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William Loney RN - Background
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EXPEDITION TO THE RIVER NIGER
DURING THE YEARS 1841-2.
HISTORY OF THE FEVER.
Treatment of the Fever.
"Pessimum aegro Coelum est, quod aegrum facit".
The most important step in the treatment of African fever is comprehended in this maxim of Celsus. By common admission of all who have served on the western coast, the causes of fevers exist in a state of concentration in the rivers; and hence, as a general rule, the greatest amount of mortality will be found on board those ships whose crews are most employed in river service.
I have no hesitation in saying that in most instances, a favorable turn in the form of the fever, even in its earlier stages, will attend a speedy removal from the locality where the disease originated; and that after the fever has run its course, change of climate is indispensable, if we wish to avoid intermittents, visceral complaints, and a host of ailments that rarely fail to follow in its train.
Having stated these as general principles, I shall now proceed to make a few remarks upon the effects of the remedial measures that were adopted on board the Albert.
General bloodletting. This remedy, which I had found to be so valuable in the treatment of fever in the West Indies, and even of some parts of Africa,* has not, within my own experience, nor in that of most others, been at all successful on the west coast. In the adynamic form of fever which occurs in the rivers, general bleeding is certain to do harm. The patient may, it is true, feel relieved after bleeding, but the amendment is transient. The remission will not be prolonged, and the succeeding accession will be equally severe as the former ones, with this disadvantage, that it will now act upon a system weakened by the bleeding, and consequently less able to withstand it. There is, further, great danger of producing immediate depression of vital energy, so as in a great degree to prevent reaction, in which case the fever will assume a low asthenic type, from which wine and other stimulants will fail to rally.
Local bleeding will sometimes be beneficial: for instance, cupping the temples or the nape of the neck will in some cases relieve head symptoms; and vomiting was sometimes checked by cupping the epigastrium, when this symptom occurred early in the disease.
Blisters. As the type of the fever in general contraindicated bloodletting, general and local, blisters were much used, and were unquestionably of great service, especially when applied to the nape of the neck, while cold lotions were kept on the head at the same time. Sinapisms to the epigastrium generally checked vomiting; but they were less useful when put upon the extremities, during the low stage, than I had before observed them. I have also seen irritability of stomach, nervous twitchings, and other symptoms, successfully combated by the rapid production of a crop of pimples along the course of the spine, by means of the ointment of tartarized antimony. One precaution must be observed with regard to the application of cantharides as a blister. During the progress of the fever the mucous membranes generally are peculiarly susceptible of morbid action, and repeated blisters caused in most of the cases considerable strangury; and in one instance, well-marked inflammation of the bladder with hematuria ensued.
Mercury. My previous experience in the treatment of tropical fevers had generally pointed to mercury as the remedy to be prescribed when bleeding was inadmissible. In some of the cases that occurred in the Niger, the production of gentle ptyalism certainly did good, especially when the depression was not very great. In many cases, in which the vital energies were low from the very beginning, and continued so as long as we remained in the river, the full action of mercury would have been attended with danger. Calomel, combined first with opium and afterwards with quinine, appeared to me to be the best modes of exhibiting this remedy.
Purgatives. The bowels were in general constipated, and required active purging, particularly during the early stage. Calomel, jalap, and the bitartrate of potash were given at first, so as to cause free evacuations, which were in general dark or of a bilious character. After the bowels had been well emptied, castor oil and the milder aperients answered better than strong purges; which then indeed do much harm. Enemata were given with benefit, when epigastric tenderness or irritability of the stomach, rendered the administration of purgatives by the mouth inadmissible.
Diaphoretics. The best diaphoretic was the true James’s powder, which kept up the action of the skin, without producing nausea so often attending the exhibition of other antimonials. Its operation is certain. In cases in which the hot stage was disposed to be protracted, and the patient was weak, quinine was given with the James’s powder, to obviate too much exhaustion from sweating. With quinine the medicine seemed to be more gentle and uniform in its operation, an advantage that will be obvious to all who have witnessed the debility and languor often caused by profuse cutaneous discharges in tropical climates.
Quinine. In general when the tongue began to clean, and the other symptoms indicated that the functions were returning to their normal condition, quinine was given in large doses with great benefit. But it was not to this period alone that the use of this valuable remedy was restricted, for there were many cases in which, from the tendency to sinking from the very beginning, it was necessary to commence with quinine, wine, and light soups. In a disease like the Niger fever, so little amenable to treatment, no rule can be laid down for the exhibition of a particular remedy; but no medicine was found so efficacious as quinine in diminishing the severity of the paroxysms. In some of the more protracted cases, the red tinge over the sharp features would occasionally indicate that whatever power of reaction remained in the wasted system, was exerted to establish a feeble exacerbation, the exhaustion following which was often lessened by the liberal use of quinine.
Brandy, wine, camphor, opium, and ammonia were freely given when the pulse began to flag, and when the symptoms generally denoted depression of vital energy; and often with almost miraculous effect, as in Case xiii.
Sponging the body with tepid water and vinegar, in general afforded relief, but I never could carry the cold affusion further than the application of large wet clothes to the head. The warm bath was not much used, and in those cases in which it was tried the benefit obtained was only temporary, the relaxation and exhaustion produced by it, contraindicated its general use in a disease which was marked by debility and tendency to sinking; tenderness at the epigastrium was, however, often relieved by applying to it a japanned case filled with hot water, and concave so as to fit closely to the abdomen. A large oblong case of similar construction was advantageously applied to the feet during the low stage of the disease; and at earlier periods, when the nervous depression retarded the development of the stage of reaction, in which case the extremities often continued cold after the chest and abdomen had become quite hot.
The period of convalescence, under any circumstances, requires much care, especially if the chief remedy —removal from the climate — be impracticable. We have then, while cautiously conducting a tonic plan of treatment, to be in constant apprehension of ague, dysentery and other diseases, depending upon the various lesions of the mucous lining of the bowels. I found sago, arrow-root, and fowl-soup, with a small allowance of wine, the best diet during the early period of convalescence. Quinine is indispensable in the event of intermittent supervening, and the solution of iodide of iron given at the same time twice a day, during the intervals, had a marked good effect. When rheumatism followed, which was sometimes although not very often the case, colchicum and hydriodate of potash were of most service. Unless when there was great debility, dysentery yielded to calomel and opium more readily than to any other remedy we tried.
But as the fever itself is rarely combated with success, so long as the patient continues within the pale of malarious influence, so during convalescence little permanent benefit is to be expected without a change of climate. How many naval medical officers on the African station have witnessed their sick daily wasting and pining, and all their endeavours to relieve them unavailing, so long as the vessel remained on the coast; and what a salutary change have they seen to result after even a short residence at Ascension. The south-east trade wind blows perpetually over this island, and there is a freshness of atmosphere singularly exhilarating to an invalid from the coast. In the lower districts the heat is considerable during the summer months, but the green mountain, the peak of which is at an elevation of 2870 feet above the level of the sea,* possesses a climate whose average temperature is at least nine degrees of Fahrenheit under that of the plains below.†
There are doubtless many cases to which so great a change of temperature, with considerable alteration in the barometric and hygrometric conditions of the atmosphere would prove anything but beneficial. But a proper selection of cases can on all occasions be made, and I feel assured that, with moderate caution, the greater number of invalids from the coast will be found to mend in the mountain. I can speak from experience in my own case, as well as in others. On my arrival at Ascension in the Albert, I was subject to severe attacks of intermittent, (following the adynamic remittent of the Niger,) which tormented me for nearly six weeks while I remained on board the ship in the roads. I then went up to the mountain quarters, and after one fit of ague, was rid of every symptom of the disease as long afterwards as I continued on the island, nearly eight months.
A convalescent hospital, or sick quarter, established at the mountain, would greatly enhance the value of Ascension to the cruizers on the west coast of Africa.
The best site for such a building appears to be on the flat land under the ridge on which the present quarters are situated. It would there be easily accessible, and the air in this situation is much drier than that of the more elevated grounds immediately surrounding the peak.
As happened in some instances among the convalescents of the expedition, cases will from time to time occur which admit of no amelioration, except by a total change from the tropics to native climate; and it will be always well to bear in mind that the warmer the period of the year in which the patient arrives in England, the less likely will he be to suffer from the transition.
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