Relapsing Fever.

Synonyms.—Typhus Recurrens; Bilious Typhoid; Famine Fever; Hunger Pest; Spirillum Fever.

Definition.—An acute, infectious, and contagious fever, characterized by a series of exacerbations and remissions, each lasting from five to seven days, and prevailing epidemically.

History.—There is but little doubt that this fever prevailed previous to 1739. Some indeed believe that it existed during the time of Hippocrates, and cite, as evidence, his description of an epidemic which prevailed during his time. The first authentic account, however, dates from the epidemic which prevailed in Ireland, Scotland, and England in 1839, since which time it has gradually extended to other parts of the world, few countries escaping, notably Spain, Switzerland, Italy, and in France only a few sporadic cases.

It made its appearance in the United States in 1844 at Philadelphia, being brought by Irish immigrants. In 1847 it appeared in New York and Buffalo. In 1869-70 it again appeared in Philadelphia, and in the same way; viz., through Irish immigrants. In 1872-73 it made its last visit to our shores. New York being the place of its visitation.

Etiology.—The predisposing causes are similar to those of typhus fever: viz., filth, poverty, and overcrowding. This combination of conditions is prolific in furnishing a soil which readily generates toxins of an intense character, and occurs among a class whose vitality is lowered by insufficient and defective food.

Age and Sex.—Age has but slight bearing upon the etiology, although the greater number of victims are between the age of fifteen and thirty. More males are affected than females.

Race.—Race also plays but a very little part, save that some are more uncleanly than others, the negro being slightly more susceptible than other races. Neither season nor climate figures in the spread of the disease.

Famine.—During the time when scarcity of food prevails, the impoverished are peculiarly susceptible, and no doubt this bears upon its etiology.

Exciting Cause.—In 1873, Obermeier discovered in the blood of patients suffering from this fever a characteristic spirillum, which has been termed the "Spirillum Obermeier." Since then the same micro-organism has been found by many observers, and this specific germ is now generally recognized as the causal factor in producing the disease. It is found in large numbers during an exacerbation, but disappears during the period of intermission, small granular bodies being seen at this time, supposed to be the spores of the spirillum.

Pathology.—There are no characteristic changes in the solids of the body. The voluntary muscles are inclined to undergo granular degeneration, and where there is icteric discoloration during the disease the tissues are stained after death. The liver, kidneys, and spleen are somewhat enlarged, especially the latter organ, and hemorrhagic infarcts are not uncommon. The kidneys and spleen present a mottled, appearance, with extravasation of blood beneath the surface. The heart, in severe and prolonged cases, becomes soft, and granular changes take place. Pleurisy and pneumonia are often present, although not a constant feature. The body retains its heat a long time after death, and the blood coagulates slowly, if at all.

Symptoms.—The period of incubation is from five to seven days, although it may be much shorter where the system is impoverished and the infection is intense. The onset is usually sudden, although there may be the usual prodromal symptoms for twenty-four or forty-eight hours preceding the invasion, which is usually announced in the early part of the day by a severe rigor, although there may be only chilly sensations.

This is rapidly followed by reaction, extreme in character, the temperature often rising to 104°, 105°, or 106° at the end of the first twenty-four hours. The pulse is very rapid, from one hundred and twenty to one hundred and fifty per minute. The prostration is great, and the patient is compelled to take to his bed. The face is flushed, the eyes contracted, the skin hot, dry, and pungent, although frequently profuse sweating occurs. There is nausea and sometimes severe vomiting. The pain in the head is intense, with more or less vertigo. Myalgia is a marked feature, and the patient complains of pain in back and limbs; in fact, of aching all over.

By the second or third day a characteristic icteric discoloration makes its appearance, although this is not constant. Although the fever is intense, there is rarely delirium, the patient retaining his mental faculties throughout the disease. Owing to his sufferings he is restless and secures but little sleep.

From the third to the sixth day the fever is intense. There is tension and pain in both hypochondriac regions, due to swelling of the liver and spleen. The tongue is at first moist, but becomes dry and brown. The constipation may give way to diarrhea. Preceding the crisis, there may be an aggravation of all the symptoms, when suddenly the temperature begins to fall, the skin becomes moist, the urine is more copious, and by the end of ten or twelve hours the patient is free from pain and the temperature is normal. Convalescence is rapid, and often by the end of the second day he considers himself well.

The period of comparative health lasts from five to seven days, when a chill ushers in another exacerbation: the headache, myalgia, high temperature, and all the other symptoms of the exacerbation are repeated. It is usually, however, of shorter duration, the crisis occurring the fourth, fifth, or sixth day, to be followed by convalescence, although there may be a second, third, or even fourth exacerbation. Where there are two or more, each becomes shorter in duration.

The most frequent complications are lobar and bronchial pneumonia, more rarely acute nephritis.

Diagnosis.—The course of the disease is so characteristic that, where an epidemic has been established, the diagnosis is comparatively easy. The rapid rise in temperature, the intense headache and myalgia, great excitation of the nervous system without delirium, would suggest relapsing fever. We would recognize it from typhus fever by the absence of delirium, the characteristic rash, and by the early crisis; from typhoid fever, by the long forming stage of the latter, the dull intellect, and the intestinal lesion: from cerebro-spinal fever, by a higher and more irregular temperature range, no tenderness along the cervical region, and but slight drawing of the head backwards.

Prognosis.—The prognosis is usually favorable, the mortality being from three to six per cent. The result depends largely upon the complications and the age of the patient. Where pneumonia and acute nephritis occur, the prognosis must be guarded, as it must also be when it occurs in elderly people.

Treatment.—Although, as a school, we have not had the opportunity of testing Eclectic remedies, owing to the few epidemics which have prevailed, the general management would be similar to that for typhus fever. We would think of isolation, perfect cleanliness, and plenty of fresh air. The use of baths, probably sponging with hot water, to determine the heat to the surface, and constant fanning of the face of the patient by an assistant. This rapidly cools the surface and lowers the temperature.

Echinacea, baptisia, the sulphites, chlorates, and mineral acids as might be indicated by the tongue, for sepsis. Macrotys, gelsemium, rhamnus Californica, and the old diaphoretic powder would be suggested for the myalgia, while stimulants would be used where the temperature became sub-normal or the heart became weak. For the congestion of the liver and spleen chionanthus and polymnia would be the agents of probable value. Should respiratory complications arise, such as pneumonia, pleurisy, or bronchitis, the treatment so successfully employed by our school for these diseases would be used; in fact, whatever complication should arise, the intelligent physician would meet the condition's by appropriate remedies.

The diet will consist of broths and milk in some form till the temperature becomes normal.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.