature of the otherwise magnificent climate of California is the irregularity of the winter rains. In CLIMATOLOGY OF NORTH AMERICA 137 the southern part of the state rain falls only if the transcontinental storms are unusually severe, or take a somewhat southerly course; the feebler depressions entering the continent at Puget Sound bring little rain to the south of Point Reyes. At San Francisco the annual amounts have been 8 and 50 inches; by way of contrast, we may note that in the moderately variable climate of New York, the corresponding figures are 36 and 59 inches. The mean annual variability of the precipitation is about 25 per cent, in San Francisco, and less than 10 in New York. In western Oregon, Washington and British Columbia, also in southern Alaska, there is some rain in summer, but the winter precipitation attains such enormous pro- portions that the seasonal ratio differs but slightly from that prevailing farther south. There is, however, as we go northward, a tendency of the maximum and minimum to move forward to autumn and spring respectively, so that, as we approach the subarctic regions, the type gradually approximates to that of the circumpolar region in general, as noted for Labrador and Greenland. The following table gives details "by months : >z Int. W. Oregon. Wash. & Or. C'st Puget Sound . . . Br. Col. Coast . . Sitka 5.4 4.63.02.2 1.60.40.4 11.81 8.4 8.2 7.04.23.6 1.6 1.8 6.4: 5.0; 4.03.42.4 1.40.60.6 11.0 12.6 10.4 8.6 4.63.44.66.0 9.6:10.410.06.25.03.65.26.8 I I I I I I 1.4 3.4 4.8 7.2, 41.0 5.4 7.6 11.2 13.2 83.0 2.4 3.6 6.61 7.6 44.0 8.8 12.213.413.6108.0 11.2 13.413.6 10.0105.0 The wettest region in North America is probably the west coast of Vancouver Island, where a three years' 138 THE CLIMATIC TREATMENT OF CHILDREN record at Quatsino gives 130 inches; the Queen Char- lotte Islands possibly have a similar amount; farther north, as at Sitka, there is again a gradual falling off. The enormous totals of the winter months are quite uniformly distributed, and especially large amounts in 24 hours are unusual; the rule is an inch or two a day falls for several days at a time. The seasons vary much less than in California, and the heavy winter rains can be depended upon with perfect confidence. The number of rainy days rises from 150 days at Rose- burg to 215 at Tatoosh Island, the amount per day .ranges from 0.24 to 0.45 inch, with perhaps slightly higher figures at the wettest places. The number of snowy days is only 8 to 12 in western Oregon, rises rapidly northward, but does not reach 40 even on the south Alaska Coast, for here also most of the winter precipitation falls in the form of rain. The depth of snow ranges from about a foot in southern Oregon to two feet near Puget Sound, and four or more in the north. Thunderstorms are infrequent, two or three a year; tornadoes are -quite unknown. Rain Intensity. By this term we may designate the amount of rain for each rainy day, an important matter for the medical climatologist. It may readily be cal- culated for each district by dividing the total precipita- tion by the number of wet days, but for the sake of convenience I have outlined the data in our possession on the opposite chart. We thus readily observe the torrential character of the rains in the southeast and, to a less degree, on the North Pacific Coast, as well as the tendency to light or drizzling rains in Canada and the arid Rocky Mountain belt. CHAPTER III HEALTH RESORTS We shall find it most convenient, for practical pur- poses, to divide our health resorts into the two groups of North American and foreign. In considering the former, the preceding chapter relieves us of the task of stating climatological figures; we have therefore more space for other details. In the case of foreign resorts, numerical data will often be required; they are nearly all given according to Hann, our most trustworthy guide in this field; comparison with American resorts of similar type will form a conspicuous feature of this subdivision. NORTH AMERICAN RESORTS Greenland and Labrador. In recent years, these bleak regions have repeatedly been suggested as summer sta- tions for the treatment of tuberculosis; the good results obtained during the colder months in temperate regions have called forth the endeavor to make them perennial, by removing tuberculous subjects' to a cold summer cli- mate, for it is notorious that the hot days of our summers are more or less injurious to them. In a recent article, Sohon 1 admits that these regions are to be considered only for the summer months; he praises them highly for their ample sunshine, even temperature, and freedom from dust and other atmospheric impurities. Exception American Medicine, April 23, 1904. 139 140 THE CLIMATIC TREATMENT OF CHILDREN may be taken at once to the first statement; although the subarctic June day has a length of 18 hours in Labrador, and 21 in southern Greenland, so much de- duction must be made for clouds and fog, that the net amount of sunshine is probably rather less than in middle latitudes. The evenness of the temperature is rather a demerit, especially when we consider that the essential principle of the cold climate treatment consists in hard- ening; all the arctic explorers agree in saying that they feel the chilly dampness of the far northern summer more keenly than the intense cold of winter; the very steadi- ness of the temperature makes the body extremely sensi- tive to slight changes; and the risk of catching cold is practically limited to the mild season. The summer of Greenland or Labrador does not even remotely resemble the winter on the Riviera, although the average tempera- ture is the same. Purity of the air is the one incontestable merit of these regions, shared, however, with most other and milder seaside resorts; it can, of course, be secured only on shore, not in the narrow and stuffy ship's cabin. In the similar summer climate of Spitzbergen a hotel has been started with some success; any permanent utiliza- tion of our subarctic regions must include some such facilities. A standing objection to this method of treat- ment will always be the stormy and sometimes perilous voyage to the far northern seas. The Maritime Provinces. Eastern Canada and New- foundland have not come much into vogue as health resorts, though the cool summer, resembling that of the British Isles, should alone be a sufficient recommenda- tion. Nova Scotia and New Brunswick, in particular, HEALTH RESORTS 141 quite fulfill the ideal of such persons as. desire a really cool summer at the seaside, • with not too much wind and dampness; August and September are the best months, as fogs and rainy spells are not uncommon in June and July. The spring months are very disagreeable in the Maritime Provinces, owing to frequent changes to cold and dampness when the wind shifts to the north- east. The late autumn and the winter are subject to violent gales, with heavy rain or snow, though there are some very fine days even at those seasons. Data have been given for a number of stations in this section; others might be mentioned, but accommoda- tions are primitive at all the smaller and many of the better known resorts. The fare, in particular, is rarely such as would benefit an invalid, and improvement in this respect would do much to enhance the popularity and merits of this region. The- Maine Coast resembles the preceding section rather closely, but is decidedly brighter and colder in winter, and, toward the south, much warmer in summer; in Portland the heat sometimes becomes unpleasant, whereas hot weather is a great rarity at Eastport. The popularity of this coast, during the summer and early fall, is fully merited, though its climate is hardly superior to that of New Brunswick or Nova Scotia. Accommo- dations are, however, far better, sometimes of the first class, and this point must be allowed to weigh heavily in the selection of a health resort. The worst month in this region, as in most of New England, is April, on account of the melting of the snow and the frequent chilly northeasters from the Grand Banks. Climatic data have been given for a number of resorts. 142 THE CLIMATIC TREATMENT OF CHILDREN In addition we must mention Grand Manan, Campobello and other islands in Passamaquoddy Bay, near Eastport, but belonging to New Brunswick; Sorrento, opposite Mount Desert Island; Castine and Camden at the mouth of the Penobscot; the islands off the mouth of the Kennebec ; and Scarborough Beach, Old Orchard Beach, and Kennebunkport, near Portland. The Mountains of Northern New England. The variety of resorts in this region is very great, and the visitor may select anything from the most fashionable hostelry in a popular locality, to the almost uninhabited wilder- ness north of the Canadian Pacific Railway. Some sec- tions are partly cultivated, others consist chiefly of bare or wooded mountain side, others again present a tangle of small or large lakes and streams. The free and easy type of consumptive has not yet invaded this region to any great extent, to impair it for other persons, as has happened in the Adirondacks. The higher resorts form the favorite refuge for the victims of hay-fever, who are quite sure to obtain relief at elevations above 1,200 feet. Black flies and mosquitoes are troublesome in early summer in the heavily forested sections, but absent in the open country; malaria is unknown. The best sea- son for children is from the middle of July to the middle of September, after which date there are apt to be heavy night frosts and some rather raw days. The win- ter is altogether too cold for young subjects, and exer- cise out of doors is greatly interfered with by heavy snow and generally bad weather; only adults should be permitted to brave this climate from November until April. The early spring is the worst season of all, on account of the slushy conditions that attend the melting HEALTH RESORTS 143 of several feet of snow, which is apt to take place very suddenly late in March or early in April, and render all the roads quite impassable. Whole pages might be filled in naming all the avail- able resorts. I mention only the Rangeley Lakes and Moosehead Lake in upper Maine (see Kineo in the table), Poland Springs and Belgrade in the lower levels of the same-state (elevation 800 feet) , the entire White Moun- tain and Winnipesaukee districts in New Hampshire, and practically every nook and corner of Vermont. The last named state affords about the best summer climate in the East, if not on the continent, being just comfort- ably cool, and neither too wet nor too dry; good accom- modations are obtainable at dozens of places, too many, in fact, to be enumerated. The Coast from New Hampshire to Long Island. We gradually leave the cool summer of the Northeast behind us, but, until we reach Boston, the temperature is still very agreeable, and prolonged hot spells are uncommon. Below Boston, we begin to note a tendency to sultriness, which increases steadily as we advance toward New York City. The situation of stations with reference to the sea breeze here becomes of importance; localities facing south or east are much cooler than such as face west or north, the latter getting a good deal of hot weather and being more or less deprived of winds from the ocean. Thus, the so-called South Shore of Massa- chusetts Bay is very decidedly inferior to the Cape Cod Peninsula and the districts near New Bedford and New- port ; similarly, the ocean front of Long Island is prefer- able to the Sound front, which is again less desirable than the Connecticut Coast. Hot weather is entirely 144 THE CLIMATIC TREATMENT OF CHILDREN unknown at Nantucket, Martha's Vineyard, and Block Island, but the nights are no longer very cool, so that the climate is a trifle enervating to all save young chil- dren, who often require moist and moderate warmth. The south shore of Long Island is warmer, on account of hot winds from the interior, when the sea breeze fails; there is a difference of three degrees in the average July temperature between Montauk Point and Rockaway. Malaria of a mild type occurs here and there in the marshy districts, which it is wise to avoid for this reason. The winter grows steadily milder as we go south, be- coming decidedly open, in ordinary seasons, from Nan-, tucket to New York, where the effect of the ocean is most manifest. Here zero weather is rare, but high northwest winds and occasional severe storms are an objection that make the outer islands quite unsuitable for a winter sojourn. The proportion of sunny days is very great, and it would be worth while to try if south- western Long Island might not rival the New Jersey Coast as a winter resort, for it is only a degree or two colder. The objectionable east winds of spring become less serious as we advance west and south from Boston, and may be disregarded on Long Island, where the trans- itional month of March, with its uncertain mixture of winter and spring, is the worst of. the year. September and October are very fine in this section, although there may be*some rather warm weather in the former; in southern Connecticut and on Long Island November also affords beautiful weather in many years, for the winter frequently holds off until December in these districts. November snowfalls in excess of an inch occur only about once in four years on Long Island, HEALTH RESORTS 145 and then invariably toward the close of the month. On the other hand, there is an even chance of some snow in April, which has,approximately the same average temperature, for the seasons are very much retarded in this region. From the legion of resorts we can single out but a few; namely, Portsmouth, N. H., and the Isles of Shoals, Cape Ann and the North Shore, offering a succession of first-class resorts, also no end of places in Barnstable County, Mass. The data given in the preceding chapter for Nantucket, Block Island, New Haven, and South- ampton give a good idea of the climate in Rhode Island and Connecticut, and on Long Island, and an approxi- mation to that of such places as Newport and Narragan- sett Pier; lack of space forbids a more detailed mention. The accommodations vary greatly, but are generally fair to good. On Long Island it will be well to avoid the prox- imity of the salt marshes, which begin here, and continue along most of the coast to the tropics ; they invariably involve a terrible plague of mosquitoes. The Adirondack Mountains. Northern New York has gradually become a vast sanatorium for invalids of all classes, but the unrestrained victim of tuberculosis, who roams about at will without systematic medical attendance, and often scatters infection broadcast, has begun to impair the value of this region for other persons. The climate of this section is practically identical with that of northern New England, but the choice of resorts is less varied, because of the preponderance of absolute wilderness. Such pleasant districts as the semi-cultivated valleys of Vermont are hardly to be found here, whereas the lake-strewn forest of northern Maine is duplicated on a similarly large scale, and much more accessible. 146 THE CLIMATIC TREATMENT OF CHILDREN The lower elevations, among the foothills of the Adirondacks, offer the attractions of a more settled region; their situation is, however, generally somewhat low, involving a rather warm summer. Still, the low valleys occupied by Lakes Champlain and George will always prove attractive; Schroon Lake is a little higher (800 feet) and therefore cooler, and its natural beauties are considerable, but the real mountains are still many miles away. All the remarks as to the seasons and their respective merits, that were made concerning the mountains of northern New England, apply equally to the Adiron- dacks. In the forested sections, comprising by far the greater part, black flies and mosquitoes are a great plague until midsummer. Our space does not permit a recounting of the indi- vidual resorts in this region, which number scores. First class accommodations are, however, less common than in New England, and rather scattered, outside the Saranac-Placid district in the north. So far as ready accessibility is concerned, many localities are well pro- vided for, whereas others, equally good, are twenty miles and more from the nearest railway; this may be re- garded as an advantage under some circumstances, where rest and remoteness from the ordinary tourist travel are desirable. The St. Lawrence Valley. This region is similar to the last, except that the winter becomes intensely cold. Very scant provision has hitherto been made for the health seeker, and visitors are usually taken care of in very primitive fashion. Among the few exceptions to the last statement are Roberval (Lake St. John), HEALTH RESORTS 147 Chicoutimi, Murray Bay, Quebec, Montreal, and Ottawa, but the last two are a little too warm in July and August. Below Quebec, the river broadens out into a great gulf, and the climate is very much like that of the Mari- time Provinces, with a colder winter. The lower St. Lawrence, beyond the mouth of the Saguenay, hardly comes within our ken; the climate is rather too raw for our purposes, even in midsummer. The upper reaches of the Ottawa Valley are now coming into vogue, but only for hardy sportsmen. The Hudson and Connecticut Valleys. Along the Hud- son and Connecticut Rivers we find no end of resorts, all of which are too warm for comfort in summer, and not severe enough in winter to guarantee a continuous snow covering and freedom from slushy surface condi- tions. As we ascend the hills on either side, both these objections disappear, and the Berkshire and Litchfield Hills, as well as the Shawangunk and Catskill Mountains, afford hundreds of attractive sites with a pleasant cli- mate. Few climatic data are available for this region, but we can calculate the temperature of any station fairly well by taking the figures for Poughkeepsie, and deducting one degree for every 275 feet in summer, and half as much in winter; in this manner we obtain the following values for the region near the 42d parallel in the Catskills and the Berkshire Hills: Elevation, Feet January July 100 '. 24 22 20 72 . 1,200 68 2,300 VJ 64 148 THE CLIMATIC TREATMENT OF CHILDREN In the Catskill Mountains most of the resorts lie along the Ulster and Delaware Railroad and its branches, whereas Sullivan County is threaded by the Ontario and Western line; Delaware County is reached by both. East of the Hudson there is almost an infinity of good locations along the Housatonic Railway and the Litch- field Hills line, as well as along the New York and Harlem Railroad. In the Hudson Valley itself only the Saratoga region, in its upper reaches, can be recom- mended, and Saratoga Springs itself is too much of a resort of fashion to commend itself for medical purposes, save in the relatively dull early summer and fall; from late July until early September it is very warm and the life there is unsuited to every sort of invalid. The Hudson Highlands form a pretty, but, except near Newburgh, somewhat neglected hill country. The interior of Sullivan and Greene Counties, away from the railways, is ideal for restfulness, rivaling the best parts of New England. Unfortunately, the accommodations are second or third rate almost everywhere away from the main lines of travel. Malaria is unknown among the hills, not so in the lower Hudson and Connecticut Valleys. New Jersey. Northern New Jersey, away from the suburban region near New York, resembles the last- named section, but the elevations barely reach 1,200 feet; the southern part of the state is low and flat, very warm and not over wholesome in summer, fairly mild in winter. The pine belt is well represented by Lakewood, which is to be avoided from June to September, but is highly attractive in April, May, October and November. The winter is not very mild, with a continuous variation HEALTH RESORTS . 149 between snow and mud; the temperature occasionally falls near to and below zero. Up among the hills of northern New Jersey we must not fail to mention Lake Hopatcong, and the region traversed by the Greenwood Lake and Susquehanna and Western Railways. The coast is relatively mild in winter and cool in sum- mer, and affords at least a dozen first-class resorts, among which Asbury Park, Atlantic City, and Cape May rank deservedly high. It must, however, be admitted that the summer is not really cool; sultry spells are common, and a dozen or so of days in the nineties may be expected with some certainty; the nights are also either rather warm or marred by sea fogs. Thus, we must regard that season as decidedly enervating, and choose this section as a summer resort only because of its proximity to the great cities of New York and Phila- delphia. Neither is the winter especially mild, as it averages little above the freezing point in ordinary years, and below it in cold seasons; it is redeemed only by its wealth of sunshine, equaled in these latitudes only at favored spots on the Mediterranean, which are all very much warmer. Early spring suffers somewhat from damp east winds, but is otherwise agreeable; the late fall is almost perfect, and beyond criticism, but this season is the very one in which this coast is compara- tively deserted. The inland sections of southern New Jersey are hot and malarious in summer, and colder and cloudier than the coast in winter; this region has, quite properly, received little attention from medical climatologists. Central New York and Pennsylvania. This region presents a rolling country, with an elevation from 800 150 THE CLIMATIC TREATMENT OF CHILDREN to 2,000 feet, varied at its northern edge by the pretty " finger lakes" of New York State. The data for Cooperstown and Scranton give a good idea of the temperature at the lower levels, higher localities being several degrees cooler in summer; as we go south, how- ever, the summer becomes rather warm, and in the lowest valleys, as at Harrisburg, the winter ceases to afford con- tinuous cold and a permanent snow covering. Coopers- town, Richfield Springs, Sharon Springs and a number of pleasant towns on the lakes represent only a portion of the great variety afforded in New York ; in Pennsylvania the popular resorts are fewer, for only Cresson Springs, Glen Summit, the Pocono Mountains, and a very few other places are sufficiently high to be pleasant in July and August. The Delaware Water Gap is indeed pic- turesque, but the midsummer temperature there is un- comfortably high, so that this resort is better adapted to the spring and autumn. Maryland, Virginia and West Virginia. In these states we are on the threshold of the South, and must begin to distinguish between summer and winter sta- tions. Hot Springs and White Sulphur Springs, as well as Deer Park, are specimens of the former, a little too warm for northern visitors in midsummer, who will do better to visit them in May or October; for southerners they afford welcome relief from the humid heat of the lowlands. The figures given for Wytheville give a good idea of the temperature. Northern visitors may occa- sionally avail themselves of the milder stations in winter, but in general will do better by going farther south, as this season in the yirginian Mountains is decidedly unsettled and wet. HEALTH RESORTS 151 On the coast we strike the first really mild winter resort at Old Point Comfort, opposite Norfolk. Here zero is unknown, and severe cold rare, but there is still some snow and considerable frost, and the climate differs from that of Atlantic City only in being seven degrees warmer, an amount, however, worth considering, espe- cially in the transitional months of March and April. Virginia Beach is also known as a summer resort, but only for southerners, being decidedly too warm, damp and enervating for the northern visitor. The Lake Region. Notwithstanding its great extent, only certain portions of the Lake Region have special value as health resorts; these are somewhat scattered, and best taken up consecutively. In the northeast corner we have the Thousand Islands, for which the climatic data for Kingston, hear by, will answer very well; the summer is sometimes rather warm, but on the whole agreeable, the accommodations are of a high order. The stations on Lake Ontario take a very subordinate place; along the south shore the summer is considerably warmer than on the north shore, and the win- ter, while also warmer, is far more cloudy and unpleasant. In the Lake Erie district, we may begin with Lake Chautauqua, 650 feet above Lake Erie, and, therefore fairly cool in summer; the places on the American shore of the lake are apt to be very warm. On the Canadian side the summer temperature is pleasant, but there is said to be some malaria; Port Stanley is the best known station. Near Lake St. Clair we have Mt. Clemens, famous for its springs; the climate is, however, not especially attractive, except perhaps to summer visitors from the South. 152 THE CLIMATIC TREATMENT OF CHILDREN Lake Huron has the great merit of affording a cool summer nearly everywhere, except at its southern tip; a number of resorts are coming into deserved prominence, especially on the cooler Canadian side. The shores of Georgian Bay, as well as the Muskoka and other near-by lakes, are annually affording better accommodations; apart from the less rugged landscape, this section is little inferior to the lake region of Maine and northern New York, and should rival the Thousand Islands for resi- dents of the western states, who will find it more accessible. Ample climatic data have been given, those for Parry Sound being quite applicable to the Muskoka region, save that the extremes of temperature may be a trifle greater, and the average a degree or two lower at the latter. The Michigan side of the lake is relatively undeveloped, though it is nearly as cool north of Saginaw Bay; land breezes, however, occasionally raise the temperature into the nineties, which happens less frequently on the opposite shore. There is an abundance of pleasant resorts along Lake Michigan, especially on the east shore, which is the cooler in summer. The finest summer climate is found near the straits, where numerous small towns afford good accommodations; the tables for Mackinaw give a good idea of the usual temperature, which is nearly the same as that of the Maine Coast; the salt air is, of course, lacking. On the opposite side of the lake we still have a fairly cool summer at Escanaba, but southward it grows warmer, though the. frequent lake breezes mitigate the heat even at Chicago. The mineral springs, near Mil- waukee, such as Waukesha, are much frequented, but HEALTH RESORTS 153 are not cool enough to be bracing. Malaria is practically unknown in this section. The shores of Lake Superior have hitherto not re- ceived much attention; the south shore, while generally cool, occasionally experiences some very intense heat, which is not so apt to occur in the Mackinaw district; Marquette represents this section well. The north side of the lake has so far been neglected; the summer is al- most too cool at stations like Port Arthur, and other places are not very accessible; facilities for the care of tourists hardly exist on the Canadian shore. Among the hills, such settlements as White River afford a bracing summer climate, but this territory has hardly come within the scope of the health seeker. None of the lake points are adapted to a stay from November to April, the weather is too stormy, gloomy, and changeable, and the raw Winds of early spring are even worse than in New England. At favored sites, however, the month of May becomes pleasant, and from June to September the weather is good everywhere, save that midsummer is a little too warm on the south shore of Lake Erie, and in the vicinity of Chicago, which are objectionable in other ways. The Ohio Valley. This region has little to offer in the way of health resorts; it shares in most of the disadvan- tages of the Mississippi Valley, to be considered later. French Lick and West Baden Springs, in southern Indiana, are much visited; their climate is a trifle warmer than that of Indianapolis (q. v.) and therefore far from attractive in either winter or summer. The Upper South. Here we find a number of resorts worth mentioning in detail. Asheville, for which data 154 THE CLIMATIC TREATMENT OF CHILDREN have been given, is the best known, and its value is not limited to the treatment of tuberculosis alone; the sum- mer is, however, a little too warm for northern visitors, though affording welcome relief to residents of the southern lowlands. There is an occasional fall to zero in winter, with some snow, and a good deal of rain; the hills and dense forests furnish ample shelter from high winds; the whole upper South is, in fact, the least windy section in the entire East. Hot Springs, N. C, 1,300 feet high, is a degree or two cooler than Charlotte, and therefore mild in winter, but very hot in summer. Lookout Mountain, 2,130 feet high, near Chattanooga, is a trifle warmer than Asheville, therefore generally similar, but much more exposed and hardly suited to a winter sojourn. The country about I^noxville merits a more extended trial than it has had hitherto, it lies particularly well sheltered and the tem- perature is fairly uniform. All the places mentioned may safely be recommended for the spring and fall (except September). The upper South is remarkably free from malaria, considering the rather high average temperature, and presents a striking contrast to the lower South in this respect ; its utilization is, however, still in its early stages, and awaits a much greater future. The Lower South. This region can, in general, be recommended as a health resort only from November to and including April ; the rest of the year is too warm, and malignant fevers are common during the rainy season from May to October, when the coast marshes have a particularly evil reputation. We shall take up the various localities from north to south. HEALTH RESORTS • 155 Raleigh and Southern Pines, near by, have a winter that is still moderately cold, with some snow and frosty nights; the latter station is a little the milder and well sheltered from high winds. Aiken, S. C, and Augusta, Ga., are decidedly mild, some vegetation persisting in all but the coldest winters; still, sharp freezes are common, though snow is rare; Macon is very similar. Charleston and Savannah are not so typically urban as to be objec- tionable; they have the average winter temperature of southern California or Sicily,, but the occasional hard frosts constitute an important difference; Thomasville is similar, but a little drier, .lying well sheltered among the pines. Jacksonville, St. Augustine and Pensacola are almost subtropical, but still present all the eccentricities of the southeastern winter; Mobile, New Orleans and Galveston are similar, but a little colder, and not quite as suitable to invalids as the resorts of northern Florida ; the defective sanitation of New Orleans is a standing objection to that otherwise charming winter refuge. The entire region just outlined is better suited to the period from late February until mid-April than to the true winter season. During the midwinter months, the before-mentioned eccentricities of the southern cli- mate have full play; the visitor suffers from a perilous and all too frequent alternation of heat and frost, the bad effects of which have already been fully considered; it is an exaggerated northeastern April that the southern winter affords us, not uniform balminess, as advertised. The effect is a mixture of pampering and hardening which is of doubtful benefit to those who are referred to this region. In spring the climate is rather good, March in Georgia resembles April in Virginia and May in New 156 THE CLIMATIC TREATMENT OF CHILDREN England; the late fall should also be quite healthful in this district, but the experiment has been tried so little, that most of the resorts are not even open in November. The Florida Peninsula. Data have been given for Tampa and Jupiter (Palm Beach) ; the temperature for other popular resorts, such as Miami, Ormond and Pa- latka, may readily be calculated from those mentioned; it remains for us to generalize. The first common mis- take . is to speak of Florida as if it had one climate, whereas the winters of Jacksonville and Key West differ by 15 degrees, and the average minimum temperatures by almost twice as much. At the former place January resembles late April and early May in New York, save for hard frosts that are more appropriate to March than May; at Key West we have the climate of the New York June, though occasional chilly spells occur that have no counterpart in the northern month of roses. The second mistake is to put off the southern tour to the latter part of the winter, say February, and then transport the invalid from Boston or Chicago to Palm Beach or Miami, which are forty degrees warmer, with- out breaking the journey. Some days after arrival, when the process of enervation is fairly started, the visitor is' surprised by a norther, with a temperature near the freezing point, and runs at least an even chance of catching a severe cold. An " unusual " season — the ordi- nary mixed-up weather of the Florida winter is always called " unusual" for the benefit of visitors — is apt to leave the patient worse off than before. Fortunately, a wise custom postpones the return north until late April or May, and accomplishes it gradually; to take the enervated subject at once back to Boston in the HEALTH RESORTS 157 inclement weather of early spring would undoubtedly involve disaster in many a case. The third error, a common one, consists in keeping the patient in the increasingly warm and moist climate of south Florida until the fashionable season is over, in mid- April. Enervation is the chief danger to be appre- hended, it is quite certain to be accomplished by a pro- longed residence in this region. For this reason, the absolutely tropical, yet changeable, winter of Key West and Havana is to be avoided altogether; the latter city has a number of other drawbacks that need not be gone into here. There is a vigorously defended tradition that malaria is less frequent in Florida, than farther north; this may be true for the Atlantic Coast, with its trade winds, but it certainly does not apply to the West Coast during the warm months, where such places as Tampa have an unsavory reputation. The excessive humidity alone is extremely depressing to any one not a native ; this forms an objection to southern Florida even in winter, the dry season. On the whole, this region cannot be compared with southern California, or even the western Riviera, as a winter health resort ; its chief merit is its relative accessibility, and its luxurious accommodations for visitors. On the whole, it is probable that the upper South is often to be preferred to the lower South, and this in turn to Florida, in the treatment of disease; this rule, natur- ally, admits of many exceptions, but I am convinced that longer experience, even with children, will eventually bear out this statement. The Bermuda Islands. What has been said of Florida 158 THE CLIMATIC TREATMENT OF CHILDREN applies equally to the Bermudas. There is, indeed, a lack of the sudden and trying changes that characterize the former region, but the process of enervation is thereby only the more thoroughly accomplished, and it is worth mentioning that this result of a stay in the Bermudas has always been recognized as a serious demerit. The Bermudas have a certain therapeutic value, but their climate is a less important factor in their usefulness than their remoteness from the ordinary highways of commerce. The Mississippi Valley. This region is of little value for our purposes. The winter is about the most change- able in the world, and grows quite insalubrious toward the south, where the frequent warm and humid spells add the danger of enervation; the more severe but less interrupted cold of Minnesota and Iowa is far safer. The summer is hot everywhere; malaria is rife as far north as Illinois and Iowa, and the malignant types of fever are not rare in the river bottoms, though this last cir- cumstance is not often referred to in print. Almost the only health resort in all this vast district is Hot Springs, Ark., where the climate is really pleasant only in spring and autumn. The elevation of this town is 480 feet, and the data given for Little Rock, near by, give a very adequate idea of the climate, the winter being quite cool and very changeable, the summer intensely hot. The Great Plains. When the Great Plains were first settled much was said about their remarkable salubrious- ness, but we hear little of that to-day. The Canadian Northwest, however, is bracing and healthful, if one can endure the terrible cold of the long winter, which has the HEALTH RESORTS 159 compensating feature of being fairly bright and sunny, free from rain, mud and slush, and with a moderate snow- fall that lies on the ground until April. The summer temperature is, on the whole, quite agreeable; the occa- sional very hot days are tempered by a low relative humidity and frequent refreshing showers, and the nights are quite uniformly cool. Some of the merits of the Northwestern Provinces of Canada are shared by North Dakota and eastern Mon- tana, but the summer heat here is occasionally very intense; farther south, the climate has few attractions. The extremes of temperature are felt most severely, the high winds are exceedingly trying, and the low humidity acts chiefly by increasing the amount of dust. The scorching blasts of summer, the blizzards of winter, and the constant peril from tornadoes from April to August do not contribute to the otherwise scanty climatic attrac- tions of this section which, all in all, is one of the worst on the continent for neurotic persons. The dryness, furthermore, is not sufficient to afford protection against malaria, which begins to be of moment in Nebraska, and becomes a serious evil in many parts of Oklahoma and Texas. In the last-named state the summer ceases to be really dry, owing to the predominance of the Gulf winds at the season named, and the climate becomes extremely unwholesome in the river valleys. The Rocky Mountains. We must consider the Rocky Mountains with some little minuteness, if only because of the great variety of health resorts that they afford; in this respect they are perhaps destined to surpass any other portion of the continent. In the following account we shall again stop at the 37th parallel, for the Southwest, 160 THE CLIMATIC TREATMENT OF CHILDREN while not inferior, presents conditions so different as to call for separate discussion. In the Canadian Rockies, the summer is rather cold, but the winter is not unduly severe for the latitude and elevation, save on rare occasions, when the thermometer may fall to 30 or 40 degrees below zero. The Canadian Pacific Railway has done much to furnish quite good accommodations in this section, which resembles the Swiss Alps in scenery and climate; the data for Banff give a good idea of the latter. In the United States the eastern slope still has a rather changeable winter, but the average is relatively mild; the winds are less violent than on the plains, with the exception of the warm and very dry Chinook; there is usually little snow, and a low humidity, but the clearness of the sky has been overstated, except for southern Wyoming and Colorado. Spring is the least pleasant season, being relatively, but only relatively, moist, cloudy, and rainy. The summer is bright, with rather hot days, and very cool nights, occasional thunderstorms in the afternoon, and a very low humidity, which makes even 95 degrees in the shade tolerable. The fall is de- lightfully bracing, with warm clear days, and frosty nights, merging almost imperceptibly into winter. Ample tabular data have been given, and we need only mention that the best accommodations are offered at Helena, Denver, Manitou and Colorado Springs, whereas at most 'other places, otherwise quite as desirable, they are apt to be primitive. In among the mountains there is a little more moisture, and some situations are fairly well forested. Good accommodations are obtainable in the Yellowstone Park HEALTH RESORTS 161 — rather cold and open only in summer — Glenwood Springs, and Ouray, Col.; elsewhere they are usually primitive. Leadville is too high and cold for most people; snow falls there even in midsummer; at Grand Junction the summer is rather hot. In the Great Basin the climate is somewhat different; the winter is not so very bright, and brings some rain and snow, this weather continuing until late spring; the summer is warm, with almost uninterrupted sunshine; the autumn is like that on the eastern slope. An objec- tionable feature is the barrenness and dust in summer; the heat is rendered endurable by the extremely low humidity, but more rain would be welcome. High winds are a trying feature in exposed situations, as at Carson City and Winnemucca; they are not intolerable at Salt Lake City, where alone there are ample accommodations. Data have been given for the places mentioned ; the even temperature in western Nevada is worthy of note, also the usually steady winter temperature everywhere, in marked contrast to the thermometric oscillations of the entire east, including the slope. The relative warmth of the Snake River Valley was noted in the preceding chapter; the summer is, however, too dry to be oppressive; the winter is wonderfully mild for the latitude, but rather cloudy, though not very wet. The Southwest. Here we shall merely endeavor to amplify our tabulations. In northern New Mexico we have Santa Fe and Las Vegas Hot Springs, with temper- atures that rarely go beyond zero and 90 degrees, a dry winter, and a summer that is also dry, but nevertheless has abundant showers. Albuquerque is mild in winter, a little warm in summer, accommodations are not very 162 THE CLIMATIC TREATMENT OF CHILDREN good; the last is also true of El Paso, where the summer is uncomfortably hot, in spite of the low humidity. Silver City has become a popular health-resort, the cli- mate being very equable. In Arizona we have a great variety of climates. Yuma and Phoenix afford one of the best warm and dry winter climates known; with a mean temperature resembling that of Jacksonville and Charleston, and a much greater daily range, they are still far less liable to sudden changes and hard frosts. Their summer, however, is intolerably hot, and the humidity in July and August is not espe- cially low, so that the heat is quite unendurable. Tucson has a similar climate, but slightly cooler at all seasons; the deserts of southeastern California are uninhabitable during the warm months. None of these places except Phoenix have really good accommodations. In the uplands of Arizona we find a pleasantly cold winter, with some sharp weather, but very little snow, and in summer moderately hot and dry days, with occa- sional showers, and cool nights. Prescott offers fair accommodations, and there is now a good hotel at the edge of the Grand Canon; most of this fine district, how- ever, is for the present undeveloped. The Mexican resorts on the plateau must not be for- gotten; unfortunately the accommodations for health seekers, except in the capital, are rudimentary, and the City of Mexico, in spite of a good climate for such as can stand the altitude, is objectionable from other points of view. The tables given in the preceding chapter are amply sufficient for conveying an idea of the climate on the plateau, with its charming winter and only moder- ately hot summer. The dry season lasts from October HEALTH RESORTS 163 to April or May; moderate rains fall during the rest of the year, and even the rainy season has plenty of sunny days. There is a promising and still almost virgin field for enterprise in the highlands of Mexico, as well as in our own Southwest. We may now pass on to the Pacific Coast districts, which include so many very different climates that we are obliged to make a number of subdivisions. Southern California. The southwestern corner of Cali- fornia has probably the finest climate in the world, with only a tendency to drought to set against its many merits; ample tables have been given to illustrate such matters as can be reduced to figures, but a few additional remarks are necessary for a complete description. The summer temperature varies exactly according to the distance from the California Coast Current; Santa Catalina Island having a perpetual spring, Santa Barbara and San Diego a few hot days, Los Angeles and Pasadena some intense heat when the desert wind blows, fortu- nately with a low humidity; at San Bernardino and Riverside the summer, in general, is a little too warm for real comfort, though the nights are still cool. After crossing the Coast Range the heat rapidly becomes intol- erable, quickly increasing as we descend into the desert. In winter all this is changed, and the temperature is a trifle higher on the coast and islands than inland, declin- ing with the elevation in the usual way. Temperatures below the freezing point are very rare on the coast; inland 25 degrees are recorded on some occasions, but only the tenderest vegetation is likely to be injured. In summer, the afternoon fogs are apt to be annoying, but they are less frequent than farther north, and are attended with 164 THE CLIMATIC TREATMENT OF CHILDREN less violent west winds. The best season is unquestion- ably from December to May, the defects of the summer have been mentioned, the autumn has some hot days, even so late as November and, generally speaking, the only rather unsettled weather of the year. No other region affords an equal number of days suitable to out- door life, and in wealth of sunshine this strip of country is little inferior to the desert itself. The winter is an almost perfect reproduction of October in southern New York and New England. All the places mentioned offer good accommodations, and there are others, excluded only from lack of space. Not the smallest merit of this region lies in the fact that malaria is unknown, in marked contrast to places in the Old World having a similar climate. Central and Northern California. In this region we encounter a number of widely different climates, which must be discussed separately. The coast of middle Cali- fornia is delightful in winter, almost equaling the south- ern resorts; Monterey is the favorite, but Santa Cruz is not inferior. In summer, however, the coast is damp, foggy and windy, and best avoided by all save the very robust; there are some hot days in May, June, Septem- ber and October, rarely in midsummer, when the sea breeze is unpleasantly strong and constant ; the best sea- son, therefore, is from November until April or May. The interior is a little cooler in winter, with some frost, and rather more cloudy weather than on the coast, a common phenomenon, as already observed; the summer is almost absolutely cloudless and very warm, the heat increasing as we go farther from the Golden Gate. Even the low humidity does not compensate for the high' after- HEALTH RESORTS 165 noon temperature, although the nights are generally comfortable. The peculiar distribution of temperature about San Francisco has already been fully described. The North California Coast only remotely resembles that farther south; the temperature in winter is only a few degrees lower, but there is an excess of rain and storms that makes this season disagreeable ; the summer is even damper than that of San Francisco, which is say- ing all that can be said; the climate cannot be recom- mended at any season, and the very equable temperature does not atone for the exceedingly disturbed condition of the atmosphere at nearly all times of the year; only the autumn is a little better in this respect. The very pleasant and bracing climate of the mountain region of northern California has barely been utilized. The winter is not really cold at ordinary elevations, but there is a good deal of rain and some snow; the summer is fine, not too warm, but a little too dry, and a few showers would be an improvement. In the wonderful coniferous forests, however, the dust is not so objection- able as it is, to a distressing degree, in the Californian lowlands. Oregon and Washington, The coast of these states has the defects of that of northern California, plus an even more rainy and stormy winter, with occasional hard frosts; the Coast Range here is not high enough to afford perfect protection against the cold waves coming from the interior; and east winds are altogether commoner here than in California. The interior has a climate closely resembling that of southern England and north- ern France, but very much finer in summer, when a rainy day is rare. The summer is also very dry, though 166 THE CLIMATIC TREATMENT OF CHILDREN not to the degree encountered in California, and the sensible temperature is low, with very cool nights. Many of the small towns of this region offer very good accommodations, and even the cities are less objection- able than in the East, especially as they are mostly of only moderate size. Olympia is perhaps the best sit- uated of all, as it lies well sheltered, the other places on Puget Sound are a little too much exposed to the winter storms; in Oregon such places as Salem (near Portland) and Roseburg may be recommended with confidence. Behind the Cascade Mountains the climate differs radically, and - partakes of the characteristics of the Great Basin, with a moderately cold, but not too change- able winter, which brings some rain and snow, and a very dry and warm summer, not very different from that of the interior of California, but some degrees cooler. Walla Walla is typical of this region, Spokane is higher and farther north, and has a most agreeable summer; the region about Baker City is still higher, and cooler in sum- mer; but offers no accommodations to speak of. The North Pacific Region. Outside of the section near to and including Vancouver Island, the coast has nothing to offer the health seeker, as the climate is raw, though not really cold, throughout the year. The section men- tioned, however, offers fine and cool summer quarters at Victoria and New Westminster, far superior to what one would expect in this rather remote portion of the globe. The interior of British Columbia is terra incognita to the medical climatologist, chiefly because of its remote-, ness from our great centers of population. In the up- HEALTH RESORTS 167 lands the climate is alpine, with moderate extremes of temperature and deep snow in winter, the summer being exceedingly pleasant and bracing. The lowlands vary greatly according to situation, for the amount of moisture declines rapidly as we approach the mountains, but the temperature is moderate everywhere, save for some hot days below Kamloops, and an occasional spell of zero weather in winter. I have already given the tabular data that are most trustworthy; they are here pre- sented in convenient form for the first time, and may encourage experimentation with this decidedly healthful region. Alaska is either too wet' or too cold for the health seeker, and need not detain us. For the "present there are no accommodations for travelers except aboard the tourist steamers, but certain classes of neurotic invalids may be benefited by the popular Alaska tour, on which storms are not likely to be troublesome, as the course of the steamers lies behind the islands along the coast. The best and least rainy season embraces June and July, sometimes August is also pleasant; at other seasons torrential and continued rains may be expected with certainty. A CLIMATIC CLASSIFICATION OF AMERICAN RESORTS There is some advantage in classifying the American resorts along the fines laid down in the first chapter; while necessarily somewhat of a jumble of heterogeneous elements, such a list will still be of use as a general guide. A. Hot and moist. The Florida Keys, the Bahamas, the West Indies. B. Warm and very, moist. The immediate coast from 168 THE CLIMATIC TREATMENT OF CHILDREN Charleston, S. C, to the Rio Grande and beyond, the Bermudas. C. Warm and moderately moist. The inland strip imme- diately adjacent to the above, the remainder of Florida, southeastern Texas, southwestern coast of California. D. Warm and dry. Southwestern Texas, the Mexican Plateau, the hill country of southern California. E. Warm and desert-like. The arid belt from Phoenix, Ariz., to the San Bernardino Range in California. F. Very temperate and very moist. The California coast from Santa Barbara to San Francisco, also the islands off southwestern California, G. Very temperate and moderately moist. From the preceding inland to the Coast Range. H. Warm temperate and very moist. The Atlantic Coast from Cape Hatteras to Charleston. I. Warm temperate and moderately moist. The Gulf States except as noted in B and C, and the lowlands of South Carolina and southern North Carolina. J. Warm temperate and dry. The moderate elevations from central Texas to the Mojave Desert, the Great Valley of California. K. Middle temperate and very moist. The coast from Cape May to Cape Hatteras. L. Middle temperate and moderately moist. . The low- lands from St. Louis and Cincinnati to Memphis and Chattanooga; the Piedmont from Washington, D. C, to Charlotte, N. C, southern Missouri, Arkansas and Oklahoma. M. Middle temperate and dry. Southwestern localities between 3,000 and 4,500 feet. Very few stations come under this head. HEALTH RESORTS 169 N. Cool temperate and very moist. The coast from Portland, Me., to Cape May. 0. Cool temperate and moderately moist. The lowlands of New York and New England; Pennsylvania, except the highest hills; interior New Jersey; the southern Alleghanies up to 2,500-3,500 feet; the Lake Region from latitude 43.5 southward, thence to Cincinnati and St. Louis; the upper Mississippi Valley, South Dakota, Nebraska and Kansas to the 100th meridian; eastern Washington and Oregon up to 2,500-3,500 feet (the last are dry in summer). P. Cool temperate and dry. The Rocky Mountain Slope and Great Basin, the mountains themselves up to 7,000 feet in the south and 3,000 feet in Montana, the lowlands of interior British Columbia. Q. Cool and very moist. The coast from Newfound- land to Portland, Me., and from San Francisco to Alaska. R. Cool and moderately moist. The upper Lake Region/ North Dakota, nearly all of Canada, the higher Alle- ghanies from 1,000 feet in New England to 3,500 in North Carolina, upward. S. Cool and dry. The higher Rocky Mountains to the tree line. T. Cold and very moist. Greenland and the Labrador coast. U. Cold and moderately moist. All the mountains above the tree line and subarctic Canada. FOREIGN RESORTS In considering foreign resorts no attempt will be made to cover the ground completely, but only such 170 THE CLIMATIC TREATMENT OF CHILDREN regions will be dealt with as come within the ordinary scope of the American practitioner. Three groups inter- est us chiefly, namely, the coast of western Europe, the mountains of central Europe, and the Mediterranean Region. Western Europe.' Western Europe affords a wide range of moist climates, which are the mildest in the world for the latitude, with a. most even temperature, and certain conspicuous advantages even over our Pacific Coast. They all have the merit of being more conveniently accessible from our eastern cities, for, to only a passably good sailor, the transatlantic voyage is in many ways pleasanter than the four days' railway journey to the Pacific. Accommodations, furthermore, are almost universally excellent in western Europe; as much can be said only of certain especially popular resorts on our continent, the fare, in particular, being too often unsuitable to an invalid at places affording a most attractive climate. Norway and Sweden are known to Americans chiefly through the popular trip- to the North Cape, which in- volves a rather rough voyage that unfits it for delicate persons. The inland stations of this attractive section, almost ignored by the medical climatologists, afford a summer that is not very different from that of eastern Canada, cool and bracing, with some twenty hours of daylight, but perhaps a slight excess of moisture. The remoteness from fashionable life constitutes a valuable asset and makes one wish that this region be made the subject of further study. A few temperature data from this section will no doubt be welcome : HEALTH RESORTS 171 Feb. April July Oct. Year Average Max. Min. Ar^^TTo,, $ Hammerfest .... Norway | Bergen Sweden — Stockholm 23 34 26 32 42 37 53 58 62 35 45 43 35.4 44.6 41.5 75 79 88 6 12 -6 Autumn is the rainiest season on the west coast of Nor- way, elsewhere most rain falls in summer. Bergen is one of the wettest stations, with 74 inches annually; but many parts of the interior of Norway and Sweden have less than 20 inches. The climate of Bergen is almost an exact reproduction of that of Sitka, Alaska, but Bergen is three degrees farther north, and about two degrees warmer. The British Isles. We find a wonderfully even climate on the western and southern coasts of Great Britain and Ireland, whereas the interior and eastern portions of Scotland and England present more variable and ex- treme conditions. We may begin by glancing at the temperatures for the five cold months at the most favored stations : Nov. Dec. Jan. Feb. Mar. 48 48 47 46 45 46 44 43 45 45 43 42 45 46 44 43 46 47 Jersey, Channel Islands Ventnor, Isle of Wight 45 44 These stations not only have the temperature of central Italy, but more sunshine than other points in Britain; the latter is not, however, saying a great deal, and Jersey, with 1,800 hours of sunshine per year, is still as cloudy as the south shore of Lake Ontario, and very far indeed behind the least sunny Mediterranean resorts. 172 THE CLIMATIC TREATMENT OF CHILDREN The minimum temperatures at these favored stations are remarkably mild. At Valentia the average annual minimum is 29 degrees, the record is 21; even for Vent- nor 26 is reported as the mean minimum, and the same figure applies to the Channel Islands. The vegetation of these sections is mixed with subtropical forms, origin- ally introduced, but now naturalized; snow is quite an exceptional phenomenon. The summer temperature of Great Britain and Ireland varies chiefly according to the latitude, but is a little higher on the east coasts and inland. It barely touches 60 in interior Ireland or the south of Scotland in July, but reaches 61 to 62 in all the southern English counties, including the Channel coast and islands. In northern Scotland it drops to 56, and on the Shetland Islands to 53. Storminess is the main defect of the British climate, but from April to August the weather is relatively quiet. Fogs are exceedingly common, but not worse than on our extreme northeastern and northwestern coasts; the black fog of the English and Scottish cities is a local affair, as already explained. For the sake of completeness I give temperature data for the three capitals. Jan. Apr. July Oct. Year Average Max. Min. Edinburgh 37 40 37 45 47 47 58 60 62 47 50 50 46.8 49.1 49.1 76 87 Dublin 23 London (Greenwich) 17 The absolute extremes at Greenwich for a very long period are 97 and 4 degrees. London has very nearly the climate of Seattle, but the summer is rainier, the wet HEALTH RESORTS 173 season also coming on somewhat earlier, and lasting from August to January, with a fairly dry spring. The east of England has only 24 to 30 inches of rain, falling on about 180^ days, so that a drizzle is commoner than a heavy downpour; in the Scottish Highlands and in Cumber- land we find over 100 inches per annum, and in autumn these districts are fairly drowned in torrential rains. Save for the extreme south, Great Britain is only to be regarded as a summer resort, and even then, as just stated, there often is an excess of moisture. The spring is considered unwholesome, on account of the frequent east winds which, coming from the continent, are rela- tively dry; it is doubtful if they can be regarded as injurious to Americans, who are used to a drier climate. The average annual humidity in the center of England (Oxford) is 80 per cent., 86 in early winter, 74 in late spring; the last may seem dry to an Englishman, it cer- tainly would not give us that impression. The German Coasts. An abundance of climatological material is furnished from the coasts of Germany. Along the North Sea we have the following temperatures : Jan. April July Oct. Year 34 33 43 44 62 62 51 49 47.3 Sylt 46 9 The winter is colder than in Britain, the summer very slightly warmer; there is a good deal of very bad weather from October to April; 11 inches of rain, are spread over the winter and spring, and 16 over the sum- mer and autumn. The Baltic Coast is much colder in winter, but hardly warmer in summer : 174 THE CLIMATIC TREATMENT OF CHILDREN Jan. April July Oct. Year Putbus (Riigen) - 31 30 42 43 63 63 47 48 45.5 45.7 The Baltic resorts are generally preferred by the Ger- mans, as there is practically no tide or surf; but the water is only brackish, not really salt. The winter cli- mate is decidedly gloomy, raw and disagreeable, but the summer is rather pleasanter than on the North Sea. More than a third of the precipitation falls in summer, the minimum is from January to April, about a fourth of the total in all; the autumn is much damper than the spring, as on all northern coasts. Americans rarely have occasion to visit these shores, as our own northeast affords a similar temperature with less storminess. The Atlantic Coast of France has quite a uniform cli- mate, in spite of the differences in latitude; the only general change from north to south is a decrease of cloudiness. We may begin with a table of tem- peratures and include therein the coast of the Nether- lands and Belgium, which is similar, though somewhat colder. Jan. April July Oct. Year Average Max. Min. 36 43 45 47 52 54 63 64 67 51 54 58 49.2 53.0 55.8 90 98 Brest 24 23 Note that the minima are lower at Biarritz than at Brest. The former place is, all in all, perhaps the best on the French coast, being relatively sunny and not very HEALTH RESORTS 175 stormy. The distribution of rainfall is pretty uniform on these coasts, but with a slight excess from September to 'January, and a moderate summer minimum south- ward; the total exceeds 70 inches in the southwest corner. The relative humidity is high, 76 per cent, in spring and 83 in autumn, in spite of occasional dry and warm "foehn" winds. To complete the picture, I give a few temperature data from the interior of France: Jan. April July Oct. Year Average Max. Min. Paris (suburban) 36 36 49 53 65 70 50 53 50.2 52.7 93 12 In central France some 30 inches of rain are quite evenly distributed through the year" save for a slight minimum in March and maximum in May. Tempera- tures above 95 and near zero are not so very rare. The North and West Coasts of Spain and Portugal have a climate something like that of our Pacific Coast. Along the. Bay of Biscay we are reminded of southern Oregon, farther south the south California coast ie recalled, so great is the similarity in almost every detail, as to both temperature and the distribution of moisture. The following table will suffice to indicate the tem- perature of this section: Jan. April July Oct. Year Average Max. Min. Oviedo (700 feet) Lisbon 43 51 54 58 66 71 56 62 54.5 60.1 91 96 25 35 176 THE CLIMATIC TREATMENT OF CHILDREN Lisbon closely resembles Los Angeles, but is somewhat moister, with less intense hot winds in summer: 29 inches of rain fall annually, 12 in winter and only 1.5 in summer. At Oviedo 36 inches fall in the course of the year, 13 in winter and 4 in summer; here it snows a few times nearly every winter, whereas in Portugal snow is very rare in the lowlands. It is a pity that accommodations in Portugal should be generally so primitive as to bar out health seekers from perhaps the finest all around winter climate in Europe. The Azores and Madeira. Here the Portuguese type of climate is intensified, and the variations of tempera- ture become very small, as shown in this table : Jan. April July Oct. Year. Average Max. Min. 57 60 59 62 71 72 65 68 63.0 65.5 80 85 43 49 Frost is unknown in the lowlands, and the absolute minimum at Madeira is 44 degrees, 91 being the record in summer; visitors complain of the hot winds, but they cannot be unbearable under the circumstances, especially as they are notoriously dry. The Azores are too windy to be ideal for many pa- tients, and both groups are decidedly enervating, except from October to May. On the Azores we find 36 inches of rain, 13 in winter and 4 in summer; on Madeira 27 inches, 13 in winter and none from May to September. Madeira has a remarkably low humidity, 65 to 70 per cent, throughout the year; the proportion of cloudiness is also moderate, and fogs are not very common. The Pyrenees. The Pyrenees are most conveniently HEALTH RESORTS 177 considered here, though their climate resembles that of central Europe in many respects. Only the French side offers a sufficiency of good accommodations; the south- ern slope, which probably affords a better winter climate, is relatively undeveloped, though some mineral springs of the first rank are to be found there. Unfortunately we have but few climatic data from this region ; Pau, at 700 feet, has a mean January temperature of 42 degrees, with an average minimum of 20; the humidity is about ten per cent, lower than at Biarritz. The rainfall in this region ranges from 50 to 80 inches, with maxima in spring and autumn. It will be seen, from the above, that the French Pyrenean climate is cool and moist in winter, mild and often very wet in spring and autumn; the Spanish side is much drier, and among the foothills, quite extreme. I have not been able to find any thermometric data for the summer, but the average for July, at 1,500 feet, is about 68 degrees in the west, rising gradually eastward to about 72 near the Mediterranean; the latter section is very little visited, compared to the region about Pau and Tarbes. Central Europe. The hill and mountain country of central Europe has deservedly become the world's favorite playground and health resort. Its natural ad- vantages, only in part climatic, have been enhanced by artificial improvements and no little governmental aid, and the visitor is made comfortable in ways of which American resort boomers know only the veriest rudi- ments. Excellent roads, shady and smooth paths, cleanliness and good food at all prices, first-rate medical 178 THE CLIMATIC TREATMENT OF CHILDREN attendance, and a most ingenious development of every little factor that can contribute to health and enjoyment, have been held out to the traveler in the most tempting way. South and Middle Germany consist almost wholly of country resembling our Alleghanies; mountains from three to five thousand feet in height alternate with pleas- ant river valleys and interesting old towns. The climate is similar to that of our northeastern hills, but is a little cooler in summer, and decidedly milder, though more cloudy, in winter. I give a short table: Elev. Jan. April July Oct. Year Average Max. Min. Harz Mountains... . Black Forest 2,300 2,600 27 28 39 43 57 60 44 44 41.5 43.6 86 86 -4 -5 Some of the chief towns of Germany are given here for comparison: Elev. Jan. April July Oct. Year Average Max. Min. Berlin (suburban) . Frankfort a. M Munich 150 300 1,750 31 32 27 46 49 45 65 66 63 48 49 46 47.3 48.6 45.0 91 92 87 2 4 -1 Note the cool and rather extreme climate on the Bava- rian plateau (Munich); in marked contrast thereto is the high temperature of the upper Rhine Valley: Elev. 400 Jan. April July Oct. Year Average Max. Min. Heidelberg.- 34 50 66 50 49.8 91 6. The rainfall in South Germany ranges from 25 inches on the upper Rhine to over 50 in the mountains; one- third falls in summer, half as much in winter, with the other seasons exactly intermediate. The colder sections HEALTH RESORTS 179 are usually covered with snow for two or three months, in the warmer localities the snow covering is inter- mittent, because of the high mean temperature; the win- ters vary exceedingly in this respect. Save for the successful treatment of tuberculosis at Goerbersdorf (1,800 feet), Silesia is almost unknown to American climatologists. The mean temperature at this resort is 28 degrees in January, 42 in April, 61 in July, and 44 in October, the year averaging 43.4. The climate is therefore much milder than in the Adirondacks at the same level, except during the summer, when it is a few degrees cooler. On rare occasions, the thermometer falls as low as —20 in the Silesian hills; it rarely rises above 90. The distribution of moisture is exactly the same as in western Germany. Bohemia has a number of very excellent and popular resorts in its northwestern parts. The representative town of Carlsbad (1,200 feet) has the following tem- perature: • . January, 28; April, 46; July, 65; October, 47; year, 45.7 degrees. The distribution of moisture remains the same as for Germany. The Northern Slopes of the Alps have similar tempera- tures, save in certain valleys trending northward, where the colder months, as at Altdorf, are materially warmed by descending foehn winds; the following table gives a few data : Elev. Jan. April July 1 Average Max. Min. Zurich, Switzerland Altdorf, " 1,550 1,500 2,000 750 29 32 26 29 48 49 48 49 65 64 64 67 47 47.3 49 ! 48.4 49 46 . 4 50 48 A 87 86 92 7 12 Innsbruck, Austria ; Vienna (suburban), Austria. 6 180 THE CLIMATIC TREATMENT OF CHILDREN The distribution of rain is the same as in south Ger- many, with a slight increase in summer, and decrease in winter. The Alpine Plateau, being shut in by mountains, does not obtain the benefit of the inversion of temperature in winter that characterizes the peaks and their slopes; its temperature is therefore low throughout the year. The winter resembles that in the Adirondacks, but is not quite so cold or nearly so changeable, and temperatures under —20 are quite rare. The summer is cold, almost arctic, with occasional frost and even snow; the weather at that season is, in fact, altogether autumnal, and by the end of October winter resumes its sway. The worst month in this region is April, when the accumulated snow of winter melts with some rapidity. The following table gives the temperature at some well-known resorts: Elev. Jan. April July Oct. Year Average Max. Min. Davos, Switzerland, . . St. Moritz, " ■'. ". . Upper Tyrol, Austria . . 5,300 5,900 4,800 19 17 19 36 33 36 54 . 52 53 38 36 38 36.7 34.7 36.4 72 -8 The humidity at Davos is 82 per cent, in winter, and 74 in spring and summer, and the climate is therefore quite moist, even more so than that of our northeastern moun- tains. Two-fifths of the precipitation fall in summer, only one-sixth in winter; the total snowfall amounts to about ten feet. The Southern Slope of the Alps, sheltered by the excep- tionally steep declivity to the north, is relatively very mild, milder than the lowlands of northern Italy. This region affords some of the most desirable spring and HEALTH RESORTS 181 autumn resorts in the world, and even in winter the sheltered situation of these retreats gives them a high rank. The average temperature of this section some- what resembles that of the southern Alleghanies, but the weather is far less changeable, and zero is almost unknown. The following tables will furnish very ample details : Elev. Jan. April July Oct, Year Average Max. Min. Montreux, Switzerland . . : . . Lugano, Meran, Austria. 1,300 900 1,100 300 33 34 33 37 49 52 55 55 67 71 73 74 50 53 54 57 50.2 52.3 53.6 55.4 83 89 91 15 20 17 23 Pallanza, on Lake Maggiore, has a mean temperature of 37 degrees in January, and Bellagio, on Lake Como, averages 38; the respective minima are 21 and 22; the lowest temperature at Lugano in fifteen years was 12 degrees; in summer temperatures over 90 are quite common on the Italian lakes. The monthly range at Meran, in winter, is only 30 degrees, the same as at Cannes, and 6 less than at Pau. This region, therefore, affords a rare example of a moderately cold but very steady winter, in which it differs strikingly from any- thing known in the United States. Before leaving the Alpine region, we may review a few general matters. Zurich and Berne have only 1,760 hours of sunshine annually (40 per cent.)*, Montreux, on the southern slope, has 1,930 (44 per cent.), and Lugano 2,250 (50 per cent.). In January the sun shines four hours per day at Lugano and only eighty minutes at Zurich ; in July the respective figures are nine and a half and eight. The plateau makes a better showing in winter than the northern slope, for Davos has a daily 182 THE CLIMATIC TREATMENT OF CHILDREN allowance of three hours in January; in summer, how- ever, the proportion of cloudiness is a trifle higher on the plateau. The distribution of rain on the southern slope of the Alps is no longer exactly the same as farther north; the amount is relatively great, for the warm southerly winds condense their moisture on striking the mountain wall. Of the average total of about fifty inches, 15 fall in summer, and the same in autumn, only 8 in winter. The autumn rains are the first step in the transition to the Mediterranean region, where heavy October and November rains prevail throughout. In closing our survey of this section we must not fail to call attention to the accessibility of the hundreds of good resorts within this region, and the universally excellent accommodations " to fit every purse. In the latter respect it is to be regretted that American enter- prise has hitherto proved sadly remiss; single cantons of Switzerland contain more good hotels than the whole Alleghany Mountain region, and the accommodations offered in this country to persons of. moderate means are usually inferior, the table especially being unsuited to individuals whose health is impaired. Another 'defect .of American resorts is the absence of good paths, with easy grades, and in most cases, good roads for driving. The author, having an intimate personal knowledge of the mountain resorts on both sides of the Atlantic, experiences no feeling of astonishment at the enormous annual exodus of American tourists and invalids to the health resorts of Europe; the trials of the ocean voyage are more than compensated by the better care obtainable on arrival. HEALTH RESORTS 183 One of the defects of the climate of central Europe is the variability of the seasons, which equals that in the Rocky Mountains, and makes it impossible to promise the visitor anything like the normal conditions. Espe- cially is this the case in winter,. when the weather in the Rhine Valley, for example, may be as cold as at St. Petersburg or as warm as at Florence. Meanwhile the daily variability is barely one-half of that in the eastern United States; here the advantages of the European climate are conspicuous, sudden changes are indeed rare ; a change of 20 degrees from day to day occurs only once in three winters in central Europe, six times in each winter in the eastern United States,' and oftener in the middle West. Throughout central Europe the percentage of humidity is about 80 to 85 in winter, and 65 to 75 in summer; it is always low during the infrequent hot spells, when the daily range, even in the cities, exceeds 30 degrees. The nights are therefore cool in the warmest weather, a minimum as high as 70 degrees being phenomenal, whereas this is the July average in the warmer American cities. Heat-stroke is therefore very rare in central Europe ; though the maximum temperatures differ but slightly from ours. The Mediterranean Region. Here, we begin the study of a territory that offers a range of climatic attractions unrivaled on the globe. Only a small strip of North American soil, two to three thousand miles from our great centers of population, has a climate of similar type, and for extent, variety, luxuriance of vegetation, and facilities for the traveler, the most favored Mediterranean 184 THE CLIMATIC TREATMENT OF CHILDREN resorts have a rival only in one small corner of our Pacific Coast, embracing at the most 10,000 square miles, just equal in area to Sicily. Spain. But for generally primitive conditions, the Mediterranean shores of Spain would rank high among health resorts; as matters stand, only Gibraltar and Malaga can be recommended. Valencia and Barcelona also afford a pleasant winter climate, but the health seeker is treated better at other places that are quite as salubrious. We may glance at the following data of temperature : Jan. April • July Oct. Year Average Max. Min. Gibraltar Malaga 54 54 61 61 74 79 65 66 63.5 64.6 93 105 38 36 Frost is rare at Gibraltar and Malaga, but temperatures as low as 20 degrees may occur on the east coast. The hot winds of summer are as trying as in California, including also the dust and a very low humidity; the absolute maxima range from 110 to 114 degrees. At Gibraltar the influence of the Atlantic Ocean begins to be felt; the summer heat is mitigated by sea breezes, and the maxima rarely approach 100. Valencia has 260 clear days in the year; the proportion of cloudiness falls below 15 per cent, in midsummer. The summer is almost rainless everywhere, and most of the east coast suffers from drought at all seasons. Malaga is at its best from November until May, it is far too warm from June until October ; accommodations there are fairly good, and the place is gaining a very favorable reputation as a resort for the winter and early spring. HEALTH RESORTS 185 The interior of Spain has an extreme continental cli- mate, resembling that of our Rocky Mountain plateau. We may glance at the following table : Elev. Jan. April July Oct. Year Average 'Max. Min. Madrid Valladolid 2,150 2,500 40 37 54 52 75 70 55 52 55.0 53.0 103 101 17 13 The absolute extremes for ten years at Valladolid were 110 and -6. Madrid has only 16 inches of precipitation annually, of which only two fall in summer, and the remainder are pretty evenly distributed through the year, with a slight maximum in May; Valladolid is almost desert-like, with 12 inches annually. In Madrid the humidity in July falls to 44 per cent, and the cloudiness to 19; the winter is fairly damp and cloudy, as is usual in similar situations in this latitude. There is plenty of frost in winter, but the amount of snow is moderate; the total sunshine for the year is 2,930 hours (70 per cent.), about the same as at Salt Lake City, which has almost exactly the same climate in other respects, save for a decidedly colder winter. ■ Mediterranean France resembles eastern Spain, but the winter is slightly colder ; the Riviera is different and quite anomalous. In winter the icy mistral blows on two days out of three, bringing zero weather almost to the coast. Temperatures follow : Jan. April July Oct. Year Average Max. Min. 42 44 55. 55 74 72 58 60 57.4 57.8 99 15 186 THE CLIMATIC TREATMENT OF CHILDREN The mistral is most violent at Avignon, where it is powerful enough to upset railway trains, and all the trees are bent over southwards. 1 The precipitation is exceedingly small at all seasons, 20 inches per annum at Marseilles, of which 3 fall in summer and 7 in autumn Snow is not very common, for the sky is almost always clear when the mistral blows; the temperature on these occasions has fallen to zero as far south as Avignon. This climate is little better as to temperature than our Middle Atlantic Coast, and worse as regards high cold winds, which is saying a very great deal. Our own northwesters rarely exceed sixty miles per hour, a rate undoubtedly surpassed in southeastern France, where these gales are also more frequent. The region cannot be recommended to any save the very robust, and the contrast to the Riviera, lying immediately to the east- ward/ is far greater than shown by the average thermo- metric figures. The Riviera. The remarkable strip of coast known as the Riviera is usually regarded as extending from Hyeres to Leghorn, Genoa being the dividing point between its western and eastern portions. This region owes its phenomenally mild winter, in the latitude of northern New York, to the wind shelter afforded by the Maritime Alps and the Apennines; these mountains, however, rise immediately from the shore only from Nice to Spezia, the outer ends of the Riviera being less sheltered; we have therefore presented to us the anomaly of colder winters in the more southerly portions, and the greatest mildness at the center of the arch, lying farthest north- ward. At the western end the mistral still blows with ^Hann, vol. TTI., p. 47. HEALTH RESORTS 187 some frequency and violence ; Leghorn, also, is somewhat exposed to cold north winds; the intermediate parts are sheltered, and when the north winds are felt at all, they are dynamically warmed by their descent to the sea. Unfortunately but few accurate temperature data are available ; those extant are here given : Jan. April July Oct. Year Average Max. Min. Nice (C) 47 45 44 58 57 56 75 75 75 63 62 61 60.3 59.4 58.5 88 30 Genoa (C) . . . . '. Temperatures below 25 degrees are exceedingly rare, but it is evident that the winter is not nearly so mild as in southern Spain or southwestern California. Snow falls once or twice in each winter, but prolonged spells of bad weather are uncommon; we must not fail to note, however, that the rainfall gradually increases as we advance eastward into Liguria and Tuscany; the per- centage of cloudiness also rises, though the majority of the winter days are still pleasant. Even aside from the superiority of the accommodations, the western Riviera is therefore preferable to the eastern portion. In spite of its warmth, the summer on the Riviera is rather free from malaria, in marked contrast to places farther south having the same temperature; this differ- ence is unquestionably due to the absence of marshes, and is an advantageous feature for such persons as require a mild climate in the late spring or early autumn; Octo- ber is quite a safe and pleasant month on the Riviera, whereas it is rather dangerous even a short distance farther south or inland. 188 THE CLIMATIC TREATMENT OF CHILDREN The Po Valley. Most startling is the change in winter, on crossing the Apennines from Genoa to Turin; Ales- sandria, only 300 feet above sea level, and forty miles from Genoa, is 14 degrees colder in January on the aver- age, but during cold spells as much as 25 degrees, for the temperature may fall below zero. In a modified degree,, this relative coldness extends eastward to the Adriatic, but diminishes northward, toward the Alps, where the lake resorts have a much milder winter, .with minima not nearly so low as on the plain. The summer does not differ materially from that of. the Riviera, being in fact rather hot for the latitude. Temperature tables follow: Jan. April July Oct. Year Average Max. Min. Milan (C) 32 36 54 54 75 75 55 58 » 53.8 55.0 94 12 Venice (C) ." Only the spring may be safely recommended in this sec- tion; the winter is rather cold and somewhat changeable, with a good deal of cloudiness; the summer and early autumn are very malarious, and the late fall is un- pleasantly wet. Of about 32 inches of rain 10 fall in autumn and 8 in spring, a trifle less in summer and over 6 in winter; the distribution is therefore not very uneven. October is the wettest month. Heavy snow is common from December to February, and may lie on the ground for weeks at a time. The Italian Peninsula. Here we encounter a gradual increase of warmth as we go south, but the temperature of the Riviera is not reached until we come to the 41st parallel, north of which the vegetation of the warm temperate zone is but feebly developed. In the moun- tainous interior the climate, of course, is colder, and the HEALTH RESORTS 189 country is more or less liable to be snowed up in winter as far as Calabria. There is no great difference, in win- ter, between the western and eastern shores of the peninsula, but in summer the Adriatic Coast is consider- ably warmer, though perhaps not so unhealthy, marshes being less frequent and extensive. The temperature is as follows : Jan. April July Oct. Year Average Max. Min. Florence (C) 41 44 47 57 57 57 76 75 76 59 62 63 58.3 59.5 60.6 95 Rome (C) 26 Naples (C) This section, also, is at its best during the spring;' the winter is not very mild north of Naples, and the summer and autumn, outside of the great cities, are rendered very dangerous by malaria. Of 33 inches of rain, 11 fall in autumn, 9 in winter, 8 in spring, and only 5 in summer. At the last season the humidity falls to 58 per cent., with hot days and nights that are fairly comfortable if the ubiquitous mosquito be excluded. ■ The proportion of clouds at Rome ranges from 50 per cent, in winter to 25 in summer, so that Italy has- a sky no clearer than that of much of the United States. The amount of sunshine ranges from 2,200 hours in Piedmont to 2,600 and more in the south. The Mediterranean Islands. Of the islands in the western Mediterranean Sea we need consider only Corsica, Sicily and Malta; Sardinia and the other islands are in too backward a state to offer good accommoda- tions to health seekers. The following table gives an idea of the temperature : 190 THE CLIMATIC TREATMENT OF CHILDREN Jan. April . July Oct. Year Average Max. Min. Ajaccio (Corsica) Palermo (Sicily) Malta •. 49 51 54 57 59 59 77 77 77 66 67 69 62.6 63.5 64.0 103 96 35 42 The winter becomes wonderfully mild as we go south, but even Corsica is perhaps the warmest place in the world for the latitude; frost and snow are uncommon everywhere, except in the mountains, and are practically unknown in Malta; we may note that Corsica is as far north as Massachusetts, and Sicily in a line with Virginia. The *best season extends from November until April; even May is cooler than October, when the weather is still quite hot and malignant forms of malaria are rife. In' Sicily and Malta there is only about half an inch of rain for the entire summer, whereas 16 inches fall between October and January, and 5 more in February and March. The humidity rarely falls, as low as on the Italian peninsula, 60 per cent, in July being the lowest in Palermo and Syracuse. At such places, however, as Palermo, it falls to desert-like figures when a sirocco runs the temperature up to 105 to 115 degrees in the shade. 1 stria and Dalmatia. The Adriatic coast of Austria- Hungary somewhat resembles the Riviera, but it lies farther north, is decidedly colder in winter, and nowhere free from the terrific northeast wind (bora) that resem- bles the mistral of southern France. The east shore of the Adriatic is, however, very much warmer in winter than the Italian side, for the bora, though keen and cold, is still warmed considerably in descending from the Alps; in addition warm and moist winds from the Adriatic are HEALTH RESORTS 191 frequent, raising the temperature in the cold season and tempering the heat in summer. The following table gives some thermometric data: Jan. April July Oct. Year Average • Max. Min. Treste 39 41 48 54 54 58 74 73 77 59 58 65 55.9 56.1 61.9 91 91 91 21 Fiume (Abbazia) 24 31 The lowest temperatures for fifteen years were 14 degrees at Trieste, 16 at Fiume, and 21 at Ragusa. At Fiume there are 60 inches of precipitation, of which half falls from September to January, and the other half is well distributed over the other seven months. At Ragusa there are 65 inches of rain, Of which 27 fall from October to December and only 8 in summer. Snow is fairly common northward, falling in blizzard-like storms, but becomes infrequent toward the south. In sum- mer and autumn the moist sirocco is very oppressive, resembling the warm and damp sea-breezes of our South Atlantic Coast. It may be said, briefly, that the suitable- ness of this region for invalids is similar to that of the Italian peninsula, but the bora must be avoided as far as possible by a careful choice of location, e.g., at Ab- bazia, and the summer is malarious at many places. Greece. In Greece only Corfu and Athens have any interest for us, the remainder being excluded by the semibarbarous conditions still prevailing in most places. This country, in the lowlands, has a mild but somewhat changeable winter and spring and intense heat and drought after the first of June. Corfu has about 50 inches of rain, but only about 4 of them fell in summer, and the small allowance of 15 inches at Athens is con- 192 THE CLIMATIC TREATMENT OF CHILDREN centrated on the period from October to March (12 inches) ; the proportion of clouds at Athens is similar to that of interior California; indeed, these two regions resemble each other greatly in almost every climatic detail. The temperatures for Greece are as follows: Jan. April July Oct. Year Average Max. Min. Corfu 49 47 59 59 78 81 67 66 63.0 63.1 95 101 34 29 Snow is very rare at Corfu, but falls nearly every winter at Athens. Algeria: Algeria offers a number of good resorts, but Americans have hardly begun to familiarize themselves with this region, which presents every climate of our Southwest, except the cool and foggy summer of the immediate Pacific Coast. The following data indicate the temperature : Jan. April July Oct. Year Average Max. Min. 53 51 60 67 76 89 66 68 63.3 68.5 99 113 38 Biskra 32 Biskra lies at the edge of the Sahara desert, and has a climate very much like that of Phoenix, Arizona; the 8 inches of rain fall chiefly in spring and fall, but there are some summer showers; otherwise inland Algeria has a rainy season from October to March (80%) and a dry one from April to September (20%); in the city of Algiers 12 inches fall in winter, and only one in summer. Algiers is pre-eminently a winter resort on the coast and in the desert, and a spring resort in the mountain^, where deep snows are not rare from December to March, HEALTH RESORTS 193 and the temperature often falls far below the freezing point. [ Egypt, except in the lower Delta, has a dry climate, which becomes absolutely desert-like as we go south- ward. I shall begin by giving a few thermometric data: Jan. April July Oct. Year Ave RAGE Max. Min. 58 53 59 66 70 78 79 84 92 75 73 79 69.1 70.3 77.0 99 109 115 45 36 .40 At Alexandria the summer heat is mitigated by steady north winds from the Mediterranean; in autumn these often fail, and October is therefore about as warm as June; the hottest weather of the year usually occurs in September or October. The humidity is 66 per cent, in January, and 76 in July; no rain falls from March to September, ten inches during the remainder of the year. At Cairo it only rains an inch or two (in winter), and farther south rain is a curiosity; the humidity is still not so very low at Cairo, 61 per cent, for the year, and 45 in May, but in the deserts of upper Egypt the proportion of moisture is only about half as much, and the same as in our own southwestern deserts. Cairo has 30 per cent, of clouds in January and only 8 in June. Upper Egypt is tolerable only in winter, Cairo from November to March; accommodations are becoming first-rate. In every case an intermediate station should tide over the season of early spring, before returning home. Syria and Palestine. It is easy to foresee that these regions will soon be drawn upon as health resorts, for accommodations are improving rapidly, and a number 194 THE CLIMATIC TREATMENT OF CHILDREN of stations are becoming quite accessible. I give" tern peratures from Beirut and Jerusalem: Jan. April July Oct. Year Average Max. Min. 55 47 65 60 81' 76 75 69 68.7 62.8 95 102 39 Jerusalem (2,500 feet). . . 32 Beirut is too hot but very dry from April until November, Jerusalem from May to October; at the latter place the absolute range of temperature is from 112 to 25 degrees, there are 17 inches of rain in the cool months, and not a drop falls from the middle of May to the middle of October. There is some snow in most winters, but it rarely remains long on the ground. A CLASSIFIED LIST OF FOREIGN RESORTS CLASSIFICATION BY CLIMATE A. Warm and moderately moist. Madeira, the Azores; the Mediterranean islands, the Algerian coast, the south coast of Spain, southern Portugal, the coasts of Egypt and Syria. B. Warm and dry. The Algerian Sahara, lower Egypt away from the the coast. C. Warm and desert-like. Upper Egypt. D. Very temperate and moderately moist. ' The coast of northern Portugal. E. Warm temperate and moderately moist. The Riviera, southern Italy, Dalmatia, Greece, inland Algeria, the coast of Asia Minor. F. Warm temperate and dry. The Spanish plateau (lower levels), interior Palestine. G. Middle temperate and moderately moist. The south- HEALTH RESORTS 195 east of France (except the Riviera), central and northern Italy, Istria and southern Tyrol. H. Middle temperate and dry. The Spanish plateau (higher levels). /. Cool temperate and moderately moist. The remainder of central and southern France (excepr the mountainous regions), the cooler resorts south of the Alps, the middle Course of the Danube, beginning near Vienna. J. Cool and very moist. The coasts from northern Spain to the North Cape. K. Cool and moderately moist. Inland western and central Europe. (More than half of Europe,' outside of Russia, belongs to groups J and K). CLASSIFICATION BY COUNTRIES A. Western Europe England. On the south coast, from west to east: Penzance, Salcombe, Torquay, Teignmouth, Exmouth, Sidmouth, Bournemouth, Ventnor, Brighton, Hastings, Folkestone, Dover; also the Channel Islands. Netherlands. Scheveningen, Flushing (Vliessingen). Belgium. Heyst, Ostende, Blankenberghe. France. Dunkirk, Calais, Boulogne, Treport, Dieppe, Fecamp, Trouville, Cherbourg and St. Malo on the Eng- lish Channel (except the first two on the North Sea); Brest, Les Sables d'Olonne, Arcachon and Biarritz on the Bay of Biscay; Vichy near the center; Plombieres in the Vosges Mountains; Pau, Tarbes, Eaux-Bonnes, Luchon and Bareges (4,000 feet) in the Pyrenees, the last three with warm sulphur baths; Aix-les-Bains (sulphur springs), Anhecy and Evian-les-Bains on 196 THE CLIMATIC TREATMENT OF CHILDREN subalpine lakes; Chamonix (3,400 feet) in the high -Alps. Spain. San Sebastian on the Bay of Biscay. B. Central Europe Germany. Norderney, Helgoland and Sylt, islands in the North Sea; Riigen, Usedom and Wollin, islands off the Baltic Coast; Harzburg and Blankenberg in the Harz Mountains; Gorbersdorf (for tuberculous subjects) in Silesia; Aix-la-Chapelle (Aachen), with sulphur baths, in the northwest; Ems, Wiesbaden, Homburg, Wil- dungen, Nauheim 1 and Kreuznach 1 in the hill section from Mayence to Cassel; Oeynhausen 1 near Hanover; Baden-Baden, St. Blasien, etc., in the Black Forest; Kissingen in northern Bavaria ; Reichenhall 1 and Berch- tesgaden in the Bavarian Alps. Austria. Carlsbad, Marienbad, Franzensbad and Tep- litz in Bohemia; Innsbruck, Salzburg, Ischl, Hall 1 and the Dolomite Region on the north slope of the Alps; Meran on the southern slope; Riva on Lake Garda. Switzerland. Montreux and Ouchy on the Lake of Geneva; Lucerne, Brienz and Interlaken on the central lakes; Grindelwald, Murren, Davos, St. Moritz, Pon- tresina, Zermatt, and a host of others at elevations from 3,500 to 5,500 feet; Lugano and BeUinzona on the southern slope of the Alps.. Italy (Lake Region). Pallanza, Stresa, Menaggio and Bellagio on Lakes Maggiore and Como. C. Southern Europe Spain. Malaga. The Riviera. Hyeres, Cannes, Nice and Mentone in 1 Brine baths; see page 360. HEALTH RESORTS 197 France; San Remo, Bordighera, Nervi, Spezia and Leg- horn in Italy. Italy {Peninsula). Pisa, Florence, Rome; Ischia, Capri, Sorrento and Castellammare near Naples; Paler- mo, Catania and Taormina in Sicily. Austria-Hungary. Abbazia, Pola, Lesina and Ragusa on the Adriatic. SEA VOYAGES Our foregoing review of climates and health resorts, though it has included some oceanic islands, still requires a few remarks concerning conditions on the high seas, and their utilization, if we wish our account to be com- plete ; this leads to the discussion of treatment by means of ocean voyages, freely recommended some years ago to chronic invalids, including children, notwithstanding that the attendant discomforts were even greater then than now. Recent times have witnessed a great dim- inution of some of the. disagreeable features of ocean travel, yet the enthusiasm for this method of climato- therapy has fallen off considerably. Much of this abate- ment of interest is due to a better knowledge of our resources on shore, but more is attributable to a recogni- tion of the inherent defects of the sea-voyage treatment, which are so serious as often to more than neutralize its undoubtedly good features. In detailing the merits of this method we cannot do better than to follow Weber, 1 taking them up seriatim, and noting the corresponding objections one by one, as we go on. The first benefit derived, and the most obvious, is the 1 British Medical Journal, June 3, 1899. 198 THE CLIMATIC TREATMENT OF CHILDREN opportunity to breathe a really pure and germ-free air, to be found elsewhere only on the highest mountain tops and in the arctic wilderness; to this purity there is added a trace of salinity,. Which has also been considered of some therapeutic value, possibly without any real reason. Against this positively good point we must set the usually decidedly foul atmosphere of the saloon and cabins, particularly aboard small ships and in stormy weather, when the hatches are closed. As life on deck, the main object of the voyage, is almost impossible when the sea is rough, the passenger may be compelled to spend whole days under not very wholesome conditions. Secondly, Weber refers to the even temperature at sea; this does not, however, obtain universally by any means, for the northwestern portions of the Atlantic Ocean, for example, are known to experience rather wide fluctua- tions during the colder months. Relatively speaking, however, Weber's statement may be accepted'; on the tropical and subtropical seas the temperature is indeed exceedingly uniform, and rather high, ranging almost all the time between 70 and 80 degrees. Such even warmth is, of course, very enervating, as Weber himself admits; in the belt of trade winds there is some compen- sation in the way of almost uninterrupted fine weather with fresh breezes, but in the so-called horse latitudes north of this belt, as well as in the equatorial zone of calms, the heat sometimes becomes quite distressing, and is acknowledged to be harmful. Thirdly, there is the stimulating effect of abundant sunlight and strong winds. North of the 45th parallel, it must be said, the excess of sunshine is not much in evidence, and the mantle of clouds may be unbroken HEALTH RESORTS 199 for weeks at a time in autumn and winter; in warmer latitudes, save in the cloudy equatorial belt, the sun does shine for about three-fifths of the time. As to the breezes, we can understand that, they are very desirable when moderate; but since, in most regions, they develop into gales at frequent intervals, they are apt to involve considerable discomfort to the health-seeking landsman. Violent winds are an objection to many coast stations; it is easy to comprehend their still more trying roughness on shipboard. Fourthly, we may turn to consider the mental rest that comes with a sea voyage. This does exist on the longer and less traveled routes, and really forms the most incontestable advantage of such a trip; it is, unfortunately, almost altogether absent on such short and tourist-frequented lines as those to Europe and the West Indies; indeed, for the reason stated, these short voyages have been omitted from the list of our thera- peutic resources; life on a great liner has become exactly like that in a fashionable hotel, without the means of. avoiding tiresome neighbors by taking a walk or drive, a*s is possible on shore, when the sense of ennui "becomes oppressive. These objections apply almost equally to those longer tours, now extremely popular, to the Medi- terranean and the Spanish Main-, on which an almost continuous round of amusements and sight-seeing con- sumes the time and energies of the traveler; such voyages, also, can rarely be recommended to invalids, with any confidence. We have gone over the real advantages of ocean voy- ages, and noted the corresponding drawbacks, but there are other deficiencies that are without any sort of 200 THE CLIMATIC TREATMENT OF CHILDREN compensation. Most important of all, those long routes, which alone give the desired rest, are without the services of a really first-class medical attendant ; it is still cus- tomary, on many lines, to engage a very young surgeon for a single voyage; he is apt to be a practitioner with few qualifications for the management of a chronic, especially a neurotic invalid. Secondly, these same lines, as well as some very popular ones, furnish their passengers with food that is often coarse and lacking variety, readily disposed of, perhaps, by the conventional type of robust Briton, but quite unassimilable by a per- son whose digestive powers have become impaired. The situation of a delicate child, not quite accustomed to the motion of the ship, confronted with such comestibles as boiled corned beef and roast pork, instead of its proper food, is not fraught with great promise of rapid restora- tion to health. * Thirdly, of course, comes seasickness, which I mention last because it is usually overcome in a few days; some persons, however, never acquire a good pair of sea legs, and the first patient that we send on a sea voyage, for his health, may be one of those unfortu- nates. The result to him and his physician is likely to ■ be not at all questionable. We have jotted down sufficient data to establish the doubtful value of sea voyages in the treatment of disease ; ' we may add that all the adverse circumstances are aggravated in the case of children, and some of the good ones impaired. The subject has been presented for the sake of completeness, and because of its former vogue in certain medical circles of high repute; it has evidently entered on a stage of declining popularity, and shall receive little attention in the later chapters of this HEALTH RESORTS 201 treatise. The benefit - of an ocean voyage may be obtained quite as readily, with no risk and less discom- fort, at the ocean's edge. SEA BATHING While it is apart from the purposes of this manual to discuss hydriatric or balneological treatment, the special variety of sea bathing is so closely interwoven with cer- tain aspects of climatotherapy, that a few remarks on this subject are not easily avoidable. In sea baths we possess a particularly powerful stimulant; they form one of the more strenuous hydrotherapeutic procedures under some conditions; under others, again, they may be regarded as a rather mild measure. This difference is mainly due to variations in the sea temperature, partly to the quality of the surf and the coincident temperature of the air. It is clear that we must observe certain pre- cautions in administering sea baths to children, even more than in the case of adults, so that the following notes will not be superfluous. Strong surf, with violent breakers, is to be avoided totally, for, aside from the actual danger which exists at many places and has led to fatalities, the element of fear on the part of the child cannot safely be disregarded, and the physical shock of the pounding seas is almost always felt very unpleasantly, and leaves a good deal of prostration in its train, save in an unusually robust sub- ject. At places where the conditions are such as just mentioned, the period of low tide should be selected as the bathing time, for the breakers are then relatively small and feeble. This necessitates an almost daily shifting of the hour for the bath, often to inconvenient 202 THE CLIMATIC TREATMENT OF CHILDREN portions of the day, so that one is often tempted to omit treatment for a week at a time. In stormy weather, an intermission, until the sea quiets down, is also invariably necessary. For fairly robust children, the temperature of the water should not be lower than 60 to 65 degrees, for the more delicate ones 70 is the limit. Unfortunately, relia- ble data as to the ocean temperature at the various resorts are fragmentary; I shall have to furnish many facts from personal observation. On our Atlantic coast, Massachusetts is near the northern limit for children, at least of tender years, the season lasting from early July to the end of August ; in New Jersey, the water is often sufficiently warm in the latter half of June, and baths may be continued well on into September. The season progressively lengthens as we go south, until, in southern Florida, the water is none too 'cold in midwinter. On the Pacific coast the water is rather cool everywhere, the difference between the summer and winter being insignificant, whereas it amounts to over thirty degrees off New Jersey. Santa Barbara represents about the northern limit in California for all but the very robust, and even here the average temperature of the water is only 65 degrees in summer, though it averages 60 in win- ter; at San Diego fairly hardy children can indulge in ocean baths the year round, by selecting favorable days. Turning to Europe, we find that the Mediterranean is sufficiently warm only from May to November, for its winter temperature (55 to 60 degrees) is rather low for young invalids, though some seaside sanatoria adminis- ter sea baths throughout the year, even in frosty weather. In midsummer the temperature of the Mediterranean HEALTH RESORTS 203 Sea is quite uniformly 78 degrees, similar to that of our South Atlantic coast, and warm enough to permit quite a prolonged stay in the water. On the west coast of Europe conditions resemble those on our Pacific coast; north of the Bay of Biscay temperatures above 65 de- grees are rare, and only very short dips are permissible. On the German coasts we note a decided difference be- tween the North Sea and the land-locked Baltic, The former has strong tides and a fairly rough surf, and is, in fact, almost altogether unsuitable for our purposes; the latter is somewhat warmer in summer, and very much quieter, and the Germans give it a very decided preference. The Channel resembles the North Sea, save that it is warmer and less rough, but the tides are very strong. The temperature here is just warm enough for a very brief plunge, as it rarely rises much above 60 degrees under the most favorable conditions. It will be seen that the above outline is somewhat sketchy. The trouble lies chiefly with the advocates of strenuous hardening, who cannot find the water cold enough; conservative investigators in this field have remained conspicuous by their absence. As to the duration of sea baths, I can lay down a fairly good plan from my own observations. Robust children may stay in only for a minute or two, when the water is at 60 degrees ; at 65 three to five minutes may be allowed, at 70 ten minutes or a little more; on those occa- sions, exceptional on our Middle Atlantic coast, when 75 degrees are reached, even fifteen to twenty minutes may do no harm if the air is warm, and the weather sunny. For more delicate and younger children these allowances must, of course, be reduced, and the 60-degree baths cut 204 THE CLIMATIC TREATMENT OF CHILDREN out altogether. The common- American custom of pro- longing sea baths until cyanosis is fully developed is highly reprehensible and harmful; the reaction test applies to sea baths as well as to those taken in a tub, and its development is the signal for leaving the water. If the reaction fails to set in at all, the bath has been too cold, and is not suited to the individual in question. To obtain the full benefit of a sea bath, it is almost essential that the air should be warmer than the water; a slightly lower temperature of the atmosphere may, however, be compensated by bright sunshine and the absence of strong winds. The best time for bathing is about an hour before the noonday meal; when this is prevented by tidal conditions, a shorter dip before breakfast, or a bath in the middle of the afternoon may be substituted ; preferably the former, unless the weather is very cool or the sun obscured. GENERAL REMARKS Erb 1 has very wisely said that we may send our patient to a good climate, but cannot control the weather after he arrives there. When he visited the Engadine in December he found no snow to speak of; the natives assured him that this was phenomenal. When I visited Rome in January 1894, Lfound a veritable New England snowstorm raging; the remarks of the natives corres- ponded precisely to those recorded by Erb. Atlantic City, the present eastern climatic panacea, had a Massa- chusetts winter in 1904-5, and a Virginian one in 1905-6. Los Angeles, the western Mecca of health .seekers, is deluged with rain in one winter, and desert-like in 1 Sammlung klinischer Vortrage, 1900, No. 271. HEALTH RESORTS 205 another; in St. Augustine there is a frequent alternation in the prevailing equipment between furs and fans. Similar variations obtain at nearly all other health resorts. It is evident that the best laid plans of climatotherapy may end in disappointment. The gauging of climate has reached mathematical accuracy, the prediction of the weather rarely succeeds beyond forty-eight hours. All that we can promise our patient is the probability of certain conditions, but we cannot assure him that he will find more than an approximation' to the object of his search. It is a doubtful procedure, therefore, to send an invalid to a climate that does not differ from that of his home quite fundamentally; unless careful climatic study precedes such advice, it were better not to give it at all, save where the mere change of scene is a desideratum. More failures, however, result from mistaken notions about the climate of regions unfamiliar to the counseling physician. The delusion as to the remarkable mildness of Lakewood and Atlantic City, so fondly cherished by New York physicians, and encouraged by . financially interested parties, is paralleled everywhere. I have referred to the "dry" cold of the Adirondacks, and the "dry" heat of Arizona, of which only the latter is a fact, but not any too comfortable on that account. It is well to remember that winter remains winter, save in the tropics, and that summer brings some hot days every- where, except in positively arctic climates. The patient should therefore be advised to provide clothing adapted to the season, not to certain reported conditions that may be exceptional. The physician, for his part, should 206 THE CLIMATIC TREATMENT OF CHILDREN study climate from the ample data now at hand, referring to statistics when necessary; treatment according to time-honored traditions or random information is to-day as inexcusable an error in climatotherapy as in every other branch of therapeutics. CHAPTER IV THE CLIMATIC MANAGEMENT OF THE NORMAL CHILD During intrauterine life no production of heat is required on the part of the foetus; the apparatus designed for that purpose is set in action only after birth, and functionates very imperfectly at the beginning, so that the infant's temperature sinks to 95 degrees and below during the first few hours. Throughout the earli- est weeks of infancy the abstraction of body warmth is borne very badly, any reduction by radiation into the relatively cool surrounding medium, especially if accel- erated by air currents, is compensated with difficulty, and a subnormal temperature, with its attendant risk of disease, is readily established. The indifferent tem- perature declines only very gradually from 99 degrees at birth to the figure normal at a later age, and exposure of any sort must be balanced quite accurately with suit- able clothing. Great and sudden changes of tempera- ture are extremely dangerous during this period, for it is impracticable always to combat them promptly with the application of additional external warmth and cover- ing. It is therefore advisable, save during very warm weather, to keep the .infant indoors during the first month, regardless of the season. After four or five weeks the question of the baby's first outing comes up, and must be decided according to circumstances, sunshine and warmth being the prime 207 208 THE CLIMATIC TREATMENT OF CHILDREN requisites. The time should be about noon, on a bright day, with little wind, and a temperature not below 65 or 70 degrees. It is evident that in winter, or in a cold, gloomy, or windy climate, the first airing is likely to be postponed for weeks and even months; the parents as well as the medical attendant are the.n apt to become impatient. It is undeniable, however, that any material deviation from this rule, arbitrary as it seems, is a hazard- ous experiment; too often the infant's first illness is directly traceable to an ill-advised attempt of this kind, and it is better to err on the side of excessive caution. It is, of course, understood that a certain relaxation of the above -requirements is permissible in an infant that has attained the age of two, three or four months; the temperature in particular need not be nearly so high as just stated. Throughout infancy, the child should be kept at home in the early morning, and brought back within one or two hours of sunset; the advantage of breathing the purer air out of doors is more than neutralized by the dangers involved in exposure to the chilly dampness that prevails shortly after sunrise, and the increasing humidity and rapid fall of temperature in the late after- noon. In places subject to the sea breeze special pre- cautions must be taken during the latter portion of the day, the spring months calling for particular care in this regard, whereas the late summer and autumn are less dangerous: at the last-named season the early hour of sunset gives ample warning to the infant's attendant, and the temperature changes toward evening are less abrupt. After the second year the child may gradually be CLIMATIC MANAGEMENT OF NORMAL CHILD 209 inured to the climatic conditions that it will have to encounter during its school life. This is the age favored by the advocates of what is known as hardening, the training process through which the child is expected to revolutionize, both rapidly and thoroughly, the relations of its complicated and delicate organism to all kinds of atmospheric changes. We shall presently have abun- dant opportunity to give separate and detailed consider- ation to the subject of hardening; at this point it will suffice to state that any habituation to new and untried conditions must be effected gradually, step by step, as it were ; slow and sure methods are absolutely essential to secure a normal power of resistance to adverse cli- matic influences. It is, quite naturally, true that absolutely perfect results or even uninterrupted progress represents an ideal that we can hardly hope to attain; unlucky experiments and untoward happenings are almost unavoidable ; still, in view of the very remark- able eccentricities of most of the climates miscalled temperate, the net results of a system of training, fol- lowed consistently in the suggested fashion, average fairly good. This is the more creditable when we con- sider that, in a highly civilized community, the individual is endowed by heredity with a somewhat pampered constitution. The method of training just sketched, sound in theory and tolerably good in its results, is rarely carried out consistently and intelligently. Whereas the rearing of plants and the lower animals is largely in the hands or under the guidance of trained experts, that of the child is regularly intrusted to unskilled mothers or, still worse, ignorant nursemaids. The life history of the 210 THE, CLIMATIC TREATMENT OF CHILDREN average city child consists, for the most part, of a suc- cession of respiratory affections during the cooler months, and digestive troubles in summer, this seasonal distribu- tion obtaining, of course, only in a general way. The final consequence is likely to be a more or less delicate constitution by the time the school age is reached. It is quite safe to say that the majority of such children as are below par, without demonstrating any definite organic disease, owe their relative feebleness to the cause stated; in our climate, at any rate, there can' be no doubt that frequently recurring and alternating "digestive and respiratory diseases play the leading role, exceeding even that of the infectious diseases, in stocking our communities with a race of young weaklings. I fancy that very few of us will dispute the general proposition that the theory of climatic training has not progressed beyond the merest outline ; yet this con- fessedly rudimentary plan is rarely subjected to that thorough and consistent trial, which alone can aid us in filling in the present rude framework. As matters stand now, the children growing up among us have an undeniable and lamentable tendency to be physically subnormal; they are evidently imperfectly fitted to withstand the ordinary vicissitudes of their environment, among which meteorological changes form perhaps the greatest part. The statistics of infant and juvenile mortality would appear to show that an era of progress has set in, and that the situation is improving; the fallacies in this argument are only too easily demonstrated. Formerly, only the fittest survived, the others succumbed; modern medical science saves many of the latter from death, to CLIMATIC MANAGEMENT OF NORMAL CHILD 211 drag out a more or less impaired and wretched existence ; thus, many competent observers claim to note a steadily increasing ratio of subnormal children in both the urban and rural populations. It is evident, from the above discussion, that the prime indication is prophylactic; the climatic manage- ment of the normal child thus fills a large and not unfruitful field of medical endeavor. At the commence- ment of this chapter the opportunities for climatic training, in the ordinary sense, were shown to be greatly restricted during infancy and early childhood; we are therefore thrown back on those artificial aids, which may be called the climatic auxiliaries, namely, clothing, heating and ventilation. Of these, the subject of cloth- ing demands discussion here only from certain points of view; it involves at least as many social as hygienic considerations, and is known to have originated pri- marily through motives of the former class, to which the regard for mere health has always been subordinated. The employment of clothing, furthermore, may be re- duced to a minimum by an adequate supply of artificial heat; we may, therefore, for the present, pass by that subject to take up the more important themes of warming and ventilation, touching on the merits and demerits of the various methods whereby they are . obtained and regulated. Artificial Heating and Ventilation. For a young infant the proper room temperature is from 72 to 74 degrees; as the child grows older, this may advantageously be reduced to about 68. The heat of the American summer renders the maintenance of the proper room temperature 212 THE CLIMATIC TREATMENT OF CHILDREN impracticable, save during the cooler periods; when a hot wave prevails it is apt, especially in stone houses, to remain persistently above 80 degrees for a week at a time. It is a curious but inevitable result of our highly artificial life that our apartments enjoy a more even temperature in winter than in summer; it follows that the infant is exposed to greater thermal vicissitudes in its home during the latter season. Now, there is some natural hesitation about stripping off the greater portion of an infant's clothing during a warm spell, and there is apt to be remissness in adding to its wraps when the weather cools off. The result is that the infant is very often either over- or underdressed in the summer season, and it is, of course, exposed to risks in either event. We find in this circumstance an explanation of the frequency and persistency of the " summer cold," which -may attack children who rarely suffer from disease of the respiratory organs in winter. We have noted that, to the nude body of the healthy adult, the indifferent temperature of the air is about 80 degrees; it is undoubtedly higher in the case of infants and young, children, but the exact figure is indetermi- nable. Experience shows, at any rate, that a tempera- ture above 85 degrees, unless the humidity is very low, is distressing to an infant as ordinarily clothed; the baby becomes bathed in perspiration, which rapidly sets up an acute dermatitis, its sleep becomes light and fitful, its digestive apparatus becomes readily deranged; and its respiratory organs grow exceedingly sensitive to very slight thermal changes, the last two forming important parts of the physical condition called enervation. It is impossible to lay down a hard and fast rule as to CLIMATIC MANAGEMENT OF NORMAL CHILD 213 the proper season for inaugurating the supply of artificial heat. So much depends on the construction and situation of the individual dwelling, that the room thermometer is practically the only trustworthy guide. Country houses, even in the latitude of New York City, may occasionally require an open fire during an exceptionally cool spell in summer; in cities, where the houses adjoin one another, we may safely await the first hard frosts of October or early November, and discontinue heating when settled spring weather arrives in the course of April. It will, perhaps, not be out of order to devote some space to the merits and deficiencies of the various modes of heating in vogue, five systems being in more or less extensive use in this country. The iron coal-stove may be mentioned only to be condemned. Its use involves a very unequal diffusion of warmth through the apartment, and there is al- most always some contamination of the air with carbon monoxid; this reaches a dangerous amount whenever there is a tendency to back draught, as may occur with certain winds or structural defects in the chimney, or be due to simple mismanagement of the stove itself. The porcelain stove, heated with briquettes of coal waste, which is in extensive use in western Europe, is almost ludicrous in its inefficiency, even in the rather mild winters of Paris; in our northern states it would be all but worthless, and little effort has been made to popularize this very inadequate heating apparatus on our side of the Atlantic. The open fireplace, burning either wood, coal, or gas, 214 THE CLIMATIC TREATMENT OF CHILDREN has much to recommend it, since it forms a perfect ventilating plant as well, when in operation; its chief defect is that most of the heat escapes up the flue, and the room itself is barely warmed at all; almost all the benefit we get from an open fire is by direct radiation. For this reason alone, this method is suitable only for mild climates and the moderately cold spells of spring and autumn; during our northern winter it has merely auxiliary value, and may even be omitted altogether where other more efficient heating plants are provided. Most of our private dwellings are warmed with the hot-air furnace, which is easily worked and maintains an even temperature, though it will invariably be found that the upper floors receive much more warmth than the lower stories. This system combines with its un- deniable good qualities two serious defects. In the first place, it is entirely too well adapted to supplying our home atmosphere with baked street dust of various kinds, mostly unpleasant to contemplate. , This dust, further- more, is lar from sterile when it enters our rooms, for dry heat, of the moderate intensity applied in the furnace, is a most unreliable disinfectant. We may, however, mitigate this evil very largely by filtration through cotton, which must naturally be changed at intervals. The second, almost equally grave, and hardly remediable defect of this method is its effect on the relative humid- ity in our rooms. Saturated air at zero contains 0.03 ounce of aqueous vapor to the cubic yard, at 70 degrees it contains about 0.6 ounce; it follows that, in zero weather, the street air, taken into our houses and suit- ably warmed, has a saturation deficit of over half an ounce to the cubic yard, and a relative humidity of only CLIMATIC MANAGEMENT OF NORMAL CHILD 215 five per cent. This does not, of course, actually occur to this degree, for such intensely dry air absorbs moisture from everything it touches, including the furniture of the rooms, and the human bodies inhabiting them. Under the best arrangement extant, however, the re- quirement to raise the proportion of moisture to 50 per cent., namely, the provision of about six gallons of water to half saturate the atmosphere of an ordinary dwelling, 1 with frequent renewal of this supply, is not fulfilled. It is true that a ridiculously small receptacle for water is attached to the furnace and supposed to be filled regularly ; some persons fasten tiny basins, holding about a pint, to the registers in their rooms; I doubt if the amount of water thus supplied amounts to a gallon a day under the customary management. It is there- fore not at all remarkable, that all who have investigated the relative humidity in our dwellings, report a desert- like dryness; Freudenthal, 2 for example, observed 15 per cent, in zero weather, and 30 per cent, on moderately cold days in his own house. Added to the above-men- tioned dust, such intense drought is certainly injurious to the respiratory mucous membranes; whether it favors the development of adenoid hypertrophies is still an open question, but I am inclined to agree with those who answer in the affirmative; the sudden increase in the number of rhinitis cases, when the furnaces are set going, is so striking as to make some sort of etiological relation highly probable. It is not easy to suggest an adequate remedy for this defect of the hot-air furnace; the air passes through far 1 A house measuring 60x60x23 feet contains 3,067 cubic yards, \ ounce of water per yard equals six gallons. 2 Journ. of the American Med. Association, November 9, 1895, 216 THE CLIMATIC TREATMENT OF CHILDREN too rapidly to take up its proper quota of watery vapor in transit, even were it supplied. A larger furnace, with a slower air current, would entail increased expense, even if otherwise practicable. Heating with low-pressure steam has for many years been steadily gaining favor, and has monopolized the field in cool and cold climates, for all large buildings. The steam-heating plant has the great merit of sufficiency, which readily passes into excess on mild winter days, as well as in autumn and spring, when steam-heated apartments are invariably too warm. The attempt to correct this overheating by means of direct ventilation through open windows is very apt to create draughts that are the more dangerous because of the overheating. An additional drawback, of no little consequence, is the dissociation of the heating and ventilating plants; our engineers and architects have hitherto not succeeded in devising a good independent ventilating apparatus, and the air in steam-heated buildings is rarely as pure as one would desire. Heating with hot water does not differ essentially in principle from the preceding; it has found little favor in this country, and seems inadequate against the intense cold of our northern winters; in England, where severe winter weather is exceptional, it has come into use more generally. Turning to the subject of ventilation, we find that it resolves itself chiefly into the management of windows and doors. With the prevailing style of American win- dow, consisting of upper and lower sliding sashes, the admission of air from without can be regulated almost to a mathematical nicety, if the counter-openings of doors CLIMATIC MANAGEMENT OF NORMAL CHILD 217 and flues and the direction and force of the wind be carefully considered. As a general rule, when the wind does not blow toward the window, opening at the top merely permits the egress of warm and respired air, the deficiency being made up through the door and furnace, also the fireplace, when not in use. Under almost any other conditions, air will enter through the window ; such is the case when the lower sash is open, or the fireplace is in use, or when a fairly strong breeze blows toward the room. It is a popular fallacy, readily exposed on any cold and windy night, that lowering the upper sash a few inches invariably contributes only to the exit of foul air; under the conditions just mentioned the air current is exactly in the opposite direction, and a cold draught descends from the top of the window, to the floor, very much in the manner of a waterfall. It is therefore extremely hazardous for a person, unaccustomed to this sort of exposure, to sleep directly under an open window, even if carefully covered. I mention the above practice and condemn it merely in passing ; it is one of the pet measures of the advocates of hardening, which may be indicated in adults suffering from chronic tuberculosis of the lungs, but need not, therefore, be prescribed for children in the offhand routine fashion nowadays so popular with many physi- cians who read much but reflect little. Similar errors will recur from time to time as we go on, and similar observations will have to be made repeatedly. The weather strip has been commented .on rather unfavorably in recent years, but it is hard to see just why; it seems to me that a window may as well shut tightly, if it is to be closed at all. 218 THE CLIMATIC TREATMENT OF CHILDREN The so-called French window, opening sideways, is inferior in many ways, the main objection being that the influx of air cannot be regulated with any exactness. The installation of a double set of these windows is altogether objectionable, except in regions experiencing intense cold ; the single window lets in some fresh air through slight defects in fitting, an advantage lost when double sashes are provided. Many persons, including some physicians, find it difficult to appreciate the difference between an open window and the open air, though the matter is simple enough. In the former case we admit a draught of usually cold air into a warm and almost stagnant atmos- phere, while the occupant of the room is dressed to-suit the latter only, and is therefore exposed to the danger of a chill; in the open the temperature is uniform, and the individual concerned is clothed accordingly, while the air currents are diffuse and intermingle freely. It is evident, therefore, that a veranda or open tent involves far less risk than a room with an open window, notwith- standing the apparently greater exposure ; it is easy to become habituated to the former, whereas, to a child at least, the latter is always hazardous in cold weather. From the above remarks, it is plain that the so-called " house-airing," nowadays so frequently recommended as a compromise, to the timid parents of children who would do better outside even in doubtful weather, is no compromise in any sense, but a measure replete with danger; the child is exposed to a cold draught at every inadvertent opening of the door. Throwing open the window wide does not decrease the clanger, but merely increases the discomfort to the occupant of the room. CLIMATIC MANAGEMENT OF NORMAL CHILD 219 The chamber occupied by a young infant should not be ventilated directly, but through an adjoining room; an exception may be made to this rule, when the outside temperature exceeds 70 degrees, but, even then, care should be taken not to place the child right in the current of air, but to one side. The bedroom of an older child may be ventilated directly, if the following precautions be taken: the bed must not be set under the window, nor against any save a party wall, for the abstraction of warmth through an outer wall, on a cold night, is almost as dangerous as the draught through a window. It is also a good plan to fasten down the bed clothes with safety pins, for some children are in the habit of throwing off their blankets during the night, often with unpleasant consequences. In cool weather the windows of the playroom should be shut tightly, for such cold air as enters is sure to gravitate to the floor; it is a great deprivation for children to be prevented from creeping about on the rugs or carpet, so that this last precaution is quite indispensable. Housing. The demonstration of the bactericidal prop- erties of sunlight, by Downes and Blunt, 1 was hardly required, to convince us -of its supreme hygienic impor- tance; the Italian proverb: dove no va il sole, va il medico, expresses the common and correct opinion quite accurately. The exigencies of modern city archi- tecture absolutely ban the direct rays of the sun from some of our rooms, though in northern latitudes, where the sun describes considerably more than a half circle above the horizon during a great part of the year, its rays should enter every window at some time of the day ^roc. Royal Soc. London, 1877, vol. 26. 220 THE CLIMATIC TREATMENT OF CHILDREN during May, June and July. This can, of course, occur only where the houses are built widely detached. In the city of New York, the majority of lodgings in the flat and tenement houses have but one sunny room, which is usually not a bedroom; the advantages of a climate, that in wealth of sunshine fully equals " sunny Italy," are thus almost entirely thrown away, merely that land- lords may enjoy greater rents, and see real estate values rise. In most other American cities matters are some- what better, though too often only in the quarters inhabited by the well-to-do; in our small towns condi- tions in this respect are quite good, save for some bung- ling architecture that has planned unnecessary dark nooks and corners. The housing conditions in cities like New York are about as bad for children as can be imagined; to this we may add, during the colder months, a certain pro- portion of inclement weather which is less in evidence in equally crowded cities in milder regions, for instance, Naples. It is really remarkable that our city children are not more flabby and pale than we find them; that actual conditions are bad enough is seen in the report of the Chief Medical Officer of the New York Department of Health on the examination of school children. 1 The only compensation for adverse conditions, such as these, is to take the child into the open air as much as possible, and to select the sunniest places, save during hot weather. It would seem absurd to add that this does not include exposing the baby's eyes to the direct rays of the sun, but a ten-minute walk through any of our parks will furnish abundant evidence that this hint 1 New York Med. Journ., Aug. 12, 1905, p. 343. CLIMATIC MANAGEMENT OF NORMAL CHILD 221 is not superfluous; the heedlessness of many mothers and nursemaids is almost beyond belief. Shelter from strong winds is also important on these outings, and it is hard to determine whether the cold and dry " mistral" type, or the strong damp sea breeze of April and May, is the more deleterious; my experience, however, inclines me to regard the former as the worse, since it brings severe cold with it, and is of generally greater violence. In very severe weather, exposure to sunlight indoors, when available, must often suffice as a substitute; careful adjustment of clothing is, however, of some importance, for the sunlit portion of the room is apt to feel very warm, on account of the radiant heat, even when the room temperature is at 70 degrees or below. I have not fo.und it necessary to draw aline on the thermometer below which an outing is barred. Holt keeps young children indoors when the outside tempera- ture is below 20 degrees; in my own experience I have seen infants above six months old exposed to far colder weather, the sunny and sheltered side of the street being chosen for the airing, and am convinced that no harm was done. It is, after all, a matter of habit; cold that is considered intense in New Orleans is deemed very moderate in New York, and passes for a harbinger of spring in Montreal. At the last-named place, drawing the line at 20 degrees would practically mean imprison- ment during most of the winter; in New Orleans it would mean exposure to all sorts of temperature changes in that most erratic winter climate. It is probably wisest not to draw any line, but to use one's judgment as wisely as possible. Clothing. We may now take up the subject of clothing; 222 THE CLIMATIC TREATMENT OF CHILDREN I confess to doing so with considerable diffidence, and feel that the divagations of Herr Teufelsdrockh are nearly as useful as the latest manual of hygiene. Who will, for example, account for the fact that most adult males wear woolen underwear, whereas the so-called weaker sex deems cotton sufficient; yet both are liable to illness in about the same ratio, if indeed the male sex is not a little more susceptible? Man covers the chest and exposes the throat at all seasons; woman covers both or neither, regardless of the season. In my dis- pensary service the children suffering from bronchitis wear all the way from two to seven layers of clothing, plus or minus a red flannel chest-pad. I fear that the truest expression of our information on the subject is a mixture of empiricism, tradition, hearsay, prejudice^ fashion, eccentricities, dogmatism, nihilism, and a very moderate proportion of physical and physiological facts. It will take but a few lines to state what is practically useful and scientifically established. For deficiency in clothing there is one infallible test, particularly trustworthy in children, namely, coldness of the extremities in spite of a sufficiently high tempera- ture of the room; there is an equally accurate criterion for overdressing, namely, sensible perspiration, for the hyperidrosis common in neurotic adults is not often a source of confusion in early life. Many parents are strangely disregardful of the comfort of their children in this respect; young infants are apt to be overdressed, the coverings suitable to a surrounding temperature of 70 degrees are kept on in the hottest summer weather, so that an acute dermatitis is added to the ordinary distress occasioned by the hot spell; after the age of CLIMATIC MANAGEMENT OF NORMAL CHILD 223 three or four years too light clothing is commoner, and I have frequently seen children suffer intensely from the devotion of their parents to some such fad as the bare extremities fashion which is now particularly rife. As to the proper material for clothing children, there is at present a lively controversy between the advocates and adversaries of hardening. For young infants wool is generally recommended, on account of its being a relatively bad conductor of heat; on this subject some curious delusions and prejudices prevail. In the first place, wool ranks only a little lower than cotton as a heat conductor, and the low conductivity of most woolen goods is due to their loose texture and the air, one of the poorest conductors known, entangled in their meshes. Cotton goods of loose weave, such as Canton flannel, will be found to give nearly as great protection, and to have several advantages; for the rough edges of the wool fibers irritate the tender skin of the infant, as well as of many older children, and the thorough cleansing of woolen clothing is relatively difficult on account of this same roughness. Unless carefully handled, woolen fabrics tend to become felted in the laundry, thereby becoming hard and markedly increased in conductivity. It is probable that a mixture of wool and cotton is best suited to the purposes of underclothing. For outer gar- ments the above objections to wool do not, of course, obtain, and it is to be preferred in cool weather, at all events. Every observer will, however, notice, how the small boys always wear ostensibly woolen suits, and the little girls usually cotton fabrics, while the one sex seems to get on about as well as the other. Looseness of adjustment is an important desideratum 224 THE CLIMATIC TREATMENT OF CHILDREN in the clothing of children, but has no special connection with the question of warmth or coolness, unless actual constriction takes place. The question of partial nudity will be taken up in our discussion of hardening, in a later paragraph. The matter of the color of clothing involves a number of refined points in physics that are not always clear and usually disregarded; as an instance I may mention that recent studies in radiology seem to demonstrate that red is the best protective color against the summer sun — the summer dress of most mammals is reddish brown — the mere suggestion of this would have been considered absurd a decade ago. The best color in winter seems to be black in the sun, and white in the shade, which suffices to demonstrate the imprac- ticability of carrying out any rule on this subject. The data just given amply illustrate the uncertainty of the relations of clothing to climatotherapy, and ac- count for the supremacy of fashion over hygiene in this field; the only point on which we can depend with some assurance is the quantitative factor, and we instinctively feel that we have done everything when we recommend light weights in summer and heavy ones in winter. "Catching Cold" The older authors attributed most acute, and many chronic diseases to " catching cold," that is, exposure to a sudden fall of temperature or a chilling of the body after previous warming. This belief began to lose ground under the influence of bacteriolog- ical research, and reached its minimum toward the turn of the century, when many of the most competent clini- cians regarded it with the greatest skepticism. Mean- while investigations have been conducted, to settle CLIMATIC MANAGEMENT OF NORMAL CHILD 225 once for all whether the old creed is to be definitively abandoned, or merely revised to suit modern scientific standards. As far back as 1872 Rosenthal ' showed that animals warmed to a temperature of from 104 to 111 degrees assumed a subnormal temperature on ordinary exposure to the air. This experiment was supplemented by Affanassiew, 2 who cooled animals with the ether spray; so long as this cooling did not exceed a few degrees, no permanent effect was produced; when, however, the animals had been cooled off 20 degrees, many died in about 24 hours, exhibiting on autopsy cloudy swelling and granular degeneration of the hepatic and renal cells and the heart muscle, lesions which had often been referred to " colds." Control experiments were made by merely warming the animals to 104 degrees; no morbid changes resulted. Affanassiew' s experiments were varied somewhat by Lassar, 3 who employed the ordinary casualties of everyday life. He dipped rabbits, which had been kept at a temperature of 95 degrees, into ice water, then exposed them to the ordinary tem- perature of the room; within a day or two fever and albuminuria developed, of which the latter proved fatal in some cases, and led to chronic renal disease in others. There is some analogy to human disease in this process, but also an important difference; a cold in man is far more apt to entail a pulmonary than a renal affec- tion, and few investigators have succeeded in causing respiratory disease in rabbits by this method. One circumstance, of course, must not be disregarded, 1 Berliner klin. Wochenschrift, 1872, No. 38. 2 Centralblatt fur die'med. Wissenschaften, 1877. 3 Virchow's Archiv, vol. 129. 226 THE CLIMATIC TREATMENT OF CHILDREN namely, the wide gap between rodents and primates in the mammalian scale. Valuable information has been contributed by Nebel- thau and Zillessen. 1 Nebelthau found that the employ- ment of ice water is unnecessary; a mere thorough wetting of the animal's fur, and exposure to a strong draught of air as warm as 82 to 86 degrees, sufficed to produce hyperaemic lesions of the stomach and pulmon- ary lobules; some of the animals died within 6 to 12 hours, but their death was not intimately connected with the stated lesions, which were not very extensive. Zillessen ascertained, with positiveness, that no true pneumonia was developed; he again found renal lesions with relative frequency. The net result is that in many animals, notably rabbits, exposure to the thermal shocks that are supposed to cause acute respiratory diseases in man produce no such effect, but provoke hyperemia and degeneration of the kidneys, which sometimes prove rapidly fatal, but not in a way similar to anything occurring in the human subject. The injuriousness of such exposure is clear, its modus operandi is not yet determined so accu- rately as to be immediately applicable to human pathol- ogy, and we must still . content ourselves largely with inferences. As to the individual variations, we know very well that, among human beings also, some are proof to thermal influences that would almost surely prostrate others. Even if preliminary overheating is not essential, there is overwhelming clinical evidence that it materially increases the liability to take cold. There is also no 1 Inauguraldissertation, Marburg, 1899, . CLIMATIC MANAGEMENT OF NORMAL CHILD 227 doubt, as already suggested in the first chapter, that the resistance of the organism to thermal shocks is seriously impaired by having been accustomed to a temperature even slightly above the indifferent point; this is the condition concisely but not quite accurately designated enervation. Then, of course, we may add other debilitating circumstances, such as general malnu- trition and chronic visceral disease. Finally, we must not lose sight of the relatively low resisting power of childhood, shared, incidentally, with old age; not only is this shown, as explained before, in the elevation of the indifferent temperature' during early life, but it appears quite as conspicuously in an increased sensitive- ness to changes, and a greater tendency to undergo enervation under a pampering regimen. The most active resistance to the whole theory of catching cold, as here outlined, has come from the bacteriologists; yet they have contributed some of the most valuable evidence in its favor. Pasteur * increased the susceptibility of fowls to anthrax by cooling them in a bath at 77 degrees, but his experiment is not perfectly applicable, because of variations easily introduced into the biology and culture of the anthrax bacillus; objec- tion might therefore plausibly be raised by the opponents of the "cold" hypothesis. Lode, 2 however, seems to have fully proved the increased susceptibility induced by draughts of cold air, especially after a wetting (increased radiation of body heat);, the animals thus exposed succumbed readily to infections to which unex- posed animals were far more resistant. We cannot 1 Bulletin de l'academie de med., No. 12. 2 Archiv fur Hygiene, 1897, vol. 28, 228 THE CLIMATIC TREATMENT OF CHILDREN therefore doubt that exposure to cold, when the normal vasomotor compensation is interfered with, as after a wetting, or when it functionates inefficiently in conse- quence of enervation, renders the organism very much more susceptible to bacterial infection, with more exten- sive or intensive development of the contracted disease. We also see that the necessity of allowing for the presence of pathogenic micro-organisms does not affect our main proposition, for some of these microbes, for example the streptococcus or pneumococcus, are practically omni- present. Hardening. The connection between catching cold and the prevention thereof is presented in telling fashion by Kisskalt, 1 who lays down the following propositions: First, the tendency to disease is increased by arterial hyperemia, best illustrated by the condition popularly called overheating; secondly, the contraction of the blood vessels through the external application of cold (withdrawal of heat) causes an internal hyperemia, pathologically not to be distinguished from the conges- tion that forms the first stage of an inflammatory process, requiring, in fact, only the presence of bacteria or their products, to pass into that stage. Kisskalt' s third prop- osition refers to the circumstance that habituation to thermal shocks diminishes the contraction of the cutane- ous vessels and the secondary internal hyperemia; we therefore catch cold only when some part of the surface of the body has been chilled, and can reduce this reaction to surface chills by habituation. This process of train- ing the cutaneous vasomotor apparatus, so as not to react violently to every outward thermal influence, is 1 Archiv fur Hygiene, vol. 39, No. 2, p. 142. CLIMATIC MANAGEMENT OF NORMAL CHILD 229 commonly designated as hardening, and the next few pages will be devoted to a careful consideration of this mode of habituation as applied to children. It was a natural and logical trend of thought that led from the steadily increasing enervation due to our modern exceedingly h'igh standard of comfort, with the attendant risks just outlined, to the diametrically oppo- site system of physical training. Hardening is normal in the savage and barbarous races; the resisting power of the Red Indian, scantily clad as he is or rather was, to the vagaries of the American climate, had always evoked expressions of astonishment and admiration on the part of the '" palefaces," and the tendency arose in many quarters to bring up the white child in the most Indian-like manner compatible with the higher civilization. The promoters of this idea lost sight of a crucial fallacy, which has totally invalidated their argument. As a matter of fact, while the Indian does well enough in his primitive state in the lower stages of barbarism, he stands civilization very badly, becoming excessively subject to the white man's diseases so soon as he adopts his habits even in a modified degree, being, in particular, notably prone to tuberculosis. Countless generations of hardening have, in his case, been of no avail in counter- acting the enervation incidental to our civilization, and its after effects. Still, the experiment has been given a faithful trial, and, from early infancy onward, children have been exposed to wind and weather in the hope of avoiding the enfeeblement of the normal resistance that follows pampering and coddling. It is unnecessary here to enter minutely into the 230 THE CLIMATIC TREATMENT OF CHILDREN history " and details of the hardening movement in pediatrics; failure of the milder methods gradually led to increasing strenuousness, until the most popular pro- cedures attained the degree of severe physical torture, such as only an intimidated and helpless child would tolerate. Frequently repeated cold baths and insuffi- cient clothing came into vogue ; running about, barefoot, in and out of doors, ranked among the milder and there- fore more amusing measures. It is only necessary to glance at the recommendations of Hochsinger, 1 who lays claim to conservatism, to see how even cool-headed practitioners have been carried away by this monstrous fad, for it is nothing more. For all this enthusiasm, to which the comfort and happiness of countless children have been sacrificed, we can record nothing but still more failures; the young victims continued to catch cold at least as often as be- fore, and in addition developed other weaknesses which were actually rarer before strenuous hardening became the fashion. Fortunately, the movement had to come to a halt at this point, because it was physically impossi- ble to push the theory of hardening any further. The truth of the matter seems to be that any harden- ing that is at all feasible under the conditions of our civilization is bound to be imperfect; furthermore, there is great risk of overstimulating and thereby exhausting the thermoregulatory centers if an excessively strenuous system be followed; we find a parallel to this in the "going stale", of overtrained athletes. There seems to be a limit to which the endeavor to inure the organism to thermic shocks can safely go, and beyond which it 1 See bibliography. CLIMATIC MANAGEMENT OF NORMAL CHILD 231 cannot be forced without a reasonable certainty of dis- organizing the whole apparatus. This danger line is reached far more. readily in children than in adults; in the case of young infants this has indeed usually been recognized, and only the most rabid advocates of harden- ing ventured to apply their methods to the first year of life. Hecker x was the first to call a halt to the votaries of strenuousness ; he found that, among his clientele, the rigorously hardened children were just twice as likely to catch colds as the totally unhardened, and that the moderately hardened children occupied an intermediate position. The hardened children had, moreover, a marked tendency to neuroses and anaemia, and nearly always gave the impression of being " delicate." Special stress had been laid on hardening as a preventive of adenoid hypertrophy in the naso-pliarynx and fauces; Hecker found this lesion in 40 per cent, of the hardened children, but in only 20 per cent, of the unhardened. Hecker's observations have obtained ample confirma- tion, and have, of course, been vehemently attacked by the radicals; fortunately, it is most easy for any prac- titioner to satisfy himself as to the leading fact, that the coddled children are not any more susceptible to respira- tory affections than the hardened ones, while those who are handled • with ordinary intelligence, rather than dogmatism in either direction, seem to thrive best of all. The final result, suggested at once by common sense, is as follows: Young infants should be treated with the utmost care to avoid anything like severe exposure; after the first year gentle attempts should be made in 1 Miinchener med. Wochenschrift, 1902, No. 45. 232 THE CLIMATIC TREATMENT OF CHILDREN the way of a more strenuous regimen, but children under six or seven years always demand complete pro- tection against Gold and wet. With the commencement of school life a little more latitude is necessary, and may be permitted; dry cold may be disregarded, whereas dampness and chilliness still call for due precautions. Full exposure is only to be thought of after puberty, and here, too, we must beware of routine, for, as a conse- quence of centuries of civilization, with its ample pro- vision of shelter and artificial heat, many individuals are affected with what may be called hereditary enerva- tion. Such persons are and remain sensitive to sudden temperature changes, and it is quite impossible to habituate them to conditions that are regarded with indifference by the wild Indian. On the whole, however, the power of resistance usually increases up to the thirtieth year, to decline again at the onset of senility; thus, a course of hardening which would be . absolutely harmful to a young child may very possibly be suited to an adult enervated by a hot climate, dissipation, or general hygienic neglect. Hecker has appended to his admirable critique certain recommendations which embody his idea of .a rational course of hardening. He seems, withal, to stand in some awe of the radicals, for I should say that even he advocates a regime that savors of excessive* strenuous- ness in a number of minor details, as will appear in the following review of the several points that he enumerates : In the first place, he advises us to begin by accustom- ing the child to the bedroom temperature, allowing it to run about barefooted or even nude before being tucked in. This suggestion sounds a little strange from an CLIMATIC MANAGEMENT OF NORMAL CHILD 233 opponent of severe hardening, more especially from a resident of Germany, where the customary temperature of the bedroom is lower than with us, namely 60 to 64 degrees. Even an adult cannot remain stripped at any such temperature without shivering violently after a few minutes, and most of his body is at a greater dis- tance from the still colder floor. The room temperature is usually taken at about five feet of elevation, but in winter, even when artificial heat is supplied near the floor, the lower strata of the room atmosphere are from four to six degrees colder than indicated at the usual level of the thermometer. It is evident that no child should be permitted to play on the floor of its apartment in a partially or wholly undressed state, except during the warmer months of the year. Hecker's first proposi- tion is only a shade less objectionable than the cold baths he so justly condemns. His second recommendation, to take the child out of doors after the age of six months, unless the weather is very cold or stormy, I have already indorsed; when, however, he advocates the removal of shoes and stock- ings in summer, even the so-called summer of Munich, which resembles the latter half of May in New. York, he seems to be conceding' too much. Aside from the possibility, in fact likelihood, of traumatism in this age of tacks and broken glass, it is, to begin with, unsuited to even a warmer climate, except indoors in the hottest weather, and is, furthermore, unpractical as a measure of training, since the prevailing standard of civilization requires its abandonment in later life. Unless fashion will permit adults to go about barefoot it is hard to see any real purpose in this mode of hardening. 234 THE CLIMATIC TREATMENT OF CHILDREN Hecker's third recommendation, to avoid the use of furs, and to leave the throat bare, is quite proper for a climate such as that of Germany, and our middle and southern states; it must, of course, be abandoned in regions where temperatures below zero are frequent. A modicum of common sense will solve this question with- out difficulty. As to his suggestion to leave the legs and arms bare, objections will occur to us at once. This curious fashion has no special effect, except to facilitate the work of biting insects, and subject the exposed extremities to an infinity of annoying cuts and scratches, with more or less risk of septic infection, besides leading to painful sunburn under appropriate conditions. Thin coverings are almost as cool as nudity and afford pro- tection against the injuries mentioned. I might add that, even in our middle states, the summer is not adapted to exposure of this kind save during excep- tionally hot periods, and I have seen small children undergo severe suffering on cool summer evenings, simply because their parents had semi-barbaric tastes in dress, at least as far as their offspring were concerned. As to Hecker's recommendations on the subject of hydrotherapy, I may say 'that I quite agree with him when he prefers cool sponging to immersion, and uses the sensation of the child as a guide; if it enjoys the process there can be no objection, and this will usually be the case' if the room be carefully warmed and the child permitted to stand in a few inches of warm water. Strenuous objection on the part of the child makes the advisability of any but tepid baths (86 to 90 degrees) doubtful, and I would not recommend sponging with water colder than 68 degrees, even for the most robust ; CLIMATIC MANAGEMENT OF NORMAL CHILD 235 the reaction should be watched closely in every case, and its absence noted as a positive contraindication. Strenuous hydrotherapy has been the main reliance of the advocates of hardening and the most prolific source of mischief; the more radical advocates of this discipline abstracted the necessary body heat from their young victims by plunging them into tubs of cold water two or more times a- day, and then wondered why they caught cold even more frequently than admittedly pam- pered children. Hecker's final advice : to harden gradually, to indivi- dualize, to wait until the age of two or three years before beginning, and to take special care with anaemic and neurotic children, cannot be followed too conscientiously. I would add that we might, in general, harden children even a trifle less than permitted by Hecker; he him- self noted that moderately hardened children showed a higher morbidity than those not hardened at all. I do not, of course, mean thereby that children are to be pampered and coddled, and guarded from every breath of cool and fresh air as if it bore contagion, but am fully satisfied that, in this field, too little is better than too much; a manner of living that lends robustness after puberty is not for that reason suitable to an earlier age ; the young organism is far more delicate, and has in particular a smaller caloric reserve. This last is shown by the great tendency in childhood to cold hands, feet and. ears, and frostbites' of every degree, including the annually recurring winter eczema of the face and hands; it is high time that the fact were universally appreciated, that not only infants, but older children in a gradually diminishing degree, are intolerant of low temperatures. 236 THE CLIMATIC TREATMENT OF CHILDREN* Summer Resorts. From various remarks in this as well as the introductory chapter, the reader may have gained the impression, which is strictly correct, that occasional moderately hot weather, say 85 degrees of heat with less than 70 per cent, of humidity, otherwise a sensible temperature under 77 degrees, is not in itself injurious to the very young, though it may be trying to their elders, who are obliged to dress according to con- vention, and work for a livelihood besides. It was shown at the outset that, with proper general hygiene as to pure air and clean food, there is no occasion for an especially high infant morbidity and mortality during the ordinary summer weather of our northern cities, while in the country districts the summer should be conspicuously the most healthful season. It has, in addition, been noted that infants do not do much worse in our southern states, where the cities are relatively small, with detached houses and plenty of shade out of doors, provided that the milk supply be .of good quality. The matter of milk inspection, in its many aspects, does not concern us here; we have therefore to consider mainly the question of fresh and pure air, which by itself will guide us readily and sufficiently in the selec- tion of a summer, resort for young children and infants. Nearly all our country places, except the very hot ones, are beneficial to infants, who thrive luxuriantly in localities where their elders pant with the heat and humidity. There are, however, some factors that may aid us in the choice between seaside and inland resorts, the question that perennially is brought to the attention of the family practitioner, and that he must solve in an intelligent manner. As we have already . considered a CLIMATIC MANAGEMENT OF NORMAL CHILD 237 large mass of climatological data concerning individual localities and districts, it remains for us only to generalize as to climate, and specialize as to the patient, and we surely ought to be in a position to select wisely and witb good reasons. • Seashore Resorts. During the child's first summer, the seashore meets the desirable indication of an even temperature. A good sea breeze, bringing the pure ocean air, tempers the heat of the day, and the fall of the thermometer at night is relatively very small. A rather high average temperature, as we have" said, offers no objection, and the somewhat sultry summer of Long Island and New Jersey seems to be the. very thing for young infants, superior to the very cool, sometimes almost raw, summer climate of eastern Maine and Nova Scotia. At the same time an excess of windy weather is to be avoided ; such places as Block Island are perhaps a little too much exposed; the infant must be kept in- doors rather frequently, even on some tolerably bright days; this seems like a waste of good opportunities. The sea fog is, of course, to be shunned; it increases in frequency toward sunset, and as we go northeastward, and furnishes another reason for preferring the Middle Atlantic Coast to that of northern New Englaifd; for this cause also, the entire Pacific Coast north of Santa Barbara is objectionable, not to speak of the very low temperature that prevails everywhere. Residents of the North Pacific States and the greater part of California cannot take their young infants to the seashore with advantage, but must select sheltered semi-inland locali- ties, where the violent ocean winds and fog rarely pene- trate. Among European coast resorts, those of France 238 THE CLIMATIC TREATMENT OF CHILDREN are unquestionably the best; the English and German seaside stations are rather chilly, those farther south too warm and usually malarious. During its second summer the infant no longer demands a high temperature so imperatively, and the cooler seashore localities may be chosen with as good results as those of the Middle States. In Europe the south coast of England and the Baltic coast of Germany are highly salubrious for older infants, while the shores of the North Sea, being more subject to damp winds and fogs, are better adapted to children past the age of infancy. The last remark also applies to the Middle and North Pacific Coast in our country, some parts of which are, as a matter of fact, too rough for all save the hardiest adults. Inland Resorts. The inland resorts best suited to very young infants are usually felt to be a little too warm by older persons; examples of these are the river valleys from the Merrimac to the Susquehanna, which are quite free from really cool nights during July and August, and experience a large number of rather hot days. In the second and third summer we may, there- fore, with advantage, select cooler situations, provided that certain precautions are taken in the avoidance of isolated peaks, which are apt to be relatively windy, and are often shrouded in clouds when the weather round about is fair. Deep valleys and especially hollows are very objectionable, as they are subject to dampness, sultry days with a sudden fall of temperature at night, heavy dews and early frosts. While under the head of ordinary inland resorts we include elevations up to three thousand feet, we must exclude a number of places CLIMATIC MANAGEMENT OF NORMAL CHILD 239 below this level from the treatment of very young children. Among these moderately elevated localities, where the average temperature in summer is below 62-64 degrees, and the nights are sometimes frosty in late August, we . may include the highest villages and hotels of our northeastern hills, and still more the moun- tain regions of northern and central Europe, such as the Scottish Highlands, and the upper levels of the Harz and Black Forest. These regions are too cool for chil- dren a year or two old, who may be deprived of many an outing on days that are raw and windy, but quite dry; every dry day on which a .child must be kept indoors is a day lost. With proper exposure, preferably on the south side of a gentle slope, the above-mentioned mean temperature is a pretty safe guide, but naturally summers differ somewhat, and a resort that is fairly mild in a sum- mer like that of 1901 may be very chilly in a season like that of 1903, the difference for July and August having been about five degrees in the northeastern states, and considerably more in the West. After the second year, when a mild degree of harden- ing may be advantageous, we may avail ourselves of the cooler inland stations, but a certain amount of indivi- dualization is in order. Robust children do well at these resorts, but delicate specimens require more care- ful handling, and it is advisable to keep them in a rather warm summer climate a year or two longer. It is true that climatic hardening, administered during the warm season, is a very mild form of physical training; this fact, however, must not invite recklessness, and it will generally be found that the child, that has undergone the least strenuous exposure to the elements, returns 240 THE CLIMATIC TREATMENT OF CHILDREN home in autumn in the best condition. Still, I would not be understood as favoring a regime of coddling with advancing years, and consider a mild form of climatic discipline one of our best means of educating the young organism to withstand the physical strain that will be- fall it in later life. A few years later, say after the age of five, the moderate amount of exposure involved in a stay in a really cool summer resort is almost imperative ; older children undoubtedly profit more by a few months' residence at> the cooler hill resorts than by being sent to warmer localities, especially at the seaside. Whether the cooler maritime stations, such as those of eastern Maine, are or are not as beneficial as the White Mountains or Adirondacks, is hard to determine, and individual idiosyncrasy undoubtedly plays- a part; my . experience, however, convinces me that the majority of children profit more by inland climates, for there is an excess- of dampness and fog at the colder seashore sta- tions; during warm spells there may be a few sultry nights even well to the northward along the coast, whereas uncomfortable nights, when blankets are a burden, are practically unknown at even moderate elevations in our northeastern mountains. Elevations. We have seen that an elevation above 3,000 feet is not contraindicated per se in infancy and childhood, but the temperature conditions at high levels are not often suited to young infants, so that these resorts are better reserved for the third summer and thereafter. Even then the European high Alpine re- sorts are rather too cool, the temperature averaging below 60 degrees even in July, and there is often a large number of chilly and rainy days. These disad- CLIMATIC MANAGEMENT OF NORMAL CHILD 241 vantages do not obtain in the greater part of the Rocky Mountain region; children tolerate the rather warm, but very dry and sunny days particularly well, and find the cool nights exceedingly refreshing; the necessary hypertrophy of the blood, shown in the increase of corpuscles and haemoglobin, is effected with relatively great ease in the youthful organism, being completed within three weeks without the manifestation of any noteworthy strain on the system. We must not fail to note, however, that the above remarks apply strictly to normal children; in a number of the less conspicuous chronic disturbances, the high mountain resorts are far from beneficial; the higher Alps, also, are adapted only to older children, who can be out of doors during the frequent spells of* rather autumnally cool weather. The nights in the valleys of the upper Alps are very apt to be damp, with heavy dews, and frost often attains a measurable thickness in the middle of summer, as I can testify from personal obser- vation. This sort of outing involves a fair measure of hardening, and cannot be recommended where there is any suspicion of a delicate constitution, or where the general nutrition is below par; it will be found that children thus afflicted experience considerable physical discomfort, lose sleep and become restless, so that latent neuroses are very apt to become manifest dur- ing or shortly after a summer spent under the stated conditions. Winter Resorts. In the selection of a winter resort for children it is well to set out with the understanding that no attempts at hardening should be made at this season. Even in climates that border on the tropics, the winter 242 THE CLIMATIC TREATMENT OF CHILDREN months are characterized by marked and relatively sudden temperature changes, frequent frosts and occa-. sional snow, save where the mean temperature is almost summer-like. It seems hardly worth while to transfer a child to a climate that differs from that of its native surroundings only in a moderate degree; transportation from Boston to Washington, for instance, affords merely a rise of some half-dozen degrees, without any note- worthy change of the climatic type. One point, however, in which temperature does not play a part, is well worth considering. For example, we see that the winter months in 1901 furnished 56 cloudy days at Buffalo, but not a single clear one, the other 34 being partly cloudy; whereas the same period at Atlantic City embraced 32 clear and only 22 cloudy days; the days with rain or snow numbered 79 at the former place, only 26 at the latter. A change from Buffalo to Atlantic City cannot but be beneficial, and the difference in temperature, seven or eight degrees, becomes altogether subordinate to the gain of 53 dry days, and a difference in cloudiness of thirty per cent. It is a fact that a number of points in the Lake Region afford young children hardly any good weather for an airing during the winter, and the extreme northwest coast is not much better in this regard, and in some respects worse, for the endurable light snows of the Lakes are there represented by drenching rains. Some of the points of northeastern Canada also suffer from bleakness, and the interior from New England to Indiana ranks only moderately high as to the number of fine and bracing winter days. With older children, therefore, say from two to six years of age, who are not suffering CLIMATIC MANAGEMENT OF NORMAL CHILD 243 from any distinct morbid condition, but still seem to require more fresh air and outdoor exercise than they can get at home, the moderately cold resorts of the Atlantic coast, from Long Island to Virginia, may be employed with distinct benefit. Apart from the consideration just noted, we need pay attention only to such winter climates as have a decidedly spring-like temperature and plenty of sunny days ; we shall see that readily accessible places fulfilling this requirement are not very numerous, but may begin with the best, and then consider those that are only tolerably good, but nearer at hand. Almost the only perfect winter climate for young children and infants is that of southwestern California; as stated before, it resembles the New York October, but is even a little brighter, with just enough rain to lay the dust, a few rather warm afternoons, and as many light frosts. At San Diego and Los Angeles the winter usually comprises about 45 clear and only 15 cloudy days; rain falls on 20, but generally for a few hours only. We see that even tender infants need be kept indoors only exceptionally, older children only when rain is falling. » The warmer stations of Arizona, even aside from the inferior accommodations, are hardly so good; the ex- tremes of temperature are greater and there is an ex- cess of dust. On the other hand, there are very few days indeed on which children of any age must be kept in the house, and older children are almost certain to derive benefit from a brief stay in this section, especially when a really dry climate is indicated for any reason. Among foreign resorts the south coast of Spain, 244 THE CLIMATIC TREATMENT OF CHILDREN Sicily and Algiers are not very inferior to southwestern California, but the accommodations and surroundings are not quite so good. For a very dry winter climate, middle and upper Egypt are perhaps rather better than Arizona. It is unfortunate that all these resorts of the first rank are removed from most of our great centers of population by a distance of from 2,500 to 6,000 miles, thereby involving a fatiguing trip and a high -cost of transporta- tion. We are therefore obliged to consider some places that offer a more or less imperfect winter climate,- and may begin with our very accessible southeastern states. The merits and demerits of Florida have already been fully discussed; we have noted that removal to the very warm, though changeable, winter climate of southern Florida requires extreme precautions with regard to a gradual return northward, which in the case of infants and young children should in no case take place before April, an intermediate station being selected for the early spring. From Charleston to northern Florida we have a winter climate too much like the northern April to be recommendable, unless a certain amount of hard- ening is an object, as is the case only in older children who are fairly robust. For a visit to our entire South- east, it is necessary to take along summer clothing, as well as quite heavy winter wear, and frequent changes from the one to the other are required in the more erratic seasons, as March and June weather alternate. It is thus seen that the climate of this region has but a limited applicability to childhood, and is defective in many respects. As to the Upper South, the general indications are CLIMATIC MANAGEMENT OF NORMAL CHILD 245 similar to those of the Middle Atlantic Coast, but the winter in the former region is hardly so sunny, and more subject to excessive temperature changes, therefore affording no advantages over the latter. The sheltered localities in the southern Alleghanies, however are of some value, and we may say a few good words for the pine belt of the Carolinas. This entire section, like the Middle Atlantic Coast, is suitable only for older children, who either are quite robust, or only require toning up; and we may generally regard these resorts as a sort of makeshift, balancing their accessibility against their unquestionably second-rate merits. The last remarks apply equally to the Atlantic Coast of Europe, which is not very warm, though quite equable, and altogether too cloudy and stormy. ' Good results are said to be achieved so far north as the North Sea resorts of Germany ; they have indeed the mildest winter of that country, the temperature being similar to that of Cape May, but far less changeable. It is evident, however, that in these cases convenience of access has been deemed a compensating feature. The stations on the southern slope of the Alps belong to the same category, there is still a great deal of rather cold weather and some snow, atoned for, it is true, by ample sunshine and the rarity of sudden changes. Certainly the best resort among those of the second class is the Riviera, especially from Nice to Genoa. The temperature is not particularly high, but so even that neither summer clothing nor the heaviest wraps are likely to be called for. This climate involves the mildest possible degree of hardening without any enervation, and is too cool only for the extremely young and delicate, 246 THE CLIMATIC TREATMENT OF CHILDREN who have to be handled with care in the best winter climates. Far inferior to this favored strip of country are the popular resorts of the Italian peninsula, such as Naples and its surroundings, Rome, which ranks still lower, and Florence and similar places, which are hardly worth considering at all. Stations subject to the mistral (or bora) are to be avoided entirely; they are trying to the most robust adults, and invariably harmful to chil- dren, who might as well remain at home to endure the northwest gales and equally bright sunshine of the New York and Boston winter, and have their home comforts when obliged to remain indoors. The colder winter resorts, such as. the Rocky Moun- tains and the hill country of central Europe, still more such subarctic winters as prevail in the Adirondacks, White Mountains, Upper Mississippi Valley, and Canada, are not suited to children at all. The dry, sunny, and only moderately cold winter of Colorado is perhaps the least objectionable of these, and may benefit older chil- dren, near the age of puberty, who are already endowed with some robustness; the other resorts mentioned are, however, not suited to our purposes in any save excep- tional cases; experience drawn from the observation of adults must not be allowed to guide us in the treat- ment of the young, for the reasons previously given and reiterated. Spring Resorts. The principles guiding us in the selection of winter resorts apply also to early spring; the uncertainties of the weather in March, northward also in April, are, as before noted, even more dangerous and trying than the more or less uniform, if variable, cold of winter. Such subtropical regions as southern r/. The Advance op Spring (Mean Temp. 54°) CLIMATIC MANAGEMENT OF NORMAL CHILD 247 Florida and upper Egypt become too warm by the end of March, but most of our American winter stations, as well as those on the Mediterranean, are really at their best in early spring; semi-southern localities, such as Asheville and the Italian Lakes, are ideal April resorts, whereas such exposed marine situations as Atlantic City suffer somewhat from cool and damp sea breezes, though they have a high percentage of sunny days. Children who have spent the winter in the extreme South are best kept at an intermediate station during March and early April, for the benefit of California or Florida is sure to be partly lost by a too early return to our more northerly cities, even those so far south as Washington and St. Louis; New York City sometimes does not obtain real spring weather until late in April, and the Lake Region and New England until well on in May. In the accompanying map the average date of the arrival of settled warm weather is indicated, the mean temperature of 54 degrees being taken as the standard. Note the retardation of spring on the northeastern coasts, along the Lakes and in the Alleghanies. The extreme variation from the dates given is about two weeks, but in general it is remarkable how closely they apply, year after year, especially in the North; in Chicago, for ex- ample, this average temperature can be counted on, with almost absolute certainty, to be attained in the first half of May; in Philadelphia, in the latter half of April. It is not easy to strike a balance between the respective merits and defects of seaside and inland resorts in spring. As a rule, the marine localities have a larger proportion of clear weather, but suffer from strong and damp sea breezes, with fogs and low temperatures, in the late ZZSoj 'My K •Se-^ 111. iw Europe are dry enough for our 276 THE CLIMATIC TREATMENT OF CHILDREN purposes, provided remoteness from large bodies of water be secured. In this country Mt. Clemens, Mich., in spite of some little exposure to lake breezes, seems to rank highest; the various springs in central New York are perhaps not quite so good. The climate of Hot Springs, Va., is already a little too warm in midsummer, and Hot Springs, N. C, and the resorts of southern Indiana are intolerably hot at that season. The seaside and the Great Lakes are distinctly to be avoided, and even small lakes, in a thickly forested region like the Adirondack Mountains, are the cause of much dampness at night. Densely wooded tracts are always excessively moist after rainy spells, and deep valleys are subject to night fogs in quiet weather, even if the days have been quite dry. Open plateau sites and mountain slopes, especially such as face south and west, where the drainage of both water and air are good, are far more desirable. Among inland European resorts our choice is even less limited; almost all those north of the Alps, less than 3,000 feet high, have a fairly good summer cli- mate, and at the various bathing places the medical attendance is far superior to that found at most of our spas. Without referring more than casually to certain practices at such places as Hot Springs, Ark., many of our best resorts are frequented by practitioners of in- ferior caliber; it is one more instance to be added to the long roll of wasted opportunities on this continent. Meanwhile our invalids spend millions of dollars in Europe to obtain what should be quite as available on our side of the Atlantic. . Summer resorts with afternoon temperatures running CONSTITUTIONAL DISEASES 277 much below 70 degrees are to be avoided, but only the higher Alpine stations are objectionable on this account; the relative inability to take exercise must be taken into consideration. Enervation should be guarded against carefully; it is difficult to avoid, in view of the inactive life of rheumatic patients, and the only sure method is to avoid places and seasons with an aver- age day temperature much above the indifferent point, somewhere near 75 degrees, unless there is compensat- ing coolness at night. In our eastern states few inland stations south -of New York and New England fulfill this requirement in July and August; Europe is much better equipped in this regard, as every locality north of the Alps, including even the ■ warmer valleys, is available. The reader will naturally understand that any such complications, as valvular heart disease or chorea will call for a material modification of the above recommen- dations, and will especially contraindicate the high alti- tudes in very many cases. For precise details we must refer to the paragraphs that treat of those affections; the relatively simple rules that guide us in the manage- ment of uncomplicated rheumatism now give way to a far more involved situation. The seashore is almost universally deemed unsuitable for rheumatic patients ; still a few authorities, among them Yeo, claim to have observed improvement in cer- tain very chronic forms of rheumatism at marine sta- tions, and also look with favor on the employment of warm sea- water baths. With regard to the climate, the exception Yeo refers to is in a measure only appar- ent, for, as we well know, certain seaside localities, like 278 THE CLIMATIC TREATMENT OF CHILDREN southwestern California and some Mediterranean points, are drier in winter than the near-by inland districts; this does not by any means apply to coastal climates every- where, nor at all seasons. Again, we must remember that there are good and bad seasons at the seashore as elsewhere; even so moist a region as the south shore of Long Island may be fairly dry in exceptional years, when land breezes are unusually frequent. It will, however, be found a safe rule to avoid the coasts, with the possible exception of the two mentioned above; a really oceanic atmosphere is certainly not good for the victims of rheumatism in any form, the sea breeze and fogs being ' decidedly harmful. Saline baths can be given with nearly equal ease and greater benefit at an inland resort. The Hcemorrhagic Diseases. Under this heading we £re obliged to throw together a series of quite unrelated affections, which, nevertheless, require similar manage- ment with regard to climate. Purpura rheumatica calls for the same treatment as the other rheumatic diseases, only chronic cases, of course, coming under consideration here. Scurvy is so amenable to specific treatment that climatotherapy is quite subordinate, and applies only to the secondary anaemia. The curious affection known as paroxysmal hemoglobinuria, however, is worthy of a few detailed remarks in this connection, since it is, to a certain extent, a condition depending upon climatic influences. To understand this more- fully, it will be necessary for us to consider some etiological points. Attacks of paroxysmal hsemoglobinuria seem to de- pend upon the combination of two factors, namely, pre- disposition, and exposure to a low temperature; various CONSTITUTIONAL DISEASES * 279 constitutional diseases may come under the former head, notably congenital syphilis; in many cases, how- ever, the predisposing cause is not ascertainable. As to the exciting cause, the evidence is ample; thus, among recent cases, Homberger 1 reports a boy of ten years, who developed an attack from falling into the river in the cold season; Burckhardt 2 showed that cold alone could bring on a spell, but that constriction of a limb increased its severity. Chvostek 3 differs from the pre- ceding in considering the coincidence of cold and traumatism (in the broadest sense) essential, whereas Donath 4 considers a low temperature alone sufficient. Cold, or at least a chill, seems at any rate to be the essential exciting factor. I do not think it advisable, in this connection, to enter on a discussion of the more minute pathology of this curious and somewhat uncom- mon affection, especially as the authorities have not as yet come to a definite conclusion; the reader is referred to the. last three articles for further information. Sufficient has been said to furnish the climatothera- peutic indication, namely, to send the patient to the mildest and most even climate available, stopping just short of the tropics in winter, and such very warm and moist regions as our southern states in summer. The drier heat of the Mediterranean countries and our South- west is not very enervating, and may result in benefit. Yeo recommends Madeira, which is equable, and not too enervating in summer; Bermuda is similar in winter, 1 Zeitschrift fur klin. Medizin, vol. 53. 2 Jahrbuch fur Kinderheilkunde, vol. 57. 3 Ueb'er das Wesen der paroxvsmalen Hamoglobinurie, Leipzig u. Wien, 1894. 4 Zeitschrift fur klin. Medizin. vol, 52, 280 THE CLIMATIC TREATMENT OF CHILDREN but the summer is certainly too hot and moist; his recommendation of the West Indies in winter is to be accepted cautiously, but the relatively cool and dry stations, such as the hill country of Jamaica, north- western Cuba, the uplands of . Porto Rico, and the Bahamas,, may be tried, at least for one season. .Key West, outside of the tropics, but with practically the winter climate of Havana and Nassau, has a particularly even temperature, except when a norther springs up, and the rainfall is very small from December to March. In summer, the lowlands of the Middle Atlantic States, excepting the hottest places, such as the lower Delaware Valley, also the resorts of the southern Alleghanies, afford a good climate; the best stations of California, away from the immediate coast, but not too far inland, are excellent for this purpose, Los Angeles and its vicinity may safely be recommended. In Europe, I would select the southern slope of the Alps, including the Lake of Geneva and southern Tyrol, but avoiding such very low-lying stations as Riva, which has an altitude of only 300 feet, and a July temperature like that of central New Jersey and the lower river valleys of Pennsylvania. Among foreign winter resorts, Ma- deira, as stated, and upper Egypt are by far the best; in this country Florida leads, southern California comes next, all the others are inferior. Amyloidosis. Amyloid degeneration of the various cellular organs usually follows chronic suppurative processes in children, rarely congenital syphilis (Osier), in contradistinction to its frequent sequence to acquired lues, and is a subject for climatic treatment in an exquisite degree. The prognosis of amyloidosis is not CONSTITUTIONAL DISEASES 281 quite so unfavorable in the young, as in older subjects, and a consistent attempt with climato therapy, the only procedure of any great value, is always well worth the making. The most important, and the majority, of these cases follow in the train of a chronic tubercular affection, usually of the bones; the chief interest lying in the cir- cumstance that the detection of even an early stage of this serious degenerative process calls for an immediate abandonment of the hardening regime that is usually so essential a feature in the management of tne primary disease. The victim of amyloidosis urgently demands a warm and dry climate; the brisk sea and mountain air that so greatly benefits the uncomplicated tubercular osteitis, becomes exceedingly harmful when this com- plication has developed, and the patient now requires prompt transfer to a milder climate, though that may have a less favorable action on the underlying process. The organs in which amyloidosis is regularly first detected, and in which it is of the most serious conse- quence for the organism as a whole, are the kidneys; the clinical picture of amyloidosis, in fact, closely re- sembles that of a chronic diffuse nephritis in its more dangerous stages. This happens because amyloidosis is rarely detected before it is well advanced, its symp- tomatology being largely masked by ■ the underlying condition and the albuminuria which is so common in chronic febrile affections like tuberculosis; a previously existent nephritis, of mild degree and not seriously regarded, naturally aids in masking the earlier stages of amyloid degeneration. The treatment of this affection, as would be expected, 282 THE CLIMATIC TREATMENT OF CHILDREN approximates closely to that of the severer forms of chronic Bright's disease; progress is therefore slow, so that the curative process, if at all attainable, is likely to extend over a series of months or even years. This may not appear very important, inasmuch as the primary affection is also excessively chronic, but we must bear in mind that only very few climates are really beneficial to these subjects, and that the prognosis is dubious at best; thus enormous sacrifices may be imposed on the patient's family, and turn out to be fruitless after all. The only method that really commends itself is a stay at an appropriately situated sanatorium for a year or more, an expedient within the reach of only the very well-to-do in this country, where sanatoria for poor children are almost non-existent. "They order this matter better in France." For the various climates suitable to the treatment of amyloid disease the reader is referred to the paragraphs on chronic nephritis. The recommendations there worked out in detail apply here even more forcibly, the only very important differences being in respect to the duration of treatment and, unfortunately, too often in the prognosis. Congenital Syphilis. Severe cases of hereditary syphilis may derive great benefit from a change of climate; the guides we should follow are symptomatic. Thus, the management of the individual case will vary according to whether a severe anaemia of the von Jaksch type, or- intractable gastro-intestinal symptoms, or a state of lymphatism, or visceral degeneration dominates the picture. While this disease, in the adult, is conspicu- ously amenable to specific medication, this is true to a CONSTITUTIONAL DISEASES 283 far less degree in children of a tender age. Babies, in particular, often thrive but poorly in spite of most intelligent mercurialization; even if they gain some in weight and become free from all demonstrable lesions, they often remain subnormal in health and subject to a recurrence of symptoms. In addition, some of the worst cases are not very tolerant of the specific drugs ; anaemia a'nd other forms of malnutrition are apt to develop and menace the patient's life very seriously. There is therefore a considerable proportion of syphi- litic infants and children who require tonic treatment quite as much as mercury and the iodides, and one of our best tonic measures is removal to a temperate cli- mate. The best temperature for the winter is as low as is consistent with a life out of doors, higher, therefore, in the very feeble than in those in a state of fair nutrition; in this matter the physician may be called upon to employ no little judgment. In the warmer months the seaside has long been regarded as the sovereign remedy, including warm salt baths for infants and cooler ones for older and more robust children. For the latter the milder mountain resorts have hardly received their due meed of attention, and I think they merit a more extended trial than they have had hitherto. Older children, in whom moderate general malnutrition and anaemia are practically all the lesions that concern us, often require considerable toning up; I would not hesitate to send them to the more bracing resorts of the Alps or Rocky Mountains, or the colder hill stations of our northeastern states. Malaria. Although so exquisitely a climatic disease, malaria is only indirectly amenable to treatment by a 284 THE CLIMATIC TREATMENT OF CHILDREN change of air. In the direction of prophylaxis, the selection of a suitable climate is of course paramount, but in an established case departure to a non-malarious region has more effect on the secondary manifestations, such as the anaemia, than on the protozoa in the blood and viscera, which must be combated with quinine and arsenic in the usual way. So slight is the direct curative effect of a cool climate on the disease itself, that the mere trip to such a region may bring on an attack where the affection has remained latent, the exciting cause probably being a slight chilling on a cool night; it is well known that paroxysms are apt to be provoked by exposure to cold or wet. Nevertheless, our first move in the management of a case of malarial fever or masked malaria, aside from the specific medication, must be removal to an immune region, on this continent any- locality with an average July temperature below 66 degrees; in this way, at any rate, we guard the patient against reinfection. As to eradication of the disease, we can hold out no promise as the result of such a journey; the total destruction of the parasite must, apparently, be effected by drugs in most instances; the action of climate is merely auxili- ary, but I doubt if it can be considered specific in any sense, so far as a once infected individual is concerned. The spread of the disease to uninfected individuals is, of course, obviated by recourse to an antimalarial climate. Malarial cachexia is also a fit subject for medical climatology, but the indications here are quite different, being in general those discussed under the title of nutri- tional diseases. In no case, however, may we select a CONSTITUTIONAL DISEASES 285 region not absolutely free from the malarial parasite; some of the very mild winter climates, notably that of the Florida peninsula, that might possibly be chosen for extremely debilitated cases, with marked hepatic and splenic enlargement, are therefore to be rejected. In mild seasons, there is some malaria in the region named throughout the winter, for, as previously noted, killing frost visits southern Florida only about every third year, and then for only a day or two at a time. Otherwise, the principles laid down for malnutrition and severe anaemia hold good; the precise application of climato- therapy to the individual depends on the symptomatic indication. CHAPTER VI VISCERAL DISEASES The climatic treatment of disease in any single organ or group of organs usually involves a careful balancing of the relative importance of the local lesion on the one hand, and the patient's general condition on the other; only in exceptional cases are we called upon to direct our treatment to any one symptom. This is, of course, inevitable, for climatotherapy, as already stated, is so general a method, that its strictly local application is impossible, and its effect on the body as a whole must always be kept in view. The importance of maintaining this attitude is sufficiently great to warrant its repetition here, even at the risk of appearing wearisome. There are, however, a few exceptions to this broad rule, where certain climatic affections are concerned; we may add that these constitute about all the instances in which acute organic ailments come within our scope. In visceral disease, in general, the domain of climato- therapy is almost limited to chronic affections, nearly all of which are, however, included; it may be said, without exaggeration, that there are few of them that cannot be ameliorated by an appropriate climate; in a considerable number all other therapeutic procedures become of minor consequence. It is, for this reason, not remarkable that the present chapter, in spite of extreme and possibly excessive condensation, is rather 286 VISCERAL DISEASES 287 long, merely because of the very wide range of subjects presented for discussion. DISEASES OF THE UROPOIETIC SYSTEM Albuminuria. The occurrence of albuminuria without any demonstrable renal lesion is now quite generally accepted; it is variously designated cyclic, orthostatic, or adolescent, all of which terms are more or less descrip- tive of the circumstances under which it is encountered. In addition, many persons develop this disquieting symptom after excessive muscular exercise or very cold baths. As cold bathing plays an important role in the hardening regime, as well as in general physical thera- peutics, a few words on this phase of the subject will not be amiss. Rem-Picci 1 has made a series of investiga- tions, on adults, it is true, which show that albuminuria may follow an immersion of fifteen minutes in water at 60-68 degrees, and a three-minute dip at 54-56. In robust persons, who did not excrete albumen after warmer baths, the albuminuria was transitory, disappearing within twenty-four hours; we cannot help thinking, however, that frequent repetition of such baths may sometimes result in a permanent condition of the cyclic or orthostatic type, if not true renal disease. The same apprehension exists in cases where albuminuria appears after violent exercise, as indulged in by athletes; here also we may justly dread the eventual development of a chronic disorder. At this point it can do no harm to remind the reader of the series of animal experiments detailed in a previous chapter, in which chilling the surface of the body plays a leading part in causing albuminuria, and to recall the 1 II policlinico, 1901, No. 53. 288 THE CLIMATIC TREATMENT OF CHILDREN relatively feeble resistance of children to adverse influ- ences of this kind. If we omit such albuminurias as are altogether transi- tory from present consideration, I feel that we are bound to agree with Senator 1 that we cannot exercise too much caution in regarding the remaining cases as compatible with absolutely normal renal tissues. Surely, it is not a pure coincidence that cyclic or orthostatic albuminuria is particularly frequent in the train of scarlatina and diphtheria, and no experienced practitioner will be mis- led by the fact that the infectious disease may have preceded the first positive demonstration of albumen by months or even years. It is sufficient for us to remem- ber that chronic nephritis may develop most insidiously, escape observation during its early stages, and finally be revealed quite casually in the routine urinalysis which the physician is in duty bound to make periodically for every one of his patients. Continued and precise investiga- tion will show that these patients quite regularly excrete a trace of albumen during the waking hours, especially if muscular exercise is freely indulged in, though the urine passed on rising is normal. If such a patient pre- sents, in addition, what the experienced practitioner learns to recognize as the nephritic habitus, the case should be regarded as highly suspicious with respect to the presence of a true organic lesion. In this connection it is both interesting and important to note the obstinate persistence of these traces of albumen; they are pretty certain to continue for months, and extension of this abnormality over a still longer period makes the eventual diagnosis of true chronic nephritis almost unavoidable. 1 Nothnagel, specielle Pathologie u. Therapie, vol. 19, part 1. VISCERAL DISEASES 289 In view of the above array of facts, the treatment of cyclic or orthostatic albuminuria becomes identified with that of chronic nephritis. We may indeed go further, and insist on the relatively greater importance of properly managing the former; for, if it is desirable to reduce so dangerous a lesion as. nephritis to comparative innocuousness, even when there is no prospect of a real cure, it is infinitely more necessary to wage an active campaign against what may be its early stages when the prognosis is very much more hopeful. As to the precise methods, however, we may content our- selves with those to be recommended for nephritis as fully established; the differences in managing albumin- uria alone are quite trivial, and will be touched upon below. Nephritis. Acute and subacute nephritis are empha- tically subjects for home treatment, but the chronic forms of Bright's disease form an attractive and profit- able field for clima to therapy; there are indeed few dis- eases that are so likely to undergo improvement upon removal from a severe to a more genial climate. The main indication is already clear from our discussion of albuminuria; it consists in the avoidance of cold, espe- cially when combined with dampness. The choice of a warm and dry climate is not, however, limited to the above-outlined aims, which are in a measure prophylactic; it is also intended to favor a species of physiological readjustment, which has always invited the attention of therapists. In treating nephritis, it has been for centuries a recog : nized principle to spare the diseased organs as much as possible. , This indication is met most readily by 290 THE CLIMATIC TREATMENT OF CHILDREN throwing as much of their work as possible upon those excretory channels that can vicariously assume a portion of their duties. Although the kidneys, as is now generally accepted, do not constitute mere filters, yet, in a certain broad sense, the filtration of the blood is their chief function; their contribution to metabolism is less essen- tial, though we must admit that certain excreta are disposed of only with difficulty through the several vicarious agencies. Apart from the utilization of the intestinal tract, which does not concern us here, our main reliance is on the glandular- apparatus of the skin, whose activity is accelerated by external warmth, and almost in abeyance in a cold medium. We therefore appropriately employ warm clothing, hot-air and hot- water baths, besides promoting diaphoresis in every other way. Warm weather is the mildest and most con- tinuous diaphoretic known; its dosage can be gauged accurately by observing the thermometer and regulating exercise, and we can safely push this treatment to the verge of enervation; we must, however, take pains to avoid a high percentage of atmospheric humidity, as this in turn tends to check perspiration. Thus, in prescribing a warm and dry climate in the treatment of chronic nephritis, we meet the sparing indication exceptionally well; we may now pass on to details. In regard to the choice of a first-class winter climate for patients suffering from this disease, especially for such subjects as also, for any reason, require absten- tion from muscular exercise, most -of the authorities do not hesitate to recommend what Leonard Williams calls " relaxing" climates, meaning thereby such resorts as Madeira, southern Florida, and the Bermudas, which VISCERAL DISEASES 291 are decidedly warm and rather moist during the winter months. Moisture is, however, always objectionable, and such less warm, but dry, regions as Egypt, southern Arizona, and the Mexican plateau are, in my opinion, decidedly preferable. The southwest of California also takes a deservedly high rank; Algiers, Malaga and Sicily are nearly as good. With regard to California, I would refer especially to a recent communication by Edwards, 1 in which a modest claim for curing only cyclic and orthostatic albuminuria is made, but from which we are bound to conclude that cases of true chronic nephritis, following the infectious diseases, are at least brought to a standstill, with the total disappearance of albumen from the urine. The warmer portions of our South Atlantic States, as well as the Riviera, must be regarded as somewhat inferior ; both of these sections occasionally have very bad weather in winter, and are more suitable to the uncertain transitional period of early spring. Perier 2 does not hesitate at a general condemnation of the French coasts in the treatment of nephritis and albuminuria ; the material collected by the French ob- servers is sufficiently ample to justify any standpoint they may take on resorts so familiar to them; in any event, a careful climatic survey of France seems to limit the scope of its shores, in nephritis, to the thirty-mile strip on the Riviera, from Cannes to the Italian frontier. It therefore goes, almost without saying, that even. our pleasantest northern resorts, as well as the most favored stations of northwestern Europe, are not to be considered at all in treating such patients during the cold season. 1 Archives of Pediatrics, June, 1905. 2 Annales de medecine et de chirurgie infantiles, 1901, p. 479. 292 THE CLIMATIC TREATMENT OF CHILDREN In the management of this group," it is also very im- portant not to permit too early a return home; as a valuable guide I would recommend the map, previously given, which shows the progress northward of settled spring weather. As the farther South grows too warm, an intermediate station may be chosen, to bridge over the period of transition; there are many excellent semi- southern inland stations on the southern slope of the Alps and in our southern Alleghanies. This precaution, reversed, is far less important in autumn in this coun- try, for reasons before stated; we can afford to wait until really cool weather sets in, and then transport the patient to the far South at once. In summer, the whole matter is very much simpler. The best results are obtained at fairly warm localities, avoiding intense heat and a humidity in excess of 75 per cent. The best mean temperature is between 68 and 72 degrees, depending largely on the age of the patient and his capacity for exercise. Speaking gener- ally, inland resorts are best, for the fogs and damp winds of all but the warmest seaside stations are objectionable. On the other hand, places not far from the coast, but free from the aforesaid disagreeable features, with the temperature still somewhat equalized by oceanic influ- ences, may safely be recommended. Southern New England and western Europe afford many such resorts, neither too cool nor too warm, with about the right pro- portion of humidity and a moderate rainfall. The very dry climates, such as that of the Southwest, may be quite as beneficial, but there the dustiness of the summer is an objectionable element. Most of the Californian resorts are either too hot or too cold and damp at this VISCERAL DISEASES 293 season; in general the northeastern states will be found better from June to September or October. As to high altitudes, the consensus of opinion is ad- verse. Edel 1 goes into the subject at some length, and attributes the unfavorable results at great elevations to an increase of the blood pressure. It is true that the blood pressure is already excessively high in advanced cases of chronic nephritis, but this is a more serious matter in adults, who are apt to be suffering from a concomitant arteriosclerosis, and therefore dare not run the risk of a further strain on the arteries than in chil- dren, whose renal affection is likely to be comparatively recent. It is worth while to note that this same author makes a counter-recommendation, in that he deems the moderately high Alpine resorts well suited to the treat- ment of mere cyclic albuminuria. Now, we have seen that it is quite impracticable as well as inexpedient to draw a line between simple albuminuria and the more insidious forms of chronic nephritis; when, therefore, Edel says that the increase of arterial pressure at high altitudes actually benefits the former, he seems to place us in a sort of dilemma. The matter is, however, not so confused as appears at first thought, and quite suscepti- ble of explanation; the trouble lies, once more, in undue reference to children of the observations made on adults, often beyond the prime of life. Edel's standpoint is quite acceptable, if correctly interpreted; it is unques- tionably true that recent cases of nephritis, in which secondary fibrosis has not yet set in to any note- worthy extent, possibly also the early stages of the large white kidney, and naturally mere albuminuria without 1 Munchener medizinische Wochenschrift, May 10, 1904. 294 THE CLIMATIC TREATMENT OF CHILDREN demonstrable renal lesions, may do very well at moderate elevations. The wisest procedure consists in exercising a consider- able amount of conservatism in regard to sending chil- dren with Bright' s disease or albuminuria to mountain resorts; in any event, it is well to limit the altitude to 3,000 feet, save where the patient's former residence has thoroughly habituated him to a low atmospheric pressure. Therefore, children native to the middle Rocky Mountain region, who give evidence of one of these affections, may frequently be permitted to remain at home during the summer months, the more so as the temperature and humidity conditions there are of the very best. In winter, however, it is undeniable that a milder climate is far more beneficial. With the exception just mentioned, the higher eleva- tions are, in almost every case, too cold for nephritic patients, and usually also too damp ; in the mountains of central Europe I should certainly set the limit at 2,000 feet, save in carefully selected cases. The same limit may be applied quite generally in the northern Alleghanies; on the other hand, Edel's recommendation for the mild types ought to obtain the benefit of a trial in the higher southern Alleghanies; Asheville and Hot Springs, Va., are more than sufficiently warm, and I would not hesitate to make the suggested experiment in the presence of mere albuminuria. It is sufficient, in this connection, to repeat that the genuine contracting kidney is a curiosity in childhood, and that the secondary contracting kidney has rarely had time to develop; general arteriosclerosis is likewise very uncommon in early life, though cases have been VISCERAL DISEASES 295 reported in connection with congenital syphilis. As a rule, the main objections to moderately high altitudes fall away, when we consider the young subject exclu- sively. The practitioner, as already stated, cannot exercise too much caution with regard to the abandonment of the very mild regions in favor of such as are more bracing, or the home climate. No change of consequence should be ventured upon until it is quite settled that the disease has reached a standstill; when that has been satisfac- torily ascertained, the cooler climates have a field of usefulness in the way of a renal test, to determine the probability of a more or less permanent cure or ameliora- tion, before the patient returns to his former life. The worst cases seem to demand permanent residence in a mild climate, unless we wish to invite an early relapse; It should hardly be necessary to add that, even when very mild maritime resorts have been selected, sea baths are contraindicated in renal and albuminuric cases. The ocean, in summer, rarely has a temperature much exceeding 75 degrees, even in subtropical latitudes, and in winter, at the warmest stations mentioned, it is usually very much colder. On the other hand, the indoor ad- ministration of sea-water baths at 92 to 95 degrees is of great benefit, for sea water,, containing four or five times the physiological (isotonic) proportion of salts, powerfully stimulates cutaneous osmosis, promoting the excretory functions of the skin in an effective, yet not excessive degree. The "Surgical" Kidney. The suppurative renal af- fections, so far as they do not fall within the scope of the operative surgeon, are quite certain to derive some 296 THE CLIMATIC TREATMENT OF CHILDREN benefit from the somewhat relaxing treatment just recommended for nephritis and albuminuria. Chronic pyelitis and pyelonephritis are far more apt to run a favorable course in a decidedly warm climate than else- where, on the same principle of sparing the renal tissues as far as possible. Uncomplicated renal lithiasis is not, to any extent, a subject for climato therapy; but the combination of calculi and suppurative nephritis is quite frequent, at least clinically, and here we must follow the main indication, offered by the inflammatory process, so far as physical therapeutics are concerned. Even more than in ordinary nephritis is time an element in treatment, and the attendants of the child must be pre- pared for a stay in warmer latitudes, extending over the entire cool season, or it may be, a year or more, rapid cures being entirely beyond the realm of possibility. In many of these cases there is manifest advantage in combining treatment with one of the alkaline or earthy mineral waters with suitable measures of climatotherapy. Vichy in France, and Neuenahr and Wildungen in Germany, to select a few examples, are admirably adapted to this plan. It is doubtful if any American springs are equally good, at any rate there has* been no intelligent study made in this direction. Unfortunately, this combined treatment, at the European spas, is feasi- ble only during the warmer months, for these climates are all far too cold and moist from October to April; as a matter of fact, visitors are not. even expected at these resorts during the cold season. Hirsch 1 claims that the climatic theory of renal lithiasis, which is the commonest underlying cause of 1 See bibliography. VISCERAL DISEASES 297 suppurative disease of the renal pelvis, is not founded on fact; this affection is indeed exceedingly common in lower Egypt and in Italy. Notwithstanding, it remains true that practically all these cases do better in warm and dry climates than elsewhere, and that they are apt to fare rather poorly in marine or inclement localities. The indication of warmth is far less imperative in the cases of simple renal lithiasis than in those in which a suppurative process has supervened; in the latter it is the main point to be considered in treatment. The prudent practitioner will naturally be very re- served in giving a prognosis for these cases, especially with regard to the element of time. Nevertheless, al- though the prolonged course of these affections makes the benefit of climato therapy somewhat conjectural, we always seem to feel that these patients would not have got on so well at home. In contradistinction to the suppurative affections of the kidney, mere hydronephrosis rarely calls for climatic treatment. The advantage of a change of air, apart from its general beneficent influence, is very doubtful, and, in non-operative cases, the choice of residence is not very material. Operated cases, of course, recover strength more rapidly in a favorable climate, the same as other convalescents. Diseases of the Bladder. Climato therapy plays rather a minor role in vesical diseases, but removal to a milder climate will often be highly beneficial in cases of chronic cystitis. Some care is, however, advisable in adopting this plan of treatment, in view of the tendency to a higher concentration of the urine in warm weather, caused by the increased elimination of water through the skin. 298 THE CLIMATIC TREATMENT OF CHILDREN When the urine attains a high specific gravity, it is apt to increase the vesical irritation, and thus neutralize some of the improvement to be expected in a mild climate. It is therefore wise to exercise some discretion, and avoid localities where the day temperature rises much above 70 degrees; in winter, merely temperate regions, such as California and the Riviera, as well as the South Atlantic States, are best in every way; in summer, we should select the moderately cool and moist inland resorts, avoiding the high and cold .mountain stations, as well as arid regions. The observations on mineral springs, made a few pages before, apply here with special force, for the alkaline waters are of the highest value in these affec- tions. It is a curious and inexplicable fact, that equally good results' are never obtained from the same waters when taken at a distance from their source, though they are of some value even then. The treatment of enuresis belongs, more appropriately, to the section on nervous diseases, but, apart from the undeniable neurotic element, vesical irritation is often an important factor, especially in such forms as are diurnal and associated with pollakiuria; the climatic indication here is similar to that of manifest cystitis. In the purely nocturnal type of enuresis the neurotic element undoubtedly predominates, but these cases may also be benefited by a similar course of treatment; this affection can, however, be discussed to better advantage under the heading of nervous irritability, of which it is a rather typical manifestation; anatomical lesions of the urinary tract are usually quite absent in purely noc- turnal enuresis. VISCERAL DISEASES 299 DISEASES OF THE DIGESTIVE SYSTEM The interrelation between diseases of the alimentary tract and climatic conditions obtained full consideration in the first and fourth chapters, where the prophylactic value of climatotherapy in this group of affections was made evident. Owing to local causes, the study of this branch of our subject has centered largely in certain American cities; hot summers and sanitary neglect, either of which might have been tolerated by itself, in combination had become 'irresistibly fatal to infants and very young children, and the amelioration of hygienic deficiencies, by means of the inspection of milk and the improvement of the tenements, was taken in hand with some vigor. But, as previously noted, progress in this direction has certain well-defined limits, set by unfavor- able climatic and housing conditions which, of course, cannot be obviated ; within these limits the prophylactic measures just mentioned are attended with reasonably good results. When, however, gastro-intestinal disease has actually set in despite all precautions, removal to a better climate is our main resource. For our purposes, the topic of digestive disturbances centers on the presence of diarrhoea, and the best manner of proceeding with our subject is to divide it into the two sections of acute and chronic diarrhceal diseases. The anatomical picture, be it a mere indigestion, a bacterial intoxication, or an entero-colitis, is relatively unimpor- tant so far as climatotherapy is concerned, and chiefly affects the duration of treatment and the prognosis, the methods being the same for all. 300 THE CLIMATIC TREATMENT OF CHILDREN Acute Diarrhoea! Diseases. Since a high atmospheric temperature and humidity are the prime factors in pro- ducing acute diarrhoeal disease, the obvious indication is removal to a locality that is cooler or drier, preferably both. In the case of the children of the well-to-do, this is a comparatively easy matter, and a few days at a cool seaside or mountain resort will almost invariably work wonders. The distance traveled need not always be great, and with badly exhausted children, who do not bear railway transportation well, this is a matter of some little consequence. Even in the suburbs of cities, the night temperature is three to four degrees lower in sum- mer, and in the actual country districts there is a differ- ence of seven degrees and more at night in clear weather, though the day temperature may not be any lower. Thus the daily range in New York City, in July and August, is between 66 and 81 degrees, whereas among the low hills of Westchester County it ranges from 59 to 81. At the seashore the nights are not so much cooler than in town, but the sea breeze cuts down the afternoon temperature, so that the south coast of Long Island has a daily range from 64 to 76 degrees. In the former region the humidity is a little lower than in the city, in the latter a little higher; the chief gain is in a lower tempera- ture and purer air. It is, of course, better, whenever, practicable, to remove the infant to such cool and bracing climates as the northeastern coast or mountains, or the cooler stations in the Lake Region; in the presence of a severe attack, however, a long journey may be inadvis- able, and in the case of the large cities near the seaboard and lakes, it is not generally necessary. The children of the poor cannot, for pecuniary reasons, VISCERAL DISEASES 301 be transported to distant resorts, and must avail them- selves of the best near-by situations. In our seaboard towns the problem is relatively simple, and children may be conveyed to the breeze-swept ocean front, a thousand or more at a time, in boats or barges, the trip itself being something of a remedial measure. Transportation by rail, on the other hand, is rather injurious, and should be avoided whenever a journey by water is feasible. A very easy, but unfortunately rather ineffectual, plan of treatment is by means of the day trip in the so-called floating hospitals. These institutions, in the form of great barges, under the supervision of a competent- physician who is aided by a staff of nurses, leave the city in the early morning, call at convenient landing places, cruise about the quiet waters of the harbor, and return toward sunset. Great as is the relief afforded by the floating hospitals, it is but palliative, owing to the necessity of returning the sick infant to the fetid tenement for the night; it is doubtful if the trip perma- nently benefits any but the mildest cases and older chil- dren, and there is every reason to believe that the chief value of the floating hospital is in the good food, medical attendance, and educational influence afforded on board. The imperfections of the floating hospital may be largely remedied by operating it in connection with a seaside sanatorium. All the serious gastro-intestinal cases should be referred from the former to the latter; the floating hospital thus forms a' capital channel for the selection of patients for the sanatorium, which alone can effect a real cure in all but the milder dyspeptic cases. Our seaside sanatoria are all deficient in allowing the little patients too short a stay, two weeks being usually 302 THE CLIMATIC TREATMENT OF CHILDREN the limit; it must be admitted, in extenuation, that these institutions are not entirely free agents, owing to popular ignorance and insufficient accommodations. We are evidently still in a stage of early development in regard to these matters, and more education is needed by both the philanthropist and his beneficiaries. In- inland cities, such as Cincinnati or St. Louis, the problem of caring for the children of the poor, during the intensely hot summer that prevails in those latitudes, presents the gravest difficulties. The seashore or lake front is hundreds of miles away, and the level character of the surrounding country renders a reasonably cool refuge in the vicinity absolutely unobtainable. In the unusually hot July of 1901, for example, not a single locality in the state of Missouri was as cool as the low- lands of Porto Rico and Cuba, and the other central states were but little better. At the same time the average temperature on the eastern Maine. coast, in the higher northern Alleghanies, and in northern Michigan, ranged from 62 to 68 degrees, though that month was one of the hottest on record in these localities also. These cool regions are inaccessible to the children in the cities mentioned, except in the case of very well-to-do families, who rarely spend the summer in town in any event. The credit for developing and studying the subject of floating hospitals and seaside sanatoria belongs, in the first instance, entirely to private philanthropy in Boston, whence these institutions have spread to New York and Chicago, but to few other localities. The municipalities, with all their wealth and resources, have done little or nothing, as is usual in this country. When we analyze the subject carefully, we see that even such private VISCERAL DISEASES 303 activity as has been manifested in this direction is al- most entirely due to the fact that the cities mentioned have been relatively favored by nature, as their situation on the water front affords unusually good opportunities for communal work of the kind described. This remiss- ness of the municipalities, to which there are hardly any exceptions — New York is only to-day awakening 1 to the situation, now that nearly all of her magnificent water front has been occupied for other purposes — should not astonish anybody who is familiar with our municipal administrations and their ways. It is true that we have done better than the Europeans in a few details, but our climate renders our necessities infinitely greater. Chronic Diarrhceal Diseases. Next to the immediate peril to life, the chief danger involved in the acute diarrhceal diseases of infants and young children is the eventual development of a chronic enter o-colitis. This is peculiarly apt to. follow an acute intestinal inflamma- tion, but is also a frequent result of a neglected or in- adequately treated indigestion. It appears more than probable that the treatment of acute diarrhceal affections by a mere day's outing is often responsible for this un- toward outcome. The baby shows some improvement after its trip, but is not quite well; the same treatment is repeated for days with only partial success; the infant in the mean time sleeping in a stuffy tenement and possibly being improperly fed besides. It is evident that a case of this sort would have fared better under sanatorium treatment in the first instance, prolonged until an actual cure had been effected, and maintained for some days thereafter. 1 Boston awoke a few years ago. 304 THE CLIMATIC TREATMENT OF CHILDREN For chronic diarrhoea in children, as it occurs during the • summer months, a change to a cooler climate is absolutely imperative, and we may say at once, the cooler the better, barring such as are absolutely raw, for example, exposed situations from San Francisco north- ward; on the Atlantic coast there is almost no place that is too cool for these cases, and Maine and Nova Scotia are probably best of all. In a line with these might be set the higher elevations from the Catskill Mountains northeastward, the hill country from Penn- sylvania southward being hardly cool enough for the best results, as the day temperatures are apt to be rather high. Long Island and New Jersey are likewise a little too warm and sultry to achieve the best results in chronic diarrhceal disease; the cooler portions of the Lake Re- gion, as for instance northern Michigan, are decidedly better, but still not so bracing as our northeast coast. The shores of northern and western Europe offer many excellent situations, but the ocean voyage is an impedi- ment to be regarded seriously in digestive disorders; in selected cases, especially in older- children, the resorts along the English Channel, North Sea, and Baltic may be tried, and the mountains of central Europe offer no end of highly salubrious stations, with the additional important consideration of better food than is dealt out by the average American hotel proprietor. It must not be forgotten, in this connection, that cases of chronic diarrhoea no longer tolerate the semi-starvation that is often a valuable curative agent in acute indigestion. On the contrary, the food must be rather ample, and, furthermore, of a kind and preparation to spare the diseased intestine as much as possible. Persons familiar VISCERAL DISEASES 305 with the dietary at many American summer hotels, even some of the higher-priced grade, will appreciate the force of these remarks, and the difficulties likely to be en- countered. For the children of the poor, climatic treatment is even more essential, but the question of expense is, at least in this country, an obstacle to the selection of a truly first-class climate, so far as most cities are concerned; it usually becomes necessary to choose the best near-by locality for a children's sanatorium. While it is incon- testable that some very fair work has been done in this field, the greater part still awaits realization ; at present the sojourn of the patients in the mountains or at the seaside is generally limited to a few weeks, a period altogether too short to effect a cure in a large proportion of cases, the more so as the children are sent back to the noisome atmosphere of the city before the hot season is over. Better provision should be made for keeping obstinate diarrhceal cases, especially such as show a general impairment of health, in the country at least until the end of August in the North and some weeks later in the South. This can, unfortunately, be effected only after an increase of the present facilities, which suffice only for the more urgently sick children. We must, moreover, not forget that a little more education of the public is also demanded; too many parents are apt to desire the return home of their children, long before anything like a complete cure has been effected. Children above the age of three or four years are not benefited so much as infants by a stay at our moderately warm seaside resorts, and an earnest endeavor should be made to send them to a truly bracing summer climate, 306 THE CLIMATIC TREATMENT OF CHILDREN preferably aksome little elevation. The older the child, the more persistent a type of intestinal catarrh is apt to be before us, since a more serious, long-continued, or often repeated acute disturbance was necessary to set up a chronic condition. We cannot, therefore, go far astray in choosing a more energetic form of climato therapy in older children, and insisting on its prolonged continu- ance, preferably until cool weather has come to town for the season, even if the patients appear thoroughly well weeks before that time. All our eastern highlands are suitable to these cases; the far northeastern coast resorts are' not quite so good, being too damp, and sometimes rather raw, but they often prove quite adequate. For children *of the school age, the July isothermal of 66 degrees represents the southern limit, which it is best not to overstep, if we desire to achieve really brilliant results. The Rocky Mountain resorts are rather warmer, but the extreme dryness acts as a compensatory factor, so that a few extra degrees of warmth may be disregarded. In central Europe, nearly all the popular resorts suit our purpose, as is also true of the Atlantic coast from France northward and eastward to the Baltic Sea. It is useful and important to remember that a pro- longed stay, beyond what is actually necessary to achieve an apparent cure, will in no case be superfluous; as observed before, children of the school age are in any event a troublesome proposition under our modern con- ditions, and a little surplus of vitality can only be advantageous in the long run. Non-diarrhceal Dyspepsia. Digestive disorders that are not attended with diarrhoea do not usually call for climatic treatment. An exception should, however, be VISCERAL DISEASES 307 made in all cases of infantile dyspepsia, even if diarrhoea be absent; though this statement seems almost unnec- essary, its important therapeutic suggestion is often disregarded, with disastrous results. The practitioner who sends all infants and yoimg children that manifest any sort of severe digestive disturbance during the warm season to a cool resort in the country will have the smallest proportion of debilitated subjects on his hands in the autumn. It is a grave error to await the appearance of diarrhoea, before resorting to a change of climate; its success is so certain,' its omission so fraught with danger, that the only safe procedure is to prescribe it promptly in every case, losing no time with temporiz- ing or mere internal medication. Material considera- tions should not be allowed to stand in the way of the one sovereign remedy, and fortunately it is usually available in some of our cities for rich and poor alike, although perhaps inadequately so far as the latter are concerned. RESPIRATORY DISEASES We have already remarked that the diseases of the respiratory system, so far as seasonal distribution goes, present a sort of complement to the affections of the digestive tract; the association of climate and disease is, however, far less intimate in the group here under discussion. Another difference lies in the circumstance that acute respiratory diseases are not in any way sub- jects for climatotherapy, but require home treatment alone. The question of "catching cold," so interesting in this connection, has obtained ample consideration in 308 THE CLIMATIC TREATMENT OF CHILDREN a previous chapter, and does not call for further mention; in the same place the prophylactic aspects of the subject received full attention, and repetition here would be superfluous; the few points not touched upon adequately will be developed as we go on to describe therapeutic details. ' Chronic Bronchitis. Chronic bronchitis is not an uncommon affection even in very young children, if we include recurrent bronchitis, which belongs here clinic- ally and for purpos.es of treatment. On the other hand, cases in which this affection merely complicates a tu- berculous process are to be excluded from considera- tion here; they are best disposed of in connection with the underlying disease. If we adopt the classification just mentioned, we find that we are dealing with a tol- erably well-defined group. We sometimes encounter chronic bronchitis as a primary affection, in hearty, well-nourished children whose apparent robustness is indeed somewhat magnified by the exaggerated development of the thorax that results from the frequent and violent cough and occa- sional dyspnoea. Chronic pulmonary emphysema^ of the type so commonly associated with the chronic bronchitis of advanced fife, is rare, if not unknown, in childhood; at this age emphysema is an acute and transitory affair, differing widely in its histology from the lesion of that name in elderly subjects. Most of the children, however, that come to us with chronic bronchitis, suffer from rickets or its sequelae, such as a thoracic deformity (pigeon-breast) or a spinal curvature. Next in order come those who present some form of lymphatism, be it a true scrofulosis, or a VISCERAL DISEASES 309 glandular hypertrophy in the faucial ring. Not especially rare are the cases associated with congenital syphilis; here the immediate cause usually consists of gummatous deposits, with lymphatic infiltration,, about the larger bronchi'; such patients usually do well enough under specific medication, but the cure is likely to be acceler- ated by removal to a good climate. Many of the worst cases are unquestionably the product of experiments in hardening that have miscarried, especially when ir- rational persistence in the regime of strenuousness has established a vicious circle, as not infrequently happens. These last embody the most telling reply to the relentless advocates of cold plunges and the like for young chil- dren, and are a standing reproach to the blind devotees of routine treatment for young and old alike. In entering upon a detailed review and* classification of chronic bronchitis, we may begin by distinguishing three types. First, we have the recurrent -cases that suffer from repeated attacks, with more or less brief intermissions, most persistent and severe in the cold months, but sometimes tending to run on into the spring, the summer being relatively free. Secondly, we note the asthmatic cases, presenting similar seasonal variations, but with less tendency to complete remission while cold weather lasts, and attended with the symptom group known as bronchial asthma. Thirdly, there are the cases characterized by free secretion, with or without the development of bronchiectatic cavities, but without any tangible evidence of tuberculosis; this last type is peculiarly apt to follow an attack of measles or pertussis. It goes without saying that many children do not fit exactly into any one of these groups, and the first and 310 THE CLIMATIC TREATMENT OF CHILDREN second are apt to run into one another; a case of simple recurrent bronchitis may gradually become asthmatic, and, on the other hand, the sufferer from severe asth- matic attacks may improve so far as to present merely a recurrent cough with abundant rhonchi and tenacious secretion. The treatment of these cases with a change of climate is anything but simple. Rickets and scrofulosis, includ- ing the various phases of lymphatism, are to be managed according to principles laid down elsewhere in this work, but, aside from these complications or underlying dis- orders, it is not easy to lay down any general rules. So much is clear, that in any event a moderately warm climate, not likely to entail enervation, is to be chosen, so that the child can pass the greater part of the day in the open air, without excessive exposure to cold winds. When we come to the choice between inland and seaside resorts, we find that the authorities differ amazingly; thus, Hoffmann 1 and Keller 2 favor the mild marine cli- mates, whereas Weber and Foster 3 prefer elevated' inland sites. The balance of opinion, however, inclines to the former, and we must remember, once more, that the seaside is not necessarily damp in winter, but, on the contrary, has a tendency to be drier than the hinterland in southerly latitudes. Rode's 4 claim of good results at Norderney, even in the cold months, stands almost alone; the raw and damp winter climate on the North Sea coast, with an average temperature little above the freezing point, is the very one we would look on with disfavor 1 Op. cit. 2 Monatsschrift flir Kinderheilkunde, Oct. 1903. • 1 See bibliography. 4 Berliner klin. Wochenschrift, April 13, 1896, • VISCERAL DISEASES 311 in treating chronic bronchitis; Perier 1 distinctly rejects the far milder coast stations of France, even those of the southeast (Cette), with a doubtful exception in favor of the Riviera. California and the warmer Mediterranean resorts are therefore quite suitable, and the South Atlantic coast ranks just a little lower. Our Middle Atlantic coast must be employed with some discrimination, as the temperature is a little too low, though there is a high proportion of sunny days; in view of the high and fre- quent northwest winds this sect-ion is best reserved for the purpose of bridging over the treacherous period of early spring, or for an after-cure. The same may be said even of the milder stations of western Europe, as the English Channel resorts. I see little occasion for dilating on the treatment of these cases in the mountains, during the winter and early spring, for the weather is quite certain to be too cold and windy. An exception may be made in the case of the southern Alleghanies and the southern slope of the Alps, as well as the Pyrenees, in early spring, before the final return north. We shall always do well to adhere to the rule of extending the course of treatment over the entire cold season, that is, until the temperature at home begins to average from 50 to 55 degrees. After the above general review, we may glance at a few exceptions. First, as to the asthmatic cases, we are in a sort of quandary; Avellis, 2 for example, says that only children are likely to* improve at the seashore, admitting, at the same time, that no climate guarantees 1 Loc. cit. 2 Miinchener med. Wochenschrift, Nov. 15, .1904. 312 THE CLIMATIC TREATMENT OF CHILDREN relief; Osier 1 praises California and Florida; Holt 1 prefers a drier climate than the latter, with some eleva- tion; Henoch 1 thinks that an inland resort should be selected to inaugurate treatment in any event, and reserves the seaside for an after-cure, as being of uncer- tain value. On only one point do the authorities agree, namely, that high elevations are objectionable; other- wise the differences of opinion are so great as to impress us chiefly with the empirical status of the whole matter. It is evident that the climatic treatment of asthma is unsatisfactory, though perhaps not quite to the degree experienced in adults. We may now turn to those cases of bronchitis, a fairly large proportion of the total, that are characterized by abundant and not very viscid secretion, with or without demonstrable bronchiectases. Here we find little divers- ity of opinion ; it seems to be quite generally agreed that these patients do best in a dry climate ; in this connection, however, it is of interest to note the very scant reference to the very arid desert regions, an omission readily accounted for. It is indeed plain that extreme drought, with its inevitable fine dust, is one of the worst possible, irritants to the inflamed bronchial mucosa, and the wise physician will precede the ultimate disposal of this class of cases with a glance at the tables of relative humidity as well as the temperature, choosing a climate having 65 to 75 per cent, of moisture, with a reasonable amount of rain to obviate dustiness. This last annoyance is mitigated to a great extent on the eastern slope of the Rocky Mountains, where afternoon showers are not uncom- mon in spring and early summer; between showers the 1 See bibliography. VISCERAL DISEASES . 313 atmosphere there is quite dry. The summer months are very much too arid in California, away from the coast, and the dust forms a fearful plague. At best, the western half of the continent, with very few ex- ceptions, while unsuited to the treatment of asthmatic cases, is more likely to benefit cases with excessive secre- tion and bronchiectases; selected patients of the latter group may be referred to such regions as the eastern slope, with some prospect of affording relief. Apart from the cases with free secretion, just disposed of, there is little of real importance to be said concerning a suitable summer climate. The simple and recurrent cases improve in summer in any event ; we shall do well, however, to avoid high elevations, very low tempera- tures, high winds and sea fogs. The asthmatic cases present so uncertain a proposition that we are driven to resort to individual experimentation whenever the mere arrival of summer does not occasion improvement. In closing the discussion of the treatment of chronic bronchitis, we may emphasize the importance of treat- ing any discoverable underlying affection; it .is a curious fact that the primary cases afford the more vexatious difficulties in therapy, and medicinal treatment is even less satisfactory than climatic management, so far as cure or permanent amelioration is concerned. Chronic Affections of the Upper Air Passages. Apart from such cases as merely complicate lymphatism, the principles stated in the paragraphs on chronic bronchitis apply here also in a general way; our guide is once more the amount of secretion, according as we are confronted with a hypertrophic or an atrophic catarrh. Solly 1 goes 1 Journ. of the Amer. Med. Association, Nov. 14, 1903. 314 THE CLIMATIC TREATMENT OF CHILDREN into the merits and deficiencies of the climate of Colorado, for the treatment of this group, in fairly minute detail. He observes that nasal obstruction usually becomes ag- gravated, and that respiration becomes more impeded; operative measures that were regarded as optional in the east, become imperative in the Rocky Mountain region. Atrophic rhinitis and ozsena also grow worse, the dryness and dust being extremely deleterious; moist hyper- trophic rhinitis, on the other hand, regularly undergoes improvement in this climate. It is just as well, however, to remember that the transformation of hypertrophic rhinitis into the atrophic form is apt to be favored by excessive dryness; we shall therefore not go far astray in regarding Solly's opinion on the hypertrophic group as somewhat optimistic. The abatement of a nasal blennorrhoea does not necessarily denote real progress, and its transformation into an atrophic condition, possi- bly with ozsena, is of doubtful advantage to the patient. In any event, it is usually advisable not to encourage too long a stay in the semi-arid regions, unless we are pretty thoroughly convinced that there has been real improvement; as a general thing, better results will be achieved at the moderately moist resorts even in mark- edly hypertrophic cases with a good deal of secretion. The atrophic cases unquestionably do best at the sea- shore, and even the most typically oceanic climate is hardly too damp for them. All forms of nasal catarrh are influenced unfavorably by cold and dry winds of the mistral type; it is indeed probable that they are largely responsible for the exces- sive prevalence of these affections on our continent. Warm and moist air is quite certain to be beneficial; a VISCERAL DISEASES 315 really high temperature is, however, not needed, an average range of ten degrees or so above the freezing point being quite sufficient; the semi-southern coast climates will therefore be found quite satisfactory during the cold season. I have repeatedly found that persons who suffered a good deal from nasal catarrh in the dry and dusty cli- mate of the Great Plains, experienced marked relief when residing in New York, except in the rather dry and very windy period from December to March. During the warm and damp New York summer we hear but few complaints from these patients; all forms appear to undergo a relative improvement during that time. The lymphatic hypertrophies in the naso-pharyngeal region are often intimately connected with local lesions of the mucous membranes, though at times merely part of a general lymphatism; the rules for their climatic treatment follow those just indicated for the underlying catarrh. The very moist climates are not especially good in these cases; they are too relaxing, even if they would not add to the difficulties of normal nasal respira- tion. Far worse, however, are the cold and dry climates; here we regularly observe an increase in the tendency to mouth breathing, which becomes especially conspicu- ous on entering a warm apartment after exposure to a brisk northwester. It is easy to understand the harm- fulness of mouth breathing in cold weather; the alterna- tion of high and low temperature seems* to add to the mischief, and the effect of the overheated and dry air of most dwellings undoubtedly is worst of all. Pneumonia and Pleurisy. The pneumonia cases that concern us here are those with delayed resolution, for 316 THE CLIMATIC TREATMENT OF CHILDREN which Holt well says that change of air is more important than all other forms of treatment combined. In winter and early spring, the usual seasons in which we encounter this condition, the removal should be to a decidedly warm climate, especially in the case of an infant, for whom the more southerly Florida stations are none too warm. Only after all the physical signs of consolida- tion have disappeared, may transfer to a more bracing climate be attempted, and in any case the return north is best postponed until the middle of spring. During the warmer months an unresolved pneumonia does not require removal to a very different climate, but even then the change to a sheltered inland locality is advan- tageous. The seashore is not particularly good for these cases, and the higher mountain resorts are apt. to be too cold; the situation often calls for the exercise of considerable judgment, but the physician will not go far astray by recommending a climate such as that of interior New York and New England during the warmest months, and New Jersey in the early autumn. A point to be remembered in this connection is that •the patient is usually not in condition to withstand a long journey," and it is therefore advisable to select the nearest locality that is likely to prove beneficial, in pref- erence to a slightly better, but more remote resort, Chronic interstitial pneumonia, with or without bronchiectases, is to be managed according to the indi- vidual case; the more robust subjects may be treated like those of simple bronchiectasis, the more feeble ones demand the greater care appropriate to unresolved pneu- monia; here, too, there is plenty of opportunity for wise discrimination. VISCERAL DISEASES 317 Under the head of pleurisy we are mainly concerned with the treatment of the later stages of empyema. Suppuration is apt to continue for months after surgical intervention, and the danger of a general deterioration of the patient's condition is an important item. The best climate to begin with is the one we would select for an unresolved pneumonia; if the child's general health is fairly good, a slightly cooler region may be even more beneficial. The greatest importance attaches to the post-suppurative stage, when pleuritic adhesions inter- fere more or less with the expansion of the lung. Here a stimulating regime is called for, the child should spend the following summer at one of the cooler seaside resorts or at some elevation inland, for at this period enervation is the chief danger. The best places of all are probably the Alpine resorts, even the colder ones at elevations exceeding 3,000 feet; next come the higher stations. of New England and New York; Colorado is perhaps a little too warm during the day, but otherwise ranks high, owing to the large proportion of sunshine. Of seaside resorts those of western Europe and our extreme northeast rank about equally high; as we go south from the English Channel or Maine the climate becomes pro- gressively more relaxing and less suitable to these cases. On the Pacific Coast only certain spots, such as the sheltered portions of San Francisco Bay (e.g., San Rafael), interior Oregon, and Puget Sound, are neither too warm nor too raw. The other forms of pleurisy calling for climatotherapy are mostly associated with tuberculosis, and occur in older children, whereas metapneumonic empyema is peculiar to infancy and early childhood. For the man- 318 THE CLIMATIC TREATMENT OF CHILDREN agement of the former the reader is referred to the paragraphs devoted to tuberculosis. A few words may be added on the sanatorium treat- ment of chronic respiratory diseases in children. It is notorious that these cases do not do well in the ordinary hospital aiid are apt to fall an eventual prey to grave anaemia or tuberculosis. Much of this, however, is due to errors in hospital management and is not true to the same degree of the most modern institutions. The weak spot of the general hospital is its lack of accommodation for convalescents, to which group these children most emphatically belong. Winter sanatoria are unf&rtu- nately still a novelty in this country, whereas Europe has been most plentifully supplied with them for decades. Only institutions of this type are adapted to the success- ful handling of this class of patients, for empyema and unresolved pneumonia, though occurring in well-to-do families, are pre-eminently diseases affecting the ill- nourished children of the poor. In one respect the foundation of a sanatorium for this class of cases presents some difficulty. A mild climate is quite essential, but is not obtainable within many hundreds of miles of our northern cities; to start such an institution in the South involves possibly legal ob- stacles, and certainly an expense for transportation that would prove burdensome; the difficulties of adequate supervision must also be considered. It is evident that the matter is far simpler in such countries as England and France, where a really mild winter climate is at the most five hundred miles away from, but generally much nearer to the great centers of population. The problem afforded by this* situation is assuredly worthy of serious VISCERAL DISEASES 319 consideration by the medical profession and the chari- tably disposed public; the amount of physical impair- ment, associated with the far from negligible increase in the death-rate of young children, that is inseparable from our present methods, urgently calls for a remedy, to which foreigners have already shown us the way. Pertussis. The climatic treatment of pertussis has hitherto been somewhat neglected; a strange circum- stance, in view of the fact that it is almost the only one that really amounts to anything. The subject may be attacked from two points : first, as to the influence of a change of climate on the disease itself; secondly, as a prophylactic measure against the complications which form the chief danger of this otherwise not very serious affection. We shall begin with the former indication. Every practitioner has observed the benefit that chil- dren with whooping cough derive from a stay out of doors. The attacks are always fewer and milder in pure air than in the more or less vitiated atmosphere of the house, and the patient should be at home during the day as little- as possible. This presupposes suitable weather, is easily carried out in summer, but becomes a most difficult matter in the northern winter, especially where infants are concerned. During the first year of life, removal to a mild winter climate, where there is plenty of bright weather, is almost imperative, whereas older children, especially after the second year, may stay North in a fairly sunny region such as the Middle Atlantic Coast, where outdoor exercise is possible on a good many days, save in unusually cold or stormy seasons. In the Lake Region and the extreme Northeast or Northwest this is not often possible, and a change of climate is best 320 THE CLIMATIC TREATMENT OF CHILDREN for older children also; this need not be radical, and New Jersey, for example, is almost always sufficiently mild and pleasant. It may be added that cases occurring during the sum- mer, south of Mason and Dixon's Line, do better farther north than at home, because they are less apt to be de- prived of the outdoor air by intensely hot days, which often necessitate staying indoors during the brightest weather and best hours. The second indication refers chiefly to the danger of pneumonic complications, especially in winter and spring; as to simple bronchitis, prophylaxis is quite in- effectual, and few young children escape. In summer these children, especially in the cities, are peculiarly liable to diarrhceal diseases, fostered by. a state of mal- nutrition in consequence of the frequent vomiting of food and the exhausting paroxysms. Both these con- siderations are extremely important during infancy, but become less serious with advancing age. It is a good rule to treat babies suffering from whoop- ing cough exactly like cases of chronic bronchitis or un- resolved pneumonia, according to the general state of health. The climate selected should be decidedly mild in the case of infants, for older children it may be more bracing. In summer the best plan is the one outlined as a prophylactic against gastro- intestinal disorders; here again, however, we must take infants to moder- ately warm resorts, for they run a considerable risk of pneumonia even in summer, when sudden variations of temperature take place. Do patients with pertussis get on better at the sea- shore or inland? American observers, as Holt and VISCERAL DISEASES 321 Powell, 1 incline to recommending the former; Szego 2 is in doubt, and thinks that pure air inland, may be of equal value; Fischl 3 is convinced that the paroxysms are mitigated in the moderately warm mountain resorts, but that the terminal stage is cut short at either the sea- side or among the hills. From the above divergence of opinion, I have come to the belief that the essential point is freedom of the atmosphere from irritating mat- ter, chiefly smoke and dust; this position is substan- tiated by the familiar observation that the paroxysms, that in town persist for many months after the disease has run its course, and which physicians as well as lay- men are apt to misinterpret as persistence or recurrence of the whooping cough itself, usually cease promptly when the patient is removed to either the mountains or the, seashore. Pertussis seems to be regularly followed by increased irritability of the epiglottic mucous mem- brane, and the avoidance of smoke and dust seems al- most indispensable as an after-cure; thus, any good country resort may meet the indication. No climate seems effective in cutting short the disease itself; the most we can do is to moderate the intensity of the paroxysms according to the method just stated. The efficacy of the saline sea breeze is mythical; the balsamic air of pine woods is a mere tradition, coniferous forests are simply freer from dust than deciduous woods. The infinitesimal traces of resin in the "piny air" cannot possibly have therapeutic value comparable, for example, to the inhalation of cresol vapor, which seems 1 See bibliography. 2 Archiv fiir Kinderheilkimde, 1899, vol. 27. ? Berliner klin, Wochenschrift, May 21, 1906. 322 THE CLIMATIC TREATMENT OF CHILDREN to be of some little use. It is time that the medical pro- fession ceased to imbibe its ideas on therapeutic matters from hotel circulars and railway folders. The main obstacle to the climatic .treatment of per- tussis is the difficulty of finding a locality where other children will not be infected by our patients. Fortu- nately, this disease occurs in such peculiarly sweeping epidemics that the proprietor of a suitable resort will occasionally find profit in catering to this class of patrons exclusively. Hay-fever. Hay-fever is not excessively rare in older children; Wyman 1 claims that fifteen per cent, of all the victims of this affection have their first attack by the tenth year. We have already referred to the recent discovery of a specific therapy, but this, while undoubt- edly correct in principle, does not give permanent relief, and has scored a considerable percentage of failures. It is therefore simpler, and preferable for other reasons also, to take the affected children to the immune summer and autumn resorts, whenever circumstances will permit. The. choice of locality must be in accordance with the data given in the first chapters; the results are then striking, relief being afforded almost instantaneously; moreover, these immune climates are otherwise ideal for most children, notably those of the age here under consideration. If it is desired to avoid the onset of this affection entirely, the patient must leave his home before the pollination of the ragweed begins. This happens about the middle of August in the latitude of New York, and Boston. The map at the end of the first chapter gives 1 Autumnal Catarrh, 1885. VISCERAL DISEASES 323 the immune regions in a rough way, by indicating the July isothermal of 66 degrees at the lower levels; relief may, however, often be obtained in more southerly latitudes in the Alleghanies by ascending the mountains. The altitude, approximate of course, of the immune line in the eastern highlands is as follows : St. Lawrence Valley, near Montreal : 800 to 1000 feet. White and Green Mountains, Adirondacks 1200 to 1400 ' Berkshire Hills and Catskill Mountains 1800 to 2200 " Pennsylvania 2400 to 3000 " Virginia and Wes^ Virginia 3000 to 3600 " North Carolina 4000 to 4400 " South of New York there are very few well-equipped resorts above the stated elevations. In Pennsylvania only a few ridges are sufficiently high; farther south the altitudes named are uninhabited or nearly so, and con- ditions unspeakably primitive. Only the northeastern hill country is therefore worth considering at all. The return home should not take place before the frosts arrive; the dates for the first killing frost are nearly the same for Boston, New York, and Washington, falling with almost imf ailing regularity in the first half of October, rarely earlier or later. DISEASES OF THE EAR The literature on the climatic treatment of aural diseases is rather uneven, very complete and accurate in some points, but almost ignoring others of no less interest; the following outline is therefore somewhat sketchy. Otorrhcea seems to do well at the seashore, especially in summer; even sea bathing, which we should naturally view with suspicion, appears to be distinctly beneficial; some discrimination, however, is called for, 324 THE CLIMATIC TREATMENT OF CHILDREN Koerner 1 did not note any relapses of otorrhoea follow- ing sea baths, but Danziger 2 advises caution when a per- foration of the drum membrane is present, as is. indeed obvious; dry perforations are, however, a less serious matter than such as are discharging. It is curious how individuals differ as to the likelihood of water penetrating the external meatus, so as to reach the tympanic mem- brane and cause distress even in a normal subject, possi- bly harm in one already suffering from otitis media. The uncertainty in this regard in the particular child under treatment makes any prediction impossible; it is therefore wise, in my judgment, not to permit sea bathing in case there is any discharge, present or recent; also to proceed cautiously in patients with a persistent perfora- tion, even if otitic manifestations have been absent for years. If this safe rule be not followed, there will in- evitably be an occasional disaster to remind the prac- titioner that the entrance of sea water into the ear is not an indifferent matter, and he is pretty sure to be blamed severely, even unduly, if the risk was taken with his advice. For the winter, I should be inclined to recommend rather mild resorts for children with otitis media, the same as for catarrhal affections in general, and for similar reasons. After all, the disease of the ear is usually a complication of or sequel to an inflammatory trouble in the uppermost respiratory region, and must be treated more or less as an integral part thereof. This is also the reason why this group calls for discussion in this place, following the consideration of the respiratory 1 Zeitschrift fur Ohrenheilkunde, 1900, vol. 36. 2 Monatsschrift fur Ohrenheilkunde, September, 1899. VISCERAL DISEASES 325 tract. In pursuance of this same trend of argument, it also seems a good idea to refer patients with a free discharge, especially when associated with a hyper- trophic catarrh of the nose or naso-pharynx, to moder- ately elevated and fairly dry inland localities instead of the seashore. The scantiness of the literature on aural climatology is intimately connected with an excessive devotion to routine in the application of this form of therapeutics; there has been no individualization to speak of, hence the dearth of satisfactory special articles. Neither has any attention been paid to the possible value of a change in atmospheric pressure, such as is involved in a removal from our lowlands to the Rocky Mountain Region. This might be considered in connection with the earlier stages of otosclerosis, as met with in childhood, the only age at which much can be accomplished. The otologists have still to determine whether such a climate as that of Colorado tends to check or further this disastrous lesion ; the subject certainly calls for a detailed investigation, which might profitably include a study of the effects of a reversal of the change mentioned, namely, from the high western plateaus to the sea level. DISEASES OF THE HEART There are but scanty data on the climatic manage- ment of heart disease in children, for, here again, most of the work extant relates to adults, and is not always applicable to the very different conditions found in the young. The chronic cases, which alone concern us here, fall clinically into the compensated and uncompensated groups, but the dividing line is marked less clearly than 326 THE CLIMATIC TREATMENT OF CHILDREN in adults; on the other hand, the effects of a rational therapy are more rapid and satisfactory, for the almost invariable absence of irreparable myocardial and vascular degeneration aids us materially in re-establishing the balance of the circulation. The greater part of the field before us is covered by valvular heart disease of the rheumatic type ; we shall begin with the cases that pre- sent complete or tolerable compensation. Compensated Valvular Lesions. In the adult, a perfectly compensated valvular defect does not usually require continuous surveillance; with a fairly intelligent pa- tient, it is generally possible to enforce a regimen as to diet and exercise that will keep matters running quite smoothly for years and even decades. These remarks do not apply to children. Just as compensation is rather easily established in them by appropriate treat- ment, so it is more readily upset by adverse influences, among which, apart from the great and peculiar risk of intercurrent febrile affections, there is the difficulty of regulating the amount of muscular exertion. It is not easy to keep a child from violent play, still more difficult to obviate the strain involved in frequent and rapid stair-climbing. Now that the New York Department of Education is building schools on sky-scraper lines, without elevators, an ironclad "system" compels chil- dren suffering from valvular heart disease to ascend some sixty feet of stairs several times a day at an almost military pace. It is surely time for the medical frater- nity to call attention to this grave abuse, which a tenant in an office building would not tolerate for a day, I can personally recall several cases in which protests were una- vailing, and a child with barely adequate compensation VISCERAL DISEASES 327 was compelled to choose between attending a class on the top floor or doing without schooling altogether. Such are the consequences of a routine in which the individ- ual is completely submerged. Children with perfect compensation do not demand systematic climatotherapy, with the exception of guard- ing against enervation; moderate exercise is absolutely essential, for any tendency to flabbiness is a rather serious matter ; it is therefore wise to select a fairly cool climate for the summer months. In the precise choice a little discrimination will be necessary, according to the localization of the lesion and the stability of the compen- sation. Compensated mitral cases, especially where regurgitation is the main feature, do well at considerable elevations; thus, Galli 1 obtained very favorable results at 3,800 feet in the Alps, Determann 2 does not think the Engadine too high in carefully selected cases, and Babcock 3 arrives at a similar conclusion with regard to the Rocky Mountains. So much can be said with some confidence, that these cases do not belong at the warmer and often sultry seaside resorts, where they are apt to lead a rather indolent life, especially in the case of girls approaching puberty. Such children are sure to do better at a somewhat elevated site, where the nights are cool, and the days rarely oppressive; the northern Alleghanies afford no end of suitable localities, but the watering places of Central Europe seem to be even superior, and indeed often well worth the trouble and expense of an ocean voyage. A severe mitral obstruction, even if fairly compensated, 1 Riforma Medica, March 23, 1904. 2 Loc. cit. 3 Medical News, July 15, 1899. 328 THE CLIMATIC TREATMENT OF CHILDREN must be treated with less strenuousness, and the com- bination with a lesion of the aortic valve requires the exercise of considerable caution, for fear of disturbing a balance at best somewhat labile. These children are often benefited very greatly by removal to a southern region during the winter, avoiding, of course, excessive warmth as tending to enervate instead of tone up the patient. Such resorts as Florida and Egypt are less desirable than the lowlands of Virginia, the southern Alleghanies and Pine Belt, the south slope of the Alps, and the foothills of the Pyrenees, as at Pau. The reader will not fail to observe how strenuousness is gradually discarded as we pass on to the borderland between com- pensated and uncompensated cardiac disease. Cardiac Insufficiency. This clinical picture obtains when compensation for a valvular defect has not yet been established by hypertrophy of the myocardium, also when the seat of disease is the heart muscle itself. As in the case of muscular insufficiency everywhere, such cases require a most judicious adjustment of rest and exercise, and every patient must be regarded individu- ally in the administration of these opposite therapeutic measures. Some general rules may, however, be laid down by way of introduction. The high levels, in the first place, are absolutely contraindicated, for their unre- mitting stimulation to the heart action is likely to be harmful; it is distinctly dangerous to add to the strain on an organ already insufficient, and requiring rest, not exercise; for the same reason the colder seaside resorts are not to be thought of. On the other hand, the warmer marine stations are apt to cause enervation after a time, so that the usefulness of the oceanic climates is rather VISCERAL DISEASES 329 limited in this group of patients. Still, the Riviera, southern California, and similar regions may be of value, in selected cases, during the cooler months; and during the summer the coast of southern New England may prove salutary; most other coast stations are too cold or too warm, and especially too windy, to affect uncom- pensated heart lesions favorably. We are, therefore, almost entirely restricted to inland resorts at or reasonably near the sea level, with a tem- perature permitting a very quiet outdoor life, yet not enervating. The range thus afforded is still considerable, varying of course greatly with the season, for it goes almost without saying, and cannot be too clearly under- stood by the attendant, that the climatic treatment of cardiac insufficiency is a matter, of many weeks' dura- tion, if relapses are not to set in promptly. In com- mencing with a case of some severity, but still in a chronic or sub-acute stage, it is best to begin with a climate just too cool to be enervating. In midwinter northern Florida, southern Georgia, Sicily, southern California and the Riviera are eminently suitable; we may then, toward spring or as the patient improves, advance to a somewhat more northerly and bracing climate, without, however, seeking true stimulation, which we shall do well to reserve for the time of appar- ently restored compensation, as a sort of after-cure. For the last, a mountain resort, not over 3,000 feet high, is of some value; it is sufficiently bracing to have a tonic effect, and serves as a sort of test of the efficacy of the preceding rest cure. It is impossible to exercise too great discrimination in the climatic treatment of cardiac insufficiency ; all stages 330 THE CLIMATIC TREATMENT OF CHILDREN from a rather labile compensation to almost total heart failure are met with, and nearly all may be benefited by an exactly appropriate climate. With children we may look for excellent results in conditions that are almost desperate in later years, so great is the recupera- tive power of the myocardium at an early age. It is not within the scope of this work to discuss the methods and admirable results achieved at such places as Nauheim ; we shall merely mention that an important element of this treatment is the general hygienic regula- tion, with a large proportion of climatotherapy. The best evidence of this is the great inferiority in results obtained by means of the so-called Nauheim cures in our cities; and one season's sojourn among the hills of middle Germany between May and September is a convincing argument that the climate there, during those months, is hardly rivaled and certainly unsurpassed. Only in certain hilly sections of New York and New England, so far as this continent is concerned, can we secure a similar combination of pleasantly warm days and cool nights, moderate humidity, and not excessive rains; unfortu- nately, the medical skill that frequents the German spas is conspicuous by its absence at nearly all similar resorts in this country. It is unnecessary to add that the accurate imitation of the baths themselves is the easiest part of the whole problem, and within the scope of any competent chemist; moreover, very similar springs exist in this country; the surroundings, however, in the shape of well-kept roads and woods, with level paths, also first-rate medical attendance and hotel accommoda- tions, are rudimentary or absent at most of our resorts, and up to the German standard at none. It is really VISCERAL DISEASES 331 astonishing that American invalids should be almost compelled to seek health four thousand miles away, when equally good opportunities might he at their very doors. Congenital Heart Disease. Most cases of congenital heart disease have little chance of viability beyond puberty or adolescence, but there is a certain proportion in whom the prognosis is relatively good under careful handling. These more favorable cases are usually dis- tinguishable on inspection by the absence or slightness of cyanosis, though this is not invariably the case; markedly cyanotic subjects have survived to middle life and beyond. Very little has been done in regard to studying the climatic treatment of these patients, but a few general points suggest themselves readily. Thus, H. Vierordt 1 wisely proposes wintering in a mild climate; he does not specify very precisely, but an exact recom- mendation is not possible for a condition whose severity varies so widely. We are once more called upon to exercise discrimination, selecting a rather bracing climate for well-compensated cases, with little dilatation and no cyanosis of consequence, sending the severe types to warmer resorts, but reserving the truly relaxing climates for such patients as offer a rather poor prognosis in any event. Vierordt' s standpoint in advising against even moderately high elevations seems wisely taken, and I would extend this to include the colder and windier sea- side resorts; congenital heart disease does even worse under undue strain than an acquired lesion, and an upset compensation is often never re-established, even in the very young. In some of the most promising cases, the 1 Nothnagel, specielle Pathologie und Therapie, vol. 15, part 2. 332 THE CLIMATIC TREATMENT OF CHILDREN balance of the circulation is apt to be more unstable than appears On physical examination, for we must remem- ber that, in the congenital group, we are dealing with imperfectly diagnosticable lesions, whose gravity cannot always be gauged when matters seem to be going on fairly well. Pericarditis. For our purposes only the cases of peri- cardial adhesions sufficient to impede the heart action need be considered; when the lesion is so serious as to produce this effect the prognosis in regard to complete restitution is regularly unfavorable, for the circulatory impairment tends to grow steadily worse. One of the few measures that have any value in this condition is removal to a moderately warm climate at a low level, where the smallest possible demands are made on the heart. In these, as in the more severe congenital heart cases, it is probably the wisest plan, whenever feasible, to determine on permanent residence in such a region as southwestern California, one of the few sections that offer a comfortable climate throughout the year, for most of the other mild winter resorts become excessively hot in summer. Such a change of abode is the more desirable, as otherwise an annual long jouney, with its risks and annoyances, is inevitable ; we are dealing with conditions that are irremediable, and our only thought must be to prolong life with comfort. If an isolated case may be restored to partial efficiency by this, almost the only promising measure, continuance of the achieved amelioration is also largely dependent on favorable cli- matic conditions, so that in any event a choice of the sort mentioned will be wisely made, provided that the circumstances of the child's family permit a radical and VISCERAL DISEASES 333 permanent change of base without involving too serious financial impairment. DISEASES OF THE NERVOUS SYSTEM The discussion of the climatotherapy of nervous dis- eases in childhood presents certain difficulties in classi- fication, but it will suffice, for our purposes, to divide them into groups calling for similar treatment, without going too far into pathological details. Nervous Irritability and Nervous Exhaustion. It is best to avoid the much abused term neurasthenia in this connection, both because that designation is rather inaccurate to begin with, and for the reason that the picture described under that name in adults is rare in childhood. On the other hand, early life has some char- acteristic clinical groups of its own that are plainly manifestations of subnormal or perverted nervous func- tions, yet cannot be regarded as neurasthenic in the current sense. The nervous disorders here discussed rarely exist alone, but are usually associated with visceral derangements, simple malnutrition or one of the other chronic nutri- tional or systemic diseases noted in the preceding chapter, sometimes scrofulosis or lymphatism, and so on. This contrasts markedly with the state of affairs in the so- called neurasthenia of adults, which is often associated with almost normal vegetative functions. Nervous irritability may appear at a very early age, even in infancy, though nervous exhaustion is commoner in the very young. When, however, we remember that there is no hard and fast line between these conditions, which are indeed often mutually interdependent, we 334 THE CLIMATIC TREATMENT OF CHILDREN shall have no trouble in recalling infants who showed more fretfulness and capriciousness than nervous ineffi- ciency, and might properly be classed as irritable. The general nutrition of the child suffering from nervous irritability tends to be subnormal, though this is not constant; careful examination will usually elicit one of the deficiencies or diseases mentioned above. In the way of direct etiology, we regularly obtain a history of faulty training; the patient eats unsuitable food and has vicious habits of eating; there is a tendency to ex- cessive mental application and too little life out of doors. Then, there are such items as too much association with older persons, sensationally minded nursemaids, ghost stories, late hours, children's parties, and no end of such other indulgences and perversions as are occupy- ing the time and energies of the young to an increasing extent. The most characteristic symptom in these cases is a disturbance of sleep. In the mildest ones, the child merely finds difficulty in falling asleep, and is apt to wake up occasionally during the night; those more severely affected dream vividly, the apparitions ranging all the way from mere passing impressions to horrible nightmares and night terrors; grinding of the teeth dur- ing sleep and somnambulism are mere variations, and most of the cases of nocturnal enuresis undoubtedly come under this head. Only the very worst cases suffer from real insomnia, characterized by long waking spells during the night, with a tendency to unconquerable drowsiness in the early morning. In this last group, nervous exhaustion is sure to supervene in the course of time, somewhat confusing the clinical picture. VISCERAL DISEASES 335 The child afflicted with nervous irritability is also quite certain to exhibit characteristic manifestations during the daytime. In the first place, it is highly emotional, being moved to tears or laughter by the merest trifles; it has also a morbid fondness for the impressions that produce these psychical outbursts, and often an inclination toward moroseness or introspection, apt to be mistaken for precocity by persons who habitually underrate the intelligence, mental activity and curiosity of normal children. Secondly, such children are fre- quently addicted to daydreaming, a state of auto- suggestibility which they induce in themselves with increasing readiness and profoundness, as the neurotic condition progresses. Thirdly, the temper is highly unstable, the temptation being great to set this down to defective training; it is so in a sense, but not the or- dinary one; these children are not merely spoiled, accus- tomed to having their own way, and without respect for authority; on the contrary, they are likely to be well be- haved toward their elders, and models of obedience under ordinary circumstances. Their outbursts are always more or less irrational, unpredictable, and altogether out of proportion to the exciting causes; they are more apt to disagree with their playmates than with their par- ents or teachers. In our last statements we may, perhaps with some justice, be accused of wandering from the subject, for the general picture we have given bears some resemblance to, and foreshadows, the true psychoses. These are in fact a frequent later phase of the nervous irritability of childhood; degeneration into hysteria is quite common with the approach of puberty, the supervention of one 336 THE CLIMATIC TREATMENT OF CHILDREN of the juvenile forms of dementia is a matter of frequent record, the relation to migraine and epilepsy is more doubtful. In addition, many persons who suffer from various types of insanity in later life, exhibit the above picture in childhood, notably when they bear the heredi- tary taint of a degenerative neurosis or psychosis; in these individuals the symptom group I have called nerv- ous irritability is merely a prodromal stage. Unfortu- nately, it is just the neuropathic parents of such a child who are most* likely to be proud of its "high-strung" disposition, and who overburden its mind in the hope of developing a genius. It is true that genius is peculiarly apt to be associated with just such antecedents, but real genius develops spontaneously, without artificial foster- ing; more harm, indeed, is done by cramming the minds of these children than of those apparently less gifted but better balanced. The main and almost sole indication in these cases is rest; to further this there is nothing so effective as a change of air and scene to quiet, even monotonous, sur- roundings. In this regard the matter of climate is not indifferent, knowing; as we do, that climate may be a powerful stimulant as well as a sedative; as usual, it is easier to caution than to advise, but both are quite feasible. Evidently, hot summers, cold winters, great elevations, excessive drought, and high winds are to be shunned; in addition, of course, we must place an absolute ban on city life, with its nervous wear and tear. Our first object should be to select a fairly genial and moderately moist locality, at a low or moderate eleva- tion, where an outdoor but restful life can be led to its fullest extent. Often, therefore, mere removal from the VISCERAL DISEASES 337 city. to the suburbs will achieve the end in view, for the irritation caused by the constant and fearful noises of an American city renders amelioration impossible; it is to be understood, naturally, that the neighborhood of rail- way stations and factories may impair even a rural site very greatly, for our purpose. Other physical, notably hydro therapeutic, measures, of great value in this con- dition, do not concern us here, and will not be dwelt upon. The clinical picture of nervous exhaustion, in its typical development, is quite different. Combinations of nervous irritability with nervous exhaustion are frequent, and the relative predominance of one or the other of these elements is often puzzling; in treating such cases the wisest plan is to consider the latter first, although the former is usually primary. Cases of nervous exhaustion almost invariably present one of the before-mentioned disturbances of nutrition; the keynote to the entire situation is inadequacy to meet the normal demands on the nervous system; its characteristic psychical expression is best described as apathy. The details previously recounted under the heading of malnutrition fit this group fairly well, if we allow for the relatively greater prominence of nervous, as opposed to visceral, inefficiency. Our procedures also follow closely the rules laid down in the discussion of nutritional diseases, with certain modifications, to allow for the neurotic factor. In the more severe forms, where the affected child seems totally devoid of nervous energy and will power, and disinclined to anything like physical or mental exertion, even play, we must begin with a somewhat 338 THE CLIMATIC TREATMENT OF CHILDREN relaxing climate, that permits sitting and lying in the open air most of the day, without having to consider the question of warmth; the last point presents some little difficulty, in that these patients require a temperature somewhat higher than is advisable for normal children. After distinct improvement has set in, a more bracing climate should be sought without delay, for enervation is particularly undesirable in neurotic patients. On the other hand, it is a grave error to inaugurate the treat- ment of severe cases with removal to a mountain resort, and the benefit of high altitudes, even when improve- ment has clearly set in, is very doubtful. S. Brown 1 and Pearce 2 have pointed out that the limit for bad cases is a few hundred or, at the most, 1,000 to 1,500 feet; as progress is noted an ascent may be made to 3,000 feet, but this is the outside extreme. In the Rocky Moun- tain districts the intense stimulation of bright and almost unremitting sunshine, sudden and frequent changes of temperature, and the excessive dryness Of the air, is apt to aggravate rather than ameliorate the child's condi- tion; 'insomnia is apt to come to the front as a distress- ing and ominous symptom. The good results noted by Determann 3 and Krafft-Ebing 4 in certain phases of the torpid neurasthenia of adults bear little if any relation to the subject here in hand, the type of disease referred to is of more than doubtful occurrence before adoles- cence. We may, furthermore, even at the risk of ap- pearing wearisome through repetition, again refer to the different reaction of children, as opposed to adults, with 1 New York Med. Journal, July 17, 1897. 2 Ibid. October 5, 1901. 3 Loc. cit. 4 Nothnagel, spec. Path. u. Ther., vol. 12, part 2. VISCERAL DISEASES 339 respect to hardening procedures, among which removal to cool climates at high elevations unquestionably be- longs; in fact, Hecker, 1 as before stated, observed that systematic hardening entails conspicuously bad results in this very group of children. The more bracing seaside resorts are almost or quite as harmful in the severer stages of this neurosis. We may again refer to the remarks by Ide 2 on the over- stimulation due to high winds and excessive sunlight, including its reflection from the water, sand, and rocks; these agents have anything but the sedative effect that is urgently demanded by the victims of nervous exhaus- tion. In milder cases, however, or in the severer ones when a distinct improvement has been noted, such mild seaside resorts as southern New England and Long Island from June to October, and the South Atlantic Coast during the winter, with Atlantic City or Old Point Comfort as an intermediate station, may be chosen with every prospect of success. The west coast of Europe is, speaking generally, rather too stimulating; Perier, 3 for example, does not recommend either the Channel or southwestern resorts for neurotic children, though he looks on the Mediterranean shore with favor. It appears, however, that the resorts along the English Channel and the Baltic Sea, as well as on the New England Coast, from Bar Harbor southward to Boston, are invaluable as an after-cure, when also sea bathing, cautiously ad- ministered, is sure to be beneficial. The really raw marine climates, such as are found in our far Northeast or Northwest, or along the North Sea, are best avoided 1 Loc. cit. 2 Loc. cit. 3 Loc, cit, and Annales de med, et chir. infantiles, 1899, p. 613. 340 THE CLIMATIC TREATMENT OF CHILDREN altogether; the more so as sea baths are entirely out of the question in those parts. Our main reliance in treating the neuroses of children are the low or slightly elevated inland localities, where our range of choice is fortunately ample, for the exact temperature need be regarded only in the very severe cases. Such places as the Italian Lake Region, southern Tyrol, the Lake of Geneva, praised by Bergougnian/and our southern Alleghanies, are not too cold, even in mid- winter, for the milder neuroses, save possibly in excep- tionally severe seasons ; all the warmer stations, short of those that are actually subtropical, are likewise eligible. Good judgment should, of course, be exercised, and here also, as in the treatment of malnutrition, I should prefer to individualize according to age, and reserve the colder group of resorts, during the winter months, for children of the school age; they are, however, excellent spring and autumn stations for all ages, and cannot be recom- mended too highly in this respect. In summer, all the moderately elevated sites, in the Middle Atlantic and New England States, as well as central Europe, are available and quite sure to be useful. In the Pacific States a choice must be made with some care, but the great valleys of western Oregon, and many places in the interior of Washington are quite good from June to September, the dry season. A few words may be added on nervous exhaustion in infants, of which Northrup 2 adduces some typical examples at ages of only a few months. In such cases the home surroundings are so evidently at fault, that a 1 La p&Iiatrie pratique, 1903, No. 3. 2 Archives of Pediatrics, January, 1905. VISCERAL DISEASES 341 change of climate will effect little, if anything, unless assisted by a correction of the mismanagement of the baby, and the installation of an intelligent nurse. With these improvements, however, satisfactory results may often be attained at home, and a long trip avoided, though frequently, in the colder months, removal to a genial climate, and in summer a stay in the country, will facilitate a cure very materially. This phase of the subject is only now arousing attention, but its importance cannot be overrated ; it is reasonably certain that many cases of nervous exhaustion in children have been as- siduously cultivated from earliest infancy. Enervation. The condition somewhat loosely called enervation, referred to so frequently in this work, is of particular interest to the medical climatologist, and merits an extended discussion. We may begin by observing that enervation is not properly a form of nervous exhaustion, but of debility, analogous to the condition in the muscular system called flabbiness, as distinguished from tiredness. It is characterized by a deficiency in reactive power in responding to ordinary meteorological as well as other physical stimuli; the patient has either not been trained to resist untoward influences, or has forfeited this faculty from disuse; he is therefore in a condition the exact reverse of hardened. In addition to distinguishing enervation from nervous exhaustion, we must also differentiate it from certain types of neurasthenia, common in adults, but rare or unknown in children, where the symptom of sluggishness is the misleading factor; outside of this torpidity, the two diseases have almost nothing in common. I have attempted to draw up a small diagnostic table 342 THE CLIMATIC TREATMENT OF CHILDREN illustrating nervous irritability and exhaustion, and enervation; the reader must understand, however, that the data given therein are to be employed only as guides. Combination of any two or all three of these neuroses are quite common; the one fact alone, that the enervated nervous system is especially liable to overexcitation or exhaustion accounts for this circumstance sufficiently. Nervous Irritability Nervous Exhaustion Enervation 1. General appearance neurotic apathetic flabby normal or sub- normal subnormal above normal 3. Susceptibility to physical normal increased very great 4. Emotional susceptibility. excessive subnormal normal " capricious subnormal 6. Psychical energy excessive subnormal normal or sub- normal 7. Vegetative functions .... irregular subnormal sluggish The observations under the first heading characterize these three groups well, in a general way. In enervation, as will be observed from the table, nearly or quite normal mentality is associated with a subnormal physique, in nervous exhaustion the impairment is more diffuse, but affecting the psychical functions rather more than the physical. The keynote to nervous irritability is capri- ciousness and unstableness. The etiology of enervation consists essentially in pam- pering and coddling. The patient has lived in too warm and even a climate, or has been protected from adverse weather conditions more than necessary or advisable. It is, therefore most apt to be encountered among the resi- dents of southern latitudes or well-to-do families farther VISCERAL DISEASES 343 north. The logical treatment, of course, is hardening, and this might be adopted in the adult at once and with considerable strenuousness. We have, however, seen the untoward effects of severe measures in young chil- dren, and must therefore modify this plan very materially at that time of life. Transfer to a cooler climate, be- ginning in the late spring, whenever possible, is perhaps the least harmful method of hardening, and we may thus gradually accustom such children to northern weather; To advance to this degree is, of course, only desirable if a permanent change of residence is held in prospect, otherwise it is quite useless to go to the trouble of gradually inuring southern children to the rough con- ditions of higher latitudes. For such as are to return South, removal for the summer only is called for; the locality selected should be decidedly cool, averaging 64 to 66 degrees for older children and 68 to 70 for infants, in July and August. A good practice for residents of such very enervating climates as that of our Gulf Coast is to send their children North toward the end of April or beginning of May, when the mean temperature rises into the seventies, arid not permit their return until well on in October. Such a measure naturally entails heavy expense, also consider- able trouble, but the reward is reasonably sure, for the summer of the far South is extremely injurious to very young children, making them excessively susceptible to the first cool nights of September «or October, even when the summer itself has passed without severe illness. It is worth noting that children born in the North have great difficulty in becoming acclimated in our southern- most sections; they become badly enervated in a few 344 THE CLIMATIC TREATMENT OF CHILDREN months, apparently far more thoroughly than the natives, and the consequences are most serious. It is commonly assumed that the chief danger to such children lies in acute or chronic diseases of the alimentary tract; this peril does exist, but is exceeded by the extreme risk of contracting fatal respiratory affections from trivial ex- posure. Crombie 1 has effectively dwelt on this circum- stance in the typically, but not in the very highest degree, enervating climate of India, where the mortality of pneumonia in young children amounts to fifty per cent., though the morbidity from that disease possibly does not equal that of northern regions. We have noted, in the first chapter, the high death-rate from this disease in our southeastern states; the cause is undoubt- edly the same as in India. Insomnia. The question whether or not a patient is suffering from insomnia is not to be decided merely by counting the hours of sleep, but requires a somewhat complicated and searching analysis. Holt gives the normal amount of sleep as follows : Age Hours 14—15 13—14 11 — 12 10—11 9—10 Children vary, however, very much as do adults; a range of an hour or more in either direction is still com- patible with normal health. The seasonal variation must likewise be regarded; about an hour less than the above figures is required in summer, as much more in 1 British Medical Journal, Sept. 14, 1901. VISCERAL DISEASES 345 winter. A child of one year may, therefore, demand as much as 17 hours of sleep in winter, and as little as 12 in summer, without the necessary inference of anything pathological. A history of interrupted sleep is most important; never quite normal in the adult, it is distinctly morbid in childhood, and if not dependent on external influences (noises, etc.) or physical pain, becomes an exquisitely neurotic manifestation, usually associated with general nervous irritability. It is rare to note this symptom without evident sequelae in the early waking hours, such as general torpor, peevishness, and an impaired appetite at breakfast;, indeed, the absence of all of the latter symptoms justifies a skeptical attitude as to the entire history. As previously mentioned, the severe types of insomnia are rare in children; it is therefore all the more essential to look out for the minor form just described, which is likely to be the precursor of more serious disturbance. With regard to the influence of climate on insomnia, we may begin with reference to the data in MacFarlane's admirable monograph. 1 Adverse influences are severe cold, intense heat, especially when associated with a high humidity, and high elevations. As to the first, we must, of course, differentiate from the deepening and ultimately fatal coma that results from a marked lower- ing of the body temperature; the first effects of a low temperature are irritant, and contribute to wakefulness. The irritation due to great heat and humidity has already been touched upon, and the general relative anaemia, with its inevitably concomitant cerebral irritation, 1 Insomnia and its Therapeutics, New York, 1890. 346 THE CLIMATIC TREATMENT OF CHILDREN following removal to high levels, has also obtained ample notice in the first chapter. The effect of the seaside has been recorded variously as favoring or relieving insomnia. MacFarlane's remarks as to the former may very well apply to the cool and bracing northern coast resorts, whereas the American and other references to the sedative influence of the sea air are certainly more generally applicable. Still, Pearce x reports a case that suffered from the high winds at Atlantic City, but obtained relief at Philadelphia; it is doubtful if any other city in this country can boast of a parallel achievement, save possibly in the outer suburbs. All authorities seem to agree on the benefit to be derived from a sojourn at moderately elevated and reasonably mild inland stations. The Spasmodic Affections. For our purposes we may throw this heterogeneous assemblage of diseases under one heading, to save space. Chorea, of the rheumatic type of Sydenham, requires detailed and distinct con- sideration, for, apart from any associated articular or cardiac symptoms, it is likely to undergo considerable amelioration in a suitable climate. We may distinguish between two sets of chorea cases, namely, the mild and the severe, as they present a clinically very different picture, and call for entirely different treatment. The milder cases, well nourished, and in generally fair condi- tion, require only the moderately sedative regimen indicated in other cases of nervous irritability. The severe cases, however, which present symptoms of physi- cal as well as nervous exhaustion, are often serious enough to call for rest in bed as a preliminary treatment, followed 1 Loc. cit. VISCERAL DISEASES 347 by removal to a very mild and sedative climate, even one of those near the enervation point, which are too relaxing for most invalids. After all', however, we are here apply- ing a treatment similar to that advised for nervous ex- haustion, only in a still higher degree. Of course, as progress is noted, it is well to transfer the patient to a more bracing climate; in any case, several months will be required for a cure. The habit spasms, including tic convulsif and stam- mering, may be benefited by the treatment accorded to cases of nervous irritability in general, of which they are common manifestations. The nodding spasms of infancy are generally associated with a nutritive disturbance, usually rickets; here the indication is to treat the under- lying condition. Epilepsy is amenable to climatother- apy only to the extent that a good climate will benefit anybody. The secondary spastic conditions associated with spinal disease require no separate treatment; we need attend only to the patient's general condition. As a rule, the plan outlined for malnutrition will yield the best results; I would also call attention to the recommend- ations in the following paragraph, concerning the at- tendant paralytic affections. In the spinal diseases of children we regularly find contractures and paralyses combined. The Paralytic Affections. These call for climatic treatment only indirectly. Children afflicted with par- alysis require an abundance of fresh air, but naturally cannot avail themselves of exercise to any extent worth mentioning. They, therefore, necessarily require a milder climate than such as are able to move about freely, and 348 THE CLIMATIC TREATMENT OF CHILDREN must frequently be taken away from home for this reason. Other things being equal, the seashore com- mands our first choice; the moist and equable air from the ocean is particularly grateful to these little sufferers, and a judiciously followed course of sea bathing rarely fails to benefit the general health. In the management of the individual cases many variations will suggest themselves, such as a tolerably bracing climate in the later stages of poliomyelitis, and a more relaxing one in the earlier stages, before improvement has begun to set in; a fairly cool and dry climate in facial palsy, where general exercise is possible, but wet weather does harm; and a very mild region in post-diphtheritic paralysis, where the general condition may be far below normal. This field, as a whole, is rather difficult, and does not admit of the laying down of any hard and fast rules; the patient's state of nutrition is a valuable guide, ranking with the capacity for muscular exertion. In view of the rather empirical administration of climatotherapy to many of these subjects, the wisely discriminating physi- cian will often be astonished at the improvement in cases that made no progress at home; a stationary con- dition in these cases implies deterioration, in view of the secondary changes that are inevitable. It is true that some of these children might likewise have improved under adequate utilization of a fairly good home climate, but. it is a matter of daily observation that the mere reference to a well-known health resort seems to reawaken the dormant or flagging interest of* the parents. The recommendations of the attendant as to exercise, diet, bathing, etc., are invariably carried out with greater fidelity and exactness at a watering place than at home. VISCERAL DISEASES 349 The Painful Neuroses. These play a comparatively small role in childhood, but we may nevertheless touch upon a few items of interest. Facial neuralgias in chil- dren are usually secondary to otitis media or dental caries, and call for treatment of the primary affection; a few cases, however, are independent of any such con- nection, and are then likely to improve on removal to a warm and dry climate. The relation of neuralgia to meteorological conditions is precisely similar to that described in the case of rheumatism (page 274) ; in this connection we may cite an interesting case reported by Weir Mitchell, 1 in which, during seven years, every storm brought on a neuralgic attack. Such a patient will naturally do far better in the western half of our con- tinent, where general storms are relatively more moderate and infrequent in the winter months than in the tem- pestuous climate east of the Rocky Mountains; the greater dryness westward would likewise afford the patient relief , as nothing seems to favor neuralgia quite so much as a high relative humidity. The status of migraine among the neuroses is at present in doubt, but a large mass of recent testimony seems to assign to this affection a position among the epileptoid diseases; such is pre-eminently the standpoint of the German school, and my own experience also has taught me to differentiate true migraine from the headaches due to gastro-intestinal intoxication. On the basis of the epileptoid theory, treatment of the digestive tract alone should be supplemented by the regime of rest recom- mended for the other spasmodic neuroses. Mendel 2 1 American Medico-surgical. Bulletin, Mav 16, 1896. 2 Deutsche med. Wochenschrift, 1906, No. 20. 350 THE CLIMATIC TREATMENT OF CHILDREN recommends elevated inland climates in preference to the seashore; the indication thus agrees with that given for the neuralgic affections. Migraine is not at all a rare disease in children, but there are not yet extant sufficient data as to its climatotherapy to warrant more than the above suggestion. The subject has hitherto received little separate or detailed consideration. DISEASES OF THE SKIN The integument is the organ most conspicuously subject to adverse external influences, and might there- fore be expected to manifest great sensitiveness to the vicissitudes of weather and the variations of climate. It is true that modern clothing acts as a protection against these agencies, but its function is imperfect, incomplete so far as the head and extremities are con- cerned, and subject both to mismanagement and neglect because of the dictates of fashion and the stress of poverty. Yet this subject has received little, almost no attention, and one of the least frequent recommendations by the dermatologist is a change of climate. Many cutaneous lesions are quite independent of meteorological conditions,' but this is probably true only of the minority, if we regard the number of our patients, rather than the variety of diseases. It is no exaggera- tion to say that many thousands of sufferers from skin disease can be benefited greatly by a change of climate, and this is conspicuously true of children. Among typ- ically climatic dermatoses, prickly heat (lichen tropi- cus) is a characteristic example, for which removal to a different, in this case, cooler region is an unfailing spe- cific. Frostbites, chilblains, and the chronic • eczema VISCERAL DISEASES 351 of the face and hands from which so many children suffer intensely in winter, are promptly benefited by transfer to a more genial zone. These two groups represent most exquisitely the respective effects of hot and cold weather on the skin, aided by a high degree of humidity in the former ailment, and apparently aggravated by a dry atmosphere in the case of winter eczema, though exces- sively frequent ablutions with cold water seem to play an important part in causing the latter. I have observed patients in whom a winter tour from one of the very damp lake cities (Cleveland) to the drier Middle Atlantic Coast brought on this disease with great promptness, though the temperature at the latter was decidedly higher. Too little attention has been paid to the climatic treatment of ichthyosis, though it is the obvious corollary to the regular alternation of improvement in summer and exacerbation in winter. The objection, of course, holds good that we cannot cure this disease, or rather mal- formation, and that removal to a mild and moist climate is merely palliative. Still such removal, for the winter in moderate cases, permanent in the severest forms, is worth serious consideration, in view of the great discom- fort these patients often experience. As to large groups of other cutaneous affections, it will suffice for us to generalize. In most chronic skin diseases it is not easy to separate climatotherapy from balneology, and these two forms of treatment should be combined more often than is the case. It should not be necessary to point out the absurdity of sending patients afflicted with skin diseases to the baths of northern latitudes in winter, or to the corresponding southern 352 THE CLIMATIC TREATMENT OF CHILDREN resorts in summer, but the importance of a suitable cli- mate is very often ignored. The value of adequate climatological information to the dermatologist seems obvious, but its possession is rarer than we might justly expect; the appropriate combination of climatic treat- ment with the prescribed course of baths will be found invariably to increase the efficacy of the latter. Certain aspects of phototherapy might be referred to in this place, but this department of dermatology is too highly specialistic to be disposed of in a general treatise of this kind; the field, moreover, is still very new, and results are only just beginning to be reported. For an example of what is being done I shall merely call atten- tion to a recent paper by Guhr 1 on the heliotherapy of psoriasis; it is quite likely that we are on the threshold of some very interesting and valuable innovations in treatment, opening up an entirely new field in climatic therapy. 1 Berliner klinische Wochenschrift, April 23, 1906. CHAPTER VII SCROFULOSIS AND TUBERCULOSIS The great bulk of the literature on climatotherapy relates to the treatment of scrofulosis and tuberculosis; the reader will be struck with the abundance of references on this subject, whereas the other applications of cli- matic treatment have not called for more than a few dozen articles within the past decade. It will, there- fore, be a relatively easy task to handle this chapter in a fairly thorough manner. In the adult the discussion of tuberculosis of the lungs covers practically the entire field, the other forms of this disease being numerically unimportant. In childhood the situation is altogether different; in the first place the more or less restricted involvement of the lung alone is extremely rare in infancy, and becomes comparatively common only toward puberty; secondly, childhood is characterized by polymorphous and more or less gener- alized tuberculous manifestations, besides an enormous group of affections, of which the tuberculous character is either obscure or doubtful. It is easy to see that the study of thjs subject in the young is not only broader and very much more comprehensive, but that it must also be regarded from a somewhat different point of view; in addition there is the constant differential appropriate to early life, which has been so often referred to on preceding pages. 353 354 THE CLIMATIC TREATMENT OF CHILDREN We can take up the entire question most advantage- ously by beginning with a consideration of the tuber- culous and pseudotuberculous affections peculiar to infants and children, commonly designated as scrofulous. SCROFULOSIS AND LYMPHATISM. In a monograph of this kind, concerned essentially with therapeutics, it is quite a serious venture to enter on an extended discussion of the relations to one another of tuberculosis, scrofulosis, and lymphatism, especially as complete agreement on the subject does not yet exist. A few remarks, giving a brief outline of the opinions at present prevailing, are, however, necessary and may not be superfluous. Cornet, 1 in his well-known monograph, distinguishes the following forms of scrofulosis: 1. Tuberculous, caused by the tubercle bacillus; 2. Pyogenic, resembling the former very closely Clinically, but caused by streptococci and staphylococci, not necessarily progressing to the formation of an abscess; 3. Mixed tuberculous and pyogenic infection. The second group, only apparently tuberculous, yet undistinguishable save by refined laboratory methods, leads up to a series of cases that have often been caHed scrofulous, but are as frequently, nowadays, designated as manifestations of lymphatism. The term " lymphat- ism " at present includes a wide or narrow field, according to the taste and fancy of the author; for my part, I prefer to limit it to that group of infants and young chil- dren who have been variously described as suffering 1 Nothnagel, specielle Pathologie u. Therapie, vol. 14, SCROFULOSIS AND TUBERCULOSIS 355 from thymic asthma, congenital laryngeal stridor, or the status lymphaticus. The almost universally accepted view that this clinical picture rests on a glandular hyper- trophy, with marked predilection for the thymus gland, surely does not fit all cases, for such recent reports as Koplik's 1 show that many cannot be accounted for by enlargement of the thymus gland alone, and that lym- phatism represents a constitutional condition, related to those discussed in Chapter V. I have referred to this group here merely because of its clinical relation to the scrofulous glandular affections. A few words may also be added in connection with the adenoid hypertrophies of the upper respiratory and faucial regions, which were once regarded as typically scrofulous, but afterwards became relegated to the status of a local affection. The fact is that either aspect of the case may be correct, according to the individual. The majority of cases seem to be merely secondary to local inflammatory lesions, and I have therefore referred to them under the heading of chronic rhinitis and allied affections; there is no good reason, however, why they should not be placed in Cornet's second group of scrofu- losis. The maintenance of this standpoint is made the more justifiable through the researches of Wood 2 and others, who found tuberculous deposits in a fairly large percentage of these hypertrophies. It is clear that an accurate distinction is not within our clinical resources, and that these glandular affections may be dealt with here as properly as in the other connection mentioned. Fortunately, all the above theoretical considerations 1 Archives of Pediatrics, December, 1905. 2 Journ, of the Amer, Med, Association, May 6, 1905 f 356 THE CLIMATIC TREATMENT OF CHILDREN have no great modifying influence on our therapeutic procedures, so far as the selection of a beneficial climate is concerned. ■ The indication in the entire group calls for a system of gentle hardening, applied, of course, with considerable regard to individual circumstances. It is much to be regretted that American authors have almost entirely neglected this extraordinarily interesting and important subject, whereas the contributions of foreign observers would fill many volumes; those quoted at intervals below constitute a relatively small part of the total. The seashore seems most favored by competent au- thorities, even in fairly cold regions. Thus Rode 1 re- cords very favorable results at Norderney, where the children do well even in the stormy but not intensely cold winter months; warm sea-water baths are adminis- tered three times a week. The other German sanatoria report similarly good results under similar management; a marked improvement is said to be effected in six weeks. Grebner 2 rightly claims that the percentage of complete cures would be even higher, if the regulations of the German sanatoria permitted a longer course of treatment; at present it amounts to about a third of the children admitted, though nearly all the remainder show some improvement. The French sanatoria have reached a somewhat higher state of efficiency, D'Espine's 3 recent report from Cannes being especially worth noting; the course of treatment averages five months, against six weeks at Norderney, and this accounts, at least in part, for the good results at that station, though we must not 1 Loc. cit. 2 Jahrbuch fur Kinderheilkunde, 1896, vol. 42. 8 Archive de medecine des enfants.. 1904. SCROFULOSIS AND TUBERCULOSIS 357 forget that Cannes is about twelve degrees warmer in winter, and has two or three times as many pleasant days. At the French sanatoria on the Mediterranean it is the custom to give the children sea baths through the winter; they are not intermitted even during cold spells, when the thermometer is near the freezing point. So strenuous a procedure seems to me of rather doubtful merit, in view of what we have learned of the effects of cold baths; the Mediterranean is remarkably warm in winter, but its temperature along the Riviera averages only 55 degrees in January and February; I am inclined to believe that these baths might well be exchanged for warmer indoor sea-water baths from December to March or April. D'Espine admits that the summer at Cannes is a little too warm; its temperature is similar to that around Delaware Bay; there is therefore considerable risk of enervation at that season. Dining the warm months, however, there still remain the resorts on the Bay of Biscay and the English Channel, on which Perier 1 and Robin and Binet 2 bestow the highest possible praise. Along the Bay of Biscay the water is. sufficiently warm for short sea baths in summer and early autumn. Weber and Foster 3 recommend the winter stations on the north shore of the English Channel only for robust children; for cases showing marked enfeeblement they decidedly prefer the Riviera. This opinion diverges somewhat from those we have quoted, since the Isle of Wight, for example, has a winter temperature about half way between that of Norderney and the warmest points on 1 Loc. cit. 2 Archive gen. de medecine, July 21, 1903. 3 See bibliography. 358 THE CLIMAT-IC TREATMENT OF CHILDREN the Riviera, with a fair number of sunny days, while the summer climate along the Channel is about the best in Britain. When we proceed to balance these opinions, we must consider that the German and French reports embrace a larger and more scientifically gauged material, whereas the British observers seem to have made a more thorough study of climatic minutise, often such as cannot be recorded by instruments of precision. An important point in deciding on the seaside in scrofulous cases is the presence of a dry catarrh; a ten- dency to febrile temperatures and pulse frequency also argues for one of these resorts, but in such subjects any tendency to bleakness should be avoided. Turning to American resorts, hitherto so sparingly exploited, we may find climates similar to the above from Long Island to northern Florida in the east, and from San Francisco to San Diego in the west, during the winter months; those farther north are too cold on the Atlantic side, and too wet and stormy on the Pacific. Of the eastern stations those north of the Virginia capes are somewhat too severe from the middle of December until the end of March, save for fairly robust children,- Atlantic City being quite as cold in winter as the North Sea coast of Germany, though far less cloudy; both have a tendency to high winds, which are apt to be damp and mild along the North Sea, but dry and piercingly cold in New Jersey, with temperatures at times near zero. All the stations on our Great Lakes are too raw, even the mildest are subject to violent storms and deep snow. In summer it is wise not to select climates that tend to enervate, and I should set New Jersey as the extreme southern limit even for enfeebled children; the coast SCROFULOSIS AND TUBERCULOSIS 359 east and north of central Long Island is far preferable. In general it is safe to follow the rules laid down in the discussion of enervation. As to sea baths, we have noted the wide variations on our coasts, but may say that at the Atlantic stations, from Massachusetts south- ward, the water is often sufficiently warm in midsummer for a fairly long immersion that would be harmful in the colder waters of the Calif ornian or west European coast; we again repeat our caution against excess, and our counsel as to the avoidance of a strong surf. With these ample opportunities afforded on our side of the Atlantic, it is pitiful to record that our summer seaside sanatoria are both insufficient in number, and grant the patient far too brief a stay. As to winter sanatoria, but one exists/ opened so recently as the fall of 1904, whereas in effete Europe they have been flourish- ing for over half a century, the coasts being at present plentifully dotted with them. Inland resorts have been advocated less than those by the seaside ; they have certain advantages when there is an attendant moist catarrh, and in the obstinate and un- varying torpid cases presenting lethargy as a prominent feature. In treating these groups exposed plains are not so desirable as moderate elevations with a good wind shelter; the excellent results obtained at the German ^ and French hill resorts may very well be repeated here, choosing such regions as the southern Alleghanies in winter, and the northern mountains in summer. In the former season the lower levels of the arid Southwest are also worth trying; Phoenix and Tucson are possibly a trifle too dry, but otherwise admirable, whereas San Diego and Los Angeles are a little too moist and relaxing 360 THE CLIMATIC TREATMENT OF CHILDREN except in the case of very young, neurotic, or very delicate children. The more robust scrofulous patients urgently call for a considerable amount of hardening. In Europe flattering results have been achieved by combining one of these inland resorts with saline baths, furnished at a number of spas that afford a delightful climate between May and September. At these places it is possible to furnish a brine much more concentrated than sea water; 1 solutions up to ten per cent, and more are employed in treating the more robust subjects, where- as feebler ones do better by beginning with the isotonic strength of 0.9 per cent. The baths should be prolonged and warm, 95 degrees for enfeebled children, reducing to 86 degrees for the more hardy ones. The indifferent temperature appears to be lower in salt than in fresh water, and the last-mentioned temperature is sufficiently high for a prolonged immersion in many cases. The rationale of this treatment is thought to lie in a general stimulation to metabolism, undoubtedly some- what conj ectural as to its finer details. For a good account of brine baths, their action and employment, I would refer to an article by Keller. 2 Anything like routine treatment is apt to be harmful, and the exact procedure must be left to an experienced resident physician. A bath of this sort is readily prepared; still, there has been no attempt made to introduce this treatment in our country; experience is altogether lacking on this side of the Atlantic, although we possess an ideal locality for carrying it out at the popular resorts near Salt Lake City, 1 The ocean contains 3.5 per cent, of salts, the Baltic Sea 0.7, the Great Salt Lake 22.0; the waters of Kreuznach (near Bingen) con- tain 1 .3, of Reichenhall (Bavaria) 23.0 per cent. See page 196. 2 Correspondenzblatt fur schweizer Aerzte, 1891, No. 8. SCROFULOSIS AND TUBERCULOSIS. 361 where the climate also is eminently suitable during the greater part of the year. It has been suggested that the employment of natural brines is preferable to artificial salt solutions, and that much of the effectiveness of the former is due to the radioactivity of certain ingredients. This statement still requires confirmation, before it can be accepted as a definite fact. Reports from inland resorts are somewhat less numer- ous than those from the seashore, but almost equally favorable. Hurlimann 1 shows that a majority of the cases are cured in an average of six months at ^Egeri, near Zurich, the reports collected by Mouti, 2 relating to the' treatment with saline baths are still more glowing, and rival those from the seashore. Practically all the very scanty American reports refer to inland stations at moderate altitudes, but they amount to little numer- ically and cannot be successfully utilized for purposes of scientific demonstration. Bergougnian 3 speaks highly of Evian-les-Bains, on the Lake of Geneva, and the other French observers do not dissent entirety, though they consider their exceptionally good seashore climate preferable. The vast similar area in New York and New England, as well as in the higher southern Alleghanies, is surely calling for similar endeavors on the part of our pedia- tricians; in this country .the advantage of the seashore over a large number of available inland resorts, at moderate elevations, is less evident than in France. 1 XVII Jahresbericht der Ziircherschen Heilstatte bei ^Egeri, etc., Zurich, 1902. 2 Die Kinderheilkunde in Einzeldarstellungen, Heft 8. Berlin and Vienna, 1889. 3 Loc. cit. 362 THE CLIMATIC TREATMENT OF CHILDREN As to the higher altitudes, I think that we must agree with Cornet 1 in reserving them for so-called after-cures. An exception may be made to the extent of sending older children, whose general condition is tolerably ro- bust, to Colorado or New Mexico, where the winter has but few intensely cold or stormy days, and there is little snow. Cornet's remarks refer to the higher Alps, where the winter is certainly too severe for delicate children, and the summer is also rather cold. The mere elevation is not a very serious objection, though not to be dis- regarded by any means. To expose an enfeebled child to the winter climate of the Adirondacks is often nothing less than cruelty; the little patient is likely to suffer intensely from the severe cold, and the high ratio of cloudy and stormy days also acts as a depressant. The methods worked out in treat- ing tuberculous adults cannot be safely applied to scrofulous children; now and then, however, an older patient, in or near the teens, may- do well in a rather rough climate, especially if a generally good condition be associated with purely glandular involvement, par- ticularly of the very chronic pyogenic type. TUBERCULOSIS Many volumes could easily be filled with the literature on the medical climatology of tuberculosis; one might fancy that the specific for this, the most destructive of all chronic diseases, had been discovered. The trend of thought, however, that characterizes the communica- tions flooding medical journalism in these latter days shows clearly that a reaction has set in; the authorities 1 Op. cit. SCROFULOSIS AND TUBERCULOSIS 363 are beginning to doubt if any particular climate is of superior value in the management of this affection; one might almost fancy that the experience of decades had been resting on a delusion. This embarrassing situation, of recent development, is the result of a fallacious course of reasoning, not very difficult to account for. Some years ago, it was the general opinion that the victim of tuberculosis, at least in its earlier stages, should seek the coldest and roughest climate obtainable, so as to be hardened as expeditiously as possible, and enabled to check the progress of the disease by an increase of his resisting power. When patients treated in milder regions were found to do just about as well, it was hastily argued that the element of temperature was not so very important after all; simi- larly, the excellent results achieved in our moist eastern mountains, almost equaling those obtained in the extremely dry climate of Colorado, seemed to relegate the matter of the relative humidity to the background, though a lame effort is still being made to class our eastern hill climate, as well as that of- the Alps, as dry, to save an exploded theory. We are naturally led to ask if such a thing as a climatic phthisiotherapy really exists. The answer is best furnished with the aid of an historical retrospect. In the middle of the nineteenth century it was still good practice to send tuberculous sub- jects to the warmest possible climate, Florida, Madeira, and Sicily being favorites, great value being also attrib- uted to the West Indian Islands. Those were the days of the " neglected cold" theory of phthisis, the obvi- ous logical antidote to cold being warmth. From our 364 THE CLIMATIC TREATMENT OF CHILDREN present knowledge of the perils of enervation we readily see why these unfortunates usually succumbed rapidly, in such numbers, indeed, as to make the reaction inevitable. Attempts in the opposite direction, made in our western deserts and plains, also in the higher and more lonely Alpine valleys, yielded results that by comparison were nothing less than brilliant; medical opinion then ran to the other extreme, cold and dryness were deemed to be the essentials, though as a matter of fact the high Alpine climate is rather moist; such inclement regions as the far Northwest and the Adirondack Mountains came into vogue. When, however, reports from milder regions, some indeed semi-southern, showed similarly good re- sults, the essential element of a' successful phthisio-ther- apy was decided to be merely a sound system of general hygiene. Here the matter seems to rest at this date, at least in the opinion of very many. It is not a difficult matter to prove that this point of view is mistaken. In the first place, the sanatoria in mild regions, such as the vicinity of New York City, do not benefit their patients much during the summer months, when the mean temperature exceeds 68 to 70 degrees. Secondly, we begin to hear complaints from southern California of the general infection of a previously immune population with tuberculosis, which would be impossible were that climate really very unfavorable to the progress of this disease. The specialists have now agreed that southern California is too warm for the best results, and reserve this region for enfeebled and ad- vanced cases, who would often do better to stay at home. Thirdly, we need merely repeat the old untoward ex- periences in the truly subtropical climates. It is plain, SCROFULOSIS AXD TUBERCULOSIS r 365 therefore, that warm weather and warm climates are not salutary to tuberculous patients, the reason, as before stated, being the rather rapid development of enervation and a lowered resistance, the early stages of which prob- ably existed at the onset of the disease and invited its invasion. On the other hand, intense cold is not a necessary therapeutic factor. There is indeed that type of winter weather, with a mean temperature near the freezing point, which in a moist climate involves frequent al- ternations of snow, sleet, frost, thaw, and rain, with a general average of sloppiness and muddiness, and is ob- jectionable on account of its interference with outdoor exercise and a tendency to fogs. TYhen, however, the temperature keeps well above or below that point most of the winter, also when the amount of precipitation is small, the stated objections do not obtain. The intense cold of the far Xorth or at high elevations is depressing to all but the robust ; during the prevalence of temperatures below zero careful attention is needed to keep the pa- tients comfortably warm; in the case of children, who nearly always lack the prerequisite of robustness, the very cold climates are to be recommended only in excep- tional cases. Thus we have a difference between the respective management of children and adults, winch at a first glance appears fundamental, yet is not so in reality, for the treatment that might well be called sub- arctic is now well known not to be essential, as it repre- sents an extreme attitude. Judicious hardening is as important in the treatment of tuberculosis in children as in adults: we have seen what limitations must be applied to a scheme of hardening in young subjects, but 366 THE CLIMATIC TREATMENT OF CHILDREN the general principle remains the same for them as for older persons. The polymorphism of tuberculosis in children, as com- pared with the overwhelming preponderance of local- ized pulmonary involvement after puberty, has already been referred to. The adult lesion is very rarely, if at all, foimd by itself in infants, who are so susceptible to the ravages of the tubercle bacillus that the infection in them has a disastrous tendency to become generalized and assume the rapidly fatal miliary type. After the age of three or four years there is a greater tendency to localization, but here also conditions differ from those in later life, in that the bones and serous 'membranes are far more apt to suffer than the viscera; there is also a decided predilection for the extensive or even universal lymphatic involvement which has been discussed under the heading of scrofulosis. During the years of school life, however, the transition to the adult types of tuber- culosis becomes increasingly manifest, so that by the twelfth year the ordinary pulmonary lesions become quite frequent, though their course still tends to be rapidly progressive. Thus tuberculosis in childhood is in every way a matter apart from the phases of this infection as ordinarily understood. It is plain that we can dispose of our subject to greater advantage, and derive more satisfaction from its study, if we divide the entire field, aside from such mild forms as have already been discussed under the heading of scrofulosis, into the two divisions of surgical and visceral tuberculosis, and pay separate attention to the climatic management of each. Surgical Tuberculosis. The majority of tuberculous SCROFULOSIS AND TUBERCULOSIS 367 children, especially between the ages of four and twelve years, belong to this group. Their treatment closely follows that outlined for those afflicted with scrofulosis, so that authors like Cornet consider them under the same title, and draw no dividing line between them. For our purposes also, it will not be necessary to repeat what was dealt with at length in the preceding paragraphs; we are here called upon to refer only to certain details re- garding procedure and results. To begin with, a sufficient duration of the treatment of surgical tuberculosis cannot be urged too strongly; we have already noted the weak point of the German sana- toria in this regard, and can readily see why Keller 1 says that the results are only fairly good. At the Asyle Dollfus at Cannes children have been kept for eight months, and at other French sanatoria a year or more. Thirty per cent, of cures is not an exceptionally good result under these circumstances, some stations claiming twice as high a ratio. Larsen, 2 for the rather raw cli- 'mate of Frederiksvarn, Norway (mean February tem- perature 28 degrees), reports 72 per cent, of cures after an average stay of ten months. Gevaert 3 re- ports good results from Middelkerke, near Ostende, as the effect of an average treatment of eight months' duration; the winter climate there being not much warmer than at Cape May. As to milder climates, we obtain a most optimistic report from Haudek 4 who re- cords excellent results from Abbazia, on the Adriatic, where the climate is little better than at the entrance of 1 Monatsschrift fiir Kinderheilkunde, October, 1903. 2 Norsk Magazin for Laegevidenskaben, 1901. 8 Journal medical de Bruxelles, 1902, No. 10. 4 Wiener medizinische Presse, 1904, No. 46. 368 THE CLIMATIC TREATMENT OF CHILDREN Chesapeake Bay; he also insists on a stay of a year or more, if the case seems to demand it. Older reports have been collected by Monti, 1 Brauer, 2 and Uffelmann, 3 reaching back to 1865. In view of the above mass of statistics, embracing in all no less than twenty-one sanatoria, with the omission of a still greater number, the allowance of a few weeks in summer at our sanatoria for children can be regarded only as a wretched apology for treatment. The patients cannot possibly derive any permanent benefit from such a makeshift ; they may pick up a little under the influence of the purer air and better food, but are usually returned to the tenements before the summer is over, and are almost certain to relapse into their original state within a very short time. It is therefore pleasing to note that an attempt has at last been made to establish a winter sanatorium for children in this country. The beginning was made at Coney Island in the winter of 1904-5, and the municipality of New York is apparently making an earnest effort to take up this subject seriously and with a true appreciation of its vastness. Brannan 4 has re- ported concerning this first experiment at Coney Island, on a very small scale, which was an achievement of private philanthropy; 5 unfortunately, the winter was exceptionally cold, averaging 27 degrees instead of the normal 32, and the results obtained were only fairly good. This was possibly due in part to the excessive amount of snow, and to the prevalence of high and intensely cold northwest winds, but much may also be 1 Op. tit. 2 Dissertation, Berlin, 1886. 8 Archiv fur Kinderheilkunde, 1881, vol. 2. 4 Medical News, November 11, 1905. 5 Adequately endowed on June 30, 1906. SCROFULOSIS AND TUBERCULOSIS 369 set down to the shortness of the course of treatment, the defect adversely commented on in connection with the German sanatoria. It remains an open question, whether the climate of the coast near New York is not a little too cold and exposed for the best results, and the unusually mild and sunny winter of 1905-6 (average temperature 36 degrees) will not tend to clear the situa- tion, for the next report is certain to be better, under such exceptionally good meteorological conditions. The Long Island coast has, however, the incontestable advan- tage of abundant sunshine in winter, in which the re- sorts of western Europe are deficient, and in particular a highly salubrious climate in the autumn months. The spring is rather changeable, and the summer often so sultry that it is doubtful if this region is really very beneficial in surgical tuberculosis during July and August. At any rate, repeated trial is urgently called for before giving up so promising a project, which has a half century of European experience to back it. The attempt to found a sanatorium farther south would entail heavy additional expense, besides involving an almost insoluble question of jurisdiction in case of an official or semi-official enterprise. Moreover, the hostil- ity to sanatoria for tuberculosis is at present growing apace, knowing neither reason nor common humanity, and cannot be ignored by the state authorities, even if the legal difficulties prove quite surmountable. The older physicians made a distinction between the erethitic and torpid types of scrofulosis and tuberculosis, which has some relation to climatic treatment. The erethitic type comprises " delicate" looking children, slender in build, with an almost transparent skin, poor 370 THE CLIMATIC TREATMENT OF CHILDREN .development of adipose and muscular tissue, and a neurotic temperament; the torpid type includes heavily built, often quite stout and active children, of a phleg- matic temperament. It is evident, of course, that these groups represent respectively opposite degrees of sus- ceptibility to, or virulence of, the tuberculous infection; naturally, also, a very large proportion of our young patients will occupy an intermediate and perhaps inde- terminable position. Often every factor in each case will have to be carefully weighed, if the most appropriate treatment is to be inaugurated. The main point is that torpid cases may at once be submitted to a plan of hardening at cool seaside or moun- tain resorts, whereas this method is very apt to injure the severer erethitic cases at the outset. Perier, 1 who recommends the seashore whenever possible, urges the re- moval of the latter patients to a fairly warm inland resort, at least to begin with ; the colder climates are probably best avoided altogether, except as an after-cure. An element that we must not disregard in the manage- ment of these children is the harmf illness of too much physical exercise, but when a rather sedentary life is to be led, a mild temperature becomes absolutely necessary, if the child is to spend most of the day in the open air. The torpid type of surgical tuberculosis is one of the few conditions in which we can recommend a sea voyage; Weber, 2 Williams, 3 and Doyle 4 speak highly of this procedure, and furnish good evidence of its efficacy. The main thing is that a tour of ample duration, like the 1 Loc. cit. 2 Loc. cit. . 3 Edinburgh Medical Journal, March > 1905. * Lancet, 1890, vol. 2. SCROFULOSIS AND TUBERCULOSIS 371 popular one to the Mediterranean, be chosen, and that the child be under really good and intelligent manage- ment; in that event considerable improvement may be looked for; cruises in the tropics or in notoriously stormy seas are, of course, entirely barred. On the trip I have mentioned there is usually the rare advantage of really competent medical attendance, which I consider quite indispensable. We have previously referred to the radical change in the management of tuberculous cases that must be adopted if a renal complication or amyloidosis super- venes, and may refer back to those pages. The immedi- ate cessation of every attempt at hardening is of course not favorable to the eradication of the tuberculous pro- cess, but we are, most unfortunately, reduced to a choice between two evils, when either of these complications turns up, and the underlying affection, while sufficiently serious, is the one less liable to run a rapidly unfavorable course under inferior climatic conditions. Such cases as are debarred from exercise by the locali- zation of the tuberculous process in the lower extremities may require a slightly warmer climate in winter than the others; these patients were, for example, those that showed relatively slight improvement at Coney Island. Sitting in the sun on a very cold day is possible only with perfect shelter from the wind, and the sun is, of course, on the windward (west) side of the sanatorium in the afternoon on our most blustering days; thus a certain proportion of the opportunities for outdoor life is bound to be lost Visceral Tuberculosis. Visceral tuberculosis in the adult signifies; for all purposes, pulmonary tuberculosis 372 THE CLIMATIC TREATMENT OF CHILDREN with possibly secondary implication of other organs, such cases forming perhaps 99 per cent, of the total. In chil- dren the pulmonary lesion is less predominant, particu- larly in the earlier periods of life; during the school age pathological conditions tend more and more to approach those in the adult, so that, at puberty, there is no radical difference from the conditions in later years. In early childhood, visceral tuberculosis has a great tendency to assume the miliary type and become generalized; we therefore rarely have to deal with an isolated affection of a limited area of the lung; intestinal tuberculosis is possibly quite as common, and the occurrence of menin- geal complications is frequent. It is not practicable to regard any case in a young child as incipient, as may often be done in older subjects with perfect safety; we shall do better by our young patients, if we consider every positively diagnosticated case as advanced, for there is almost surely more extensive visceral and glandu- lar involvement than is accessible to our diagnostic methods, and the chances for a rapid spread or miliary generalization are much greater. To state the matter concisely, pulmonary tuberculosis in the young child is usually not a local affection, but only part of a more or less general systemic invasion by the tubercle ba- cillus. The above considerations have a vital bearing on the subject of climatic treatment; to the previously stated objections to sending young children to severe climates we have added the circumstance that the individual case is usually past the stage for such removal. The prog- nosis of these cases is, in fact, far worse than the statis- tics compiled from adult material would suggest; in the SCROFULOSIS AND TUBERCULOSIS 373 first few years of life it is practically fatal, and even at puberty far worse than in the twenties and thirties, partly for the reasons mentioned, partly from the feebler general resisting power, partly because of the objections to entering upon a severe hardening regimen. It may not be superfluous to mention the essential requirements of a good resort for the treatment of pul- monary tuberculosis; there are few matters on which the medical world is so generally in accord. In the first place, there must be ample wind shelter and freedom from dust; the former is obtained by the selection of a well-forested region and a hillside with a leeward expos- ure, which is easterly and southerly in our latitudes, as our worst winds come from the northwest; the latter is secured by fairly frequent and moderate rains in summer and a covering of snow in winter. Secondly, good food, perfect general sanitation, and ample facilities in the way of intelligent medical attendance and nursing, are equally important; the satisfactory combination of these require- ments is hardly obtainable in this country outside the better grade of sanatoria, whereas they can be secured by the ordinary visitor at dozens of European resorts. Thirdly, the tuberculous patient requires good roads and paths for short walks, with abundant seats and benches, the latter to be placed as advantageously, as possible; here also everything has been done in Europe, nothing at American resorts, with but few exceptions. Fourthly comes the matter of accessibility ; this is important only for the poorer classes, as the modern means of travel are rarely very trying to any save advanced cases; the item of expense is the main consideration in this re- gard. Fifthly comes the matter of temperature, which 374 THE CLIMATIC TREATMENT OF CHILDREN is also the easiest to dispose of, for the limits are arctic cold (for children) on the one hand, and enervating warmth on the other, the second being an objection at all ages; this last subject has already received a good deal of attention in this manual, and requires only a few additional remarks, to follow. We must again repeat that, with the exception of children near the age of puberty, the very cold climates are absolutely barred' from consideration. 1 The best resorts are similar to those recommended for the merely scrofulous, when the progress of the disease is slow, and there is relatively little pus formation. The actively catarrhal cases must be referred to inland resorts, which can hardly be too dry. Arizona and the warmer parts of New Mexico are none too arid for cases with free expectoration, provided that there is no laryngeal in- volvement, and the febrile movement is not severe; Egypt is inferior for our purpose, as it can be utilized only during the winter, and thus renders long voyages necessary and frequent. Weber 2 recommends these climates particularly for cases with albuminuria; our discussion of that symptom on preceding pages quite accords with this view. The main objection to the semi- desert regions is the dust; for the cases here spoken of a little aseptic dust is less harmful than a high humidity. The great advantage of the American desert region is the feasibility of removal to the cooler mountain regions of the West, during the summer; these patients do not suffer at high elevations during the warm weather, even if somewhat asthmatic (Weber). 1 See, however, Morse, N. Y. Med. Journal, Dec. 1, 1906. 2 3Loc. cit, SCROFULOSIS AND TUBERCULOSIS 375 Such warm and moderately moist resorts as the Riviera and southern California in winter, and the Middle Atlantic Coast and the Lake Region in summer, are tolerably well suited to the more enfeebled cases, such as have laryngeal symptoms more particularly; but in general it is wiser to send these patients somewhat inland in the warm season. In our discussions on climatology we noted that the seaside is drier than the hinterland in winter and moister in summer; it is wise for the less well-informed to study the humidity tables with some care, and avoid places with figures over 75 per cent. In winter, the colder seashore stations, including those of western Europe more particularly, have proved failures in the phthisis of children, and the same will be found, upon further investigation, to be true in this country north of the 38th parallel. C. T. Williams 1 says that cases with extensive cavities, fibrosis, severe pyrexia, complicated visceral involve- ment, and previous degenerations due to residence in warm climates (enervation), do badly in the mountains; the French and German observers, already quoted, say that they do badly at the seaside. As a matter of fact, they are apt to go from bad to worse anywhere and everywhere, but an attempt should be made to arrest the progress of the infection at mild inland resorts, such as the southern slope of the Alps and the Alleghanies; in the latter it is, of course, understood that some such alternation as North Carolina in winter, and New York in -summer, be carried out. More enervating climates accomplish no permanent good; the patient may feel more comfortable imder their influence, but makes no 1 The Practitioner, June, 1898. 376 THE CLIMATIC TREATMENT OF CHILDREN real progress; the far southern winter resorts should be reserved for hopeless cases, whom it is still kinder to keep at home, if the surroundings there are fairly good. Some of these courses of treatment involve a journey of several days or a voyage lasting a week or two; we may therefore glance at the contraindications to pro- longed travel. Nothnagel 1 thinks that moderate fever does not contraindicate travel; in fact, the temperature often falls and remains normal shortly after arrival. I would not hesitate to send patients with typical hectic fever a comparatively short distance, say 500 or even 1,000 miles, if conditions at home are so unpromising as to lend no prospect of amelioration without removal. Severe diarrhoea, according to Cornet 2 and others, con- traindicates travel, which is both difficult and exhaust- ing under such circumstances; this objection does not, of course, apply to a short ride on a first-class railway, •such as the four hours' journey from New York City to Liberty, N. Y. The ordinary pulmonary cases, with or without com- plications, that affect older children similarly to adults, may now be treated at a number of sanatoria in this country devoted primarily to older persons. These cases are not so numerous as to require the establishment of separate institutions; the results of treatment are similar to those in adults, when the cases are really incipient. As before stated, this point is ascertained with greater difficulty in children than in adults, and we know full well that a too optimistic diagnosis and prognosis is common enough at the latter period of life. 1 Allgemeine Wiener Medizinalzeitung, 1885. 2 Nothnagel, specielle Pathologie u. Therapie, vol. 14, part 2 b. SCROFULOSIS AND TUBERCULOSIS 377 The strenuous hardening measures that, often prove extremely valuable in fairly robust men and women are, of course, not to, be carried out in young subjects to. anything like the same degree; otherwise the treatment need not be varied essentially because of the patient's age; enervation is equally bad for both groups. Turning now from those cases in which the pulmonary lesion is uncomplicated or predominant to the other phases of visceral tuberculosis, we are confronted with a most trying problem. Meningitis is practically a hope- less affair, but renal tuberculosis is occasionally amen- able to climatic measures, when unilateral; 1 pleurisy is almost always secondary to a pulmonary lesion, and does not usually impair its prognosis to a very serious degree. As to tuberculous peritonitis, which is an affection almost peculiar to childhood, we are in less of a quandary than the surgeons, who have a most puzzling operative indica- tion to deal with; the climatic treatment recommended for scrofulosis and .surgical tuberculosis is absolutely indicated in these cases, and will certainly yield a fair proportion of good results in this far from hopeless affection. As an after-cure to surgical measures, the removal to a favorable climate is even more important, but in such an event it would be well to begin with a rather mild resort, until the patient recovers a certain measure of strength; then moderate hardening becomes decidedly the order of the day. SANATORIA This is perhaps the most appropriate place for the introduction of a few remarks on sanatoria for scrofulous 1 See Morse, loc. cit. 378 THE CLIMATIC TREATMENT OF CHILDREN and tuberculous children. As climate and location have been dwelt on in ample detail, this space may be devoted to less obvious matters. Architecturally, there can be no doubt that the one-story cottage plan answers all purposes best. The cottages may be built of timber or iron, with an attic for purposes of storage and to keep the main floor cool in summer, but not for occupancy; the entire structure should be elevated a foot or two, to guard against dampness and flooding during cloud- bursts or from the melting of snow, and the floor should be waterproof. The sides should form practically one great window, the upper portions being constructed in such a fashion as to permit opening at the top alone in cold weather. An ample covered and partly enclosed porch should be built on the eastern or southern front, but I do not regard a solarium as very important. The maximum number of patients to each cottage should be twenty. This permits the classification of patients as to age and type of disease, and also allows the treatment of non-tuberculous children under the same management; thus a cottage might be devoted exclu- sively to rhachitis, another to chronic bronchial affec- tions, and so on, for the cottage plan is not greatly limited as to size; it is easy to group eight of these small structures around a central administration building, though the E-shaped plan is in some ways preferable. Communication with the central building may be by covered and enclosed passageways; food may thus be more readily transported to the cottages without becom- ing cold, and the plan also has advantages for the at- tending staff in bad weather. The staff, when off duty, must be furnished with quarters in the administration SCROFULOSIS AND TUBERCULOSIS 379 building, else lamentable institutional infections are likely to ensue. The entire institution should be heated by steam supplied from the main building, and all save minor surgical procedures should also be carried out there. Visitors should be excluded' entirely if possible, other- wise epidemics of measles and scarlatina will be of fre- quent occurrence. To provide for such acute infections as are bound to break out, with the best of care, a sepa- rate cottage, with a separate small kitchen, should stand quite distinct from the rest of the institution. There must be no communication by covered passages, and the attending and working staffs should be distinct. The pathological department is also to be maintained in a distinct building, preferably also without direct com- munication. Ample playgrounds are a necessity ; also, at the seaside, facilities for bathing. Our hot summers demand the erection of tents for sojourn during the day, so that exposure to excessive insolation may be avoided. Dense woods are objectionable because of dampness, but an open grove, especially of coniferous trees, answers very well as a substitute for tents, and allows the children more freedom. We may here state that anything like crowding or cramping of the institution or its surround- ings is a grave error; a half acre to each building, as much more for outside space, and twice as much more for playgrounds, bathing beaches and the like, is none too much; thus a sanatorium with eight " effective" cottages requires a minimum space of about twenty acres, one to eight patients. There should be no fixed limit set for the duration of 380 THE CLIMATIC TREATMENT OF CHILDREN treatment, save that three months may be regarded as the minimum. Accommodations should be sufficient to allow slowly progressive cases a year or more, and the number returned home " improved" should be as small as possible, for these children regularly relapse. It is a serious mistake for an institution devoted to the treat- ment of tuberculosis to include " improved" cases among its successes; the lay public is already observing the frequency of recurrence in this group, and becoming skeptical as to the merits of sanatorium treatment. The German custom of returning every patient home within a definite time, usually three months, will eventually bring the entire system into discredit; a year is none too long for the cure of any well-developed tuberculous lesion. There is much less difficulty in maintaining good institutional discipline with children than with adults; it is indeed remarkable how rapidly children become accustomed to the surroundings of a well-managed sana- torium. Home means very much less to them than their parents fondly imagine, and there is no trouble, in keeping the little patients in good spirits after the first few days. Nostalgia, which leads so many adults to quit the sanatorium before much benefit has been achieved, is not an element to be weighed in the young; on the other hand, the importunities of parents for the return of their half-cured children is a serious obstacle to the highest efficiency of a sanatorium, and calls for all the tact and patience at the disposal of the manage- ment, if it is to be effectively counteracted. Laxity in this respect will assuredly impair the record and reputation of the institution; imperfect results may SCROFULOSIS AND TUBERCULOSIS 381 confidently be reckoned among the failures, only actual and permanent cures redound to its credit among the public at large. Thus, the problems that confront the management of a sanatorium for scrofulous and tuberculous chil- dren are manifold, and at least as much sociological as medical. GENERAL BIBLIOGRAPHY American Summer Resorts, Medical Record, June 13, 1896. American Winter Resorts, Medical Record, October 31, 1896. Baedeker. Canada. Baedeker. The United States. Baginsky. Die Bedeutung der Seehospize fur die Behandlung der Skrophulose, Berlin, 1903. Canada, Dominion of, Meteorological Service, Annual Reports and Monthly Weather Review. Crook. Some Topographical and Climatic Features of the Florida Peninsula, Medical News, January 26, 1901. Davidson. Notes on the Health Resorts of Southern California, British Medical Journal, January, 1893. Dettweiler. Die Therapie der Phthisis, Wiesbaden, 1887. Freudenthal. The Climatic Influence of our Southwestern States, etc., New York Medical Journal, March 26, 1898. Greeley. American Weather, New York, 1889. Hann. Handbuch der Meteorologie, Stuttgart, 1897. (First part also in English translation.) Hann. Lehrbuch der Klimatologie, Leipzig, 1901. Hare. Text-book of Practical Therapeutics, 11th edition, Phila- delphia, 1906. Henoch. Vorlesungen iiber Kinderkrankheiten, 11th edition, Ber- lin, 1903. Hinsdale. Climates and Health Resorts in the Dominion of Canada, Journal of Balneology and Climatology, October, 1903. Hirsch. Handbuch der historisch-geographischen Pathologie, Stutt- gart, 1881. Hochsinger. Die Gesundheitspflege des Kindes im Elternhause, Leipzig, 1896. Holt. The Diseases of Infancy and Childhood, 3d edition, New York, 1906. Koplik. The Diseases of Infancy and Childhood, 2d edition, Phila- delphia, 1906. 383 384 THE CLIMATIC TREATMENT OF CHILDREN Knight. The Climates of New England, International Medical Mag- azine, July, 1897. Landois. Physiologie des Menschen, Berlin, 1900. (Also in English translation.) Loewy. Die Wirkung der Hohen- und Seeklimas auf den Menschen, Deutsche medizinische Wochenschrift, January 21, 1904. Manson. Tropical Diseases, London, 1904. New York Department of Health, Reports. Osier. Practice of Medicine, 6th edition, New York, 1905. Perry. Some Observations on the Occurrence of Malarial Fevers on the Pacific Coast, New York Medical Journal, December 3, 1898. Powell. Sea-air and Sea-bathing in Convalescence, American Text- book of the Diseases of Children, Philadelphia, 1894. Solly. Medical Climatology, Philadelphia, 1897. Strasser. Erkaltungund Abhartung, Deutsche Klinik, Volume 1, 1905. U. S. Census Report, 1900, Volume 3, Vital Statistics. U. S. Department of Agriculture, Weather Bureau, Reports and Papers. U. S. War Department, Signal Service (to 1891). Reports and Papers. (Also reports from corresponding departments of various states.) Van Dyke. Southern California, New York, 1886. Verrill. The Bermuda Islands, New York, 1903. Weber and Foster. Climate in the Treatment of Disease, Allbutt's System of Medicine, Volume 1, London, 1896. Weber and Hinsdale. Climatology, Health Resorts and Mineral Springs; Solis-Cohen, a System of Physiologic Therapeutics, Volumes 3 and 4, Philadelphia, 1902. Yeo. The Therapeutics of Mineral Springs and Climates, Chicago, 1904. LIST OF AUTHORS Affanassiew, 225. Anders, 18. Avellis, 310. Babcock, 327. Bergougnian, 340, 361. Bowditch, 256. Brannan, 368. Brauer, 368. Brit ton and Brown, 48. Brown, S., 338. Bunsen and Roscoe, 28. Burckhardt, 279. Biirgi, 26. Chvostek, 279. Cornet, 354, 362, 376. Crombie, 344. Danziger, 326. D'Espine, 356, 357. Determann, 260, 270, 327, 338. Donath, 279. Downes and Blunt, 219. Doyle, 370. Dunbar, 48. Edel, 293, 294. Eolwards, 291. Egger, 24, 27. Erb, 204. Fischl, 321. Freudenthal, 215. Galli, 327. Gevaert, 367. Gottstein, 24. Grawitz, 24. Grebner, 356. Greeley, 86. Guhr, 352. Hann, 4, 44, 61, 139, 186. Hansemann, 263. Harrington, 14. Haudek, 367. Hecker, 231-235, 339. Henoch, 312. Hirsch, 44, 296. Hochsinger, 230. Hoessli, 273. Hoffmann, 3. 310. Holt, 221, 256, 312, 316, 320, 344. Homberger, 279. Howard, 45, 47. Huchard, 270. Hurlimann, 361. Ide, 261, 339. v. Jaksch, 269 Jilek, 46. Keller, 310, 360, 367. Kisskalt, 228. Koppen, 33. Koerner, 326. Koplik, 355. KrafTt-Ebing, 338. Kundig, 25. Langley, 28. Larsen, 367. Lassar, 225. Lazarus, 269. Lode, 227. MacFarlane, 345, 346. Mendel, 349. Mitchell, Weir, 349. Monti, 361, 368. Morse, 269, 374, 377. Nebelthau, 226. v. Noorden, 269. 385 386 THE CLIMATIC TREATMENT OF CHILDREN Northrup, 340. Nothnagel, 376. Osier, 280, 312. Pasteur, 227. Pearce, 260, 338, 346. Perier, 291, 310, 339, 357, 370. Porter, 256, 257. Powell, 261, 321. Quetelet, 256, 257. Rem-Picci, 287. Robin, 261. Robin and Binet, 357. Rode, 310, 356. Rosenthal, 225. Ruhemann, 18. Saake, 28. Seibert, 41, 43. . Senator, 288. Sohon, 139. Solly, 313. Szego, 321. Thierfelder and Giinther, 43. Uffelmann, 368. Viault, 23. Vierordt, H., 331. Vincent, 15. Wachenheim, 43. Weber, 197, 198, 270, 370, 374. Weber and Foster, 310, 357. Weinzirl, 26. Whymper, 27. Williams, C. T., 375. Williams, L., 290, 370. Wolff and Koeppe, 24. Wyman, 322. Wood, 355. Yeo, 260, 277, 279. Zillessen, 226. INDEX Heavy face type refers to numerical data. Localities will be found under their respective states. Acclimatization, 5, 23, 343. Adenoid hypertrophy, 315; and bronchitis, 308; and hardening, 231; and hot-air furnace, 215; and malnutrition, 256; and - scrofulosis, 315, 355. Africa, pneumonia in 44; sleeping sickness in, 47. Alabama, cloudiness and humidity, 108; precipiation, 126-129; temperature, 76, 77, 109; Mobile, 76, 77, 109, 155; Mont- gomery, 76, 77, 109, 129. Alaska, cloudiness, 117; as health resort, 167; precipitation, 137, 138; temperature, 100, 101; Nome (Port Clarence) , 101; Sitka, 100, 137; Unalaska, 100, 117. Alberta, cloudiness, 113; precipitation, 130; temperature, 85, 114; Banff, 85, 160, 275; Edmonton, 85, 114. Albuminuria, cyclic and orthostatic, 287-289; etiology, 225, 287 288; treatment, 289-295, 374; see also Nephritis. Algeria, climate, 192, 193; Algiers, 192, 244, 291; Biskra, 192. Alleghanies, cloudiness and humidity, 104, 107; as health resort (Northern), 239, 247, 249, 283, 294, 302, 304, 323, 340, 359, 375; (Southern), 245, 247, 260, 280, 294, 311, 323, 328, 340, 359, 361, 375; precipitation, 124, 127, 128; temperature, 66-68, 74-76, 105, 107, 247; winds, 60, 154. Alps, cloudiness and humidity, 180, 181, 183; as health resort, 240, 241, 245, 260, 268, 270, 272, 280, 283, 292, 293, 311, 317, 327, 328, 362-364, 375; precipitation, 180-182; temperature, 179- 181. Ambrosia (ragweed) , 48, 49, 322. Amyloidosis, 280-282, 371. Anaemia, 269-272. Anopheles, 45, 46. Arizona, cloudiness and humidity, 116; as health resort, 162, 243, 274, 291, 374; precipitation, 133-135; temperature, 15, 91-93, 117; Grand Canon, 162; Phoenix, 91, 92, 116, 117, 133, 134, 162, 359; Prescott, 91, 92, 162; Tucson, 162, 359; Yuma, 93, 116, 117, 135, 162. Arkansas, cloudiness and humidity, 107; precipitation, 127; tem- perature (Little Rock), 75, 107, 108; Hot Springs, 158, 275, 276. Asthma, and bronchitis, 309; treatment, 311-313. 387 388 THE CLIMATIC TREATMENT OF CHILDREN Atlantic Coast, as health resort, 243, 259, 261, 304, 358; winds, 59, 60, 79; see also New England, Middle Atlantic Coast, South- eastern States. Austria-Hungary, health resorts, 196-197; precipitation, 180-182, 191; temperature, 179-181, 191; winds, 190, 191; Carlsbad (Bohemia), 179; Fiume (Abbazia), 191, 367; Ragusa (Dal- matia), 191; Riva (Lake Garda), 181, 280; Trieste (Istria), 191; Tyrol (northern, Innsbruck), 179; (southern, Meran), 181, 280, 341; (upper), 180; Vienna, 179. Autumn, atmospheric pressure and winds, 55; resorts, 248, 249. Bacteria, and colds, 228; and moisture, 20; and sunshine, 18, 219. Bahamas, climate, 80; as health resort, 280. Basin, the Great, see Plateau, the Western; and Rocky Mountains. Baths, in childhood, 230, 234; cold, 230, 309, 357; and hardening, 230; reaction, 204, 235; saline, 196, 278, 283, 295, 330, 360; sea, 201-204, 261, 266, 267, 283, 324, 348, 357, 359; sponge, 234, temperature of, 8, 234. Belgium, climate, 174; health resorts, 195; Ostende, 174, 367. Bermudas, as health resort, 157, 158, 279, 290; precipitation, 126-129; temperature, 31, 80. Bladder, diseases of, 297, 298. Blood cells, at elevations, 24-26; in summer and winter, 26; see also Ancemia. British Columbia, as health resort, 166, 167; precipitation, 133, 137, 138; temperature, 89, 99, 100, 119; Barkerville, Mamloops, 89, 167; New Westminster, 166; Quatsino, 138; Victoria, 99, 100, 119, 166. Bronchiectasis, 309; and pneumonia, 316; treatment, 312, 313, 316, Bronchitis, 308-313; and pertussis, 320. California, cloudiness and humidity, 116-119; dust, 165, 313; earth- quakes, 136; fogs, 98, 118, 163, 164; frost, 97, 98, 163, 164; as health resort, 163-165, 237, 243, 247, 248, 259, 267, 274, 278, 280, 291, 292, 298, 311-313, 329, 332, 359, 364, 395; precipi- tation, 135-137; temperature, 31, 42, 93-99, 117, 119; winds, 58, 60, 96, 163, 164; Death Valley, 93, 116; Eureka, 97, 93, 118, 119; Farallone Islands, 31, 96; Fresno (San Joaquin Valley), 58, 98, 119, 136; Independence, 93, 117; Lake Tahoe (Sierra Nevada), 95, 135, 136; Los Angeles, Pasadena, 94, 95, 117, 163, 243, 248, 280, 359; Monterey, Santa Cruz, 94, 164; Mt. Tamalpais (Coast Range), 96, 97; Oakland, San Rafael '96, 97, 248, 317; Red Bluff, 58, 98, 117; Riverside, San Bernar- dino, 163; Sacramento, 98, 117, 119; Salton (Colorado Desert), 93, 162; San Diego, 94, 95, 117, 163, 243, 358, 359; San Fran- cisco, 42, 96, 97, 117, 164, 304, 358; Santa Barbara, 94, 163, 267; Santa Catalina Island, 94, 163. Canada, as health resort, 242, 246; see also the various provinces. Childhood, peculiarities of, 2, 3, 33-40; see also Infancy and Puberty. Chlorosis, 254, 269, 272; see also Anosmia. Chorea, 277, 346, 347. INDEX 389 Cities, bad effect on children, 36, 252, 299, 336; temperature in, 62, 300. Climate, classification, 32-34, 167-169; disease and, 40-49, 307, 344; physiology of, 6-32; population and, 5, 6; weather and, 4. Climatotherapy, application, 1, 34-40, 204-206; (seasonal), 236- 249; delicacy of, 8; disappointments, 205; for normal children, 3, 207-249; as prophylactic, 2, 211, 251, 264, 284, 308, 320, 343. Clothing, and acclimatization, 6; color of, 224; and indifferent temperature, 7; materials, 222, 223; and seasons, 205, 222-224; sufficiency of, 221-223, 234, 258; weight of, 222. Cloudbursts, 128, 135. Cloudiness and disease, 17, 18; estimation of, 102; in North Amer- ica, 102-119; physical and psychical effects of, 17-19; at sea- shore, 31, 104, 117, 242. Cold, diseases and, 6, 224-228, 279, 284, 287, 345, 350; hyperesthesia to, 36, 255, 257, 263; perception of, 13; waves, 57-58. Colds, enervation and, 227; etiology, 12, 224-228; hardening and, 228, 230, 309; in summer, 12, 212. Colorado, cloudiness and humidity, 113, 114; as health resort, 160, 246, 314, 317, 362, 363; precipitation, 130, 131, 134; tempera- ture, 85, 86, 89, 90, 114; Colorado Springs, Manitou, 90, 160; Denver, 85, 86, 113, 114, 160; Durango, 89; Glenwood Springs, Ouray, 161, 275; Grand Junction, Leadville, 89, 161; Pike's Peak, 90. Connecticut, cloudiness and humidity, 104; as health resort, 143- 145, 147, 148; precipitation, 123; temperature, 66, 105; Litch- field Hills, 147, 148; New Haven, 66, 105, 145. Convalescence, 258-261, 318. Cuba (Havana), as health resort, 157, 280; temperature, 90. Cystitis, 297, 298. Diarrhceal diseases, 300-306; climate and, 41-43; pertussis and, 320. Digestion, diseases of, 210, 258, 299-307; climate and, 41-43. Diphtheritic paralysis, 348. Dryness, see Humidity. •• Dust, 22, 135, 159, 161, 165, 184, 243, 275, 292, 313, 374; hot-air furnace and, 214; irritation from, 312, 314, 321; precipitation and, 19, 20. Ear, diseases of, 323-325. Earthquakes in California, 136. Eating, bad habits of, 38, 256, 334. Eczema, 350, 351; etiology, 235, 350. Egypt, climate, 193; as health resort, 244, 247, 274, 291, 328, 374. Elevations, atmosphere at, 22, 23, arterial pressure at, 293; blood changes at, 23-26; classification, 34; emplovment of, 40, 240, 241, 260, 261, 268-270, 283, 295, 311, 312, 329, 330, 340, 362 375; Metabolism at, 25, 26, 40; mountain sickness, 26, 27; neuroses at, 338, 345; phototherapy at, 27-29; physiology of, 23-26; radioactivity at, 27, 28; sleep at, 338, 345; solar heat 390 THE CLIMATIC TREATMENT OF CHILDREN at, 28, 29; sunburn at, 28; temperature at, 29, 30, 68, 90, 147, 178-181. Emphysema, 308. Empyema, see Pleurisy. Enervation, as cause of disease, 227, 258, 344, 365; definition and diagnosis, 341/342; etiology, 12, 40, 212, 342, 343; prophylaxis and treatment, 343. England, cloudiness and humidity, 171-173; as health resort, 195, 238; precipitation, 173; temperature, 171, 172; English Chan- nel (Isle of Wight, Jersey), 171, 195, 238, 259, 267, 304, 311, 317, 339, 357, 358; London, 21, 172. Entero-colitis, see Diarrhoeal diseases. Enuresis, 298, 334. Epilepsy, 347. Europe, central, climate, 177-183; as health resort, 196, 239, 246, 262, 294, 304, 306, 340. Europe, southern, health resorts, l()6, 197; see also Mediterranean Region. Europe, western, climate, 170-177; as health resort, 195, 196, 265, 304, 311, 317, 359, 369, 375. Exercise, at elevations, 26, 27; indications for, 259, 327; indifferent temperature and, 7; limitations of, 7, 274, 328; overexertion, 287, 326, 370; school life and, 38, 326. Exposure and disease, 224-228, 278, 279, 287. Florida, cloudiness and humidity, 110; frost, 78, 79, 156, 285; as health resort, 155-157, 244, 247, 259,265, 271, 280, 285, 290, 312, 316, 328, 329, 358, 363; malaria, 157, 285; precipitation, 126-129; temperature, 76-79, 109, 110; Jacksonville, St. Augus- tine, 76, 77, 109, 155, 156, 260; Jupiter, Palm Beach, 78, 110, 128, 156; Key West, 78, 110, 128, 156, 280; Miami, Ormond, Palatka, 156; Pensacola, 155; Tampa, 78, 110, 156. Fog, 20, 21, 103-105, 141, 163, 164, 172, 176, 237, 265, 266, 276, 313, 365. Food, as cause of disease, 39, 258, 334; forced feeding, 37. France, as health resort, 195, 196, 237, 248, 267, 271, 291, 306, 311, 326, 356, 359; humidity, 175, 177; precipitation, 175, 177, 186, 187, temperature, 174, 175, 177, 185, 187, 190; Biarritz (Bay of Biscay), 174., 259, 260, 267, 357; Brest (Brittany), 174; Corsica (Ajaccio), 190; Lyons, 175; Marseilles, Montpellier, 185; Paris, 175; Pau, Pyrenees, 177, 248, 260, 275, 311, 328; see also Riviera. Frost, causation, 21; in summer, 82, 95, 180, 239, 241; in valleys, . 21, 238; in warm regions, 75, 77-79, 83, 97, 151, 155, 156, 163, 164, 184, 190, 193, 242, 243. Frostbites, 235, 257, 350. Georgia, cloudiness and humidity, 107, 108; as health resort, 329; precipitation, 126-128; temperature, 75-77, 107-109; Atlanta, 75, 107, 108, Augusta, 76, 77, 109, 155; Macon, Thomasville, 155; Savannah, 76, 77, 109, 155. INDEX 391 Germany, as health resort, 196, 238, 245, 330, 358, 359; precipi- tation, 173, 174, 178; temperature, 173, 174, 178, 179; Baltic Coast, 174, 238, 267, 306, 339; Berlin, 18, 42, 178; Black Forest, 178, 239; Frankfort a. M., 178; Goerbersdorf (Silesia), 179; Harz Mts., 178, 239; Heidelberg, Munich, 178; North Sea Coast, 173, 238, 245, 261, 267, 311, 339, 356, 357, 359. Glossina, 47. Greece, climate and health resorts, 191, 192. Greenland, cloudiness and humidity, 103; as health resort, 139, 140; precipitation, 122, 123; respiratory diseases, 44; tem- perature, 63. Gulf Coast, cloudiness and humidity, 108-112; precipitation, 126- 129; temperature, 76-78, 82, 83, 109, 110, 112; winds, 60. Haemorrhagic diseases, 278-280. Hardening. 228-235; difficulties, 9, 229; disease caused by, 230, 231, 309, 339; fallacies, 229; treatment by, 239-241, 265, 360, 363, 365, 370. Hay-fever, etiology, 47-49; treatment, 48, 142, 322-323. Health resorts, classification, 167-169, 194-197; foreign, 169-197; North American, 139-169. Heart disease, 325-333; climate and, 44; congenital, 331-332; myocardial, 328-331; valvular, 277, 325-331. Heat, as diaphoretic, 9, 290; harmfulness of, 40, 212; humidity and, 10-12; physiology of, 7-10; prickly (lichen tropicus), 212, 222, 350. . Heating, 7, 211-216. Heat-stroke, in children, 38; etiology, 11; in Europe, 183; in India, 22. Hibernation, 255. Hospitals, floating, 301-303. Housing, 219-221; tenements and disease, 220, 264, 299; tents and verandas, 217. • Humidity, 10-13, 312, 351; fallacies, 10-11; in heated rooms, 215; in North America, 102-120; perception of, 11-12; at seashore, 30, 300; perspiration and, 10; temperature and, 10-11. Hurricanes, 55, 57, 127. Hysteria, 254, 335. Ichthyosis, 351. Idaho, cloudiness and humidity, 115; precipitation, 132; tempera- ture, 89, 115; Snake River Valley (Boise City, Pocatello), 58, 89, 115, 161. Illinois, cloudiness and humidity, 105, 106, 110, 111; precipitation, 124, 130; temperature, 70, 71, 81, .106, 111; Cairo, 81, 111; Chicago, 42, 70, 71, 105, 106, 152, 153. India, heat-stroke in, 22; pneumonia in, 344. Indiana, cloudiness and humidity, 106; precipitation, 124; tem- perature (Indianapolis), 73, 107; French Lick, West Baden, 153. Infancy, hardening in, 231; outdoor life in, 207-209, 220, 221; sum- mer mortality in, 41-43; see also Childhood. 392 THE CLIMATIC TREATMENT OF CHILDREN Infectious diseases, climate and, 17, 18, 44-49: school life and, 38, 253. Influenza, climate and, 17, 18. Insect-borne diseases, 45-47. Insomnia, 338, 344-346; climate and, 8, 241, 345, 346; nervous irritability and, 334. Intestine, tuberculosis of, 372; see also Diarrheal diseases. Iowa, cloudiness and humidity, 10, 110, 111; as health resort, 158; precipitation, 130; temperature (Des Moines), 81, 111. Ireland, climate and health-resorts, 171, 172. Islands, see Seashore. Italy, cloudiness and humidity, 189, 190; health resorts, 196, 197; malaria, 46, 187-190; pneumonia, 44; precipitation, 182, 187- 190; temperature, 46, 181, 187-190; Florence, Pisa, 189, 246, 248; Genoa, Leghorn, 187, 245; Lake Region (Bellagio, Pall- anza), 181, 247, 340; Malta, 190; Milan, Venice, 188; Naples, 189, 220, 246; Rome, 46, 189, 204, 246; Sicily (Palermo), 190, 244, 291, 329, 363. Kansas, cloudiness and humidity, 110, 111, 113, 114; precipita- tion, 130, 131; temperature, 81, 82, 84-87, 111, 114; Dodge City, 85, 114; Kansas City, Wichita, 81, 111. Kentucky, cloudiness and humidity, 106; precipitation, 127, 128; temperature, 73, 74, 107; Louisville, 73, 107. Kidneys, amyloidosis, 281; effect of cold and exposure on, 44, 225, 226, 287; function of, 290; surgical affections, 295-297; tuber- culosis of, 377; see also Nephritis. Labrador, cloudiness and humidity, 103; as health resort, 139, 140; precipitation, 122, 123; temperature, 63, 64. Lake Region, cloudiness and humidity, 105, 106; as health resort, 151-153, 242, 249, 267, 276, 300, 304, 319, 351, 358, 375; pre- cipitation, 124, 125; temperature, 69-73, 106; winds, 60. Leukaemia, 272, 273. Louisiana, cloudiness and humidity, 108; precipitation, 127-129; temperature. 76, 77, 82, 83, 109, 112; New Orleans, 76, 77, 109, 155; Shreveport, 82, 112. Lungs, effect of cold on, 225, 226; see also Pneumonia. Lymphatism, 354-362; adenoids and, 315; hereditary syphilis and, 282. Madeira, climate, 178; as health resort, 279, 290, 363. Maine, cloudiness and humidity, 104; as health resort, 141-143, 237, 240, 267, 302, 317; precipitation, 123-126; temperature, 66-69, 105, 302; Belgrade, Poland Springs, Camden, Castine, 142; Eastport, Portland, 66, 67, 105, 142; Moosehead Lake (Kineo), 66, 143; Mt. Desert (Bar Harbor), 66, 142, 340; Rangeley Lakes, 143. Malaria, etiology, 45-47; distribution, 45-47, 148, 149, 151, 154, 157-159, 238, 285; treatment, 283-285. Malnutrition, 255-262; and neuroses, 255, 333, 334. Manitoba, cloudiness and humidity, 110, 111 ; precipitation, 129-131 ; temperature, 81-83, 111; Winnipeg, 81, 82, 111. INDEX 393 Maritime Provinces, cloudiness, 104; as health resort, 140, 141, 267; precipitation, 123; temperature, 64, 65, 105; see also Nova Scotia. Maryland, cloudiness and humidity, 104; as health resort, 150, 151; precipitation, 124, 125; temperature (Baltimore) 31, 62, 67, 105 ; Deer Park, 150. Massachusetts, cloudiness and humidity, 104; as health resort, 143-145, 147, 148, 359; precipitation, 123-126; temperature, 66-69, 105, 147; Berkshire Hills, 147, 148; Boston, 42, 66, 67, 105, 323, 340; Cape Ann* etc., 145; Nantucket, 32, 66, 67, 105, 144, 145. Mediterranean Region, climate, 183-194; as health resort, 196, 197, 247, 259, 279, 311, 357. Meningitis, tuberculous, 377. Metabolism, in children, 2, 37; at elevations, 25, 26, 40; at puberty, 254; and temperature, 7. Mexico, as health resort, 161-163, 291; precipitation, 134, 136; temperature, 83, 91, 92, 94, 95; Chihuahua, 92, 134; Lower California, 95, 136; Mazatlan, 94, 134; Mexico City, 92, 134, 162; Saltillo, 92; Sonora (Guaymas), Topolobampo, 94. Michigan, cloudiness and humiditv, 105, 106; as health resort, 151-153, 276, 302, 304; precipitation, 124, 125; temperature, 70-72, 106, 302; Alpena, 70, 71, 106; Detroit, 42, 70, 71, 106; Grand Haven, Port Huron, 70-72, 106;. Mackinaw, 70, 152; Marquette, 70, 71, 106, 153; Mt. Clemens, 151, 276. Middle Atlantic Coast, cloudiness and humidity, 104; as health resort, 237, 238, 245, 260, 265, 280,' 311, 319, 351, 359, 375; precipitation, 123-126; temperature, 66-69, 105; winds, 60. Migraine, 349, 350. Milk, decomposition of, 43; supply of, 236, 299. Mineral springs, 143, 150-154, 458, 160, 161, 177, 195, 196; in cystitis, 298; in heart disease, 330; radioactivity of, 361; in renal lithiasis, 296; in rheumatism, 275, 276; in scrofulosis, 360; in skin diseases, 351. Minnesota, cloudiness and humidity, 10, 105, 106, 110, 111; as health resort, 158; precipitation, 124, 125, 129-131; tempera- ture, 70, 71, 81, 82, 106, 111; Duluth, 70, 71, 105, 106; Moor- head, St. Paul, 81, 111. Mississippi, cloudiness and humidity, 108; precipitation, 126-129; temperature, 76-78, 109; Vicksburg, 76, 77, 109. Mississippi Valley, cloudiness and humidity, 108, 110, 111 ; as health resort, 158, 246; malaria, 158; precipitation, 126-131; tem- perature, 76-78, 81, 82, 109, 111; winds, 60. Missouri, cloudiness and humidity, 110, 111; precipitation, 129-131; temperature, 81, 82, 111, 302; Kansas City, 81, 111; St. Louis, 81, 111, 302; Springfield, 82. Montana, cloudiness and humidity, 113, 114; as health resort, 159; precipitation, 129-131; temperature, 84-90, 114; Havre, 85, 114; Helena, 85, 114, 130, 160; Kalispell, 89. Mountains, see Elevations. Mountain sickness, 26, 27. 394 THE CLIMATIC TREATMENT OF CHILDREN Nasopharyngeal catarrh, 313-315; etiology, 215. Nebraska, cloudiness and humidity, 110, 111, 113, 114; as health resort, 159; malaria, 159; precipitation, 129-131; tempera- ture, 81, 82, 84-88, 111, 114; North Platte, 85, 114; Omaha, 81, 111. Nephritis, 289-295; albuminuria and, 288, 289; climate and, 44; exposure and, 225; tuberculosis and, 371; see also Albumi- nuria. Nervous exhaustion 333, 337-342. Nervous irritability, 333-337, 342; habit spasms, 347; enuresis and, 298, 334. Netherlands, climate, 174; health resorts, 195. Neuralgia, 349. Neurasthenia, 333, 338. Neuroses, 333-350; combinations of, 342; elevations and, 338, 346> hardening and, 231, 339; malnutrition and, 255, 333; painful, 349, 350; thunderstorms and, 21. Nevada, cloudiness and humidity, 115; precipitation, 132, 133; temperature, 88-91, 115; Carson City, Winnemucca, 89, 115, 161. New Brunswick, cloudiness, 104; as health resort, 140; precipita- tion, 123, 124; temperature, 64, 65, 105; Chatham, 64, 105; Campobello, Grand Manan, 142; St. John, 64. New England, cloudiness and humidity, 104 ; as health resort, 141- 145/ 237, .262, 267, 292, 317, 329; 330, 339, 340, 361; precipita- tion, 123-126; temperature, 66-69, 105. . Newfoundland, cloudiness, 104; as health resort, 140; precipita- tion, 123, 124; temperature (St. John's), 64, 105. New Hampshire, cloudiness and humidity, 104; health resorts, 143-145; precipitation, 123-125; temperature, 66-69; Lake Winnipesaukee, 143, Portsmouth, etc., 145; White Mountains (Bethlehem, Mt. Washington), 55-59, 142, 143, 240, 246, 272, 323. New Jersey, cloudiness and humidity, 104; as health resort, 148, 149, 237, 267, 271, 304/316, 358; malaria, 149; precipitation, 123-125; temperature, 67, 68, 105; Asbury Park, 149; At- lantic City, 31, 67, 105, 149, 242, 249, 261, 339, 346, 358; Cape May, 149, 367; Lakewood, 61, 67, 148, 248. New Mexico, cloudiness and humidity, 116; as health resort, 161, 362, 374; precipitation, 133, 134; temperature, 91, 92, 117; Albuquerque, 26, 161; Las Vegas, 161, 275; Santa Fe\ 91, 92, 116, 117, 161; Silver City, 162. New York, cloudiness and humidity, 10, 104-106; as health resort, 262, 316, 317, 330, 361, 375; precipitation, 123-126; temper- ature, 15, 66-72, 105, 106, 147; Adirondack Mts. (Saranac Lake), 10, 66, 145, 146, 240, 246, 276, 323, 362, 364; Albany, 66, 67, 69, 105; Buffalo, 41, 70-72, 106, 242; Catskill Mts., 147, 148, 272, 304, 323; Chautauqua Lake, 151, Cooperstown, Richfield and Sharon Springs, 66 t 150, 276; Lakes Champlain and George, 146; Liberty (Sullivan Co.), 66, 148, 376; Long Island (Southampton), 31, 66, 143-145, 237, 243, 267, 278, 300, 304, 339, 358, 368, 369; New York City, 10, 12, 31, 41, 61, 66, INDEX 395 105, 113, 137, 300, 323, 364; Oswego, 70, 105, 106; Pough- keepsie (Hudson Valley), 66, 147, 148; Rochester, 70, 71, 106; Saratoga, 148; Thousand Islands, see Ontario, Kingston. North America, atmospheric pressure, 52-55; cloudiness and hu- midity, 102-120; precipitation, 120-138; sunshine, 102-120; temperature, 61-102; (sensible), 103-119; topography, 50-52; weather, 56-60; winds, 52-60. North Carolina, cloudiness and humidity, 107, 108; as health resort, 245, 271, 323, 375; precipitation, 126-129; temperature, 74-77, 107-109; Asheville, 75, 153, 247, 260, 294; Charlotte, 75, 107, 108, 154; Hatteras, 76, 77, 126, 260; Raleigh, Southern Pines, 75, 107, 108, 155; Wilmington, 76, 77, 109, 129. North Dakota, cloudiness and humidity, 110, 111, 113; as health resort, 159; precipitation, 129-132; temperature, 85-88, 114; Bismarck, Williston, 85, 114. Northwest Provinces, as health resort, 159; see also Alberta, Mani- toba, Saskatchewan. Norway, climate, 170, 171 ; as health resort, 367. Nova Scotia, cloudiness, 104; as health resort, 140, 237, 304; pre- cipitation, 123; temperature (Halifax, Sydney, Yarmouth), 64, 105 ; Sable Island, 32. Ohio, cloudiness and humidity, 105, 106; precipitation, 124, 125; temperature, 69-74, 106; Cleveland, 70, 71, 106; Cincinnati, Columbus, 73, 106; Toledo, 70. Ohio Valley, cloudiness and humidity, 106; as health resort, 153; precipitation, 124, 125; temperature, 73, 74, 106; winds, 60. Oklahoma, cloudiness and humidity, 112; as health resort, 159; malaria, 159; precipitation, 129-131 ; temperature, 82, 83, 112. Ontario, cloudiness and humidity, 105, 106; precipitation, 124, 125; temperature, 65, 69-72, 105, 106; Ottawa, 65, 105, 147; Parry Sound, Muskoka Lakes, 70, 71, 106, 152; Port Stanley, Thou- sand Islands (Kingston), 70, 71, 106, 151; Rockliffe, 65, 105; Saugeen, Toronto, 70, 71, 106; Port Arthur, White River, 70, 71, 106, 153. Oregon, cloudiness and humidity, 115, 117-119; as health resort, 165, 166, 249, 317, 340; precipitation, 132, 137, 138; tem- perature, 89, 90, 99, 100, 115, 119; Astoria, 99; Baker City, 89, 115, 166; Portland, Salem, 59, 99, 100, 118, 119, 166; Rose- burg, 59, 99, 100, 119, 138, 166. Otitis and Otorrhcea, 323-325. Outdoor life, 7, 207-209, 220, 221, 319, 336; in winter, 221, 264. Pacific Coast, cloudiness and humidity, 117-119; as health resort, 237, 249, 259, 317, 340, 358; precipitation, 135-138; tempera- ture, 94-102, 119; winds, 22, 58, 60; see also California. Palestine, climate, 193, 194. Paralytic affections, 347, 348. Pennsylvania, cloudiness and humidity, 104-106; as health resort, 150, 323; precipitation, 124, 125; temperature, 67-74, 105-107; Cresson Springs, Glen Summit, Mt. Pocono, Delaware Water 396 THE CLIMATIC TREATMENT OF CHILDREN Gap, 150; Erie, 70, 106; Harrisburg, 67, 105, 150; Philadel- phia, 67, 150, 346; Pittsburg, 73, 107; Scranton, 32, 67, 150. Pericarditis, 332, 333. Peritonitis, tuberculous, 377. Perspiration, see Sweat. Pertussis, 319-322. Phototherapy, at elevations, 27-29; in skin diseases, 352. Plains, the Great, blizzards and tornadoes, 87, 88, 131; cloudiness and humidity, 113, 114; dust, 22, 159; as health resort, 158, 159, 315, 364; malaria, 159; precipitation, 129-131; tempera- ture, 84-87, 114; winds, 22, 60, 87. Plateau, the Western, cloudiness and humidity; 114, 115; precipi- tation, 132, 133; temperature, 88-91, 115; winds, 60; see also Rocky Mountains. Plateaus, temperature, 29, 30. Pleurisy, 317-319. Pneumatotherapy, 23; in diseases of the ear, 325. Pneumonia, 315-319; and climate, 44, 344; and pertussis, 320; and seasons, 43, 44. 'Poliomyelitis, 348. Population and climate, 5. Portugal, climate, 175, 176; the Azores, 176. Precipitation, in central Europe, 178-182; in Mediterranean region, 185-194; in North America, 120-138; at seashore, 31, 32; in western Europe, 171-177. Pressure, atmospheric, in ear diseases, 325; at elevations, 23; in North America, 52-55; and neuralgia, 349; and rheumatism, 274. Prince Edward Island (Charlottetown), temperature, 64, 105. Psoriasis, heliotherapy, 352. Psychoses, 335. Puberty, 232, 254; see also Childhood. Pyelitis and Pyelonephritis, 295-297. Quebec, cloudiness, 104; precipitation, 123-125; temperature, 64, 65, 105; Chicoutimi, 65, 146; Father Point, 64, 105; Lake St. John, 146; Montreal, 65, 105, 147, 323; Murray Bay, 147; Quebec (City), 65, 105, 147. Radiation, of body heat, 9; from open fire, 214; of solar heat, 7, 18, 28, 29, 221; in solarium, 265, 266. Radioactivity, at elevations, 27, 28; of mineral springs, 361. Radiotherapy of tuberculosis, 28. Rain, cloud-bursts, 128, 135; disadvantages and value of, 19, 20, 312, 373; intensity of, 138; in North America, 120-138; at seashore, 31, 32. Respiratory diseases, 210, 212, 265, 307-323; climate, seasons and, 43, 44; see also Colds, Pneumonia, etc. Rest and rest cures, 4, 6-9, 35, 328, 329, 332, 337, 338. Rheumatism, 273-278; climate and, 44. Rhode Island, cloudiness and humidity, 104; precipitation, 123- INDEX 397 125 ; temperature, 66, 67, 105; Block Island, 31, 60, 66, 67, 105, 144, 145, 237; Narragansett Pier, Newport, 145. Rickets, 262-269; bronchitis and, 308, 310; nodding spasms and, 347. Riviera, the, climate, 159, 160; as health resort, 196, 197, 245, 260, 271, 291, 298, 311, 329, 357, 375. Rocky Mountains, cloudiness and humidity, 113-115; as health resort, 159-161, 241, 246, 260, 268, 272, 275, 283, 294, 306, 312, 314, 325, 327, 338, 349; precipitation, 129-133; temperature, 84-91, 114, 115; winds, 60. Sanatoria, 377-381; in diarrhceal diseases, 301-303, 305; in respi- ratory diseases, 318; in rickets, 268; in scrofulosis, 356-361; in tuberculosis, 367-369, 373. Saskatchewan, cloudiness, 113; precipitation, 129-131; tempera- ture, 84-87, 114; Medicine Hat, Regina, Prince Albert, 85, 114. School life, unfavorable influences of, 38, 253. Scotland, climate, 171-173; as health resort, 239. Scrofulosis, 354-362; and adenoid hypertrophy, 315, 355; and bronchitis, 308, 310; and neuroses, 333. Scurvy, 278. Sea baths, 201-204; in ear diseases, 323, 324; in malnutrition, 261; in paralytic affections, 348; in rickets, 266; in scrofulosis, 357, 359; in congenital syphilis, 283. Seashore, cloudiness and humidity, 30, 31, 277; employment, 237, 238, 245, 247-249, 259-261, 265-267, 277, 278, 283, 295, 300, 301, 304, 310, 311, 320, 321, 339, 346, 348, 356-359, 367-370; fogs, 20, 21, 103, 104, 141, 163, 164, 172, 237; overstimulation at, 261, 339; precipitation, 31, 32; 'salt air, 32, 198, 321; tem- perature, 31, 32, 237; winds, see below. Sea voyages, 197-201; in tuberculosis, 370, 371. Skin diseases, 350-352. Sleep, normal amount, 344; see also Insomnia. Sleeping Sickness, 47. Snow, melting in spring, 20, 180; in Europe, 172, 176, 179, 180, 185, 187, 188, 190, 191; in North America, 124-126, 128, 129, 131- 134, 136, 138; usefulness, 20, 373. Solarium, 265, 266, 378. South Carolina, cloudiness and humidity, 108; as health resort* 245; precipitation, 126-129; temperature, ?6-78, 109; Aiken, 155; Charleston, 76, 77, 109, 155, 244. South Central States, cloudiness and humidity, 112; precipitation, 126-129; temperature, 82-84, 112. South Dakota, cloudiness and humidity, 110, 111, 113, 114; pre- cipitation, 129-131; temperature, 81, 82, 84-87, 111, 114; Huron, 81, 111; Pierre, Rapid City (Black Hills), 85, 114. Southeastern States, cloudiness and humidity, 107-110; as health resort, 244, 291, 298, 311; malaria, 154, 157; precipitation, 126-129; temperature, 74-79, 107-110; Lower South, 154-156, 244; Pine Belt, 245, 328; Upper South, 153, 154, 244, 245, see also Alleghanies (Southern). Southwest, the, cloudiness and humidity, 116; dust storms, 135; 398 THE CLIMATIC TREATMENT OF CHILDREN as health resort, 161-163, 279; precipitation, 133-135; tem- . perature, 91-94, 117. Spain, cloudiness and humidity, 184, 185; as health resort, 196, 243; precipitation, 176, 184, 185; temperature, 175, 176, 184, 185; Gibraltar, Malaga, 184, 291; Madrid, Valladolid, 185; Oviedo, 175. Spasmodic affections, 346, 347. Spinal affections, 347, 348. Spitzbergen, as health resort, 140. Spring, the advance of, 247; atmospheric pressure and winds, 53, 54; melting of snow, 20, 180; respiratory diseases, 44; re- sorts, 246-248; variability of, 13, 14, 246. Stegomyia, 47. Stimulation, contraindicated, 3, 338; at elevations, 26, 40, 328, 338; by heat, 9, 12; by sunshine, 19, 261, 338, 339. Storm paths in North America, 56, 57; see also Hurricanes, Torna- does. Sultriness, 12. Summer, atmospheric pressure and winds, 54, 55; duration,. 109; • frosts, 82, 95, 180, 239, 241 ; infant mortality, 41-43; resorts, 236-241; respiratory affections, 12, 212. Sunburn, 234; at elevations, 28.- Sunshine, absorption of, 27, 28; at elevations, 29, 181; estimation of, 102; in Europe, 18, 104-106, 171, 181, 185, 189; exposure to, 7, 15, 18, 219-221; germicidal effects of, 18, 219; indifferent temperature in,' 7, 8; in North America, 102-120; stimulating effects of, 19, 261, 338, 339. Sunstroke, see Heat-stroke. Sweat, causation and function, 9, 10. Sweden, climate, 170, 171.. Switzerland, cloudiness and humidity, 180-182; health resorts, 196; precipitation, 180-182; temperature, 179-181; Davos, 180, 181; Engadine (Arosa, St. Moritz), 29, 180, 204, 270, 273, 328; Lake of Geneva (Montreux), 181, 280, 340, 361; Lake of Lu- cerne (Altdorf), 179; Lugano, 181; Zurich, 179, 181, 361; see also Alps. Syphilis, congenital, 282, 283; bronchitis and, 309. Syria, climate, 193, 194. Teeth, defects of, 255, 256, 349. Temperature in cities, 62, 300; at elevations, 29, 30, 68, 90, 147, 178-181; humidity and, 10-12; inversion of, 29, 68, 91, 180; metabolism and, 7; in North America, 61-102; of ocean, 202, 203; for outdoor life, 7, 208, 221; perception of, 13-17; for rest cures, 8; in rooms, 7, 211, 212, 265; in rural districts, 62, 300; at seashore, 31, 32; sleep and, 8, 345; for training cures, 8. Temperature, indifferent, 7; in water, 8, 16, 360; in childhood, 39, 205, 212. Temperature, sensible, 14-17; in North America, 102-120. Temperature, variability of, 13, 14; in Europe, 183; in North Amer- ica, 52, 58, 68, 71, 74, 75, 77, 82, 83, 87, 90, 92, 99, 183. INDEX 399 Tennessee, cloudiness and humidity, 107; precipitation, 127, 128; temperature, 74-76, 107, 108; Knoxville, 75, 107, 154; Look- out Mountain, 154; Memphis, Nashville, 75, 107, 108. Texas, cloudiness and humidity, 112-114, 116; malaria, 159; pre- cipitation, 126-129, 133-135; temperature, 82-87, 91, 92, 112, 114, 117; Abilene, Amarillo, 85, 114; Corpus Christi, San An- tonio, 82, 112; El Paso, 91, 92, 117, 133, 134, 162; Galveston, 82, 112, 155. Thunderstorms, and neuroses, 21; in North America, 123, 124, 129, 131, 133-136, 138. Tornadoes, 22, 87, 129, 131. Training, delicacy of, 8; difficulties, 4, 6, 210; indications, 3, 35, 40; temperature and, 8; see also Hardening. Tropics, harmfulness of, 13, 40; origin of man in, 6; pneumonia in, 44, 344. Tuberculosis, 355-381; adenoids and, 355; advanced, 375, 376; age and, 353, 366, 372; amvloidosis and, 281, 371; climate and, 362-365; forms of, 353, 369, 370; hardening and, 370, 377; in- cipient, 372; intestinal, 372; laryngeal, 375; latent, 259; men- ingeal, 377; miliary, 366, 372; peritoneal, 377; pleural, 377; polymorphism of, 353, 366; pulmonary, 372-377; radiotherapy of, 28; renal, 377; sanatoria, 367-369, 376-381; sea voyages in, 370, 371; surgical, 366-371; travel and, 376; visceral, 371-377; see also Scrofulosis. United States, pneumonia in, 44; see also North America. Utah, cloudiness and humidity, 115; precipitation, 132, 133; tem- perature, 88-90, 115; Salt Lake City, 89, 115, 161, 360. Valleys, fogs in, 21, 105; frost in, 21, 238; inversion of temperature in, 29; undesirability of, 238. Vasomotor system, heat and, 12; training of, 228. Vegetation in North America, 63, 65, 69, 72, 74-76, 78, 83, 84, 91. 100, 115, 155, Ventilation, 211-219; house-airing, 218. Vermont, cloudiness and humidity, 104; as health resort, 143, 323; precipitation, 123-126; temperature, 66-69, 105; Northfield, 66, 67, 105. Virginia, cloudiness and humidity, 104; as health resort, 150, 151, 243, 323, 328, 359; precipitation, 124-126; temperature, 66-69, 105; Hot Springs, 150, 276, 294; Lynchburg, 67, 105; Norfolk, Old Point Comfort, 67, 105, 150, 248, 339; Richmond, 67; WytheviUe, 67, 150. Washington, D. C, 62, 67, 105, 323. Washington (State), cloudiness and humidity, 115, 117-119; as health resort, 165, 166, 249, 340; precipitation, 132, 133, 137, 138; temperature, 88-90, 99-101, 115, 119; Puget Sound (Seattle, Olympia), 99, 118, 119, 166, 317; Spokane, Walla Walla, 89, 115, 166; Tatoosh Island, 99, 100, 118, 119. Weather and climate, 4; in Central Europe, 183; in North America, 56-60, 183, and neuralgia, 349; and rheumatism, 274. 400 THE CLIMATIC TREATMENT OF CHILDREN Weight of children, 256. West Indies, as health resort, 13, 280, 363. West Virginia, cloudiness and humidity, 106; as health resort, 150; precipitation, 124-126; temperature (Parkersburg), 73, 74, 107. Windows, management of, 216-219. Winds, cold (bora, mistral, norther), 21, 59, 78, 83, 185, 186, 190, . 221, 314; Chinook, foehn, 57, 59, 84, 86, 175, 179; hot (sir- occo), 22, 87, 95, 183, 184, 190, 191*; monsoon, 79; in North America, 52-60; physiology of, 21-23; sea breeze, 22, 31, 60, 96, 97, 143, 184, 208, 221, 237, 247, 248; shelter from, 8, 58, 221, 373; storms, 21, 56, 57, see also Tornadoes; trade, 53-55; velocity of, 60. Winter, atmospheric pressure and winds, 52, 53; hardening in, 260; rain and snow, 19, 20; resorts, 241-246; sunshine, 17, 18. Wisconsin, cloudiness and humidity, 105, 106, 110, 111; precipita- tion, 124, 125, 129-131; temperature, 69-72, 81, 82, 106, 111; Green Bay, 70, 71, 106; La Crosse, 81, 111; Milwaukee, 70-72, 106; Waukesha, 152. Wyoming, cloudiness and humidity, 113, 114; as health resort, 160; precipitation, 129-131; temperature, 84-87, 114; Cheyenne, Lander, 85, 114; Yellowstone Park, 85, 160. Yellow Fever, 47. Yukon (Dawson City), 101, 102. MAY 15 1907 LIBRARY OF CONGRESS 022 169 297 4