The effects of climate on tuberculous disease

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Appendix

NOTICES OF SOME OF THE PLACES MOST FREQUENTED ON ACCOUNT OF THEIR CLIMATES, IN THE SOUTH OF FRANCE, ITALY, ETC.

The following brief notices of the leading peculiarities by which several places of resort are characterized, are derived in great measure from my own observation, and from the information acquired from local authorities' and other available sources during the periods of my residence there. They may perhaps suffice to indicate in a general way, and in the absence of more detailed accounts, the localities suitable to many patients labouring under tuberculous disease.

PAD.

Pau presents many advantages as a winter residence for several invalids, being situate near the mineral springs of the Pyrenees, where there are always in the summer a great many persons whose state of health requires later in the season the beneficial influence of a mild climate. It is easy of access from the more northern parts of France by means of railroad communication with Paris — brought within a six hours' drive. Occupying part of an elevated plateau, which overlooks a picturesque valley fertilized by the Gave or mountain river of the same name. Pau consists principally of a long street terminating near the old castle — celebrated for its historical associations — of short divergent streets, and two Places, of which the one (Henri IV.) is very large, the houses being built on colonnades ; the other (Royale) has only houses on three sides, the fourth forming a terrace facing the south, whence a rich and varied panorama is displayed to the view, encased towards the south by the chain of the lofty Pyrenees, and on the southwest by the verdant slopes of Carangon. The town is lighted with gas ; it possesses a public library, a cercle where the principal French and English papers are received, libraries for the loan of books, and a theatre. There is an agreeable, though not bruyante society in the winter season. The population amounts to about 14,000 souls. A park wall, sheltered by lofty trees, extends from the chateau to the distance of half a league parallel with the valley, and at a considerable elevation above it. The environs are extremely interesting, and the roads are maintained in a good state. Riding is very general among the visitors.

A prolonged sojourn at Pau would, however, not unfrequently have a depressing effect upon persons out of health and unable to take part in the pleasures of society, as, except the salons of the cercle, there is no place of reunion in the evening, or for exercise in bad weather, and it rains a great deal at Pau ; so that persons in health, and more especially invalids, are often deprived of the source of outdoor exercise, and are obliged to confine themselves to their apartments.

The climate of Pau is relatively mild, less warm than that of Provence, but also less liable to great variations of temperature. It is milder, and, at the same time, on account of its elevated position and the absorbent nature of its soil, less humid than the other towns in that part of the country.

It is sheltered on the north by the Landes of Pont Long, which gradually ascends in that direction to a distance of five or six leagues.

High winds seldom occur, and are but of short duration. A principal characteristic of the climate is the calmness of its atmosphere. Sir James Clark, in his work on climate, states the mean annual temperature to be only four and a half degrees higher than that of London, and five lower than Marseilles, Nice, and Rome. In winter, it is two degrees warmer than London, six colder than Nice and Rome, and eighteen (Fahrenheit) colder than Madeira ; but, in spring, Pau is six degrees warmer than London, and only two and a half colder than Marseilles and Rome. The daily range of temperature at Pau is seven and a half degrees, at Rome eleven. Schouw, in his meteorological tables, states 135 as the mean of rainy days in the year; and Dr. Taylor, in his work on the climate of Pau, admits that the amount of rain is as great, if not greater, than in London. Rain seldom, however, continues for more than two days at a time, the ground dries rapidly, and the atmosphere generally is but little laden with moisture. The west wind blowing directly from the Atlantic is accompanied by rain. The wind from the northwest, and from this point to the northeast, brings dry cold weather ; while that from the northeast to the south is usually attended with clear mild weather. The south and southwest winds are warm and oppressive. The westerly, or Atlantic, are the most prevalent winds. The north wind is not frequent, and blows feebly. Dr. Taylor contrasts the climate of Pau with that of Nice as being of a directly opposite nature. " It has the effect of diminishing the nervous energies, and of inducing nervous congestion in internal organs. Strangers in health complain of languor and indisposition to exertion, a feeling of fulness in the head, and oppression at the epigastrium. Hence, in all diseases of an atonic character, in a depressed and relaxed state of the nervous system, and in congestive diseases, the climate is injurious." It is, on the other hand, beneficial in many chronic affections of the larynx, trachea, and bronchia, of an erethetic character. As respects patients labouring under tubercular disease of the lungs, though the climate of Pau may be less calculated than one of a different nature to fulfil the indication of ameliorating the abnormal condition of the blood, it would be well suited to allay irritability in patients of a sanguineous or nervous temperament, with marked acceleration of the circulation, to whom a prolonged residence in warmer or drier climates would be too exciting or enervating, and who do not require in the place of their abode much variety of resources for occupation or recreation.

EYtKES.

The aspect of the greater part of Provence is rather dreary and monotonous from the comparative deficiency of trees (except the olive) and of vegetation, consequent upon the dryness of the climate. The heat in summer is almost unbearable ; the roads are thick laid with dust, which, during the prevalence of winds, is raised in clouds. Though the temperature in winter as marked by the thermometer, is not low, the air is sharp and often cold, the strong northwest wind {mistral) is not unfrequently painfully experienced, especially in January, February, and March. In spring the sun acquires great power, and its influence alternating with the occasional cold winds produces frequent and rapid changes of temperature, very tryiug even to those in health. The rains fall at irregular periods, last during several days or weeks, leaving a long interval of fine weather, during which the sky is bright and clear. The best seasons for residing in this part of France are from April to the middle of June, and from September to the end of November.

Hyeres presents an exemption from some of the disadvantages of the general climate of Provence. It is about an hour's drive from Toulon. On approaching through olive plantations and vineyards, the attention is attracted by the extensive ruins of its ancient castle and walls, crowning the hill at the base of which the town lies, and by which it is sheltered from the north. Passing in front of the large hotel lies d'Or, the chief street being the high road to St. Troper, is traversed. About the centre is a terrace, with five magnificent palm-trees, commanding a delightful view of the plain, with its rich and varied vegetation of olives, oranges, palms, cypresses, &c, extending to the sea, which is four or five miles distant. The islands of Hyeres, about two leagues from the Roie, add to the beauty of the scene. Opposite the terrace is a small library, but indifferently provided with books, and adjacent are the two other principal hotels, De L'Europe and Des Ambassadeurs. In the former is a saloon appropriated to the* cercle, where the leading French journals are received. At the extremity of the street is a Place of very ordinary appearance. The divergent streets are narrow and badly paved. The resident population amounts to 10,000 souls.

The lodgings and general accommodations are inferior to those found in most places of resort, and the sheltered space for outdoor exercise is but limited. Though protected from the north winds, which are severely felt in the neighbouring districts, Hyeres is a good deal exposed to the mistral, which prevails more especially during the latter part of the winter and in early spring.

The only medical accounts published of late years is that of M. Honorates, who admits that the town is exposed to the northwest, and says, moreover, that it is not sufficiently sheltered from the east. The orange and lemontrees are smaller than at Nice. Rain in autumn and fogs are not uufrequent. In winter there is a long succession of fine weather. The temperature is not subject to so much variation, and there is less difference between the sun and shade than at Nice. The number of rainy days is said to be not more than forty in the year.

The climate of Hyeres is well adapted to many cases of pulmonary consumption, on account of the purity and dryness of the air, which is less agitated by winds than that of places directly lying upon the sea slope. The want of promenades and of resources, as well as the inferiority of the accommodation, will, however, be sufficient inducements for those persons to whom this kind of climate is applicable, to prefer Nice. Those who seek repose, and who purpose wintering at Hyeres, would be less exposed to wind if lodging near the terrace, and eastward than at the entrance of the town.

The small town of Cannes, on the opposite side of the Estrelles (part of the maritime Alps) has been a good deal frequented of late years by those desirous of a quiet winter residence in a mild climate. It is sheltered from the mistral, though somewhat exposed to the east. It lies on the high road to Italy, and has a population of 4000 souls. The environs are agreeable, though having only lately come into notice, Cannes is very deficient in accommodation.

NICE.

Nice, in the Piedmontese territory, occupies a picturesque position on the sea-shore, about a league distant from the French frontier; it possesses a population of 40,000 souls, independently of a large garrison. The greater part of the town is separated from the port by a rocky hill, rising precipitously from the sea, and surmounted by the ruins of a fort. A parapeted road, cut round the rock, at some elevation above the sea, forms the principal means of communication between the two ports. The Place Victor, a spacious square, and some new streets, lie to the north of the port; the old town and the new streets, inhabited by visitors, to the west. The streets of the old town are lined with shops, and, with one or two exceptions, are not wide enough to allow the passage of a carriage. The Corso, a public promenade parallel with the sea and planted with trees, and the adjacent streets, contain some good houses, which are let to visitors. A long range of low buildings, consisting of shops and cafes, separates the Corso from the beach. Their flat roofs form spacious terraces, extending from the Castle Hill to the Boulevard du Midi, which is the usual afternoon promenade. A river, or rather the dry bed of a river (the Paglion) forms the limits of the town on tbe west. The houses on the opposite quay are (next to those on the Boulevard du Midi) most sought after; here are the principal hotels. Beyond this quarter is the suburb of the Croix de Marbre, which extends a considerable distance westward along the high road to France, and contains several lar"e houses, to which orange gardens leading down to the shore are attached. A promenade (Chemin des Anglais) is continued along the beach close to the garden wall.

The environs of Nice are delightful ; the soil is extremely rich in vegetable productions ; various kinds of flowers, the olive, pomegranate, lemon, orange, almond, and fig, grow luxuriantly. Upon the top of the Castle Hill a charming prospect is presented of Nice, with its numerous villas, gardens, orange plantations and olive-clad hills, its beautiful bay, and the lofty mountains which shelter it from the north, and to which it owes its advantages of climate, while immediately beneath, the houses of the old town, thickly clustered together, contrast pleasingly with the beauties of the scenery by which they are surrouuded.

Nice presents a good many resources for occupation and amusement. There is a cerale with a good library and reading rooms (the principal French, English, and Italian papers being received), rooms for cards, &c., and concerts; two good libraries, with reading rooms, Visconte's establishment, a tolerable theatre where Italian operas and French dramas are represented. The Church of England service is performed by a resident clergyman, before a tolerably numerous congregation. Excursions are frequently made on donkey or horseback among the hills and valleys of the neighbourhood, and to more distant points, amoog which may be particularly specified, Villefranche, which is separated from Nice by a steep hill. The little town is almost surrounded by olive-covered hills, and being sheltered from all cold winds, its climate is warm and equable. It possesses a spacious harbour which can admit the largest vessels ; but there is no accommodation for visitors.

Nice has long been resorted to by invalids, for the sake of its winter climate, which differs materially from that of Provence, inasmuch as it is less dry, and is sheltered from the north winds and from the mistral by the maritime Alps, and the Estrelles, which terminate at the sea westward ; but still it is at times, especially in spring, liable to cold winds, and to the transitions which, without great precautions, render a residence in the south of Europe not unattended with danger to invalids. Hence much discrimination is required in the selection of cases likely to be benefited by its climate, as also in the choice of a residence, and as respects the proper period of remaining there. The season at which the greatest_ amount of rain falls (autumn) is generally over when strangers begin to arrive; and the months of November, December, and January are usully fine and warm, the temperature bein" seldom lower than 45 degrees in the daytime, and sometimes as high as 60 in the shade. The sky is mostly cloudless, of a deep blue, and the sun is often powerful in the middle of the day. The general character of the air is light, dry, and exciting, and the climate is consequently suited to most persons of a torpid or relaxed habit. Cold winds occasionally occur in these months, but are most felt in the spring, when they occasionally blow sharply over the mountains, at that period still covered with snow, while, at the same time, the sun acquires great power, rendering the climate extremely tryiDg to invalids labouring under disease of the lungs and air-passages.

The mean temperature may be estimated as follows : winter, 7.7 ; spring, 14.4; summer, 18.6; autumn, 10.3; that of the year being 12.7 (Reaumur). In winter there is a difference of from 12 to 24 degrees between the temperature of places exposed to the south and the north, between those in the shade and in the sun, and especially between those sheltered spots and those which are freely exposed to the air, or in the shade.

The most frequent winds at Nice are the southeast, the north, the east, and northeast ; the rarest are the west, the north, northwest, west-southwest, south-southeast, and south-southwest.

" The greatest quantity of rain," says the local writer from whom the above statement is taken, " may be estimated at 43 inches in the year ; the smallest at 16, the mean quantity at 26. The maximum and minimum of rain which falls in the four seasons is usually in the following proportions : winter, from 4 to 7 inches ; spring, 4 to 8 inches ; summer, 2 to 7, and in autumn, from 6 to 10. It is by no means a rare occurrence to see fall at certain periods of the year, especially at the equinox, great and continued rains, producing five cubic inches of water in less than twenty-four hours. The mean of rainy days in the year is 30." 1

From the general remarks on the effect of climate it may be inferred that the winter climate of Nice, or of its environs contrasting forcibly with that of the countries in which tubercular cachexy is most frequent, would tend to accomplish in many cases of incipient consumption, or of a predisposition to the disease, the objects chiefly sought to be attained by means of this remedial agent in favourably modifying the abnormal condition of the system. The sunshiny days, the purity and relative dryness of the air, the variety of the scenery in the environs, the cheerful society met with, presenting many inducements to invalids to be much out of doors, cannot fail to produce a beneficial influence upon their physical state and mental disposition.

The climate is more especially indicated in cases where the patients are of a lymphatic or torpid habit, or where a scrofulous constitution is connected with tubercular disease, who are not very susceptible to be affected by atmospherical variations within a moderate range. To patients of an excitable temperament, or where there exists much irritability of the respiratory organs, with a tendency to recurring haemoptysis, it would generally be prejudicial, though to many patients with whom a residence in the town or suburb near

1 Roubandi. Nice et ses Environs.

the sea would disagree, the more sheltered and equable climate of the villas under the hills of Cinriez or Carabacel would not be unsuited.

It is advisable for most invalids with pulmonary disease, not to remain at Nice throughout the spring, but to proceed further into Italy, or to some more suitable climate, or if remaining, to reside in one of the more sheltered localities of the environs.

MEJfTON.

About five hours' drive from Nice on the Genoa road is Menton, which is remarkable for the mildness and equability of its climate. It consists principally of a street along the shore through which the road passes, inhabited by shopkeepers and artisans. Possessing no resources for occupation, notwithstanding the beauty of its site, Menton is only occasionally visited by invalids.

Foder6, in his Voyage aux Alpes Maritlmes, said of it : " The country is beautiful, the climate mild, the inhabitants well-mannered, yet after having seen the little there is to see, one feels a strong desire to go further on."

Though having a southern aspect, and being exposed to the sun's influence during the greater part of the day, there are but few houses where strangers could be accommodated.

Several patients after wintering at Nice, and desirous of seclusion, might pass with advantage a few weeks in the spring at Menton, in one of the hotels, where the accommodation is tolerable. The climate would be best suited to persons suffering from pulmonary disease in an early stage, accompanied with great susceptibility of the air-passages to atmospherical variations; though to some of these patients where the circulation is accelerated, and the cough and dyspncea are urgent, a more humid atmosphere would be better adapted. In many cases, on the other hand, the warmth of Menton, and the comparative deficiency of free ventilation, would be attended with enervating effects, as may be inferred from the general appearance of the natives, who are for the most part of an indolent or lymphatic temperament, with a tendency to embonpoint, and of placid disposition.

PISA.

About five leagues distant from Leghorn — fifteen from Florence (with which cities it is connected by rail) — and two from the sea, Pisa lies, in an extensive, plain, which after heavy rains is partially covered with water, on which account intermitting fevers were formerly prevalent ; of late years, however, drainage has improved the salubrity of the district.

The town is of considerable extent, being inclosed by high walls, and is divided into two unequal parts by the Arno, which flows through it with a semicircular bend. The quays are handsome, the streets wide, clean, and, as in most towns of Tuscany, are paved with flag-stones. When formerly the capital of a republic, the population amounted to 150,000 souls; it does not, however, now exceed 20,000, which circumstance imparts to the town a melancholy and deserted aspect. Three stone bridges cross the river. The principal movement is along the northern quay (Lung' Arno), which has a southern exposition, and is the only part where invalids reside. Pisa possesses an Academy of Arts, a university, a large public library, subscription reading room, and a handsome theatre where operas are given. It is, however, but indifferently provided with promenades, with the exception of the Cascina, an extensive park two miles distant, with fine avenues of oak and poplar-trees.

Pisa is in great measure sheltered from the north and east winds, by a range of mountains which rise some miles off to an elevation of 3000 feet. The winter climate is considered, next to that of Rome, the mildest and most equable in Italy. The plain being fully exposed to the southern winds blowing from the Mediterranean, and over marshes, the sirocco is at times unpleasantly felt. Rain is more frequent than in most towns in Italy. The quantity has been estimated at nearly as much as fulls in the rainy county of Cornwall. It must, however, be borne in mind, that as the rain falls in large quantities at a time (great part in autumn), the weather is less variable than in England, and longer intervals of fine weather occur. Rain falls on an average on 160 days in the year. The concave bend of the Lung' Arno, concentrating the sun's rays, includes a climate peculiarly warm, differing by many degrees from that of other parts of the town, where cold winds are often severely experienced, especially in the early part of spring. The mean winter temperature is 7.82 (centigrade scale), spring 14.82, autumn 17.31. The general temperature of Rome is somewhat higher in winter than that of Pisa, but much lower than that of the Lung' Arno. In spring Pisa is better sheltered from cold winds than Rome; the winds most prevalent at Pisa being the west, south, and southwest, which last is usually charged with moisture. This kind of climate agrees well with many patients suffering from pulmonary disease, having the character of excitability, and is therefore opposed to that of Naples or Nice, which is better suited to the chronic forms of disease where there is but little irritability of the air-passages. Invalids would, however, often come depressed in spirits from a prolonged sojourn in Pisa, on account of the dulness of its aspect, and the few resources which it presents. A few weeks in the spring are not unfrequently advantageously passed at Pisa, by persons who have been remaining great part of the winter at Nice, and who thus partly avoid the cold winds which prevail at that place without being sufficiently long in Pisa to be affected by the more relaxing influence of its atmosphere. For those who, together with a mild climate, require recreation and amusement, Rome is preferable, though many find Pisa agree better with them for a prolonged sojourn than the calmer air of Rome. 5

ROME.

The valley of the Tiber is inclosed by two ranges of diverging hills. The mounts Pincian, Quirinal, and Viminal, constitute the eastern limit of Koine ; the mount Mario, and the Vatican, which is almost continuous with the Janiculum, forms the limit on the west; whilst on the south are the Aventine, the Capitol, and the Esquiline. The river makes a considerable bend, of which the concavity is directed towards the Pincian and Quirinal hills; its banks being rather low, the adjacent grounds are not unfrequently inundated after heavy rains; the inundation sometimes extending into the city.

Rome is surrounded by high and massive walls ; the streets are for the most part narrow, and are often dirty, except in the neighbourhood of the Piazza di Spagnu, the quarter in which strangers almost exclusively reside. The fixed population amounts to 170,000 inhabitants.

Apartments having a southern aspect are more difficult to be obtained in the circumscribed strangers' quarter, than in other towns in Italy frequented in winter, which, like Nice and Naples, are built along the shore, or like Pisa, where the visitors' quarter on the quay of the Arno, is fully exposed to the solar rays.

It is scarcely necessary to observe that Rome possesses more resources for occupation and recreation than any other place of winter resort. These are, however, not unfrequently detrimental to invalids, who are often induced to do more in the way of sight-seeing than they are able to accomplish without risk, and who are likewise negligent in guarding against the variations of temperature experienced at different times of the day, in cold picture or statue galleries, &c.

The environs afford ample scope for horse exercise, and the principal roads for carriage driving are maintained in tolerably good order.

The climate of Rome is milder, and the winter shorter than in most other parts of Italy. The air is soft, comparatively seldom agitated by sharp winds. «nd is at times oppressive, especially during the prevalence of the sirocco, which, however, agrees very well with many pulmonary invalids. The tra- ■montane, or cold north wind, sometimes blows strongly in the winter and ■spring, usually lasting three days; the neighbouring hills are not sufficiently ■high to protect the city, and cold winds are the more sensibly felt on account •of the general softness and the relaxing qualities of the air, which may be considered humid, as compared with that of the other places of resort in Italy. The most common causes of the moisture of the atmosphere are its state of •comparative'stagnation ; the occasional fogs from the Tiber, and the exhalations from the earth after sunset, which are sometimes so great as to wet the pavement. Within the short space of half an hour at this time of the day, there is a marked difference in the temperature, on which account strangers, ■and especially invalids, should, when out of doors, be provided with an extra garment.

The mean temperature of the different seasons (by the centigrade thermometer) is as follows: Winter, 8.1; spring, 14.20; summer, -22.96; autumn, 16.40. Sir James Clark (whose tables are computed by the scale of Fahrenheit) states the mean winter temperature to be ten degrees higher than London, seven higher than Pau, and one higher than Nice. More recent observation has, however, shown that the difference between London and Rome is not so great, and that Nice has a winter temperature higher than Rome of more than a degree. In spring the temperature of Rome is five degrees above London, three above Pau, four below Nice, four below Madeira, and about the same as Naples. With respect of steadiness of temperature from day to day, Rome precedes Naples and Pau, but comes after Nice and Pisa. " The inconstancy of the atmospheric conditions," observes M. Carriere, "and a degree of humidity which varies according to the season and the predominance of certain winds, constitute the leading features of the climate. This inconstancy is especially remarkable during the first weeks of winter. At this period the northern winds are in conflict with the southern. Clear alternates with a cloudy sky, and sun with rain. After December, the northern influences predominate. Cold and dry winds are experienced with a certain continuity, but they do not cause much agitation of the atmosphere, and soon give place to antagonistic or collateral winds. The air is tolerably calm, and the sun shines on most days at the beginning of February. The spring is mild, and the weather settled. October is the favourite month of the Romans ; abundant rains water the earth, and reanimate vegetation ; the sun shining between the intervals of rain imparts the appearance of a second spring. November retains some analogy with October, being characterized by the alternation of rains with sharp cold." 1

According to Colandrelli, the southeast, south, south-southwest, and the west, the warm and cool winds of Italy preponderate in the proportion of 62 to 100. This preponderance of warm winds is, however, far from having an absolute regularity. The southwest wind from Africa (passing over the sea and Albano) is next in frequency to the south, which meets but little obstacle to its passage. Next in frequency is the north-northeast, which enters by the valley of the Tiber; then the southeast, or sirocco wind, which is less felt at Rome than on the Mediterranean shore. The northwest (mistral) which is powerfully experienced in Provence, and in the bay of Naples, presents the weakest proportion at Rome. The east-southeast and south winds favour most the fall of rain. 3

The average number of rainy days (from observations made during 37 years) is 114. In this respect Rome may be considered intermediate between the Vale of Arno and Genoa on the one hand, and Nice and Provence on the other. A third more rain falls at Rome than at Nice, somewhat more than

1 Sur le Climat de l'ltalie.

at Florence, but much less than at Pisa. It appears also that more rain falls in Rome than in London, where the number of days on which rain falls is on an average 178 in the year ; the mean quantity of raiu being 31 inches, whereas at Rome it is 29 inches. It must, however, be remembered with reference to the number of rainy days, that small quantities at a time, or showers, are very common in England, whereas at Rome, the rain falls more violently, and in larger quantities, in particular seasons, leaving longer periods of fine weather.