Part 61

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).

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 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.

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 facial palsy was developed six days after the second crisis.

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 again carefully studied it.

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 found disease of the middle ear in no less than 8 per cent. of his cases.

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.

Sudden collapse occurs with such comparative frequency in relapsing 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 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.

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.