rheumatic muscular induration with trichinous muscular changes. The differentiation can be made readily and certainly by excising a small piece of muscle and examining it microscopically. Scarcely anything of a definite nature is known with regard to the anatomic alterations of muscular rheumatism, because opportunities for post-mortem examination are wanting. The prognosis is favorable, as there is scarcely any danger to life, although chronic muscular rheumatism is one of the most obstinate and often incurable diseases. The treatment is the same as that for acute and chronic articular rheumatism. Often speedy and successful results are obtained with electricity. III. INFECTIOUS DISEASES ATTENDED WITH LOCAL ALTERATIONS IN THE BLOOD AND THE BLOOD-GENERATING ORGANS. RELAPSING FEVER. Etiology.-Relapsing fever constantly prevails in endemic distribution in some countries of Europe (Ireland, Russian Poland). From these places the pestilence is occasionally carried to other countries, either through vagrants, peddlers, or emigrated laborers. Cases of relapsing fever have from time to time occurred with especial frequency in the larger cities of northern Germany, as, for instance, Königsberg, Dantzic, Berlin, Braunschweig, Magdeburg, Hamburg, etc., and often visiting patients have been the cause for the occurrence of an epidemic of relapsing fever. Irish emigrants have in a number of instances been the means of conveying the disease to America. Infection may take place through personal association, through inanimate objects, through the air, or through the intermediation of a third person. It undoubtedly occurs most frequently through personal association or domestic articles. Generally epidemies of relapsing fever are spread from low-class lodging-houses or jails -that is, from places in which roving people of doubtful repute are likely to be found. The bedding, which in such places is but rarely changed, is an especially favorable source of infection, so that many a traveller, in addition to the longed-for rest, finds himself infected if the bed he has used had been previously occupied by a patient suffering from relapsing fever. The dissemination of the disease is further materially favored by the fact that patients suffering from relapsing fever are still for a time capable of travelling in spite of their infectiveness. The conditions indi cated make it comprehensible that relapsing fever is generally a disease of the lower classes, occurring especially in the autumn and winter, when lodging-houses are well patronized. In consequence of the conditions described men are more frequently attacked by relapsing fever than women, and the disease occurs principally in adults. Recovery from one attack is almost always followed by permanent immunity. The infective agent is contained in the blood, as inoculationexperiments with the blood have been successful in human beings. Although it is probable that the spirilla of relapsing fever, which are unexceptionally found in the blood during the febrile period, constitute the infectious agents, nevertheless the blood remains infective after the contained relapsing spirilla are purposely destroyed, so that probably spores, which hitherto it has not been possible to demonstrate, constitute the actual agents of infection. The channels through which the infected materials gain entrance into the body have not as yet been discovered. Symptoms and Diagnosis.-The period of incubation of relapsing fever is from five to seven days. Premonitory symptoms -prodromes—often are wholly wanting, although some patients complain of general malaise, anorexia, and an indefinite sense of illness. As a rule, the disease sets in with a single chill, followed by a febrile period of an average duration of a week, with elevation of temperature to 39° or 40° C. (102.2° or 104° F.), and frequently even above. In the course of seven days the temperature declines by crisis, with profuse sweating. The patients are now again free from fever and well for a period averaging seven days, when a renewed chill occurs, and continued fever sets in, and only after the new febrile paroxysm terminates by crisis in from five to seven days do most patients recover permanently. In some cases, it is true, a third and a fourth febrile recurrence take place, the apyretic intervals, as well as the febrile periods, being of shorter duration. As may be understood, the course of the temperature of relapsing fever is so distinctive (Fig. 61) that it is possible to make the diagnosis from this alone. A similar temperature-curve is known to occur only in some cases of pseudoleukemia, although the latter is unattended with the blood-state that is distinctive of relapsing fever. During the febrile period spirilla of relapsing fever-spirochetæ of Obermeier-are found unexceptionally in the blood, and no careful physician will, at the present day, diagnose relapsing fever without demonstration of the spirilla in the blood. In making the examination it is only necessary to remove a drop of blood from the cleansed tip of a finger by puncture with a needle, and to make microscopic examination with a magnification of from 300 to 500. Unless one be skilled he will do well to examine more carefully for some time especially those places in the blood-prepa ration where red or colorless corpuscles are apparently engaged in purposeless movement, as this is often due to the actively moving relapsing-spirilla, which displace the blood-corpuscles that are in their way. FIG. 61.-Temperature-curve from a case of relapsing fever, with a single relapse (personal observation). The spirilla of relapsing fever are spiral, filamentous structures, in which from five to eighteen turns can be distinguished (Fig. 62). They attain a length of from 16 to 40 p (one equals 0.001 FIG. 62.-Blood from a case of relapsing fever containing spirochetæ of Obermeier; immersion; magnified 1150 times. mm.) and they shoot across the field of vision often with great activity, exhibiting movement from before backward, and the reverse, lateral twisting and rotation about their longitudinal axis. They are extremely sensitive to all protoplasmic poisons, as a result of the action of which they lose their power of movement. With the occurrence of the crisis of the fever they generally disappear suddenly from the blood, to reappear with the succeeding febrile paroxysms. Occasionally, it is true, they may also be encountered in the blood for a few days after the crisis, with gradual diminution in motility. It has hitherto not been possible to cultivate them artificially. In hermetically sealed capillary tubes they retain their power of movement in the blood for several days, after which they lose this power and disintegrate into gran ular masses. Individuals with relapsing fever complain frequently of severe pulsating headache and of such marked vertigo that they are compelled to remain in bed. The face presents a sallow appearance. The liver and the spleen are enlarged and generally tender on pressure. In addition, the manifestations of fever are present, particularly increased thirst, a coated tongue, and anorexia. The urine is scanty, high-colored, and frequently contains albumin (febrile albuminuria). The occurrence of the crisis is not rarely preceded for a short time by symptoms of a critical perturbation, as disclosed in unanticipated chill, unusual elevation of temperature, and delirium, and which are likely to persist but for a short time (from one to three hours). They are without serious significance. On the termination of the crisis the patients improve with almost remarkable rapidity, and in the course of a few days are able to get out of bed again. Complications not rarely attend relapsing fever, those referable especially to the spleen and the liver being distinctive. The presence of cardiac-systolic vascular murmurs over the spleen is not significant. Symptoms of perisplenitis (perisplenitic friction-murmur, pain), and still more those of abscess of the spleen, are worthy of greater consideration. The existence of the latter complication will be indicated-in addition to pain over the spleen and enlargement of the spleen-especially by long-continued fever, chills and sweats, the fever not rarely exhibiting an intermittent character. Occasionally abscess of the spleen ruptures suddenly into adjacent structures, as, for instance, the pleura, the bronchial tubes, the stomach, the intestines, or the urinary passages, the peritoneal cavity, or externally. Some of these occurrences are almost necessarily fatal, particularly rupture into the abdominal cavity, which is usually complicated by fatal peritonitis. Rupture of the spleen has been observed in a number of cases of relapsing fever. Bilious relapsing fever results in consequence of profound disease of the liver. It is known also as bilious typhoid, although 1 This is a symptomatic disorder of varied origin having nothing to do with relapsing fever, and is not due to the activity of the spirillum peculiar to that disease. It may be compared to the so-called hepatic intermittent fever resulting from the presence of suppuration or other irritation within the hepatic ducts.A. A. E. it is well to avoid this designation, as it has obviously been applied to various morbid conditions. Patients with bilious relapsing fever exhibit marked jaundice of the skin and mucous membranes. The urine also acquires a deeply icteric hue, generally becomes diminished in amount, and contains, in addition to biliary coloring-matter, albumin and tube-casts, and often also tyrosin-needles and leucin-spheres. Erythema and urticaria often appear upon the skin, and finally symptoms of blood-dissolution (hemorrhagic diathesis) make their appearance. Smaller and larger hemorrhages occur beneath the skin, and extravasations of blood take place from various mucous membranes, thus, for instance, bleeding from the gums, epistaxis, hematemesis, enterorrhagia, hematuria, etc. The patients fail rapidly, become unconscious and delirious, and succumb frequently within a few days from excessive exhaustion. The liver is generally exceedingly sensitive to pressure, and increases considerably in size. The clinical picture resembles that of acute yellow atrophy of the liver, and is probably dependent upon a hepatogenous auto-intoxication that has been designated also cholemia. Prognosis. The prognosis of relapsing fever is not unfavorable so long as complications are absent. Drunkards especially are exposed to great risk. Anatomic Alterations.-The dead body generally presents a slight degree of icterus. The viscera exhibit alterations such as are observed in other acute infectious diseases (dry, ham-colored muscles, with granular turbidity and fatty or waxy degeneration of the muscle-fibers, granular turbidity and fatty degeneration of the fibers of the heart-muscle and of the glandular cells, enlargement of the spleen and the liver). It is distinctive for the follicles of the spleen to be enlarged, and often to be transformed into necrotic or purulent foci. In the bone-marrow also necrotic and purulent foci are not rarely demonstrable. In the venous spaces of the spleen and the bone-marrow relapsing spirilla are encountered, occasionally in a convoluted arrangement. The spirilla of relapsing fever retain their motility in the dead body for a few hours, and the cadaver is therefore infective. Treatment. The treatment of relapsing fever is the same as that for typhus fever (pp. 314-316). Blood-serum therapy has been attempted, but has not yet yielded encouraging results. In cases of bilious relapsing fever quinin (2.0:30 grains) has been recommended. MALARIAL FEVER (SWAMP-FEVER). Etiology.-Malarial diseases are justly designated swampfever, because they occur especially in marshy localities. The swampy regions of Italy, Hungary, and Greece, and the tropics |