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. 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. Meschede21 found disease of the middle ear in no less than 8 per cent. of his cases.
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. 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.