Part 56

{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. 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.

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.

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 and Lewis; and during 1879-80 it prevailed in Königsberg, an account of which epidemic has been published by Meschede.

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 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.

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).

Nationality does not act as a predisposing cause, except in so far 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.

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 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.

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.

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.