members of the family. In some instances, where health is impaired or notably affected by residence in the city, a permanent change of place of living should be advised, if practicable. Pure air, pure water, wholesome food, and a regulated life are the conditions of health and longevity, and, therefore, are factors in the therapeutic problem. A patient cannot live on climate alone, although, in popular discussions of the subject, this is dwelt upon as if it were the only thing to be considered. With this in mind, we will proceed to outline the climatic treatment of some principal diseases:Acute diseases, as the rule, should be treated at home, or in the immediate vicinity.

Anæmia and Chlorosis.-Such cases are benefited by life in the open air, where there is abundance of sunshine and the temperature does not forbid physical exercise. The sea-coast, early in the summer, followed by a stay at the mountains later, is advisable, together with out-door amusements and bicycle or horseback exercise. If much debilitated, a preliminary visit to a good hydropathic institution would be of great value in building up the nervous system and increasing hæmatosis. Weber recommends places where the whole day may be spent in the open air without demands being made on the bodily strength. Long sea-voyages are often curative.

Asthma. Where there is no heart complication and no emphysema, these patients do well at mountain stations, or on inland plateaus. Where there is much bronchial complication, a dry climate should be preferred; where the secretion is scanty, the patient may improve more rapidly among the pine-woods, near the coast. We cannot predict, in any given case of asthma, whether it will be benefited by a marine climate or not; but, as a general rule, especially if there is emphysema present, these cases do better at a moderate elevation inland. Mountain-climbing is useful as a form of respiratory gymnastics, especially in catarrhal complications.

Children and nervous subjects are usually benefited by the sea-shore. Hay-fever patients seek a pure atmosphere, free from dust and pollen. They may find relief either in mountain resorts (Bethlehem, White Mountains, Kane, etc.) or on islands (such as Nantucket).

Bronchial Catarrh.-Chronic bronchial catarrh, with merely increase of secretion and a moderate amount of cough, may be benefited by either a marine atmosphere or by mountain or inland climate. The change of residence of itself is of service, even where there is not much difference in climate, altitude, or temperature. In the declining stage of whooping-cough systematic exercise in the open air is an important part of the treatment; and, as a general rule, in chronic cough, unattended by much pathological change, the best results are obtained from pedestrianism, especially in mountain regions, such as the Catskills.

Blood Disorders.-In morbid conditions of the blood the climatic treatment is a useful adjunct to the ordinary treatment by alteratives, tonics, and chalybeates. Careful regulation of the diet and hygienic management are also required in all cases. Residence at the sea-shore exercises a powerful alterative effect, and, owing to the presence of ozone, it is a decided stimulant to tissue-construction. As anæmia and chlorosis may result from a warm, humid climate, a change to a moderately cool, bracing atmosphere is attended by improvement. A moderate amount of cold, even, will do no harm if the clothing and living-rooms be properly adapted to the temperature; the cold will improve the appetite and favor out-door exercise. In

cases attended by profuse menstruation sea-climates are often injurious, and in early pregnancy abortion may occur at the sea-shore. The favorable effects of altitude upon the number of red blood-cells, and the proportion of hæmoglobin, have already been referred to.

Climacteric disturbances of health are greatly influenced by climatic conditions. Not only at the change of life in women,-at the cessation of menstruation, but also at puberty do we meet with evidences of disorder, particularly of the nervous system; but the circulation and organs of digestion and assimilation are also affected. There may be delayed development or insufficient evolution of the sexual system and deterioration of the general health. In such cases change of climate, the excitement of change of scene, and pleasure of voyaging are useful adjuncts to the means employed to bring about the normal state. Premature senility, either of organs or of the general system, is sometimes mistaken for ordinary disease, and uselessly treated by medicines. Lowering of general activity, easily-produced fatigue, liability to catarrhal attacks, with impaired digestion, are the prominent symptoms of this condition. By a resort to warm, sunny, and dry climates during the winter season and a moderately elevated mountain climate in the summer many of these complaints are overcome or avoided, and in this way life may be prolonged and senile decay deferred.

Consumption. The climatic treatment of pulmonary phthisis, or consumption, has been the subject of study from the earliest times, and an abundant literature has accumulated upon it, including such valuable recent works as that of J. A. Lindsay or C. T. Williams. It has also received favorable consideration in the writings of Jaccoud, Austin Flint, Charles Denison, Trudeau, and other authorities. No climate can be regarded as possessing a specific effect in arresting phthisis, although some exert a much more favorable influence than others in bringing this about. According to Flint, "Dryness, equability, and purity of the atmosphere are essential elements of a favorable climate," and he further declares that "there is reason to believe that the benefit derived from climatic treatment is often, in a great measure, due to accessory circumstances."1

In his address read before the Berlin International Medical Congress Dr. Weber considered the influence of climatic, local, and social conditions on the occurrence and course of pulmonary tuberculosis. As already stated, no climate is entirely exempt from phthisis. He agrees with Hirsch that, if we consider the distribution of phthisis over the world, we must come to the conclusion that the climatic conditions alone, apart from other conditions, especially the social ones, will not afford a sufficient explanation of that distribution. It is necessary to consider the temperature, condition of the soil (dryness or dampness), the elevation above the sea-level, race, effect of colonization, social circumstances, and the industrial pursuits. Phthisis progresses more rapidly in the tropics than in the temperate zones, and he considers that the bacilli are favored in their development by heat and moisture, and also that their products are more toxic under such conditions. Hygienic regulations are more apt to be obeyed at a health resort than at home. There is also a freedom from the cares of business or the household, combined with associations with new acquaintances, affording diver

sion and mental relaxation, which act as nerve-tonics. Very often patients can eat more food when away from home than when at their own table. All these accessory agencies are of value, and contribute to the undoubtedly beneficial effects of change of scene. Cold and damp locations are to be avoided, especially if the patient is thereby compelled to remain in his room. The great object is to select a climate favorable to living in the open air the greater part of the time. In New Mexico it is possible to remain day and night in the air, on account of the dryness of the atmosphere. Distance and convenience of access must be taken into consideration; so that, if the patient becomes homesick or desires to be taken home, it will not be impossible to bring him back without unduly taxing his strength. If the patient be very feeble, it will not be advisable to disturb him with a journey, unless it be merely to the suburbs of the city during hot weather. On the other hand, if the case be in its incipiency and the patient young and his health not much impaired, it may be better for him to emigrate, and remain permanently in some climate that will agree with him. Dr. Flint suggested that, if the patient bear hot weather well and is worse in cold weather, he should go south, at least during the winter; on the contrary, if he is always better in cold weather, he would do wisely in going to a northern resort, such as Denver, Colorado Springs, St. Paul, etc. Some cases have done very well at Newport, but during the summer a stay in the woods is to be preferred to the sea-shore, for reasons already indicated. The Adirondacks have attained a world-wide reputation for the cure of pulmonary diseases, and White Haven, Pa., Lakewood, N. J., and Asheville, N. C., are also famous health stations for the cure of consumption.

Dr. Anderson, of Colorado Springs (6000 feet above the sea), says that patients do not always tolerate this high altitude, and the expected relief is not obtained. In a certain proportion of these cases benefit will follow change to a lower altitude, as 3000 to 4000 feet above sea-level, and residence there until improved and somewhat acclimated. He mentions approvingly the Mesilla Valley of New Mexico, where are found combined the important essentials of a maximum of sunshine and dry air, together with only a moderate elevation.

Open-Air Treatment.-The majority of patients, however, are unable to change from one climate to another, and all such should be advised to live as much as possible in the open air. The early stage of pulmonary tuberculosis, other forms of tuberculosis, neurasthenia, rachitis, chlorosis, and anæmia are susceptible of much benefit from this mode of life. Even in hospitals it has been found beneficial to keep such patients about the grounds or on the verandas, and to have them sleep on balconies.

Exhaustion from Overwork and So-Called Neurasthenia. These are conditions, in a sense, allied to hypochondriasis and hysteria, and, with these, are benefited by combined balneotherapeutical and climatic methods. of treatment.

Indigestion and dyspepsia are closely related to the foregoing, being largely functional and are greatly benefited by change of climate. The same remark holds good for chronic diarrhoea, which can often only be permanently arrested by a sojourn in a dry and equable climate.

Insomnia is relieved by change of residence, either to the mountains or the sea-shore. In nervous erethism, where patients are easily excited, it is of importance to learn the character of the hotel to which they are sent,

inasmuch as their comfort and health depend principally upon freedom from noise and excitement. If music and dancing until after midnight is the rule of the house, their sleep may be more broken than at home. A suitable environment is of as much importance as a proper climate.

Lesions of the Nervous System.-According to Weber, nervous disorders should more often be subjected to treatment by climate than is customary.

Leukæmia is apparently benefited by long cruises in yachts, and Weber advises, in addition, prolonged stay in Egypt or Algiers. In advanced cases little can be expected beyond extending the duration of life. In malarial toxæmia mountain regions are curative; damp situations are to be avoided on land, but sea-voyages are useful.

DIET IN DISEASE.

The principles of dietetics, and likewise the physiology of nutrition, apply equally in disease and in health, the only difference being that the power of digestion and assimilation with the secreting and excreting functions are more or less impaired; the food must, therefore, be of a character suitable for assimilation, of nourishing quality, and administered in quantities, and at such intervals, as appear best suited for the case. The aid which properly-selected food can render in the treatment of disease is now generally acknowledged. If, as Abernethy is reported as saying, it be a fact that the cause and cure of most diseases is at the table, the importance in therapeutics of food is no less than drugs. Oliver Wendell Holmes, nearly thirty years ago, in his essay on the "Border-lines of Knowledge in Some Provinces of Medical Science," declared his high appreciation of this subject as follows: "I cannot help believing that medical curative treatment will, by and by, resolve itself, in great measure, into modifications of the food swallowed and breathed, and of the natural stimuli, and that less will be expected from specific and noxious disturbing agents, either alien or assimilable." Dr. Austin Flint, in his posthumous address on the "Medicine of the Future," prepared for the meeting of the British Medical Association in 1886, expressed a similar idea. "It is a pleasant thought that hereafter the practice of medicine may not be so closely interwoven as hitherto in the popular mind with the use of drugs. The time may come when the visits of the physician will not, as a matter of course, involve the co-operation of the pharmacist; when medical prescriptions will be divested of all mystery, and have no force in the way of fortifying the confidence of the patient. The medical profession will have reached an ideal position. when the physician, guided by his knowledge of diagnosis, the natural history of diseases, and existing therapeutic resources, may, with neither selfdistrust nor the distrust of others, treat an acute disease by hygienic measures without potent medication. When this time comes a system of practice which assumes to substitute medicinal dynamics for the vis medicatriz naturæ will have been added to the list of by-gone medical delusions."

1

This and the preceding quotation from Holmes also appear in the admirable address of Medical Director A. L. Gihon, U. S. N., President of the section on Medical Climatology and Demography. "Transactions of the Ninth International Medical Congress," held at Washington, 1887, vol. v.

The influences of climate, custom, and nationality upon diet and the reciprocal relations of diet upon customs and ethnical traits are of the highest importance in the study of demography. Dr. Gihon (loc. cit.) says that "the food of a people largely determines its national characteristics, but climate determines the food." He supplies the following apposite illustration: "The Chinese of the northern provinces live on millet and wheat and vegetables, because these thrive best in the dry and dusty soil and severe winter; while the moist, hot climate of Southern China produces rice, which with fish, is the staple aliment of many millions of people. The lack of variety harmonizes with the conservatism of the race, and has contributed to that spirit of contentment and domesticity which, as in Japan, are elements of rare happiness not enjoyed by nations boasting a higher civilization." The relation of this to the subject under consideration is twofold. First, in selecting a dietary for a sick person, it is important to learn what kind of food his stomach is accustomed to, as, other things being equal, it will also be the kind that he can most readily assimilate. Secondly, many diseases are traceable to the food being insufficient in quantity, or deficient in quality, or improperly combined. Thus, insufficient nourishment produces anæmia (anhæmatosis), emaciation, debility (neurasthenia), myalgia, neuralgia, and probably rachitis, scrofula, and is an active predisposing cause for phthisis. Food of inferior quality causes such wide-spread disorders as pellagra, beriberi, or kakké, and ergotism. Improperly-assorted food causes Bright's disease, scorbutus, many of the disorders of infancy, gout, rheumatism, and possibly cancer (?). Other disorders due to infected food, such as trichinosis, hydatid disease, intestinal parasites, and infectious disorders,-cholera, typhoid fever, dysentery, etc.,-need only be mentioned here in order to put us on our guard, so that the dietary for the sick may be quite innocent and free from such disturbing elements. Dr. Gihon insists upon the relationship between food and climate, and points out the fact that the climate of India and equatorial Africa is deadly to those Europeans who keep up the style of eating and drinking that they follow at home, whereas others who suit their dietary to the climate find themselves not injured by it. Major Charles E. Woodruff, Surgeon U. S. A., declares, on the contrary, that the tropics are not suitable for white races, especially the blondes, on account of the excess of light, which is too stimulating for them. He denies that the white races can become acclimated to the tropics.

The proportion to be preserved in the daily diet of man has been especially studied by the civilized nations of the earth in order to determine the best ration to issue to large bodies of men employed in the military and naval services, so as to maintain them in health and the highest degree of efficiency. It may therefore be of interest to give a recent statement as to the dietetic requirements of the army. The equivalent ration for United States soldiers on duty in the tropics is calculated by Capt. E. L. Munson, Assistant Surgeon U. S. A., as follows: