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.
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 ([above]) 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 Parry25 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.
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.
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 Obermeier26 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.