Part 18

For many cases of nervous break-down, so common a feature of our over-strained civilisation, I regard the Cape trip as an invaluable restorative. Persons who have had a severe attack of influenza would regain their strength more surely in a holiday spent in going and returning from the Cape than in any other way. I particularise influenza for its frequency, but the benefit is equally great in many other affections in which the nervous system especially suffers. Thus I have seen extraordinarily good results follow in a case of persistent insomnia of many months' duration. The patient completely conquered his sleeplessness during the voyage out, and was perfectly free from it on his return, and has remained exempt for years. In another instance a gentleman whose symptoms pointed to the early nervous break-down of general paralysis, recovered his faculties of mental concentration and memory as a result of a visit of a few weeks' duration. In the case of phthisical patients, whose special desiderata I shall discuss throughout this paper, it would be well for the companies to arrange, where possible, for facilities for their sleeping under cover on deck, in order to avoid the unavoidable closeness of cabins during the night. This would be a matter of no difficulty or discomfort for three-quarters of the voyage. The wants of delicate infants are met by the carriage in most of the mail steamers of a cow, so that fresh milk can be obtained throughout the voyage; but a store of milk, adequately sterilised before leaving England, may with advantage be taken with them by anxious mothers to ensure proper supplies for their infants. The milk keeps perfectly, and a couple of dozen pint-bottles will last out the voyage, and be a security against lacking this essential nourishment.

The ports of arrival in South Africa are usually Durban for the East Coast routes and Cape Town for the West Coast. The health-characteristics of these ports will be discussed after a general survey of the climatic conditions of the country has been made.

It is a common mistake to send patients to South Africa with no detailed instructions as to the localities best suited for individual cases, and regardless of the fact that the physiography of the country is so varied that no general statement as to the climate is possible. Two broad features, however, may be immediately distinguished, if we regard South Africa as consisting of interior highlands surrounded by a narrow, low-lying coast belt, the width of the latter varying much, but seldom exceeding fifty miles. The largest towns, with the exception of Johannesburg, are comprised in the coast-belt, the uplands being for the most part sparsely inhabited. The climate of the seaboard is further conditioned by the prevalence of currents and winds, so that towns on the east coast have a materially different atmosphere from those of the west. It will, of course, be remembered that the seasons in the southern hemisphere are exactly reversed with respect to those of the northern. For the Cape the division of the year may be made as follows:--

_Spring_--September, October, November. _Summer_--December, January, February. _Autumn_--March, April, May. _Winter_--June, July, August.

In South Africa, however, the matter is complicated by the fact that the rains occur, in some parts, mostly in the winter, as in England and northern countries generally, and in other parts are strictly confined to the summer. The humidity of the air is probably the most important factor in the healthiness or otherwise of a climate for many diseases, and this point must therefore be most carefully considered. For phthisis in particular moist warmth has long been condemned as only less harmful than moist cold. Madeira and the Riviera have consequently lost much of their former vogue as suitable resorts for phthisis, on account of their high degree of humidity. It is to be earnestly desired that the claims of the highlands of South Africa to be considered the most advantageous country in the world for all but the latest stages of this disease, should become more widely known, alike to patients and physicians. A further consideration, of the highest importance to non-wealthy consumptives, is that South Africa is a new and progressive country, in which there are good prospects that the change of environment will lead, not only to restored health, but to the means of earning a livelihood as well.

It will be necessary now to examine more in detail the special characteristics of the several regions of South Africa and their relative fitness for receiving patients and visitors. Besides the question of climate many other factors must be considered, such as the accommodation for invalids, the possibility of obtaining comfort and suitable food, and the social conditions which form, from a psychological standpoint, an important element in the treatment. To take the last point first, I would earnestly deprecate the focal accumulation of a large number of invalids, especially of tubercular invalids, in one centre; not so much because of the infectivity of such an accumulation, but because of the deplorable mental depression which results from the constant contemplation of other sufferers from this disease. Any one who has had experience of large hospitals or sanatoria for phthisis must have been struck with the undesirability, from this point of view, of the aggregation of patients. Mind and body are so inextricably mingled that the intelligent physician will attach not less importance to factors concerning the first than to those affecting the second. Let the sick man, therefore, avoid his sick fellows, when this is possible, and mix by preference with the healthy and robust. Health, like ill-health, is contagious. But when the patient's forces are too far shattered to allow of this, sanatoria become necessary. I contend still that these should be small and disseminated, rather than central and on a colossal scale. This subject will be discussed in greater detail later.

Accommodation and the obtaining of creature comforts for invalids are, of course, more practicable in the towns than in the sparsely-populated country districts, but, unhappily, the towns are mostly confined to the coast-belt, which is not the healthiest part of South Africa. The variations of climate within this coast-belt are great, and are influenced, as has been said, by the prevalence of winds and rains, and sea-currents. The eastern and south-eastern parts of the seaboard have heavy summer rains; the southern and south-western parts have in the first a rainfall somewhat evenly distributed through the year, with winter rains as one approaches the west. The imaginary approximate line between the summer and winter rains would divide the southern coast in the longitude of Grahamstown. West of this line the rainfall may be said to vary between ten and twenty-five inches; east of this line it is uniformly above the latter figure. The mean humidity of the coast-line is about 75 per cent. It may be said at once that for this reason none of the coast districts, as regards climate, is an advantageous resort for all-the-year-round residence for phthisical patients, but that the seaboard having winter rains is _ipso facto_ less suitable than that in which the rainfall is chiefly in the summer months. It is unfortunate that hitherto many circumstances have conspired to make the English visitor in search of health reluctant to live out of the towns, though these are often by no means the most suitable places for him. Political dissension between the two great occupying races has been the bane of South Africa and especially of the Cape Colony. It has come about that the progressive English have settled in the towns, while the unprogressive Dutch have kept tenaciously to the country. As a corollary from this, it is still the reproach of South Africa that, outside of a few towns, it is impossible to obtain good accommodation for the traveller, and still less for the invalid. It is earnestly to be hoped that the wider knowledge of the country, consequent upon the attention which has been concentrated upon it during the war, will lead to a large immigration of settlers who, eschewing the goldfields, will be content with the securer, if less considerable, competence to be obtained from agriculture, and will thus develop the country. It was a very wise and far-seeing plan of the late Mr. Rhodes to settle energetic English farmers in the midst of a stagnant Dutch district, and it is desirable in every way to break up the hard-and-fast racial division which has made so permanent an impress on the land. But this must be a matter of time, and for many years it must remain true that in the precious search for health the English invalid must be content to live in the midst of an alien majority, sometimes bitterly antipathetic to all things English. An even more important reason for keeping to the towns is that owing to the devastation of cattle caused by rinderpest and red-water, food, especially fresh meat, milk, and butter, has become dear and difficult to procure. To sum up, it may therefore be said that to the seriously ill, who are incapable of roughing it in any sense, the coast lands, though as regards climate not so satisfactory as the upper plateaux, are the only possible resource; but the sick man who is not yet so sick as to be laid up, is urged to quit the coast as soon as possible, and to take up his abode in the higher plains.

HEALTH RESORTS IN THE COAST-BELT

Cape Town, the capital of the Cape Colony, is the usual terminus of the voyage from England. It lies at the foot of Table Mountain, on the shores of Table Bay. Though an ugly town, it has natural surroundings of great beauty, and its suburbs are picturesque in the extreme. It has an excellent water-supply derived from Table Mountain, but its drainage is bad and the death-rate excessively high for a position of such natural advantage. Living is dear and at the present time exorbitant, owing to the large influx of persons wishing to go up to the goldfields, and unable to proceed on their way by reason of the congestion of the railway and the impossibility of finding house-room at their ultimate destination. The hotels are for the most part expensive, and leave much to be desired as regards cleanliness and comfort to the traveller fresh from Europe. There are numerous boarding-houses which are often comfortable and well managed, and in which the charges are about £12 per month for each person. The city itself, however, is not a pleasant place to live in, and most of the business community have houses in the suburbs, retaining only offices and shops in the town. The pleasantest residential district within the metropolis itself is the part called "the Gardens," at the top of Government Avenue, a fine shady walk not open to wheeled traffic, with a double row of oak trees on each side, some of them planted by Governor Van der Stell, between 1679 and 1699. The magnificent Parliament buildings, Government House (the residence of the High Commissioner), many of the Government offices, the Public Library and Museum, the South African College, are all in close proximity to this part of the town. The library contains the most notable collection of books to be found in any of our colonies, including, as it does, the great Grey collection and the Dessinian bequest. It is particularly rich in literature dealing with South African history.

There is a large native quarter where the Malays congregate. It is overcrowded and insanitary to a degree, and contributes conspicuously to the high death-rate.

The residential suburbs, which are very healthy, stretch east and west of the town, and are connected with it by rail and electric car. The former are the more fashionable, and have become familiar to English readers during the past three years. Rondebosch, in which is Mr. Rhodes's house, Groot Schuur (bequeathed to the High Commissioner), is five miles out. Claremont, a couple of miles eastward, has a large and excellent sanatorium which was of great value to the military. Wynberg, a mile further east, has a military hospital, and is a particularly healthy and pleasant district. It has an excellent independent water-supply. The Government wine-farm, Constantia, which gives the name to the well-known Cape liqueur, is situated in the neighbourhood. The suburban railway is continued to the east, passing by Muizenberg and Kalk Bay, favourite seaside resorts for holiday-makers, and terminating at Simonstown, the headquarters of the Cape and West Coast Imperial naval squadrons. To the west of the bay lie the suburbs of Green and Sea Point, separated from the town by a large expanse of flat open land adjoining the sea, and called "the Common," upon which a large military camp was located during the war. The fresh Atlantic breezes blow directly across the Point, and this is one of the healthiest spots on the coast-belt. A magnificent new road, the Victoria Road, has been made along the sides of the precipitous slope forming the western edge of the Cape peninsula, as far as Houts Bay. From this there is an inland carriage-drive to Wynberg. The Victoria road a little resembles, but is far more magnificent than, the celebrated Corniche road in the French Riviera. The late Lord Carnarvon, when he visited South Africa in 1887, called this "the finest drive in the world." January, February, and March are the hottest months of the year in Cape Town. The mean maximum temperature for these three months is 80°. June, July, and August are the coldest, with a mean maximum of 62°, and a mean minimum of 49°. Clothing as for the English summer and winter respectively is recommended, but it must be remembered that even in summer the nights are cool, a drop of over 20° between midday and evening temperatures being common. The mean humidity is 79.

Fruit in the Cape peninsula is plentiful and good--grapes, oranges, tangerines, peaches, apricots, nectarines, strawberries, plums, apples, quinces, melons, pears, pomegranates, grenadillas, loquats, figs, guavas, tomatoes, are all procurable in season. The flora of the Cape peninsula is one of the most interesting in the world. Over 10,000 varieties of heath have been described as occurring in this small area. Mr. Chamberlain should be interested in the _Disa grandiflora_, the celebrated orchid to be found only on the summit of Table Mountain.

It is well to give a caution as to the prevalence of venomous snakes which abound in the Cape peninsula and South Africa generally. The cobra and the puff-adder are the most dangerous of these fearsome things. A celebrated South African authoress has confided to me that her habit of looking at her feet when walking, a habit upon which she received much banter in Europe, was derived from her early timidity of snakes. Cautious observation of one's tread in tramping across the Cape plains is very necessary, and many fatal accidents have been due to carelessness in this respect. The visitor is strongly urged to carry with him on any such expedition a hypodermic syringe and a supply of Calmette's "Antivenene," which may be obtained from the British Institute of Preventive Medicine. Calmette's experiments go to show that the venom of all species of snakes and of scorpions is of a similar nature. His serum is obtained by the inoculation of horses with the poison of the cobra. The remedial injection should be made immediately upon the occurrence of the bite. The serum keeps well for months if retained in a cool dark place. The dose is about five cubic centimetres of the serum, to be injected hypodermically.

It is curious that this late observation of modern science should have been in a measure anticipated by the natives, who have been accustomed for many years to eat snakes and swallow their venom, with a view to render themselves immune to the bites of these reptiles.

An infective sore, occurring mostly on the hands and feet, is often contracted in walking on the veldt in South Africa, and it has been called veldt-sore. Its bacteriology has lately been thoroughly worked out, and it appears to be due to a specific micro-organism, though Professor Wright, of Netley, claims it to be the ordinary microbe of suppuration. I have had personal experience of this small ailment, and can vouch for the discomfort and intractability of the sore thus produced. Free drainage of the wound and antiseptic dressings are recommended.

Another note of warning may be fitly included here. Domestic service being performed almost entirely by natives, it is often necessary to entrust young children to their care. Unhappily, venereal diseases are exceedingly common among the coloured population. I have seen deplorable instances of the infection of young children with gonorrhoea and syphilis derived from their native nurses. These should, therefore, be selected with the utmost circumspection.

Durban, the second most usual termination of the voyage from Europe, is the seaport of the Colony of Natal. Cape Town and Durban have the distinction of being the only ports in South Africa at which landing can be effected direct from the ocean-steamers. The hottest months are January, February, and March, with a mean maximum of 84°, and a mean humidity of 76 per cent. Its dry season is the winter, and it is at its best then, and is a favourite winter resort for residents of Johannesburg, from which it is only twenty-four hours by rail. From April to September, bright, clear, sunny weather may be expected, and the climate is exceedingly enjoyable. The town is one of the most English in South Africa, and its hotels, boarding-houses, &c., are good, but woefully deficient in number for the present influx of settlers. Houses are extremely difficult to procure, and building is very expensive. The recent working of important coalfields near Durban has increased its value as a port and coaling station. The water-supply is ample and excellent, being derived from rivers several miles from the town, and being passed through filter-beds before distribution. A modern drainage system is approaching completion, and the town is being supplied with electric lighting. Mangoes, pine-apples, bananas, and custard apples are plentiful, in addition to many of the fruits previously enumerated as growing in the Cape Colony. There are large sugar and tea plantations in the vicinity, and rice, coffee, pepper, and tobacco are cultivated with success. To sum up, it may be said that although the summer humidity and heat make it not well suited for phthisical patients, the town is in the winter months one of the healthiest in South Africa, and one of the most progressive and pleasant to live in.

Port Elizabeth, the third most important of the coast-towns, is not to be recommended as a permanent residence for invalids. Its rainfall is more evenly distributed through the year, and the humidity, which is remarkably constant, is about 75 per cent. The variations in summer and winter heat are also within a small range; the highest mean temperature for summer being 75°; the lowest mean for winter 48°. But the winds are trying, and render it unsuitable for invalids. Uitenhage, a small village three-quarters of an hour's run from Port Elizabeth, is far healthier, and is rapidly becoming a favourite suburb. It has an exceptionally good water-supply. In the near neighbourhood are the largest vineyards in the Eastern Province.

These three towns may serve as types of the climatic conditions to be met with on the south-western, southern, and south-eastern coast-line respectively. It must be again emphasised that climatically none of the coast resorts are as beneficial for phthisis and chest affections generally as the uplands; but that other factors render them at the present time, and for the immediate future, the most suitable resorts for the seriously ill. And though climatically they are not the best that South Africa can afford, they are, nevertheless, better than most of the European resorts that have hitherto been frequented. For they all afford more prolonged sunshine, and purer air, and are more exempt from the infectivity of overcrowding than is the case with the fashionable recruiting places of Europe. But it is to the highlands of South Africa that we eventually look with confidence as promising the maximum of benefit, which will be available as soon as the difficulties of food and accommodation and social environment are adjusted. From the coast-line a series of terraces rise to the northward, with extreme regularity on the western three-fourths, with less uniformity on the eastern fourth of the southern continent, as far as the Zambesi. Four terraces may thus be distinguished, and are divided as follows:--

1. The coast plateau comprising the land within fifty miles of the coast, and reaching a level below 1000 feet.

2. The Southern Karroo, the plateau between the Outeniqua and Langenbergen mountains to the south, and the Zwaartebergen to the north. Level from 1000 to 1500 feet.

3. The Great or Central Karroo, the plateau between the Zwaartebergen range to the south, and the Nieuwveld and Roggeveld to the north. Height between 2000 and 3000 feet.

4. The Northern Karroo, stretching north to the Orange River at a level of 4000 feet and over. The Transvaal and Rhodesia, though not commonly included as within the Karroo districts, are high tablelands with similar altitudes, and may be described under this heading.

The climate of the coast plateau is similar to that of the seaboard, and much need not be added to the description given under that heading. Visitors to the higher plains of South Africa must be warned to go not unprovided with warm clothing, and to be careful of evening chills. The fall of temperature as night comes is very great. It has been observed that chills which in England usually result in nasal catarrh, in South Africa take the form of intestinal catarrh, and most visitors experience this discomfort soon after arrival.

In the Southern Karroo is situated the important health-resort of Ceres, much frequented by the residents of Cape Town, from which it is distant only 84 miles. It is a pretty little Dutch town, 1700 feet above sea-level, with picturesque surroundings. It has a small sanatorium under very competent medical supervision. The water-supply is derived from mountain springs, and is very pure. The climate is drier than that of the coast plateau, and its ease of access from Cape Town enables supplies to be readily brought up. Being within the line of winter rains it is not recommended for phthisical patients in other than summer months, but during the latter, which may be taken as extending from October to March, the phthisical patient could live and sleep in the open air in properly-constructed sanatoria. It is much to be desired that further accommodation of this kind should be supplied, as Ceres forms a comfortable halting-place, where the phthisical patient may with advantage spend a few weeks on his road to the higher plateaux, and it would be an invaluable resort for delicate persons whom physicians are obliged to send out of England during the English winter, a time at which Ceres would be at its best.