the air expired during the pyrexia is diminished, the total quantity
exhaled is increased, the proportion being as 1.5 to 1 in the
non-febrile state.
[Footnote 16: "U. d. Resp. in Fieber," _Deutsch. Arch. f. klin. Med._,
1870, 536, quoted by Murchison.]
Elaborate investigations have been made of the condition of the urine
in relapsing fever by numerous observers, and in the Philadelphia
epidemic of 1870 we had the great advantage of being assisted by the
distinguished chemist, the late Horace B. Hare, who conducted an
extensive series of analyses in our cases. In a number of cases
quantitative analyses were continued daily throughout the entire
course of the disease.
As a rule, the quantity of the urine is comparatively free during the
febrile periods, very scanty at the time of crisis, except in the
cases where critical discharges of urine occur, and excessive for some
days after the crisis.
Still, there were not rare exceptions, especially to the first of
these statements. Thus on four successive days of the relapse of a
severe case with delirium, but without albumen, and which ultimately
recovered, the analysis gave--
Temperature. Amount in ccm. Sp. gr. Urea in Grm. Na. Cl.
103 400 1024 23.8 2.64
105 300 1025 15.27 1.95
106 500 1024 24.7 4.3
106 to 97 850 1021 24.735 5.525
{388} And in another severe case, also resulting in recovery, the
analysis was, for two days preceding the crisis of the initial
paroxysm--
Amount. Sp. gr. Urea. Na. Cl.
500 1014 12.9 Traces of albumen.
650 1014 15.85 1.365
After the crisis:
2250 1004 18.9 15.75 No albumen.
And again, in another case at the height of the initial paroxysm,
within twenty-four hours of the crisis, no vomiting, purging, or
epistaxis being present; temperature 105°; only 500 ccm. was passed of
dark reddish colored urine, non-albuminous, and with sp. gr. 1011.
In a fatal case there was total suppression of urine for three days,
the catheter drawing off only a few drops of almost pure liquid blood.
When crisis occurs by copious urination the discharges are frequent,
large, and of light color and low specific gravity.
The urine of the intermissions is of similar character, and for
several days after crisis it is not rare to have 2000 to 2500 ccm.
passed. The largest amounts we noted were in a man who recovered, and
who passed at the crisis of the relapse and during the following days
the amounts here given.
Amount. Sp. gr. Urea. Na. Cl.
1000 ccm. 1010 14.9 2.6
2000 " 1003 20.2 42.8
3550 " 1002 26.625 130.995
2600 " 1002 19.24 27.30
2800 " 1005 24.96 22.66
2500 " 1013 47.25 11.25
2700 " 1014 59.13 7.29
Carter reports a case where the patient continued for two weeks after
the relapse to pass 130 oz. of sp. gr. 1002.6.
The amount of urea varies considerably, and is evidently under the
influence of complicated conditions. The rule appears to be that it
increases during the paroxysms, diminishes during the crisis,
increases during the few days following crisis, and then falls off
again. These results are stated upon the authority of Murchison,
quoting from Pribram and Robitschek, Wyss and Bock, and others. Our
own observations, however, while agreeing in the main with these, show
that there are numerous and important exceptions, especially to the
occurrence of the post-febrile increase in the elimination of urea.
The largest amount of urea excreted in twenty-four hours by any of our
patients was 59.13 grammes, or 912 grains, on the sixth day after the
end of the relapse, but as much as 74 grammes (1142 grains) have been
found.
Deposits of urates were very common in the urine of the paroxysms and
of the crisis. The uric acid has been found increased, and so also
have the phosphates, crystals of which are frequently found mixed with
the urates.
The chlorides diminish during the paroxysms, until just before the
crisis their amount is very small, or they may even have disappeared.
Immediately after the crisis they reappear slowly or quickly, and even
{389} very large amounts may be discharged, as seen in the figures
given by Hare's analyses: 2.6 grm. on day of crisis, 42.8 grm. the
following day, and the enormous amount of 130.995 grm. on the next
day. A copious flow of urine corresponds with great augmentation in
the amount of the chlorides.
Bile-pigment was constantly present in jaundiced cases, the amount
being proportioned to the depth of the jaundice and the quantity of
the urine. Bile-acids have been detected (Carter and Schmidt), and
also leucin and tyrosin (Pribram and Robitschek).
Albumen, with or without tube-casts, is not uncommonly found, and
traces of sugar have been detected in a few cases. More careful
consideration will be given to these under the head of Complications.
The following appearance of the tongue has been repeatedly described,
and when present may be regarded as possessing some diagnostic value:
The body of the tongue slightly swollen, so as to show the impressions
of the teeth, and by the second day the central part of the dorsum
covered with a peculiarly white fur, while the edges and a small
triangular space at the tip are clean and red. Such a tongue was seen
in many cases at the beginning of the Philadelphia epidemic, but later
it was present in but a small proportion. We find it specially
mentioned in 97 of our recorded cases, or about 50 per cent., the
general description being given that it was moist, rather large, with
pink, clear edges, and a triangular clear space at the tip, and with
heavy white fur in the centre.
Some accurate observers, as Wyss and Bock, did not notice anything
peculiar about the tongue, but merely described it as moist and coated
with a thick white fur. The tongue often remains moist throughout the
case, the coat becoming yellowish, and later brownish. Of course if
there is nasal obstruction from epistaxis or catarrh, and the patient
breathes through the mouth, the tongue will soon become dry and brown;
but in addition, this state of the tongue with sordes on the teeth and
lips, appears in a small proportion of cases (3 per cent., Zuelzer; 12
per cent. of our own patients) in conjunction with grave typhoid
symptoms.
During the intermissions the tongue clears off quite rapidly, unless
marked gastric disturbance persists, but regains its former state as
soon as the relapse occurs.
In rare cases the tongue is red and glazed, and Parry and ourselves
observed peculiar painful cracks continuing obstinately after the
relapse. It is apparent, therefore, that the tongue presents evidences
of vitiated secretions, of local catarrh of the buccal mucous
membranes, and of the high grade of gastric irritation so constantly
attendant on this disease.
As a rule, there is complete anorexia during all of the febrile
paroxysm, while in the intermission the appetite soon returns, and is
sometimes truly ravenous. We did not, however, observe in any case a
voracious appetite during the febrile paroxysms, such as was very
often present during the London epidemic of 1843 and the Irish
epidemic of 1847, and is particularly mentioned by Murchison.[17]
[Footnote 17: _Op. cit._, p. 360.]
Thirst is constant and intense, and is excited not only by the high
temperature, but by the irritation of the stomach; it may continue
through {390} the intermission, when natural appetite and the power of
digesting solid food have returned.
Nausea and vomiting are always prominent symptoms, and most especially
so in children. In some cases nausea occurs among the prodromes; and
occasionally the attack is ushered in by profuse and uncontrollable
vomiting instead of by a chill, and the stomach continues entirely
non-retentive throughout the paroxysm. Vomiting is not usually so
obstinate and severe, however, and with extreme care in feeding and
medication it will often be allayed after two or three days. It
occasionally recurs profusely immediately before the crisis, as in the
case given in full at page 394, where after a violent attack of
vomiting the patient fell asleep, and awakened in a profuse sweat.
This symptom was present in 146 out of 182 of our cases, was usually
confined to the febrile stages, and was, as a rule, worse in the
initial paroxysm.
The matters vomited consist of the ingesta colored with bile, of
glairy mucus tinged with bile, or of green bile, sometimes in
considerable quantity. Small particles of blood may occasionally be
noticed in the matters vomited, and in rare instances true hematemesis
occurs. Judging from the frequency with which in fatal cases we find
ecchymoses of the gastric mucous membranes with blood-stained mucus in
the cavity of the stomach, we should expect black vomit to be more
often observed than is the case. Murchison (p. 361) states that it was
not noted in any British epidemic except that of 1843, and then it
occurred in only a few cases, although it seems to have varied in
frequency at different places. Arrott at that time described the
symptoms as "quite common" in the fever at Dundee; and W. Reid of
Glasgow recorded the case of a girl in the same epidemic who vomited
large quantities of clotted blood, and who also had hemorrhages from
the bowels and from the ears. It has occasionally been observed in the
continental epidemics. It was observed in four of our cases. By all
who have observed blood-vomiting in relapsing fever it is recognized
as a symptom of almost invariably fatal import. Three of the four
cases in which we observed it proved fatal, but one patient, who had
copious hematemesis, both at the close of the first relapse and during
the second relapse, recovered after a desperate and protracted
struggle.
The bowels are not so often constipated as in typhus, and it is not
rare for diarrhoea and constipation to alternate, or for the bowels to
be loose throughout the paroxysms. They are noted in 181 of our cases
as regular in 32, loose in 61, and constipated in 88 instances.
Meschede states that diarrhoea was present in nearly one-half the
cases of the Königsberg epidemic of 1879, though usually as a late
symptom, the early stage being marked by constipation, which in a few
cases persisted throughout. The stools may be consistent and dark or
thin and bilious, or occasionally, when gastric or intestinal
hemorrhage has occurred, they contain black coffee-ground matter.
Occasionally, the diarrhoea has a critical character, and occurs at
the close either of the initial paroxysm or of the relapse, though it
may not entirely substitute sweating. This mode of crisis occurred in
two of our cases, but Douglas observed it in 6 out of 33 cases.
The abdomen may appear enlarged, but this is as much the result of the
{391} enlargement of the liver and spleen as of gaseous distension,
which is rarely present in a high degree. Abdominal pain is almost
constant, and may be very severe. It is especially mentioned as having
been present in 148 out of 182 of our cases. It commonly extends
throughout the epigastrium and both hypochondria, but may be present
on one or the other side, while, on the other hand, there may be
general abdominal soreness. It is associated with tenderness on
pressure, which may be so great as to hinder the movements of the
trunk and to render the descent of the diaphragm in breathing painful.
This may be the first symptom to usher in the attack, and it occurs at
an early stage in most cases. Many of our patients when admitted to
the hospital had already been cupped or blistered over the region of
the liver or spleen. This distress was greatest in cases attended with
jaundice and marked gastric irritation; and Parry reports that in his
cases (occurring in the early part of the epidemic which we studied)
jaundice was rare (4 out of 37), and abdominal tenderness was not
present. It is not difficult to explain its almost universal presence
in view of the severe lesions of the substance of the liver and
spleen, the distension of their capsules from the acute swelling of
the organs, and the implication of the coats of the stomach.
Enlargement of the liver and spleen probably exists to a greater or
less degree in every case of relapsing fever without exception. This
statement is based on the concurrent testimony of accurate observers
in all epidemics and upon the evidence of post-mortem examinations.
The enlargement of the liver can be demonstrated in nearly all
instances by careful percussion. It varies greatly in its degree,
however; in mild cases it may be slight, while in severe ones the
liver may be found extending at least three inches below the margin of
the ribs within three or four days from the initial symptom. In our
own fatal cases the weight of the liver averaged between four and four
and a half pounds.
The spleen enlarges even more rapidly and to a greater degree than the
liver. In fact, its enlargement in relapsing fever is greater than in
any other acute disease. It may be detected by percussion by the first
or second day, and may then continue to rapidly increase until by the
fifth or sixth day a large painful mass is readily recognized by
palpation and percussion, or even by inspection. The organ often
weighs twelve or sixteen ounces, not rarely twenty to twenty-five,
and, as an instance of the extreme limit that may be reached, Küttner
reports sixty-eight ounces in one case. This enlargement is greatest
toward the close of the first or second paroxysm, and subsides quite
rapidly in most cases during the intermissions and as convalescence
progresses; we have, however, known a moderate degree of enlargement
of the spleen to persist for some weeks after the crisis of the last
paroxysm.
The occurrence of jaundice in a considerable proportion of cases of
relapsing fever is a clinical fact of much interest. Its frequency
varies greatly in different epidemics, and even at different stages of
the same epidemic. At times it is rarely met with (1 out of 14, 20, or
35 cases), while in other epidemics it is present in 1 out of every 6,
5, or even 4 cases. Of 182 of our own cases jaundice is recorded in
45, or exactly in 1 out of 4. According to our observation, it
occurred in a larger proportion of cases among negroes (14 out of 32)
than in whites, and {392} Stillé states that it occurred in nearly
every such case that came under his observation. When present it
usually occurs during the first paroxysm, and may be limited to that
stage; or, again, it may be present in each of three or four
successive paroxysms in the same case; or, finally, it may first
appear in the relapse. As a rule, it subsides speedily after the
crisis, though Carter states that in two or three cases the symptom
made its first appearance just after the crisis. It varied from the
slightest yellow tinge of the conjunctiva to the deepest staining of
the whole surface. The urine is discolored in proportion to the
intensity of the jaundice, and the serum of a blister will be deeply
tinged. It must be carefully noted, however, that the feces are not
decolorized, but, as already described, contain fully a normal amount
of biliary coloring matter. This fact has been relied on by Murchison
and others to prove that the jaundice in relapsing fever is purely
dependent on the morbid state of the blood, and is not due to
obstruction of the biliary passages; and we are prepared to admit that
the element of blood-dyscrasia may play a part in the production of
the jaundice. The anatomical evidence, however, given on page 414,
renders it probable that in many cases at least the essential cause is
to be sought in an obstructed state of the minute gall-ducts of
certain areas of the liver. If the main hepatic duct or the common
duct were obstructed, there would of course be paleness of the feces,
as the bile would be prevented from entering the duodenum. But when a
large amount of highly-colored bile is being secreted, as in relapsing
fever, it seems clear that the obstruction of a certain number of
minute ducts would cause sufficient resorption of the bile to induce
jaundice of varying degrees of intensity, while at the same time
allowing a flow of bile through the patulous ducts.
Jaundice must be regarded as an unfavorable or even a grave symptom in
relapsing fever, but not to the extent that would be the case were it
directly connected with the intensity of the blood-dyscrasia. Many of
the most violent cases in all epidemics have been unattended with
jaundice, while, on the other hand, many cases in which jaundice has
been marked "have had not a single symptom that made them differ from
ordinary cases excepting the yellowness" (Henderson). It follows,
therefore, that the gravity of a certain proportion of the jaundiced
cases does not follow directly from the presence of bile in the blood
and tissues, but from the lesions of the liver of which the jaundice
is a symptom, or from the existence of widespread irritation of many
parts of the body. Thus jaundice is present in an unusually large
proportion of the cases attended with marked enlargement and
tenderness of the liver and spleen, whether vomiting is also present
in extreme degree or not. It was noteworthy that it was
disproportionately frequent in negroes, and that in these patients the
lesions of the liver and spleen were also unusually pronounced. Again,
jaundice is present in an unusually large proportion of the cases
attended with low delirium, extreme prostration, defective secretion
of urine, and the other features of the typhoid state--so much so that
such cases have been described by various writers under the name of
bilious typhoid fever.
But, as already stated, it is not legitimate to consider the gravity
of these cases as the result of the jaundice, but rather that the
jaundice is merely a symptom of the widespread irritative lesions,
which in such {393} cases not only involve the liver and spleen, but
the kidneys, the lungs, the marrow of the bones, the muscle of the
heart, and occasionally the membranes or substance of the brain and
cord.
The true prognostic value of jaundice in relapsing fever would then
seem to be, that of itself it indicates merely an obstructed state of
a certain number of minute bile-ducts, but that its presence justifies
the apprehension that the local lesions of the liver may become
excessively developed, or that there is a tendency to widespread
tissue-changes which at a later stage of the disease may lead to the
appearance of grave constitutional disturbance of a typhoid type.
Hemorrhage in relapsing fever is not uncommon, and may occur from
various surfaces. Epistaxis is, however, the only form which is
frequent enough to justify being regarded as a symptom. It usually
occurs in from 5 to 15 per cent. of cases of relapsing fever, but in
the Philadelphia epidemic it was much more frequent than this,
occurring in not less than 83 out of 182 of our cases. It was not more
frequent or profuse in grave cases than in those of ordinary severity,
and consequently could not be regarded as a reliable indication of the
intensity of the blood-dyscrasia. Although ordinarily moderate in
amount, it was occasionally so copious and persistent as to require
prolonged plugging of the nostrils, and in at least one case
contributed chiefly to cause an intense anæmia, which long delayed
convalescence. It occurs at all periods of the paroxysms, but more
commonly toward the close. In fifteen of our cases extraordinarily
profuse epistaxis attended the crisis, and evidently replaced in part
the copious sweating by which the paroxysm more commonly terminates.
SYMPTOMS ATTENDING THE CRISIS.--We have already described the
aggravation of all the symptoms which immediately precedes the crisis
in typical cases of relapsing fever, and the abrupt fall of
temperature, and usually of the pulse, that follows. But this
extraordinary change is nearly always attended with some profuse
critical discharge, of which sweating is by far the most common,
though copious epistaxis, metrorrhagia, diarrhoea, or vomiting may
also occur, and to a greater or less degree, but seldom entirely,
replace the sweating. In 182 cases in which we carefully noted the
mode of termination of the paroxysm there was no definite crisis
(termination by lysis or gradual and irregular defervescence) in 76;
profuse sweating, 89; profuse epistaxis, 15; profuse diarrhoea, 2.
In most epidemics the proportion of true crises is greater than in the
above table--a fact dependent upon the unusually severe and
complicated form of the disease which we were studying. The beginning
of the sweat may be preceded by chilliness or rigors, by extreme and
dangerous prostration, or by violent nervous disturbances; or there
may be an attack of profuse vomiting, followed by sleep, during which
sweating begins. The sweat may be moderate in amount, but is often
extraordinarily copious; the patient is literally bathed in it, the
bed- and body-clothing is saturated, and we have seen the mattress
saturated. It has an acid reaction, but we do not know of any accurate
analyses of it. Some writers have attributed to it a characteristic
disagreeable odor, but we did not notice any in our cases that could
be considered peculiar to this disease.
CONVALESCENCE.--We have already stated the average duration of {394}
relapsing fever to be eighteen or twenty days, while the extreme
limits are from eighteen to ninety days. Despite the fact, however,
that the mortality is in most epidemics only about 5 or 7 per
cent.--greatly less, therefore, than in typhus fever--the
convalescence from relapsing fever is frequently slow and protracted.
The obvious cause is, just as in the case of typhoid fever, the
existence of numerous and serious lesions of the solids and the
tendency to many troublesome complications and sequelæ. We have,
however, seen many instances of rapid recovery of strength and health,
even after prolonged attacks with several successive relapses.
The following case is quoted partly on account of the numerous
relapses, and the long duration of the sickness: