summer, and are worth a trial in carefully selected cases. It is well not to set too great store by a change of climate. We now understand that neuralgia is usually a mere symptom of a general or local infection which may not be influenced by physical therapy, so that climatotherapy in such a case is likely to score a failure.

Skin Diseases.-Many children who suffer from diseases of the skin can be benefited by a change of climate. Some procedures are obvious, as removal southward for winter eczema, and transfer to a cool region for prickly heat. Not so well known, however, is the fact that winter eczema is aggravated by high winds and a low humidity, so that its victims are relatively numerous on the immediate sea-coast and on inland plateaus, and may be relieved in damper localities, such as the Lake region or the southern Alleghanies.

Ichthyosis, as is shown by its seasonal variation, is benefited by transfer to a warm and moist climate, and becomes worse in cold and dry situations.

As to the exposure of the skin to direct sunlight, employed in heliotherapy, it may be noted that distinct benefit is claimed in psoriasis. In general, however, we cannot deny its injuriousness. Severe sunburn after undue exposure may occur from early spring on through the summer. Such exposure is certain to produce intense dermatitis, unless the skin of the patient has become gradually accustomed to the powerful chemical action of direct sunlight. It is therefore evident that this agent must be employed with caution at all times in warm climates and throughout the summer in more temperate regions, more especially at high altitudes, where the actinic rays are not mitigated by passage through the dense lower atmosphere.

Scrofulosis and Lymphatism.-Chronic glandular hypertrophy of non-tuberculous origin is often benefited by climatic treatment, which treatment should consist essentially of gentle but prolonged hardening. For scrofulous children most authorities recommend the seashore, preferably in rather cool regions, such as the Middle Atlantic coast which is quite mild enough during the winter months, and preferable to the South Atlantic and Californian litoral. In summer we do well to transport the patient to the shores of northern New England or the maritime provinces of Canada; at this season the seaside is not quite so essential, and the cooler localities on the Great Lakes or in the northern Alleghanies are a good second choice. The essential requirements are the absence of sultriness, a high ratio of sunny days, and the opportunity for an almost unlimited outdoor life.

High altitudes have not proved especially beneficial in infantile scrofulosis, so that such regions as Colorado are inferior to those suggested above. The winter climate of the interior of the northeastern states is too severe for very young subjects. There is too much zero weather and too much cloudiness to afford a sufficiency of outdoor life. In the case of older children, however, these disadvantages are of less moment and may usually be disregarded.

Tuberculosis.-Climatic treatment is no longer regarded as the most important element in the management of tuberculosis. The best results, however, are achieved with the aid of a suitable climate, so that this treatment proves a valuable adjunct. Although relaxing climates are unquestionably injurious to tuberculous patients, it is not essential to go to the opposite extreme. In fact, the routine recommendation of a subarctic winter resort has been overdone, and there is no question as to its unsuitability for young children. However, such territory as that ranging from southern New England and New Jersey westward through the Ohio Valley, in which the winter temperature averages around the freezing-point, and in which there is more or less slushy conditions under foot, is less desirable than the continuously snowed up sections farther north, or the milder but still bracing climate of the upper South. In fact, the greater portion of the Lake Region is objectionable, because of its high ratio of cloudiness from November until March.

The fact is, that tuberculous patients have been observed to do about equally well in semi-southern winter resorts as in the subarctic climates of the White Mountains and Adirondacks. This is especially true of young children. For the ages beginning at puberty and thereafter the extreme hardening regime of the far North is, on the other hand, quite effective.

For the summer months, the necessity of a decidedly cool climate is now undisputed. Tuberculous children do best in Canada, northern New England and New York, the cooler parts of the Lake Region, and the northern Rocky Mountain resorts. Our choice between the mountains on the one hand, and the sea and lakeside on the other, must be determined individually, and, as stated below, according to the type of tuberculosis present.

The majority of tuberculous children exhibit the surgical forms of the disease, the lymph-nodes and bones being the organs chiefly affected. These types of tuberculosis, including the group known as tuberculous scrofulosis, require climatic treatment similar to that previously outlined for pyogenic scrofulosis, and do best at cool seaside resorts enjoying a high percentage of sunshine. Heliotherapy, or exposure to direct sunlight, has been extensively employed in this group of cases. Satisfactory results have been claimed, though the superiority of this method is not yet firmly established and requires further trial. The initial exposure should not exceed five to ten minutes. Prolonged treatment should not be attempted until the patient's skin is thoroughly tanned by the sun; otherwise a painful dermatitis will ensue. We may again note that the action of the solar rays is much more intense at high elevations than at the sea-level.

Sufficient time should be allowed for a positive cure to take place. The few months formerly granted are quite insufficient, and a minimum of one year is none too great. This error makes all the older statistics worthless as a measure of what can be effected in tuberculosis

by climatotherapy, and its elimination fully accounts for the better results achieved in recent years.

Pulmonary tuberculosis of the adult type is rare in young children, but becomes increasingly frequent toward puberty. The climatic treatment of phthisis in older children is the same as that of similarly affected adults, namely, to subject the patient to the most intense climatic hardening that he will stand. Inland stations which are more or less elevated, with the lowest attainable temperature at all seasons, are, as a rule, the most beneficial. A few young children cannot stand the intense rigor of our northeastern mountains. For these a milder but not warm winter climate is better suited; for example, Colorado, New Mexico, or the higher points in the southern Appalachians. Time is a factor in pulmonary, even more than in surgical, tuberculosis. A trial of a few months is merely in the nature of a reconnaissance, a preliminary test of the efficiency of climatotherapy in the case under consideration. For a real cure a space of at least two years should be allowed. Phthisis in children offers a very grave prognosis in any case, as the young organism resists the invasion of the tubercle bacillus with relative feebleness, while the danger of rapid extension, or relapse after apparent cure, is much greater than in adults.

Great caution must be exercised with regard to the diagnosis of incipiency. Unless this is corroborated by some months of clinical observation, as well as by x-ray studies, it is better, regardless of the history and physical findings, to regard supposedly early cases as if the disease is well on in the second stage. This is to a large extent true of adults and still more so of children, and influences the probable duration of treatment very materially.

Other forms of visceral tuberculosis, such as involvement of the kidneys or peritoneum, are to be classed with surgical tuberculosis and treated accordingly. Rapidly progressing pulmonary disease is not likely to yield to climatotherapy any more than to other treatment, which is apt to be as successful at home as elsewhere.

BIBLIOGRAPHY

American Summer and Winter Resorts, Med. Record (June 13 and Oct. 31, 1896). Hann, "Handbuch der Klimatologie," 3d edition (1908–11).

Rollier, Die Sonnenbehandlung der Tuberkulose, Monatss. f. Kinderh., ii (1912–13). • Solly, "Medical Climatology" (1897).

Wachenheim, "Climatic Treatment of Children” (1907).

Weber and Foster, Climate in the Treatment of Disease, Allbutt's System, i (1896).

CHAPTER XI

HYGIENE OF CRIPPLED CHILDREN

BY H. WINNETT ORR, M.D.

LINCOLN, NEB.

One of the most interesting and profitable of the newer sociological movements is that which has to do with the care of cripples. There has been some special provision for the hospital care and training of adult cripples, but in large part the movement is one which has to do with the care of children.

The problem of providing care for cripples is a much larger one than at first appears. We find that such provision involves much more than simply to provide asylums for those crippled and deformed individuals whom we occasionally see on the streets and in other public places. Not only do many of our cripples belong to the shut-in class, known to few save their families and friends, but there are hundreds sick at home or in hospitals suffering from acute or chronic deformity producing diseases. It is not generally appreciated how many infections there are which, in the absence of special care, lead inevitably to crippling or deformity. We have found that not only may many of such diseases be cured, but that deformities which have existed for some time may be corrected or ameliorated by adequate hospital care. It is true also that many of those individuals who are largely or wholly dependent for their very existence upon the ministrations of those about them can be restored to usefulness and independence by combining special education or training with institutional care. The solution of the whole problem becomes a task of some difficulty, to be sure, but it is one which carries with it very great rewards. It is this feeling, no doubt, which has influenced so many people of wealth and influence in this country and elsewhere to offer opportunities for the care of such children.

From the viewpoint simply of loss and gain it has long been considered that the education and training of normal children is a profitable undertaking for the state. Considering therefore how much larger a proportion of the crippled children, unless given the necessary training and medical attention, become dependent or are made the objects of special care, it is evident that the state is simply using ordinary business foresight in erecting suitable hospitals and providing the education that will make these cripples partially or wholly independent and self-supporting.

While much that has so far been accomplished in this country has been done with private funds, there are many reasons why the care and education of crippled children is naturally a state function. It

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has long, been considered that the education and training of normal persons is a profitable undertaking for the state, but it is certain that a much larger proportion of those who are crippled become dependent if not made the object of special care. Economically, therefore, the state is simply using ordinary business foresight if by suitable hospital care and education these patients are treated and trained so as to become partially or wholly independent and self-supporting.

"The effort to provide properly for the care and education of crippled children has probably been more energetically exerted in Germany than in any other country in the world. The movement started early with the foundation of the Munich institution in 1832, and since that time the homes have grown steadily in number and the standard of work has been raised higher and higher.

"Furthermore, this movement in behalf of the cripples has been an intelligent and concerted one. For several years there has been a national society for cripple care, the Verein für Krüppelfürsorge. Since 1900 there has been published a year book on the subject, the Jahrbuch der Krüppelfürsorge; since 1908 there has been issued an excellent quarterly journal dealing with the work, the Zeitschrift für Krüppelfürsorge. By these means the persons in Germany having in charge the care of cripples have been kept thoroughly informed regarding improvements in methods, and there has been free and constant interchange of experience. This feature of the German work should be especially suggestive to those in America engaged in the same field. "The greatest possible aid to the development of the work in Germany was derived from a census of all the crippled children in the Empire in 1906. Individual data regarding each cripple under 16 years of age were recorded and tabulated. The results and findings have been excellently presented by Biesalski. In all there were found 75,183 crippled children under the age of 16. In relation to the population this made an average of 14.8 crippled children under 15 years of age to each 10,000 of population of all ages. Calculated on the basis of proportion to the total population of children within a similar age group, it is found that there were among each 10,000 children 35.73 crippled children. That is among the juvenile population 0.36, or nearly four-tenths of 1 per cent., were crippled."*

There has been but little conception in the United States of the scope of this work. Within the past few years several statistical studies have been made. Some of these were definite "Surveys" to determine as accurately as possible how many individuals there are who require special care of the nature above described. Several years ago the writer, after extensive correspondence and after having dealt personally with nearly 2,000 cripples in Nebraska, came to the conclusion that there was in this State approximately one cripple to every 250 of the population. Supposing that the figures for other areas are nearly the same, it may be assumed as a fair estimate that there is a Douglas C. McMurtrie, M.D., The Care of Crippled Children in Germany, New York Medical Journal (Feb. 21, 1914).