fever as to require special attention as one of its complications. It
may occur at any period of the disease, but it is most common at the
crisis of the first paroxysm or of the relapse. The symptoms are
usually those of cardiac failure, with rapid, small, and feeble pulse;
shallow and hurried, or slow, labored, and imperfect respiration;
coldness of the extremities, while the central temperature may remain
elevated; muttering delirium, rapidly passing into unconsciousness.
Occasionally almost instantaneous death occurs from syncope induced by
some muscular exertion, as standing up or even rising in bed. In other
cases the symptoms indicate the development of cardiac thrombosis, and
subsequent examination has verified this opinion. In still other cases
the symptoms resemble those which occur in extreme hyperpyrexia
dependent upon overwhelming and paralysis of the nervous centres.
Copious hemorrhage from the stomach and nose may also induce syncope
of alarming and even fatal severity. When from the latter cause,
reaction may be induced and the patient may ultimately recover, as we
saw in a case where after repeated hematemesis the patient sank into
profound collapse. In all of its forms, however, this complication is
of extreme and imminent danger, and death follows, as a rule, in a few
hours. The cases in which it occurs are usually of severe type,
occurring in persons who have previously been in poor health or
intemperate, or who have been subjected to privation and improper
exposure previous to and during the early stages of their attack.
Still, collapse may occur in mild cases {402} also, and whatever the
type of the disease there may be no special indication of approaching
trouble, when the patient rapidly passes into collapse, to be followed
by death in a few hours. It occurred in nine of about two hundred
cases under our observation. In one it was the result of hemorrhage
from the stomach, and ended in recovery; in one, at the close of the
initial paroxysm the patient, who was stupid, with muttering delirium,
sank into collapse as the temperature rapidly fell from 105° to 97°,
and died in a few hours; in one, on the fourth day of the relapse the
temperature suddenly fell from 102° to 96°, with free sweating, but
suddenly rebounded to 102°, with very rapid, feeble pulse, distinct
basic cardiac murmur, constriction of chest, restlessness and
delirium, slight convulsions, and death in eight hours; in one, a man
at the end of the initial paroxysm, immediately after his admission to
the hospital in apparently fair condition, became violently delirious,
with bounding pulse, soon grew comatose, and died in one hour; in one,
a man who was in feeble condition, on the nineteenth day, with
irregular persistent fever (he had splenic abscess), sat up on the
edge of the bed, sank back in syncope, and died in less than an hour;
in one, a man who did well until the second day of the relapse, when
pleuro-pneumonia and pericarditis were developed, died suddenly four
days later: there was considerable pericardial effusion; in one,
sudden death from syncope or cardiac thrombosis occurred on the
twelfth day in a man who had suppurative parotitis and metastatic
abscesses of the lungs; in one, sudden collapse and death occurred in
one and a half hours at the end of the initial paroxysm; in one, a
drunkard with large fatty liver had pyrexia continuing after the
initial paroxysm, and on the ninth day, while in a state of hebetude,
with mild delirium and a pulse of 112, coma suddenly occurred, and
death followed in two hours.
Pericarditis is a rare complication, and is apt to coexist with
pleuro-pneumonia. This combination occurred in one of our cases where
pleuro-pneumonia and pericarditis were developed on the second day of
relapse, and proved fatal by sudden collapse on the fifth day, with
the pericardial sac distended with serum and its layers coated with
plastic lymph.
Thrombosis of veins, as in phlegmasia alba dolens, occurs much more
rarely than after typhoid fever. Arterial embolism, on the other hand,
is not uncommon. Murchison[22] reports a case in which gangrene of the
left foot from obstruction of the left femoral artery, together with
cerebral softening from obstruction of the left middle cerebral
artery, occurred in connection with cardiac thrombosis. Zuelzer
alludes to similar cases in the St. Petersburg epidemic of 1865-66,
where, in addition to the extremities, the nose, ears, and lips became
gangrenous. Other examples of embolism are found in lesions of the
spleen and kidneys, where infarctions are of frequent occurrence.
[Footnote 22: _Op. cit._, p 384.]
Heart-clot, or cardiac thrombosis, appears to occur more frequently
than in any other acute zymotic disease, with the exception of
diphtheria. Even when the occurrence of passive hemorrhages and of
ecchymoses of various tissues indicates marked dyscrasia of the blood,
there will not rarely be found firm white clots in one or other of the
cavities of the heart. These frequently present unmistakable evidences
{403} of ante-mortem formation, and, as already stated, there is a
certain proportion of the cases of rapid and unexpected death where
the fatal result is directly due to cardiac thrombosis, attended with
the usual symptoms.
The constant affection of the spleen has been fully described; it is
not therefore surprising that both complications and sequelæ arise in
connection with it. At times, in cases which ultimately recover, the
pain in the splenic region is so violent and continuous, and is
attended with so much tenderness over the enlarged organ, that
localized peritonitis is undoubtedly present. Occasionally this
perisplenitis persists, and in conjunction with the inflammatory
changes in the substance of the spleen maintains an irregular fever
after the specific pyrexia has run its course. This was noticed in
several of our cases, but especially so in a case where, after the
initial paroxysm, an irregular fever was kept up, obscuring the
relapse, until the nineteenth day, when death occurred suddenly from
syncope on rising on the edge of the bed, and where examination showed
splenic peritonitis, with a splenic abscess as large as a pigeon's
egg.
The enlargement of the spleen usually subsides during the
intermission, and disappears speedily or in the course of a few weeks
after convalescence is established. Occasionally, however, it
persists, and is attended with marked anæmia. In one case, where death
occurred from pneumonia, the sequel of relapsing fever, at about the
thirtieth day, the spleen weighed twenty-nine ounces; and in another
case, where death occurred from gangrenous pleuro-pneumonia, at the
fortieth day, the spleen was still enlarged and presented
characteristic changes in its pulp. On the other hand, in a case where
death occurred on the twelfth day of typhus, occurring forty-four days
after recovery from a very bad case of relapsing fever, making it
altogether the one hundredth day, none of the lesions of the first
disease were discoverable.
Rupture of the spleen occurs occasionally, and is usually attended
with sudden pain, collapse, and speedy death. Murchison refers to two
examples recorded by Zuelzer and one by Hudson; Petersen reports
fifteen cases, in seven of which sudden rupture occurred with speedy
death, while in the other eight the rupture followed local softening
from infarction, and resulted in death in a few days from purulent
peritonitis.
In one of our cases, where death occurred on the sixteenth day,
apparently from double pneumonia and heart-clot, it was found that
there was a rupture in the enlarged spleen near its upper end, recent
plastic peritonitis in the region of the spleen, and a moderate amount
of bloody pulpy fluid throughout the peritoneal cavity.
As we have seen, disturbances within the respiratory tract occur with
very different frequency in different epidemics. In many they are
rare, while in 1870 we noticed cough and other evidences of
respiratory trouble in no less than 90 out of 200 cases.
Severe catarrhal laryngitis is a rare and dangerous complication. It
did not occur in our cases, but both Begbie and Paterson report cases
of it which required tracheotomy, and Wyss and Bock met with
ulcerative laryngitis with perichondritis.
Bronchitis of moderate severity, although rare in many epidemics,
{404} occurs so frequently in others, as in Philadelphia in 1870, as
to rank as a symptom of the disease.
Pneumonia is one of the most fatal complications. The results of our
own observations agree with the statements of Jenner and of Carter,
that it is the next most common lesion after enlargement of the liver
and spleen. On the other hand, Murchison noted it only in 4 or 5 out
of 600 cases. It occurred in at least 11 of our cases, 8 of which were
fatal; and unquestionably less extensive inflammation was present in
other cases which recovered, in view of the marked respiratory
disturbances frequently present. Both lungs were involved in 4 cases;
of the remainder, the right and left were about equally divided. Out
of 23 autopsies, the lesions of pneumonia were found 8 times. The
lower lobes were affected in every case. The form of this disease was
croupous in 9 cases; in 1 it was that of metastatic suppuration, and
in 1 it was more properly described as splenification. The amount of
plastic pleurisy associated with it was usually great, and in one case
there was also severe pericarditis. In another case the disease
advanced to the stage of gangrene of a circumscribed area of the
pleura and of the superficial layer of the lung. In only one instance
was albuminuria present. In two cases the pneumonia occurred so late
in the course of the disease that it might be regarded as a sequel.
Death occurred in one of these on the thirtieth day, and in the other
(that in which gangrene ensued) it ran a subacute course, and death
did not take place until the fortieth day. In the other cases the
disease began at the close of the initial paroxysm, during the
intermission, or early in the relapse. As would be expected, the
sympathetic fever due to this complication modified and obscured the
characteristic course of the specific pyrexia.
This rare termination in gangrene has been noted by other observers;
in all five or six times. Parry met with a truly remarkable case of
double pneumonia, followed by gangrene, and yet resulting in recovery.
Jaundice is apt to attend cases of relapsing fever which are
complicated with pneumonia.
Pleurisy is an almost constant accompaniment of pneumonia, and
frequently occurs in marked degree. It may also be present in cases of
severe splenic inflammation. In all probability, localized plastic
pleurisy is not infrequent, and may cause some of the severe thoracic
pains so frequently present.
Metastatic abscesses of the lung occur occasionally as a result of the
profound toxæmia, and are apparently preceded by patches of
infarction, which soften in the centre, as in the usual development of
pyæmic abscesses. This condition was found in one of our cases in
conjunction with suppurative parotitis. It has been included among the
instances of pneumonia.
Acute miliary tuberculosis, involving chiefly the lungs and intestinal
canal, occurred as a sequel in one case under our observation, and
phthisis has been found to follow by other observers (Carter). It is
to be expected that if the patient did not so quickly pass from under
observation it would be found that an affection so gravely
complicating nutrition as does relapsing fever is frequently followed
by serious organic disease.
Parotitis is mentioned by so few authors as to show that it is a {405}
rare complication in most epidemics, varying from 1 in 600 to 1 in 50
cases. One gland only is affected at a time as a rule, though both may
be involved successively. The inflammation begins either during the
intermission or the relapse, and may terminate by resolution or by
suppuration. Although a painful and severe complication, it is
followed by recovery in a considerable proportion of cases. Carter[23]
states "that in some degree it was noted in 2 or 3 per cent. of all
cases, and nearly as often amongst survivors as in the casualties." It
occurred in three of our cases (185); once it underwent resolution;
once suppuration occurred in the parotid and in the masseter muscle,
with metastatic abscesses in the lungs, and death; and once the
patient, who had previously existing amyloid degeneration of liver and
spleen without albuminuria, had severe relapsing fever with two
relapses, in the first of which parotitis occurred in both glands,
successively terminating in suppuration, after which he did well
through an apyretic period of six weeks, when sudden high fever
appeared, followed by speedy death.
[Footnote 23: _Op. cit._, p. 210.]
Pharyngitis and tonsillitis of mild grade occur in from 3 to 25 per
cent. of the cases in different epidemics.
Hiccough deserves to be ranked among the complications, because it is
of frequent occurrence, obstinate and annoying. It occurred in a
considerable proportion of our cases, and much more frequently in
those who had jaundice. It was often present both in the initial
paroxysm and in the relapse, but disappeared soon after the end of the
pyrexia. It bore no constant relation to the severity of the vomiting.
Not rarely it lasted several days and nights, causing exhaustion and
interference with sleep and proving rebellious to treatment.
Hypodermic injections of morphia and atropia, chloroform internally,
and extremely careful alimentation proved most serviceable.
Hemorrhage from the stomach has already been spoken of (see p. 390).
Diarrhoea, as already stated (see p. 390), occurs much more frequently
than in typhus fever, varying from 1 per cent. (Murchison) to 15 per
cent. (Scotch epidemics) or 33 per cent. (Philadelphia), or even 50
per cent. (Königsberg). It is usually of moderate severity, but
occasionally is so profuse and intractable as to constitute the main
cause of death. In some epidemics the attacks of looseness occur
almost exclusively after the relapse, but in others the bowels are
frequently loose during the febrile stages. In our cases there were
not infrequently from three to eight thin, dark, bilious or light
yellowish stools daily after the second or third day of the initial
paroxysm, and then the looseness would stop during the intermission,
probably to recur in the relapse. Occasionally diarrhoea with very
frequent liquid stools occurs at the close of one or both of the
febrile stages, assuming a critical character, and substituting more
or less of the sweating which is the common mode of crisis, although
in several such cases quoted by Murchison from Douglas the sweating,
despite the critical diarrhoea, was usually profuse. It can scarcely
be said that there is any relationship between diarrhoea and vomiting;
both are frequently present, and may even be severe and persistent in
the same case, though either may be marked while the other is moderate
or slight. Abdominal pain and tenderness in the epigastrium and
hypochondria are constant symptoms, but when diarrhoea is marked there
are apt also to be griping {406} pains and tenderness in the lower
segment of the abdomen. When diarrhoea occurs as a sequel, either
beginning after the close of the relapse or continuing in cases where
the bowels have been loose during pyrexia, it is apt to prove
obstinate and intractable, or even to lead to a fatal result.
The character of the stools varies much; usually thin and dark, they
may be light yellowish or even whitish. Thus, in a severe case with
deep jaundice we observed seven liquid and decidedly whitish stools in
twenty-four hours. In such instances there is undoubtedly more or less
complete closure of the biliary ducts by plugs of mucus or by swelling
of the mucous membrane. On the other hand, the stools may be inky
black from admixture with altered blood, or, lastly, they may consist
of mucus and blood, in which event the complication assumes the form
of actual dysentery and is attended with increased abdominal pain and
with tenesmus. Dysentery was, as would be expected, quite frequent in
the Indian epidemics studied by Carter.[24] It is usually of moderate
severity, but occasionally it runs into gangrenous inflammation, is
attended with perforation of the bowel, or is followed by hepatic
abscess. In one instance we noticed a peculiarly fetid puriform
discharge from the anus, which occurred during the relapse and
persisted for several weeks, gradually subsiding, as though from some
unhealthy ulceration which slowly healed.
[Footnote 24: _Op. cit._, p. 218.]
Jaundice is of frequent occurrence, but has been sufficiently
discussed at page 391.
Peritonitis is not rare in its circumscribed form. This statement is
based on the comparative frequency with which localized splenic
peritonitis, of varying degrees of severity, is found after death in
relapsing fever from various causes, and from the great frequency of
severe pain and tenderness in the region of the enlarged spleen in
favorable cases. In its lesser degrees it may not add materially to
the danger of the patient, but in more severe forms, associated with
serious splenic lesions, it may run a protracted subacute course and
maintain irregular fever.
General peritonitis is, on the other hand, a rare complication,
occurring not more than once in several hundred cases. It results from
dysenteric perforation of the bowel, from rupture of a splenic
abscess, or from rupture of the spleen itself. An example of this
latter accident which occurred under our observation has already been
given. Speedy death invariably follows, though in the case just
referred to the symptoms of peritonitis were totally masked by those
of the coexisting double pneumonia, which seemed to be the immediate
cause of death.
Suppuration of the mesenteric glands is a rare complication, mentioned
especially by Wyss and Bock. As these glands are not usually found
enlarged, there being no irritative lesion of the intestines of common
occurrence in relapsing fever, it is probable that the collections of
pus which have been found were metastatic in origin.
Dyspepsia is not an infrequent sequel, as would necessarily be the
case after a disease characterized by so much gastric irritation and
by such serious lesions of the liver and spleen. As a consequence,
care in diet is often required for a considerable period after the
course of the disease has ended; dyspeptic symptoms are frequently
complained of, and marked emaciation and anæmia often protract
convalescence.
{407} It may be observed that a striking appearance of emaciation is
often developed shortly after the crisis of the first paroxysm, or,
more particularly, of the relapse. It is partly due to the actual loss
of weight during the high pyrexia, but even more to the abrupt
transition from a state of extreme febrile turgescence to one of
equally extreme relaxation and maceration of the surface.
The amount of urine has been seen (p. 387) to vary greatly in cases
distinguished by no special disorder of the kidneys; the extremes in
ordinary cases being from twelve or fifteen ounces just before the
crisis to from eighty to one hundred and twenty within forty-eight
hours after the crisis. Suppression is, however, sometimes noted, and
is always a grave symptom, though Parry[25] reports more than one case
in which on several successive days there was not more in twenty-four
hours than one fluidounce of non-albuminous urine, and in which no
symptoms of uræmia occurred, and the sweat had no urinous odor. In one
of our fatal cases, with intense jaundice, hematemesis, inky black
stools, and oedema of the feet and of the lungs, there was not a drop
of urine secreted during the last four days of the initial paroxysm;
death occurred on the eighth day, and the kidneys were found intensely
engorged, of a deep blackish-blue color, with numerous ecchymoses in
the cortex, due to impaction of the convoluted tubules with blood,
while the renal epithelium was granular and swollen, and many tubules
were filled with epithelial cells and granular matter. At the autopsy
the urinary bladder was firmly contracted and contained a very small
amount of bloody liquid.
[Footnote 25: _Op. cit._]
More frequently, incontinence of urine, with or without retention,
occurs during the febrile stages--according to our observation, most
commonly in cases attended with mental disturbance and tending to a
typhoid condition. The symptom was not of very grave significance,
however, and after the use of the catheter for a few days the bladder
regained its tone.
Albumen is quite frequently present in small amounts during the
pyrexia of relapsing fever. Thus, in 18 cases of ordinary severity,
which all recovered, and in which the urine was carefully examined
daily, a trace of albumen was found in 5; in 2 cases it appeared both
in the initial paroxysm and in the relapse, but in all instances its
presence was of brief duration. In one of these five cases the albumen
appeared at both critical periods, when the amounts of urine in
twenty-four hours were respectively 150 ccm. and 250 ccm.; but in the
other cases the transient albuminuria coincided with free secretion of
urine (1250 ccm., 1850 ccm.). It is probable that were the same
careful search to be made in all cases the presence of albumen would
be detected in fully 20 to 25 per cent. On the other hand, in fatal
cases the occurrence of albuminuria is by no means constant, although
undoubtedly it is present in a larger proportion of such cases than of
those of ordinary severity.
Our experience does not confirm that of Murchison, who states that he
never met with typhoid symptoms in relapsing fever without albuminuria
or some other evidence of retarded elimination by the kidneys. In
several of our cases where the typhoid state was developed in the
highest degree repeated examination of the urine failed to discover
albumen.
{408} Most observers have been struck with the comparative immunity of
the kidneys from serious disturbance in a disease presenting such
complicated morbid processes and widespread lesions as relapsing
fever. To show, however, that these organs suffer specially in certain
epidemics, it may be mentioned that Obermeier[26] reports having found
albumen with tube-casts of various kinds in 32 out of 40 cases of
relapsing fever, thus showing that, in the particular epidemic he was
studying, catarrhal nephritis was of almost uniform occurrence. It is
true that serious interference with the elimination of urea and other
nitrogenous matters may occur without the coexistence of albuminuria,
so that it is impossible to deny that severe nervous symptoms may
result from impaired renal activity even when the urine contains no
albumen.
[Footnote 26: "U. d. wiederkehrende Fieber," _Arch. f. path. Anat. u.
klin. Med._, Bd. xlvii. p. 170.]
Attention has already been called to the variations presented in the
amounts of urea, but more extended observations are required to show
the precise relations of these variations to the graver nervous
phenomena. It will be found, we venture to opine, that, while in one
group of relapsing-fever cases of grave type, cerebral symptoms are
dependent upon the retention and accumulation in the system of urea
and other effete nitrogenous products, owing to interference with
renal activity from pre-existing organic disease of the kidneys or
from an exceptional degree of congestion of those organs, there are
other groups where similar typhoid cerebral symptoms are more directly
dependent upon the specific toxæmia, upon the hyperpyrexia, upon
exhaustion of the nerve-centres by intense peripheral irritation, or
upon congestion or other morbid conditions of the nerve-centres
themselves.
In all cases where cerebral symptoms manifest themselves in relapsing
fever the daily examination of the urine--which here, as in other
zymotic diseases, is a duty in all cases--becomes of extreme
importance. Three conditions should be borne in mind in such
examinations. In the first place, the attack of fever may have
occurred in one already the subject of organic kidney disease, and,
considering the classes from which the majority of the cases of
relapsing fever are drawn, this possibility cannot be of rare
occurrence. Out of eighteen post-mortem examinations in which the
kidneys were studied with especial care we found positive evidence of
pre-existing organic disease four times. In these cases the
albuminuria was marked and persistent, though tube-casts were rarely
found, and severe cerebral symptoms of typhoid type were prominently
present. In another highly interesting case the patient, who had
amyloid disease of the liver, spleen, and kidneys, contracted severe
relapsing fever; he had increased albuminuria during both febrile
stages, suppurative parotitis, but no grave cerebral symptoms, and
apparently recovered. After an apyretic period of six weeks, during
which the symptoms of the amyloid visceral disease persisted, a sudden
and rapidly fatal pyrexia occurred. Unfortunately, the existence of
spirillar infection of the blood was not known at the time.
In the second place, the attack of fever may become complicated with
acute nephritis from special localization of the poison, as in
Obermeier's cases, or from vulnerability of the kidneys. In such cases
careful study of the urine should indicate the event, and the
prognosis, though grave, is not so hopeless as in the first instance.
An interesting example of {409} this occurred under our observation,
where the patient, who had apparently an ordinary attack, was seized
with acute catarrhal nephritis, with temporary uræmia, during the
relapse, but after a dangerous illness recovered without any organic
renal disease as a sequel.
In the third place, may be found the more usual and more
readily-determined condition of slight and transient albuminuria (with
variations in urea excretion) which has already been discussed, and
which has no serious prognostic significance.