Cornell University Library 
 QC 989.r6C44 
 
 Some effects of the climate of Italy. 
 
 3 1924 012 336 404 
 
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 cS*' 
 
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SOME EFFECTS 
 
 CLIMATE OF ITALY. 
 
SOME EFFECTS 
 
 CLIMATE OF ITALY 
 
 THOMAS KING CHAMBEES, M.D., 
 
 FELLOW OF TUB EOTAL COLLEGH 0» PHYSICIANS; UONOEARY PHYSICIAN TO 
 
 H.R.K. TUB PBINCB OF WALES; COHSULTIWG PHYSICIAN AMD LBCTOBBB 
 
 ON THB PEACTICB OF MEDICINE AT ST. MABY's HOSPITAL ; 
 
 CONSULTING PHYSICIAN TO THB LOCK HOSPITAL. 
 
 LONDON: 
 
 JOHN CHUECHILL AND SONS, 
 
 NEW BURLINGTON STREET. 
 
 MDOCCIXT. 
 
 JD 
 
-shH-TS"^ 
 
 PRlNTtD BY I. li. ADT.ARD, BAnTHOI.OMT.W CI.OSB. 
 
PREFACE. 
 
 This small volume contains the substance of a 
 short course of lectures, written during the leisure 
 of an involuntary holiday, delivered a few weeks 
 since in the theatre of St. Mary's Hospital, and 
 reported in the 'Lancet.' I rejoice. in the oppor- 
 tunity which publication affords of thus again 
 acknowledging my debt of gratitude for the sweet 
 influences of Italian skies, by revising the whole 
 and making it somewhat easier reading. To this 
 end I have broken up the lectures and re-arranged 
 them into subjects, filling up gaps with a little 
 fresh matter. 
 
 T. K. C. 
 
 22b, Bkook Stbeet, Geostenob Sqttaee; 
 Wovemier, 1865. 
 
CONTENTS. 
 
 PAET I. 
 
 
 Pebsonai Expebience . 
 
 PAGE 
 
 1 
 
 PAET II. 
 
 
 Statistical Evidence . 
 
 . 29 
 
 PAET III. 
 
 
 POWEBS or THE AlB . 
 
 . 49 
 
 PAET IV. 
 
 
 Pbactical Applications 
 
 . 69 
 
ON SOME EFFECTS 
 
 CLIMATE 'OE ITALY. 
 
 PART I. 
 
 PERSONAL EXPERIENCE. 
 
 It is now nearly a year and a half since I was 
 obliged to have a thigh amputated on account 
 of the degeneration and rupture of the popliteal 
 artery. In the eighth month after the operation 
 I tried to resume a moderate amount of practice, 
 but found myself quite knocked up by it. My 
 circulation was so weak, and the renewal of the 
 body evidently so tardy and unequal to calls made 
 upon itj that my kind professional friends became 
 anxious; and they urged me to free myself from 
 the physical and mental labour of London 
 life for about a twelvemonth. They recom- 
 
 1 
 
Personal Experience. 
 
 mended me to travel, with the idea of 
 keeping me out of the temptation to transgress 
 their orders which the near view of work to be 
 done oflfers to a working man. Like a well- 
 behaved patientj without questioning the why or 
 wherefore, I put my house in order and set off. 
 It was early in last winter ; and partly by accident 
 and partly with an intention to renew the feelings 
 of youth by visiting scenes hallowed in school and 
 college memories, I gradually got to Italy, and 
 spent most of my time there. And now I receive 
 the reward of my obedience in meeting again, 
 sooner than I had even hoped, my old pupils and 
 friends in St. Mary's lecture room, with restored 
 health and strength, and by God's blessing 
 enabled to engage actively in the duties of my 
 profession. 
 
 It may readily be guessed that I fell in with 
 not a few of my countrymen wandering, as I was, 
 in compliance with medical prescription, and a 
 good many stationed in what may be called 
 'health-resorts.' Conversation with them and 
 the natural direction of my thoughts to my own 
 case led me to reflect much on the subject of 
 
Personal Experience. 
 
 travelling for health ; and it struck me that the 
 ideas of both patients and medical men about it 
 are governed much by accident or individual 
 fancy, and fluctuating with fashion more than is 
 seemly in a scientific age. 
 
 Invalids are often imprisoned in some spot 
 which happens to have been brought prominently 
 before the world by a well- written pamphlet, when 
 a frequent change of air would have been bene- 
 ficial to them physically, and when the moral 
 effect of change of scene would have been still 
 more useful. On the other hand, those who re- 
 quire calm rest are allowed to rush wildly along 
 through a tour as an opus operatum, and pass the 
 greater part of their time in railway trains and 
 travelling carriages. 
 
 I noticed that, except in selecting places of even 
 temperature for cases of pulmonary phthisis, both 
 patients and their advisers seemed more impressed 
 with the value of some bath or spa, whose phy- 
 sical contents and effects are often quite inap- 
 preciable, than with the effect of the whole change 
 of air, water, place, and scene, which the use of 
 that bath or spa involves. Even if they acknow- 
 
Personal Experience. 
 
 ledged the general wholesomeness of travelling, 
 they -vrere evidently not convinced of any advan- 
 tages to be derived in special cases from special 
 climates. Apparently they feel too strongly the 
 vagueness and small extent of our knowledge of 
 the action of climatic influences on the human 
 body to be dogmatic in their application of phy- 
 siological science to cure disease by their means. 
 
 Yet can we suppose these cosmic powers null ? 
 Shall we not rather look upon them as the 
 most active agents that we have for the restora- 
 tion of health ? Shall we not try to remedy the 
 ignorance which makes our use of these agents 
 unsE^sfactory, and look forward to physical re- 
 search into natural phenomena as the chief hope 
 for the future of medicine ? 
 
 Physiological induction not aiding, the next 
 best guide to the right use of a remedy is obser- 
 vation conducted on a large scale by the collection 
 of independently recorded facts. One might in 
 this way have a fair means of judging what mor- 
 bid changes promoted by one climate are likely to 
 be counteracted by another. But above all things 
 it is necessary that these facts should not be col- 
 
Personal Experience. 
 
 lected in the spirit of an advocate, to praise or to 
 condemn ; they must be recorded without a pur- 
 pose. Upon such body of evidencCj however, I 
 could not find that any of the opinions about 
 climate, especially the climate of Italy, rested. 
 
 T observed this when thinking about my own 
 case, before I started. And my first idea was to 
 try and remedy the ignorance which I could not 
 but confess by a recourse to the stores of our 
 medical literature. " I am thinking of travelling 
 in Italy, Mr. Librarian, and I want some book to 
 tell me whether the climate in general will suit 
 my state of health, and whether one part is better 
 than another.^' " We have many local works, sir, 
 about various parts of the country." " Very good^ 
 I dare say, but monotonous. Each one that has 
 any mineral waters declares those particular 
 waters to be useful in almost every disease under 
 the sun ; and if they have not any mineral waters, 
 that the temperature is very even during the 
 winter, and more suitable for phthisical patients 
 than Florence or Naples (which it may very 
 easily be) . Then the bigger monographs give a 
 list of the indigenous plants, with a history of the 
 
Personal Experience. 
 
 place from the time of the Romans, and the 
 smaller ones do not — and there's an end. The 
 more comprehensive works are still less satisfac- 
 tory, for they merely inform you that the climate 
 has its advocates and opponents, whose opinions 
 they repeat, and leave you with a table of mean 
 temperatures suspended in a fluctuating balance 
 of opinions. I want something more than the 
 ideas of the ' oldest inhabitants.' Have yon any 
 statistics to show what forms of disease are pre- 
 valent or fatal, and what are rare and not fatal ?" 
 " No, sir ; the works published do not give any. 
 You must trust to opinions, for it seems impos- 
 sible to get facts about Italy." " Impossible ! 
 is it ? Well, we shall see." 
 
 So it was with some misgivings and with the 
 feeling that I was an experimental traveller, that 
 I set foot on the Mediterranean shores. I could 
 not see that I had any of the complaints for 
 which various spas and baths are recommended in 
 various treatises. I had no tubercles in the lungs, 
 no instinctive desire for the even temperature 
 promised in the sheltered nooks appropriated to 
 the phthisical. I had no clearly defined organic 
 
Personal Emperienoe, 
 
 change in anyviscusj or any of the ailments classi- 
 fied hy the nosologists "vrith names ending in 
 " — itis." Nobody could point to a part diseased, 
 yet I was very weak and ill. The history and the 
 symptoms seemed to indicate tendency to slow- 
 ness of repair, a proneness to dilapidation which 
 had already resulted in the destruction of one 
 part, and might at any time ruin others. 
 
 I was, in short, a convalescent who did not con- 
 tinue to convalesce. This was an anxious position ; 
 for we all know that in health, as in morals, 
 standing still is very rare, and that not advancing 
 is usually synonymous with falling back. I was 
 in a state which one knows by experience may 
 beget almost any organic change, though as yet 
 none; a result of which the "may"' or "may 
 not" is a question of slow death or of renewed life. 
 
 But I must not abuse the lecturer's chair by 
 turning it into an opportunity for egotism, as if 
 there was anything peculiarly instructive or ori- 
 ginal in my own case. The condition is unfortu- 
 nately common enough, and shows itself locally in 
 a great variety of parts and in a great external 
 variety of forms, which, when complete, are de- 
 
8 Personal Experience. 
 
 scribed in books of pathological anatomy as 
 degenerations of those parts ; that is to say, where 
 the normal tissue is replaced by a less vitalized • 
 one — a lower kind of animal matter, retaining the 
 same shape as the healthy organ. It is scarcely 
 needful to specify Bright^s kidneys, pale and thin 
 hearts, paralytic muscles, white-softened brains, 
 as familiar instances. 
 
 Doubtless, this change may originate in a single 
 organ; but more often, perhaps, than has been 
 suspected, begins by affecting the whole constitu- 
 tion in a way which receives shrewder notice from 
 the observation of those near and dear to the 
 patient than from the cold science of the physi- 
 cian. The mind of the medical attendant recurs 
 naturally to his post-mortem examinations ; it is 
 directed to the degree of alteration in some organ 
 which his diagnosis enables him to fix upon ; and 
 he names the ailment accordingly, thickening of 
 the bronchi, cirrhosis of the liver, enlargement of 
 the heart, Bright's kidney, or what not. To 
 loving eyes the veil of the future seems more 
 transparent ; they take cognisance of the earlier 
 change in the whole man, the interruption in the 
 
Personal Experience. 
 
 circle of lifcj the breach in the chain of those vital 
 processes whose continuity constitutes health. 
 And hence it is not a bad term, when lay friends, 
 no less philosophically than tersely, call the disease 
 a break-up, or broken health. 
 
 I think it of great importance in the application 
 of treatment to recognise as a definite disease this 
 period of broken health which precedes the various 
 degenerations above alluded to, and to see that, 
 however much the final symptoms may difier, 
 their origin, and the mode of curing them when 
 curable, are similar. I will therefore describe it 
 at some length, and beg your attention to identify 
 the various phenomena named in one or other of 
 the cases you may come across. 
 
 The approaches of the enemy are very insidious . 
 The sufferer is unable to draw any clear picture of 
 the symptoms; no one place is painful, and no 
 one function of life absolutely abnormal; yet he 
 feels himself less capable than formerly of trans- 
 acting the ordinary work of life; the business- 
 letter, that it was lately a pleasure to write, first 
 loses its interest, and then becomes a burden ; the 
 little misfortunes of the pigs or of the turnips, the 
 
10 Personal Experience. 
 
 worries of the kennel or of the parish^ of the 
 patients or the clientSj become so intolerable that 
 he gives up his very hobbies. Then he grows stiff 
 and knocked up after the daily shorter consti- 
 tutional j going up-hill is especially fatiguing, 
 though he does not suffer from shortness of 
 breath. 
 
 The night's rest is almost always insufiScient. 
 The patient drops asleep on getting into bed out 
 of utter weariness, but soon wakes up again, and 
 is restless for the remainder of the time spent in 
 bed. The ears buzz, and the back of the neck 
 aches, and the bowels keep up a fidgety grumble, 
 which leads to nothing more. 
 
 Then he feels uncomfortable after a moderate 
 meal; his meat oppresses him, and his wine 
 flushes him. As time goes on, he finds he can 
 take less and less alcohol with advantage to 
 himself; he says he " feels to want it," but that 
 it does not do him good as of yore. 
 
 Symptoms of defective circulation are seldom 
 absent ; the knees and ankles are stiff and swelled 
 of an evening; and, as he stands about at his 
 morning wash, he sees his feet flushed and con- 
 
Personal Experience. 11 
 
 gested with stagnant blood. Mysterious pains 
 in the tack and side are felt after sitting down or 
 riding for even short periods; often a dull dis- 
 comfort at the hack of the neck seems as if it 
 were going to be a sick headache, but does not 
 prove so. 
 
 The urine is usually pale; it irritates the 
 bladder, especially in the forenoon, and causes 
 frequent micturition. There is often flatulence 
 after exertion of mind or body, and apparently 
 independent of the quality of food taken. 
 
 Perhaps at first all this is attributed to what 
 is called "derangement of stomach;" but ob- 
 servation of the action of the bowels shows not 
 enough to account for the continued ill-health. 
 The stools are, iadeed, scanty and softer than 
 natural ; but they occur at the usual hours daily, 
 and are rarely diarrhoeic. The wind from the 
 intestines, when flatulence is present, seldom has 
 that fetor of sulphuretted hydrogen so character- 
 istic of dyspeptic decomposition. That is to say 
 it has not naturally ; but if purgatives are taken, 
 then the indigestion, which I have described as 
 absent, is sometimes artificially induced. 
 
12 Personal Experience. 
 
 Soon the complexion loses its transparency, 
 and acquires a faded dingy or gray hue ; though, 
 if there is any fixed colour in the skin, this 
 becomes darker and more fixed. The nose looks 
 blue and wintry, and wrinkles are brought out as 
 the disease advances, giving an air of premature 
 old age to the patient. 
 
 In spite of the loss of strength, he sometimes 
 gets burly and heavy from the growth of soft fat 
 in the cellular tissue ; and this increase of weight 
 is a further distress by impeding the exercise of 
 the bodily powers. The nails get friable and 
 crack ; the hair is dry, and easily faUs off j some- 
 times it quickly tm'us gray, increasing the' aged 
 look before mentioned. 
 
 Sometimes the detection of an imperfection of 
 one or other of the senses drives the puzzled 
 invalid to look after his health. He grows deafish 
 without there being visible cause in the ear to 
 explain deafness; and his aurist finds the usual 
 local remedies fail. Or the sight becomes weak, 
 especially towards evening ; and yet his ophthal- 
 mic surgeon can find nothing wrong in the eyes. 
 
 I have used hitherto the masculine pronoun in 
 
Personal Experience. 13 
 
 speaking of the person affected ; but the symptoms 
 are, mutatis mutandis, much the same in the 
 female sex. The defective power of active ex- 
 ertion is less observed by women, because they 
 are usually less called upon to make active ex- 
 ertion, and the idleness which tortures the mind 
 of the husband is not infrequently the daily 
 labour of the wife even in health. When the 
 more busy-brained complain of not being able to 
 go on as usual, they are assured by their friends 
 that they are merely falling into a more properly 
 feminine style of life, and so they come to mind 
 less their deficiencies. Thus they have some ad- 
 vantage over the other sexj but on the other 
 hand, the symptoms are with them apt to advance 
 rapidly, and the morbid changes to fix soon on 
 some local viscus. The heart especially is in 
 great danger of becoming dilated. The anaemia, 
 too, is marked in females, partly because they are 
 proner to it naturally, and partly because there is 
 less fixed colour of exposure in their faces and 
 hands. Instead of increasing in size, they are 
 the rather apt to become thin and emaciated. 
 Also the reproductive organs in them are early 
 
14 Personal Experience. 
 
 noticed to be affected; the montUy evacuations 
 become scanty and irregular, thougb not painful, 
 and many wives lose suddenly the inclination for 
 and tbe power to bear their matrimonial privi- 
 leges. These are the chief diflferences of the 
 symptoms in women. 
 
 To the mind of the physiologist perhaps the 
 most striking evidence of the defective vital power 
 in botli sexes is in the urine. I have said it is 
 pale and scanty; it is also of lower specific gravity 
 than one would expect from its scantiness. Yet 
 there is not that deposit of lithates which shows 
 imperfect assimilation in a healthy person. Ex- 
 amined under the microscope, it exhibits not in- 
 frequently floating crystals of oxalate of lime, and 
 I have heard the irritability of bladder attributed 
 to the pricking of these sharp crystals. But they 
 are really a great deal too small for that, and, 
 besides, I have found great irritability when they 
 were absent. No — the symptom seems rather 
 due to the deficiency of the normal cause of 
 acidity. For usually the pale urine of these 
 patients is alkaline or neutral, either of which 
 states is sufficient to cause the desire to evacuate 
 
Personal Experience. 15 
 
 the bladder without any diseased state of the 
 urinary organs. 
 
 The deficiency of urine is not supplemented hy 
 any iacrease in the secretion from the skin, as is 
 the case in health. The perspirations are scanty 
 and chillyj and appear to be mere transudations 
 of water, instead of being impregnated with the 
 sebaceous secretion as in robust persons. 
 
 What I have been endeavouring to depict is the 
 incipient stage of the disease. 
 
 If the patient submits his case to the physi- 
 cian, the history seems obscure enough, and 
 indeed consists mainly of negative symptoms. It 
 is not so much that the functions go wrong, as 
 that they do not go on sufficiently. Perhaps 
 sometimes he is told he is "nervous," and an 
 effort is made to quiz him into good health. I 
 do not think this quizzing wise or kind. If 
 judicious treatment be employed, I believe the 
 condition to be perfectly amenable to art, and 
 that recovery need not be despaired of if the 
 means of attaimng it be taken in good time. But 
 in the majority of instances, unfortunately, this 
 does not happen ; attention to the general health 
 
16 Personal Experience. 
 
 is postponed till the separate deficiency of some 
 one organ excites alarm as well as discomfort, 
 and enables the ailment to be classified under a 
 more definite name. 
 
 This fixing of the disorder in some spot in, such 
 a degree as to lead to the diagnosis of the dis- 
 organization of that spot, I would designate as 
 the second stage. 
 
 The failing part is usually one which has been 
 overworked during the early period. If bodily 
 exertion has been persisted in, spite the natural 
 warniag to abstain, the heart is very apt to be- 
 come dilated. In quieter persons some of the 
 arteries become opaque and thickened or dilated ; 
 there are throbbings in the head, faintings, 
 threatenings of apoplexy, or perhaps only weak- 
 ness and irregularity of pulse. If one Hmb, or 
 certain muscles of one limb, are alone overexerted, 
 as in some peculiar bodily exertions or awkward 
 postures, atrophic paralysis of these often occurs, 
 accompanied by pain in the atrophying parts. 
 This sometimes saves vital viscera by putting a 
 stop to the hurtful employment. 
 
 Amongst our labouring classes Bright's disease 
 
Personal Experience. 17 
 
 of the kidney is a very usual result. Next to dilated 
 heart, it is with hospital patients the commonest 
 local expression of a general degenerative dia- 
 thesis; whereas in the upper ranks of society 
 Bright''s disease is, according to my experience, a 
 primary lesion of the renal tissue, and much less 
 frequently preceded by the injured state of con- 
 stitution which we are now concerned with. 
 
 There are two causes to which it is possible to 
 attribute this liability of the lower orders to have 
 general degeneration fix itself in the renal organs : 
 intemperance and exposure. Though both may 
 have some influence, the last, according to the 
 histories I have been able to collect, is by far the 
 most powerful and the most common. Caeteris 
 parihus sober persons seem to me quite as liable 
 as drunkards, or even as spirit-drinkers. I attri- 
 bute the lesion in these cases to the extra work 
 thrown on the kidneys by the exposure of the skin 
 to cold and damp, when those viscera are suffering 
 a defective vitality along with the rest of the 
 body. The resulting albuminuria is sometimes 
 temporary; sometimes it is only induced by 
 passing external circumstances, such as a catarr^ 
 
 2 
 
18 Personal Experience. 
 
 an exposure to chill, an imprudence in eating or 
 drinking, a mental emotion. It is very rare to 
 find blood in the urine ; even casts of the tubes 
 are not common ; and the quantity of albumen is 
 invariably small. It is, in short, a slowly march- 
 ing, little-marked form of the disease. 
 
 Chronic bronchitis not infrequently appears as 
 the disease advances in persons past middle life. 
 It seems due to the degenerative thickening of 
 the mucous membrane of the air- tubes and to 
 hardening of the bronchial cartilages. 
 
 Atrophic softening of the brain is another local 
 expression of the condition I am describing. It 
 is slow in its progress, often intermittent, less 
 marked in its symptoms, and more likely to be 
 recovered from than where it is a purely local 
 disorder. When I speak of recovery, I do not 
 mean to affirm that the softened parts resume 
 their transmission of psychical influence — I have 
 no proof that this is possible, — but that their 
 place is taken by other portions of the brain, and 
 the functions are performed in a normal manner. 
 
 Atrophy of the testicles and other forms of im- 
 potency in the male sex are rare. I do not know 
 
Personal Experience. 19 
 
 whether it is by accident or not, hut I have not 
 happened to meet with these symptoms preceded 
 by broken health, except in Europeans who have 
 been exposed for long periods to tropical heat. 
 
 So far as I am aware, the deafiiess and weak- 
 ness of sight, alluded to in the description of the 
 incipient stage, do not get much worse, nor do 
 they appear to lead to any serious disorganization 
 of the organs affected in the second stage. 
 
 Among the effects of general degeneration I do 
 not think we can include tuberculosis. Asso- 
 ciated together they are sometimes — perhaps I 
 might say, not infrequently ; and the relief of 
 pulmonary symptoms, when the degenerative pro- 
 gress is arrested, is so remarkable as to suggest 
 that the latter is the origo mali. But anatomical 
 experience tells another tale. It is rare to find 
 tubercles in degenerated tissue; when tubercles 
 and degeneration occur together in the same 
 body, they are usually in different organs, and 
 the tubercles appear of the oldest date. The 
 cliidcal observation above mentioned must be ex- 
 plained on the supposition that the degeneration 
 is a consequence and an aggravation of the con- 
 
20 Personal Experience. 
 
 sumption, adding to its symptoms when present, 
 and giving them relief when it is itself relieved. 
 Though "consumption/^ as it appears to non- 
 medical eyes, may be in great part a consequence 
 of degeneration, yet tuberculosis is not so. 
 
 It would seem to be a rule that all local diseases 
 commencing as general degeneration proceed less 
 quickly to an incurable stage than when they 
 begin locally at once. They are less fatal in 
 themselves, and give much more encouragement 
 to the medical man to hope for their arrest than 
 when they start frankly in one organ. The 
 patients must not therefore be condemned hastily ; 
 for if taught to manage themselves aright, they 
 may live for years and years without becoming 
 worse. 
 
 The great danger lies in the insidious latency 
 of the symptoms, which often conceals from even 
 a careful eye how far the disease has advanced, 
 and beguiles us into an unjustifiably favorable 
 diagnosis till it is too late for beneficial action. 
 
 I have thus described two stages of the disease 
 which we may describe technically among our- 
 selves as "general degeneration," and to the 
 
Personal Experience. 21 
 
 public as "broken bealtb," — the first stage, or 
 that of general diathesis, where cure may reason- 
 ably be aimed at ; the second, or that of local 
 development, where we can hope only to prevent 
 the patient getting worse. There is also a third 
 stage — or that where these local developments 
 have brought their consequences of dropsy, 
 ascites, increasing paralysis, consumption, &c., — 
 where you can hardly hope to stay the progress 
 towards the grave, and can do no more than 
 endeavour somewhat to retard it, and make it 
 easier. It does not enter into the scheme of these 
 pages to enlarge upon this last stage. 
 
 I have spoken first of the symptoms of the 
 m.orbid state I am engaged upon, because about 
 them we know most. But it is upon its essential 
 pathology that I ground the suggestion I am 
 about to contribute towards its care, and it is 
 necessary therefore that I should now come to my 
 ideas on that subject. 
 
 The first cause which underlies the whole series 
 of these pathological changes seems to me to be 
 a weakness of blood-circulation — local in those 
 instances where the disease is confined to one 
 
22 Personal Experience. 
 
 part — generalj where it is distributed through the 
 body. Sometimes this weakness is induced — as, 
 for example, by long-continued sedentary occupa- 
 tions, where the contractile fibres of the heart and 
 arteries become sluggish from want of use; or 
 again, by anxiety of mind, where the nervous 
 energy is withdrawn from the involuntary muscle ; 
 or by exhausting debaucheries and laziness. 
 Sometimes it is congenital ; sometimes it is here- 
 ditary, — in which case it is apt to be increased by 
 over-exertion. But there are hardly any instances 
 where you cannot trace a diathesis of weak circu- 
 lation of blood ; and I think it will be by paying 
 more and more attention to this point that we 
 shall be enabled to rectify the morbid states ia 
 question. The greatest step towards rightly con- 
 ducting a cure will be to find under what circum- 
 stances the circulation becomes more active, and 
 under what circumstances a weak circulation is 
 least injurious to the patient. 
 
 I do not hold that we ought, in view of patho- 
 logical changes, to sit down like the Alpine herds- 
 man, who watches day by day the march of the 
 glacier over his little farm, hoping that it -will 
 
Personal Experience. 23 
 
 stop, and knowing that it often does stop, but 
 powerless to control the event. I am sure we 
 need not do so ; I am sure that a carefcd study 
 of the conditions under which disease " gets well 
 of its own accord" (as it is phrased) wUl enable us 
 to imitate those conditions and to induce them 
 when absent. 
 
 There is no more dangerous snare to the 
 earnest open-hearted practitioner of the present 
 day than the sceptical reading of " Expectant 
 medicine." Many an ardent student, when he sees 
 a patient get well without some, or mayhap with- 
 out any, of the treatment detailed in his text- 
 book or by his first teacher, is very apt to take 
 refuge from his puzzled state in the conclusion 
 that all treatment is useless. And I am afraid 
 that in this he is too much encouraged by many 
 a hasty hospital physician. But as patients not 
 unreasonably insist upon having something done 
 to them for their money, an unscrupulous or igno- 
 rant man fills up the gap with the traditionary 
 mixture of various remedies. Hereby you may 
 know him, according to the indication given long 
 ago by Lord Bacon, who says broadly that 
 
24 Personal Experience. 
 
 " Polypharmacy'^ (as he calls it) is a sure proof 
 of ignorance. And the ignorance is of the worst 
 sort, voluntary and obstinate. No attempt is 
 made to cure it by experience — ^no attempt can 
 be made to render the case useful to individuals or 
 to the profession^ when a heap of medicines are 
 given at once. Such practitioners not only refuse 
 to enter in at the gate of knowledge themselves, 
 but they tumble down and bar the way against 
 others. 
 
 Permit me to return to myself for a minute. I 
 was able to hail returning health, and yet had 
 taken no medicine. I had tried fairly and exclu- 
 sively the experiment of travelling in Italy, and I 
 felt myself a different man. Pirst the pulse beat 
 evenly, then stronger and firmer ; soon the heart- 
 stroke could be felt with the hand. Then the 
 muscles regained their power, and instead of 
 prostration after exertion, there came a healthy 
 feeling of weariness. The cold sweats after mental 
 attention ceased gradually. The congestion and 
 serous cedema of the lower limb were only occa- 
 sionally perceptible. Alcoholic stimulants were 
 less and less demanded, and the digestion pros- 
 
Personal Experience. 25 
 
 pered better without them. Flatulence was no 
 longer trouhlesomCj and the motions were more 
 copious and solid. I could apply my mind to 
 whatever interested me without being punished by 
 a sleepless night afterwards. 
 
 Was the change due to time only, or had the 
 climate anything to do with it ? It was an in- 
 teresting question as regards myself, and an im- 
 portant question as regards many a patient, whose 
 downward progress might perhaps be arrested in 
 this way ; and I assure you it gave me occasion for 
 much thought at most uncongenial times and places, 
 starting up amongst the gay walls and homely 
 relics of Pompeii, the Doric solemnity of Sicilian 
 temples, the noisy fun of Naples, or the triumphs 
 of Florentine art, and leading me to bore with 
 questions people of all classes likely to assist me 
 with information. I wanted to put to the test of 
 facts our vague notions ; I wanted to know from 
 collateral and indirect evidence what was the actual 
 effect of the Italian climate in the production of 
 disease, and what in the progress of disease when 
 once produced. I was determined to bring back 
 somewhat more than a mere collection of opinions. 
 
26 Personal Experience. 
 
 The first frtiit of my inquii'ies was this — that 
 throughout both mainland, peninsula, and 
 islands, what was talked about, thought about, 
 dreaded and avoided, what had to be treated by 
 the physician, and was generally the cause of 
 death, was acute disease and not chronic. When 
 directly questioned on this head, medical men 
 concurred in observing that the greater part, and 
 often allowed that almost the whole of their work 
 was made up of acute cases. Some considered 
 this the natural state of things, and seemed not 
 aware that it could be otherwise ; but a few, and 
 especially my friend Dr. Pantaleoni of Nice 
 (late of Rome), had used travelling experience to 
 remark this difference between their practice and 
 that of brethren in England and Northern France. 
 He told me that of Italian patients he had ninety- 
 five acute to five chronic, and those latter chiefly 
 hysterical and neuralgic; whereas, as he justly 
 said, in the case-books of London physicians the 
 proportions might be inverted without being far 
 wrong. Others fixed at a guess on four fifths, 
 others on two thirds, as the proportion of acute 
 cases in their native clientela ; but as their 
 
Personal Experience. 27 
 
 minds had not specially been addressed to the sub- 
 ject, the numbers are very likely under the mark. 
 The accomplished man whose name I have quoted 
 had, on the contrary, thought much and deeply 
 on the matter, and indeed it was by him that my 
 attention was first turned to it. 
 
 Now this evidence is very important ; for I may 
 appeal to the experience of every London physi- 
 cian as to the approximate truth of Dr. Panta- 
 leoni's reckoning of the proportions of acute and 
 chronic in our practice. An important difference 
 is shown, and that proves either (1) that chronic 
 diseases comparatively seldom originate in Italy, 
 or (2) that they are so little troublesome that the 
 afflicted do not go to physicians for them, or (3), 
 that they both seldomer originate, and are also 
 less painful, less ^injurious to the general health 
 than in England or places of similar latitude. 
 Now under any of these circumstances it would 
 seem prima facie to be a climate suitable for 
 their cure. And if it is a climate suitable to 
 the cure of those forms of disease which consti- 
 tute so large a proportion of our practice, have 
 we not here a most potent engine to use which 
 
28 Personal Experience. 
 
 aright implies a weighty responsibility ? Is not 
 any knowledge about it deeply important to us 
 both as physiologists and as physicians ? 
 
PART II. 
 
 STATISTICAL EVIDENCE. 
 
 The knowledge which I hare described as 
 gained will he felt probably by all to be rather 
 suggestive than satisfactory. There is just enough 
 consent of opinions to indicate the existence of a 
 truth, but not enough to put it into a definite 
 practical shape. Any one accustomed to the 
 rigid demands of modern scientific investigation 
 will not be satisfied without registered statistics 
 to modify the suggestions of memorial experience ; 
 and if he took the trouble to put his requirements 
 into words, they would probably take some such 
 form as the following questions : 
 
 First, whether registered facts confirm or not 
 the idea of the minor gravity of chronic diseases 
 in Italy as compared with England : 
 
 Secondly, whether they confirm also the idea of 
 their minor prevalence : 
 
30 Statistical Evidence. 
 
 Thirdly, whether there is any pathological con- 
 dition to which this chronicity of disease can be 
 referred : 
 
 Fourthly, whether the difference in the propor- 
 tionate gravity and prevalence of acute and chronic 
 disease in the two countries extends to all classes, 
 or whether it is confined to the easy classes, of 
 whom a private practice is made up. On the 
 answer to this last question depends, of course, 
 the probability of its being due to climate or to 
 any social causes out of a stranger's reach. 
 
 As the first step in the solution I will compare 
 the mortality of Genoa with that of London. 
 These two capitals resemble one another in con- 
 taining a large manufacturing, commercial, and 
 seafaring population, a nearly similar proportioi 
 of poor and of persons in easy circumstances, in 
 the hygienic conditions of drainage and water- 
 supply (which are of average character, not so bad 
 as Naples, though not so good as they ought to 
 be), in a great influx of strangers of all classes, 
 and iu the active industry and general robustness 
 of the people. 
 
 It may be remarked that Genoa contains 
 
statistical Evidence. 31 
 
 130,000, and London 2,804,000 inhabitants ; but 
 the difference in population does not affect the 
 propriety of the comparison, as both come equally 
 under the category of great cities, and are Uable 
 to the same social causes of ill-health. 
 
 This latter fact is proved, as far as it is capable 
 of statistical proof, by the returns of the mortality 
 from zymotics. By the last annual return (1860) 
 at Genoa, the class of smallpox measles and 
 scarlatina {"dermatoses"), typhus and typhoid 
 pertussis and croup together, caused 1 in 5'6 of 
 the deaths ; by the last annual return in London 
 (1862) 1 in 5-2. The difference is less than the 
 accidental annual variation. 
 
 The authority I take for Genoa is a Register of 
 the mortality for the year 1860, origiaally pub- 
 lished in the ' Liguria Medica,' by Dr. Giovanni 
 Du Jardin ;* that for London the Registrar- 
 General's Report for 1862 ;t each, I believe, the 
 last printed records on the subject in their respec- 
 tive countries. Unfortunately, the nomenclature 
 
 * Saggio Sfcatistico della Mortalita di Geneva nell' anno 1860. 
 Tip. de' Sordo-Muti, Geneva, 1864. 
 t Published in 1864. 
 
33 Statistical Evidence. 
 
 and classification of causes of death are not the 
 same in the two, so that it is impossible to make 
 so accurate a comparison as could be wished ; and 
 I have therefore thought it more conducive to a 
 probability of true results to extract a few speci- 
 mens of well-marked disease as examples, rather 
 than to attempt to divide the whole into the two 
 classes we want to compare. 
 
 I wiU take first specimens of chronic diseases. 
 
 Anasarca, or General Dropsy, caused in London 
 1 in 93, in Genoa 1 in 239 deaths.* 
 
 And with regard to this cause it may be 
 remarked, that the real difference is probably 
 much greater than would seem from the above 
 numbers, for in England many deaths of anasar- 
 cous persons are registered as from " Nephria " or 
 from " Kidney disease" which items do not appear 
 at all in the Genoese bills of mortality. 
 
 * I give the proportion of deaths by several diseases to the 
 total deaths rather than their per-centage in the population, 
 in order to make the table harmonious with one further on, 
 where such a mode of reckoning only is possible. As the object 
 is simply to show the proportion of acute and chronic disease, 
 not the death-rate, it is sufficiently accurate. 
 
Statistical Evidence, 33 
 
 The mortality by " Kidney disease " and " Ne- 
 phria " in London was 780, in Genoa 0. 
 
 The Chronic affections of the respiratory organs, 
 which in England are registered as "Asthma" and 
 " Bronchitis," in London caused 1 in 10, in Genoa 
 only 1 in 20 deaths. 
 
 Pulmonary Consumption is not included in the 
 last item. It caused in London 1 death in 8, in 
 Genoa only 1 in 13 ; and even that Dr. Du Jardin 
 considers extraordinarily high for Italy. 
 
 As respects Chronic affections of the nervous 
 system, I cannot find any cases recorded at Genoa 
 of Softening of the brain. Epilepsy in London 
 caused 1 in 180 deaths, in Genoa 1 in 253. 
 
 Among Chronic affections of the organs of circu- 
 lation, Aneurism in London caused 103 deaths, in 
 Genoa 0. 
 
 Chronic affections of the other organs of circu- 
 lation (that is, practically speaking, of the Heart) 
 caused in London 1 in 27 deaths, in Genoa 1 in 33. 
 
 Cancer caused in London 1 in 50 deaths, in 
 Genoa 1 in 64. 
 
 You may remark that in all these (which are 
 the names followed by the highest numbers in the 
 
 3 
 
34 Statistical Evidence. 
 
 list of diseases capable of being considered as 
 chronic), except the last trro, the mortality pro- 
 portioned to the total is in each case greatly 
 on the side of London ; and, as a rule, the more 
 decidedly chronic and degenerative the disease 
 is, the more marked is the difference between 
 the two cities. By the total of these chief chronic 
 diseases it wiU be seen that the mortality is not 
 far short of double that of Genoa. 
 
 But the difference is more than compensated 
 when we come to examine acute and inflammatory 
 affections. 
 
 Enteritis, Gastritis, Diarrhoea, and Dysentery* 
 together — ^that is to say, the most common affec- 
 tions of the abdominal viscera — caused in Genoa 
 1 in 8"9; in London but 1 in 30'3 deaths. 
 
 Acute affections of the respiratory organs caused 
 in Genoa 1 in 9; while in London Laryngitis, 
 Pleurisy, and Pneumonia (which is a fair rough re- 
 presentation of the Itahan class) caused but 1 in 16. 
 
 Acute inflammations of the nervous centres, or 
 
 * I write down these together, because in a great number of 
 cases, both in Italy and England, which of the four names is 
 given depends on the taste and habits of the registrar. 
 
Statistical Evidence. 35 
 
 Encephalitis, Meningitis, and Spinitis, caused in 
 Genoa 1 death in 59 ; in London 1 in 119. 
 
 Apoplexy and Cerebral congestion caused in 
 Genoa 1 death in \2, in London 1 in 40. 
 
 Acute inflammations of the heart caused at 
 Genoa 1 death in 44 ; in London (where they are 
 all classed as Pericarditis) , only 1 in 606. 
 
 The total of these acute and inflammatory 
 diseases shows in a striking manner their pre- 
 ponderance in the Italian city^ their prevalence 
 being considerably more than double that found 
 in our metropolis. 
 
 It is quite true that the proportions of acute 
 and chronic represented by these numbers are 
 not so different as I have stated in my last 
 lecture to be reported to me by Italian physi- 
 cians from their memory. But it must be re- 
 membered that the diseases here reckoned^ even 
 with the zymotics, do not represent much above 
 two-thirds of the whole mortality. Many classes 
 must obviously include both acute and chronic ; 
 and even of acute ailments it is often the chronic 
 effects which in the end destroy life, and of 
 chronic ailments the acute developments which 
 
36 Statistical Evidence. 
 
 are immediately mortal. In such an item, for 
 example, as " Convulsions," which comprehends a 
 very large section of the unclassified remainder 
 in both registers, who can say which pathological 
 condition is indicated? Again, Surgical Injuries 
 may be fatal by acute lesions in one place, by 
 chronic in another. Children who die Teething 
 and the "Esposti morti"* have probably succumbed 
 in London to one disease and in Genoa to ano- 
 ther. I have no doubt that, if these classes could 
 be analysed, the evidence of the bills of mortality 
 concerning climatic peculiarities would add force 
 to the argument I have already inferred from it. 
 I have no doubt that the fatality of degenerative 
 and chronic diseases is really even greater in 
 England and less in Italy than these limited ex^ 
 amples seem to show. 
 
 I subjoin a table which exhibits the above 
 quoted facts in a more convenient form for ocular 
 comparison. 
 
 * This is a singular class, to which there is no parallel in the 
 English register. At Genoa, and at many other Italian cities, 
 all illegitimate children are so much as a, matter of course 
 thrust into the tuming-hox at a foundling hospital, that Dr. Du 
 
Statistical Evidence. 
 
 Si 
 
 Comparison of selected Causes of Death in 
 Italy and England, 
 
 
 
 London. 
 
 Genoa. 
 
 
 
 Propor- 
 
 
 Propor- 
 
 
 No. of 
 
 tion to 
 
 No. of 
 
 tion to 
 
 
 deaths. 
 
 total 
 deaths. 
 
 deaths. 
 
 total 
 deaths. 
 
 Total from all causes 
 
 67,371 
 
 
 4,303 
 
 
 Typhus, typhoid, smallpox, measles, 
 
 
 
 
 
 scarlatina, whooping-cough, and 
 
 
 
 
 
 croup 
 
 13,915 
 
 1 in 5-3 
 
 779" 
 
 1 in S'6 
 
 
 '■Aaiaaarca or general dropsy 
 Nephria and, kidney disease 
 "Asthma" and " broncMtis," or 
 
 718 
 
 liu93 
 
 18 
 
 1 in 339 
 
 
 780 
 
 — 
 
 
 
 — 
 
 
 
 
 
 
 
 chronic affections of the re- 
 
 
 
 
 
 1- 
 
 spiratory organs, except oon- 
 
 
 
 
 
 sumpilon 
 
 6,553 
 
 linlO 
 
 315 
 
 Iin30 
 
 (4 
 
 Fulmon^ consumption 
 
 7,871 
 
 lin8 
 
 318 
 
 linl3 
 
 8 
 
 Epilepsy 
 
 373 
 
 1 in 180 
 
 17 
 
 1 in 353 
 
 
 Aneurism 
 
 103 
 
 — ,. 
 
 
 
 — 
 
 
 Chronic affections of heart 
 
 3,840 
 
 Iin37 
 
 136 
 
 Iin33 
 
 
 -Cancer 
 
 1,335 
 
 lin50 
 
 67 
 
 lin64 
 
 Total of chief chronic diseases, as 
 
 
 
 
 
 above 
 
 20,573 
 
 1 in 3-3 
 
 761 
 
 1 in 5-6 
 
 
 'Acute affections of digestive vis- 
 
 
 
 
 
 
 cera, or " enteritis," " gastri- 
 
 
 
 
 
 
 tis," "diarrhoea," and "dy- 
 
 
 
 
 
 
 sentery" 
 
 3,310 
 
 1 in 30-3 
 
 480 
 
 1 in 8-9 
 
 
 Acute affections of respiratory 
 
 
 
 
 
 S 
 
 organs, or "laryngitis," "pleu- 
 
 
 
 
 
 P • 
 
 risy," and " pneomonia" . . . 
 
 4,021 
 
 linl6 
 
 460 
 
 lin9 
 
 5 
 
 " Cephahtis," " encephahtis," 
 
 
 
 
 
 " menindtis," and " spinitis" 
 
 566 
 
 1 in 119 
 
 73 
 
 1 in 59 
 
 
 Apoplexy and cerebral congestion 
 
 1,653 
 
 lin40 
 
 193 
 
 lina3 
 
 
 Acute inflammations of the organs 
 
 
 
 
 
 
 of circulation, or " pericardi- 
 
 
 
 
 
 
 tis" 
 
 111 
 
 1 in 606 
 
 97 
 
 lin44 
 
 Total of chief acute diseases, as 
 
 
 
 
 
 above, not including zymotics 
 
 8,661 
 
 1 in 7-7 
 
 1,391 
 
 1 in 3-3 
 
38 Statistical Evidence. 
 
 I will now compare not the fatality, but tlie 
 frequency of occurrence^ of these diseases, at least 
 when sufficiently severe to induce people to seek 
 the aid of a physician. There are very few records 
 available for this purpose, and the best I have 
 been able to find are those of the Ospitale Mag- 
 giore of Milan,* and those of St. Mary's Hospital 
 in London. t The former are limited to the years 
 1858, '59, '60, but record the cases of 61,761 
 medical patients; the latter are spread over a 
 period of nine years, ending with 1861, after 
 which the register unfortunately ceased to be 
 
 Jardin divides all births into " Legittimi " and " Esposti." He 
 conjectures that a few of the latter may be legitimate, put away 
 by their parents because they are sickly or starring ; hut ex- 
 perience does not enable him to stretch his fancy so far as to 
 suspect that any children born out of wedlock are ever kept by 
 the mother. Of these " exposed " children, numbering 699 in 
 the year, 336 were either taken out of the box dead or died 
 within the current twelvemonth, so that the " Esposti morti " 
 number nearly 1 in 12 of the deaths. The social bearing of the 
 fact is obvious. 
 
 * Rendiconto della Beneficenza dell' Ospetale Magglore, &c., 
 del Direttore D. Andrea Verga. Milano. Tipografia di Ma- 
 uini. 1862. 
 
 + St. Mary's Hospital Annual Reports from 1853 to 1861 
 inclusive. " Summary of Medical Cases." 
 
Statistical Evidence. 39 
 
 made up for publication. It takes in 7319 
 medical patients. I will arrange them in as 
 nearly as possible the same order as the last lists 
 — namely, first the abdominal, then the pulmo- 
 nary, then the cerebral organs, and then those of 
 circulation. The nomenclature is somewhat dif- 
 ferent from that of the bills of mortality lately 
 cited, but at the two hospitals it is sufficiently 
 harmonious for the present purpose. And I may 
 remark also that the degree of severity of the 
 complaint in individual patients admitted is very 
 similar, judging from the percentage of deaths 
 under each item. 
 
 With Brighfs disease, or dropsy with diseased 
 kidneys, there were admitted at St. Mary's 232, 
 or 1 patient in 31 ; at the Milan Hospital 22, or 
 but 1 patient in 2807. 
 
 I fancied at first there must have been a mistake 
 here, and that at Milan they had got entered 
 under another heading. I looked about for " Ne- 
 fria," or some such correlative term to that 
 adopted by our Registrar-General. But it does 
 not appear. "Nefrite," indeed, I find, but it is 
 evidently restricted to real cases of inflammation 
 
-1^ Statistical Evidence. 
 
 of the kidneys, as still smaller numbers are en- 
 tered there than under " Malattia di Bright." 
 
 With Anasarca without diseased kidneys, de- 
 pendent on diseased heart, chronic bronchitis, or 
 on no known cause, there were at St. Mary's 74 
 patients, or 1 in 98 ; at Milan Hospital 776, or 1 
 in 78. Here there might be a suspicion that the 
 lieadings are not correspondent in England and 
 in Italy, that slighter cases might be included in 
 one which were otherwise registered at the other 
 hospital. This suspicion, however, is dissipated 
 by the mortality, which is as nearly equal as pos- 
 sible, amounting at St. Mary's to 35'3, at Milan, 
 to 33-8 per cent. 
 
 With Ascites there were admitted at St. Mary's 
 54, or 1 in 135 j at Milan Hospital 625, or 1 in 
 98. 
 
 This would appear to' depend on the greater 
 prevalence in Lombardy of disease of the liver, to 
 show which I have compared the number of cases 
 of hepatitis in the two countries. And I have 
 entered this item among the chronic diseases, 
 simply for the convenience of bringing it next to 
 Ascites, not because I believe it to be chronic. 
 
Statistical Evidence. 41 
 
 It will be seen by the table (a few pages further 
 on) that at Milan 46 Jj, or 1 in 133, were admitted 
 with this morbid condition, at St. Mary's only 9, 
 or 1 in 813. 
 
 With " Chronic bronchitis" or " Bronchorrhoea" 
 at St. Mary's there were admitted 224, or 1 in 
 32; at Milan only 7, or 1 in 8823. 
 
 What these numbers show is not the absence 
 to that entire extent in Italy of chronic bronchitis, 
 but, at all events, the slight nature of the iUness, 
 which does not bring the patient to the hospital. 
 
 With Pulmonary Consumption there were ad- 
 mitted into St. Mary's 527, or 1 in 13 j at Milan 
 1551, or 1 in 39. 
 
 Chronic diseases of the brain do not seem to be 
 sufficiently numerous at Milan to constitute a 
 separate class. 
 
 Aneurism of the aorta, again, is so rare there 
 that it is hardly worth tabulating. There were 
 but 4 cases, or 1 in 15,440 ; whereas at St. Mary's 
 there were 29, or 1 in 252. 
 
 External anewLim seems to be nearly equally 
 rare. There were at the enormous hospital at 
 Milan only 6 cases, against the same number (6) 
 
42 Statistical Evidence. 
 
 at our little St. Mary^s. I do not make a more 
 rigorous comparison because I have not tabulated 
 the surgical cases. 
 
 With Organic disease of the Heart there were 
 admitted at St. Mary^s 260, or 1 in 25 ; at Milan 
 1717, or 1 in 35. 
 
 The total of the above-named chronic diseases 
 admitted was at St. Mary^s 1412, or 1 in 5 ; at 
 Milan 4702, or 1 in 13. So that it is clear that 
 in prevalence, stUl more than in fatality, chronic 
 disease in London has far greater importance 
 than it has at Genoa. The fatality was nearly 
 double ; the prevalence is more than double. 
 
 In acute diseases the numbers are very dif- 
 ferent. 
 
 Enteritis, Gastritis, Diarrhma, and Dysentery 
 (which in this instance again I have thought best 
 to add together, for the reasons before given) are 
 represented at Milan Hospital by the number 
 7415, or 1 in 8 ; at St. Mary's by 90, or but 1 in 
 81 ; — Pneumonia, and Pleurisy at Milan by 4904, 
 or 1 in 12 ; at St. Mary's by 330, or 1 in 22. 
 
 It is clear, therefore, that the old idea of 
 avoiding inflammation by sending patients to 
 
Statistical Evidence. 43 
 
 Italy is a very fallacious one ; for the prevalence 
 of inflammations of tlie lungs is, by the above 
 numbers, nearly twice as great as it is in England. 
 
 The same may be observed of febrile Bronchitis, 
 the line between which and pneumonia is very 
 fine drawn. With febrile Bronchitis, including 
 influenza and acute catarrh, there were admitted 
 into Milan Hospital 5668, or 1 in 10 ; into St. 
 Mary's 245, or 1 in 29. 
 
 With Acute inflammations of the brain [Ence- 
 phalitis, Meningitis) there were at Milan Hos- 
 pital 513, or 1 in 120 ; at St. Mary's not half so 
 many — ^namely 29, or 1 in 252. 
 
 But the most remarkable diflerence appears in 
 Inflammations of the spinal cord, of which 
 disease, so rare with us, there were at Milan Hos- 
 pital 475 cases, or 1 in 130 ; at St. Mary's there 
 was only 1 in 7319. And a serious inflammation 
 it is too ; for of the 475 cases, 50 were fatal. 
 
 Apoplexy and sanguineous congestion I ranked 
 at Genoa amongst the acute diseases, and found 
 the mortality by it in that city nearly double 
 of that in London. As an hospital disease, how- 
 ever, it does not appear to be so prevalent : at 
 
44 Statistical Evidence. 
 
 Milan the numbers admitted were 230, or 1 in 
 268; at St. Mary's 90, or 1 in 81. In each in- 
 stance the cases seem to have been of equal 
 severity, half proving fatal — namely, at Milan 
 114; at St. Mary's 45. Though doubtless an 
 acute disease, yet in so many instances the way 
 for it is prepared by degenerative -conditions, that 
 I do not know if 1 have done right to put it in 
 this class. However, as the only effect to make 
 my argument slightly less strong, I have let it 
 stand. 
 
 With Pericarditis and Endocarditis there were 
 at Milan 316, or 1 in 195 ; at St. Mary's 119, 
 or 1 in 53. 
 
 The prevalence of this acute inflammatory dis- 
 order at St. Mary's is explained by the large 
 amount of Rheumatic fever , of which there were at 
 St. Mary's 835 cases, or 1 in 8 ; whereas at Milan 
 there were 3203 or only 1 in 19. 
 
 With Erysipelas there were at Milan 1000, or 1 
 in 61 ; at St. Mary's 69, or 1 in 106. 
 
 The proportion of deaths by zymotic diseases in 
 Genoa and London was so nearly equal that I 
 excluded them from the calculation as not 
 
Statistical Evidence^ 45 
 
 affecting the result. Here they are different, the 
 numbers of Typhus fevers being at Milan 8236, 
 or 1 in 7 ; at St. Mary's 471, or but 1 in 15. The 
 comparison of smaU-pox, scarlatina, and measles 
 I do not make, because practically they are not 
 treated in the wards of general hospitals in 
 London. 
 
 Taking now the totals of the acute diseases 
 named above, it will be found that at Milan they 
 amount to 31,950, or 1 in 1*9 ; at St. Mary's to 
 2293, or but 1 in 3-2. 
 
 I have no doubt that in looking over the 
 appended table you will be able to make other 
 deductions, but I feel sure they will all tell in con- 
 firmation rather than in abatement of the conclu- 
 sions I have been led to. 
 
46 
 
 Statistical Evidence. 
 
 Table of Comparison of Hospital Patients. 
 
 
 At OsplTAii Mag- 
 
 At St. Maet's 
 
 
 GIOKE, MiLAH.IS 
 
 HOSPIIAL, LOHDON 
 
 • 
 
 THBKZ YKAKS. 
 
 IN MIME YEAIS. 
 
 No. ad- 
 
 Proportion 
 
 No. ad- 
 
 Proportion 
 
 
 mitted. 
 
 to total. 
 
 mitted. 
 
 to total. 
 
 All medical diseases 
 
 61,761 
 
 _ 
 
 7,319 
 
 
 
 -Blight's disease, or general dropsy 
 with diseased kidneys 
 
 
 
 
 
 
 22 
 
 1 in 2,807 
 
 232 
 
 Iin31 
 
 
 Anasarca without diseased kid- 
 
 
 
 
 
 
 neys, dependent on diseased 
 
 
 
 
 
 
 heart, chronic bronchitis, or 
 
 
 
 
 
 6 
 
 no known cause 
 
 776 
 
 lin78 
 
 74 
 
 lin98 
 
 2 
 
 Ascites 
 
 625 
 
 liu98 
 
 54 
 
 1 in 135 
 
 S' 
 
 Hepalitis 
 
 (464) 
 
 (1 in 133) 
 
 (« 
 
 (1 in 81S) 
 
 a 
 
 "Chronic bronchitis" or "bron- 
 
 
 
 
 
 o 
 
 chorrhcea" 
 
 7 
 
 1 in 8,823 
 
 224 
 
 lin32 
 
 
 Pulmonary consumption 
 
 1,661 
 
 lin39 
 
 627 
 
 liulS 
 
 
 Chronic brain disease, softening. 
 
 
 
 
 
 
 abscess, &c 
 
 
 
 __ 
 
 12 
 
 
 
 
 Aneurism of aorta 
 
 4 
 
 1 in 16,440 
 
 29 
 
 1 in 252 
 
 
 LOrganic disease of heart 
 
 1,717 
 
 lin35 
 
 260 
 
 lin25 
 
 Total of the above diseases, ex- 
 
 
 
 
 
 cept hepatitis 
 
 •4.702 
 
 lin]3 
 
 1,412 
 
 linS 
 
 
 ^Enteritis, gastritis, gastro-enteri- 
 
 
 
 
 
 
 tis, diarrhcea, and dysentery . 
 
 7,416 
 
 linS 
 
 90 
 
 1 in 81 
 
 
 Pneumonia and pleurisy ... 
 Bronchitis (febrile) 
 
 4,904 
 6,668 
 
 linl2 
 linlO 
 
 330 
 245 
 
 lin22 
 lin29 
 
 
 Eneephahtis, meningitis 
 
 613 
 
 1 in 120 
 
 29 
 
 1 in 252 
 
 » 
 
 Noteo-myehtis or inflammation of 
 
 
 
 
 
 p ■ 
 
 the spinal cord 
 
 475 
 
 1 in 130 
 
 1 
 
 1 in 7,319 
 
 ^ 
 
 Apoplexy and sanguineous con- 
 
 
 
 
 
 
 gestion of brain 
 
 230 
 
 1 in 268 
 
 90 
 
 1 iu 81 
 
 
 Pericarditis, endocarditis... .., 
 
 316 
 
 1 in 196 
 
 119* 
 
 1 in 53 
 
 
 Erysipelas 
 
 1,000 
 
 1 in 61 
 
 69 
 
 1 in 106 
 
 
 Uheumatic fever, acute and sub- 
 
 
 
 
 
 
 acute rheumatism 
 
 3,203 
 
 1 in 19 
 
 835 
 
 1 in 8 
 
 Zymotic, continued fever — to wit ty- 
 
 
 
 
 
 phus, typhoid, gastric, catarrhal, 
 
 
 
 
 
 angiosteuic and typho-puerperal... 
 
 8,226 
 
 lin7 
 
 471 
 
 linl5 
 
 Total of the above-named acute 
 
 
 
 
 
 diseases 
 
 31,960 1 in 1-9 
 
 2,293 
 
 lin31 
 
 ad 
 
 * In 6,*16 patients in eight years ■ 
 ded to the totals. 
 
 so one eighth of tha 
 
 number has been 
 
Statistical Evidence. 47 
 
 This collection of numerical factsj imperfect as 
 it is, confirms, defines, and explains the conjec- 
 tures mentioned in my last lecture, as made by 
 physicians in Italy, in respect of the comparative 
 prevalence of acute and chronic disease in their 
 practice. It shows : 
 
 First. That there is a remarkable excess in the 
 mortahty from chronic disease in London over 
 that of an Italian town similarly circum- 
 stanced. 
 
 Secondly. That this excess in mortality is 
 united to and probably arises from an excess in 
 prevalence. 
 
 Thirdly. That the excess is most striking in 
 diseases where a tendency to degeneration of 
 tissue is the most marked, and the most directly 
 the cause of disease. 
 
 I refer especially to morbus Brightii and aneu- 
 rism ; but it is scarcely less observable in patholo- 
 gical changes of mucous membranes, which in 
 England have a great tendency to pass into a 
 chronic degenerative stage, and thus to destroy 
 life. This is strikingly shown by the pulmonary 
 mucous membrane. At St. Mary^s Hospital, 
 
48 Statistical Evidence. 
 
 though the cases returned as febrile bronchitis are 
 scarce above one third of the proportion at Milan 
 Hospital (1 in 29 against 1 in 10), yet the num- 
 bers of chronic bronchitis are extraordinarily dis- 
 proportionate (1 in 32 against 1 in 8823) . 
 
 Fourthly. The proportion of degenerative to 
 other diseases is here exhibited in such as are 
 wont to seek public aid in sickness, and is not 
 confined to those in easy circumstances. It may 
 therefore with reason be attributed to the climate 
 or endemic habits of life, and not to any pecu- 
 liarities of class. 
 
 It will be observed that these four propositions 
 are answers to the questions which I mooted at 
 page 29. Whether explicable by other physical 
 phenomena of the country, or standing alone in 
 solemn mystery, they are equally facts, which it 
 behoves us seriously to reflect on and to turn, if 
 possible, to useful purpose ! 
 
PART III. 
 
 POWERS OF THE AIR. 
 
 Do you know a design by Dayid Scott called 
 " The Procession of the Unknown Powers " ? It 
 was the last product of his poetical pencil. — Man 
 sits naked on the hare earth in the act of rising, 
 and looking up into vacancy with a painfully 
 loving, longing gaze. His throat swells with 
 emotion, his hair is dank with toil-drops, his arms 
 are braced up to effort ; the little wings sprouting 
 from his active wrists flutter, but are ridiculously 
 unequal to the task of raising him. Behind his 
 back roll onwards in a vast orbit dim shadows of 
 mighty king-like forms, bearing on their left palms 
 transparent tongues of flame, their eyes looking 
 only forwards, illumined and swelling with the 
 reflected light from the one source of everlasting 
 law and love. To praise and glorify that for ever 
 their right hands are half-raised in adoration ; but 
 
 4 
 
50 Powers of the Air. 
 
 though so mighty their course is sUent and still ; 
 no ray from their all-subduing flames falls on 
 man's intellect ; they pass by and leave him 
 
 Irrequietmn animi, et quserentem indagine van^ 
 Naturam semper fugientem. 
 
 I do not think anything^ I am sure no words of 
 minCj could more accurately describe the position 
 of the physiologist, when he comes to reflect on 
 the influence of climate on health. He perceives 
 dimly by their shadows that almighty forces are in 
 action, but what they are he can barely guess. He 
 calls one Electricity (and he may just as well at 
 once put a capital E to it), another Magnetism, 
 another Ozone ; but he knows little more of their 
 relation to his special subject of investigation. He 
 hardly knows whether the phenomena he has 
 observed arise from their excess or deficiency. 
 
 Therefore, now that I come to speak of the causes 
 which originate the variations of disease and health 
 in difierent climates, I shall avoid all but a cursory 
 mention of the probably chief factors. As we 
 know so little of these things, so much would 
 be required to be said about them, that I am loth 
 
Powers of the Air. 51 
 
 to give up the time. I shall confine myself to the 
 obvious and external peculiarities of life in Italy, 
 without entering upon the question whether it is 
 of such things, little in themselves, and weak in 
 separate action, that the sum of the specific action 
 of climate upon health is made up, or whether 
 more subtle cosmic influences are at work. 
 
 § 1. Take the map of Italy and follow its three 
 thousand miles of coast line. How it winds and 
 folds upon itself, as if every mountain was trying 
 to wet its feet in the sea, and every plain was 
 anxious to enfold at least one little baylet of salt 
 water, and to be kissed by a breeze fresh from its 
 dance with the waves ! 
 
 Then gather from the now popular works on 
 physical geography the characters of those waves 
 and of their sister breezes. The supply of fresh 
 water by rivers to the Mediterranean is very much 
 less than that which is brought down by the Gulf 
 stream from the Polar glaciers to the Atlantic. It 
 is therefore salter, and would be Salter still, and in 
 course of years all salt, were not a vast stream of 
 Atlantic water flowing in to Straits of Gibraltar. 
 It is, consequently, more ready to remove mois- 
 
52 Powers of the Air. 
 
 ture from the air, and less ready to part with it to 
 the air under varying temperatures than the ocean 
 which surrounds us at home. Its temperature 
 also is more equalised throughout ; there are not 
 as with uSj hot and cold streams, the vapours from 
 which meet in the air and precipitate their watery 
 burden on the earth. So that the atmosphere is, 
 in the first place, clearer, or has a minor degree 
 of hygrometric saturation than in the British Isles, 
 and, in the second place, is less rainy. 
 
 Of course there is rain, and of course there is 
 east wind and north wind in Italy as elsewhere ; 
 but there is not that continuous depressing in- 
 fluence of the combination of a cold wind with a 
 saturated air which we have. Then the avoidance 
 of these black un-Italian days does not involve an 
 imprisonment of a week or two in the house ; and, 
 in travelling, a change of residence of a few miles 
 will often put you completely under shelter. 
 Those who go abroad with an old-fashioned guide- 
 book, or take their ideas of Italy from the queer 
 little pictures in blue body colour that used to 
 adorn our nurseries, may be found grumbling, but 
 • those who have ever tried to travel in England, 
 
Powers of the Air. 53 
 
 and have the gift of comparison, will be well con- 
 tent. When they see the deep indigo horizon, 
 the mark of extra saltness in ocean, which so 
 generally bounds the traveller's landscape in 
 Mediterranean lands, they will bless it for the 
 clear air of which it is not only the indication but 
 the cause. 
 
 § 2. The high temperature of this great body 
 of water, so intimately intermingled with the land, 
 preserves that of the air from the variations which 
 we experience., This is of course most especially 
 the case on the coast, but even inland it may be 
 experienced, as is amply shown by the published 
 tables. The only exception is that of spots in the 
 immediate vicinity of snow-clothed mountains, 
 the air blowing over which in the early spring is 
 much chilled. So that in such places as Florence, 
 for example, a change of wind from a sea breeze 
 to a tramontana may cause a very sudden fall of 
 the thermometer. But these are matters of com- 
 parison — the even temperature of Italy as a 
 whole compared with England as a whole must 
 be allowed; its exposed climates are less vari- 
 able than our exposed climates, and its sheltered 
 
54 Powers of the Air. 
 
 nooks more completely even than our sheltered 
 nooks. 
 
 § 3. There is a higher amount and degree of 
 sunlight than in our skies, so that all the chemical 
 actions in the animal body must be intensified. A 
 conspicuous evidence of this is the readiness with 
 ■which the skin of the face becomes tanned even 
 in the short and fresh winter days. 
 
 § 4. The nervous system is much more awake 
 to the effects of alcohol ; so that instinctively less 
 quantities are taken to produce _ the required 
 effects. There are south of the Alps very few, 
 if any, water drinkers ; but there are also very 
 few indeed who indulge in strong drink. One 
 does not "feel to want it." A single glass of 
 Orvieto or Capri there seems to produce as much 
 exhilarating relief as an allowance of the domestic 
 Port or SheiTy containing five times the quantity 
 of spirit. 
 
 Not only is it felt superfluous, but positive dis- 
 comfort is felt as the immediate effect of what 
 appears to a stranger moderate doses of alcohol. 
 Watch one of the half-French Piedmontese ber- 
 saglieri recently arrived from his Alpine home 
 
Powers of the Air. 55 
 
 with his regiment at Naples. He takes his ac- 
 ciastomed dram as naturally as a French Zouave ; 
 but he comes out of the shop looking grim and 
 uncomfortahle, his face flushed, his eyes dim and 
 staring; and it is lucky if he does not commit 
 some extravagance which sends him for a few 
 days to the guard house, to ruminate on the 
 difierent effects of alcohol in different climates. 
 The pleasurable effects of drink are drowned in 
 the rapidly accruing discomforts. 
 
 Thus is accounted for the rarity of the usual 
 bad consequences of intemperance in Italian hos- 
 pitals. In the list of medical diseases which I 
 have tabulated from the reports of the Ospetale 
 Maggiore at Milan, there are but 22 cases of 
 delirium tremens, or 1 in 2807 ; whereas in the 
 lists of St. Mary's Hospital, London, which I 
 compared with it, there are 71 cases, or 1 in 103. 
 
 § 5. An analogous observation may be made in 
 respect of animal food. Less is felt to be re- 
 quired, and moreover a less rich or fat meat, 
 than in Great Britain. New arrivals may often 
 be seen exulting in the improved digestive powers 
 which enable them to eat meat dishes at break- 
 
56 Powers of the Air. 
 
 fastj and to take toll from each passing delicacy 
 at the table-d''h6te. But you will soon find them 
 returning to tea and toast at the one^ and re- 
 stricting their performances at the other more to 
 the vegetables and the maccaroni. Fortunate 
 indeed it is that butter is not much wanted, for 
 it is very seldom to be got of a sort fit for the 
 consumption of those used to better. 
 
 § 6. There is scarce a stranger in Italy but 
 what complains at first of want of sleep. This 
 often makes travellers quite full of anxiety about 
 themselves : they know they suffer from want of 
 sleep at home, and expect to suffer when it is 
 deficient in Italy. They have sometimes recourse 
 to opium, which makes matters worse, produces 
 constipation, loss of appetite, sometimes even 
 bilious attacks and jaundice. But if they leave 
 matters alone, they find that the anticipated evil 
 results do not follow j that the few hours of rest 
 which they have is as good, for all practical pur- 
 poses of refreshment, as the long unconsciousness 
 to which they have been used, and which is really 
 requisite at home. The fact is that the nervous 
 system, being more alert and active, is better 
 
Powers of the Air. 57 
 
 able to get through its day's work, and less ex- 
 hausted by it. So that sleep is less profound, 
 and easier shaken off and dispelled by slight 
 disturbances. This light and short repose is 
 soon found to be the custom of the country, 
 and the mind being set at rest is satisfied with 
 it. 
 
 § 7. There is no land where there is so much 
 variety to divert the mind from preying ou its 
 own thoughts as Italy. It may be doubted 
 whether the past, the present, or the future offers 
 most here to attract the attention. If none of 
 the strata of historical relics interest the traveller, 
 he can still hardly help feeling their present 
 picturesqueness, and the loveliness of the forms 
 and colours by which they are surrounded ; while 
 to the social or political observer the specimen of 
 a naturally intellectual and industrious people, 
 long restrained by untoward circumstances, and 
 now at length bursting out for good and for evil 
 into new life, is unique. He desires to live, were 
 it only to see what becomes of them. 
 
 Now reflect how these various agencies may 
 act on the human body. The dryness of air. 
 
58 Powers of the Air. 
 
 without excessive heat or cold^ renders it unneces- 
 sary for the mucons membranes to put on their 
 slimy coats of mucus. They are in a more active 
 condition for the work of absorbing oxygen, 
 digesting, extracting nutriment or water, or what- 
 ever else they are required to do. They are filled 
 with blood, and pass it on rapidly with its fresh 
 burden of renewed life to the tissues. 
 
 The evenness of temperature renders it possible 
 for all, invalids included, to be a great deal in the 
 open air. 
 
 The action of sunlight in reddening the blood 
 is familiar to even the poets. The etiolated plant 
 of northern climes is quickly by it rendered crisp 
 and hardy, and the same effect may be inferred 
 to take place in the etiolated animal. 
 
 Spite of all the arguments of philanthropists, 
 alcohol will always remain an evil necessity 
 to brain-working populations in Northern climes. 
 I do not know but what its occasional use is 
 a necessity in all climes. But certainly a little 
 goes further in the South, and therefore less 
 is requisite, if any. Thus is avoided the tempta- 
 tion to the slight daily excess, which is the most 
 
Powers of the Air. 59 
 
 powerful agent in the production of that degene- 
 ration of tissues so fatal to our invalids.* 
 
 By the taking less meat, and a less fat meat, is 
 avoided the rancidity so familiar to us in slow 
 digestions which renders the food innutritious, 
 and which we have therefore to counteract by our 
 remedies. I have heard it remarked that English 
 physicians are always prescribing alkalies, whereas 
 Italians find the great majority of their patients 
 better for acids; and I think this may be ex- 
 plained by the acid fermentation of oily food 
 which takes place in torpid stomachs in our 
 country, and is less frequent under a southern 
 diet. Now the renewal of the digestive powers 
 implied in the removal of rancidity, cannot but 
 be an important element in the supply of new 
 material to the worn-out tissues, to replace the 
 degenerated and degenerating. 
 
 You may perhaps say that many of those whom 
 you would wish to send to Italy, and which seem 
 proper cases, are already taking oil as a remedy — 
 
 * For the action of small quantities of alcohol, see the experi- 
 ments detailed in my lecture " On Alcohol" in ' Lectures, chiefly 
 Clinical,' page 563 (4th edition). 
 
60 Powers of the Air. 
 
 probably cod-liver oil — and that it is inconsistent 
 to send them to a country where the meat is es- 
 pecially wanting in this constituent. That diffi- 
 culty is easily got over by continuing to take 
 the cod oilj which is much more wholesome and 
 lighter of digestion than mammalian fats after 
 their usual preparation in the kitchen. It is not 
 at all rare to find persons who can take a good 
 clear pale fish-oil, with whom bacon, cream, fat 
 beef, and various other attempted dietetic substi- 
 tutes for it obstinately disagree. Nay more, I 
 have often had patients who had tried in vain to 
 take cod-liver oil immediately after their meals, 
 as had been recommended to them, and in whom 
 the nausea, eructation, &c., ceased when they 
 took the same identical dose at a time equi-distant 
 from meals, in the mode I recommended to you 
 in my Lecture on Consumption.* 
 
 The shortness and lightness of sleep must not 
 invariably be looked on as an evil. It is rather 
 an indication of the rapidity with which the 
 nervous system refreshes itself after daily fatigues, 
 an indication, that is to say, of unaccustomed 
 
 * ' Lectures, cliiefly Clinical/ p. 275 (4tli edition). 
 
Powers of the Air. 61 
 
 power and vitality. But I must allow that the 
 functions of animal life become sooner used to it 
 than the mental faculties, and if the latter are 
 most exerted a weariness and exhaustion is ex- 
 perienced. As long as there is nothing to call for 
 intense or concentrated thought, the want of 
 sleep produces no inconvenience by day, and the 
 health often, to the surprise of the traveller, feels 
 the benefit of the increased vigour of nervOus ac- 
 tion. But no anxious business must be entered 
 on till the stranger is acclimatised to his short 
 nights, or the mind will be driven to require what 
 it cannot get. 
 
 It is not alone on the passing traveller that 
 Italy's special (I will not call it "fatale) dono di 
 beUezza'' acts. There is scarce a peasant but 
 what is proud of the external aspect of his 
 country,* and I am not at all sure that this 
 feeling is not as powerful an assistant as any 
 
 * A genuine Italian will often prefer his country's praises to 
 his own in whimsical ways. At Salerno we commended a 
 souffle to a waiter, who was the author of the delicacy : " Call 
 that well made ?" said he, " why every little lad in Salerno 
 can make as good an one — Si, signori, ogni ragazz' di dieci 
 auni nella citta — and there are thirty thousand inhahitants !" 
 
62 Powers of the Air. 
 
 material agency in enabling him to live and 
 flourish contentedly on what would starve or 
 drive into melancholy madness an English convict 
 or pauper. Do not set down this as sentimentalism 
 or artistic whim. Consider how continually the 
 converse of the experiment is impressed upon us 
 by Blue-books and sanitary reporterSj who are 
 constantly repeating that a monotonous colour- 
 less life, such as finds its exaggerated type in 
 solitary confinement, renders absolutely requisite 
 an excessive quantity, and under other conditions 
 unwholesomely stimulating quality, of food, to 
 preserve in health the mind and body, although 
 no complaint is made by the sufi^erer. Why then 
 should it not be true that the daily life among 
 picturesque and cheery scenes saves the victuals, 
 although the benefited are ignorant of their 
 blessings ? 
 
 But it is indubitably for the stranger, as Filicaja 
 complains in his touching sonnet, that this 
 banquet of sweets is principally spread. The 
 temporary resident profits more than the native 
 by the fair scenes and their associations, by their 
 ennobling and rousing effect on the mind, and 
 
Powers of the Air. 63 
 
 through the mind on the body. They have for 
 him the additional charm of variety and novelty. 
 
 By thus tracking effects to their possible causes^ 
 we get a considerable confirmation of the statistical 
 evidence as to the value of the climate. We can 
 allow ourselves to hope from it increased activity 
 in the repair of tissues, increased activity of cir- 
 culation to supply the material of repair, and of 
 nervous energy to regulate the whole. We may 
 hope from it, in short, a Renewal of Life, 
 the converse and cure of that half-death which 
 was described in an early part of the volume as 
 the origin of so much disease. 
 
 It may be observed, especially by those ac- 
 quainted with the country, that the places from 
 whence I have taken my statistics are not those 
 where the characteristics of a Mediterranean cli- 
 mate are most exhibited. They are physically 
 less Italian than most parts of Italy. An invalid 
 who had come so far in search of change of air 
 would certainly never be advised to spend much 
 time at Milan or Genoa. But I had no choice ; 
 these two were, so far as I could ascertain, the 
 only towns among those I visited where hospital 
 
64 Powers of the Air. 
 
 and municipal records of disease are kept; and 
 if I wanted a statistical argument at all to steady 
 the floating impressions wliicli I had gained from 
 rough observationj I must put up with them or 
 none. 
 
 And now that we find not only that they con- 
 firm individual opinion, but that their results are 
 to be explained by the obvious and universal phy- 
 sical peculiarities of the country, we can apply 
 our knowledge of those peculiarities to a com- 
 parative estimate of the value of difPerent places. 
 If Genoa and Milan are better than England for 
 a certain class of invalids, on the score of atmos- 
 pheric phenomena which are less displayed in 
 those towns than in other parts, how much better 
 stiU wUl those other parts be ? 
 
 The clearness and even warmth of the air which 
 I have conjecturaUy ascribed to the great inland 
 sea are found to greatest advantage along the west 
 coast from Ventimiglia to Reggio. The shores 
 and islands here enjoy all the warm breezes, and 
 are screened in winter by the Alps and Apennines 
 from the icy blasts which traverse the northern 
 and eastern plains of Europe. The spring arrives 
 
Powers of the Air. 65 
 
 earlier^ and the summer is more shady and less 
 Sirocco-ridden than on the Adriatic. In the more 
 northerly part of this coast it is the shelter from 
 the cold and exposure to the warm winds and sun 
 which causes the mildness of climate in winter, 
 rather than the latitude. For it may be observed 
 that Marseilles, which is more to the South than 
 some parts of it, but lacks the protection, suflTers 
 much from frost in winter, and from dry heat in 
 summer. But the southerly parts of Calabria and 
 the important island of Sicily approach much 
 nearer to a tropical zone by their geographical 
 position; in fact, they are just so placed as to 
 unite all the natural advantages for our invalids 
 which a tropical climate possesses with those of a 
 temperate climate. And, excepting for a few 
 weeks occasionally in summer, there are none of 
 the counterbalancing evils. 
 
 These natural advantages are in some places 
 outweighed by accidental circumstances, and 
 sometimes by man's mismanagement. Thus at 
 Genoa there are in the amphitheatre of hills some 
 high snowy gaps, which let in icy blasts right 
 down upon the town in winter, while the high 
 
 5 
 
66 Powers of the Air. 
 
 houses shut out all sun from the narrow streets. 
 Florence is open to the same objection, from 
 standing high up in Val d^Arno in a sort of gully, 
 towards which the winds from the hills converge, 
 and the majority of its streets are like Hanway 
 Passages bordered with Newgate Prisons. A 
 great inconvenience also to invalids are the fre- 
 quent floods of the river, caused by the emptying 
 (for the purpose of gaining land) of the highland 
 lakes which acted as regulating reservoirs, and 
 whose removal makes the Arno practically into a 
 gigantic mountain torrent. Naples again sits 
 in a pool of her own excrements, opening to- 
 wards the east, and exposed to the cold winds 
 blowing from that quarter over the snowy 
 Apennines, which are just far enough off not 
 to shelter the town. The m9,rshes from Civita 
 Vecchia to Capo Miseno render their neigh- 
 bourhood uninhabitable by all but those whom 
 stern necessity forces to cultivate the soil ; and 
 again from near Salerno downwards the same 
 cause drives away the traveller. It has not been 
 always so — at Baite, now occupied by a few fever- 
 stricken peasants, the approach to the land in a 
 
Powers of the Air. 67 
 
 boat is cumbered by the foundations of the villas 
 of the ancient Roman aristocracy ; and the well- 
 known temples at Psestum, standing alone in 
 solitary grandeur like three megatheria which had 
 survived the chaos^ testify to the old wealth and 
 health of the population whose bones have rotted 
 in the deadly swamps. At Rome also the malaria 
 is mastering man's endeavours to live cheaply in 
 his forefathers' habitations without the trouble his 
 forefathers took to make them habitable. It is 
 year by year more unhealthy. Yet even here 
 you will find people resorting for health, and 
 gaining it too, though under disadvantages they 
 would not have elsewhere in Italy. 
 
 But I must not continue quoting examples, or 
 I should have to go through the geography of the 
 kingdom. It will be better to make a separate 
 subject of the practical applications of what I have 
 put together, and more conducive to a useful 
 result to say what places I recommend than to 
 enumerate those which are objectionable. 
 
PART IV. 
 
 PEACTICAL APPLICATIOKS. 
 
 The principal reasons which I have given for 
 thinking highly of the effects of a Trans-alpine cli- 
 mate in renewing to more vigorous life certain mor- 
 bid states of constitution, do not apply to one season 
 more than another. The causes to which I have 
 ascribed those effects are more or less in action all 
 the year round. So that I should have no hesi- 
 tation in recommending a permanent residence 
 as the most complete cure for the degenerative 
 diathesis, by which I mean the most sure way of 
 preventing a recurrence of the evils it entails. 
 
 You may say, indeed, that Italy is a more un- 
 healthy country than England — that its rate of 
 mortality is much higher. True ; but that high 
 rate of mortality is caused by diseases which are 
 fatal to opposite states of the constitution from 
 that under which our patient labours — diseases to 
 
70 Practical Applications. 
 
 which active circulations, arterialized bloods, and 
 easily lacerated capillaries are most liable. It is 
 scarcely probable that such a complete change of 
 constitution should take place as would lay your 
 patient open to this source of danger without 
 fair warning. Any such thorough revolution of 
 diathesis will take place so slowly as to give him 
 plenty of time to return leisurely to his own fire- 
 side a new man, able to enjoy it in safety. 
 
 But while I look upon permanent residence as 
 the most complete and the most sure way, expe- 
 rience shows that the cases are few which need 
 such thorough exile. I feel satisfied that in 
 nearly all instances a temporary residence will do 
 all that can be done by art. Happy so in good 
 deed ; for what greater trial can there be for a 
 man, and the greater the more thoroughly human 
 and manly he is, than to be debarred from ever 
 being more than an occasional visitor in the home 
 of his fathers ? From the pleasure we feel on 
 leaving England for a holiday we sometimes think 
 we should not mind leaving it for good ; and while 
 enjoying the exhilarating sensation of strange 
 scenes we are apt to wish to pass our life among 
 
Practical Applications. 71 
 
 them. Experto crede, holidays are no holidays 
 after a few short weeksj or at most months, are 
 over ; and earthly happiness is to he found only 
 in steady, regular work. There cannot be a more 
 drear purgatory than the purposeless existence led 
 by some of our countrymen resident without fixed 
 occupation in foreign parts; either tiring them- 
 selves out by flitting with foolish perseverance in 
 search of amusement which has ceased to amuse, 
 or gaping with open shells in a vain hope that the 
 tide of events may wash some food into their 
 minds. One almost pardons them their scandal- 
 mongering, and even still worse modes of excite- 
 ment, when it is remembered that this is all that 
 distinguishes their lives from those of the butterfly 
 or the oyster. I shrink from exposing any one to 
 this trial except as a matter of stern necessity ; 
 and after what I have seen abroad it must be a 
 stern necessity indeed which makes me counsel a 
 patient to throw up for ever home duties and live 
 and die in a strange land. 
 
 StiU in some cases it must be done; and in 
 those cases of degeneration to which a permanent 
 residence is suited the climate is beneficial all the 
 
72 Practical Applications. 
 
 year round. It is not needful, nor indeed desira- 
 ble, for the patient to migrate in summer to 
 Northern Europe. The cases I allude to are — 
 torpid phthisis with degeneration of the pulmonary- 
 tissue, emphysema of the lungs, and Bright's 
 disease of the kidney. 
 
 For an invalid's fixed home I cannot imagine a 
 spot more perfect than the Gulf of Spezia. A 
 villa with grounds sloping to the shore may he 
 easily found for him, and with equal ease may be 
 furnished with home comforts either by sea from 
 England or by rail from Florence. There are few 
 days in the year when he cannot enjoy in his 
 garden or terrace the breeze softened by an almost 
 tideless sea. A very slight improvement in 
 strength will enable him to be wafted along the 
 shore past the busy little land-locked bays and 
 slumbering islets, the picturesque villages bosomed 
 high in orange and olive groves, and merry with 
 an amphibious brown-skinned swarm, broken 
 rocks crowned with stone-pines and mediseval 
 castles, or spots of more modern interests, illus- 
 trated by the quaint remarks of the boatman, all 
 backed by the ever-varied snowy or dark ridge of 
 
Practical Applications. 73 
 
 the Apennines. Very soon he will enjoy drives 
 along very fair macadamized roads shaded by 
 trellised vines, and with daily new scenery. But 
 I must not weary you with these reminiscences, 
 and will merely say further that the temperature 
 is more even and the air more transparent than 
 in any other part of the kingdom ; and the moun- 
 tain-chains, the ornaments of the horizon, keep 
 off and break the clouds and storms which afflict 
 the interior. Nor need the mind be neglected 
 while the body thrives. In places frequented by 
 a SomerviUe and a Lever the intellect need not 
 stagnate ; and, when weather and health permit, 
 the nearness of Pisa and Florence by rail offer 
 every advantage. 
 
 It is necessary, however, to remark that the 
 town of Spezia is not so desirable for residence as 
 the neighbourhood. Ten thousand inhabitants 
 are crowded into rather a narrow space, and the 
 drainage is of a primitive sort; while the new 
 works for the harbour and arsenal, upon which 
 the Grovemment is engaged, increase the crowding 
 and limit the accommodation. Unless a country 
 villa can be secured, I do not commend the 
 
74 Practical Applications. 
 
 locality, and should advise a trial of Sestri, Chia- 
 varij some of the spots on the other side of Genoa, 
 such as St. Eemo or Bordighera, or an island, such 
 as Ischia or Corsica. But wherever the patient 
 goes, he must take care that there are good car- 
 riageable roads in various directions, and not 
 mere scrambling mule tracks, as is often the case 
 in otherwise desirable places. 
 
 Where a temporary exile is sufficient — that is 
 to say, in those curable cases I described as the 
 first stage of general degeneration, and in a good 
 many slighter examples of the second stage, — a 
 selection of season may be profitably made. The 
 climate is good for them all the year round ; but 
 they are able to take advantage of it one time 
 better than another. And, moreover, the climate 
 they are leaving is worse for them at one time 
 than another. Some individuals are benefited by 
 remaining in one place ; but more forms of disease 
 require a frequent removal to receive the fuU 
 profit to be derived from change of air. 
 
 I will set in order, under the heading of the 
 several seasons, the classes of patients to whom an 
 Italian atmosphere is curative, dividing them into 
 
Practical Applications. 75 
 
 those who seem to do best by a fixed residence^ 
 and those who are most benefited by travelling 
 about. 
 
 In winter (that is^ December, January, and 
 February), cases of chronic bronchorrhcea, languid 
 phthisis pulmonalis with copious expectoration, 
 and albuminuria without dropsy, should be housed 
 in a sheltered spot with fresh morning and evening 
 sea breezes. Such a cheerful nook is Nervi, on 
 the Riviera di Levante, within a short drive of 
 Genoa ; but very different in point of climate 
 from that temple of the winds. The orange 
 gardens sloping down to the sea from the back of 
 its comfortable, and not expensive, boarding- 
 houses attract at first sight, and offer an inimitable 
 lounge even at Christmas. Palms and stone-pines 
 are evidences of the mildness of the air; but, 
 perhaps, the surest are lemon-trees, which are im- 
 perilled by a second nighf's frost, and would not 
 be grown as an article of commerce where there 
 was danger of such an occurrence. The nearness 
 of Nervi to the provincial capital renders it 
 superior to Bordighera, St. E.emo, the Sestri, 
 Chiavari, and other places to the west and east ; 
 
76 Practical Applications. 
 
 for it certainly is of importance to a sick person 
 to be able to obtain in an hour or two home com- 
 forts, English medicines, English medical advice, 
 or such a change of food as a whimsical appetite 
 may suggest. 
 
 Equal, if not superior in climate, and certainly 
 superior in accommodation, though perhaps 
 rather more expensive, is Palermo. It is accessible 
 now by a direct mail boat from Marseilles, and is 
 thus within four days' post of London. To those 
 who take their families with them it offers pe- 
 culiar advantages : an ample supply of water and 
 good drainage, good roads, a pleasant resident 
 English colony, numerous objects of interest to 
 the lovers of antiquities and architecture, infinite 
 " bits" for the artist, with a colouring that will 
 warm his brain up for the rest of his life, and 
 good shops for the " materfamilias." The de- 
 cisive measures being taken when I was in Sicily 
 effectually checked, and I trust by this time have 
 quite put a stop to, brigandage, so far as travellers 
 are concerned. The secret bands are broken up, 
 and those who remain confine themselves to the 
 safer proceeding of extracting black-mail from 
 
Practical Applications. 77 
 
 their own countrymen; so that strangers need 
 not avoid the country on that score. Such of 
 the party as are well enough can make excursions 
 by sea to Messina, Taormina, Catania, Syracuse, 
 Girgenti, Trapani, or take a smooth night's run 
 to Reggio or to Naples. But to the latter place I 
 had rather my patient did not go tiU the warm wea- 
 ther is established, as there can hardly be a more 
 treacherous place than Naples for the delicate, 
 should a mistral wind set in during winter or 
 early spring. Altogether a pleasanter place than 
 this clean cheery island-capital for a winter home 
 can scarce be imagined. 
 
 Cases of languid tuberculosis without much ex- 
 pectoration, of weak heart and arteries, of relaxa- 
 tion of the vocal cords and allied conditions of 
 the larynx, are benefited, even in vrinter, by 
 moving about from place to place more than by 
 stopping still all the time. Sheltered tours for 
 them may be found along the Riviere to the west 
 and east of Genoa ; and stopping a week or ten 
 days at each halt will give a succession of changing 
 scenery before each palls on the mind. The fre- 
 quent migration is especially important if there is 
 
78 Practical Applications. 
 
 hypochondriasis or atonic dyspepsia joined to the 
 other symptoms. The same tour under the same 
 conditions is well fitted for cases of chronic gout, 
 and of sciatica, where a morbid change in the 
 nerve or its envelopes is indicated by pain on 
 pressure. 
 
 Where a weak circulation is partly exhibited in 
 netualgic symptoms, such as constitutional head- 
 aches, sciatica intermittent or painless on pressure, 
 functional tic douloureux, or the like, without 
 there being any affection of the mucous mem- 
 branes, there is not the same need of shelter and 
 high temperature. Then a more interesting tour 
 to Milan, Plorence, Venice, Bologna, Naples and 
 its charming coast as far as Salerno may be 
 made. The places especially to be avoided by 
 the neuralgic, hypochondriac, and hysterical, by 
 all, in short, when the vitality of the nervous 
 system fails, are low-lying, moist, relaxing places 
 inland, such as Rome and Pisa. With the ex- 
 ception of a few localities of this character, the 
 whole of the peninsula is open to them. 
 
 Spring is the time to enjoy the genuine charms 
 of Ausonia. March, April, and May, when they 
 
Practical Applications. 79 
 
 visit her, appear really as they are sung by poets 
 and allegorized by painters^ fanned by the wings 
 of life-giving zephyrs and rollicking in flowers. 
 They would not know their dreary namesakes in 
 England. As soon as ever the weather gets 
 settled, which is at different times in different 
 years, I would strongly recommend patients to 
 move about a little in search of an enlivening 
 change. Short sea-voyages, especially in a yacht 
 of their own, from place to place along the coast, 
 are then most useful. The invalid who has been 
 at Palermo for the winter may then make his 
 voyage round the island ; and if he is not interested 
 by it, he must be a very flabby-minded person. 
 I should, however, advise his not penetrating into 
 the interior. The journeys on horseback are too 
 long, the accommodations are infamous, and worst 
 of all, there is little to repay you for the trouble. 
 In April Naples becomes safe, and what can be 
 more exhilarating than sauntering drives in that 
 month through its merry suburbs, now laughing 
 at the humours of noisy Santa Lucia, now looking 
 down from the gardens and villas of PosUippo or 
 Vomero over the acknowledged queen of all land- 
 
80 Practical Applications. 
 
 scape scenery ? No wonder that the pulse heats 
 quicker and stronger ; that the heart which was 
 erst only to he discovered by auscultation, can 
 now be found with the hand ; and that* the worn- 
 out nervous system feels as it did at twenty-five. 
 
 I know of no restrictions or limitations neces- 
 sary to mention as to the advantages of Italy in 
 the spring, except those general cautions to tra- 
 vellers which I wiU give before I conclude. 
 
 In summer, the following morbid states are 
 capable of restoration quicker in Italy than at 
 home: — Scrofula, when the pulse is slow and feeble, 
 the skin greasy, and the tubercular matter de- 
 posited in glands. The sea-bathing without sub- 
 sequent chill, which is so useful in these cases, 
 may be found in perfection in the Mediterranean. 
 Chronic rheumatisms and chronic gouts may lay 
 in a store of health sufficient to last them for 
 some months, or perhaps years, but they must 
 not expect to be quite cured. From aU I can hear, 
 a second summer in Italy does not do them equal 
 good with the first, and sometimes is pernicious. 
 Dyspepsia, especially if it is of the atonic kind, is 
 benefited by the summer diet of a south European 
 
Practical Applications. 81 
 
 population. One does not require, and has no 
 temptation to, the kinds of food which aggravate 
 the symptoms ; and moreover, the increased force 
 of the circulation quickens the digestion, and 
 makes a small quantity of food go farther. Eczema 
 in elderly persons, old painful wounds and 
 necrosed bones, and I dare say many others 
 might he added, provided always that they are 
 cases in which the circulation is weak and im- 
 perfect, and the functions of- life generally are 
 sluggishly performed. 
 
 The best places to go to in summer are, the 
 islands of Ischia and Capri, Sorrento on the sea- 
 cliff. Cava amongst the chestnut woods inland, if 
 the patient is down in the south ; or if he is in 
 central Italy, when he finds himself overtaken by 
 too warm weather, he may go the Bagni di Liicca, 
 not so much on account of the baths as on account 
 of the air and the shade. I do not advise rapid 
 travelling about at this season except by sea. 
 
 In Autumn, that is, in September, October, and 
 November, it is mostly cases of exhausted nervous 
 energy, or what Dr. Marshall Hall used to call 
 "brain-fag," which are restored to health. In 
 
 6 
 
82 Practical Applications. 
 
 these cases what is required is rather change of 
 scene than change of air. The mind shotdd be 
 relieved of its intrusive tenants^ Worry and 
 Anxiety, not by remaining empty — for such brains 
 abhor a vacuum — but by a succession of new ideas. 
 In Italy, after the summer heats have passed away 
 travelling is healthy and agreeable. Then is the 
 time to visit the infinite variety of interesting 
 objects in the towns of the northern and central 
 parts of the kingdom. Southern Italy is safest 
 for the traveller in October and November ; for 
 September is rather a bad time for malaria and 
 fever. So that if the patient is in South Italy in that 
 month, he had better confine himself till its close 
 to the regions I have mentioned under the^head of 
 " Summer," or else travel northwards, to Venice 
 for example, or to the lakes of Xiombardy, which 
 are delightful at that season. 
 
 I do not think it wise for those whom I have 
 advised to pass a winter in Italy to get there 
 before the end of November. The autumn affords 
 them no advantages, and if they leave England 
 sooner than I could wish, I recommend their 
 spending the time in passing slowly through the 
 
Practical Applications. 83 
 
 middle and south of Prance, where the ■weather 
 will he found still bright and cheery, and where 
 there is much to interest those of the party who 
 are strong enough to enjoy it. 
 
 It will be seen on reflection, that the common 
 link uniting all the cases which I have enumerated 
 as likely to profit by seeking an Italian cliniate, is 
 a weakness of circulation, and a consequent ten- 
 dency to chronic and degenerative changes. I 
 believe it is this which is curable and cured in 
 them, and not anything special in the several pa- 
 thological changes by which their ailments are 
 named. Thus is explained what has hitherto 
 appeared mysterious and inconsistent in medical 
 experience J one case has received benefit, and 
 another called by the same name has received 
 only injury from a residence in the same spot, or 
 from travelling over the same ground. It is easy, 
 for example, by inquiry to find instances of pul- 
 monary tubercle in the first, second, or even third 
 stage, which have decidedly improved during a 
 residence in Italy, and equally easy to find the 
 same nximber of corresponding cases which have 
 died, or got worse quicker than they probably 
 
84 Practical Applications. 
 
 would have done at home. The difference between 
 them will be found to lie in the diathesis which I 
 have mentioned. 
 
 It will be well understood from what has gone 
 before^ that I consider some morbid states of body 
 as likely to be aggravated by that climate which 
 is so beneficial to others. All those to whom 
 excitement of the circulation is injurious should 
 flee the country. Persons of apoplectic habit run 
 great risks there, as may be seen by comparing 
 the comparative number of deaths from that cause 
 at Genoa with those in London in the table at 
 page 37 ; where it will seem that the propor- 
 tion is nearly double. Those also who have a 
 tendency to congestive inflammations ; such, for 
 example, as cases of sharply-beating hearts with 
 imperfect valves, who are apt to have pneumonia 
 quickly supervene. Harm also is done to early 
 cases of tubercular consumption with a quick, ex- 
 citable circulation, and a liability to haemorrhage ; 
 whether that haemorrhage appear externally as 
 haemoptysis, or is extravasated in the pulmonary 
 tissue. Piles also and menorrhagia are made 
 worse, and sometimes brought on, by travelling 
 
Practical Applications. 85 
 
 in Italy, in spite of precautions. All such cases, 
 therefore, should be warned off, and indeed often 
 are warned off by the honest medical advisers 
 resident in the country. 
 
 It would appear, from the extraordinary number 
 recorded in the Rendiconto of the Milan Hospital 
 of inflammations of the brain and spinal cord, that 
 the nerve-tissue is very liable to suffer acute 
 organic change there. I have not been in the 
 way of confirming this by personal observation, 
 but I have noticed that, certainly, functional 
 diseases of the nervous system are often inten- 
 sified, and sometimes brought on in previously 
 healthy parties. And notably hysteria. Hyste- 
 rical women should never be sent on tour to these 
 climes without great caution, or a travelling medi- 
 cal man with them. 
 
 I wiU now fulfil my promise of giving a few 
 hints necessary in order to ensure a good use 
 being made of the change of climate as a remedy ; 
 and I wiU arrange them in the order which I 
 adopted when enumerating the more obvious pe- 
 culiarities of the conditions of life in Italy likely 
 to act curatively on the invalid.* 
 * Page 51. 
 
86 Practical Applications. 
 
 1 . Let a patient not forget that he goes abroad 
 for the powers of the air. The great object to be 
 gained by a winter traveller is the license of being 
 out of doors at a season when he would have been 
 imprisoned in the house if at home. Let him take 
 full advantage of this liberty and not neglect daily 
 gentle exercise. And let the spring and summer 
 traveller be as much in open carriages aiid boats 
 as he can. 
 
 3. He leaves England to shun the depressing 
 influence of damp joined to low temperature. Let 
 him not expose himself to these abroad. He must 
 be cautioned in winter against the cold frowse of 
 unfrequented churches, usually the most inter- 
 esting to the antiquary ; the bleakness of pic- 
 ture-galleries, whence a ray of sun-light is ex- 
 cluded as an enemy ; and, as a rule, all show- 
 houses. It is hardly necessary to speak of cata- 
 combs, as they are dangerous even to the healthly. 
 The night dews are always to be avoided; in 
 malarious districts even a single exposure may 
 induce ague. I suspect their mode of acting is 
 as a sudden chill on the body long exposed to the 
 heat of the sun ; for even in the healthiest spots 
 
Practical AppRcatiom. 87 
 
 — — ^ c;* „_^ 
 
 they have a great tendency to give one a sore 
 throat of a peculiar temporary character, such as 
 I have never experienced in England. 
 
 3. Sunlight is of great importance to the in- 
 valid. This is a matter which should never be 
 forgotten in the choice of a house for winter resi- 
 dence. Italian architects in general think much 
 more of shutting out Phcebus when he is too fierce 
 than of letting him in when he is wanted as a healer. 
 The consequence is that the most fashionable 
 localities and the most elegantly fiirnished apart- 
 ments are by no means those which have the 
 aspect best suited to our sanitary purposes. Look 
 first outside at the rooms for a patient's use, 
 choose them first by their windows, and then set 
 to work to make the inside complete. Even in 
 summer sunlight is of value, though sxmshine in 
 the middle of the day is too powerful. I have 
 always observed that those travellers spoke the 
 most favorably of the climate who had got the 
 most browned by it. By defending the skuU vrith 
 a pugrah or a folded white handkerchief tied 
 round the hat, the fear of sunstroke may be 
 
88 Practical Applications. 
 
 avoided. And, artist or no artist, it is as well to 
 have a brown holland umbrella. 
 
 4. That intensity of tbe vital processes which 
 all go to seek as a remedy, is exhibited in disease 
 by an acuteness astonishing to us foggy islanders. 
 This must be remembered by all who are called 
 upon to go as travelling physicians in Mediter- 
 ranean climes. People get well quicker, it is 
 true, but they also get ill quicker of iheir inter- 
 current or accidental complaiats, and pass though 
 their stages quicker than in England. This is 
 especially true in respect of the congestive in- 
 flammations of fever, of pericarditis in rheuma- 
 tism, and of pneumonia in diseased heart. Italy 
 is not a place where you can indulge in procrasti- 
 nation of appropriate treatment ; la medicine ex- 
 pectante is sadly out of place. 
 
 5. The invalids whom I shotdd advise being 
 sent to Italy are such as usually are injuriously 
 affected by the chronic action of alcohol. Their 
 vital processes are already too torpid, and alcohol 
 still further retards them. But in England they 
 cannot do without it, to stay mental depression 
 and the wear and tear of the nervous system. In 
 
Practical Applications. 89 
 
 those sunny lands their minds are cheered by the 
 pleasant sauntering life, and their nervous systems 
 are not worn or torn ; and so they do not want it. 
 Let them exchange the furnace-heat of British 
 port and sherry for a glass of those bottled sun- 
 beams which call the white grapes of Orvieto, 
 Monte PulcianOj Capri, or Asti their parent. If 
 these disagree with the stomach, as is sometimes 
 the case, let them take it as a hint to worship the 
 nymph(B,QX more properly speaking \\ielyniph(B loci. 
 6. T think it a prudent general rule to imitate 
 the natives of a country in their diet as far as 
 possible. And therefore it is advisable to obey 
 the instinct which in Italy soon leads one to take 
 less animal food than we Britons have been ac- 
 customed to. And I think also medical men may 
 wisely take a hint from the observation I made 
 respecting the practice of their Italian brethren. 
 Acids are more often required in medicine than 
 alkalies in Italy. Thus, a summer diarrhoea, which 
 is rebellious against chalk misture and opium, 
 yields immediately to lemon juice. In England 
 lemons would have brought it on and chalk 
 stopped it. 
 
90 Practical Applications. 
 
 I believe too, it is in great measure from taking 
 too much animal food that our countrymen so 
 often suffer from bleeding piles in Southern 
 Europe, and that if they would take less, this in- 
 convenience might be often avoided, or at least 
 considerably alleviated. Where the dietary is 
 excessive, the hsemorrhoidal discharge acts as a 
 sort of safety valve, and should not be forcibly 
 arrested by local means. 
 
 7. The knowledge that the deficiency of sleep 
 is normal ought to prevent a rational traveller 
 having recourse unnecessarily to opiates. But I 
 am sorry to say people are very stupid on this 
 point, and I have heard them almost boasting 
 that they never could sleep without some pet 
 preparation of a narcotic nature, and that they 
 were obliged to persist in it, though it gave them 
 a racking headache next day. Why — ^this headache 
 is the proof that the artificial sleep was unnatural 
 and harmful. It was the sleep that gave it 
 them, not the abused drug. Many persons who 
 are wakefal at night can often take an hour's 
 siesta in the afternoon with advantage. If even 
 they do not sleep, the repose is good for them. 
 
Practical Applications. 91 
 
 They must not fancy that it will spoil their noc- 
 turnal rest; on the contrary, that is often the 
 sounder, "while it lasts, from the body not being 
 too tired. 
 
 The beds in Italy are generally very good. The 
 elegant iron and brass frame-work manufactured 
 at Genoa is the neatest and cleanest bedstead that 
 can be devised. The bolsters and mattresses are 
 very light and moveable, and even in Capuchin 
 convents are usually shaken out of window 
 daily. But, alas ! all this care does not exclude 
 fleas. Wherever man is, be it in a hovel on a 
 desert mountain inhabited perhaps once a month, 
 be it in an excavation at Pompeii, or in a Greek 
 theatre where no one has sat for more than two 
 thousand years, there is his agile tyrant. So 
 that it is not to be expected that the bedrooms 
 should be free. I say this in mere justice to try 
 and save Maritornes an unmerited scolding, when 
 the unhardened traveller has found himself pre- 
 sent at a nocturnal feast, " not where he eats, but 
 where he is eaten." He had better console him- 
 self with the popular Italian dictum that such 
 punctures are wholesome in moderation. If he 
 
93 Practical Applications. 
 
 cannot attain to such philosophy, authorities re- 
 commend his taking a calico sleeping-hag to a 
 country inn. So far, so good — ^hut hefore he starts, 
 let him try one night in it to see that it is long 
 and wide enough. If too small, repose there is as 
 difficult as in a Venetian dungeon [probatum est) ; 
 and the materials for a new one are unattainable 
 in provincial shops. 
 
 While on the subject of sleeping accommoda- 
 tion, I would remark that, except in very favoured 
 localities, the window must not be left open at 
 night. Sunrise is as dangerous a time as sunset 
 in Italy, and even the robust suffer from it. 
 
 Where there is any fear of malaria, get, if pos- 
 sible, a room with a fire-place in it, and have a 
 fire lighted immediately on your arrival. You 
 can let it out if you like when you go to bed. In 
 Sicily, unfortunately there are no fire-places except 
 at Ragusa's Hotel, but then there are no mala- 
 rious districts that you can ever want to pass 
 through. 
 
 8. Inasmuch as a certain portion of the advan- 
 tage of going abroad is due to the interesting suc- 
 cession of novelties offered to the mind, do not 
 
Practical Applications. 93 
 
 imprison your patients too much in one spot. I 
 have already mentioned several cases of even or- 
 ganic change, which are benefited hy moving 
 aboutj but I by no means wish to restrict it to 
 them. I was quoting my own experience only, 
 and I am quite sure there are many others ca- 
 pable of receiving profit from change of scene. 
 Perhaps the best way to put the rule is to say 
 that if patients can travel about without harm, it 
 is sure to do them good. 
 
 At the same time, I would strongly blame the 
 precipitate hurrying over the greatest quantity of 
 ground in the smallest quantity of weeks, which 
 so often makes our countrymen ridiculous. This 
 is an imprisonment of a still duller kind — namely 
 in a travelling carriage (often a close one) or a 
 railway car. Stop in each place till its novelties 
 cease to strike, and then leave it for another. 
 Let the guide-book be used as a curb, rather than 
 as a spur, to restrain impatience by telling you 
 how much there is to interest in the place where 
 you are, than what attractions there are ahead. 
 
 It is also not unworthy of consideration that 
 these sauntering, sketching, vetturino journeys 
 
94 Practical Applications. 
 
 usually furnisli the most agreeable and most im- 
 proving recollections of the healthy members of 
 the party. The studies of red-skinned fishermenj 
 mediaeval farmsj and fantastic olive-trunks call up 
 in after years scraps of knowledge and feehng 
 worth all the art-galleries in the world. 
 
 Before I conclude, I hope my professional 
 brethren will excuse my adding a few words of 
 warning agaiast sending to Italy unsuitable cases. 
 I have already mentioned several classes of 
 patients as likely to be injured,* and I woidd 
 add to that list such as, though appropriate as re- 
 gards the pathological nature of their complaint, 
 yet are too far advanced for you to expect con- 
 scientiously that they will return home alive. I 
 refer especially to cases of rapidly increasing 
 vomicae in the lungs. A death-bed abroad is more 
 painful and even quicker than at home. Avoid, 
 also, sending patients who would be more bene- 
 fited elsewhere. Such as those affected with irri- 
 tative phthisis, who suffer much with cough in 
 dry weather, and to whom a sedative, soft air is 
 beneficial. To these the warm and moist Atlantic 
 
 * Page 84. 
 
Practical Applications. 95 
 
 breezes at Madeira and the Azores, or even Tor- 
 quay in some seasons, are so much more suited, 
 that, though Italy is better than no change, you 
 do harm in sending them there by preventing 
 their adopting quite the best course. 
 
 Also — do not send people across the Alps who 
 cannot afford to spend upon comforts and luxuries 
 somewhat more than they are in the habit of 
 spending at home. It is not the place for a poor 
 man, unless he is strong enough to rough it ; and 
 the misery of invalids who have to forego habitual 
 indulgences in order to make both ends meet is 
 very great, and quite outweighs the advantages of 
 climate. This only chance is to get some ap- 
 pointment abroad, which will give them an in- 
 come as well as a home. 
 
 tRlKTED B^ J. K. ADLAKD, BAETHOLOMKW CLOSE. 
 
By the same Author, lately published, price Us. 
 
 LECTURES, 
 
 CHIEFLY CLINICAL. 
 
 FOURTH EDITION. 
 
 " In the two first editions I named the selection of clinical ob- 
 servations laid before the public ' The Renewal op Lipe,' meaning 
 thereby to intimate what is more fully stated early in the volume, 
 that the main point for the physician's consideration in disease is 
 the deficiency of vital action, and that all successful medical treat- 
 ment is a renewal of that vital action." — Freface. 
 
 SUBJECTS OF LECTUEES. 
 
 I. Death and Life. 
 
 II. Disease and Cure. 
 
 III. IV, V. rormation of Mucus and 
 Pub. 
 
 VI, VII, VIII, IX. Typh-fever. 
 
 X. Smallpox. 
 
 XI, XII, XIII. Rheumatic Fever. 
 
 XIV. Gonorrhceal Rheumatism. 
 
 XV. Pericarditis. 
 
 XVI. Pleurisy. 
 
 XVII. Hydrothorax. 
 
 XVIII. Acute Laryngitis. 
 
 XIX. Capillary Catarrh. 
 
 XX. XXI. Pneumonia. 
 
 XXII. Emphysema of Lungs. 
 
 XXIII. Pulmonary Consumption. 
 
 XXIV. Thoracic Aneurism. 
 
 XXV. Disease of the Heart. 
 
 XXVI. Purpura. 
 
 XXVII. Ansmia. 
 
 XXVIII. Prominence of Eyeballs. 
 
 XXIX. Atrophy of Muscles. 
 
 XXX. Chorea. 
 
 XXXI. Epilepsy. 
 
 XXXII. Hysteria. 
 
 X XXIII. Spinal Paralysis. 
 
 XXXIV. Sciatica. 
 
 XXXV, XXXVI. Albuminuria. 
 
 XXXVII. Ascites. 
 
 XXXVIII. Diabetes. 
 
 XXXIX. Mortification, 
 
 XL, XLI. Indigestion in General. 
 XLII. Slow Digestion and Acidity. 
 XLIII. Pain in the Stomach. 
 XLIV. Eructation and Vomiting. 
 XLV. Diarrhoea. 
 
 XLVI. Costiveness and Constipa- 
 tion. 
 XLVII. Dietetics. 
 XLVIII. Corpulence. 
 XLIX. On Pepsiue. 
 L. On Alcohol. 
 LI. On Bloodletting. 
 LII. Eeview, and L'Envoi. 
 
 PUBLISHED BY JOHN CHURCHILL AND SONS, 
 NEW BURLINGTON STREET, LONDON. 
 
 MDOCCLXV.