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THE CLIMATE OE SOUTH AFRICA AND ITS CURATIVE INFLUENCE. Change of climate in the treatment of disease is a very old method, and is often adopted by patients themselves acting on their own judgment, in the absence of any medical advice. In a large propor- tion of such cases change of climate is regarded mainly or exclusively as a means whereby cold may be avoided and exposure to a warm temperature, and especially to sunshine be secured. Experience daily teaches us that pains and aches, catarrhs and coughs, are usually alleviated by warmth and rendered worse by cold. Consequently sufferers not unnaturally infer that, means and circumstances per- mitting, they do well to make a change in conformity with this experience. In mild cases, of an indefinite type, the removal is often followed by the desired results, the production of which is attributed to the increased temperature, whereas the latter is often greatly aided by other circumstances of a less obvious character. In advising change of climate for the relief or cure of disease physicians are naturally and instinctively guided by their own experience or by that of others whose authority carries weight. As in all matters of a similar kind, systematic inquiry into the modes of action of the powers of nature is the tardy product of a long series of efforts to utilise those powers for practical purposes. Climatology as a science is of modern date, and its development is mainly due to the labours and observations of British physicians at home and abroad. At first sight it may appear a very simple matter in any given case of disease to suggest the best climatic conditions, and to select the most suitable health resort; but as a general rule the question is surrounded with difficulties. It is easy to lay down a few broad principles to serve as a working hypothesis. Such a hypothesis is based mainly on theo- retical grounds, partly also on the results of experience acquired by systematic observation. By the application of these principles we may determine in a general way the character of climate best adapted to different types of sufferers. But when we seek to grapple closely with the subject, to deal with individuals, and to ascertain with fair accuracy the special and predominant influences operative in different localities, with their bearings upon the ever varying conditions of health and disease, we find ourselves engaged in a task of consider- able magnitude. One difficulty associated with our imperfect ac- quaintance with the climatic peculiarities of most countries has been very considerably lessened during the last few' decades. Of many places it may be affirmed that we know almost as much as can be THE CLIMATE OF SOUTH AFRICA AND ITS CURATIVE INFLUENCE. 105 ascertained with regard to that aggregation of meteorological phe- nomena which constitutes climate. A still greater difficulty arises from the complexity of the operations to which the body is submitted under the varying conditions in which it may be placed; and even when we have satisfied ourselves, as far as possible, on these subjects, the peculiarities of the patient whom we wish to benefit, may cause us to modify or even change our previous determination. Assuming that the patient be willing and able to make the change, the selection of the particular spot, out of many well calculated to suit his case, may be, and often is, attended with much difficulty. Half a century ago a decision could be easily arrived at. Patients suffering from general debility, perhaps without any obvious disease, were sent into the country or to some convenient seaside resort. For those afflicted with chest-complaints, the choice lay between Hastings, the Isle of Wight and Torquay, or some other protected seaside spot in the South or West of England, the object being, as already stated, to secure as much warmth and sunshine as possible together with the beneficial influence of sea-air. At the present day, however, the case presents very different features. Places unmarked in any map a few years ago are now extolled for their health-giving and curative influences in many cases of disease, and their reputation has often been fairly deserved. Whereas the element of warmth was formerly considered to be of primary importance, it now occupies a compara- tively subordinate place, and is, in fact, nearly absent from the list of advantages possessed by some mountainous resorts whose curative powers have been repeatedly demonstrated in those very cases for which heat was once considered an imperative necessity. After these preliminary remarks I proceed to describe and examine certain features of the climate of South Africa, to which its effects on cases of pulmonary disease are in great measure attributable. My attention has been specially drawn to this subject in consequence of the severe illness of a member of my family whom I accompanied to South Africa in August last. Our English climate during autumn, winter, and spring is a dangerous one for persons suffering from chronic disease of the lungs, as the consumptive. Catarrhs and bronchial in- flammations are notoriously rife in this country during those portions of the year. Such disorders have a perilous tendency to hasten the progress of consumption, or, at any rate, to promote the development of the disease should a dormant predisposition exist. Many cases of consumption can be traced to a catarrh and no further. " Migration to an exotic climate is" as Sir Thomas Watson points out "to be re- commended not so much for the sake of any positive virtue or special sanative influence which the climate may be supposed to possess, as for the protection it affords against the dangerous influence of our own ■winter climate with its chilling dampness, its fogs and gloom, its 106 THE CLIMATE OF SOUTH AFRICA AND ITS CURATIVE INFLUENCE. lack of cheering and salutary sunshine, its inhibition of enough exer- cise in the open air." We may, indeed, go far beyond this qualified statement, and claim for the region we are about to discuss the possession of a special sanative influence in properly selected cases. It is unnecessary to describe the voyage from England to the South African ports; but I would fain add my testimony to that of others with regard to the extremely comfortable and convenient arrange- ments to be met with on board the steamers of the " Castle " Line, which are not only fine sea boats, but are really " floating hotels." Speaking from my experience of sea voyages, I would say that nothing conducive to the comfort or welfare of the passengers, invalid or otherwise, escapes the attention of the owners and officers of these ships. Cape Town is reached in from seventeen to twenty days after leaving Southampton, and the passengers who have escaped sea-sick- ness are apt to complain that the time has passed only too quickly. It is not advisable that the invalid should stay more than a few days at Cape Town itself. His first step is to consult a local physician, who will advise him where he should settle. Besides climate the following advantages are specially to be desired: comfortable hotel accommodation ; proper food, well cooked and sufficient in quantity ; good sanitary arrangements; adequate means of amusement; facility of access and competent medical advice. The height above sea-level is, perhaps, the most important geographical consideration; in cases of consumption the chances of benefit seem to be in direct proportion to the altitude of the place in which a sojourn is made. Dr. H. Weber, speaking of high latitudes, says the main physical features important to us are the purity or aseptic nature of the air ; dryness of air and soil; coldness or coolness of the air-temperature and great warmth of the sun temperature; rarefaction and low pressure of the atmosphere; intensity of light; stillness of air in winter and a large amount of ozone. Each of these factors doubtless contributes towards the good results produced; it is, however, desirable to examine somewhat minutely, into the alleged effect of altitude in diminishing the liability to consumption, and in arresting its progress in persons already subject to it. Observations as to the extreme rarity of the disease on the high plateaux of the Andes, and the good effect upon sufferers of a residence thereon constituted the original basis of the opinion referred to, which has been strengthened by further inquiries in the same direction. It must, however, be admitted that consumption does sometimes occur in the highest inhabited spots on the globe, whilst it is rare in many places situated on low plains. Still the fact is beyond doubt that, ceteris paribus, consumption is much less frequently met with at high altitudes than in those at a lower elevation or on the same level. THE CLIMATE OF SOUTH AFRICA AND ITS CURATIVE INFLUENCE. 107 Dr. Kirsch's investigations show that the number of cases stands in some degree of definite proportion to the degree of elevation; while the exceptions to the general rule find satisfactory explanation in other etiological factors coming into play at the same time. Reports collected from various stations in the Rocky Mountains demonstrate the truth of the assertion above made. Trustworthy information has been obtained from Mexico, Colorado, and Utah, as well as from Guatemala, Salvador, Costa Rica, and New Granada. At Quitto, local examples of the disease are unknown. A similar experience is characteristic of many elevated districts of the Eastern hemisphere. In Europe a certain rarity of consumption begins to be noticed at even comparatively small elevations ; and the law of immunity of the more elevated places has been thoroughly confirmed by the experience of Baden and Switzerland. It is as yet quite impossible to state the minimum of elevation which a locality must possess before the effect of altitude in diminishing consumption is manifested. Dr. Hirsch thinks that a notable decrease in the disease can be shown to occur at 1500 feet, provided that other circumstances are favourable. But, he adds, immunity from consump- tion, due to the height of the place alone does not occur until we go to elevations so great as to be uninhabitable in temperate climates like that of Europe. We must go to the equatorial part of the earth to study the sanative effects of altitudes ranging from 6000 to 10,000 feet, and examine the reports from the large towns on the plateaux of the Andes in Central and Southern America, the highest of which, Potosi, is at an elevation of 13,000 feet. In all such towns, most of them occupied with trade and commerce, and exhibiting many and grave sanitary defects, consumption is either rare among the natives or does not exist at all. It is therefore evident that the influences associated with very considerable altitude are able to over- come the injurious effects and unsatisfactory social conditions in so far as these tend to produce consumption. Enough has been adduced to demonstrate the fact that high altitudes afford a greater or a lesser protection against consumption ; and many attempts have been made to discover the manner in which the influence is produced. Some authorities regard the purity of the air and its freedom from decomposing product as the principal factors; others point to the dryness of the air and soil. There is yet a third theory, advocated by Dr. Hirsch, who attributes the beneficent powers of mountain air to the frequent and deep inspirations necessary in breathing a rarefied atmosphere. The quantity of oxygen contained in a given volume of air at an elevation of say 8000 feet is consider- ably less than at the sea-level, and a man must take in a large quantity of air in a given time or must inspire oftener than on the plains in order to obtain his requisite amount of oxygen. Persons thus situated 108 THE CLIMATE OF SOUTH AFRICA AND ITS CURATIVE INFLUENCE. are continually practising a kind of pulmonary gymnastics, which results in a vigorous development of their breathing organs, and a greater power of resistance on their part to noxious influences from without. The celebrated Sydenham was wont to recommend exercise on horseback as a remedy for consumption. Its efficacy, which he declared to be equal to that of Jesuits' bark in agues, maybe explained by Dr. Hirsch's theory. Other competent authorities are inclined to dissent from this view, and, while admitting that rarefied air may not be without influence, they lay stress rather on the maintenance of the purity of the air by its rapid movement and on its freedom from micro-organisms. Investigations, set on foot for the purpose, have demonstrated a complete absence of microbes at heights of over 6500 feet, and a much diminished number at such comparatively slight elevations as 1800 feet. It must, however, be admitted that almost absolute freedom from microbes has also been found in air collected from near the surface of the ocean and at certain spots on the sea- coast. South Africa possesses many stations the natural conditions of which render them very suitable for the treatment of affections of the chest. One region called the Karroo (signifying the dryness of the climate), is pre-eminent in this respect. It is divided into two por- tions, termed the Great and the Northern Karroo. The former consists of a vast plateau of considerable elevation, averaging about 3000 feet above the level of the sea, whilst the average height of the mountain ranges is about 5000 feet, some places rising to 7000. Its special character is its excessive dryness-it is said that a clean polished steel razor can be left out all night in the open without fear of its acquiring one single speck of rust. Kain falls very irregularly, and at rare intervals only, and in small local showers-many months may elapse without a drop of rain. The atmosphere is pure and wonderfully exhilarating. The summer temperature, though high, is easily tolerated ; the winter is cold but bright and bracing, with abundant sunshine. Among the places best adapted for sanatoria are Ceres (1493 feet), Matjesfontein, Beaufort West, and Cradock, all at an elevation of nearly 3000 feet. The Northern Karroo lies at a much greater elevation than the Great Karroo, averaging about 4000 feet above the sea-level, while some of the mountain ranges reach 7800 feet. Its atmosphere is characterised by peculiar dryness which, in conjunc- tion with the rarefaction, the constant sunlight, and its generally uniform character, endows the climate with properties obtainable in Europe only at much higher altitudes. Chest affections are rare, and consumption is almost unknown among the inhabitants born and bred in this region. The district can boast of a long list of stations, all of which may be strongly recommended as regards climate and natural advantages. Among them may be mentioned Erazerberg (4500), THE CLIMATE OF SOUTH AFRICA AND ITS CURATIVE INFLUENCE. 109 Richmond, Victoria (West), Hanover, Aliwal (North), and Kimberley, all at an elevation of from 4000 to 4500 feet. All these places, and many others might be added, possess a climate which experience has proved to be highly curative to consumptive patients. It is likewise beneficial in cases of debility and want of tone, many examples of which are to be found in our own country, especially that form of general tiredness with insomnia resulting from the wear and tear of modern life. But climate per se will not suffice, there are other factors which are equally necessary. It is within the knowledge of everybody that the diet of sufferers from consumption and other wasting disorders, should be as sustaining and nutritious as they can take or bear. In the cases referred to the appetite is often capricious, and the amount of food taken is altogether insufficient to counterbalance the daily losses. Hence one important aim in treat- ment is to improve the appetite and digestion, and this object may often be attained by a sojourn in pure mountain air. But it is use- less and almost cruel to stimulate the appetite, unless proper means of satisfying it can at the same time be secured, and in many of the places mentioned above there is a great defect in this respect, as well as in other matters of hygiene. In some letters which appeared a few months ago in the Standard newspaper, it was pointed out that in the " parts of South Africa suitable, as regards climate, for con- sumptive patients, comfortable quarters, good wholesome, well-cooked food and kindly attention are an unknown combination. Up-country hotels, even those advertising for invalids, are primarily bars and canteens, ill-adapted for delicate people. Small ' Sanatoria ' have been started, but none have yet arisen in which the invalid is the first consideration, or with sufficient capital to place comfort and good food within reach of the invalid." It is pleasant to be able to state that this drawback will soon cease to exist. While in South Africa I had opportunities of discussing the subject with Mr. Cecil Rhodes, and later on by his desire, with Mr. Lawrence, of Kimberley, and since my return Mr. Lawrence has forwarded to me by Mr. Rhodes' request, gratifying reports embody- ing the ideas which were discussed at our interviews. The resolution, emanating from Mr. Rhodes, was speedily adopted, of establishing a sanatorium at Kimberley for the treatment of persons suffering from pulmonary complaints, especially in the incipient stages. Mr. Rhodes promised a contribution of £4000 from some funds at his disposal, and £1000 from his own purse. Another letter informs me that Mr. Rhodes has promised an additional £5000. Such public-spirited generosity is deserving of the highest praise, the money eordd not be devoted to a better purpose. Small institutions for the reception of invalids already exist, but in few, if any, are the arrangements of an altogether satisfactory charac- 110 THE CLIMATE OF SOUTH AFRICA AND ITS CURATIVE INFLUENCE. ter. A model sanatorium of the kind now proposed, will not only be a source of benefit to those who can avail themselves of it, but will stimulate the foundation of similar institutions in suitable localities, and will indicate to all concerned the necessary conditions for the attainment of favourable results. Kimberley, the station chosen for the erection of the buildings, presents many advantages. Its climate is equal to that of any health resort in South Africa, and its surround- ings are generally better than can be found elsewhere. Among its advantages may be enumerated various clubs, the library, the theatre, and other places of amusement, also opportunities for golf, tennis, cricket, coursing and shooting, and the proximity of the river. The nuisance due to the dust, of which I can speak by personal experience, at Johannesburg and other localities, has been greatly lessened at Kimberley since the present water-supply was obtained. The management of the Kimberley Sanatorium will be vested in a Board, several members of which, well-known Kimberley men, occupying the highest public and social positions in the town, have been already nominated. There will be a medical representative at Cape Town from whom patients arriving from Europe will be able to obtain all requisite information and advice. The fees for admission will be such as to secure a fair remuneration to the resident custodians. Large profits will not be aimed at, but the tariff will probably be a little higher than at ordinary hotels-with which the institution will compare favourably as regards comforts and necessaries for invalids. Ad- mission will be granted only to those patients whose condition promises a fair chance of recovery. A sum of £8000 has been set aside for the building, and plans have been invited by advertisement. I cannot but express my sincere gratification at having been associated in any degree with the inception of so benevolent and desirable a project. Robson Roose.