relapsing fever in the wards of the Philadelphia Hospital during the
spring of 1870, and in May had an attack apparently of this disease,
which, however, subsided in four or five days and was followed by no
immediate relapse. He continued his attendance at the hospital during
the remainder of May and the whole of June; in July took a trip to the
South, where there was no relapsing fever prevailing, and after
exerting himself for several days during intensely hot weather, he
became sleepless and much prostrated. He returned home, and after
recovering from the fatigue felt quite well for about a week, until 3
A.M., August 1st, when he was attacked with a severe chill, followed
by great insomnia, obstinate vomiting, intense headache, especially in
the back of the neck, occasional sweating, violent fever, recurrence
of very severe chill the following day at 11 A.M., epigastric and
hypochondriac tenderness, decided jaundice, costive bowels, and
scanty, high-colored urine. This paroxysm lasted till the morning of
August 9th, when severe vomiting took place, followed by sleep, during
which crisis occurred by drenching sweat lasting several hours.
Appetite and strength soon began to return, though some jaundice
persisted, and by August 17th he felt able to drive out a short
distance, and retired feeling somewhat fatigued. He awoke with pain in
the back of the neck, which continued increasing till 11 A.M., August
18th (second paroxysm), when a severe chill occurred, lasting three
hours and followed by the same train of symptoms, including jaundice,
which persisted five days, till Aug. 23d, when crisis again occurred
by sweating. On the 24th he felt well enough to use slight exercise,
which was followed by prostration and by a return of chill (third
paroxysm) the next day at 11 A.M., with subsequent headache, fever,
irregular sweats, etc., lasting but one day. Again felt well until
Aug. 30th, when he was attacked (fourth paroxysm) at 11 A.M. with
severe chill, lasting three hours, followed by severe paroxysm,
lasting six days, till Sept. 5th, when crisis again occurred by
sweating. Again felt well for eight days, until Sept. 13th, when the
fifth paroxysm occurred, lasting five days, ending Sept. 18th by
critical sweating. This was followed by an intermission of nine days,
until Sept. 27th, at 11 A.M., when the sixth paroxysm occurred,
lasting four days, and less severe than the preceding ones. This was
followed by an intermission of ten days, till Oct. 11th, when the
seventh paroxysm occurred at the same hour of the day, and lasted
three days. He then went sixty miles from home to a fine, pine-bearing
district, and enjoyed an intermission of eleven days, when the eighth
and {395} last paroxysm occurred at the same hour, and lasted three
days, until Oct. 25th. His convalescence was very satisfactory, and he
was enabled to resume his studies by the middle of November. No
sequelæ occurred. In 1878 Dr. Y., who had been working very steadily
with a rapidly-growing practice, was attacked with severe typhoid
fever, with grave nervous symptoms and with albumen and tube-casts in
the urine, and died on the twelfth day.
It will thus be seen that in this unusually protracted case there were
seven distinct relapses, one of which was brief and interrupted one of
the regular intermissions, while the rest were all severe.
Duration of
1st paroxysm, violent, 8 days. 1st intermission, 9 days.
2d " violent, 5 " 2d " 1 day.
3d " less violent, 1 day. 3d " 6 days.
4th " severe, 6 days. 4th " 8 "
5th " severe, 5 " 5th " 9 "
6th " less severe, 4 " 6th " 10 "
7th " less severe, 3 " 7th " 11 days,
8th " mild, 3 " followed by convalescence.
The total duration of the case, which was entirely free from
complications, was therefore ninety days.
VARIETIES.--The foregoing clinical description prepares us to
appreciate the varieties of relapsing fever that may be said to exist.
They consist of--
The abortive form, in which a single paroxysm of variable length and
severity occurs, terminating in a critical fall of temperature and
usually with some critical discharge, but not followed by any relapse.
There can be no doubt of the existence of such cases, although they
are not common; and at times the paroxysm is so slight that were it
not for the known exposure of the individual to the prevalent epidemic
influence, in the absence of any other adequate cause, the case might
readily be regarded as one of non-specific febricula. The caution
must, however, be borne in mind as to the occurrence of relapses of
such extreme shortness of duration (less even than twenty-four hours)
as to readily escape notice unless a careful watch be kept for their
detection.
The ordinary or typical form, including the cases with one or two
relapses, presenting the usual variations in the severity of the
symptoms and in the duration of the paroxysms and of the
intermissions.
The multiple or protracted form, if it be thought desirable to thus
particularize cases presenting an excessive and unusual number of
relapses, as three, four, five, six, or even seven.
The grave or subintrant form, which is designed to include the highly
congestive form of Cormack and the bilious typhoid of Griesinger and
Lebert.
Under another heading (see relations to other diseases, p. 420) we
shall give reasons for regarding the bilious typhoid fever of
Griesinger and Lebert as merely a form of relapsing fever, with which
a certain proportion of cases of true typhoid fever complicated with
hepatic catarrh may have been included.
The characteristics of this grave subintrant form are as follows:
Jaundice, occasionally absent, but usually present in an intense
degree; marked enlargement of the liver and spleen; a tendency to
hemorrhage from various mucous surfaces; extreme prostration;
defective or suppressed {396} secretion of urine; hypostatic
congestion or inflammation of the lungs in a large proportion of
cases; dry brownish tongue; low muttering delirium, often passing into
stupor or coma; hiccough; imperfect crisis; and a continuance of some
morbid phenomena, so that merely a remission occurs to separate the
paroxysms; and a high percentage of mortality. The great modification
of the intermission which is so highly characteristic of typhoid
relapsing fever is doubtless due in chief part to the serious local
lesions developed, and seems to justify the name of subintrant as
above suggested. The course of such fever is well illustrated by the
following case, in which the characters of typhoid relapsing fever
were present in the highest degree, death occurring on the fifteenth
day:
Charles Hood, colored, æt. 28, of temperate habits, was taken ill on
April 5, 1870, after malaise lasting thirty-six hours, with fever,
nausea and vomiting, headache, and general aching throughout body; and
was admitted to the hospital April 6th. There was already marked
jaundice, and epistaxis had occurred; there were also insomnia;
wandering delirium; extreme tenderness over the liver and spleen, both
of which were enlarged; dryness of tongue, vomiting, and distension of
the abdomen. These symptoms continued, his condition becoming daily
more aggravated. Restless delirium alternated with heavy sopor. The
jaundice grew deeper. Marked digital formication existed, but the
arthritic pains were not so severe as in ordinary cases. The tongue
was dry and of a red orange color. Profuse epistaxis occurred on the
seventh day of the disease, requiring plugging of both anterior and
posterior nares, and followed by great prostration. A gradual fall in
the temperature occurred during the sixth, seventh, and eighth days,
reaching 99° on the latter day. During this decline the delirium
ceased and the mind remained merely dull; the jaundice decreased, as
did also the tenderness of the hypochondriac zone. The pulse and
respirations improved, and diarrhoea ceased. The improvement was but
brief; for about eighteen hours he lay apyretic, with cool hands and
feet, and with eyes closed and mind dull but free from delirium. Fever
then reappeared and with the ascent of the temperature the unfavorable
symptoms recurred. The relapse lasted but two days, and was followed
by irregular decline of fever till death occurred on the fifteenth day
of the disease. Obstinate hiccough appeared on the eleventh day, and
continued, accompanied with occasional vomiting on the fourteenth day.
Delirium alternating with sopor reappeared. Jaundice again became
marked, and again there was extreme tenderness over the liver and
spleen. The pulse grew small and feeble, the respirations shallow and
labored, with an expiratory moan. Cough began on the twelfth day, and
was soon followed by the physical signs of pneumonia of the lower lobe
of both lungs. The urine continued free from albumen. The patient sank
into deeper coma, and died on the fifteenth day. Post-mortem
examination showed highly-developed characteristic lesions of the
spleen and liver, with red hepatization of lower lobe of both lungs.
There was no affection of the glands of Peyer. The course of the fever
is shown in the following tracing (see Fig. 22).
[Illustration: FIG. 22. From a case of the bilious typhoid or grave
subintrant form of relapsing fever.]
COMPLICATIONS AND SEQUELÆ.--As would be anticipated from what has been
said of the wide range of the symptoms and of the remarkable course of
the temperature in relapsing fever, there are many complications and
sequelæ liable to occur, and which require special consideration.
{397} They may be classified according as they affect the febrile
movement, the state of the blood, or one or other of the groups of
organs.
We have already described the various irregularities presented by the
febrile paroxysms and the intermissions, and no further allusion need
be made to mere variations in length, severity, or number of the
former. In rare cases, however, a peculiarity is presented, usually in
the first intermission, which is difficult of explanation. About
twenty-four hours after an apparently complete crisis, with a fall of
temperature to a subnormal point, there may be a sudden and rapid rise
or rebound of temperature to 104° or 105°, attended with distressing
symptoms of high fever, but lasting only twenty-four or forty-eight
hours. A good example of this is given in the case described on page
394; and Carter[18] cites several examples of it terminating either in
recovery or in rapid death. He asserts that examinations of the blood
during such post-critical febrile rebounds invariably showed an
absence of spirilla, so that in his opinion such fever must be
considered non-specific. Their explanation seems difficult, since the
pyrexia is too brief to be associated with any local inflammatory
complication.
[Footnote 18: _Op. cit._, p. 172.]
More frequent and serious is the protracted post-critical pyrexia
which we have already described as modifying the interval, so as to
produce a subintrant type by maintaining continuous though irregular
fever until the accession of the relapse, unless cut short by death.
This post-critical fever is non-specific, is unattended with spirilla
in the blood, and is to be associated with the extensive irritative
processes in the liver, spleen, kidneys, lungs, and other parts that
are present in these grave and {398} complicated cases. It is to be
noted that the course of those paroxysms which terminate in lysis
indicates that they may represent a milder type of the above process.
The peculiarities of the delirium, amounting sometimes to maniacal
excitement, which attends some cases of relapsing fever, has been
fully described.
Less common are the following: mental hebetude, lasting some days or
even weeks after the close of the last paroxysm, or, as in a case of
Carter's, gradually increasing mental feebleness, terminating in
imbecility. In such cases suspicion must arise of the occurrence of
some local lesion of the membranes or substance of the brain.
Partial palsy is mentioned by numerous authors as occurring during or
shortly after attacks of relapsing fever. Paralysis of one or both
deltoids has been noted, the latter by Cormack, who saw it continue
ten days after the patient was well in all other respects. Temporary
paralysis of the forearm (Douglas) or of the whole arm (Parry,
Meschede) has been observed; and Parry also describes loss of power in
the legs lasting for one week. In one of our cases temporary loss of
power of the left arm and leg occurred, attended with such impairment
of sensibility that the woman had to feel for the fingers of the left
hand to assure herself of their existence. This loss of power occurred
during the initial paroxysm, and gradually passed away, but she was
unable to stand alone on the thirty-first day of the disease. In a
case reported by Tennent[19] facial palsy was developed six days after
the second crisis.
[Footnote 19: _Glasgow Med. Jour._, May, 1871, p. 379.]
Various explanations have been offered for these local palsies, but,
as already stated (see page 386), it seems probable that they are
referable to morbid conditions of the nerve-trunks, or, less commonly,
of the spinal cord. It must be noted, however, that in a certain
number of autopsies serious intracranial lesions are found, which are
evidently the results of the attack of relapsing fever. These consist
of abscess of the brain, meningitis, and specially cerebral
hemorrhage. This was present in one of our cases, but Carter found
copious hemorrhage in no less than 8 out of 54 autopsies, and in 5
others there were minute capillary cerebral hemorrhages. Still, in
nearly all the cases of large hemorrhage we have found recorded the
effusion was upon the surface of the brain, and this, combined with
the absence of true hemiplegia from the forms of paralysis noted in
relapsing fever, and the transient character of these palsies, makes
it clear that they are not to be explained by any considerable
cerebral hemorrhage. On the other hand, however, it must be admitted
that an additional possible cause of them is to be found in minute
hemorrhage into small areas known to govern the movements of certain
groups of muscles. Again, we have had occasion to note the occurrence
of both thrombosis and embolism among the lesions of relapsing fever,
and it is evident that either of these accidents, if involving a
comparatively small branch of a cerebral vessel in certain motor
areas, might cause transient paralysis, such as has been described.
Nor can we fail to see that, while such symptoms as the delirium,
mania, coma, or subsequent mental impairment may receive other
explanations, it is possible that they may arise from similar
processes of minute hemorrhage, thrombosis, or embolism involving
other parts of the brain.
{399} The frequent occurrence of severe rheumatic pains in the muscles
and joints during the course of the disease has been dwelt upon (p.
385); but in some cases they persisted during the intermissions and
for a considerable time after all other symptoms of disease had passed
away. Occasionally they greatly retarded convalescence by interfering
with exercise and sleep. These pains were mostly in the legs, and were
increased by exercise, and also seemed to be influenced by changes of
weather. Patients who suffered thus were also liable, after exposure
or in consequence of severe atmospheric changes, to sharp attacks of
similar pains elsewhere, and especially in the course of the
intercostal nerves. Occasionally violent and persistent headache
follows the disease, not improbably associated with changes in the
membranes of the brain, although in other cases severe neuralgia
occurs in consequence of the anæmia which may remain in an intense
degree after the fever. Troublesome numbness and soreness of the soles
of the feet and of the palms of the hands, increased by pressure, has
been noted as a sequel persisting for several days or weeks.
Affections of the special senses are not rare. The most remarkable
among these is the affection of the eyes, which is apt to occur far
more frequently in connection with relapsing fever than with typhus or
typhoid. The proportion of cases in which this sequel appears varies
greatly in different epidemics. In the British epidemics of 1826 and
1843, when this form of post-febrile ophthalmia was first accurately
described by Mackenzie of Glasgow, it was very frequent; and it was
equally so in Finland in 1867-68, when Estlander[20] again carefully
studied it.
[Footnote 20: "U. Choroiditis nach Febris Recurrens," _Arch. f.
Ophth._, 1869, Bd. xv., Abth. ii., 108.]
On the other hand, so far as can be stated in regard to a sequel which
may appear after convalescence is far advanced and the patient
discharged from medical care, it was very uncommon in the Philadelphia
epidemic of 1869-70. This ophthalmia may occur during the course of
the fever, but more frequently it begins during convalescence, and
even some months after convalescence has been established. It occurs
in patients of both sexes and at all ages. Usually it affects but one
eye, but both may be attacked simultaneously or consecutively.
Patients who were very ill-nourished and debilitated were most apt to
present this sequel, and Murchison regards previous starvation as one
of its main causes. The exciting cause and true pathology appear
obscure as yet, however, and the existence of a neural origin is not
improbable. In some cases the ophthalmia has seemed to result directly
from exposure to cold. Among our own patients, as already stated, eye
symptoms were less common and severe. A careful record of 184 cases
was kept in reference to this question. Several patients complained of
diplopia during the febrile stage, and one asserted that every object
appeared fourfold to him. Conjunctivitis of moderate severity, usually
associated with otorrhoea, occurred in about 5 per cent. of our cases;
it generally affected only one eye, and occurred in a few instances as
late as the third week after the relapse. In a few cases (four) also
there was dulness of vision in one eye, noted during the course of the
disease and persisting for some time after convalescence began. In
only one instance, however, did permanent impairment of vision ensue,
and this man had passed through a violent attack of the fever with
unusually grave nervous symptoms. {400} It left him with optic
neuritis on the right side, which induced partial atrophy of the nerve
and great limitation of the field of vision. Meschede reports
intraocular affections in 6 cases out of 180 specially examined,
though it is not certain that such affections were directly connected
with the febrile process. Ocular ecchymosis occurs in a small
proportion of cases, especially of the graver types.
Dulness of hearing is not so common in relapsing fever as it is in
typhoid. It was present in 14 out of 184 of our cases during the
course of the disease, and in a few instances partial or almost
complete deafness in one ear persisted after convalescence, owing
doubtless to a slight affection of the middle ear. In one case marked
deafness appeared suddenly on the day after the termination of the
relapse by crisis. Meschede[21] found disease of the middle ear in no
less than 8 per cent. of his cases.
[Footnote 21: _Loc. cit._]
Purulent otorrhoea from one or both ears is of more frequent
occurrence, and without any special exciting cause may present itself
at any time during the course of the disease or more commonly after
the relapse. In the same manner purulent coryza may occur.
The eruptions occasionally present during the fever have been
described. Bed-sores from pressure are much less common than in
typhus, but are met with in a small proportion of cases. As a rule,
they are of moderate size and heal quickly. Superficial gangrene of
the lips, nose, and ears has also been noted in rare cases (Zuelzer)
in connection with gangrene of the extremities, probably from
embolism. The occasional occurrence of painful boils, of abscesses in
the cellular tissues (Wyss and Bock), and the more rare occurrence of
erysipelas may be mentioned among the sequelæ.
As already stated, the severe pains in the joints and members which so
frequently occur during relapsing fever are, as a rule, unattended by
any redness or swelling of the joints. In rare cases, however, there
is effusion into the joints during the fever, or more commonly there
are attacks during convalescence which simulate subacute rheumatic
arthritis. Such attacks may last but a few days, but in several of our
cases there was painful swelling of the knees, wrists, and fingers
which persisted for several weeks after the fever, being attended with
slight crepitation on motion, and altogether behaving like subacute
rheumatism.
As would be expected from the severity of the fever, the marked
disorder of digestion, and the lesions of the spleen and liver in
relapsing fever, anæmia is a common sequel. In cases where there has
also been free hemorrhage, usually in the form of epistaxis, the
anæmia may indeed reach an intense degree.
The cardiac murmurs which have been described as present in a certain
proportion of cases are dependent upon the blood-changes, and when the
anæmia is extreme these murmurs are also audible over the large veins
and the pulmonary artery, and persist after convalescence is fully
established.
Oedema of the lower extremities occurs in a considerable number of
cases. It is clearly due in part to the anæmia, but the cardiac
debility which follows the fever is also largely concerned in its
production. It was, indeed, marked in some of our cases where no
anæmic murmurs existed, but where there was great nervous and muscular
debility. {401} Usually limited to the feet and ankles, it
occasionally extended above the knees, and in one case, where great
anæmia and debility from fever and over-exertion coexisted, there was
oedema of the hands and wrists, with great distension of the legs up
to the hips. It is not associated with albuminuria as a rule, and
yields readily to treatment and rest, in the course of a few weeks.
Hemorrhages from various surfaces have already been mentioned, and a
full account given of epistaxis, which is by far the most common form.
Bloody vomiting has been noticed in a small proportion of cases in
various epidemics. It varies in amount, but is always attended with
great gravity of the attack, and usually is followed by fatal results.
It occurred in four of our cases, two of which presented also black
stools containing altered blood, and suppression of urine; while in
another it occurred at the close of the first relapse, and during the
second relapse was copious and repeated. In this case it was attended
with alarming symptoms of collapse, from which the patient rallied,
and after a desperate struggle recovered.
Blood may also be discharged from the bowels in such large amount as
to constitute actual hemorrhage--a symptom of great gravity; or in
small quantity and completely altered, so as to impart an inky black
color to the stools--a condition not necessarily attended with urgent
danger; or, finally, there may be frequent bloody dysenteric stools.
Hemorrhage has also been observed from the uterus, from the kidneys,
from the ears, and from the old cicatrix of a syphilitic chancre.
Hemorrhage occurred in 87 out of 183 of our cases, or in nearly 50 per
cent. It was from the nostrils in 82 cases, from the uterus in 1 case,
from the stomach in 4 cases, and from the cicatrix of a chancre in 1
case.