A clinical study of relapses in typhoid fever : with an analysis of 25 relapses in 21 out of 166 typhoid fever cases / by H.F.L. Ziegel.

  • Ziegel, Hermann Fred Lange, 1876-
Date:
1912
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Credit: A clinical study of relapses in typhoid fever : with an analysis of 25 relapses in 21 out of 166 typhoid fever cases / by H.F.L. Ziegel. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    so far as the relapse is concerned are syphilis, relapsing fever, and the subacute infective endo- carditis of Libman and Celler,^^ a study of the blood in which diseases shows that there can be a true septicemic relapse in an infectious disease without the supervention of a new infection. From clinical considerations the recurrences in scarlet and rheumatic fever would appear to be analogous bacteriologically to the relapse in ty- phoid fever. As to the occurrence of relapses in Mexican typhus, I wrote to Dr. Joseph Goldberger of the United States Public Health and Marine-Hos- pital Service, whose reply was in part as follows: “With respect to relapses in typhus I can tell you but little from my own experience. I have seen only one instance of it. I enclose the fever chart of this case. You will note that after an intermission of 48 hours the temperature again rose and was up about 48 hours. Mexican friends tell me that relapses are extremely infre- quent ; my own experience is in harmony with this opinion. Similarly, although quite infre- quent, second attacks may be observed. I saw one such case in his second attack in Mexico City last winter. The interval between attacks was four months. “With reference to typhus attacks in the monkey, I can speak more definitely. In our work—Dr. Anderson’s and mine—we have so far encountered two very well-marked relapses. In one monkey the relapse following an apyretic interval of 5 and in the other of 12 days; the former was a typhus following blood inocula- tion, and the latter was one following the bites of body lice. I think I showed these fever curves on the screen at the New York Academy of Medicine.” Month ^7 2-f // TS?? / / 7 Day f u /I. rJ >s K, n IS- If t/ 12 disease*- “Cent. 41 40 39 J \J k 38 ' i\ 37 \f '1 h j '1 3G i/' V / f Temperature curve in a case of Mexican typhus with Relapse (rare). Courtesy of Drs. John F. Anderson and Joseph Goldberger of the United States Public Health and Marine-Hospital Service. Though my unfamiliarity with Mexican typhus hardly permits me to pass judgment, yet I am of the opinion that this is not a relapse in the proper sense of the term (v. section V. on definition of relapse, etc.). In typhoid fever, at any rate, this temperature curve would be interpreted as exhibiting a spurious relapse or pre- critical drop of temperature with a recrudescence. IV. Blood cultures; etiological and pathologi- cal considerations.—In 2 of the 21 relapse cases on which this study is based, blood cultures dur- ing the relapse were positive whereas they had been negative during the original attack. In the triple relapse case, which was originally ad- mitted to the service of my colleague. Dr. Sydney Stein, there was a positive blood culture during the second relapse, which clinically was much more severe and of much longer duration than any of the other three attacks. Wood^'‘ mentions 19 relapses in which the bacilli reappeared in the blood in 16. Cabot^® describes a case of multiple relapses in which the diagnosis was established during one of them by a positive blood culture and positive Widal reaction, the patient having been ill five months before admission to the hos- pital, and appendicitis, tuberculosis and typhoid having been considered as possibilities. If we disregard the infrequent instances in which in typhoid fever a true second infection takes place, the question arises as to the modus operandi of the original infection in producing a relapse. Periodical exposure to the same source of infection before or during the devel- opment of the disease might account for the re- lapse. Regarding the etiology of relapses my revered teacher. Dr. Francis Delafield^® says: “The relapses of typhoid fever are a curious feature of the disease; they seem to be a fresh attack of the disease produced by a fresh infec- tion within the patient himself.” Another pos- sible explanation is that one group of typhoid bacilli becomes localized under more favorable conditions than another, the former developing rapidly and causing the original attack, the latter multiplying more slowly and causing the re- lapse ; or possibly one strain of organisms may not become neutralized by the antitoxin formed during the original attack, retaining their pathogenicity to produce the relapse. The well known persistence of typhoid bacilli in the gall bladder may possibly bear some causal relation to the relapse,—for instance, the passage of a considerable number of bacilli from the gall blad- der into the intestine. It is conceivable also as hypothesized by Bena, that scabs and mucus from some of the healing ulcers wander else- where to infect new follicles; this hypothesis would apply particularly to those cases with long interpyrexial periods in which the patches origin- ally involved are shown by autopsy to be higher than those affected just before and during the relapse. Before the days of blood cultures, the Widal reaction, and even the side-chain theory, RosenblatM’^ conceived that because of relative inefficiency of the body reaction, though the con- tagium had become attenuated and a cure al- most effected, yet a small residue of the poison retained its viability and caused a recurrence of the symptoms; in favor of this supposition were the observations which seemed to show that re- lapses were more frequent after tubbing, this therapeutic procedure having been assumed to