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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Licence: In copyright

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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    under different conditions and at different times, many writers, including Ziemssen,^^ Cursch- I have compiled the following table: mann-® and A. Jacobi-® have called attention. No. of No. of Percen- Author Place Year Epidemic Typhoid Relapse tage of or Endemic Cases Cases Relapses May Munich 1882-1885 Endemic 209 29 13.8 Deumie Paris 1881-1886 Endemic 227 19 8.3 Schill Jena 1875 Epidemic 37 12 324 Knebel Wiesbaden 1885 Epidemic 371 26 7 Stecher Paris (barracks) 1885 Epidemic 193 6 3-2 Eichhorst Zurich 1884 Epidemic 411 23 5-6 Bena Strasburg 1872-1891 Endemic 598 72 12 Bena Konigsberg 1877-1887 Endemic 168 7 4.1 Osier Baltimore Previous to 1896 Endemic 500 40 8 Schlesinger Vienna 1902-1907 Endemic 155 13 8.3 Koplik and Heiman New York 1901-1906 Endemic (in children) 160 24 15 Ziegel New York 1909-1912 Endemic (adults and children) 166 21 12.6 As to the number of relapses, 18 of our 21 Jacobi says for instance. that “the greatest cases were single relapses, 2 were double and i care must be taken in those cases in which the was triple. The relative frequency of double relapses in our series was 9.5% ; compare this with 132 relapses cases studied by Bena with 13 double relapses, or 9.8%. Bena has observed one quintruple relapse and mentions a quadruple relapse studied by Deumie in which roseolae were present during the fourth recurrence. In our series there were 13 males and 8 fe- males. The sexes are said to be about equally affected. The average age of these 21 patients with 25 relapses was 20.4 years; the youngest was 6 years; the oldest 56 years (the only fatal case, complicated with intestinal hemorrhage and pneumonia). Four of the patients were younger than 13. Relapses are more common in chil- dren than in adults. Fleischl-^ mentions 5 cases of relapse occurring in patients over 40 years of age; 2 of our patients were 44 and one was 56; I was unable to find in the literature a case of relapse in a person as old as this one, though Schultz has reported a case in a patient of 55. VII. Interpyrexial period; persistent enlarge- ment of the spleen during; prognostication of relapses.—The average interpyrexial period in our series was 7.92 days, the longest was 28 days (in the second relapse of the triple case), the shortest was 4 days (in 6 cases). After ten days of normal temperature relapses are infrequent (3 of our cases), and after two weeks of apy- rexia relapses are rare (i of our cases). Eb- stein^® in 1869 collected 22 cases of relapse and found the average intercalary period to be 12.3 days. The time to look for a relapse is when the patient is entirely free from symptoms and con- valescence is apparently well established. There is, however, no certain way of prognosticating a relapse. A presumptive sign is the persistent tumefac- tion of the spleen after defervescence, to which spleen, when tumefied during the progress of the disease, does not nearly assume its normal size about the middle of the third week. When it remains large a relapse may be looked for.” This sign was investigated in 13 of our cases. Of 12 single relapse cases, the spleen remained enlarged during the interpyrexial period in 8; in one of the double relapse cases, the tumefac- tion of the organ persisted in both afebrile in- tervals. VIII. General features and symptomatol- ogy.—Since the relapse begins without pro- dromata and frequently the rise of temperature IS the only sign of its onset, it is important to ob- serve patients for at least two weeks after the termination of the original attack. Subjective symptoms are not present as a rule during the first few days of the relapse. The patient may be up and about with a good appetite, he may be gaining in weight, and not infrequently he is expecting to leave the hospital when the relapse begins. As Osier expresses it, “the tempera- ture has become normal, the patient is happy and hungry, the relatives contented, the doctor con- gratulates himself that he has cured a case of typhoid fever, and then comes the relapse and the tempest of the soul, so to speak.” A feeling of well being may continue throughout the re- lapse in spite of the, fever and other signs. In exceptional cases with severe onset, however, symptoms may appear early with the initial rise of temperature—in such instances much earlier than in an original attack. Nervous and ab- dominal symptoms and circulatory disturbances such as are usually present in the second week of the original attack are rare during the re- lapse. During the early days of the relapse the appetite is usually not lost, and the patient often wonders why the diet is being restricted. As a rule, there is no diarrhoea, and pea-soup stools are rarely seen in relapses. Epistaxis, general