► Royal Navy ► Naval Surgeon West Coast of Africa ◄► Table 5
Statistical Report of the Health of the Navy - 1864.
CAPE OF GOOD HOPE AND EAST INDIES STATION
ON comparing the outline map of this station for the present year with that of 1863, it will be perceived that a very great extension has been made of its boundaries. The East Indian division of the China Station was, in fact, added to the Cape of Good Hope command in the early part of 1864, and, as stated in the Statistical Abstract of the Health of the Navy for 1864-65, had the squadron employed in the East Indies been large, this alteration of boundary would have seriously affected any comparison between the ratios for the present year and those of the Cape and the East Indian and China commands for former years. Fortunately, however, the force employed in the East Indies has always been so very small that, practically, its withdrawal from one station and its addition to the other has had little or no effect, in a statistical point of view, on the returns of either.During the year 1864 the force on the East Indian and Cape of Good Hope Station consisted of fourteen vessels, among which were comprised one line-of-battle ship of the second-rate; two frigates of the fourth-rate, and three of the sixth; five sloops; two gun vessels, and a receiving ship, permanently stationed in Simon's Bay. Seven of these vessels were on the station during the whole year, and the returns from the others are for periods varying from six to eleven months. The mean force corrected for time was 2,620, and the total number of cases of disease and injury entered on the sick-list was 4,251, which is in the ratio of 1622·5 per 1,000 of mean force. Of these 140 were invalided and fifty-one died, the former being in the ratio of 63·4, and the latter, of 19·4 per 1,000 of mean force. The ratio of cases is much below that of the preceding year, but the invaliding rate is considerably higher, and there is also an increase to the extent of 3·2 per 1,000 in the ratio of mortality.
The daily loss of service from fevers was in the ratio of 3·1 per 1,000 of mean force; from diseases of the brain and nervous system, 0·2; of the organs of respiration, 4·2; of the heart and blood-vessels, 1·0; of the alimentary canal, 4·5; of the liver, 0·4; of the genito-urinary organs, 8·8; from rheumatism, 5·1; from diseases of the bones and joints, 0·5; from diseases of the organs of the special senses, 0·4; of the skin and cellular tissue, 20·2; from diseases not classed, 2·2; and from wounds and injuries of various kinds, and hernia, 12·7. The average daily loss of service from all causes was equal to 174·5 men, which is in the ratio of 66·6 per 1,000 of mean force, and 12·4 per 1,000 below the average daily sick-rate of the preceding year.
CAPE OF GOOD HOPE AND EAST INDIES STATION
Fevers.- Two hundred cases of continued and remittent fever, seventy-five of intermittent fever, and three of smallpox were under treatment during the year. Of these, one case of primary fever was invalided and six proved fatal. There was no invaliding either for ague or small-pox, but one case of the latter disease terminated fatally.
Continued and Remittent Fever.- There were nine cases of primary fever in the Ariel, one of which is returned as continued fever; seven as remittent; and one as typhoid. The surgeon (Dr. Robert Borrows) of the ship makes the following observations with reference to them:-
"This class of disease, as it has come under my observation in the period of this journal, has had little to distinguish its several forms, and much to obscure a distinctive diagnosis. They exhibited one feature in common - enteric complication. Indeed they appear to be of a somewhat nondescript character - a combination of fever, enteritis, and dysenteric diarrhoea.
"Five of the cases of remittent fever occurred at Zanzibar, in the month of May. Similar sickness was prevailing on shore. Only one of my patients became seriously ill. He applied on the thirteenth day after coming into harbour. For a day or two the symptoms were perplexing; combining an aspect of stupor, with passive dusky features strongly suggestive of typhus or typhoid fever. Partial remissions, however, soon convinced me that I had the ordinary coast fever to treat, modified, or it might be excited, by the poisoned carbonaceous air of our very limited lower deck. Delirium and other active cerebral symptoms required a careful regulation of the quinine. Profuse perspiration on the seventh day of treatment reduced the patient almost to a state of collapse. But it proved a critical period, and he made a rapidconvalesence, with only a slightly impaired memory. His recovery I greatly attribute to timely removal to the upper deck.
“The typhoid case occurred at the Cape in January, and seemed at first sight to be of the usual coast character; but the tongue became rapidly brown and dry, and a few rose-coloured spots appeared on the abdomen. The man had returned ill from Cape Town, where he had spent two days of his leave in bed. No previous excess had been committed, I feel assured. There is no system of covered drainage in the town, and the so-called water-closets of the lodging-houses are terrible accumulations of filth. Here, though the exposure was brief, five or six days I believe, he caught the disease. Such cases are common in the local medical practice."
There were thirteen cases of primary fever in the Hornet, eleven of which were of the remittent type, and two ephemeral. The cases of remittent fever appear to have been of considerable severity, the average duration of each on the sick-list on board ship being about three weeks. No information, however, is furnished respecting them. They appear to have been occasioned by exposure in the Red Sea.
In the Lyra there twelve cases of primary fever, nine of which were ephemeral, and none of any importance. They appear to have been chiefly owing to solar exposure at Zanzibar; but one or two of a remittent character probably owed their origin to malarial influences to which they were exposed in the River Lindy.
There were thirty-five cases of primary fever in the Orestes, but thirty-one of these were of a purely ephemeral nature their average duration on the sick-list not being much more than three days. Of the remainder two are entered as continued fever, two as remittent, and one as febrile cachexia. In the latter instance the patient, a non-commissioned officer of marines, had suffered severely from remittent fever, but his constitution was also much impaired by syphilitic disease. The febrile affection, however, appeared completely to prostrate him, so that it was found ultimately necessary to send him to England. Fifteen of the cases of ephemeral fever occurred in the Christmas quarter of the year, and appear to have been referable to atmospheric vicissitudes encountered during a passage from Seychelles to Madagascar and the Mozambique Channel.
There were seven cases of primary fever in the Pantaloon one or two of these are, strictly speaking, not referable to this station, the vessel having been temporarily detached to Borneo, where remittent fever of a severe type, and tedious in its progress, affected some of the men. The average duration of each of these cases on the sick-list was between twenty-nine and thirty days, but this is attributable rather to the complication which in one or two instances recovery was attended, than to the fever itself. These complications were dysentery and rheumatism. Very little information is given in connection with these cases in the returns from this vessel.
There were only four cases of primary fever in the Penguin, all of which were contracted in the Lady quarter of the year, in the Mozambique Channel. They were of the remittent type, and, excepting in one instance, do not appear to have been of much importance. With reference to the exceptional case the medical officer (Dr. Wm. Stables) says:-
"In one case only have I seen occasion to make use of further antiphlogistic remedies than the administration of salines by the mouth, or an emetic at the onset of the disease. In the case excepted the patient was a full-bodied, strong man, who had always enjoyed good health, was of the sanguine temperament, and rather inclined to plethora. He had a very slight attack of fever, but on the morning of the third day his pulse was unusually full and hard. Two or three hours afterwards his face began to swell and flush until it became of a dark red colour. The skin was very hot, the tongue furred, there was intense headache, and he soon became delirious. Bleeding was had recourse to, followed by small doses of tartar emetic, and the attack declined almost as speedily as it had come on. This patient had broken his leave at Zanzibar, and getting intoxicated remained on shore all night, and there is little doubt had thereby caught fever."
There were twenty-four cases of primary fever in the Princess Royal. Twenty-one of these were ephemeral in character, and of the remainder, one was of the remittent and two of the enteric type. One case of the latter form of fever proved fatal in the General Hospital at Bombay. Diarrhoea was a very prominent symptom in this case, but the characteristic eruption was wanting. The cases of ephemeral fever are attributed to insolation. The average duration of each case was about four days.
There were twenty-two cases of primary fever in the Rapid, five of which were returned as of the typhoid type; one was remittent, and sixteen were ephemeral. Two of the cases of so-called typhoid fever were fatal. One of these occurred in the person of a petty officer, who it appears was the subject of chronic intestinal disease; the ileum being the part of the bowel chiefly affected. He died in the hospital at Simon's Bay. In the other fatal case, the disease was doubtless contracted at Port Louis, Mauritius. The subject of it was a boy, who from doing duty in the dingy was almost constantly employed between the ship and the shore, and in running into Port Louis on messages. Fever of a similar description to that which carried him off was said to be very prevalent and very fatal in the town. The surgeon (Surgeon D.G. Pendrith) says:-
"Contracted first by one dingy-boy at the Mauritius, the fever spread to the other dingy-boy, and afterwards to two men on board; for I have no reason whatever to doubt the second dingy-boy's statement, that he did not visit the town. On the contrary, he is a most trustworthy lad, and he could have had no interest whatever in misleading me; for they were sent messages, and it remained with themselves which should go, and which remain in the boat. Of the two men it is much more reasonable to attribute their fever to the agency of infection on board the Rapid than to having brought it on board with them when they returned from leave: for the ship's company returned from leave at eight o'clock in the morning of the 24th of October, and the first of the two men did not apply for treatment till the 16th of November, or twenty-three days after coming from leave; and the second did not apply till the 19th, twenty-six days after his return. Their fever must therefore have been contracted on board the Rapid from one or other of the two boys.
"I have stated that fever of the same character was very prevalent in Port Louis, and I discovered that the mortality from this cause, during the time of our stay there in October, was very considerable. The general belief is, and this belief is partially confirmed by some of the medical men there, that this fever is being constantly introduced afresh from the coasts of India by crowded coolie immigrant ships. I have no doubt this belief is quite correct, but I am convinced that the disease is fostered and increased both in numbers and in virulence, as well as in mortality, by the nearly total want of drainage and other sanitary regulations, which is felt so much by all visitors to the island of Mauritius.
"The diminution in the severity of the fever, in proportion to the distance of time elapsed from its first introduction to its reception by the patient, is worthy of notice. Each case, as it presented itself for treatment, proved milder than its predecessor."
The fatal cases that occurred at this time presented rather the character of malignant remittent than of enteric fever, if that is the fever intended to be designated by the term typhoid, employed in this instance; and the other cases also presented no character of enteric fever.
In a very excellent and elaborate paper on the diseases, &c. of the East Coast of Africa, the same officer makes the following remarks on the fevers peculiar to this part of the station:-
"In their order of importance the fevers of East Africa hold the first place among the diseases. Remittent and intermittent fevers are prevalent, with varying severity, along the whole of East Africa included in our original station. A few towns towards the northern extremity of the station, built on a sandy sea-board, with only a stunted vegetation near then, alone enjoy an immunity from the severer forms of the endemics. Of the two, the remittent and intermittent, the latter is decidedly the most important on the East Coast, from its frequency of occurrence in proportion to the other, and from the liability to repetition of the attacks on slight exposure after a first attack. Whilst we had only three instances of remittent fever, neither of them of great severity, we had twenty-eight of intermittent fever during our service on that coast, whilst the loss to the service in days' sickness from the latter was very much greater than from the former. I have already pointed out one of the most influential and important causes of the great immunity enjoyed by this coast from the fevers of the West Coast, and which, accompanied on some parts of the coast with a little ordinary precaution and prophylactic measures, ensures a nearly complete security from them during the dry season. I allude to the south-east trade wind, which blows with such steadiness on the coast as to prevent the accumulation and. concentration of the miasmal poisons emanating from the soil and from decaying animal and vegetable matter; and there can be no doubt that this dilution of the poison is the reason why intermittents are so much more prevalent here than the remittents, for the latter is only the effect of a more concentrated imbibition of the same poison which causes the former. In most of these places on the coast, for instance, into which this wind penetrates with force, and where there are no other influences of a counteracting nature, where the natural drainage is good and the country comparatively open, one may pass through such a part without much fear of contracting fever, and, when contracted, it is usually mild in character. Other parts, again, having a warm, moist, marshy soil, covered with rank vegetation, shut out from the influence of this wind, give rise to fevers of the worst description. Examples of the former comparative immunity may be found on several parts of the coast, the Delta of the Quilinan, for instance, the windward side of Johanna, several of the islands along the coast, portions of Zanzibar, and of the Island of Mombaza; whilst the densely wooded and jungle-covered coasts in the neighbourhood of Mozambique, and mainland abreast of Zanzibar, through which no wind can find a passage for any distance, are examples of parts of the coast combining in themselves the most favourable conditions for the production and concentration of fever of the worst kind. Parts of Zanzibar, and nearly the whole of Madagascar and Mayotta, and the southern parts of the coast about Delagoa Bay, also possess the same condition of unhealthiness.
"The circumstances enumerated as forming the most favourable condition for the production and concentration of these poisons, known to emanate from a certain combination of soil, decaying vegetable and animal matters, combined with moisture, when acted upon by a powerful sun and when unaffected by currents of air, are those which obtain with augmented force during the months of November, December, January, February, and March, constituting the hot or rainy season on the southern portions of the coast. This is the combination which in its aggregate constitutes the unhealthy season, and which ought to be avoided if possible by the European on the coast. In this season, following the commencement of the heavy rains which set in now, and continuing during their continuance, fevers of the remittent type prevail, accompanied with derangement of liver and spleen, and bowel affections, which not unfrequently terminate in dysentery. The diseases prevalent at this season of the year leave behind them as legacies a complete and permanent derangement of system, a sallow chachetic appearance, a total loss of appetite, a tongue constantly loaded, a breath offensive, a prostration of strength never properly overcome in this climate; and only after several years' residence in a cool climate, if several attacks have been endured; a mind depressed, anxious, fretful, frequently gloomy, with imaginary forebodings, and not unfrequently productive of moments in which life itself seems a burden. The liver, spleen, and pancreas become congested, enlarged, and frequently softened; and the mucous lining of the bowels presents evidences of irritation and inflammatory action. Diarrhoea and dysentery soon follow, and dropsical effusion into the lower extremities is one of the most constant of the sequelae of this fever.
"During the remaining months of the year, from April till November, when the south-east trade wind blows strongly, when the weather is dry and bracing, the heat moderate, the ground dry, parched, and cracked, fever of the intermittent type prevails on the southern part of the coast, and this is in consequence termed the dry and healthy season.
"Remittent Fever.- The number of forms into which this fever has from time to time been divided by different authors is very absurd. As forms or varieties of the fever they have in reality no existence, and are merely modifications caused by something totally distinct from the source of the fever itself, some peculiarity of constitution in the subject of attack, some indiscretion he may have been guilty of, some hidden predisposition of system; and perhaps some modification caused by the use of prophylactic measures, and by the length of time they have been in use.
"For all practical purposes, and indeed in reality, remittent fever may be divided into two forms, or rather grades, the sthenic, or inflammatory, and the asthenic; either of which may vary from the most severe malignant and deadly fever to one of the mildest and most easily amenable to treatment. The former, or sthenic grade, is met with in robust, healthy persons on their first arrival, is usually severe in character, and gives the first shock to the constitution, which subsequent attacks help to undermine entirely: the latter, or asthenic grade, may be said to include all those varying forms assumed by this fever in delicate persons, in those who have lived long in inter-tropical countries, or who have suffered from repeated attacks of it, in which latter it assumes frequently a character so closely resembling intermittent fever as only to be distinguished from it by the remissions.
"This fever begins in various ways, but the most usual form of attack and course is this: After an exposure to the exciting cause for a period of time varying with the strength of the poison, the time of the year, and the predisposition of the person, but usually after an exposure of two, three, or four days, the person begins to be sensible of uneasy feelings creeping over him, not at first referrible to any particular locality, such a feeling as is well described by the familiar expression ·out of sorts;· his appetite becomes bad; he has no inclination for exertion of any kind; he is dull and listless and only desires to be left alone; the bowels may be constipated from the first; this feeling continues only for a short time - one or two days - when other and more marked symptoms begin to make their appearance; frequent cold shivers creep over him, beginning at the extremities and passing along the spine, sometimes resembling a current of cold water; he now complains of languor, lassitude, aching pains of all the limbs, a fixed pain of the loins, which gives rise to a feeling as if the back were about to break, on attempting any sudden movement of it; headache, slight confusion of ideas, debility, and prostration of mind and body. Soon after this the face gets flushed, the eyes become heavy and painfully hot, the action of the heart is increased, the breathing becomes quick and hurried on the slightest exertion. Nausea sets in and the headache becomes intense just before the commencement of the hot stage, when all the symptoms are increased. The headache becomes excruciating, the eyes are hot and cannot bear the light; the skin is hot, and the palms of the hands and soles of the feet are dry, throbbing, and hot; the pulse is quick and sharp, the tongue dry and white, and there is great thirst. Urine is not generally passed, but if so, it is scanty and high coloured; the pain of the back is now intense and fixed, vomiting sets in, and there is occasional delirium; a painful constrictive feeling is usually experienced round the epigastric region, as if something tight were bound round it, and occasionally a disagreeable irritating cough accompanies this tightness. When this stage passes off, which it does in from ten to fourteen hours' time, with profuse perspiration, considerable relief is soon experienced to the more urgent of the symptoms, and exhaustion, accompanied with snatches of sleep, follows, but the fever continues though in a milder form; he wakes from his sleep to find that his pulses are still throbbing, his aches and pains, though diminished, still severe; considerable headache remains, there is a loathing of food, irritability of stomach, occasional nausea, great thirst, and a lowness and despondency of mind that cannot be overcome.
“The remission lasts for three, four, five, six and sometimes more hours, after which the exacerbation returns, and the fever becomes as strong as ever; it is, indeed, a repetition of the first attack.
"This is the usual form of commencement of this fever, but it by no means follows this course as a rule: occasionally the first indications of its approach are nausea, sickness, and vomiting, followed soon by the febrile excitement. Again, diarrhoea, may be the first indication; and yet, again, I have known the first indication of its approach to be a faintness approaching syncope, as if the first impression of the poison were so strong and powerful as to swallow up all the other symptoms. I have also seen instances of this fever at Tamatave, in Madagascar, in which there were no premonitory symptoms whatever, the patient gliding slowly from his usual state of health into one of intense fever, which lasted five or six hours, leaving him nearly entirely for fifteen or sixteen hours, and then returning in the same way. Another, and by no means uncommon peculiarity of this fever at the same place, the same person having frequently suffered from it in exactly the same way, occurs. The patient, without any premonitory chill or cold stage, feels himself gradually drifting into fever; the pulses begin slowly to beat, the temples to throb, the palms of the hands and the soles of the feet become burning hot, and he is tormented with thirst. Headache and pains of the limbs and back follow, and now he is in an intense burning fever which lasts four or five hours, when it begins to subside, and leaves him without an ache or pain of any kind. This complete relief lasts usually a couple of hours, when it is followed by profuse perspiration. The instance quoted may with greater propriety be classed among the irregularities of the intermittent fevers; but there is often such a blending of the two, that in some cases, and especially in early attacks, it is impossible to say to which type to refer it.
"I make the following short extract from my notes respecting our visit to Tamatave. ·The usual remittent fever of Madagascar, as witnessed by me, is severe in grade, is accompanied by headache of the most severe description, and in the great majority of cases by delirium; the tongue in advanced stages is soft and flabby, and in still more advanced stages becomes dry, black, and cracked. In the patients seen, who were mostly residents of some standing, great tenderness was complained of in the epigastric region and over the speen, the liver being tumefied, tender, and enlarged; there was a deep yellow suffusion of the conjunctivae and a yellowish tinge of the skin; there were evident indications of inflammatory action going on in the mucous membrane of the bowels, and in some this had terminated in dysentery; the irritability of the stomach was one of the most distressing of the symptoms, and was often very difficult to allay, as it obstinately rejected for days everything swallowed, even the smallest portion of liquid or solid. This fever is much more severe here than on the mainland of Africa - as a rule, severer in grade, but in every other character identical. Most of the cases were a second or third attack, and many had had several; in all after the second or third attack, oedematous swelling of the feet and ankles occurred, which usually subsided of itself in about a fortnight after recovery, in cases of good constitution. This oedema does not appear to have its origin in any inflammatory action or organic disease: there may be congestion and enlargement of the liver, giving rise to obstructed circulation, which may partially account for it; but I believe it to be much more rationally accounted for by attributing it to an impoverished condition of the blood, resembling more the oedema of chlorosis, its removal being expedited by the same remedies as are found useful in that disease, viz., tonics and nourishing, wholesome diet.
"A singular and noteworthy exception to the regular occurrence of this fever, or rather to its more frequent occurrence and greater severity during the hot and rainy months on the mainland of East Africa, and indeed elsewhere, occurs at Tamatave. The natives of Madagascar, the "Hova" population and their dependents, are attacked by remittent fever during the same months as it is most prevalent elsewhere in East Africa, i.e. during the hot months; whilst visitors and natives of other countries, even though acclimatised, are invariably attacked during the months of May, June, July and August, the coldest months of the year. During our short stay there in July 1863, 1 had ample opportunity of witnessing this for myself, for I visited most, if indeed not all, of the fever cases then in Tamatave, and they were, without an exception, in the persons of natives of other parts of the world, of Mauritius, of India, of America, of the continent of Europe, of England, and of Scotland, and I was assured by those who had themselves suffered for years, that this is the regular course of events here. During our stay at Tamatave we had heavy rains, and although we were there during the coolest month of the year, when the south-east trade is usually at its strongest, there was not a single record of easting among the winds; the prevalent wind was a south-west deflected wind; the south-east trade beaten back, and its moisture extracted by the cold rugged ranges of mountains it came in contact with. These heavy rains may account for the prevalence of the remittent fever, but it cannot very well explain why it should bring remittent fever to one class of people and not to another.·
"The asthenic remittent fever of East Africa occurs, as already stated, in debilitated subjects, especially in those debilitated by long residence in intertropical countries, or who have suffered from repeated attacks of fever. The subjects of this fever are always ailing; they are constantly suffering from dyspeptic symptoms, from derangements of the bowels, from flatulence, from hypochondriacal symptoms, and from headaches; they are constantly taking medicine, and especially quinine; their complexion is sallow and unhealthy; their appetite is bad, and their bowels are either inclined to constipation or to diarrhoea, or these two frequently alternate; there is a shrunken, emaciated, without-stamina look about these people, and the attack and course of the fever is just such as might be expected in them. It is ushered in by none of the high febrile symptoms of the other; there are little or no shiverings or creeping; but there is an indescribable and insurmountable weariness, with yawning and stretching of the limbs, perhaps with nausea and vomiting; this may be followed by slight fever with heat of skin, quickness of pulse and headache, which, in from ten to fourteen hours passes off with sweating, or a clammy feeling of skin only; sometimes there may only be a deep hectic flush of countenance, with quickened pulse, headache, and thirst, and abdominal distension; or the symptoms may present nearly the extreme prostration of typhus, with tremulous black and dry tongue, followed by delirium, incessant jactitation, teeth covered with sordes, lips covered with dry brown or black encrustations, frequent attempts to get out of bed, involuntary discharge of urine and faeces, coma, and death. This latter is a very common form of the fever among the natives of India who visit East Africa in pursuit of trade or occupation, and among the thin emaciated Goanese, who are the most numerous amongst the servant population of the wealthier merchants on the coast. The complications of this fever have been already incidentally mentioned; they are chiefly referrible to the head and abdomen; cerebral congestion is one of the most frequent, most distressing, and least amenable to treatment of all the symptoms that accompany this fever; derangements of the mucous membrane of the bowels, irritability of stomach, inflammatory action in the bowels; derangement of liver, with decreased secretion at first, followed by increased and vitiated secretion; splenic and pancreatic disorders, and in some cases a congested condition of the kidneys; chest complications are not frequent.
"The sequelae of the East Coast remittent fever have also been mentioned; they are such as might be expected to result from a constitution shattered and debilitated by a disease which impoverishes the blood, weakens the nervous energy, destroys appetite, and deranges the functions of the chylo-poietic viscera. They are, emaciation of body, listless indifference, dropsical effusions, permanent organic disease of liver, spleen, bowels, &c., and great impairment of the mental faculties; the memory is weakened, and the sexual desires are blunted. Persons who have suffered from repeated attacks of this fever, are liable to ulcerations and blotches of the lower extremities, not only during the course of the fever, but after recovery. The slightest blow, or abrasion, or scratch of the shin, or skin in the vicinity of the ankles, is followed by ulcers of the most intractable nature : a varicose condition of the veins of the lower extremities usually follows this fever.
"The prognosis in this disease must be very guarded. In the inflammatory form or grade danger must always be looked for. The symptoms which more especially augur a favourable termination are, the absence of gastric irritability, or its easy subdual, the absence of excessive cerebral congestion during the exacerbations, and only a moderate congestion of the conjunctivae; a distinct well-marked remission, with a profuse perspiration, followed by relief to all the symptoms, and a comparatively refreshing sleep; a regular state of bowels without tenderness of any parts, and without flatulent distension; a tongue moist, a pulse not too frequent or hard, and the absence of excessive debility and delirium. In the asthenic grades of the remittent, immediate danger is not to be apprehended, excepting in the very much debilitated, or in those in whom it assumes a low typhoid character. I have seen men suffering from this form of it who did not confine themselves to bed except during the exacerbations, but got up and transacted business during the remission, sitting in an arm-chair of course; in these cases, the approach of the fever is well marked to the patient by his own feelings. Others, more severe in character, are met with, in which the prognosis must be more doubtful, and in which the dangers arising from complications must be carefully taken into account, and their probable result well weighed. The expression of the countenance I have found a most reliable index of the gravity of the case.
"The treatment of remittent fever may be discussed in a few words. In the commencement of the inflammatory grade, if not contraindicated by gastric irritability or cerebral congestion, an emetic has been recommended. The treatment is not without its dangers, for irritability of stomach is such a constant and in many cases such an intractable accompaniment of this fever, that anyone who has once had the treatment of one such case would hesitate before voluntarily inducing nausea and vomiting; and, indeed, this irritability of stomach is in the majority of cases the one that claims our first attention, and until it is allayed the treatment is at a standstill. The judicious practitioner will therefore avoid the risk of inducing a condition of stomach which in itself is one of the most formidable things to contend with in this disease.
"The usual and most rational treatment of this disease at the commencement is to give a smart purgative, of calomel and jalap, perhaps. This I would recommend even should a slight diarrhoea exist, for this diarrhoea is usually a consequence of a lodgment in the bowels of some irritating substance whose removal tends not only to the allaying of the diarrhoea but also of the nausea and vomiting, to the subdual of the cerebral determination and the epigastric fullness, and constrictive feeling there. Should, however, the stomach be incapable of retaining purgative medicine, its irritability must be allayed by mustard cataplasms and draughts containing aether, morphia, chloroform, or hydrocyanic acid, in combination with effervescing draughts or diaphoretics. Turpentine applied on hot flannels is sometimes useful, and in obstinate cases enemata have been found serviceable in allaying the irritability. Large doses of calomel have also been found useful, combining in these doses their sedative or antiphlogistic with their cathartic action. After the subsidence of the irritability by one or other, or by a combination, of the above medicines, and the induction of a free catharsis, if the fever be not high and the headache not severe, quinine may be administered, especially during the remissions. If there is, however, a dry, hot, parched skin, great congestion of the head. thirst, a quick and sharp pulse, saline aperients, in combination with diaphoretics and diuretics, may be given. These and other remedies of like action may be administered in various combinations, whilst the cutting off the hair or shaving the head, the sponging the skin all over with vinegar and cold water, and in more urgent cases the application of leeches to the temples, and the administration of cooling acid drinks, lime juice, tamarind whey, &c., will be found the remedies most serviceable till the subdual of the more urgent of the febrile symptoms, when the quinine must be administered.
"The complications and more urgent symptoms must be treated carefully, according to their gravity, having due regard to the powers of the system and to the nursing of the strength for a more thorough re-establishment of the health after the fever has gone. In most of the complications the use of the quinine may be continued steadily during the time that the other remedies appropriate for the subdual of the complication are in use.
"In the asthenic grades of this fever the quinine may be commenced at once, due attention being paid to the action of the bowels and to any complications present. People in this climate are constantly taking this medicine as a prophylactic, and the system becomes blunted to its influence. It becomes necessary, therefore, to employ it in larger doses, and sometimes, indeed, to increase its strength by the addition or combination of other antiperiodics. I have found the combination of the sulphates of quinine and zinc, dissolved in dilute sulphuric acid, sometimes effectual, when the quinine alone failed. In the more advanced stages of this fever, the chlorate of potash, with decoction of cinchona, wine, and even brandy, may be given with advantage.
"The most suitable time for the exhibition of the quinine, either as a prophylactic or for the actual cure of disease already contracted, is in the morning before anything is swallowed, and about half an hour before each meal. At these times the stomach is empty, and the quinine is instantly absorbed and carried into the system. In any case it should be continued until cinchonism is produced."
The two cases of primary fever in the Seringapatam presented no features of any importance.
There were thirty cases of primary fever in the Severn, all of which were of the remittent type. Twenty of these occurred during the Midsummer and Michaelmas quarters of the year, when the vessel was in Ceylon, and on the East Coast of Hindostan. The total days' sickness on board ship, from all the cases, gives an average duration of about eleven days to each. With reference to some cases that occurred at Trincomalee, the surgeon (Surgeon Henry Loney) says:-
"On the 21st of May an officer was sent to the temporary sick quarters on shore, for an attack of what appeared to be remittent fever. He had imprudently exposed himself to the full force of the sun for several hours together in an open boat, sailing about the harbour. He was suffering, when taken on shore, from great weakness and nervous debility, and was sent to sick quarters to avoid the noise of caulking and hammering that was going on on board the ship. This officer suffered a long time from debility and anorexia, and did not return on board until the 12th of July. Eight other cases of remittent fever were put on the sick-list during our stay at Trincomalee, the most part of them in the month of July, or toward the latter part of our time there; the majority of those attacked were mild cases, and recovered after a few days' illness, but in one case the disease was followed by ascites, for which the patient was ultimately invalided home."
There were four cases of primary fever in the Valorous, three of which were of a trifling character, but the fourth proved fatal. The disease in that instance occurred in a boy who was taken ill when on leave at the Mauritius, and conveyed by his shipmates to the military hospital there. When seen there by the surgeon of his ship on the following day, his face was congested, his eyes suffused, and the expression of his countenance very apathetic, presenting, in fact, all the characters of a very grave case of fever. He died twelve days after his admission to hospital.
In the Vigilant there were five cases of primary fever, all of which, with one exception, appear to have been of an ephemeral character. In the exceptional case the patient was a Krooman, who was entered on the sick-list at Trincomalee with remittent fever. He died in a state of collapse on the fourteenth day of the disease. He had had a similar attack on the day previous to his death, but by the repeated administration of stimulants, and the application of heat to the feet, the axillae, and the sides, reaction was established in the course of the day, and quinine in large doses was ordered. He progressed favourably until eleven p.m. of the following day, when another fit of collapse occurred, which carried him off. Death in the algide stage (as it is termed) of remittent fever is not common on this station.
There were thirty-three cases of primary fever in the Wasp, all of which were of an ephemeral character, the average duration of each case on the sick-list being only about four days.
Intermittent Fever. The ratio of cases of ague is not much more than one-third of that of the previous year. Only seventy-five cases altogether were under treatment during the year, and in many instances two or three cases are referable to one person.
Small-pox.- A case of small-pox occurred in the person of a stoker of the Severn, a negro, at Bombay, where the disease was very prevalent on shore. He was at once sent to the European General Hospital there for treatment, where he recovered.
Two cases of small-pox occurred in the Vigilant, also at Bombay, and were discharged to hospital; but no other information is given in connection with them.
Diseases of the Brain and Nervous System.- A fatal case of meningitis occurred in the person of a Krooman, of the Ariel. He had been placed on the sick-list for a slight contusion of the left leg, caused by a box of coal falling upon it on the previous day. On the day after the accident he was observed to lie down, and two hours afterwards he complained of feeling cold, and that his leg pained him. He was put to bed, and only spoke once afterwards. There was no laboured breathing nor convulsions, but it gradually became more difficult to rouse him to even partial consciousness. He died at six o'clock on the following morning. The body was examined at the Royal Naval Hospital, and the following is the report of the autopsy:-
"Body.- Well formed, moderately muscular. On the head there were the marks of an old injury over the right eye, with a deep cicatrix adherent to the bone. There was a curious depression in the vertex corresponding to the course of the longitudinal sinus, apparently from an old sword-cut, or suchlike injury. Removing the calvarium, the external surface of the dura mater appeared unnaturally dry; beneath the frontal injury it was otherwise healthy, but at this part there was a considerable bony projection internally, very old. Under the vertex, at the seat of the external depression, the inner table was perfectly plane, and did not correspond with the indentation of the outer one. Over and beneath the cerebral arachnoid membrane, there was an extensive effusion of gelatinous lymph, in greater quantity around the cerebellum and at the base. The substance of the brain was apparently healthy. The ventricles were distended with clear serum. At the base of the skull there was a collection of sero-purulent fluid.
"There was slight hypostatic congestion of the right lung. The heart was engorged; the valves perfectly healthy; no sign of pyaemia could be discovered.
"Nothing remarkable was to be found at the seat of contusion on the left leg. Around the lower third of the tibia there was a mass of rather old thickened tissue, but no trace of actual osseous lesion was to be seen. Neither was there any appearance of purulent deposit in sections of the bone, or in the medullary canal."
A death from disease of the brain occurred in the person of a strumous boy of the Lyra. He had been long a sufferer from otorrhoea, the discharge of purulent matter, which was exceedingly offensive, having begun two years previously. On the occasion on which he was last placed on the sick-list, an abscess was forming over the mastoid process of the left side, from which four days afterwards about half an ounce of highly offensive pus was evacuated by incision. Three days afterwards, when getting out of his hammock, he became giddy and almost insensible; this happened simultaneously with a partial suppression of the discharge from the ear. He was suffering from headache, the tongue was coated, skin hot, and he complained of much thirst. In this condition he was sent to the hospital at Simon's Bay. There the symptoms of constitutional irritation increased much, and about a fortnight after his admission he had an attack of convulsions, which resulted in partial paralysis of the left side of the body. He became delirious on the following day, and in the evening died. The report of the post-mortem examination of the body is to the effect that a probe could be passed through the opening behind the ear into the mastoid process to the extent of two inches:-
"On opening the head there was remarkably little evidence of inflammation. Throughout there was venous congestion, and the dura mater over the left temporal bone was abnormally dry. At the junction of the left lateral and inferior petrosal sinuses with the internal jugular vein, there was a fibrinous coagulum, apparently the result of inflammation of the wall of the sinus from the meatus auditorius externus. Through the latter a little pus escaped. No pus was found in the sinus, nor were there any purulent deposits in the internal viscera. The left lung was congested, and there was some tubercular deposit at its apex. There were some old adhesions about the right lung. The liver was much congested. No other morbid changes were found."
A marine of the Princess Royal, while onshore on leave at Madras, and in a state of intoxication, having exposed himself to the full force of the mid-day sun, fell to the ground insensible, and was at once taken to the garrison hospital, where he died a few minutes after his admission. On examining the head after death, the vessels of the brain and membranes were found much congested, and there was effusion of serum at the base of the brain.
Seven cases of delirium tremens were under treatment during the year, and of these one proved fatal. Three of the cases occurred in the persons of officers, one in a seaman, and three in marines. The case that proved fatal was in the person of an officer.
Diseases of the Organs of Respiration.- There was a reduction in the ratio of cases coining under this head, as compared with the preceding year, equal to 71·5 per 1,000 of mean force. This was almost altogether attributable to the less prevalence of cases of influenza and catarrh. Phthisis was much more prevalent, and this disease caused a large loss to the squadron, both by invaliding and death.
In the Orestes, the Severn, and the Valorous there were a good many cases of catarrh during the year, in every instance attributable to climatic vicissitudes, or to exposure during a long continuance of heavy weather.
Diseases of the Heart and Blood-vessels.- There is a very considerable increase in all the ratios under this head, as compared with the preceding year. In 1863 there were no deaths from these diseases; in the present year there were five.
A Krooman of the Narcissus died from what was presumed to be disease of the heart, on board the Maeander. He was subject to angina pectoris, stated to have been probably dependent upon softening of the muscular structure of the heart, and he was in a state of general debility from long-continued bad health. On the morning previous to his death he had an epileptiform seizure, which lasted about an hour; and on the following morning there was a recurrence of a similar attack. On its passing away he appeared to be exceedingly weak, and gradually sank, dying a few hours afterwards. No postmortem examination of the body appears to have been made.
A petty officer of the Orestes died suddenly while on shore near Simon's Town. After drinking at a public-house with two companions, the three men lay down to sleep in a skittle alley. The nights were cold, the thermometer in the open air falling to 48° In the morning, on rising about seven a.m., his companions found this man dead, and death appeared to have been very recent, the body being warm. A post-mortem examination was made at the Naval Hospital, when no very evident signs to account for death were discovered. The stomach was empty, and the deceased did not smell of liquor. All the internal organs were slightly congested; the liver was large and the gall-bladder full of bile; the lungs were perfectly healthy; the heart was healthy, excepting that there were some points of ossification on the aortic valves. The brain was healthy.
A seaman of the same vessel also died in the Naval Hospital at Simon's Town, from disease of the mitral valves, complicated with disease of the liver and dropsy.
A seaman of the Princess Royal died suddenly from disease of the heart, complicated with pneumonia. He had long suffered from the heart disease, and the supervention of pneumonic symptoms brought it rapidly to a termination. On account of the weather, which was very boisterous, it was not possible to examine the body after death.
Another death from disease of the heart appears in connection with this vessel. The immediate cause of death, however, in this case was tetanus supervening on gangrene of both feet. The man, a Krooman, had been sent to the hospital with a bubo of the left groin and swelling of the left foot. The bubo had burst and was proceeding favourably, but the foot continued much inflamed and painful. In hospital, six days after his admission, the whole of the upper surface of the left foot was gangrenous, a line of demarcation forming just about the line of Chopart's operation. Five days afterwards, viz., on the 1st of June, sloughing action was arrested, and healthy action commencing at the margin. On the 6th of June there was no sensation in the sole of the foot, which was becoming gangrenous, and on the 10th it had quite separated from the bones, so that a probe could be passed between them. A large portion of the soft parts, half an inch thick, was removed by scissors. On the 26th the ligaments were divided without pain, and the toes removed, leaving the three cuneiform bones and scaphoid exposed. On the 29th the right foot began to show the same tendency to gangrene. On the 1st of July the left stump was looking quite healthy, and the skin gradually extending over the granulations. The right foot was slowly separating at the metatarso-phalangeal articulation. On the 6th he was going on well. On the 8th he complained of some uneasiness in his throat, and on the following day there was spasmodic pain of the sterno-mastoid muscles. From this time tetanic symptoms increased. On the slightest movement there was pain along the spine, with convulsive spasms on attempting to drink. Perspiration was profuse, the pulse 120, and during the attacks there was constant diaphragmatic pain. On the 11th the spasms increased in severity, and the patient became greatly exhausted; about mid-day the powers of life began to fade, and in the evening he expired. These notes are an abridgment of those by the staff-surgeon (Dr. J. Stirling) of the hospital, by whom also the following report of the post-mortem examination of the body was furnished:
"A muscular fairly built man, with a large amount of fat about the extremities and abdomen. Stump of the left foot healthy. Gangrenous state of right foot arrested; line of demarcation forming at metatarso-phalangeal articulation. Arteries of leg not atheromatous. The lungs were healthy but unusually small. The heart was smothered externally with fat. Internally the columnae carneae of both ventricles showed fatty degeneration, and from them grew two large fatty tumours which passed through the auriculo-ventricular openings, and filled the auricles and commencements of the vessels. Both tumours had attachments to the valves. These growths under the microscope were unmistakeably fatty in the greater part of their extent. At the base of their attachment there were atheromatous specks. The aorta and pulmonary artery were apparently healthy. The abdominal organs were healthy, and there were no signs of irritation in the intestines. The brain and spinal cord showed little trace of disease; the arachnoid was perhaps a trifle redder than usual. There was no fluid to speak of in the ventricles."
Diseases of the Alimentary Canal.- There is a very considerable decrease in the ratio of cases under this head as compared with the preceding year, attributable altogether to the less frequency of the milder forms of disease, viz., diarrhoea and colic. There was an increase in the ratio of cases of dysentery to the extent of 6·7 per 1,000 of mean force, and this disease gave rise to a considerable increase in the invaliding and death rates. Seventy cases of dysentery altogether were under treatment throughout the year, and of these nine were invalided and three proved fatal.
A case of enteritis caused by the impaction of foreign matter in the vermiform appendage of the caecum, and terminating in perforation and fatal peritonitis, occurred in the person of a young officer of the Narcissus. He was placed on the sick-list complaining of having suffered from severe colicky pains during the night. An attempt was made to act upon the bowels, but this seems to have failed from the nausea and vomiting that followed every effort to swallow medicine. On the following day there was tenderness in the right iliac region, which next day became more general. He was discharged to hospital on the following day, at which time there was less pain, but it was increased on the slightest movement; there was general tenderness over the lower part of the abdomen, but it was greatest in the right iliac region. He had vomited once during the night, the pulse was 108; there was much thirst, and the face was flushed. In hospital the most urgent symptom besides pain was constant vomiting, which could not be restrained. About eighteen hours before his death there was a sudden violent accession of abdominal pain, chiefly around the umbilicus, with failure of the pulse, and other symptoms of collapse. The following report of the post-mortem examination of the body is by the medical officer (Dr. John Cotton) at that time in charge of the hospital:-
"Abdomen. Bowels rather largely distended with air. Omentum very large, covering the entire front of bowels, and descending deeply into pelvis, attached to the abdominal wall by a thin delicate layer of lymph in the right inguinal, and by firmer adhesions in the left lumbar region. Peritoneum of remainder of abdominal wall, outside ascending colon, around liver, stomach and spleen, and over transverse colon, slightly congested. Both large and small intestines below the transverse colon glued to each other and to the omentum by a thin and readily torn layer of lymph. All parts not adherent were bathed in a mixture of serum and pus. In the left lumbar region the opposed surfaces of the abdominal wall, omentum, colon, and upper sigmoid curve, were covered by a thicker and firmer layer of lymph, coated in patches by a pasty layer of puriform matter forming a cavity capable of containing about six fluid ounces, filled with serous pus like that in the general cavity of the abdomen. The end of the ileum and a small adjacent portion of the caecum were bound to the omentum and pelvic peritoneum over the upper and right aspect of the bladder, adjacent wall of pelvis and crural ring, by firmer adhesions, forming cavity about the size of three walnuts, containing thick pasty pus. It lay over the end of the ileum and caecum, embracing in its wall the end of the vermiform appendix, which curved upwards on the end of the ileum. The appendix was rather long, its terminal half inch much enlarged, gangrenous, ruptured and lined by a layer of whitish pus. Into it projected from above a solid body of nearly the size and shape of an orange pip. On a section of this, its outer third was found to be soft, of the consistence of slightly dried putty. The centre contained a nucleus like a piece of earthy gritty substance, not unlike a mixture of mortar and sand. The intervening portion resembled the exterior, but was harder."
Diarrhoea and Dysentery.- These diseases were more prevalent in the Orestes and Severn than in any of the other vessels on the station. In the former vessel they are ascribed to irregularities in diet and to exposure to viscissitudes of weather; and in the latter the majority of cases occurred at a time when the vessel was detached from the squadron and employed in China. One of these proved fatal. There was also a death from dysentery in the Rapid, and one in the Wasp. In the former vessel it occurred in the person of a Krooman, who was attacked shortly after being employed for six days in boat's service, examining the creeks and harbours of the island of Pemba, during the whole of which time it rained almost incessantly. The disease ran a very rapid course, without being in the least degree checked by treatment.
Two cases of dysentery occurred in the Wasp, in the month of July, while she lay at Trincomalee. One of them proved fatal. With reference to the prevalence of bowel complaints amongst the crew, the officer at that time in medical charge (Acting Surgeon James A. Allan) of the ship says:-
"The ship remained at Trincomalee until the end of July, and during that month diarrhoea was extremely prevalent. The purging was attended with griping pains in the abdomen, the stools were watery and very frequent, as many as twelve or fifteen during the day. During the month there were two cases of dysentery, one of which ended fatally and the other recovered. Both these men had been affected with the same form of diarrhoea as was prevalent amongst the ship's company, and had been eight days ill before the appearance of sanguineous stools and other dysenteric symptoms. The cause of the diarrhoea was at first not known. It was thought to be the effect of the climate, for fruits were not plentiful, and the water was said, both on shore and on board, to be remarkably good. One day the well in the dockyard, from which the water for ships is obtained, was observed to be rather dirty, and the smell arising from it was most disagreeable. The well was cleaned and allowed to fill, and the water to settle before being used. In the meantime distilled water had been used, and it was noticed that the number of cases of diarrhoea very much diminished, and no fresh cases occurred. The well water was again used, and a fresh outbreak of the diarrhoea took place. There being now a great probability that the water was the cause of the disease, it was recommended that distilled water only should be made use of, which was done, and in two days afterwards there were only two cases in which diarrhoea continued, and no fresh cases occurred. The water at Trincomalee is, I have heard, highly charged with earthy matter, and this I believe to be the cause of the diarrhoea, the earthy salts acting as irritating purgatives."
Diseases of the Genito-Urinary Organs.- It was observed in the Statistical Report of the Health of the Navy for 1863, that the ratio of cases of venereal disease appeared to be steadily increasing on this station, and that while the mean ratio of cases of syphilis taken for a period of seven years was 24·5 per 1,000 of mean force, and of gonorrhoea 9·3; in 1861 the ratio of syphilis had risen to 47·3, and of gonorrhoea to 12·8; in 1862 the ratio of syphilis was 52·5, and of gonorrhoea 17·7; and in 1863 the ratio of syphilis was 60·0, and of gonorrhoea 27·4. In the present year the increase in the ratio of syphilitic cases continues, that being 63·7, and there is only a reduction to the extent of 4·2 per 1,000 in the ratio of cases of gonorrhoea. The medical officers generally testify to the increased prevalence of syphilis in the Cape Colony, and to the large amount of disease that prevails on the East Coast of Africa, especially at Zanzibar, and at the Seychelle Islands, and the ports in Madagascar visited by our cruisers.
A seaman of the Narcissus, whose system appears to have been completely saturated with the syphilitic poison, was seized, shortly after his return from hospital, where he had been under treatment for syphilitic rheumatism, with deep-seated pain in the occipital region, which two or three days afterwards was accompanied with spectral delusions, and loss of speech. Coma speedily supervened, and he died in an epileptiform convulsion. Unfortunately, no post-mortem examination of the body appears to have been made, but death was attributed to syphilitic meningitis.
Rheumatism.- There is a very considerable decrease in the ratio of cases of rheumatism as compared with the previous year, which is doubtless in a great degree attributable to the comparatively small amount of river service performed by the squadron on the East Coast of Africa. In the remarks on the Total Force in the Statistical Report of the Health of the Navy for 1862, occasion was taken to point out the proportionate increase in the ratio of cases of rheumatism with the ratios of remittent and intermittent fevers and the inference was drawn, that the rheumatic cases were in all probability due to the same causes as induced the fever. And so here it may be shown that with a decrease in the ratio of fever cases, there is a decrease in the ratio of cases of rheumatism. Thus, in 1862, the ratio per 1000 of mean force of cases of remittent fever was 210·1; of intermittent fever, 154·2; and of rheumatism, 121·1. In 1863 the ratio of cases of remittent fever was 105·1; of intermittent fever, 76·2; and of rheumatism 113·3. In the present year the ratio of remittent fever was 76·3; of intermittent fever, 28·9; and of rheumatism, 96·9. Without placing any very extravagant value on these figures, they may at least be said to be interesting.
Wounds and Injuries.- Three men sustained fatal fracture of the skull by falling from aloft; and one man was killed in action with natives.
Six men fell overboard and were drowned; one man is supposed to have teen washed overboard from the head in a gale of wind one man was drowned by being capsized in a shore-boat; and one man was found drowned, but how the casualty occurred is not known.
In two instances the causes of death are not stated.
There were fifty-one deaths altogether, thirty-six being from various forms of disease, and fifteen from wounds and injuries and drowning. The ratio of mortality from disease alone was 13·8 per 1,000 of mean force, and from casualties 5·6, making a total death-rate of 19·4 per 1,000, which is an increase of 3·2 per 1,000 as compared with the preceding year.
Invalided.- One man was invalided for the sequelae of fever; eight for epilepsy; twenty-three for diseases of the organs of respiration, twenty-one of whom were phthisical; twelve for diseases of the heart and blood-vessels; eleven for diseases of the alimentary canal, chiefly dysentery; four for disease of the liver; seven for diseases of the genito-urinary organs; twenty-two for rheumatism; four for diseases of the bones and joints; six for affections of the special senses; seventeen for diseases of the skin and cellular tissue; seven for dyspepsia and debility; one for dropsy; eleven for wounds and injuries; and six for hernia. The total number invalided was 140, being in the ratio of 53·4 per 1,000 of mean force, an increase, as compared with the preceding year, of 14·9 per 1,000.
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