Part 63

In the second place, the attack of fever may become complicated with acute nephritis from special localization of the poison, as in Obermeier's cases, or from vulnerability of the kidneys. In such cases careful study of the urine should indicate the event, and the prognosis, though grave, is not so hopeless as in the first instance. An interesting example of {409} this occurred under our observation, where the patient, who had apparently an ordinary attack, was seized with acute catarrhal nephritis, with temporary uræmia, during the relapse, but after a dangerous illness recovered without any organic renal disease as a sequel.

In the third place, may be found the more usual and more readily-determined condition of slight and transient albuminuria (with variations in urea excretion) which has already been discussed, and which has no serious prognostic significance.

The following very interesting case deserves special mention: The 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, 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.

Sugar is sometimes present in small quantity as a transient symptom; and diabetes has been observed as a sequel.

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 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.

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 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.

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 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.

Ponfick also first described 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.

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.