Travels in West Africa, Congo Français, Corisco and Cameroons/Appendix 2
APPENDIX II
DISEASE IN WEST AFRICA
Great as is the delay and difficulty placed in the way of the development of the immense natural resources of West Africa by the labour problem, there is another cause of delay to this development greater and more terrible by far—namely, the deadliness of the climate. "Nothing hinders a man, Miss Kingsley, half so much as dying," a friend said to me the other day, after nearly putting his opinion to a practical test. Other parts of the world have more sensational outbreaks of death from epidemics of yellow fever and cholera, but there is no other region in the world that can match West Africa for the steady kill, kill, kill that its malaria works on the white men who come under its influence.
Malaria you will hear glibly talked of; but what malaria means and consists of you will find few men ready to attempt to tell you, and these few by no means of a tale. It is very strange that this terrible form of disease has not attracted more scientific investigators, considering the enormous mortality it causes throughout the tropics and sub-tropics. A few years since, when the peculiar microbes of everything from measles to miracles were being "isolated," several bacteriologists isolated the malarial microbe, only unfortunately they did not all isolate the same one. A résumé of the various claims of these microbes is impossible here, and whether one of them was the true cause, or whether they all have an equal claim to this position, is not yet clear; for malaria, as far as I have seen or read of it seems to be not so much one distinct form of fever as a group of fevers—a genus, not a species. Many things point to this being the case; particularly the different forms so called malarial poisoning takes in different localities. This subject may be also subdivided and complicated by going into the controversy as to whether yellow fever is endemic on the West Coast or not. That it has occurred there from time to time there can be no question: at Fernando Po in 1862 and 1866, in Senegal pretty frequently, and at least one epidemic at Bonny was true yellow fever. But in the case of each of these outbreaks it is said to have been imported from South America, into Fernando Po, by ships from Havana, and into Bonny by a ship which had on her previous run been down the South American ports with a cargo of mules. The litter belonging to this mule cargo was not cleared out of her until she got into Bonny, when it was thrown overside into the river, and then the yellow fever broke out. But, on the other hand, South America taxes West Africa—the Guinea Coast—with having first sent out yellow fever in the cargoes of slaves. This certainly is a strange statement, because the African native rarely has malarial fever severely—he has it, and you are often informed So-and-so has got yellow fever, but So-and-so does not often die of it, merely is truly w retched and sick for a day or so, and then recovers.
Regarding the hæmaturia there is also controversy. A very experienced and excellent authority doubts whether this is entirely a malarial fever, or whether it is not, in some cases at any rate, brought on by over-doses of quinine, and Dr, Plehn asserts, and his assertions are heavily backed up by his great success in treating this fever, that quinine has a very bad influence when the characteristic symptoms have declared themselves, and that it should not be given. I hesitate to advise this, because I fear to induce any one to abandon quinine, which is the great weapon against malaria, and not from any want of faith in Dr. Plehn, for he has studied malarial fevers in Cameroon with the greatest encergy and devotion, bringing to bear on the subject a sound German mind trained in a German way, and than this, for such subjects, no better thing exists. His brother, also a doctor, was stationed in Cameroon before him, and is now in the German East African possessions, similarly working hard, and when these two shall publish the result of their conjoint investigations, we shall have the most important contribution to our knowledge of malaria that has ever appeared. It is impossible to over-rate the importance of such work as this to West Africa, for the man who will make West Africa pay will be the scientific man who gives us something more powerful against malaria than quinine. It is too much to hope that medical men out at work on the Coast, doctoring day and night, and not only obliged to doctor, but to nurse their white patients, with the balance of their time taken up by giving bills of health to steamers, wrestling with the varied and awful sanitary problems presented by the native town, &c., can have sufficient time or life left in them to carry on series of experiments and series of cultures, but they can and do supply to the man in the laboratory at home grand material for him to carry the thing through; meanwhile we wait that man and do the best we can.
The net results of laboratory investigation, according to the French doctors, is that the mycetozoic malarial bacillus, the microbe of paludism, is amœboid in its movements, acting on the red corpuscles, leaving nothing of them but the dark pigment found in the skin and organs of malarial subjects.[1] The German doctors make a practice of making microscopic examinations of the blood of a patient, saying that the microbes appear at the commencement of an attack of fever, increase in quantity as the fever increases, and decrease as it decreases, and from these investigations they are able to judge fairly accurately how many remissions may be expected; in fact to judge of the severity of the case which, taken with the knowledge that quinine only affects malarial microbes at a certain stage of their existence, is helpful in treatment.
There is, I may remark, a very peculiar point regarding hæmaturic disease, the most deadly form of West Coast fever. This disease, so far as we know, has always been present on the South-West Coast, at Loando, the Lower Congo and Gaboon, but it is said not to have appeared in the Rivers until 1881, and then to have spread along the West Coast. My learned friend, Dr. Plehn, doubts this, and says people were less observant in those days, but the symptoms of this fever are so distinct, that I must think it also totally impossible for it not to have been differentiated from the usual remittent or intermittent by the old West Coasters if it had occurred there in former times with anything like the frequency it does now; but we will leave these theoretical and technical considerations and turn to the practical side of the question.
You will always find lots of people ready to give advice on fever, particularly how to avoid getting it, and you will find the most dogmatic of these are people who have been singularly unlucky in the matter, or people who know nothing of local conditions. These latter are the most trying of all to deal with. They tell you, truly enough no doubt, that the malaria is in the air, in the exhalations from the ground, which are greatest about sunrise and sunset, and in the drinking water, and that you must avoid chill, excessive mental and bodily exertion, that you must never get anxious, or excited, or lose your temper. Now there is only one—the drinking water—of this list that you can avoid, for, owing to the great variety and rapid growth of bacteria encouraged by the tropical temperature, and the aqueous saturation of the atmosphere from the heavy rainfall, and the great extent of swamp, &c., it is practically impossible to destroy them in the air to a satisfactory extent. I was presented by scientific friends, when I first went to the West Coast, with two devices supposed to do this. One was a lamp which you burnt some chemical in; it certainly made a smell that nothing could live with—but then I am not nothing, and there are enough smells on the Coast now. I gave it up after the first half-hour. The other device was a muzzle, a respirator, I should say. Well! all I have got to say about that is that you need be a better-looking person than I am to wear a thing like that without causing panic in a district. Then orders to avoid the night air are still more difficult to obey—may I ask how you are to do without air from 6.30 P.M. to 6.30 A.M.? or what other air there is but night air, heavy with malarious exhalations, available then?
The drinking water you have a better chance with, as I will presently state; chill you cannot avoid. When you are at work on the Coast, even with the greatest care, the sudden fall of temperature that occurs after a tornado coming at the end of a stewing-hot day, is sure to tell on any one, and as for the orders regarding temper neither the natives, nor the country, nor the trade, help you in the least. But still you must remember that although it is impossible to fully carry out these orders, you can do a good deal towards doing so, and preventive measures are the great thing, for it is better to escape fever altogether, or to get off with a light touch of it, than to make a sensational recovery from Yellow ack himself.
There is little doubt that a certain make of man has the best chance of surviving the Coast climate—an energetic, spare, nervous but light-hearted creature, capable of enjoying whatever there may be to enjoy, and incapable of dwelling on discomforts or worries. It is quite possible for a person of this sort to live, and work hard on the Coast for a considerable period, possibly with better health than he would have in England. The full-blooded, corpulent and vigorous should avoid West Africa like the plague. One after another, men and women, who looked, as the saying goes, as if you could take a lease of their lives, I have seen come out and die, and it gives one a sense of horror when they arrive at your West Coast station, for you feel a sort of accessory before the fact to murder, but what can you do except get yourself laughed at as a croaker, and attend the funeral?
The best ways of avoiding the danger of the night air are—to have your evening meal about 6.30 or 7,—8 is too late; sleep under a mosquito curtain whether there are mosquitoes in your district or not, and have a meal before starting out in the morning, a good hot cup of tea or coffee and bread and butter, if you can get it, if not, something left from last night's supper or even aguma, Regarding meals, of course we come to the vexed question of stimulants—all the evidence is in favour of alcohol, of a proper sort, taken at proper times, and in proper quantities, being extremely valuable. Take the case of the missionaries, who are almost all teetotalers, they are young men and women who have to pass a medical examination before coming out, and whose lives on the Coast are far easier than those of other classes of white men, yet the mortality among them is far heavier than in any other class.
Mr. Stanley says that wine is the best form of stimulant, but that it should not be taken before the evening meal. Certainly on the South-West Coast, where a heavy, but sound, red wine imported from Portugal is the common drink, the mortality is less than on the West Coast. Beer has had what one might call a thorough trial in Cameroon since the German occupation and is held by authorities to be the cause in part of the number of cases of hæmaturic fever in that river being greater than in other districts. But this subject requires scientific comparative observation on various parts of the Coast, for Cameroons is at the beginning of the South-West Coast, whereon the percentage of cases of hæmaturic to those of intermittent and remittent fevers is far higher than on the West Coast.
A comparative study of the diseases of the western division of the continent would, I should say, repay a scientific doctor, if he survived. The material he would have to deal with would be enormous, and in addition to the history of hæmaturic he would be confronted with the problem of the form of fever which seems to be a recent addition to West African afflictions, the so-called typhoid malaria, which of late years has come into the Rivers, and apparently come to stay. This fever is, I may remark, practically unknown at present in the South-West Coast regions where the "sun for garbage" plan is adhered to. At present the treatment of all white man's diseases on the Coast practically consists in the treatment of malaria, because whatever disease a person gets hold of takes on a malarial type which masks its true nature. Why, I knew a gentleman who had as fine an attack of the smallpox as any one would not wish to have, and who for days behaved as if he had remittent, and then burst out into the characteristic eruption; and only got all his earthly possessions burnt, and no end of carbolic acid dressings for his pains.
I do not suppose this does much harm, as the malaria is the main thing that wants curing; unless Dr. Plehn is right and quinine is bad in hæmaturia. His success in dealing with this fever seems to support his opinion; and the French doctors on the Coast, who dose it heavily with quinine, have certainly a very heavy percentage of mortality among their patients with the hæmaturic, although in the other forms of malarial fever they very rarely lose a patient.
But to return to those preventive measures, and having done what we can with the air, we will turn our attention to the drinking water, for in addition to malarial microbes the drinking and washing water of West Africa is liable to contain dermazoic and entozoic organisms, and if you don't take care you will get from it into your anatomy Tinea versicolor, Tinea decalvans, Tinea circinata, Tinea sycosis, Tinea favosa, or some other member of that wretched family, let alone being nearly certain to import Trichocephalus dispar, Ascaris lumbricoides, Oxyuris vermicularis, and eight varieties of nematodes, each of them with an awful name of its own, and unpleasant consequences to you, and, lastly, a peculiar abomination, a filaria. This is not, what its euphonious name may lead you to suppose, a fern, but it is a worm which gets into the white of the eye and leads there a lively existence, causing distressing itching, throbbing and pricking sensations, not affecting the sight until it happens to set up inflammation. I have seen the eyes of natives simply swarming with these filariæ. A curious thing about the disease is that it usually commences in one eye, and when that becomes over-populated an emigration society sets out for the other eye, travelling thither under the skin of the bridge of the nose, looking while in transit like the bridge of a pair of spectacles. A similar, but not identical, worm is fairly common on the Ogowé, and is liable to get under the epidermis of any part of the body. Like the one affecting the eye it is very active in its movements, passing rapidly about under the skin and producing terrible pricking and itching, but very trifling inflammation in those cases which I have seen. The treatment consists of getting the thing out, and the thing to be careful of is to get it out whole, for if any part of it is left in, suppuration sets in, so even if you are personally convinced you have got it out successfully it is just as well to wash out the wound with carbolic of Condy’s fluid. The most frequent sufferers from these filariæ are the natives, but white people do get them. I hear there is an account in the Lancet, October 17th, 1894, of one that was extracted from the eye of a European. This case came from Calabar, but the disease is more frequent on the South-West Coast.
Do not confuse this filaria with the Guinea worm, Filaria medinensis, which runs up to ten and twelve feet in length, and whose habits are different. It is more sedentary, but it is in the drinking water inside small crustacea (cyclops). It appears commonly in its human host’s leg, and rapidly grows, curled round and round like a watch-spring, showing raised under the skin. The native treatment of this pest is very cautiously to open the skin over the head of the worm and secure it between a little cleft bit of bamboo and then gradually wind the rest of the affair out. Only a small portion can be wound out at a time, as the wound is very liable to inflame, and should the worm break, it is certain to inflame badly, and a terrible wound will result. You cannot wind it out by the tail because you are then, so to speak, turning its fur the wrong way, and it catches in the wound.
I should, I may remark, strongly advise any one who likes to start early on a canoe journey to see that no native member of the party has a Filaria medinensis on hand; for winding it up is always reserved for a morning job and as many other jobs are similarly reserved it makes for delay.
I know, my friends, that you one and all say that the drinking water at your particular place is of singular beauty and purity, and that you always tell the boys to filter it; but I am convinced that that water is no more to be trusted than the boys, and I am lost in amazement at people of your intelligence trusting the trio of water, boys, and filter, in the way you do. One favourite haunt of mine gets its drinking water from a cemented hole in the back yard into which drains a very strong-smelling black little swamp, which is surrounded by a ridge of sandy ground, on which are situated several groups of native houses, whose inhabitants enhance their fortunes and their drainage by taking in washing. At Fernando Po the other day I was assured as usual that the water was perfection, "beautiful spring coming down from the mountain," &c. In the course of the afternoon affairs took me up the mountain to Basile, for the first part of the way along the course of the said stream. The first objects of interest I observed in the drinking-water supply were four natives washing themselves and their clothes; the next was the bloated body of a dead goat reposing in a pellucid pool. The path then left the course of the stream, but on arriving in the region of its source I found an interesting little colony of Spanish families which had been imported out whole, children and all, by the Government. They had a nice, neat little cemetery attached, which his excellency the doctor told me was "stocked mostly with children, who were always dying off from worms." Good, so far, for the drinking water! and as to what that beautiful stream was soaking up when it was round corners—I did not see it so I do not know—but I will be bound it was some abomination or another. But it’s no use talking, it's the same all along, Sierra Leone, Grain Coast, Ivory Coast, Gold Coast, Lagos, Rivers, Cameroon, Congo Français, Kacongo, Congo Belge, and Angola. When you ask your white friends how they can be so reckless about the water, which, as they know, is a decoction of the malarious earth, exposed night and day to the malarious air, they all up and say theirs is not; they have "got an awfully good filter, and they tell the boys," &c., and that they themselves often put wine or spirit in the water to kill the microbes. Vanity, vanity! At each and every place I know, men have died and worms have eaten them. The safest way of dealing with water I knew is to boil it hard for ten minutes at least, and then instantly pour it into a jar with a narrow neck, which plug up with a wad of fresh cotton-wool—not a cork; and should you object to the flat taste of boiled water, plunge into it a bit of red-hot iron, which will make it more agreeable in taste. Before boiling the water you can carefully filter it if you like. A good filter is a very fine thing for clearing drinking water of hippopotami, crocodiles, water snakes, catfish, &c., and I daresay it will stop back sixty per cent. of the live or dead African natives that may be in it; but if you think it is going to stop back the microbe of marsh fever—my good sir, you are mistaken. And remember that you must give up cold water, boiled or unboiled, altogether; for if you take the boiled or filtered water and put it into one of those water-coolers, and leave it hanging exposed to night air or day on the verandah, you might just as well save yourself the trouble of boiling it at all.
Next in danger to the diseases come the remedies for them. Let the new-comer remember, in dealing with quinine, calomel, arsenic, and spirits, that they are not castor sugar nor he a glass bottle, but let him use them all—the two first fairly frequently—not waiting for an attack of fever and then ladleing them into himself with a spoon. The third, arsenic—a drug much thought of by the French, who hold that if you establish an arsenic cachexia you do not get a malarial one—should not be taken except under a doctor's orders. Spirit is undoubtedly extremely valuable when, from causes beyond your control, you have got a chill. Remember always your life hangs on quinine, and that it is most important to keep the system sensitive to it, which you do not do if you keep on pouring in heavy doses of it for nothing and you make yourself deaf into the bargain. I have known people take sixty grains of quinine in a day for a bilious attack and turn it into a disease they only got through by the skin of their teeth; but the prophylactic action of quinine is its great one, as it only has power over malarial microbes at a certain state of their development,—the fully matured microbe it does not affect to any great degree—and therefore by taking it when in a malarious district, say, in a dose of five grains a day, you keep down the malaria which you are bound, even with every care, to get into your system. When you have got very chilled or over-tired, take an extra five grains with a little wine or spirit at any time, and when you know, by reason of aching head and limbs and a sensation of a stream of cold water down your back and an awful temper, that you are in for a fever, send for a doctor if you can. If, as generally happens, there is no doctor near to send for, take a compound calomel and colocynth pill, fifteen grains of quinine and a grain of opium, and go to bed wrapped up in the best blanket available. When safely there take lashings of hot tea or, what is better, a hot drink made from fresh lime-juice, strong and without sugar—fresh limes are almost always to be had—if not, bottled lime-juice does well. Then, in the hot stage, don't go fanning about, nor in the perspiring stage, for if you get a chill then you may turn a mild dose of fever into a fatal one. If, however, you keep conscientiously rolled in your blanket until the perspiring stage is well over, and stay in bed till the next morning, the chances are you will be all right, though a little shaky about the legs. You should continue the quinine, taking it in five-grain doses, up to fifteen to twenty grains a day for a week after any attack of fever, but you must omit the opium pill. The great thing in West Africa is to keep up your health to a good level; that will enable you to resist fever, and it is exceedingly difficult for most people to do this, because of the difficulty of getting exercise and good food. But do what you may it is almost certain you will get fever during a residence of more than six months on the Coast, and the chances are two to one on the Gold Coast that you will die of it. But, without precautions, you will probably have it within a fortnight of first landing, and your chances of surviving are almost nil. With precautions, in the Rivers and on the S.W. Coast your touch of fever may be a thing inferior in danger and discomfort to a bad cold in England.
Yet remember, before you elect to cast your lot in with the West Coasters, that 85 per cent. of them die of fever or return home with their health permanently wrecked. Also remember that there is no getting acclimatised to the Coast. There are, it is true, a few men out there who, although they have been resident in West Africa for years, have never had fever, but you can count them up on the fingers of one hand. There is another class who have been out for twelve months at a time, and have not had a touch of fever; these you want the fingers of your two hands to count, but no more. By far the largest class is the third, which is made up of those who have a slight dose of fever once a fortnight, and some day, apparently for no extra reason, get a heavy dose and die of it. A very considerable class is the fourth—those who die within a fortnight to a month of going ashore.
The fate of a man depends solely on his power of resisting the so-called malaria, not in his system becoming inured to it. The first class of men that I have cited have some unknown element in their constitutions that renders them immune. With the second class the power of resistance is great, and can be renewed from time to time by a spell home in a European climate. In the third class the state is that of cumulative poisoning; in the fourth of acute poisoning.
Let the new-comer who goes to the Coast take the most cheerful view of these statements and let him regard himself as preordained to be one of the two most favoured classes. Let him take every care short of getting frightened, which is as deadly as taking no care at all, and he may—I sincerely hope he will—survive; for a man who has got the grit in him to go and fight in West Africa for those things worth fighting for—duty, honour and gold—is a man whose death is a dead loss to his country.
The cargoes from West Africa truly may "wives and mithers maist despairing ca' them lives o'men." Yet grievous as is the price England pays for her West African possessions, to us who know the men who risk their lives and die for them, England gets a good equivalent value for it; for she is the greatest manufacturing country in the world, and as such requires markets. Nowadays she requires them more than new colonies. A colony drains annually thousands of the most enterprising and energetic of her children from her, leaving behind them their aged and incapable relations. Moreover, a colony gradually becomes a rival manufacturing centre to the mother country, whereas West Africa will remain for hundreds of years a region that will supply the manufacturer with his raw material, and take in exchange for it his manufactured articles, giving him a good margin of profit. And the holding of our West African markets drains annually a few score of men only—only too often fer ever—but the trade they carry on and develop there—a trade, according to Sir George Baden-Powell, of the annual value of nine millions sterling—enables thousands of men, women and children to remain safely in England, in comfort and pleasure, owing to the wages and profits arising from the manufacture and export of the articles used in that trade.
So I trust that those at home in England will give all honour to the men still working in West Africa, or rotting in the weed-grown, snake-infested cemeteries and the forest swamps—men whose battles have been fought out on lonely beaches far away from home and friends and often from another white man's help, sometimes with savages, but more often with a more deadly foe, with none of the anodyne to death and danger given by the companionship of hundreds of fellow soldiers in a fight with a foe you can see, but with a foe you can see only incarnate in the dreams of your delirium, which runs as a poison in burning veins and aching brain—the dread West Coast fever. And may England never again dream of forfeiting, or playing with, the conquests won for her by those heroes of commerce, the West Coast traders; for of them, as well as of such men as Sir Gerald Portal, truly it may be said—of such is the Kingdom of England.
- ↑ See also Klebs and Tommasi Crudeli, Arch. f. exp. Path., xi.; Ceci, ibid, xv.; Tommasi Crudeli, La malaria de Rome, Paris, 1881; Nuovi studj sulla natura della Malaria, Rome, 1881; "Malaria and the Ancient Drainage of the Roman Hills," Practitioner, ii., 1881; Instituzioni de anat, Path., vol. i,, Turin, 1882; Marchiafava e Cuboni Nuovi studj sulla natura della Malaria, Acad. dei Lincei, Jan. 2; 1881; Marchand, Virch. Arch., vol. lxxxviii.; Laveran, Nature parasitaire des accidents d'intpaludisme, Paris, 1881; Richard, Comptes Rendus, 1881; Steinberg, Rep. Nal. Board of Health (U.S.), 1881. Malaria-krankheiten, K. Schwalbe; Berlin, 1890; Parkes, On the Issue of a Spirit Ration in the Ashantee Canpaign, Churchill, 1875; Zumsden, Cyclopædia of Medicine; Ague, Dr. M. D. O'Connell Calcutta 1885.