Relapsing Fever.

Synonyms:—Febris recurrens, relapsing typhus, spirillum fever, famine fever, seven-day fever.

Definition:—An acute infectious fever, marked by regularly recurring abatement and relapses, and caused by the presence in the blood of the spirillum or spirochete of Obermeier.

Etiology:—The disease occurs more frequently where there is great destitution and in filthy and unhygienic localities. A larger proportion of males is usually affected. It is most common between the ages of fifteen and twenty-five years. In 1873 a special organism was found by Obermeier in the blood of these patients, and subsequent observations have proven that these germs exist only during the paroxysm, and at this time inoculation with this blood will reproduce the disease. They disappear entirely before the crisis and are absent during the apyrexial period. Inoculation at this time does not induce the disease. These organisms are in the form of a spiral filament about five times as long as the diameter of a red blood corpuscle. It rotates actively in the blood during the fever. It is found in none other of the body fluids.

Symptomatology:—The period of incubation is from five to ten days, but there are few prodromata. The invasion is abrupt and unannounced. A chill usually occurring early in the morning before the patient has arisen is the first announcement of illness. This is sometimes rigorous, at others there is a succession of light chills. Immediately there are pains in the loins and in the limbs. There is severe frontal headache, vertigo, nausea and vomiting and physical prostration. The temperature rises rapidly and by night of the first day it may reach 105 degrees. The face is flushed and the eyes are sunken, but not dull and expressionless, as in typhoid. The skin is dry and harsh, and on the second or third day presents a slightly jaundiced, a characteristically dirty yellow or bronzed appearance. There is no constant characteristic eruption, but because of profuse perspiration sudamina may appear, and small petechiae or ecchymoses. A peculiar odor is sometimes observed.

Constipation is present usually at the time of the invasion, and persists; there is thirst, loss of appetite and a substance, greenish yellow or black in color, mixed with blood and the gastric secretions, is vomited.

With the rapid rise of temperature the pulse also rises to from 120 to 140 beats. It is full, strong and regular for the first day, but rapidly loses strength and character, becoming irregular and intermittent. The headache persists, but delirium is not pronounced, if present at all, the intellect remaining undisturbed, though there may be restlessness and insomnia. There is rapid respiration which, just preceding the crisis, may become difficult. The spleen and liver may both be enlarged and tender, and lung or bronchial complications may occur.

The temperature usually attains its highest point on the second day, sometimes reaching 107 degrees, usually, however, not rising above 105 degrees. A rather regular uniformly high temperature is maintained for from five to seven days, when, with a premonifory sudden increase in the temperature for a short time, it then falls, often within twelve hours to the normal point or below. With the decline of the temperature sweating begins and is sometimes extreme for a short time, or in its stead a profuse diarrhea or an intestinal hemorrhage or epistaxis or a metrorrhagia in women occurs. There is then an immediate cessation of all symptoms, and within forty-eight hours the patient is apparently in his usual health.

There are, however, slight recurrences of temperature in the evening, and the peculiar appearance of the skin remains. After four or five days, without change, there is another chill and all the phenomena of the first attack are reproduced. This attack leaves the patient with an enlarged and tender spleen and increased weakness. The second attack is usually the worst of the scries, which may consist of two, three, four or five, all similar, but decreasing in severity after the second, with perhaps a slightly lengthened interim.

Complications and Sequelae:—Rupture of the spleen has occurred in these cases. In pregnancy abortion is induced. Pneumonia follows also and epistaxis is not uncommon and hemorrhagic nephritis, while marked icterus, hematemesis, uremia and sudden collapse should be looked for in extreme and protracted cases.

Differential Diagnosis:—The disease may be distinguished from typhus by the eye and skin symptoms. Yellow fever has a shorter and less marked, less complete, remission, and the jaundice is intense, with black vomit in the collapse. The blood will show the characteristic spirochete, which will be confirmatory.

Prognosis:—This depends upon the number of the relapses. Ordinarily there are but two exacerbations, and in these cases the course of the disease will terminate within twenty-one days.

Treatment:—The phenomena should each be dealt with similarly to those of typhoid and typhus. The indications for specific remedies will be very conspicuous. Anticipating splenic enlargement polymnia uvedalia should be given in small doses from the first with whatever fever remedy is suggested. The indications for bryonia will occur more frequently on relapsing than in typhus fever. Aconite is often indicated in the first stage of the disorder as is belladonna and perhaps rhus toxicodendron. Tf called when the temperature was running a steady high course I should advise the phosphate of iron persistently in minute doses, as suggested for high temperatures in my Materia Medica. I have had surprising results from this remedy. During the intermission the following should be given, a capsule every three hours, if the stomach will permit:

Give one capsule every three hours, preferably after eating a few mouthfuls of bread or a small cracker. This, with well selected diet, the patient remaining in bed during the time of the intermission, will often ward off the first relapse and abruptly terminate .the disease. More care should be taken concerning the diet than in typhus because of the hemorrhagic tendencies of this disorder.

The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.