A remarkable symptom unnoticed in any other fever is taken notice of by our author; viz. an affection of the testicles. “About the end of the second day the patient began to complain of a violent pain in these parts, accompanied with a contraction of the spermatic cord, and a drawing up of the testicles towards the abdominal ring. On examination they appear very much lessened in size, are drawn up considerably towards the abdomen, and the scrotum appears at the same time remarkably flaccid and empty. The surface of the scrotum becomes soon after very painful, and an excoriation takes place, chiefly at the most descending part, from which a considerable quantity of very offensive purulent matter issues: at the same time a similar discharge from the urethra takes place, which ceases with the disease when the event is favourable, or becomes ichorous and bloody, and insufferably fœtid when death is the consequence. In cases which terminate favourably, the whole of the scrotum, in a few days, is covered with a crust of hardened pus, which in the convalescent state, comes away very easily by means of a warm bath. The thickness of this coat may be about the fourth of a line; and, when separated, it much resembles moistened parchment. In fatal cases, this affection of the scrotum always terminates in gangrene a few hours before death.”
Another remarkable symptom is the change of voice to a shrill, soft and low sound when compared with the natural tone, at the same time that the syllables are more distinguished, and the words are strangely lengthened out in a drawling and whining manner. This change of voice affords a pretty certain prognostic; every alteration towards the natural tone being an almost certain sign of a favourable change, and the contrary if the voice becomes farther removed from it.
The pains felt in this fever were in a great measure peculiar to it, and seem to have been of a spasmodic nature. In the head the pain shot from the forehead, to which it was confined, invariably towards the bottom of the orbits, where it was generally exquisite. Sometimes it extended to the temples, where there was always a throbbing; but in no case did it extend to the back part, or over the whole head. This pain extended also to the balls of the eyes, which were protruded, and seemed ready to start from their orbits, with an inflammation externally, and a sensation of pain internally, rendering the admission of light intolerable. In the legs the pain had its seat at the top of the great tendon, immediately below the calf, and in the point where it was seated a gnawing sensation was felt, occasioning exquisite torture, with an involuntary contraction of the limb; so that, on the whole, our author concludes that this pain much resembles the cramp, differing only in being more permanent.
With regard to the pulse, our author observes, that in this disease “it never intermits. Even at the approach of death it has not intermitted, but has generally been remarkably tremulous, and so slow as to beat no more than thirty times in a minute. On the whole, it has not been found quicker than 130, or slower than 30, in a minute.” In violent cases the pulse was hard, quick and small, but sometimes full; and when it was so it was a good sign. It was however subject to excessive variations; and it frequently happened, “especially in the robust, that, after the first stage, flushing and chillness have often alternated in less than a minute; and that, although the skin felt considerably warm, the pulse has been no more than 52; but that, even when the low state came on, in which there was always a disagreeable coldness of the surface, it has been as quick, and nearly as full, as during the preceding febrile stage, although unaccompanied with thirst, or any other evident symptom of the existence of fever.”
In the state of delirium, Dr. Chisholm observes, that, whatever was the subject of the patient’s raving thoughts, he was always strongly under the impression of fear; and a word from the physician always reduced him to implicit obedience, however restless he might have been before. During this state he complained of no pain, even from blisters, nor was he sensible of the operation of laxative medicines. On being asked about his situation, he always answered that he was very well, and sensible of no pain, as in the yellow fever already described. It is observable, however, that the yellow colour, so remarkable in the former, seldom took place in the Boulam fever; but indeed this symptom, as has formerly been noticed, is by no means a characteristic either of the one disease or the other; but Dr. Chisholm observes “that in some protracted cases on shore, and in some among the sailors, which might have been a combination of the pestilential and yellow fevers, this symptom appeared about the 5th, 7th or 9th day.”
Besides the petechiæ and vibices, already mentioned, Dr. Chisholm takes notice of two other sorts of eruptions, which appeared about the lips: the one was such as frequently appears at the termination of the common remittents, and was favourable; the other resembling spots made by the fine black pencil of a painter, all round the mouth, but especially the upper lip, and certainly affording a fatal prognostic.
This disease was attended with a suppression of urine, a violent pain above the os pubis, a scalding in the urethra, a sense of fulness, without any visible swelling, a contraction and distortion of the penis; the urine generally of a deep red, sometimes brownish, green, very often bloody, and in a few cases much inclining to black, and of an oily consistence. Its smell was generally very offensive. All the excretions were exceedingly offensive, but the fæces most remarkably so towards the latter end of the disease; for in the beginning they had no remarkable fœtor. The sick were almost universally costive, which our author supposes to have arisen from a suspension of tone in the intestinal canal; for by exciting action in the fibres a large evacuation generally ensued. The colour of the fæces varied from yellow, or a yellowish white, to black; and from a considerable degree of thickness, to the exact appearance of coffee-grounds. The matter discharged by vomit also varied from porraceous to black, and resembling coffee badly boiled.
In this disease, as in the plague described by Thucydides, most other diseases degenerated into it, or partook of its nature. Dysenteries suddenly stopped, and were immediately succeeded by the symptoms of pestilential fever. A remarkable instance of this is given in twenty-seven recruits, who had been seized with dysentery, in consequence of being exposed to rain, receiving the infection in the hospital to which they were carried. The medicines exhibited with a view to cure the dysentery seemed to be attended with surprising effect; but in a short time symptoms of pestilential fever came on, even in a few hours after those of dysentery had disappeared. In like manner catarrhal complaints soon changed their nature. Convalescents from other diseases, such as laboured under chronical complaints, particularly rheumatism and inflammation of the liver, were particularly subject to it. “The puerperal fever became malignant, and of course fatal; and even among pregnant negro women, who might otherwise have had it in the usual mild degree peculiar to that description of people, many were reduced to a very dangerous situation by it. In short, every disease in which the patient was liable to infection, sooner or later assumed the appearance, and acquired the danger, of the pestilential fever.”
This fever was said to be propagated from Grenada to others of the West India islands, and to the United States, where in the same year, 1793, it raged with great violence in Philadelphia. Without entering into any inquiry at present concerning the truth of this report, or the origin of the fever itself, let us see whether from the symptoms enumerated by Dr. Rush, who hath written a very lengthy dissertation upon the disease, it was the same with the Boulam fever already described. According to him the fever in 1793 was frequently preceded by “costiveness, a dull pain in the right side, defect of appetite, flatulence, perverted taste, heat in the stomach, giddiness or pain in the head, a dull, watery, brilliant, yellow or red eye, dim and imperfect vision, hoarseness, or slight sore throat, low spirits, or unusual vivacity, a moisture on the hands, a disposition to sweat at nights, or after moderate exercise, or a sudden suppression of night sweats. . . . On entering a sick room the physician was first struck by the countenance of the patient. It was as much unlike that which is exhibited in the common bilious fever, as the face of a wild animal is unlike that of a domestic one. The eyes were sad, watery, and so inflamed in some cases as to resemble two balls of fire. Sometimes they had a most brilliant or ferocious appearance. The face was suffused with blood, or of a dusky colour, and the whole countenance was dusky and clouded. After the 10th of September, when the determination of blood to the brain became universal, there was a preternatural dilation of the pupil. Sighing attended in almost every case. The skin was dry, and frequently of its natural temperature. . . . The pulse at the beginning of the attack was sometimes full, tense and quick, but frequently weak; sometimes so low that it could not be perceived without pressing the wrists; and sometimes it had no preternatural quickness. In many it intermitted after the fourth or fifth, and sometimes after the fourteenth stroke. In some it was extremely slow; even as low as thirty strokes in a minute. The pulse was also tense and chorded. The slow intermitting pulse was observed more frequently in children than adults, and supposed to proceed from a collection of water in the brain. Impressed with this idea, I requested Mr. Coxe, one of my pupils, to assist me in examining the state of the eye. For two days we discovered no change in it; but on the third day after we began to inspect the eyes, we both perceived a preternatural dilatation of the pupils in different patients; and we seldom afterwards saw an eye in which it was wanting. In Dr. Say it was attended with squinting, a symptom which marks a high degree of a morbid affection of the brain. Had this slowness or intermission of the pulse occurred only after signs of inflammation or congestion had appeared in the brain, I should have supposed that it had been derived wholly from that cause; but I well recollect having felt it several days before I could discover the least change in the pupil of the eye. I am forced therefore to call in the operation of another cause, to assist in accounting for this state of the pulse, and this I take to be a spasmodic affection, accompanied with preternatural dilatation or contraction of the heart. Lieutaud mentions this species of pulse in several places, as occurring with an undue enlargement of this muscle. Dr. Ferriar describes a case, in which a low, irregular, intermitting and hardly perceptible pulse attended a morbid dilatation of the heart. . . . After the 10th of September this undescribable or sulky pulse became less observable, and, in proportion as the weather cooled, it disappeared. It was gradually succeeded by a pulse full, tense, quick, and as frequent as in pleurisy or rheumatism. It differed, however, from a pleuritic or rheumatic pulse, in imparting a very different sensation to the fingers. No two strokes seemed to be exactly alike. Its action was of a hobbling nature. . . . It was an alarming symptom. . . . The pulse most frequently lessened in its fulness, and became gradually weak, frequent and imperceptible before death; but I met with several cases in which it was full, active, and even tense, in the last hours of life.
“Hæmorrhages occurred in the beginning of the disorder, chiefly from the nose and uterus. Sometimes only a few drops of blood distilled from the nose. As the disease advanced, the discharges of blood became universal. They occurred from the gums, ears, stomach, bowels, and urinary passages. Drops of blood issued from the inner canthus of the left eye of Mr. Josiah Coates. Dr. Woodhouse attended a lady who bled from the holes of her ears which had been made for ear-rings. Many bled from the orifices which had been made in performing venesection, several days after they appeared to have been healed; and some from wounds in veins made in unsuccessful attempts to draw blood. These last were very troublesome, and in some cases precipitated death. . . .