84 Transactions of Clinical Society of London, 1880.
RELAPSES.—Much difference of opinion will be found to exist among authors in regard to the frequency with which relapses occur in typhoid fever, and this difference does not appear to be due to any greater frequency of this accident in some countries than in others, since Liebermeister met with them in 8.6 per cent. of the cases treated at the hospital at Basle, while, according to other German observers quoted by him, they occur in 6.3 per cent. (Gerhardt), in 11 per cent. (Bäumler), and in 3.3 per cent. (Biermer). Murchison noted them in 80 of 2591 cases in the London Fever Hospital, or in 3 per cent., and Maclagan in 13 of 128 cases at Dundee, or in 10 per cent. about. Immermann85 of Basle says that they occur in 15 per cent. of the cases, and that in very unfavorable years the proportion may be as high as 18 or 19 per cent. Prof. Henoch86 observed relapses in 16 cases out of 96, or 16.6 per cent. In my own practice they have not been very numerous. I find that in 80 cases of which I have full notes they are recorded five times, or in 6.25 per cent., and I believe this ratio correctly represents the frequency with which they have happened in all the other cases which have come under my care. Part of this difference of opinion is unquestionably attributable to the fact that under the term relapse are sometimes included two distinct conditions: (1) Mere recrudescences of fever, which occur during the stage of defervescence or that of convalescence, and which are provoked by errors of diet, mental or bodily fatigue, or some other irritating cause. They usually last a day or two, and are entirely distinct from (2), true relapses, in which all the characteristic symptoms of the primary attack are reproduced, and which commonly occur some time after the disease has apparently run its course. There is occasionally no distinct apyretic interval between the two attacks, but in by far the greater number of instances the relapse occurs in the second or third week, or even later, after the establishment of convalescence. In 20 cases reported by W. M. Ord and Seymour Taylor87 the relapse occurred in the third week of the disease in 1; in the fourth week in 5; in the sixth week in 3; in the seventh week in 7; in the eighth week in 3; in the ninth week in 1. James Jackson refers to a case in which the date of the relapse is not given, but in which he was able to detect the rose-colored eruption in the sixty-sixth day88 from the commencement of the disease. In my five cases the relapse occurred on the seventh, eighth, ninth, eleventh, and twentieth day after the apparent establishment of convalescence. In these cases the duration of the relapse was 11, 13, 17, 20, and 13 days respectively. The highest temperature noted in any of the relapses was 105°, which occurred in two cases. In both of these this temperature had also occurred in the original attacks. In one of the others, however, a temperature of over 104° F. was repeatedly observed in the relapse, while in the primary attack it had never risen above 102°.
85 Schweiz. Corr. Bl., viii. 1878.
86 Charité Ann., ii. 1875.
87 St. Thomas's Hospital Report, vol. ix., London, 1879.
88 Since the above was written I have had under my care a case of typhoid fever in which a third relapse occurred nearly four months after the patient, a woman aged thirty years, was first taken ill. The following is a brief abstract of the history of this remarkable case: The original attack began about Sept. 20, 1883, was of moderate severity, and lasted between three and four weeks. Convalescence, which seems to have been nearly complete, as the patient had left her bed, was interrupted on Nov. 1st by a relapse, during which she was admitted into the Pennsylvania Hospital. This relapse was severe, and before it had entirely run its course was itself interrupted, on Nov. 17th, by an intercurrent relapse, which lasted two weeks. During these two relapses extensive bed-sores formed upon the nates, occasioning more or less irritation and consequent febrile reaction. On Jan. 11, 1884, a third relapse occurred. This relapse was accompanied by diarrhoea, rose-colored spots, tympany, dry and brown tongue, and other characteristic symptoms of typhoid fever, the diagnosis being fully concurred in by my colleague, Dr. Morris Longstreth, who saw the case with me. Convalescence was again interrupted on Feb. 13th by fever, which continued for two weeks, but which possessed none of the characters of typhoid fever, and was clearly due to imprudence on the part of the patient. The patient is now (April 25, 1884) entirely well, and will shortly be discharged from the hospital.
The onset of a relapse is usually much more abrupt than that of the original attack. It is rarely preceded by prodromata. The temperature rises more rapidly and attains its maximum earlier, which may be much greater than in the original attack. In one case under my care it reached 105° on the evening of the first day, and temperatures of 103.5° and 104° on the evening of the second day are not infrequent.
The rose-colored eruption appears earlier. In 38 cases investigated by Murchison with reference to this point, it appeared on the third day in 7; on the fourth in 8; on the fifth in 7; on the sixth in 2; on the seventh in 12; and at a later date in 2. In the case the history of which is given below it was detected on the second day. The delirium also comes on sooner. The relapse is usually less severe, and is of shorter duration, than the primary attack. All my cases terminated in recovery. Occasionally, however, it is much more severe. In one case in which the primary attack was so mild that the patient could scarcely be persuaded to remain in bed, the relapse was so severe that for many days it was uncertain whether the patient would recover. In another intestinal hemorrhages to an alarming extent occurred on two occasions. Moreover, of Murchison's 53 cases, 7 were fatal; in 2 of the cases death was due to perforation; in 2 to peritonitis, induced by infarction of the spleen; and in 1 to abortion; and of Ebstein's 13 cases, 3 were also fatal. Occasionally, a second, and it is said even a third, relapse is noted. In one of Da Costa's cases hemorrhage from the bowels took place during a second relapse.
| FIG. 15. |
| Pulse. |