Volynian Fever

Volynian fever, or five-day fever (febris quintana s. wolhynica), represents a febrile disease, the attacks of which recur, approximately, every fifth day and are characterized by severe general phenomena and pains in the legs. References to five-day fever are found already in Hippocrates, Galen, and Razes. In the literature of the 12th century, the term febris quintana appears; it is assumed that it was then widespread among the Crusaders. A similar disease was described by Saint-Simon, who observed it in Flanders among the troops of Louis XIV. During the Russo-Turkish War of 1877-78, this disease was described by Degio under the name "Moldavian-Wallachian fever". Volynian fever attracted special attention during the imperialist war. On the Russian-German front, it was described by Werner and His under the above-mentioned names. On the western front, it received the name trench fever (trench fever). V.l. was also widespread during the war in Mesopotamia, Syria, on the Balkans, and in other places. A number of designations for this disease are associated with its geographical distribution: Maasfleber, Ikwafieber, fievre ondulante russe. One of the characteristic symptoms—pain in the legs—served as the basis for the names: Schienenbeinfieber, fievre tibialgique. After the German authors who described it, V.l. is often designated as the His-Werner disease. Etiology. V.l., undoubtedly, is an infectious disease, but the nature of its causative agent has not been established. It is only known that the virus during the attack is in the peripheral blood of patients, and is also excreted with saliva and urine. Werner and Benzler found in V.l. a special microorganism belonging to the Chlamidosoa group and named by them Strongylopasma febris quintanae. A number of authors described spirochetes in this disease (Couvy and Dujaric de la Riviere-Sp. gallica, Yakimov-Sp. Hisi-Werneri). The greatest attention is deserved by the works of Toepfer, da-Rocha-Lima, Arkwright, Bacot, and Duncan, who consider the causative agent of V.l. to be a microorganism close to Rickettsia Prowazeki described in typhus, but differing from the latter in greater size (0.3-0.4 μ) and relation to stains (stains more easily). This microorganism, designated by various authors as Rickettsia wolhynica, quintana, pediculi, has been found in the blood of patients, in smears from the spleen, liver, bone marrow, and in large quantities in lice removed from patients. Transmission vector. The main, if not the only, role in the transmission of V.l. from person to person is played by the body louse (Pediculus vestimenti). It becomes contagious 5-9 days after biting a patient and can transmit the infection to several people in succession. The louse excretes the virus with excrement for 60 days. In the excreta, the virus can persist for up to 4 months. The virus is not transmitted to lice hereditarily. These facts have been established, primarily, by the work of special commissions—English and American. According to the opinion of the first, the main role in infection is played by rubbing the louse secretions into scratches; according to the Americans, the louse infects primarily by biting. Patho-anatomical picture of V.l. does not present anything specific. Clinic. The incubation period of V.l. lasts about two weeks or more. The attack begins suddenly, with chills, severe headache, pain in the sacrum and legs. The temperature quickly rises to 39-40° and remains with small remissions for 2-3 days (see figure). The attack is accompanied by general malaise, sometimes slight clouding of consciousness. The patient's face is red, sometimes puffy. The conjunctiva of the eyes is injected. Pains behind the eyeballs and their sensitivity to pressure are observed. Very characteristic are the sensitivity of the periosteum, soreness of the tibial bones, ribs and costal cartilages, pains, especially in the calf and intercostal muscles. Pains in the legs increase toward evening. Enlargement of the spleen can be detected only by percussion. The pulse, in general, corresponds to the temperature. Heart sounds are often not clear. From the intestine, constipation is common, sometimes diarrhea. The tongue is mostly coated, with a reddish border. Jaundice and urobilinuria are absent. Leukocytes sometimes do not show significant changes; mostly leukocytosis up to 15-30,000 is observed, mainly due to an increase in neutrophils with rejuvenation of their average age composition (shift to the left); irritation cells are also encountered. The disappearance of agglutinins is noted in patients who previously gave a positive Widal or Weil-Felix reaction. From the nervous system, sensitivity when pressing on nerve trunks, increased reflexes, sometimes positive Oppenheim are often observed. Hyperesthesias are common—the patient cannot tolerate the touch of a blanket on his legs. Sometimes—sphincter weakness. Protein in urine is observed, appetite, excitability of the heart muscle, shortness of breath and tachycardia with small strains. Immunity to V.l., apparently, does not remain. During epidemics and, apparently, outside them, rudimentary cases also occur, which proceed very easily and are indistinguishable from influenza or muscular rheumatism. Diagnosis. Diagnosis of sporadic diseases is possible only in typical cases. During an epidemic, the diagnosis is established with greater certainty. In the initial stage, it is easy to suspect typhoid or paratyphoid, but the frequency

iiiiliiii shsh t i Eu? very rarely. The drop in temperature is accompanied by profuse sweating. In the interfebrile period, general weakness and headaches are observed. After 4 days (in typical cases) or after 3-5 days, a second attack occurs, after which a 3rd, 4th, and 5th may follow with the same interval. The second and third attacks are less prolonged but, in general, of the same strength as the first. The remaining attacks are weaker. Sometimes, instead of the next rise in temperature, there is a worsening of the general condition, increased pulse rate, and intensification of pains. Depending on the number of attacks, their alternation, and duration, the disease can vary greatly: both very rapidly progressing cases and chronic prolonged courses are observed. On average, the disease ends within 3-5 weeks. V. l. in pronounced cases greatly exhausts the patient (significant weight loss is observed). The period of convalescence is very prolonged: anemia, loss of pulse, leukocytosis, and pains in the legs persist for a long time, which allows one to quickly discard this assumption. From influenza, V. l. differs in the absence of catarrhal phenomena; from Dengue fever, in the absence of leukopenia; moreover, the latter disease is rarely observed in the subtropical zone in winter, while V. l. rages with greatest force precisely during this time of year. Malaria and relapsing fever are excluded due to the absence of parasites in the blood. With pappataci fever, V. l. is similar in the redness of the patient's face, injection of the conjunctiva, and pains behind the eyeballs; but in V. l., there is no bradycardia and leukopenia: pappataci fever, moreover, is limited to the area of distribution of Phlebotomus papatasii. - Prognosis. The prognosis is always favorable. There are no fatal outcomes in the absence of complications from other diseases. Prevention. In view of the undoubted role of lice in the transmission of V. l., preventive measures are basically the same as for typhus and relapsing fever-changing bedding and bathing no less than once a week, disinsection. Due to the infectiousness of urine and saliva, disinfection of the patient's excretions is also necessary. - Treatment - exclusively symptomatic. For pain relief, pyramidon (0.3), phenacetin, and sodium salicylate are prescribed. For bone pains, ointments with menthol are applied locally. Autogenous blood therapy was also used. Bed rest and isolation of the patient during attacks are indicated not only in the interests of the patient but also from an epidemiological point of view-to reduce the danger of spreading the infection. During the period of convalescence, it is necessary to spare the strength of patients: due to weakness and exhaustion of the heart muscle, patients should gradually be accustomed to walking and physical work. - Epidemiology. There are reasons to believe that V. l. is endemic in many countries. Sporadic cases have been described in Berlin (1904), Hamburg (1910), Lviv, Leningrad. But from the conditions of transmission of this disease, it is clear that for the development of an epidemic, special conditions are necessary that promote mass infestation with lice. Therefore, although the disease itself, apparently, is not connected with climate, it is natural that it flares up, mainly, in winter among people living crowded in unsanitary conditions. During the imperialist war, Volynian fever mainly affected soldiers and non-commissioned officers, primarily those in trenches, as well as doctors and sanitary personnel working on the front lines. Epidemics of V. l. mostly occur in the form of small outbreaks affecting only part of the population of individual premises. - Statistics. Exact statistical data on the spread of Volynian fever during the last and, even more so, previous epidemics are not available. The main difficulty is the confusion of this form with influenza and other infections, with malaria giving irregular attacks, as well as the large number of rudimentary forms that do not come under medical observation. Joachim and Jungmann consider that 20% of all diseases in the German army on the eastern front were due to Volynian fever.

Sh. Moiseovsky