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Relapsing fever in Northern Nigeria
195
RELAPSING FEVER
IN
NORTHERN
NIGERIA,
SOME OBSERVATIONS. BY P. J. CAFFREY, M.B. West African Medical Service.
The following observations have been recorded while personally treating 192 cases of this now wide-spread epidemic disease. The patients have all been retires resident in Sokoto Province. The Hausa t e r m " Massassera " is generally used, but it is not a specific name for relapsing fever ; other fevers are included under this term. CLIMATOLOGY.
The disease has a very definite seasonal incidence. The outbreak very closely followed the advent of the dry, cool season, when the average temperature is 70 ° F. to 80 ° F. and the average humidity is 50 to 60. From figures supplied to me a chart has been prepared showing the total monthly mortalityrate and rainfall covering a period of twelve months. The excessive mortalityrate--53"4 per 1,000--amongst a population of 273,000,was due solely to relapsing fever. The chart admirably shows the increased death-rate during the months ill which the rainfall was nil. The peak of the mortality curve occurs in the month of March. Then the relative temperature and humidity have risen-ideal conditions to favour the bionomics of pediculus. A few isolated cases of infection have been found, though, during the season of heavy rainfall. ~ETIOLOGY.
All the cases seen revealed the presence of spirochmtes in the blood during the pyrexial stage. This spirochmte appeared to be exactly similar to the Spiroch~vta recurrentis of European relapsing fever. All the available evidence pointed to its being transmitted to the human body by the louse--Pediculus corporis. Examination of sixty lice for spirochmtes, collected from cases of fever, gave four positive findings, numerous faintly-stained, mature and immature spironemata being found. T h e lice were simply crushed in saline, fixed and stained. No evidence, whatsoever, was found to associate infection with the tick--
Ornithodorus moubata. BLOOD EXAMINATION.
Dilute borax methylene blue was found to be an excellent and easily workable stain for the spironemata. It also differentiated the leucocytes. During the pyrexial periods numerous spirocha~tes were easily found in all cases, using a
196
RELAPSING FEVER IN NORTHERN NIGERIA.
moderately thick film. They showed up either as separate, wavy spirals, or, more frequently, as coiled, hair-like clumps. Severe cases especially exhibited this clumping tendency. The average length of each spirochmte was 18 #. A definite leucopenia was evident during the first two days of attack, succeeded by a polymorphonuclear leucocytosis and a small-celled lymphocytosis. About the eleventh day after onset of the initial fever this leucocytosis disappeared, to reappear after each relapse. Close examination of the leucocytes did not reveal spiroch~etes engulfed therein. SYMPTOMATOLOGY.
Marked signs of dyspncea, jaundice and enlargement of the spleen were nearly always superimposed on the ordinary signs of a severe pyrexia. Dyspnoea.--Increased and anxious respiration: with or without cough was present from the 9nset of fever. It gave one t[~e casual impression of a commencing pneumonia. Jaundiee.--An icteric conjunctival tinge was noticeable on the second day from onset, gradually deepening to a definite staining by the sixth day. Oldstanding untreated cases having had two, three, or four relapses, showed sometimes a well-marked jaundice. Enlargement of the Spleen.--The spleen was enlarged and tender during the pyrexial periods, but one cannot say to what extent this was due to a probable concurrent malaria. PyreMa.--The initial fever in untreated cases invariably lasted from six to eight days, then occurred an apyrexial interval, to be followed by a relapse about the thirteenth to the fifteenth day. This relapse ran a course of three or four days, to be succeeded by a period of quietude. Irregular relapses often occurred throughout the ensuing two months. A rash was not seen on any case. A moist, grey fur, covering a red-tipped and red-edged tongue, was typical. A morning remission of temperature to 99 ° F., from 104 ° F. of the previous evening, was common during the febrile stage. MORTALITY.
Of the 192 cases treated two died. These were practically moribund when seen, and did not react to injection. The chief danger of death existed during the first three days of fever. Untreated cases living t h r o u g h these first days generally recovered, though subject to frequent relapses and a very protracted convalesence. Figures supplied gave a mortality rate of 35 per cent. amongst cases which did not obtain professional attendance. TREATMENT.
Novarsenobillon.--The efficacy of this drug was unquestionable.
One intravenous injection of 0'3 gin. for children to 0'6 gm. for an adult male, caused an early disappearance of spiroch~etes from the blood without unpleasant symptoms.
RELAPSING
FEVER
IN
NORTHERN
197
NIGERIA.
Stovarsol.--A dose of gr. iv. t. d. s. in water by the mouth, was employed. . ~ Very severe cases this drug was inefficacious and novarsenobillon was ~ministered. In the less acute cases stovarsol did good, producing a crisis and ~isappearance of spiroch~etes from the blood within forty-eight hours. Probably ~ e s e latter cases wouId have recovered without any medication. Spiroch~etes ere discovered in the blood thirty hours after commencing stovarsol adminis~ation. Stabilarsan.--Intravenous injections of 0"45 gm. and 0"6 gm. were used ith satisfactory results. It did not possess the wonderful curing properties of ovarsenobillon. In four cases treated with stabilarsan spiroch~etes were dis{covered in plenty in the blood of patients who had had the above injection eighteen i~hours previously. In three very acute cases it did not produce a satisfactory Crisis within twelve hours, and novarsenobillon was injected. Other cases treated with stabilarsan were cured. My thanks are due to the Director of Medical and Sanitary Services, ~:Nigeria, for his kind permission to publish these notes.
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RELAPSING FEVER
IN
NORTHERN
NIGERIA,
SOME OBSERVATIONS. BY P. J. CAFFREY, M.B. West African Medical Service.
The following observations have been recorded while personally treating 192 cases of this now wide-spread epidemic disease. The patients have all been retires resident in Sokoto Province. The Hausa t e r m " Massassera " is generally used, but it is not a specific name for relapsing fever ; other fevers are included under this term. CLIMATOLOGY.
The disease has a very definite seasonal incidence. The outbreak very closely followed the advent of the dry, cool season, when the average temperature is 70 ° F. to 80 ° F. and the average humidity is 50 to 60. From figures supplied to me a chart has been prepared showing the total monthly mortalityrate and rainfall covering a period of twelve months. The excessive mortalityrate--53"4 per 1,000--amongst a population of 273,000,was due solely to relapsing fever. The chart admirably shows the increased death-rate during the months ill which the rainfall was nil. The peak of the mortality curve occurs in the month of March. Then the relative temperature and humidity have risen-ideal conditions to favour the bionomics of pediculus. A few isolated cases of infection have been found, though, during the season of heavy rainfall. ~ETIOLOGY.
All the cases seen revealed the presence of spirochmtes in the blood during the pyrexial stage. This spirochmte appeared to be exactly similar to the Spiroch~vta recurrentis of European relapsing fever. All the available evidence pointed to its being transmitted to the human body by the louse--Pediculus corporis. Examination of sixty lice for spirochmtes, collected from cases of fever, gave four positive findings, numerous faintly-stained, mature and immature spironemata being found. T h e lice were simply crushed in saline, fixed and stained. No evidence, whatsoever, was found to associate infection with the tick--
Ornithodorus moubata. BLOOD EXAMINATION.
Dilute borax methylene blue was found to be an excellent and easily workable stain for the spironemata. It also differentiated the leucocytes. During the pyrexial periods numerous spirocha~tes were easily found in all cases, using a
196
RELAPSING FEVER IN NORTHERN NIGERIA.
moderately thick film. They showed up either as separate, wavy spirals, or, more frequently, as coiled, hair-like clumps. Severe cases especially exhibited this clumping tendency. The average length of each spirochmte was 18 #. A definite leucopenia was evident during the first two days of attack, succeeded by a polymorphonuclear leucocytosis and a small-celled lymphocytosis. About the eleventh day after onset of the initial fever this leucocytosis disappeared, to reappear after each relapse. Close examination of the leucocytes did not reveal spiroch~etes engulfed therein. SYMPTOMATOLOGY.
Marked signs of dyspncea, jaundice and enlargement of the spleen were nearly always superimposed on the ordinary signs of a severe pyrexia. Dyspnoea.--Increased and anxious respiration: with or without cough was present from the 9nset of fever. It gave one t[~e casual impression of a commencing pneumonia. Jaundiee.--An icteric conjunctival tinge was noticeable on the second day from onset, gradually deepening to a definite staining by the sixth day. Oldstanding untreated cases having had two, three, or four relapses, showed sometimes a well-marked jaundice. Enlargement of the Spleen.--The spleen was enlarged and tender during the pyrexial periods, but one cannot say to what extent this was due to a probable concurrent malaria. PyreMa.--The initial fever in untreated cases invariably lasted from six to eight days, then occurred an apyrexial interval, to be followed by a relapse about the thirteenth to the fifteenth day. This relapse ran a course of three or four days, to be succeeded by a period of quietude. Irregular relapses often occurred throughout the ensuing two months. A rash was not seen on any case. A moist, grey fur, covering a red-tipped and red-edged tongue, was typical. A morning remission of temperature to 99 ° F., from 104 ° F. of the previous evening, was common during the febrile stage. MORTALITY.
Of the 192 cases treated two died. These were practically moribund when seen, and did not react to injection. The chief danger of death existed during the first three days of fever. Untreated cases living t h r o u g h these first days generally recovered, though subject to frequent relapses and a very protracted convalesence. Figures supplied gave a mortality rate of 35 per cent. amongst cases which did not obtain professional attendance. TREATMENT.
Novarsenobillon.--The efficacy of this drug was unquestionable.
One intravenous injection of 0'3 gin. for children to 0'6 gm. for an adult male, caused an early disappearance of spiroch~etes from the blood without unpleasant symptoms.
RELAPSING
FEVER
IN
NORTHERN
197
NIGERIA.
Stovarsol.--A dose of gr. iv. t. d. s. in water by the mouth, was employed. . ~ Very severe cases this drug was inefficacious and novarsenobillon was ~ministered. In the less acute cases stovarsol did good, producing a crisis and ~isappearance of spiroch~etes from the blood within forty-eight hours. Probably ~ e s e latter cases wouId have recovered without any medication. Spiroch~etes ere discovered in the blood thirty hours after commencing stovarsol adminis~ation. Stabilarsan.--Intravenous injections of 0"45 gm. and 0"6 gm. were used ith satisfactory results. It did not possess the wonderful curing properties of ovarsenobillon. In four cases treated with stabilarsan spiroch~etes were dis{covered in plenty in the blood of patients who had had the above injection eighteen i~hours previously. In three very acute cases it did not produce a satisfactory Crisis within twelve hours, and novarsenobillon was injected. Other cases treated with stabilarsan were cured. My thanks are due to the Director of Medical and Sanitary Services, ~:Nigeria, for his kind permission to publish these notes.
~
~
i I,B,~
i,i,¢ I rt
ll~c I
12~
I
i
iio. q~
iI / //i ,_.,
6~
•~
!/J
,