as certain countries may present more frequently than others the
conditions favorable for the development of this disease. Of 1170
cases in Philadelphia in which the nativity was noted, 219 were Irish,
61 English, 161 German, 729 American. Of the latter 729, about
one-half, or nearly 28 per cent. of the whole number, were negroes,
while the negro population of Philadelphia was only about 3.3 per
cent. of the total. This excessive proportion of cases among the
negroes was undoubtedly due in large part to the fact that in
Philadelphia overcrowding is notoriously more common and extreme among
them than in any other portion of the population, although it is also
likely that they present an excessive susceptibility to the virus of
this as of many other specific diseases.
[Footnote 6: Hirsch's _Geog. and Hist. Pathology_, New Syd. Soc. ed.,
1883, vol. i. p. 615.]
Attempts have been made to show some connection between the period of
the year or the atmospheric conditions and the rise and spread of
epidemics of relapsing fever; but, as Murchison clearly showed, these
epidemics are wholly independent of such influences. In Philadelphia,
of 1176 cases in which the date of occurrence is known, there occurred
in September, 1869, 4 cases; December, 1869, 6 cases; January, 1870, 5
cases; February, 1870, 13 cases; March, {372} 1870, 124 cases; April,
1870, 209 cases; May, 325 cases; June, 293 cases; July, 115 cases;
August, 19 cases; September, 28 cases; October, 15 cases; November, 1
case; December, 2 cases; January, 1881, 2 cases; February, 1 case;
March, 2 cases; May, 7 cases; June, 2 cases; September, 2 cases;
October, 2 cases.
Occupation exerts no predisposing influence, but in all epidemics the
great majority of cases occur among the vagrant classes, who lead a
precarious life and commonly sleep in foul, overcrowded lodgings.
Murchison noted that in the London epidemics a considerable proportion
of cases occurred among recent residents, but he attributed this,
correctly, not to any special local cause, but merely to the fact that
this floating population is largely of the vagrant type. In
Philadelphia a careful inquiry showed that recent residence produced
no special predisposing influence, and a study of other epidemics
confirms this view.
Contagion is, however, the essential cause of the spread of relapsing
fever when the virus has once been developed. It seems clear from the
distinct periods and from the widely-separated localities in which
different outbreaks of relapsing fever have occurred that its special
poison is capable of being called into existence or activity by
favoring conditions. Murchison held the belief that it was very
intimately connected with, if not generated by, destitution, and, as
already stated, much evidence exists to show that the disease is most
apt to break out after periods of scarcity; but no just and convincing
proof exists that destitution, any more than over-crowding and other
depressing influences, can actually engender a specific contagium
capable of being transported to great distances and of originating
widespread outbreaks of the specific disease among differently
situated populations. It appears necessary to assume the existence of
some unknown special virus which finds its suitable nidus for
development in the conditions attendant on filth and overcrowding, and
which attacks with greatest facility the systems of those who are
enfeebled by want and depressed by vitiated air. When once this
specific poison has been called into active existence, however, there
can be no doubt as to the fact that it can be carried by fomites, and
that it is given off from the bodies of relapsing-fever patients so as
to affect any who may approach. Although a few observers have doubted
this contagiousness of relapsing fever, the evidence in its favor is
overwhelming. In many epidemics, as in Philadelphia in 1869, its
contagiousness is at least as intense as that of typhus fever. A
single case may, indeed, be admitted to a healthy family among the
better classes or into the wards of a well-ventilated hospital without
propagating the disease, although striking cases of contagion are on
record where a patient has communicated the disease to all the members
of a family favorably situated and living at a distance from any other
possible source of contagion. On the other hand, if admitted to an
overcrowded and filthy lodging the disease is apt to spread rapidly.
Wyss and Bock report seventy-one cases as having occurred in a single
lodging-house during the course of the Breslau epidemic of 1868, and
in Philadelphia single houses in several instances furnished more than
a score of cases, and several short streets more than one hundred
cases each.
In the Philadelphia Hospital twenty-three persons lying sick in the
wards with other affections contracted relapsing fever from the
patients {373} admitted with that disease; two of the visiting staff,
five resident physicians, and nine nurses also suffered attacks of
varying severity. This corresponds with the general experience of
those connected with fever hospitals during the prevalence of
relapsing fever.
As in the case of typhus and other contagious diseases, the distance
at which relapsing fever can be contracted by direct contagion through
the atmosphere is a very short one, not exceeding a few feet at most.
The poison may be carried by fomites. Instances are on record where
persons having visited infected districts have conveyed the disease to
others at a distance without contracting it themselves.
When rooms which have been occupied by relapsing-fever patients are
subsequently occupied by other persons, these are very liable to
acquire the disease. Parry relates two remarkable cases in which
relapsing fever was transported to a distance by infected clothes; and
it has been more than once observed that during epidemics of this
disease laundry-women engaged in washing the clothes of fever
patients, but without any means of more direct communication with the
sick, were frequently attacked (Cormack, Wyss and Bock).
In connection with the etiology of relapsing fever it is necessary to
consider the rôle played by a minute organism which has been
frequently detected in the blood of patients suffering with this
disease. This spiro-bacterium was first observed in relapsing fever by
Obermeier[7] in 1873, and has since been identified as a spirillum or
spiroechete. The very numerous observations of Obermeier, Albrecht, H.
V. Carter, Motschutkoffsky, Koch, Cohen, Holsti, Enke, Meschede, and
others leave no doubt that this peculiar parasite does occur at least
very frequently in the blood of patients with this disease. The
failure to detect it, which has been reported by several good
observers, may readily have been due to the extreme delicacy of the
organism, or to the neglect of the proper method of preparing the
slides of blood for examination, or to delaying the examination of the
blood until after death, when it rapidly disappears. Thus no value can
be attached to the negative observations of Rhoads and myself, made
prior to Obermeier's discovery, since our method of examination was
not sufficiently exact.
[Footnote 7: _Centralbl. f. die med. Wissensch._, 1873, No. 10.]
The following description of the mode of examining the blood, and of
the spirillum, is condensed from H. V. Carter's account: It is
necessary to employ magnifying powers of not less than 500 diameters.
The fresh blood may be examined immediately after obtaining it by
pricking the washed finger of the patient. For preservation dried
specimens are needed: a very thin layer of fresh blood is evenly
spread with the needle over the glass cover, exposed to the weak fumes
of a solution of osmic acid, and allowed to dry under protection from
dust; the dried film of blood may then be treated with glacial acetic
acid or may be stained.
[Illustration: FIG. 19. Spirillum from the blood in a case of
relapsing fever, X 700 (Koch).]
The spirillum [See Fig. 19] is a colorless, slender, twisted filament,
which when quiescent has a length of 2.66 times the diameter of a
blood-disc (1/1500 to 1/500 inch = 0.012 to 0.043 millimetre). When
unfolded they become distinctly elongated. They are very narrow (not
more than 1/40000 inch), and present four to ten spiral turns; when
fresh they are in active movement and unfold in part, becoming wavy or
bent. They {374} resist the action of concentrated acetic acid, and
are readily stained by certain dyes. In number, five or ten may be
visible in a field or they may be too numerous to count. They have not
been detected either in the secretions or in the evacuations. Both
Koch and Carter have succeeded in cultivating this special form of
bacteria outside of the body.
To judge from the observations thus far made on this difficult
question, the parasite is found first toward the close of the period
of inoculation or soon after the beginning of the fever, or it may be
detected throughout the febrile stage; but shortly before the
cessation of the fever it quickly disappears, to reappear at the time
of the relapse. There would seem, therefore, to be some close
connection between the febrile paroxysms and this organism, and it is
not remarkable that many observers have concluded that this spirillum
is the essential and specific cause of the fever, and that it is
impossible to have this disease present without the appearance of the
parasite in the blood; nor that the name spirillum fever has been
applied to the disease by Carter.
Such conclusions appear to be premature, however, and we prefer to
regard the undoubted existence of the spirillum in the blood of
relapsing-fever patients as at present only an important aid in
diagnosis, and to await the occurrence of other epidemics and the
repetition of careful studies upon this organism, both within and
without the human system, before venturing to decide whether it is
merely one of the phenomena of the disease or whether it is its true
cause and specific contagious principle.
It must be added that both Carter and Koch have succeeded in
inoculating monkeys with relapsing fever, and Motschutkoffsky[8] of
Odessa, who had the opportunity of inoculating a human being, asserts
that he succeeded in producing the disease, and found the incubation
period to be not less than five nor more than eight days. Carter also
gives an interesting table[9] of six instances of inoculation, four of
them by cuts while making autopsies, with consequent development of
relapsing fever in each instance. Some allowance must be made for the
fact that in all the instances of this series there had been exposure
to contagion by close communication with fever patients, though this
exposure had existed for several months previously without leading to
the development of relapsing fever.
[Footnote 8: _Centralblatt f. d. med. Wissenschaften_, 1876, No. 11,
p. 194.]
[Footnote 9: _Op. cit._, p. 403.]
GENERAL CLINICAL DESCRIPTION.--After a period of not less than five or
six days from the reception of the contagion the disease begins {375}
abruptly with a chill of variable severity, accompanied by headache
and aching pains in the back and limbs. The patient feels weak and is
often giddy, but is not always obliged to go to bed the first day.
Nausea and vomiting are among the earliest symptoms, and distress at
the epigastrium, with tenderness, may attend or even precede the
chill. Fever quickly follows; the pulse runs up from 110 to 130 in a
few hours; the temperature reaches from 103.5° to 106° by the end of
twenty-four hours; the pains increase, and there are insomnia and
great restlessness; appetite fails; thirst is extreme; the tongue is
moist and furred, and the bowels quiet. During the subsequent six days
these symptoms persist. The temperature presents a daily remission at
some period of the twenty-four hours amounting to one or two degrees,
the maximum reached in fully-developed cases varying from 104° to
108°. The pulse continues very rapid, and not rarely exceeds 140; the
respirations are hurried and rapid, and cough attends many cases.
Delirium is rare, but insomnia, restlessness, headache, and rheumatic
pains in the back and limbs may prove constantly annoying. Appetite is
variable, more frequently lost; nausea and vomiting are common; thirst
is very troublesome; and the bowels are constipated or loose. No
characteristic eruption appears, but sudamina are frequently present,
since in a large proportion of cases there is more or less sweating,
even during the continuance of high fever. Abdominal pain, tenderness
in the epigastrium and hypochondria, and demonstrable enlargement of
the liver and spleen are almost invariable. The urine is concentrated
and dark or bile-stained. Jaundice is a common symptom, though its
frequency varies greatly in different epidemics. The same may be said
of epistaxis.
While these symptoms are at their height and the patient is suffering
severely the paroxysm suddenly ceases, and in a few hours he is
entirely relieved. This remarkable crisis occurs usually at the close
of the seventh day, but may occur as early as the third or as late as
the fifteenth day. It is attended with a critical discharge, copious
sweating being by far the most common, though diarrhoea, free
epistaxis, or hemorrhage from some other surface may replace it. The
patient feels weak and languid; the temperature and pulse have fallen
below the normal, and remain so for a day or two. Soon there is a
rapid improvement in the appetite and the appearance of the tongue,
and the patient regains strength day by day, and often feels so well
that it is difficult to persuade him that he must avoid exertion and
exposure. The enlargement of the spleen subsides rapidly, that of the
liver more gradually; epigastric tenderness subsides, but in many
cases some degree of it persists for several days. This interval or
apyretic period lasts about a week, when, again without warning or
provocation, the patient relapses, and is seized abruptly with the
same set of symptoms which attended the first attack. This relapse
does not usually last more than three days (one to five are the
limits), and is terminated by a similar crisis, after which a slow
convalescence is entered upon, or else after an apyretic interval of
some days' duration a second relapse ensues, and this may, in rare
cases, be in turn followed by a third, fourth, fifth, or even sixth
similar relapse. In addition, it must be noted that many serious
complications are liable to occur. The total duration of the disease
thus varies from eighteen to ninety days. Convalescence is often
tedious, and there are many troublesome sequelæ. {376} The mortality,
however, is not great, averaging 5 or 6 per cent. Death may occur
suddenly from collapse at the close of the first paroxysm or from
heart-clot; it may be produced by exhaustion in protracted cases; or
be hastened by any serious complication; or the patient may sink into
a typhoid condition, with low delirium, coma, and suppression of urine
for several days before the fatal termination.
DETAILED STUDY OF SPECIAL CONDITIONS.--It is usually difficult to
determine the period of incubation. In the unique case in which
Motschutkoffsky is said to have produced relapsing fever by
inoculation the initial symptoms occurred seven days after the
inoculation. Wyss and Bock had several good opportunities of
determining the minimum period of incubation, and found it to be six
days. We may assume that the ordinary period is six to eight days, but
that it varies, in accordance with the virulence of the virus or the
susceptibility of the system, from four to fourteen days. During this
time the patient feels as well as usual, or at most suffers for a day
or two from slight malaise, with vague rheumatoid pains, headache,
giddiness, and anorexia. In only 13 out of 181 of our cases in which
this point is noted was the invasion gradual. Examination of the blood
prior to the invasion does not discover any spirilla.
The invasion is usually abrupt and during the daytime; the patient can
often fix the very hour of its occurrence, a severe chill attacking
him while at work or at meal-time. This is the most common initial
symptom (138 out of 168 our cases of sudden invasion); less commonly,
obstinate vomiting and nausea or sudden vertigo are the first symptoms
(each 8 times out of 168), or violent headache (14 times out of 168),
or sharp epigastric pain. Parry also observed that the occurrence of
obstinate and profuse vomiting as the initial symptom was especially
frequent in children.
The physiognomy is carefully noted in one hundred and seventy of our
records. The countenance is often flushed, with watery eyes and
anxious, suffering expression. The flush is less dingy and dull than
in typhus; the eye is comparatively rarely injected; and the
expression is much less dull and stupid than in that disease. In cases
where grave nervous symptoms supervene and the typhoid condition is
developed the facies assumes all the characteristics of that state.
The livid bronzing of the face, described by Cormack in 1843 and by
Carter (Bombay epidemic of 1877), was noticed in a moderate degree in
only nine of our cases, and seems to be of infrequent occurrence. When
we observed it it seemed due to an admixture of a faint jaundice tinge
with a deep flush. Jaundice, as already stated, is of common
occurrence, though its frequency varies greatly in different
epidemics. It was present in 25 per cent. of our cases, rather more
frequently in the negro patients than in whites, and in degree varied
from a slight tinge of the conjunctiva and skin to the deepest
staining of the entire body. The presence of jaundice in combination
with the general features of high fever imparts a most peculiar and
alarming appearance to such patients.
With the occurrence of the crisis the flush rapidly subsides and the
face becomes pale, or, if the discharges have been profuse, it may
appear sunken, haggard, and almost choleraic. Parry described a
peculiar puffed, velvety look at this stage, as though the skin had
been much thickened and softened at the same time.
{377} There is no characteristic eruption in relapsing fever. In 150
out of 180 cases where the condition of the skin was carefully noted
there was no eruption of any kind; in 4 cases there were small
roseolar spots, with peculiar subcuticular mottling, which resembled
the early stages of typhus eruption, but soon faded away without
becoming petechial. A similar eruption was noticed by Murchison in 8
out of 600 cases. It appears from the third to the seventh day of the
first paroxysm; it may or may not recur in the relapse, or it may
occur then only. Eruptions apparently similar to this have been
described by others as quite common in certain epidemics. Carter
describes minutely an eruption which was noted in at least 10 per
cent. of his Bombay cases, the spots of which were at first small,
slightly raised, and pinkish or rose-colored, and which either faded
away soon or changed into purplish, more persistent stains. In a
valuable report on the Königsberg epidemic of 1879-80, Meschede[10]
remarks that roseola was observed in cases complicated by exanthematic
typhus, which prevailed simultaneously, but in no case of
uncomplicated relapsing fever. While, however, this suggestion may
apply to some few of the cases of eruption observed by others, it is
certainly inapplicable to the vast majority of them. We also noticed
an eruption of pale-reddish, slightly elevated papules in seven cases.
It must be borne in mind that persons of such a low class as are the
great majority of relapsing-fever patients would naturally be expected
to present a variety of cutaneous eruptions from filth or vermin, and
that in consequence some of the appearances above described may have
been of such origin. It is certain that the bites of either
mosquitoes, fleas, or bedbugs may in this disease be followed by
persistent reddish papules passing into petechiæ. Apart from this,
however, true petechiæ have been quite common in some epidemics, while
very rare in others. Parry saw "small spots of purpura" once only, in
a delicate girl; and we did not observe petechiæ once in several
hundred cases, many of which had extensive internal ecchymoses. On the
other hand, they have been found in as much as 30 per cent. of all
cases (314 out of 1000 cases, Smith at Glasgow). They do not appear on
any fixed day, but are more common in the first paroxysm than in the
relapses; and although sometimes associated with a tendency to
hemorrhages from other surfaces, they have been so often observed in
cases of ordinary severity that scarce any unfavorable prognostic
value can be attached to them.
[Footnote 10: _Virchow's Arch._, Bd. lxxxvii., p. 405.]
Vibices and extensive ecchymoses of the surface are of much more grave
import, and in cases where fatal sinking is threatened they may appear
accompanying a purplish lividity of the countenance.
Herpetic eruptions about the mouth or nostrils were observed in 20 out
of 181 of our cases in which this point is noted. They appeared
usually toward the close of the febrile stage, and their development
was found to have value in determining the approach of the crisis.
Bärensprung mentions especially the occurrence of herpes labialis in
cases of irregular relapsing fever which bore considerable resemblance
to typhus. Sudamina are, as might be expected in a disease attended
with so much sweating, of quite common occurrence, though much more so
in some epidemics than in others, unless searched for with greater
care by the one set of observers. Desquamation was noted in 42 out of
181 of our cases, and {378} invariably at the close of the relapse. It
was usually confined to the hands and face, and occurred in the form
of comparatively small flakes. This is more frequent than has been the
case in most epidemics. Murchison quotes a case in which a piece of
epidermis ten inches square separated from the body of a lad
convalescent from relapsing fever.
A peculiar odor exhaling from patients with relapsing fever has been
repeatedly noticed. A description of this unpleasant symptom, given by
Kelly, as quoted by Murchison,[11] accords closely with what was
frequently manifest in our own cases: "The smell was peculiar, not
fetid or heavy, but somewhat like burning straw with a musty odor."
Carter, in describing a similar odor in some of his cases, notes that
the skin was not in these instances in a particularly foul state.
[Footnote 11: _Op. cit._, p. 346.]
From what has already been said, it will be anticipated that the
variations of the temperature in relapsing fever constitute the most
peculiar and characteristic feature of that disease. A careful study
of the accompanying charts will convey a more accurate impression than
can be given by any description. The temperature begins to rise before
the chill is fully developed, and when there is no initial chill the
patient may be found within a few hours of the appearance of giddiness
and headache with a temperature of 102.5° to 103.5°. Before
twenty-four hours have passed it has risen to from 104° to 106°.
During the paroxysm the febrile movement is continued, presenting
merely a diurnal variation of one to two degrees, sometimes attended
with sweating and partial relief of distressing symptoms, the minimum
being observed at different hours in different cases, or even in the
same case, though more frequently it occurs in the morning.
In a case reported by Parry a chill recurred at the same morning hour
on three successive days. Wyss and Bock report some unusual cases in
which a brief intermission occurred, with a fall of pulse and
temperature to the normal, most frequently on the day before the real
termination of the paroxysm. The highest temperature varies from
104.5° to 108.75°; in our cases the highest observed was 107.5°. This
occurs, as a rule, on the last day or the day before the last of the
initial paroxysm, and Obermeier has observed a sudden rise of four
degrees in half an hour just before the crisis. Meschede,[12] however,
found the highest temperature on the corresponding days of the first
relapse.
[Footnote 12: _Loc. cit._]