this is subject to considerable variations, as will be seen from the
following table of 160 cases in which the duration was accurately
ascertained: Initial paroxysm lasted--2 days in 1 case; 3 days in 2
cases; 4 days in 10 cases; 5 days in 19 cases; 6 days in 40 cases; 7
days in 58 cases; 8 days in 18 cases; 9 days in 2 cases; 10 days in 5
cases; 11 days in 2 cases; 14 days in 2 cases; 15 days in 1 case; and
Parry, observing the same epidemic, found the duration of the first
paroxysm to vary from 4 to 11 days. It is, however, rare for the
duration to exceed ten days unless some complication be present.
{379} [Illustration: FIG. 20. Typical case of relapsing fever, with
three relapses, terminating in recovery. (From Motschutkoffsky)]
With the beginning of the crisis there is a prodigious and sudden fall
of temperature, unequalled in any other condition of disease. Within a
few hours it may fall six or eight degrees (going down at the rate of
1.5° or 2° an hour); and falls of 12°, 13°, or even 14.4° (Murchison),
in the course of twelve hours have been noted. In our own cases the
greatest {380} fall was from 107.2° to 95°, or 12.2°; and this is as
low a point as is usually reached, though temperatures of 94°, 93°, or
even 92°, have repeatedly been observed. Murchison refers to one case
in which collapse supervened, where the rectal temperature was 90.6°.
In nearly all of our cases a subnormal temperature occurred at the
crisis, and lasted for a day or two subsequently, when it gradually
rose and remained normal until the relapse, unless some transient
complication caused a temporary rise in the interval.
[Illustration: FIG. 21. Typical case of relapsing fever (Mary Collins,
aged 32), terminating in recovery. One relapse, with slight
post-critical rise of temperature.]
Occasionally, there is no relapse whatever, but convalescence follows
{381} the initial paroxysm. This occurred in 10 out of 181 of our
cases, and Murchison found that of 2425 cases reported by various
authors no relapses occurred in about 30 per cent. Carter describes
these under the name of the abortive form, and found them to
constitute 23.8 per cent. of all his cases. It is probable, however,
that in many cases so regarded either a relapse of very transient
duration has been overlooked, or else that an attack of ephemeral
fever has been regarded as of specific nature. In ordinary cases the
duration of the intermission averages six or seven days, but here,
again, considerable variation occurs. In 139 of our cases where its
duration could be accurately determined it was as follows:
3 days in 4 cases. 7 days in 64 cases. 11 days in 1 case.
4 " " 3 " 8 " " 22 " 12 " " 1 "
5 " " 12 " 9 " " 9 " 13 " " 1 "
6 " " 12 " 10 " " 9 " 20 " " 1 "
Despite these variations in the duration of the initial paroxysm and
of the first intermission, the average date of the occurrence of the
relapse in any large series of cases is about the twelfth day from the
primary chill.
The relapse is ushered in with the same striking abruptness as the
initial attack. The temperature again rises rapidly to 104° or 106°,
and then pursues a continuous course resembling ordinarily that of the
primary paroxysm. The difference between the maximum of the two
paroxysms is rarely more than 1.5° or 2°, though either may be much
milder than the other; as a rule, the highest temperature is attained
on the last or penultimate day of the first attack. The duration of
the relapse averages three or four days, though it may last but a few
hours or a single day, and yet exhibit a rise of 5°, 6°, or 7°; or, on
the other hand, it may be prolonged to six, seven, or even more days.
Lyons, observing the disease in the Crimea, reports some relapses as
having lasted twenty-one days, though it is improbable that a greater
duration than seven days occurs without the presence of some
complication. The relapse usually terminates by crisis, with an abrupt
fall to an abnormally low temperature; though we observed at this
time, much more frequently than at the close of the first paroxysm, a
gradual subsidence of fever, or lysis. Again the patient regains
strength and appetite, but in a considerable proportion of cases
subsequent relapses ensue. As a rule, the second, third, and later
relapses are attended with a febrile movement of shorter duration and
of less severity than the first two paroxysms, and are also separated
by intermissions of increasing length. Meschede[13] found from a study
of 360 cases that the average duration was for the first paroxysm six
or seven days; second paroxysm, four or five days; third paroxysm,
three or four days; fourth paroxysm, one or two days; fifth paroxysm,
one day.
[Footnote 13: _Loc. cit._]
In a remarkable case given in full at page 394, the duration of the
paroxysms and intermissions were as follows:
First paroxysm, 8 days; first intermission, 9 days.
Second " 5 " second " 1 "
Third " 1 " third " 6 "
Fourth " 6 " fourth " 8 "
Fifth " 5 " fifth " 9 "
Sixth " 4 " sixth " 10 "
Seventh " 3 " seventh " 11 "
Eighth " 3 " followed by convalescence.
{382} The proportion of cases in which more than a single relapse
occurs appears to vary in different epidemics. Murchison found that in
1500 cases reported by various authors a second relapse occurred 109
times (1 out of 14); a third relapse, 9 times (1 out of 166); and a
fourth relapse, once. Of 182 cases noted carefully by ourselves, a
second relapse occurred 24 times (1 out of 7-1/2); a third relapse, 5
times (1 out of 36); a fourth relapse, once; and in the
above-mentioned case six or seven relapses.
It follows that the total duration of the morbid process varies from
the average of about eighteen or twenty days, in cases with a single
relapse, to forty, sixty, or even ninety days. Of course the
occurrence of complications may lead to very great modifications of
the febrile movement and of the total duration of the disease.
There are several additional points about the febrile process
requiring mention. In all the paroxysms there is a greater tendency to
local or general perspirations than is met with in other continued
fevers, and occasionally there are rigors or slight chills about the
same hour on several days after the invasion or on the day preceding
the crisis. It has been noted also that, even when the temperature is
very high, the quality of the heat, as judged by the feeling of the
skin, is different from that in typhus fever, and that the peculiar
pungent irritating sensation known as calor mordax is rarely marked.
But a more important peculiarity is the fact that the extreme
temperatures (106°, 107°, or 108°) that are frequently observed in
relapsing fever for several days in succession do not appear to
involve any great increase of danger, and in particular are not
attended with the production of the grave nervous symptoms so often
met with in connection with hyperpyrexia in typhus and typhoid, and
often regarded as the direct result of the exalted temperature itself.
This striking fact is of much interest in its bearing on the theory of
hyperpyrexia, and may possibly be explained by some marked difference
in the conditions of heat-dispersion in these different diseases.
The pulse in relapsing fever is very rapid, and on the whole the rate
corresponds with the movement of the temperature. It usually rises
above 110, the limits being 90 and 140, the lower rate being noticed
in the milder and uncomplicated cases and in subjects of phlegmatic
constitution. The pulse rises rapidly at the invasion, and may reach
120 in the course of a few hours. Its maximum is usually noticed when
the temperature is highest, shortly before the crisis; and when this
actually begins the pulse may fall with a rapidity as remarkable as
that of the decline of the temperature. Thus, within twenty-four hours
it may fall from 152 to 80, or in even a shorter time from 140 to 54,
or even as low as 48 (Obermeier) or 44 (Muirheid), or even 30
(Stillé). While this great fall is often noted, it is by no means
constant. In our own cases it was frequently observed that the
critical fall in temperature was not accompanied by a commensurate
fall in pulse. Thus, at the close of a very severe initial paroxysm
lasting nine days the temperature was 107°, and fell in the course of
twenty-four hours to 99°, and in twenty-four hours more to 96°; during
the first day of this fall the pulse was from 96 to 100, and during
the second it fell to 76.
This want of correspondence was more marked at the close of the {383}
relapse than of the primary attack; thus, in a well-marked case, where
the maximum temperature (105.4°) occurred eighteen hours before the
crisis of relapse, the temperature fell in four hours from 104.4° to
96.2°, while the pulse, which was 130, fell in twelve hours to 108,
and in twelve more to 92. In another case, in a man aged twenty, the
temperature at the close of the second relapse was 106.4°, with a
pulse of only 100; after the crisis, as the temperature fell, the
pulse rose to 120, and did not descend until the end of twenty-four
hours; and later, at the close of thirty-six hours, the temperature
was 98° and the pulse 72, lower than which it did not go. Carter[14]
states that in the Bombay epidemic it was invariably the case that the
pulse did not decline to an extent corresponding with the temperature.
[Footnote 14: _Op. cit._, p. 140.]
During the remainder of the intermission the pulse may be normal, or
it may continue accelerated in consequence of some irritative
condition; as the time for the relapse approaches it frequently again
becomes abnormally slow. In either event it is found that any muscular
exertion causes marked acceleration of the pulse.
During the paroxysm the character of the pulse is full and bounding,
and there is considerable arterial tension. This is well shown in some
of the sphygmographic tracings by Carter;[15] while in one of our
tracings from the right radial of a man æt. 32, taken on the fourth
day of a severe initial paroxysm, the line of ascent is steep and the
summit sharp. During the crisis, and for a day or two thereafter, the
pulse may be weak, compressible, and dicrotic, and occasionally
irregular.
[Footnote 15: _Op. cit._, p. 103.]
The sounds of the heart and its impulse are weakened, except possibly
during the first few days of the primary paroxysm. Blood-murmurs over
the base of the heart and along the great vessels in relapsing fever
were first noticed by Stokes, and have been frequently observed in
subsequent epidemics. They were found in a large proportion of our
cases, not rarely in both paroxysms, and during the early stage of
convalescence when anæmia was marked; but during the intermissions
they are rarely audible, and when the action of the heart was slow
they were replaced by prolongation of the first sound.
It must be further noted that the pulse-rate is not a reliable
indication of the danger in this disease, since, just as is the case
with the hyperpyrexia, extreme rapidity of pulse may be present when
the general symptoms denote no unusual danger, and when the patient
ultimately recovers most satisfactorily.
There is a remarkable disproportion and dissimilarity between the
cerebral and peripheral nervous phenomena in relapsing fever and those
familiar to us in typhus and typhoid fevers. We have seen that
patients almost invariably complain of headache. When prodromes are
present it is commonly among them, and it may be the initial symptom
to usher in each paroxysm. When the attack is fully developed headache
is usually very severe, and no symptom is more bitterly complained of.
It varies in seat and character. More commonly it is frontal or
general; occasionally we found it occipital, and still more rarely it
was unilateral, constituting hemicrania. It rarely continues during
the relapse. Headache of an equally acute and violent character may be
present in typhoid, but the headache of typhus is much more dull and
contusive.
{384} The mental condition is only exceptionally affected, a
circumstance which greatly increases the patient's perception of his
sufferings. Delirium is not present in ordinary cases, even though
very severe and attended with hyperpyrexia; or if present is limited
to the period immediately preceding the crisis, when there may be
violent and noisy delirium of transient character. In some of our
cases forcible restraint was necessary under these circumstances.
There are numerous instances on record showing the abruptness with
which noisy, demonstrative, or even destructive delirium may appear,
and the equal suddenness with which in the course of a few hours, or
even of fifteen minutes, the patient may become rational and composed.
Such attacks resemble hysteroidal spells, and probably occur more
readily in patients of a nervous or hysterical temperament. They were
certainly more common when the patients had been of intemperate
habits; and, further, we had opportunities of noting that the
occurrence of relapses in habitual drunkards who had previously
suffered with delirium tremens was apt to develop a form of delirium
which was to all appearance of that nature.
Delirium of a different and much more grave type may appear in
connection with the symptoms of the typhoid state. In some cases this
results from the presence of serious complications which induce a
state of great prostration, while in others it is associated with
great diminution or entire suppression of urine. The delirium under
these circumstances is apt to be low and muttering, with a tendency to
pass into stupor or profound coma.
Vertigo is present more frequently and in a more persistent form than
in any other febrile disease. It was noticed as among the occasional
prodromes, and was especially severe for the first few days of the
initial paroxysm, though it often continued throughout this stage and
recurred with the relapse. Occasionally it was complained of in the
recumbent position, but usually it was excited only by a change of
position.
Wakefulness was one of the most distressing symptoms in all cases, and
appears to have been noted in all epidemics. Although the severity of
the pain in various parts of the body and the absence of blunting of
the perceptions would naturally cause much loss of sleep, the degree
of the insomnia and the obstinate resistance it offers to the action
of anodynes are apparently far in excess of what could thus be
accounted for. Parry found that several of his patients could take as
much as three grains of opium every second hour throughout the
afternoon and night without either inducing sleep or causing
contraction of the pupils.
Convulsions are rare and of very grave import. They may occur at the
period just preceding crisis, when the nervous irritation is most
intense, and are then somewhat less indicative of a fatal result than
if occurring in the course of the paroxysm, when they are apt to be
associated with extreme prostration of the nervous centres, with a
tendency to subsequent fatal coma. No connection has been observed
between their occurrence and the presence of albumen in the urine.
General tremor is rare, and was observed only in those of our cases
where there had been habitual intemperance, with presumably a tendency
to delirium tremens. Muscular rigidity was noticed occasionally, but
may have been only apparent, being induced by the hyperæsthesia and
{385} soreness which were marked in some cases. The hyperæsthesia
which was observed was both cutaneous and muscular, and was attended
with tenderness of the body of the muscle, and also of the nerve-trunk
supplying it. Meschede speaks of opisthotonos as a rare complication
in his cases.
Motor paralysis involving single muscles or groups of muscles is
occasionally noticed, as of the deltoid or of one arm (Meschede).
Parry observed transient loss of power of the extremities in several
cases, chiefly during the intermission or the period of convalescence.
In one of our cases temporary hemiplegia occurred, with partial loss
of sensation on the affected side.
The bladder and rectum are rarely affected, except in cases where the
typhoid state with tendency to coma is present. Disorders of sensation
are, however, much more common. When motor palsy occurs the affected
part may also be the seat of impaired sensibility, while in a large
proportion of all cases numbness of the extremities, with or without a
sense of tingling, is complained of; out of 182 cases we noted this
symptom in 94, affecting the fingers alone in 62, the feet alone in 6,
and all the extremities in 25 cases. Cutaneous hyperæsthesia or
partial anæsthesia are also occasionally observed. But the most
noteworthy and constant symptom of this class are the pains in the
muscles and joints which are bitterly complained of by nearly all
patients with relapsing fever. They constitute, indeed, one of the
highly characteristic features of the disease, and possess a
diagnostic value. They may occur among the rarely present prodromes,
but usually they appear with the chill and increase in intensity
during the paroxysm; they may persist with even greater severity
during the intermission, or, if they have then subsided, recur with
the relapse, and may constitute one of the most troublesome hindrances
to convalescence. It will thus be seen that in frequency, severity,
and persistency they differ widely from the aching pains in the
extremities complained of in typhus and other specific fevers. They
are one of the most potent causes of the extreme insomnia, and are apt
to dwell in the mind of the patient so vividly that he dreads each
relapse on this account, and consequently looks back upon his attack
of relapsing fever as a terribly painful experience. These pains are
usually described as rheumatic in character, and several times
patients presenting themselves at the hospital on the second or third
day of the initial paroxysm stated that they had inflammatory
rheumatism. As a fact, we observed the utmost intensity of these pains
in a few cases where the patients were of marked rheumatic diathesis.
The nape of the neck, the muscles of the trunk or extremities, or the
large or small joints, or lower parts of the spinal region, may be the
seat. At times they extend along the course of nerve-trunks. In
character they are described as a deep intense aching, with occasional
severe or excruciating, sharp, lancinating pains. Pressure or movement
increases them. The joints are not red or swollen (though swelling may
appear as a sequel), and the pains seemed to us rather to be referred
to the joints than to be caused by any local irritation therein. As
already stated, there is often tenderness of the body of the muscles,
and this was especially marked in many of our cases on pressure along
the course of the nerve-trunk.
Murchison suggests that they are due to the circulation in the blood
of an {386} abnormal substance, such as uric, lactic, or phosphoric
acid; but it appears to us altogether probable that they are rather to
be connected with states of congestive irritation of the sheaths of
the nerve-trunks (early stage of perineuritis), or possibly in some
cases of the spinal membranes also. It is true that they are sometimes
shifting in their seat and fluctuating in their severity, but this is
not inconsistent with the above suggestion, while the widespread
irritative processes found in this remarkable disease, the resemblance
of these pains and the frequently attendant numbness and tingling to
the sensations caused by other forms of perineuritis, and the
occasional development of local palsies of a single muscle or group of
muscles, all are in its support.
The special senses are acute, sometimes painfully so. The eyes are
watery and occasionally injected, but this latter condition is rare
and slight in relapsing as compared with typhus fever. At the crisis
and for a few days subsequently wide dilatation of the pupils is not
infrequently observed. Dulness of hearing was present during the
paroxysm in 14 of our cases, and a few patients complained of
tinnitus; but these symptoms are not at all common in the disease,
although it will be seen hereafter that affections of the middle ear
are among its sequelæ.
Debility is not such a prominent symptom as in typhus and typhoid
fevers. Patients manage to drag themselves about for several days
during the initial paroxysm with all the symptoms fully developed, and
after admission to the hospital will often be able to help themselves,
or even to rise from bed, unless prevented by the severe pains or the
vertigo. Still, there are many cases, not necessarily of very grave
type, in which there is a marked sense of weariness and exhaustion,
and of course in all cases of typhoid character the prostration is
great. It must constantly be borne in mind that even when the patient
feels or seems able to sit up he must on no account be permitted to do
so, since the occurrence of sudden and fatal syncope is one of the
accidents constantly to be apprehended. It is not only during the
pyrexia that this precaution must be enforced; we meet with extreme
debility during the intermission in some cases, and syncope has
followed exertions made at that period as well as at others.
During the paroxysms the respirations are much accelerated, at times
to a greater degree than would correspond with the pulse-rate, while
at others extreme rapidity of pulse may be associated with moderate
elevation of the rate of respirations.
As examples of the relation between temperature, pulse, and
respirations we quote the following from our records of adult cases:
(_a_) Temperature, 108°; pulse, 124; respiration, 40. In the relapse;
no chest trouble.
(_b_) Temperature, 107.5°; pulse, 120; respiration, 28; falling to
temperature, 96°; pulse, 68; respiration, 18, within twelve hours,
during which crisis occurred.
(_c_) Temperature, 107°; pulse, 144; respiration, 31. In the relapse.
(_d_) Temperature, 107°; pulse, 108; respiration, 44. Initial
paroxysm; no pulmonary congestion.
Temperature, 106°; pulse, 116; respiration, 28. Relapse; no pulmonary
congestion.
Temperature, 97°; pulse, 76; respiration, 24. Critical fall; cough,
{387} congestion of lungs posteriorly, and left one relatively dull on
percussion, but pneumonia did not develop.
In many epidemics bronchitis, hypostatic congestion, and pneumonia are
of rare occurrence, while in others, as in Philadelphia in 1870, they
are comparatively frequent and lead to serious respiratory symptoms.
While the pyrexia was high there was very frequently an irritative dry
cough, with the fine crepitant and subcrepitant râles attending
congestion and imperfect expansion of the lungs heard at the middle
and lower portions of the chest posteriorly. In numerous instances the
râles would disappear entirely after a few full inspirations in the
sitting posture, just as in the corresponding condition in typhoid
fever. But in a considerable proportion of all the cases (fully 35 per
cent.) there was more troublesome bronchial cough, associated with
sonorous, sibilant and subcrepitant râles, with mucous or
muco-purulent expectoration.
Bronchitis of this character was a source of serious annoyance to many
patients. In several cases there was impaired resonance at the lower
margins of the lungs posteriorly, with imperfect bronchial
respiration, but without the symptoms of fully-developed pneumonia.
Such conditions were regarded as due to hypostatic congestion, and
proved amenable to treatment. Pneumonia occurred in eleven cases out
of 200 recorded with reference to this complication. It will be more
fully discussed under the head of Complications. It was attended with
the usual physical signs, and gave rise to extremely rapid and labored
breathing, especially when associated with painful enlargement of the
liver and spleen. In a case of double pneumonia, with enlarged and
ruptured spleen, the respirations were from 80 to 90 for two days, the
pulse being 130 to 136. It was a very fatal complication, death
resulting in all but two instances.