Thus the fever goes on during its first stage, which constitutes the inflammatory period, and continues from twenty-four to sixty hours. The second, which our author calls the metaptosis, is comparatively mild, and is an intermediate state between the inflammatory and gangrenous stages. In this there is an abatement of many of the former symptoms, and a kind of deceitful tranquillity, accompanied, however, with a perturbation, if the patient should happen to sleep. There now appears a yellow tinge in the eyes, neck and breast; the heat subsides, sometimes accompanied with chillness, but never with that kind of rigor, which, when it happens, terminates the disease by sweat, or by copious bilious evacuations, upwards or downwards. The retchings increase and become porraceous: the pulse flags, but is sometimes high, and sometimes soft; the skin moist and clammy; urine of a dark saffron colour, and in small quantity; the tongue in some cases is dry, hard, and discoloured, in others furred and moist; the head is confused, sometimes with delirium, with a glossiness of the eyes. This stage of the disease continues sometimes only for a few hours, at others from twelve to forty-eight, seldom longer, and too frequently the disease hurries on rapidly from the first to the third stage, which is the gangrenous or fatal state. Now the pulse sinks, intermits, and becomes unequal, sometimes very quick; the vomiting becomes frequent with great straining and noise. The matter discharged is now in greater quantity, appearing like the grounds of coffee, or of a slate colour, and the stomach can retain nothing: the breathing is difficult, the tongue black, the sweats cold and clammy, the eyes yellow and sunk; there is a yellowness round the mouth and temples, and soon after over the whole body. The deepening of the yellow colour, with an aggravation of the other symptoms, is a forerunner of death. There is a deep respiration, subsultus tendinum, a convulsive kind of sighing; the urine is quite black, and sometimes totally suppressed. There is a death-like coldness of the hands, feet and legs, while the heat still remains about the stomach; the patient is delirious, and struggles to get up in bed; he trembles, his speech falters; blood oozes from the mouth and nostrils, sometimes from the corners of the eyes and ears; a black bloody cruor is discharged both by vomit and stool: livid spots appear on different parts of the body, particularly the præcordia; hiccup, muttering, coma, and death, follow in quick succession.
The affecting case of capt. Mawhood, who died on the fourth day of the disease, at Port-Royal in Jamaica, in the year 1780, exhibits a dreadful picture of this disease in its last stage. “When I entered the room, (says Dr. Moseley) he was vomiting a black, bloody cruor, and he was bleeding at the nose. A bloody ichor was oozing from the corners of his eyes, and from his mouth and gums. His face was besmeared with blood, and with the dullness of his eyes it presented a most distressing contrast to his natural visage. His abdomen was swelled and inflated most prodigiously. His body was all over of a deep yellow, interspersed with livid spots. His hands and feet were of a livid hue. Every part of him was cold, excepting about his heart. He had a deep, strong hiccup, but neither delirium nor coma; and was, at my first seeing him, as I thought, in his perfect senses. He looked at the changed appearance of his skin, and expressed, though he could not speak, by his sad countenance, that he knew life was soon to yield up her citadel, now abandoning the rest of his body. Exhausted with vomiting, he was at last suffocated with the blood he was endeavouring to bring up, and expired.”
The symptoms just now enumerated generally take place in those who die from the third to the seventh day of the disease. But in this, as in other fevers, the symptoms vary considerably according to the constitution of the patient, and habit of the body. In some it begins neither with chillness, faintness, nor flushings of the face. Sometimes the pulse is much depressed and not quick; and in sultry weather, and damp situations, where the inflammatory state has been only of a few hours duration, the metaptosis has been so rapid, that the black vomiting and the mortified state have unexpectedly appeared, and have ended the patient in 24, 36 or 48 hours. But our author says that he never saw or heard of an instance of what Lind says, that the black vomit may attack a man when newly arrived, without any previous complaint; or of that mentioned by the same author, viz. “an uneasy itching sensation, commonly in the legs; and upon pulling down the stockings, streams of thin-dissolved blood followed, and a ghastly yellow colour quickly diffused itself all over the body.”
In some cases the disease is much more mild. There are instances where it has been protracted to the eighth, ninth or tenth day; and others where it has never passed from the inflammatory stage; but being checked, though not extinguished, it has been lengthened out, and at last converted into a remittent of great duration, most difficult of cure, and tedious of recovery.
According to our author, the stomach seems to bear the principal burden of the disease, and accordingly, after death, appears to have been principally affected. Great heat is perceived near the præcordia during all the stages of the disease, and pain and uneasiness are complained of when those parts are pressed with the hand. After death, livid spots appear over the whole body, particularly about the præcordia. On dissection, the stomach, in some part or other, is generally found mortified, especially if the black vomiting has continued long, and the livid spots have appeared before death. Frequently the upper part of the duodenum is in a gangrenous state, and always bears the marks of inflammation, lest the disease have been of ever so short a duration.
Though both liver and gall-bladder must be very much affected in this disease, yet Dr. Moseley is of opinion that nothing can be depended upon from an inspection of them after death. Some symptoms there are in common with inflammations of the liver, but none of those which distinguish it from other diseases. It never terminates in suppuration of the liver as the hepatitis sometimes does, though it is frequently carried off by an enormous secretion of bile. “Dissections (says the Doctor) have never discovered any certain and uniform appearance in the liver of those who have died of this disease. In hot climates a sound state of the liver is never to be expected after death, whether the disease has been acute or chronical. Of the latter class of diseases it is almost always either the seat, or the origin.”
Dr. Lining, in a letter to Dr. Whytt at Edinburgh, published in the Physical and Literary Essays, defines the disease, to be “that fever, which continues two or three days, and terminates without any critical discharge by sweat, urine, stool, &c. leaving the patient excessively weak, with a small pulse, easily depressible by very little motion, or by an erect posture; and which is soon succeeded by an icteritious (jaundice) colour in the white of the eyes and the skin; vomiting, hæmorrhages, &c. and those without being accompanied with any degree of a febrile pulse and heat.”
In the four times in which he mentions it to have been epidemic at Charleston, our author says, that none of the years (excepting 1739, the summer and autumn of which had been remarkably rainy) were either warmer or more rainy (and some of them less so) than the summers and autumns were in several other years in which there was not one instance of any one being seized with it. The subjects were whites of both sexes, especially strangers lately arrived from cold climates, Indians, Mistees, Mulattoes of all ages, excepting young children, and of those only such as had formerly escaped the infection. Negroes were not liable to it.
Those affected with the fever, for a day or two previous to the attack generally complained of head-ach, pain in the loins and extremities, but principally in the knees and legs, debility and lassitude; but some were taken ill suddenly without any warning. The symptoms were, shivering; frequent, full, hard and strong pulse; though sometimes small and hard, and in others soft and small; but towards the end of the fever it became smaller, harder, and less frequent. Sometimes there was a remarkable throbbing in the hypochondria and carotids, the former causing in some a tremulous motion of the whole abdomen. The heat was about 102 of Fahrenheit, and nearly equal over the whole body; some had frequent returns of chilliness without any diminution of temperature of the body. “In a few there happened so great a remission of the heat for some hours, when at the same time the pulse was soft and less frequent, and the skin moist, that one from these circumstances might reasonably have hoped that the fever would only prove a remittent or intermittent. About the end of the second day the heat began to abate.” Here Dr. Moseley takes notice that when the fever abates, some, who have mistaken the bilious remittent for the causus, speak of remissions which do not happen in this fever. “This circumstance of the endemial causus (says he) I believe, has never been mentioned before.”
Dr. Lining goes on to inform us, that the skin was rarely dry in this disease, there being generally a propensity to sweat. “On the first day the sweating was commonly profuse and general, on the second it was more moderate; but on both those, there happened frequent and short remissions of the sweatings, at which times the febrile heat increased, and the patient became more uneasy. On the third day the disposition to sweat was so much abated that the skin was generally dry; only the forehead and backs of the hands continued moist.” A great despondency and prostration of strength took place from the first attack. On the first day they generally dozed much, but were afterwards very watchful. On the second day the pains in the head, loins, &c. of which they had complained before the attack, and which were sometimes very acute in the forehead, generally went off. Many on the first day were a little delirious, but afterwards not until the recess of the fever.