Part 57

To judge from the observations thus far made on this difficult question, the parasite is found first toward the close of the period of inoculation or soon after the beginning of the fever, or it may be detected throughout the febrile stage; but shortly before the cessation of the fever it quickly disappears, to reappear at the time of the relapse. There would seem, therefore, to be some close connection between the febrile paroxysms and this organism, and it is not remarkable that many observers have concluded that this spirillum is the essential and specific cause of the fever, and that it is impossible to have this disease present without the appearance of the parasite in the blood; nor that the name spirillum fever has been applied to the disease by Carter.

Such conclusions appear to be premature, however, and we prefer to regard the undoubted existence of the spirillum in the blood of relapsing-fever patients as at present only an important aid in diagnosis, and to await the occurrence of other epidemics and the repetition of careful studies upon this organism, both within and without the human system, before venturing to decide whether it is merely one of the phenomena of the disease or whether it is its true cause and specific contagious principle.

It must be added that both Carter and Koch have succeeded in inoculating monkeys with relapsing fever, and Motschutkoffsky of Odessa, who had the opportunity of inoculating a human being, asserts that he succeeded in producing the disease, and found the incubation period to be not less than five nor more than eight days. Carter also gives an interesting table of six instances of inoculation, four of them by cuts while making autopsies, with consequent development of relapsing fever in each instance. Some allowance must be made for the fact that in all the instances of this series there had been exposure to contagion by close communication with fever patients, though this exposure had existed for several months previously without leading to the development of relapsing fever.

GENERAL CLINICAL DESCRIPTION.--After a period of not less than five or six days from the reception of the contagion the disease begins {375} abruptly with a chill of variable severity, accompanied by headache and aching pains in the back and limbs. The patient feels weak and is often giddy, but is not always obliged to go to bed the first day. Nausea and vomiting are among the earliest symptoms, and distress at the epigastrium, with tenderness, may attend or even precede the chill. Fever quickly follows; the pulse runs up from 110 to 130 in a few hours; the temperature reaches from 103.5° to 106° by the end of twenty-four hours; the pains increase, and there are insomnia and great restlessness; appetite fails; thirst is extreme; the tongue is moist and furred, and the bowels quiet. During the subsequent six days these symptoms persist. The temperature presents a daily remission at some period of the twenty-four hours amounting to one or two degrees, the maximum reached in fully-developed cases varying from 104° to 108°. The pulse continues very rapid, and not rarely exceeds 140; the respirations are hurried and rapid, and cough attends many cases. Delirium is rare, but insomnia, restlessness, headache, and rheumatic pains in the back and limbs may prove constantly annoying. Appetite is variable, more frequently lost; nausea and vomiting are common; thirst is very troublesome; and the bowels are constipated or loose. No characteristic eruption appears, but sudamina are frequently present, since in a large proportion of cases there is more or less sweating, even during the continuance of high fever. Abdominal pain, tenderness in the epigastrium and hypochondria, and demonstrable enlargement of the liver and spleen are almost invariable. The urine is concentrated and dark or bile-stained. Jaundice is a common symptom, though its frequency varies greatly in different epidemics. The same may be said of epistaxis.

While these symptoms are at their height and the patient is suffering severely the paroxysm suddenly ceases, and in a few hours he is entirely relieved. This remarkable crisis occurs usually at the close of the seventh day, but may occur as early as the third or as late as the fifteenth day. It is attended with a critical discharge, copious sweating being by far the most common, though diarrhoea, free epistaxis, or hemorrhage from some other surface may replace it. The patient feels weak and languid; the temperature and pulse have fallen below the normal, and remain so for a day or two. Soon there is a rapid improvement in the appetite and the appearance of the tongue, and the patient regains strength day by day, and often feels so well that it is difficult to persuade him that he must avoid exertion and exposure. The enlargement of the spleen subsides rapidly, that of the liver more gradually; epigastric tenderness subsides, but in many cases some degree of it persists for several days. This interval or apyretic period lasts about a week, when, again without warning or provocation, the patient relapses, and is seized abruptly with the same set of symptoms which attended the first attack. This relapse does not usually last more than three days (one to five are the limits), and is terminated by a similar crisis, after which a slow convalescence is entered upon, or else after an apyretic interval of some days' duration a second relapse ensues, and this may, in rare cases, be in turn followed by a third, fourth, fifth, or even sixth similar relapse. In addition, it must be noted that many serious complications are liable to occur. The total duration of the disease thus varies from eighteen to ninety days. Convalescence is often tedious, and there are many troublesome sequelæ. {376} The mortality, however, is not great, averaging 5 or 6 per cent. Death may occur suddenly from collapse at the close of the first paroxysm or from heart-clot; it may be produced by exhaustion in protracted cases; or be hastened by any serious complication; or the patient may sink into a typhoid condition, with low delirium, coma, and suppression of urine for several days before the fatal termination.

DETAILED STUDY OF SPECIAL CONDITIONS.--It is usually difficult to determine the period of incubation. In the unique case in which Motschutkoffsky is said to have produced relapsing fever by inoculation the initial symptoms occurred seven days after the inoculation. Wyss and Bock had several good opportunities of determining the minimum period of incubation, and found it to be six days. We may assume that the ordinary period is six to eight days, but that it varies, in accordance with the virulence of the virus or the susceptibility of the system, from four to fourteen days. During this time the patient feels as well as usual, or at most suffers for a day or two from slight malaise, with vague rheumatoid pains, headache, giddiness, and anorexia. In only 13 out of 181 of our cases in which this point is noted was the invasion gradual. Examination of the blood prior to the invasion does not discover any spirilla.

The invasion is usually abrupt and during the daytime; the patient can often fix the very hour of its occurrence, a severe chill attacking him while at work or at meal-time. This is the most common initial symptom (138 out of 168 our cases of sudden invasion); less commonly, obstinate vomiting and nausea or sudden vertigo are the first symptoms (each 8 times out of 168), or violent headache (14 times out of 168), or sharp epigastric pain. Parry also observed that the occurrence of obstinate and profuse vomiting as the initial symptom was especially frequent in children.

The physiognomy is carefully noted in one hundred and seventy of our records. The countenance is often flushed, with watery eyes and anxious, suffering expression. The flush is less dingy and dull than in typhus; the eye is comparatively rarely injected; and the expression is much less dull and stupid than in that disease. In cases where grave nervous symptoms supervene and the typhoid condition is developed the facies assumes all the characteristics of that state.

The livid bronzing of the face, described by Cormack in 1843 and by Carter (Bombay epidemic of 1877), was noticed in a moderate degree in only nine of our cases, and seems to be of infrequent occurrence. When we observed it it seemed due to an admixture of a faint jaundice tinge with a deep flush. Jaundice, as already stated, is of common occurrence, though its frequency varies greatly in different epidemics. It was present in 25 per cent. of our cases, rather more frequently in the negro patients than in whites, and in degree varied from a slight tinge of the conjunctiva and skin to the deepest staining of the entire body. The presence of jaundice in combination with the general features of high fever imparts a most peculiar and alarming appearance to such patients.

With the occurrence of the crisis the flush rapidly subsides and the face becomes pale, or, if the discharges have been profuse, it may appear sunken, haggard, and almost choleraic. Parry described a peculiar puffed, velvety look at this stage, as though the skin had been much thickened and softened at the same time.

{377} There is no characteristic eruption in relapsing fever. In 150 out of 180 cases where the condition of the skin was carefully noted there was no eruption of any kind; in 4 cases there were small roseolar spots, with peculiar subcuticular mottling, which resembled the early stages of typhus eruption, but soon faded away without becoming petechial. A similar eruption was noticed by Murchison in 8 out of 600 cases. It appears from the third to the seventh day of the first paroxysm; it may or may not recur in the relapse, or it may occur then only. Eruptions apparently similar to this have been described by others as quite common in certain epidemics. Carter describes minutely an eruption which was noted in at least 10 per cent. of his Bombay cases, the spots of which were at first small, slightly raised, and pinkish or rose-colored, and which either faded away soon or changed into purplish, more persistent stains. In a valuable report on the Königsberg epidemic of 1879-80, Meschede remarks that roseola was observed in cases complicated by exanthematic typhus, which prevailed simultaneously, but in no case of uncomplicated relapsing fever. While, however, this suggestion may apply to some few of the cases of eruption observed by others, it is certainly inapplicable to the vast majority of them. We also noticed an eruption of pale-reddish, slightly elevated papules in seven cases. It must be borne in mind that persons of such a low class as are the great majority of relapsing-fever patients would naturally be expected to present a variety of cutaneous eruptions from filth or vermin, and that in consequence some of the appearances above described may have been of such origin. It is certain that the bites of either mosquitoes, fleas, or bedbugs may in this disease be followed by persistent reddish papules passing into petechiæ. Apart from this, however, true petechiæ have been quite common in some epidemics, while very rare in others. Parry saw "small spots of purpura" once only, in a delicate girl; and we did not observe petechiæ once in several hundred cases, many of which had extensive internal ecchymoses. On the other hand, they have been found in as much as 30 per cent. of all cases (314 out of 1000 cases, Smith at Glasgow). They do not appear on any fixed day, but are more common in the first paroxysm than in the relapses; and although sometimes associated with a tendency to hemorrhages from other surfaces, they have been so often observed in cases of ordinary severity that scarce any unfavorable prognostic value can be attached to them.

Vibices and extensive ecchymoses of the surface are of much more grave import, and in cases where fatal sinking is threatened they may appear accompanying a purplish lividity of the countenance.

Herpetic eruptions about the mouth or nostrils were observed in 20 out of 181 of our cases in which this point is noted. They appeared usually toward the close of the febrile stage, and their development was found to have value in determining the approach of the crisis. Bärensprung mentions especially the occurrence of herpes labialis in cases of irregular relapsing fever which bore considerable resemblance to typhus. Sudamina are, as might be expected in a disease attended with so much sweating, of quite common occurrence, though much more so in some epidemics than in others, unless searched for with greater care by the one set of observers. Desquamation was noted in 42 out of 181 of our cases, and {378} invariably at the close of the relapse. It was usually confined to the hands and face, and occurred in the form of comparatively small flakes. This is more frequent than has been the case in most epidemics. Murchison quotes a case in which a piece of epidermis ten inches square separated from the body of a lad convalescent from relapsing fever.

A peculiar odor exhaling from patients with relapsing fever has been repeatedly noticed. A description of this unpleasant symptom, given by Kelly, as quoted by Murchison, accords closely with what was frequently manifest in our own cases: "The smell was peculiar, not fetid or heavy, but somewhat like burning straw with a musty odor." Carter, in describing a similar odor in some of his cases, notes that the skin was not in these instances in a particularly foul state.

From what has already been said, it will be anticipated that the variations of the temperature in relapsing fever constitute the most peculiar and characteristic feature of that disease. A careful study of the accompanying charts will convey a more accurate impression than can be given by any description. The temperature begins to rise before the chill is fully developed, and when there is no initial chill the patient may be found within a few hours of the appearance of giddiness and headache with a temperature of 102.5° to 103.5°. Before twenty-four hours have passed it has risen to from 104° to 106°. During the paroxysm the febrile movement is continued, presenting merely a diurnal variation of one to two degrees, sometimes attended with sweating and partial relief of distressing symptoms, the minimum being observed at different hours in different cases, or even in the same case, though more frequently it occurs in the morning.

In a case reported by Parry a chill recurred at the same morning hour on three successive days. Wyss and Bock report some unusual cases in which a brief intermission occurred, with a fall of pulse and temperature to the normal, most frequently on the day before the real termination of the paroxysm. The highest temperature varies from 104.5° to 108.75°; in our cases the highest observed was 107.5°. This occurs, as a rule, on the last day or the day before the last of the initial paroxysm, and Obermeier has observed a sudden rise of four degrees in half an hour just before the crisis. Meschede, however, found the highest temperature on the corresponding days of the first relapse.

The duration of the primary paroxysm is usually six or seven days; but 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.

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 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.

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.