before reaction has taken place, he will of course have recourse to
diffusible stimulants and external warmth to aid in the establishment
of this process. More frequently he is not sent for until after the
chill has been succeeded by fever. His treatment will then, of course,
vary with the condition of the patient. If his stomach is loaded with
food, an emetic should be administered to him. If the bowels are
constipated, a mild cathartic will often be of service, but after the
bowels have been once well moved it is generally unnecessary to
disturb them further. During the first day or two, while the fever is
still moderate in degree, and during the uncertainty which then
usually exists as to the diagnosis, it will be sufficient to prescribe
the neutral mixture or the spirit of Mindererus in tablespoonful doses
every two or three hours. Upon the third day more active remedies will
generally be required to reduce the temperature. This is best done by
the cold-water treatment in some form or other, or by the internal
administration of antipyretic doses of quinia. The manner in which the
cold water is to be used and the cases to which it is applicable must
be left in a great measure to the judgment of the physician. In the
form of the cold affusion it is now rarely resorted to, although
Currie[31] obtained most excellent results with it. It is calculated,
however, to alarm a timid patient, and it is probably owing largely to
this fact that it has fallen into disuse. The cold bath, packing in a
cold wet sheet, and sponging with cold water are the more usual means
of employing cold in the treatment of typhus fever at the present day.
The cold bath is much used in Germany in the treatment of different
forms of fever, and even of inflammation. It is also resorted to in
this country, but it has never attained the same popularity here as
abroad. The best way of using it is as follows: The patient as soon as
his temperature rises above 103° F. should be placed in a bath having
a temperature between 80° and 90°, and which, whenever practicable,
should be brought to his bedside, as when he has to be carried to the
bathroom he is sometimes not only alarmed and rendered very nervous by
the operation, but may exhaust himself in his struggles to free
himself from his attendants. After his immersion cold water should be
gradually added until the temperature of the bath is between 60° and
70° F. The length of time he should be allowed to remain in the bath
will of course depend upon circumstances. If shivering is produced by
it, he should be at once removed from it and thoroughly dried and put
back to bed. If no such symptoms are observed, he may be allowed to
remain in it longer. As a general rule, a half hour is as long as will
be necessary or safe for him to continue immersed at any one time. His
temperature will usually continue to fall for some time after his
removal from the bath, but in the course of a few hours it will be
found to have risen again to 103° or over, when he should have another
bath. In this way it may be necessary to repeat the baths from eight
to twelve times a day. Some authors recommend that the patient should
be placed at once in a bath having a temperature of 50° F., {365} but
this method of applying cold possesses no advantage over that above
described, and is, like the cold affusion, very apt to excite alarm in
the patient. The cold bath is not, however, well borne by all persons,
and alarming symptoms, and even fatal collapse, have followed its use
in the old and feeble. It is also contraindicated when the skin is
covered with a profuse sweat or when the disease is complicated by an
internal inflammation. When the means of giving a cold bath are not at
hand, the cold pack will often be found a very efficient substitute
for it. Sponging with cold water, although not so efficacious in
reducing the temperature, has advantages over either of these methods
of applying cold. In the first place, it is more agreeable to most
patients and less calculated to excite alarm in those who are timid.
Again, it may be more frequently repeated, and may be used in cases in
which the cold bath is contraindicated. Occasionally alcohol or
vinegar may be added with advantage to the water, with the view of
increasing its refrigerant effects.
[Footnote 31: _Medical Reports on the Effects of Water, Cold and Warm,
as a Remedy in Fever and Febrile Diseases_, by James Currie, M.D.,
F.R.S., London, 1805.]
When quinia is given for the purpose of reducing the temperature in
the treatment of typhus fever, it must be used in large doses, as much
as ten or fifteen grains repeated once or twice in the course of
twenty-four hours being required for this purpose. When given in these
quantities it has the disadvantage of producing deafness and
occasionally of increasing the headache. I have therefore contented
myself in the cases which have fallen under my own care with giving it
in more moderate quantities, in combination with one of the mineral
acids, as, for instance, a couple of grains of quinia in solution with
from eight to ten drops of dilute muriatic acid, repeated from four to
six times a day. The mineral acids were originally recommended in the
treatment of typhus fever in the belief that they neutralized the
poison which caused the fever, and which was supposed to be ammonia or
some of its compounds. Although this theory is now no longer
entertained, there can be no doubt that the tendency in this disease
to the accumulation of ammonia in the blood is prevented by their
administration. Digitalis, aconite, or veratrum viride may also be
given in appropriate doses if with a high temperature there coexists
great frequency of the pulse. The first-named remedy is especially
indicated if there is at the same time diminution of the secretion of
urine.
As the disease progresses other symptoms present themselves for
treatment. One of the most urgent of these is the prostration. This
not only appears early, but is often extreme, and if not met by
appropriate remedies will often of itself be sufficient to cause the
death of the patient. As soon as it makes itself manifest stimulants
must be prescribed. These are, however, not to be resorted to simply
because the patient has typhus fever. Many cases do perfectly well
without them. In the young and robust it is often unnecessary to have
recourse to them. On the other hand, in the old, the feeble, and the
intemperate they should be employed early. The rule laid down by
Stokes, that they should be administered as soon as the first sound of
the heart becomes indistinct and inaudible, may be adopted for our
guidance in this respect. At first they should be given tentatively.
If the delirium, headache, and other nervous symptoms are increased
after their administration, it is best to withhold them. They should
be continued, on the other hand, when under their use the delirium
ceases or grows milder, the other nervous {366} symptoms subside, and
the patient falls into a refreshing sleep. The amount required to
prevent fatal prostration will of course vary in each case. I have
rarely myself found it necessary to prescribe more than half an ounce
of whiskey or brandy every two hours, and frequently a very much
smaller quantity has been found sufficient. Cases are, however,
reported in which from twenty to twenty-four ounces daily have been
given with asserted advantage.
Another symptom which often demands prompt relief is the headache.
When not severe, it may be relieved by the application of cold to the
head, either in the form of the ice-cap or by means of cloths
frequently wrung out of cold water, and by the administration of
moderate doses of potassium bromide; but when intense it requires more
active treatment for its removal, such as the application of cups to
the back of the neck or of leeches to the temples. General bleeding
will accomplish the same result, but the good which is done by it is
often more than counterbalanced by the prostration it induces.
Sleeplessness is also sometimes the cause of a good deal of distress
to the patient. When it occurs early in the disease and is caused by
the headache, it will generally subside under the use of the remedies
which are employed for the relief of the latter symptom; but when it
comes on at a later period, it will often require special treatment.
There is some doubt as to the propriety of giving opium under these
circumstances, but Murchison, Gerhard, and others assert that it may
be given not only without injury, but with positive advantage to the
patient. Graves was in the habit of combining it with a small quantity
of tartar emetic in the condition in which the sleeplessness is
associated with active delirium. If, on the other hand, the delirium
is of a low muttering character, it should be given with a diffusible
stimulant.
In this condition I have often found a pill containing a small
quantity each of opium and camphor, frequently repeated, to answer an
admirable purpose, not only in procuring for the patient the needed
repose, but also in diminishing the restlessness, jactitation, and
subsultus tendinum. Opium should, however, not be used at all or used
very carefully in cases in which there is congestion of the lungs or
disease of the kidneys. The existence of the pin-hole pupil is also a
contraindication to its employment. In young and robust patients, if
the insomnia is attended by active delirium, chloral in twenty-grain
doses, repeated if necessary, may often be given with advantage, but
it should never be prescribed in cases in which the action of the
heart is feeble. Other remedies which have been recommended in the
treatment of this condition are belladonna, hyoscyamus, musk,
chloroform, and cannabis indica. Potassium bromide appears to have no
power to relieve it. No special modification of the above treatment is
needed when delirium occurs independently of sleeplessness and
headache. When the stupor is profound, efforts should be made to rouse
the patient by the use of counter-irritants to the shaven scalp or to
the nape of the neck. Murchison speaks well of the administration of
strong coffee under these circumstances. If there is at the same time
suppression or diminution of urine, diuretics should be administered
in the hope of stimulating the kidneys to increased secretion.
Retention of the urine is not an infrequent occurrence in this
condition, and the physician ought never, therefore, to accept the
assertions of the {367} nurse or friends of the patient that the
latter has passed water, but should satisfy himself by an examination
in regard to the condition of the bladder at every visit. He will
often find that the apparent passage of urine is nothing more than the
dribbling due to an over-distension of this organ. Neglect of this
precaution has occasionally been the cause of much subsequent distress
to the patient, as cystitis is sometimes set up as a consequence of
it. In one case which came under my observation, and in which this
precaution had been neglected, the patient suffered from incontinence
of urine for some time after his recovery from the fever. Thirst is a
symptom which is always present and complained of at the beginning of
the fever, and usually bears some proportion to the severity of this
process. Weak tea, an infusion of cascarilla-bark, and camphor-water
have all been recommended by different authors for its relief, but it
is probable that no one of them possesses any superiority over water.
If the stomach is irritable and water is not retained, small pieces of
ice should be allowed to dissolve in the patient's mouth. Later, when
the stage of stupor supervenes, it is very important to see that the
patient obtains a full supply of water. In this condition he will not
call for it, although it is even more urgently required than before.
Vomiting may occur at any time in the course of typhus fever. If it is
observed at the very beginning of an attack, an emetic will often
arrest it, but when it supervenes at a later period, it is generally
of cerebral origin, and will usually subside under the use of the
remedies already referred to which are prescribed for the relief of
the nervous symptoms. In addition to these, sinapisms may be applied
to the epigastrium, and champagne, when the circumstances of the
patient will permit it, should be given in the place of whiskey or
brandy. When everything is rejected by the stomach, recourse must be
had to nutritious enemata. Constipation is to be overcome by gentle
purgatives, as the use of powerful cathartics is very apt to be
followed by troublesome diarrhoea. If this should come on, it is best
treated by small doses of opium in combination with a mineral or
vegetable astringent. When these fail, it may sometimes be relieved by
a prescription containing sulphuric acid and morphia, and at others by
enemata of from twenty to thirty drops of laudanum in warm water. When
glandular swelling occurs in the parotid region or in other parts of
the body, an effort should be made to promote resolution by painting
them with tincture of iodine. Blisters have also been recommended for
the same purpose, but they should be used carefully, as in low
conditions of the system they are sometimes followed by sloughing of
the integuments. If these remedies fail, poultices should be applied.
As soon as pus has formed it should be evacuated by one or more free
incisions.
Very few attacks of typhus fever run their course without the
occurrence of some pulmonary complication. When this is slight it
demands no special modification of the previous treatment, and it is
sufficient to apply mustard poultices or stimulating liniments to the
chest. But in cases of greater gravity, it matters not whether the
complication is bronchitis, congestion of the lungs, or pneumonia, a
more active treatment is required. Under these circumstances the
ammonium carbonate in five-grain doses, given in mucilage of acacia,
frequently repeated, or from thirty minims to a teaspoonful of the
aromatic spirit of ammonia every {368} two hours, sufficiently
diluted, may be prescribed with great advantage. When gangrene
supervenes the prognosis is almost hopeless, but an effort should be
made to save the patient's life by the administration of potassium
chlorate and of an increased amount of stimulus. Murchison also speaks
well of the inhalation of tar vapor and of carbolic acid.
As the other complications of typhus are at least of as common
occurrence in typhoid fever, it will avoid a good deal of useless
repetition to refer the reader to the article on the latter disease
for a description of the treatment which they render necessary.
The patient should be kept in bed for some time after the subsidence
of fever. Although relapses are rare in this disease, recrudescences
of fever not infrequently occur as a consequence of undue exertion in
the early part of convalescence. Syncope is also not infrequently
produced by the patient's sitting up too soon. The diet should be
carefully regulated until the recovery is complete. It should at first
consist wholly of liquid or semi-liquid articles of food, but later
meat in some digestible form may be allowed. Stimulants are often as
urgently demanded at this time as during the fever itself. They should
be given as the strength returns in gradually diminishing quantities.
The length of time during which it is necessary to continue them will
depend in great measure upon the previous habits of the patient. As a
general rule, their use should not be abandoned until he is able to
leave his bed, and they may often be continued after this with benefit
to him. As convalescence progresses it will be well to substitute ale
or porter for the brandy or whiskey the patient had previously taken.
A return to health will also be promoted by the judicious use of
tonics, such as iron, quinia, Huxham's tincture, tincture of nux
vomica, the mineral acids, and even cod-liver oil in some cases.
{369}
RELAPSING FEVER.
BY WILLIAM PEPPER, M.D., LL.D.
SYNONYMS.--Febris recidiva, vel recurrens; Fièvre a rechutes; Fièvre
recurrente; Typhus icterodes, vel recurrens; Bilious Typhoid Fever;
Rückfall's Typhus; Tifo recidivo; Famine Fever, Hunger-pest,
Armentyphus, Hunger-typhus, Spirillum Fever.
DEFINITION.--Relapsing fever is an epidemic contagious disease, the
specific cause of which is not certainly known, although a peculiar
spirillum appears to be constantly present in the blood. It occurs
chiefly among the over-crowded and destitute, but may spread widely
when introduced among more favorably situated populations. Its
invasion is abrupt, and is marked by a distinct chill or rigor,
followed quickly by high fever (104° to 106°), with severe headache
and pains in the back and limbs. Delirium is comparatively rare. The
tongue is heavily coated, and there are epigastric tenderness,
vomiting, constipation, and enlargement of the liver and spleen, with
frequent jaundice. There is no characteristic eruption. These symptoms
cease abruptly from the fifth to the seventh day, with copious
sweating; but after an apyretic interval of about a week's duration a
relapse occurs similar to the first attack, but of less duration
(three to five days). Second, third, or even more numerous relapses
may subsequently occur at less regular intervals. One attack does not
protect against a second one to the same extent as with other
contagious diseases. The mortality is usually small.
HISTORY AND GEOGRAPHICAL DISTRIBUTION.--It is not important to
consider here at any length the history of this disease. Allusions to
it were made by Strother, 1729, and by Huxham, 1752, but the first
reliable account on record is the description of an epidemic in the
year 1739 by John Rutty.[1] Relapsing fever undoubtedly occurred at
different times and at various places during the next hundred years,
although the records of it are scanty, and for the most part
imperfect, owing chiefly to the want of a clear recognition of its
essential difference from typhus and typhoid fevers.
[Footnote 1: _A Chronological History of the Weather and Seasons_,
etc., London, 1770, pp. 75-90.]
During the decade from 1842 to 1852 relapsing fever prevailed in a
very active and widespread form. Epidemics occurred in England,
Scotland, and Ireland, in various parts of Germany, and it was during
this time that it was first observed and described in America. In
June, 1844, an emigrant ship from Liverpool came to America with
eighteen cases on board, which were taken to the Philadelphia and
Pennsylvania {370} Hospitals. In 1848 a few cases were imported by
emigrants to New York, and in 1850 to Buffalo in the same way.[2]
[Footnote 2: See _Fevers, their Diagnosis, Pathology, and Treatment_,
Meredith Clymer, Phila., 1846, p. 99; _Clinical Reports on Continued
Fever_, A. Flint, Phila., 1855, p. 364; Dubois 1848.]
The next great outbreak of relapsing fever began in Odessa in 1863 and
lasted until 1872. It prevailed in various parts of Russia, in
Germany, France, and Great Britain, and for the first time occurred
extensively in the United States, especially in Philadelphia and New
York. The present article is based largely on a study of this epidemic
as it presented itself in Philadelphia during the years 1869-70, when
the writer, in conjunction with the late Edward Rhoads, had the
opportunity of observing about two hundred cases, in the wards of the
Philadelphia Hospital. An admirable article on the same epidemic
appeared from the pen of the late John S. Parry, in the _Amer. Jour.
Med. Sciences_, N.S., vol. lx., Oct., 1870, p. 336.
Between the years 1877 and 1880 relapsing fever occurred quite
extensively at Bombay, and was there studied by Carter[3] and Lewis;
and during 1879-80 it prevailed in Königsberg, an account of which
epidemic has been published by Meschede.[4]
[Footnote 3: _Spirillum Fever_, by H. Vandyke Carter, M.D., London,
1882.]
[Footnote 4: _Virchow's Archiv_, Bd. lxxxvii. p. 393.]
The geographical distribution of relapsing fever is seen, therefore,
to have been very extensive; and not only has it occurred in the
above-mentioned localities, but there have also been less extensive
outbreaks in France, India, Egypt, Algeria, South America, and
elsewhere.
CAUSES.--In all probability the essential cause of relapsing fever is
a specific poison, but we know nothing of its real nature nor of the
precise conditions under which it originates. Recent investigations
have shown that the spirillum discovered by Obermeier is constantly
present during the febrile stages of relapsing fever, but it cannot
yet be decided whether this minute organism is the actual cause or
only an invariable accompaniment of the disease.
It appears that conditions of destitution, filth, and intemperance
amongst an overcrowded population favor the development of the virus,
and hence the epidemics have, as a rule, begun in towns, such as
Dublin, Glasgow, Odessa, St. Petersburg, Breslau, etc., where such
conditions prevail. Great importance has been attached, in particular,
to the scarcity of food and to destitution as powerful factors in
favoring the production of the disease. Some of its names
(hunger-pest, hunger-typhus, famine fever) have been given with
reference to this, and in the case of several outbreaks a careful
comparison has been made of the decrease of the food-supply and the
consequent advance in price of the staple commodities with the
development and progress of the disease. Although this is in all
probability true of those centres where relapsing fever originates, it
has but a partial application to the secondary centres where the
disease is imported and develops.
The presence of destitution and filth, enfeebling the vitality of a
section of the community, would favor the spread of this as of any
other specific fever, but there is considerable evidence to favor the
view that the importance of starvation as a cause of the fever has
been exaggerated. This was strongly urged by Parry[5] as the result of
his study of the {371} Philadelphia epidemic of 1870, and our own more
extended observation showed that the vast majority of the patients
appeared to be well fed. On the other hand, the influence of
overcrowding as favoring the development and spread of relapsing fever
has been clearly established by the study of many epidemics, as in the
Breslau attack of 1868, reported by Wyss and Bock, where single
tenement-houses furnished as many as seventy-one cases; in the
Edinburgh epidemic of 1869 and 1870, where Muirhead found the
breathing-space allotted to each individual in the affected houses to
vary from 250 to 400 cubic feet; and in the Philadelphia epidemic,
where the observations of Parry and ourselves showed the presence of
an extreme degree of overcrowding in most of the houses where the
disease broke out.
[Footnote 5: _Loc. cit._, p. 339.]
No age is exempt, but neither can it be said that age exerts any
influence upon the occurrence or frequency of relapsing fever. Of 1164
cases in the Philadelphia epidemic of 1869-70 in which the age was
noted, the result was as follows:
Males. Females.
Under 20 149 76
From 20 to 30 220 140
From 30 to 40 143 101
From 40 to 50 135 67
From 50 to 60 60 34
From 60 to 70 20 6
From 70 to 90 6 7
--- ---
Total 733 431 = 1164
The youngest cases were in children two or three years old; the oldest
patients were women over eighty-five years old.
Sex exerts no influence, though, on account of the larger proportion
of males likely to be exposed to the specific cause, the results of
nearly all epidemics show a preponderance of male patients in the
proportion of 33 per cent., 66 per cent., or even 85 per cent.
(Meschede).