MEDICAL HISTORY
OF THE
EXPEDITION TO THE RIVER NIGER
DURING THE YEARS 1841-2.

CHAPTER II.
HISTORY OF THE FEVER.
Section I.

Description and Morbid Anatomy of the Fever.

The following account of the fever is drawn up principally from the cases which occurred on board H.M.S. Albert, commencing at Iddah in the Kingdom of Eggarra, River Niger.

Precursory symptoms and mode of invasion. There was little uniformity in the character of the premonitory symptoms, or in the mode of attack. A number of the patients were for twenty-four hours, and sometimes more, sensible of headach, often slight; and some experienced painful scintillations along the spine, attended with a feeling of coldness before they considered it necessary to apply for medical assistance; while in others the approach of the disease was announced by a sensation of weakness, and sometimes of burning heat in the epigastrium. Giddiness, lassitude, tremulous and foul tongue, with small quick pulse, and general oppression succeeded. The eyes looked heavy, were occasionally suffused, and the motions of the pupil were performed languidly. On two occasions that came under my notice, the individuals were seized without any warning symptom, and were at once so overwhelmed as to be for a time deprived of motion and sensation.

In general, however, some of the above-mentioned symptoms, varying in duration and intensity, preceded the accession.

Character, course, and duration of the symptoms. The accession was seldom accompanied by very marked shivering, yet previous to the period of vascular excitement, the patient usually experienced a sensation of coldness, and for the sake of warmth would fain have exposed himself to the rays of the sun. He would shortly express a wish to lie down, and would complain somewhat suddenly of increase of headach or giddiness, and intense heat of the skin, which had a dry parched feel, restlessness, intolerable nausea, and difficult breathing. The dyspnea in several instances, particularly in my own case, was extremely distressing, and continued from one to four hours, until relieved by spontaneous vomiting, or the occurrence of diaphoresis. Headach was with some the prominent symptom during the hot stage, and the feeling was described as that of a cord being tightly girded round the temples. The thirst was very urgent; the tongue was foul in the centre, moist, clean or reddish, and invariably marked by indentations on the edges. The countenance was more or less flushed, the eye occasionally suffused and always looked wild. Pulse rapid but small, frequently feeble; thirst urgent, bowels constipated, and urine passed often and in small quantity. There was in general tenderness of the epigastrium, sometimes acute, but often not discoverable unless upon pressure.

In some cases, coldness of the stomach was complained of some days before death. A subsidence of febrile action in general followed in from three to six hours, or at all events, the symptoms if continued beyond the latter period became much mitigated. Diaphoresis came on, the thirst moderated, and the signs of oppression in a great measure disappeared. The principal complaint at this period was from the disagreeable odour of the perspiration, particularly in those cases that subsequently proved fatal. I was not sensible of this peculiarity in the smell of the perspiration in my own case, but I perceived it very distinctly in several others. The sweating continued until from eight to twelve hours had been occupied by the whole paroxysm. The patient, although considerably exhausted, expressed himself as free from all trouble, and the countenance also indicated improvement. This seemingly favorable change did not last long, for the accession generally returned in from six to ten or twelve hours. Occasionally the respite extended to twenty-four hours. In a few cases, there was a treacherous interval of forty-eight hours, in the early period of the disease; but these invariably assumed afterwards a low malignant type. The fever in them seemed to have rested only to give strength for a fresh accession.

The accessions did not seem to observe any law of periodicity. They came on, disappeared, and returned at all hours of the day and night. The evening, however, was a more common time of accession than any other; in which case, after the cold sensation had passed off, the paroxysm generally ran through its stages in the course of the night, and had suffered a considerable remission by the hour of breakfast (eight) the next morning.

In a few instances the remissions were as complete as in the interval of ague. These were, however, only exceptions to the general rule, for total absence of fever was indeed of rare occurrence during the course of the disease.

I cannot say that the influence of critical days was at all apparent, further than if no material improvement was evident by the eighth or ninth day, the prognosis was then most gloomy. The patient became weak, irritable, and exhausted, and extremely restless. The remissions were most indistinctly marked; the skin was dry and constricted, the tongue parched, pulse small and irregular; the fever, in short, now assumed a low asthenic form. Occasional symptoms of mental aberration would appear at this period; the countenance pale and shrunk; but not unfrequently the patient would talk most rationally upon the state of his mind, so far as regarded his eternal happiness. In several cases this stage was wonderfully protracted, as in Case xii.

Local pain was seldom much complained of: indeed, with the exception of headach (often very slight) at the commencement of the paroxysm, there were several instances in which the patients expressed themselves as quite well, throughout the disease, although this ultimately proved fatal.

When the disease was about to take a favorable turn, the remissions became distinctly marked, and the intervals were lengthened. The countenance (the best criterion) assumed a natural expression, a certain look of convalescence, that one can only become acquainted with by experience and contrasting it with that indicative of a fatal termination. The skin became moist, the thirst diminished, the pulse was more voluminous and softer; the tongue gradually lost its tremulousness, and could be more easily thrust out of the mouth; it often continued a long time loaded, but the crust was less brown, and more moist, and seemed to have lost its firm attachment to the organ: at this period diarrhoea was by no means uncommon, and also a copious flow of urine, which latter was a very favorable symptom. A strong desire for food was expressed by most of the patients who had advanced thus far, and I had more than once cause to regret having gratified it.

Such were the general characteristics of the fever as it occurred in the Niger; but the description is not to be regarded as applicable to all the cases, for, on board of the Albert alone, there were several, in which there was neither complaint nor evidence of suffering of any kind. There was a disinclination to be spoken to, or to be in any way disturbed; and a listless expression of countenance, with a clammy skin, and small pulse. The periods of exacerbation were so feebly marked as to be scarcely perceptible: food and medicine were taken when offered, but seldom or ever was anything asked for, and the invariable answer to inquiries after their health was, "I am very well." Constant watchfulness was the only appreciable symptom in these cases, which all terminated fatally, seemingly from mere exhaustion. It would have been interesting to have ascertained the nature and amount of the organic lesions in these cases; but, unfortunately, circumstances did not permit any of the bodies being examined.

Contingent symptoms. Of the contingent symptoms the most prominent were delirium, yellowness of skin, and convulsions, affecting various parts of the body.

Delirium was a very bad symptom in the fever of the Niger: of twenty-one cases in which it occurred fourteen died, of whom one was drowned by eluding his nurse, and jumping into the river. It was not uncommon for patients, whether affected with delirium or not, to be haunted by dreams of a frightful nature, — as of being drowned, stabbed, or falling from a precipice. In the worst cases the mental aberrations were expressive of some personal misfortune, or unheard-of disease. The imposition of the slightest restraint was always a heavy grievance. In one case the patient constantly harped upon his being condemned to everlasting punishment; when reason for awhile resumed her authority he would express shame and contrition for previous misconduct. The most solemn promises to behave well, if left at liberty, were not unfrequently made, only to be broken, whenever an opportunity offered for the exercise of the cunning, so characteristic of this stage of the disease.

Petechiae or sudamina were not observed in any case. In two cases which proved fatal on the seventh day, livid blotches appeared on the feet and hands, and gradually extended to the chest and abdomen.

Yellowness of the skin occurred in nineteen cases, thirteen of which were fatal, and the average day of the appearance of this symptom was the ninth. The yellow colour was first seen in the conjunctiva, and afterwards extended over the face, arms, and the rest of the body. It was in general light, and did not appear after death in any case in which it had not existed during life.

The faeces in these cases were generally of a bilious colour; the urine deposited a sediment, but its chemical qualities were not ascertained.

Convulsions. In three of the fatal cases on board the Albert, the muscles of the pharynx and larynx were convulsively affected, preventing or much impeding deglutition. In two others, also fatal, the spasms were confined to the muscles of the abdomen and limbs. Mr. Loney, the assistant-surgeon of the Dolphin, the vessel that received the sick from the Soudan, at the mouth of the river, informed me that out of eight deaths, which took place during the passage to Ascension, there were two cases in which deglutition was at first difficult, and soon stopped altogether, and two others in which there were general convulsions, more especially of the extremities.

In one case paralysis of both arms, from which the patient has not yet altogether recovered, supervened during the early period of the disease.

Partial paralysis of the right arm occurred in my own case, four months after convalescence from the fever had been going on, and lasted about six weeks. One man, on board the Wilberforce, was placed on the list, for paralysis, in November, after having had fever in the Niger.*

In no case was there the slightest appearance of "black vomit." Bilious vomiting was common in the early stage of the disease; and the attendant retching was very troublesome, irritability of the stomach, although more frequent at the beginning of the fever, was by no means confined to this period, for it was observed to have occurred also during the height and decline of the disease.

Statistics of the Periods of Deaths, and Recoveries from Fever, onboard the Albert, Wilberforce, and Soudan.

Note. A man, not included in the above, belonging to the Albert, died in June, 1842, afterwards at Ascension hospital; one belonging to the Soudan died of dropsy, on board the Warree, in January, 1842.

In the Quorra, says M'Gregor Laird, "at Iddah, on the 13th of November, all hands were laid down with fever. On the 18th the first deaths occurred, two in number; two others died on the 19th; three on the 20th; three on the 21st; two on the 22d; one on the 24th. On the 4th of December two died, and one on the 11th of the same month, making a mortality of 16 in 23."

Of the recoveries on board the Albert, there occurred on the 16th day, one. On the 18th, one. On the 20th, one. On the 23d, one. On the 27th, two. On the 30th, one. On the 32d, one. On the 42d, one. On the 43d, one. On the 50th, one. On the 56th, one, afterwards invalided. On the 57th, one. On the 61st, one, afterwards invalided. On the 70th, one, afterwards invalided. On the 74th, one, afterwards invalided. On the 84th, one. On the 89th, one. On the 91st, one. On the 92d, one, afterwards invalided. On the 97th, one. On the 95th, one, ultimately invalided. On the 102d, two; both ultimately invalided. On the 121st, one, and on the 129th, one; both of the latter were invalided some months afterwards. Average duration on the sick-list, 64.52 days.

On board the Wilberforce there recovered, on the 3d day, one. On the 4th, three. On the 5th, one. On the 6th, two: one of whom died on the second voyage up the Niger. On the 9th, one. On the 10th, two. On the 12th, one. On the 13th, one. On the 14th, one. On the 16th, three. On the 21st, two; of whom one died during the second voyage up the Niger. On the 22d, one. On the 23d, one, afterwards invalided. On the 24th, three. On the 25th, one. On the 26th, two. On the 27th, one. On the 31st, one. On the 32d, one. On the 33d, one. On the 34th, one. On the 35th, one. On the 36th, one; afterwards invalided. On the 38th, one. On the 39th, one. On the 41st, one; and, on the 130th, one. Average duration on sick-list, 26.259 days.

I have no means of ascertaining the duration of the disease in those of the Soudan who recovered, but in looking over the Tables of Vital Statistics at the termination of the expedition, it will be seen that a proportionately greater number died belonging to that vessel than either of the other two. It must, however, be borne in mind that her commander and sailmaker, both of whom died, ascended the Niger in the Albert, as high as Egga, and that her schoolmaster was seized with his fatal illness at the model farm, when the Soudan and Wilberforce had left the river. The Soudan was unavoidably much crowded by the sick from the Albert and Wilberforce. The Wilberforce, with all the advantage of following close after the Soudan, and gaining the open sea, had the additional one of having ample space for her sick, not only in the river, but during the passage to Ascension; for six had been discharged to the Soudan, while a lesser number had been received by her from the Albert.

Meanwhile the Albert was still advancing into the interior of Africa, and in spite of all our efforts and hopes the fever pursued its course little controlled by treatment of any kind, until it had prostrated nearly all the whites on board. No sooner did the disease seem to be subdued than it recurred. In short, there was a constant presence of cause, and a consequent perpetuation or reproduction of disease. On the arrival of the Albert at Fernando Po on the 17th of October, the enfeebled condition of the crew rendered her totally unfit to proceed to the southward, and the sick were accordingly sent on shore, as has been already detailed in the brief general narrative.

Morbid appearances. From circumstances which could not be controlled, the post-mortem examinations were by no means so numerous or scrutinising as is desirable in the investigation of a disease whose causes and nature are comparatively so little known. The results however, although limited, are so far satisfactory that they corroborate, in most respects, opinions derived from former experience on the coast of Africa, more especially with reference to the pathological condition of the gastroenteric mucous membrane, during and after certain forms of remittent fever. The following statements are founded on the examination of eight bodies.

Head. In two cases where the head was examined, softening was found in the corpus callosum and walls of the ventricles. In one case there was a small quantity of serous fluid in the base of the brain, and an unusual proportion in the ventricles. The dura mater was always sound. The pia mater in one case red and injected. No subarachnoid effusion was observed.

Thorax. The contents of the thorax were in nearly all cases healthy in appearance. Adhesions between the costal and pulmonary pleurae were found in one instance, with tubercular deposits in the lungs in the state of induration. In another, a cartilaginous state of the tricuspid valves, with serous effusion in the left pleural sac.

Abdomen. The peritoneum and its processes, as well as the surface of the intestinal tube, had in general a bilious tinge.

The stomach. In several cases the stomach contained from one to five ounces of yellowish-green fluid. The mucous coat was invariably softened, whether this fluid were present or not. In three cases livid patches were variously distributed over the inner surface of the stomach, becoming more distinct when the mucous tunic was scraped off, exhibiting stelliform nuclei in their centres. In two cases, the livid marks were arranged in the form of parallel streaks. These pathological appearances were chiefly in the splenic extremity of the stomach and near the pylorus. In one case there was remarkable venous arborescence on the exterior of the stomach, attended with general engorgement of the portal system. Small points of ulceration were observed in three cases, and slight thickening of the mucous lining in one instance only.

Duodenum. The lesions observed in the duodenum were of the same nature as those in the stomach, but much less marked. In one case the lower portion of this gut contained a yellowish secretion, of the consistence of mucus.

The jejunum was free from disease, and likewise the ileum, until within three feet of its lower end, where were observed, softening of the mucous lining generally and livid spots. A series of small ulcerations were seen in four cases. In one, the membrane was thickened, rough, and the ulcerations had nearly perforated the bowel; this case proved fatal by terminating in dysentery. The agminated glands of Peyer were distinct and enlarged in three cases.

Colon. The colon was usually nearly empty. On these occasions a dark, bilious, pultaceous matter was found in this portion of the tube, but in small quantity only; it was viscid and tenacious, adhering to the mucous tunic: where lividity or ulcerated points were found at the lower end of the ileum, the same lesions were seen to exist on the arch of the colon. Softening of the mucous coat was remarkable in three cases. In that of the case of dysentery already mentioned, there was softening of the tunic where it was not ulcerated, and induration and elevation round the edges of the ulcerated patches.

Liver. The liver was congested in one instance; larger than usual in two cases. It was anemious in two cases where the patients died early, and on two other occasions when death took place long subsequent to febrile action. In the latter cases this organ was of a pale gray colour, and had a dry appearance on being sliced. This condition was not confined to one lobe.

Gall-bladder. The gall-bladder was distended with bile of the colour and consistence of tar in three cases; one of which was fatal on the third, one on the seventh, and the other on the ninth day. In another instance the gall-bladder was nearly filled with bloody bile. The man in this case died suddenly, many weeks after the fever had left him.

The enlarged condition of Peyer’s glands, which is regarded by Chomel and Louis as constant in the typhoid fever of France, occurred in three cases out of eight that were examined. In four cases, the subjects of which with one exception died early, slight ulcerations of the gastro-enteric mucous membrane were observed. This fact is worthy of attention, inasmuch as it would seem to imply that the cause of the river fever, in whichever way it is introduced into the system, induces an unhealthy action in mucous surfaces much more rapidly than even the low typhoid fevers of France. Chomel does not consider that ulcerations take place in typhoid fevers earlier than the twentieth day, when there is, also, softening of the mucous membrane around the follicles, or in that part of it which covers them. Louis found the patches of Peyer natural in twenty autopsies, made by himself, of yellow-fever cases at Gibraltar, during the epidemic of 1828.

Spleen. In one case the spleen was enlarged, soft, and breaking down under the fingers; in another enlarged, gorged with blood, but firm. This viscus was not altered from the normal condition in the other cases examined. The pancreas was not in any case otherwise than natural. The kidneys were mottled and larger than usual on one occasion. The bladder was in general collapsed. A case in which bloody urine was voided was not inspected.

The morbid appearances observed in the intestines are very like those so often found in fatal cases of the typhoid fever of this country. This is not the place to recapitulate the evidence opposed to the doctrines of Broussais, regarding the nature of fever; but every day’s experience tends to prove that the ulcerations and other lesions of the bowels are a specific effect of the fever poison, and not the cause of the fever itself.

Morbid changes of some kind were found in the mucous membrane of the bowels in all cases, but none of these changes were constant, therefore are not essential to the existence of the fever. Besides, in the cases we examined the morbid appearances were plainly insufficient of themselves to account for death, so that we are obliged to admit some agency quite independent of local inflammation. In this opinion I am borne out by the high authority of M. Louis, who, when speaking of the epidemic yellow fever of Gibraltar, in 1828, says "there is in this disease something beyond what we see; we must admit that the cause of the disease often kills by itself, or independently of appreciable alteration of the organs, and even up to a certain point of apparent derangement of the functions." The morbid appearances are, however, so far valuable, that they account in a great measure for ailments that occur as sequences of the fever, weeks and sometimes months after febrile action has ceased.

I have no intention to enter upon the disputed question as to whether the blood in fever receives the morbid impression through the medium of the nerves, or independent of them; but I may state that in two cases the blood was found in a fluid state several hours after death; and the general character of the morbid anatomy seems to prove that the cause of the disease was a poison introduced into the blood, through some channel. The yellowness of skin I believe to have been owing to the bile not being eliminated by the liver, and consequently remaining latent in the circulation.