A system of practical medicine. By American authors. Vol. 1

by Unknown

The matters vomited consist of the ingesta colored with bile, of glairy mucus tinged with bile, or of green bile, sometimes in considerable quantity. Small particles of blood may occasionally be noticed in the matters vomited, and in rare instances true hematemesis occurs. Judging from the frequency with which in fatal cases we find ecchymoses of the gastric mucous membranes with blood-stained mucus in the cavity of the stomach, we should expect black vomit to be more often observed than is the case. Murchison (p. 361) states that it was not noted in any British epidemic except that of 1843, and then it occurred in only a few cases, although it seems to have varied in frequency at different places. Arrott at that time described the symptoms as "quite common" in the fever at Dundee; and W. Reid of Glasgow recorded the case of a girl in the same epidemic who vomited large quantities of clotted blood, and who also had hemorrhages from the bowels and from the ears. It has occasionally been observed in the continental epidemics. It was observed in four of our cases. By all who have observed blood-vomiting in relapsing fever it is recognized as a symptom of almost invariably fatal import. Three of the four cases in which we observed it proved fatal, but one patient, who had copious hematemesis, both at the close of the first relapse and during the second relapse, recovered after a desperate and protracted struggle.

The bowels are not so often constipated as in typhus, and it is not rare for diarrhoea and constipation to alternate, or for the bowels to be loose throughout the paroxysms. They are noted in 181 of our cases as regular in 32, loose in 61, and constipated in 88 instances. Meschede states that diarrhoea was present in nearly one-half the cases of the Königsberg epidemic of 1879, though usually as a late symptom, the early stage being marked by constipation, which in a few cases persisted throughout. The stools may be consistent and dark or thin and bilious, or occasionally, when gastric or intestinal hemorrhage has occurred, they contain black coffee-ground matter. Occasionally, the diarrhoea has a critical character, and occurs at the close either of the initial paroxysm or of the relapse, though it may not entirely substitute sweating. This mode of crisis occurred in two of our cases, but Douglas observed it in 6 out of 33 cases.

The abdomen may appear enlarged, but this is as much the result of the enlargement of the liver and spleen as of gaseous distension, which is rarely present in a high degree. Abdominal pain is almost constant, and may be very severe. It is especially mentioned as having been present in 148 out of 182 of our cases. It commonly extends throughout the epigastrium and both hypochondria, but may be present on one or the other side, while, on the other hand, there may be general abdominal soreness. It is associated with tenderness on pressure, which may be so great as to hinder the movements of the trunk and to render the descent of the diaphragm in breathing painful. This may be the first symptom to usher in the attack, and it occurs at an early stage in most cases. Many of our patients when admitted to the hospital had already been cupped or blistered over the region of the liver or spleen. This distress was greatest in cases attended with jaundice and marked gastric irritation; and Parry reports that in his cases (occurring in the early part of the epidemic which we studied) jaundice was rare (4 out of 37), and abdominal tenderness was not present. It is not difficult to explain its almost universal presence in view of the severe lesions of the substance of the liver and spleen, the distension of their capsules from the acute swelling of the organs, and the implication of the coats of the stomach.

Enlargement of the liver and spleen probably exists to a greater or less degree in every case of relapsing fever without exception. This statement is based on the concurrent testimony of accurate observers in all epidemics and upon the evidence of post-mortem examinations.

The enlargement of the liver can be demonstrated in nearly all instances by careful percussion. It varies greatly in its degree, however; in mild cases it may be slight, while in severe ones the liver may be found extending at least three inches below the margin of the ribs within three or four days from the initial symptom. In our own fatal cases the weight of the liver averaged between four and four and a half pounds.

The spleen enlarges even more rapidly and to a greater degree than the liver. In fact, its enlargement in relapsing fever is greater than in any other acute disease. It may be detected by percussion by the first or second day, and may then continue to rapidly increase until by the fifth or sixth day a large painful mass is readily recognized by palpation and percussion, or even by inspection. The organ often weighs twelve or sixteen ounces, not rarely twenty to twenty-five, and, as an instance of the extreme limit that may be reached, Küttner reports sixty-eight ounces in one case. This enlargement is greatest toward the close of the first or second paroxysm, and subsides quite rapidly in most cases during the intermissions and as convalescence progresses; we have, however, known a moderate degree of enlargement of the spleen to persist for some weeks after the crisis of the last paroxysm.

The occurrence of jaundice in a considerable proportion of cases of relapsing fever is a clinical fact of much interest. Its frequency varies greatly in different epidemics, and even at different stages of the same epidemic. At times it is rarely met with (1 out of 14, 20, or 35 cases), while in other epidemics it is present in 1 out of every 6, 5, or even 4 cases. Of 182 of our own cases jaundice is recorded in 45, or exactly in 1 out of 4. According to our observation, it occurred in a larger proportion of cases among negroes (14 out of 32) than in whites, and Stillé states that it occurred in nearly every such case that came under his observation. When present it usually occurs during the first paroxysm, and may be limited to that stage; or, again, it may be present in each of three or four successive paroxysms in the same case; or, finally, it may first appear in the relapse. As a rule, it subsides speedily after the crisis, though Carter states that in two or three cases the symptom made its first appearance just after the crisis. It varied from the slightest yellow tinge of the conjunctiva to the deepest staining of the whole surface. The urine is discolored in proportion to the intensity of the jaundice, and the serum of a blister will be deeply tinged. It must be carefully noted, however, that the feces are not decolorized, but, as already described, contain fully a normal amount of biliary coloring matter. This fact has been relied on by Murchison and others to prove that the jaundice in relapsing fever is purely dependent on the morbid state of the blood, and is not due to obstruction of the biliary passages; and we are prepared to admit that the element of blood-dyscrasia may play a part in the production of the jaundice. The anatomical evidence, however, given [below], renders it probable that in many cases at least the essential cause is to be sought in an obstructed state of the minute gall-ducts of certain areas of the liver. If the main hepatic duct or the common duct were obstructed, there would of course be paleness of the feces, as the bile would be prevented from entering the duodenum. But when a large amount of highly-colored bile is being secreted, as in relapsing fever, it seems clear that the obstruction of a certain number of minute ducts would cause sufficient resorption of the bile to induce jaundice of varying degrees of intensity, while at the same time allowing a flow of bile through the patulous ducts.

Jaundice must be regarded as an unfavorable or even a grave symptom in relapsing fever, but not to the extent that would be the case were it directly connected with the intensity of the blood-dyscrasia. Many of the most violent cases in all epidemics have been unattended with jaundice, while, on the other hand, many cases in which jaundice has been marked "have had not a single symptom that made them differ from ordinary cases excepting the yellowness" (Henderson). It follows, therefore, that the gravity of a certain proportion of the jaundiced cases does not follow directly from the presence of bile in the blood and tissues, but from the lesions of the liver of which the jaundice is a symptom, or from the existence of widespread irritation of many parts of the body. Thus jaundice is present in an unusually large proportion of the cases attended with marked enlargement and tenderness of the liver and spleen, whether vomiting is also present in extreme degree or not. It was noteworthy that it was disproportionately frequent in negroes, and that in these patients the lesions of the liver and spleen were also unusually pronounced. Again, jaundice is present in an unusually large proportion of the cases attended with low delirium, extreme prostration, defective secretion of urine, and the other features of the typhoid state—so much so that such cases have been described by various writers under the name of bilious typhoid fever.

But, as already stated, it is not legitimate to consider the gravity of these cases as the result of the jaundice, but rather that the jaundice is merely a symptom of the widespread irritative lesions, which in such cases not only involve the liver and spleen, but the kidneys, the lungs, the marrow of the bones, the muscle of the heart, and occasionally the membranes or substance of the brain and cord.

The true prognostic value of jaundice in relapsing fever would then seem to be, that of itself it indicates merely an obstructed state of a certain number of minute bile-ducts, but that its presence justifies the apprehension that the local lesions of the liver may become excessively developed, or that there is a tendency to widespread tissue-changes which at a later stage of the disease may lead to the appearance of grave constitutional disturbance of a typhoid type.