patient, a man aged thirty-six, was admitted on the fifteenth day of
an attack of acute catarrhal nephritis, with slight ascites, marked
oedema of the feet and legs, and highly albuminous urine. In the
course of ten days the oedema and albuminuria were much diminished,
when on the thirteenth day after admission he was attacked with
relapsing fever, the ward in which he lay containing a number of
persons ill with that disease. The initial paroxysm was severe, but
without any grave cerebral symptoms; the urine grew scanty, dark, and
bloody, and the oedema increased and invaded the pelvis. Crisis
occurred on the fifth day, temperature falling 9°, sweating copious,
urine 473 ccm. in twenty-four hours, color of porter, highly
albuminous, and depositing blood, renal epithelium, hyaline, granular
and epithelial casts, all stained reddish. Two days later, urine 1600
ccm., light colored, with only a small amount of albumen.
A slight and brief relapse (101° for two days) occurred after an
interval of four days; a second imperfect relapse (100.5° for three
days) after a further interval of six days; and finally, after a
further interval of only two days, a violent relapse (temperature
rising rapidly to 106°) with crisis (fall of 8° in twelve hours) at
close of fifth day. The oedema gradually diminished from the time of
the first crisis, did not increase in the relapses, and disappeared
completely and finally about ten days after the last relapse. The
urine was very free after the first paroxysm, averaging from 2000 to
2300 ccm. During the subsequent febrile periods it did not decrease,
and indeed on the second day of the last relapse, with the temperature
at 105°, the amount in twenty-four hours was 3200 ccm. Four days
subsequently, during crisis, the amount was only 350 ccm.
The albumen disappeared entirely from the urine in two weeks from the
close of the last relapse; there had then been no tube-casts for some
days, and the patient was discharged entirely well a short time
afterward. The treatment consisted of hot vapor-baths, repeated dry
cupping over the kidneys, infusion of digitalis with acetate of potash
during pyrexia, and Basham's iron mixture in the intermissions. It
seemed that the occurrence of the relapsing fever interfered
wonderfully little with the recovery from nephritis.
Hematuria is a comparatively rare and very grave complication. It may
occur as an additional evidence of the dyscrasia of the blood in
connection with hemorrhages from other surfaces, or as in the case we
have before referred to or in that reported by Murchison,[27] it
results from intense engorgement of the kidneys. In Murchison's case
hematuria, with much albumen and tube-casts, occurred in both
paroxysms {410} without any uræmic or typhoid symptoms, and was
followed by satisfactory recovery.
[Footnote 27: _Op. cit._, p. 370.]
Sugar is sometimes present in small quantity as a transient symptom;
and diabetes has been observed as a sequel.[28]
[Footnote 28: Tyson, _Phila. Med. Times_, 1871, i. 418.]
Metastatic inflammation of the kidneys, with centres of suppuration,
was observed by Wyss and Bock.
When menstruation occurs during relapsing fever, as it may do at any
time, it is apt to be excessive, and may amount to severe hemorrhage.
Crisis has been known to occur in this manner.
The numerous cases reported by various observers of relapsing fever
occurring in pregnant women establish the rule that abortion almost
invariably occurs, whatever may be the stage of the pregnancy. In a
large majority of cases the mother recovers, but the child, if viable,
is stillborn or dies in a few hours. Only two of our patients were
pregnant women, and the result in each was unusual. In one, the
patient, already the mother of several children, was in the fifth
month of gestation; the initial paroxysm was severe, with delirium,
but no symptoms of abortion occurred; the intermission lasted six
days, during which she felt very well; the relapse was also severe,
and crisis occurred on the fifth day, the temperature falling below
normal, and the case promising to do well; but on the following day
there was a sudden rebound of temperature, pulse 140, severe
præcordial pain, and death occurred in twenty-four hours, the contents
of the uterus being partially expelled during the act of dying. In the
other case, a girl of eighteen years, who had aborted at the third
month of gestation eight months previously, and who was again three
months advanced in pregnancy when attacked with relapsing fever, went
safely through a bad attack and carried her baby successfully to full
term.
MORBID ANATOMY.--The surface of the body often presents patches of
livid discoloration, and jaundice persists in cases where it has been
present during life. There is but little appearance of emaciation,
except in cases where it has been present before the attack.
When death occurs while the temperature is high the body remains warm
an unusual length of time. Thus, in one case where death occurred at
11.30 P.M., the temperature at 12 was 103°, and at 1 A.M. it was
101-3/5°, that of the room being 73°; at 6 A.M. it remained at 93°,
the room being at 73°; between 9 A.M. and 2 P.M. the room was kept at
55°, but the body was still at 82° at the latter hour.
The voluntary muscles are often jaundiced, and in prolonged cases they
may be found flabby and having undergone marked granular degeneration.
In many cases, however, they remain quite dark and firm. Ecchymoses of
the muscular substance are met with occasionally.
In one case, where during life there had been painful swelling of the
left parotid region, with fistulous openings on the cheek, and where
death occurred on the twelfth day of the disease, the masseter muscle
was swollen, with patches of dark, almost black, discoloration from
ecchymosis, and was studded throughout with small collections in its
substance. The fluid from these contained very numerous cells
indistinguishable from leucocytes. The muscular fibrils were friable
and granular, and there was multiplication of the nuclei of the
sarcolemma. {411} These unusual lesions seemed to have originated in
interstitial disintegrating thrombi, with consequent inflammation of
the muscle.
The muscle of the heart is more frequently affected, and in the fatal
cases our attention was particularly drawn to those lesions.
Ponfick[29] has also described them minutely. The degree of change
varies from a partial loss of transverse striation, with slight
granular appearance, up to a very high degree of granulo-fatty
degeneration. The organ is then flabby, its substance pale gray or
brownish, either wholly or in streaks, and microscopic examination
shows an extreme degree of fatty granular change. It must not be
forgotten, however, that many of the subjects of relapsing fever have
been leading irregular and dissipated lives, and that in some
instances the lesions of fatty degeneration detected in their organs
may have been the result of their previous habits.
[Footnote 29: _Virchow's Archiv. f. path. Anat._, Bd. lx. Hft. 2, p.
162.]
Lesions of the cardiac muscle were most marked in those of our
patients who had been intemperate, and in whom fatty degeneration of
the viscera (chiefly liver and kidneys) was also found. They were most
fully developed in cases where death occurred at a comparatively late
period, while in some very severe cases, in which death occurred as
early as the fifth day, the cardiac fibre presented merely faintness
of striation without actual granular degeneration.
Ponfick in particular notes that the great majority of the bodies he
examined were of persons who had been habitual drunkards.
Pericarditis is occasionally present, and is marked by the usual
lesions. In a very severe case in which it contributed largely to the
production of the fatal result it was associated with pneumonia. In
addition to this, effusions of blood beneath the endocardium and
pericardium are not rare; and we have seen them quite large and
numerous in cases where the muscular fibre was firmly contracted and
the cavities contained quite firm decolorized clots.
Thus in our case No. 62, Series C., "the heart was normal in size,
with no appearances of previous disease. There were numerous
ecchymoses of both layers of the pericardium. The right cavities
contained large, firm, yellowish, fibrous clots, forming a cast of the
upper part of the ventricle and of the auricle, and extending both
into the pulmonary artery and back into the veins, and so firm that by
gentle traction a complete cast of these vessels was drawn out. The
clot in the pulmonary artery was throughout firm, fibrous, and
yellowish. There were numerous ecchymoses of the pleura and of the
mucous membranes of the stomach and urinary bladder, hemorrhagic
infarctions in the kidneys and lungs, and granulo-fatty degeneration
of the cardiac muscle." Death had occurred in this case about the
close of the third week, and was preceded by hematemesis and
suppression of urine. We must note in this connection the tendency to
embolism that exists in this disease.
Especial interest attaches to the condition of the blood in relapsing
fever. Usually it presents no abnormal appearance if drawn during
life, though in grave cases it may coagulate imperfectly. We have no
knowledge of its minute chemical characters, save that in several
cases where there was great diminution in the amount of urine, with
uræmic symptoms, urea has been found in considerable amount in the
blood (Murchison, p. 368). The red globules present no definite or
{412} characteristic changes. In some of our examinations they
appeared of light color and became crenated very quickly on exposure.
On the other hand, the white corpuscles have repeatedly been observed
to be increased in number, at times considerably so (Cormack,
Thompson, Zuelzer, Carter, Boeckmann, and ourselves), though this
change is not regarded as constant or essential. It has, however, a
very great interest in connection with the characteristic lesions of
the spleen which will be described hereafter. In several cases we
observed that many white corpuscles were small and apparently
imperfectly developed. Boeckmann[30] concludes that they increase in
number during the febrile paroxysm, reaching their highest number at
the crisis, and then diminishing gradually to the normal. The red
globules are much decreased during the fever, and return to the normal
slowly during convalescence.
[Footnote 30: _Deutsch. Arch. f. klin. Med._, Sept. 1881, p. 513.]
In addition to these changes, various abnormal elements have been
observed more or less constantly. By far the most important of these
is the spirillum or spirochete of Obermeier, which has been already
carefully described. In proportion as this organism has been carefully
looked for it has been found constantly, so that the evidence has
become very strong in favor of its uniform presence in the blood of
relapsing-fever patients during the febrile stage of the disease.
Ponfick in 1874[31] called attention to the occurrence of large
granule-cells in the blood in this disease. They are found during life
as well as after death, when they exist in largest proportion in the
blood of the splenic, hepatic, and portal veins. Their shape is
spherical, ovoid, or elongated; the basis of the cells is a delicate,
translucent, albuminous substance; and the granules are of a fatty
nature, as shown by the action of reagents. These cells have been
found by other observers, and the view is generally received that they
are derived from the lymphoid elements of the spleen, and perhaps of
other portions of the lymphatic system; and Carter, who has studied
them carefully, is inclined to think there is some connection between
them and the development of the spirillum.
[Footnote 31: _Centralbl. f. d. med. Wissensch._, 1874, p. 25.]
Ponfick also first described[32] certain other large,
irregularly-shaped, pale, granular, nucleated cells, which occur in
smaller number in the blood in relapsing fever, and which he regarded
as altered endothelium, derived from the lining of the blood-vessels,
of the lymphatics, or of the lacunar spaces of the spleen.
Occasionally these cells are found with such highly granular contents
as to make them closely simulate the large granule-cells described
above. These results of Ponfick have been confirmed by other
observers.
[Footnote 32: _Loc. cit._]
In several of our reports of examinations of blood there is mention
made of quite abundant, free granular matter--an appearance also
observed by Carter. Finally, the latter describes the occurrence of
thread-like filaments and of short, rod-like bodies.
There are no characteristic lesions connected with the
gastro-intestinal canal. The mucous membrane of the stomach may be
normal or merely injected, though where there has been much vomiting,
and especially bloody vomiting, there is marked injection, and not
rarely ecchymosis and submucous extravasations of blood, with
softening of the membrane. {413} These extravasations are usually
small, but Cormack reports a case where one-third of the mucous
membrane of the stomach was the seat of ecchymosis and extravasation.
In one of our own cases the extravasations occupied an area of four
inches square.
The small intestines exhibit patches of congestion or ecchymosis less
frequently than the stomach, though it is usual to find injection of
the mucous membrane, especially of the lower portion, in cases where
there has been diarrhoea. Carter, observing the disease in India,
found in one-half of all autopsies some amount of congestion,
hemorrhage, or inflammation of the ileum. In two instances he found a
layer of diphtheritic deposit over the mucous membrane of the lower
part of the ileum.
There are no special alterations of the solitary or agminated glands,
and ulceration never occurs. Even in cases where the constitutional
infection is severe, whether diarrhoea has been present or not, it is
noteworthy that there is rarely any swelling of the solitary glands or
Peyer's patches, such as is met with in many other acute specific
diseases. It was not present in any of our autopsies.
The large intestine in like manner exhibits no characteristic lesions.
Patches of congestion and occasionally submucous ecchymoses may be
observed, and croupous exudation occurs here somewhat more frequently
than in the small intestine.
Wyss and Bock[33] speak of enlargement of the mesenteric and
retroperitoneal glands as of frequent occurrence, but we did not
observe it, and Murchison states that these glands present no abnormal
appearance.
[Footnote 33: _Op. cit._, p. 223.]
Alterations of vascularity of the brain or its membranes are met with,
but they are variable and bear no definite relation to the precedent
symptoms. Ecchymoses of the membranes are occasionally observed, and
in one of our cases extensive meningeal hemorrhage was found.
Murchison reported a case in which embolism of the left femoral artery
occurred, and subsequently of the left middle cerebral artery,
inducing death. The suggestion may be hazarded that in some of the
cases where there is severe delirium ending in stupor and death there
has been multiple capillary embolism of the cerebral vessels.
There is occasionally the evidence of catarrhal inflammation of the
upper air-passages, and in some epidemics diphtheritic exudation in
the pharynx and larynx has been noted (Wyss and Bock); and Ponfick
found acute oedema of the glottis in a considerable proportion of the
fatal cases at Berlin. The lesions of pleurisy are met with in a small
proportion of cases; in our own autopsies this complication was more
frequent than in most epidemics.
The lungs may be normal, and Murchison concludes that they are more
frequently so than in typhus. Still, they often present congestion or
oedema, and subpleural ecchymoses, hemorrhagic infarctions, and
pneumonic consolidation are not rare. Lobar pneumonia was present in
33 per cent. of our own autopsies, in 28 per cent. of Carter's, and in
20 per cent. of those conducted by Ponfick. The inflammation usually
presents the regular stages, and is associated with a moderate degree
of plastic pleurisy; but occasionally, as in one of our cases, it
terminates in gangrene. In the instance referred to there was an area
of gangrene about three inches square and one inch in depth, involving
the pleura and a {414} superficial layer of lung on the antero-lateral
aspect of the left lower lobe. In another remarkable instance, already
referred to on account of the suppurative inflammation of one masseter
muscle, the lungs, which were stained yellow throughout, presented
numerous deep purplish patches, which on section altogether resembled
the secondary metastatic deposits of pyæmia, with yellowish softening
or even puriform centres surrounded by a rim of purplish livid
discoloration. Very numerous similar patches, varying from the size of
a pea to that of a hazel-nut, and presenting every stage of
development, were found throughout both lungs. In a few instances we
found the lesions of chronic phthisis, which had, of course, existed
before the attack of relapsing fever. The bronchial glands were found
swollen and infiltrated in cases where inflammatory processes in the
lungs have existed.
Much interest attaches to the state of the genito-urinary organs in
relapsing fever, but caution is required to distinguish lesions that
have existed prior to the attack from those properly referable to it.
Owing to the intemperate and exposed lives of many of the patients,
renal lesions might reasonably be expected in no small proportion. The
comparative rarity of albuminuria (see p. 407), even in severe cases,
is suggestive of the view that when it is present it may at least
sometimes be due to pre-existing lesions aggravated by the acute
infectious process, and further that the extreme gravity generally
presented by such cases may be in part due to the impaired condition
of the kidneys.
The morbid changes most frequently referable to the fever are moderate
enlargement and congestion, occasionally very intense so that we find
it described in our notes as deep blackish-purple or blue; ecchymoses
of the capsule or of the mucous membrane of the pelvis; small
hemorrhagic infarctions, usually in the cortex; and cloudy swelling of
the glandular cells. Less commonly are found hemorrhagic infarctions,
or small embolic patches advanced to various stages of disintegration,
even to the formation of small puriform collections. In quite rare
cases the lesions of acute nephritis are present, while caution must
be used in interpreting other changes occasionally met with, such as
pallor with granulo-fatty degeneration or other advanced alterations
of the glandular cells, or hyperplasia of the intertubular connective
tissue, with or without contraction of the kidneys.
The mucous membrane of the bladder, as already mentioned, may present
ecchymoses, or, more rarely, croupous exudation (Wyss and Bock). The
urine contained may be bloody, or, as in one of our cases where there
had been total suppression of urine for over seventy-two hours before
death, there may be but a small amount of almost pure blood,
containing a few phosphate crystals, but no tube-casts. In this case
there were also ecchymoses of the bladder and of the pelvis of the
kidneys, with intense congestion and numerous small hemorrhagic
infarctions of the kidneys.
The liver is constantly though variously affected. It is found
enlarged in the great majority of cases, especially if death has
occurred during the febrile stage. The ordinary degree of enlargement
in our cases was from four to four and a half pounds, but in a few
instances the liver weighed one hundred or one hundred and two ounces,
though in most of these extreme cases the patients had been drunkards,
and there was such advanced fatty alteration of the liver as to make
it probable that the {415} organ had been diseased previously. These
figures correspond with the results of other observers.
In many cases, especially when death occurs early and during the
febrile stage, the capsule and substance of the liver are congested,
at times intensely so; and when ecchymoses are found elsewhere they
are apt to be present here also, appearing as purplish patches dotted
over the capsule and extending into the superficial layer of hepatic
tissue. Not rarely, however, the liver substance is paler than normal,
and presents a yellowish tinge, apart from the decided yellowish
staining present in cases attended with jaundice. Carter describes a
partial mottled paleness of the liver as having been frequently
observed in his cases, the circumscribed pale areas presenting a
corresponding localized degeneration of the cells, as though from some
local interruption of circulation.
Cloudy swelling and fatty degeneration of the liver-cells are indeed
very often present, and in some epidemics with preponderance of
bilious symptoms are constantly found (Ponfick). The degree of the
cell-alteration varies from a slight granulo-fatty change to an
advanced fatty degeneration, even with a marked tendency, in rare
cases, to disintegration of the cells, so as to produce lesions
analogous to those of acute yellow atrophy (St. Petersburg epidemic).
The whitish deposits described by Küttner as due to albuminous or
fibrinous infiltration are probably referable to transformed
hemorrhagic infarctions, and the minute puriform collections that have
been observed at the centre of the acini (Wyss and Bock) may have been
metastatic in origin, or attributable to the disintegration of minute
thrombi associated with irritative hyperplasia of the adjacent
lymphoid elements. The consistence of the liver varies: when death
occurs early and bilious symptoms have not been marked, it may be even
firmer than normal, but more frequently it is softer, and it may be
relaxed, flabby, and friable.
The condition of the bile-ducts is of great interest in view of the
frequency of jaundice as a symptom in relapsing fever, and most
authorities unite in saying that they present no lesions capable of
explaining it.
The gall-bladder is usually found full of dark bile, but there is no
such degree of inspissation, except in rare instances, as could
interfere with its passage through the ducts. Murchison quotes the
statement of Peacock that in some instances the bile was thick and
viscid, so as apparently to cause obstruction, but all observations
agree in showing that this is exceptional. The mucous membranes of the
larger ducts may present evidences of slight catarrhal inflammation,
but in nearly all cases where they have been carefully examined, even
when jaundice had been marked, they have been found patulous and free,
so that the jaundice cannot be regarded as due to obstruction of the
larger ducts save in rare instances (Pastau). In further confirmation
of this may be stated the fact that there is no want of bile in the
duodenum and feces.
On the other hand, a careful consideration of the lesions of the
substance of the liver will show that it would be most improbable that
the minute biliary ducts in the areas most affected should escape
implication. Münch, who investigated this subject carefully, found
that there was a catarrhal state of the fine bile-ducts in every case
of relapsing fever with jaundice; and Litten found the smallest ducts
plugged with bile-stained pellets of mucus. It would appear,
therefore, that in many cases at least {416} the jaundice is really
obstructive in its origin, the seat of the obstruction being in the
too-rarely examined minute bile-ducts, though further investigation of
this interesting question is required.
The clinical bearing of these conditions has been fully discussed in
the appropriate section.