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16
in similar condition, weight 10 oz. Spleen enlarged, weighs 22 oz. Very small scattered circular areas, pale with red centre, shining throngh capsule, about the size of a split pea. Ou section these extend into the spleen substance inch, and are pale in colour and soft. They are produced by the blocking up of the final ramifications of the terminal arteries. Liver weighs 76 oz., is the subject of fine cirrhosis, and of a certain amount of congestion. Otherwise no abnormality. Kidneys. Right, 8 oz., slight cyanotic induration, otherwise normal. Left, in same condition. Stomach and Intestines normal. Mesenteric glands not enlarged. No enlargement of superficial lymphatic glands. Brain weighs 47 oz., is normal. Bone marrow normal. No spirilla were found in the blood or smears from organs, of death-Heart Failure.
Cause
General Symptoms.-The high temperature maintained for some days and accompanied by severe backache and headache and pains in the limbs and joints, were inost noticeable. The Tongue became coated with a brownish fur, thick and moist at first, but becoming blackish and dry before the approach of the crisis, soon after which it began to get moist and to clear. The Pulse was quick, with a tendency to dierotism. About 20 hours before the crisis the respiration became affected-it was oppressed, and the patient had an anxious expression, pointed to his chest and indicated that he found it difficult to draw his breath. As soon as the crisis passed, however, all this quickly subsided, and the breathing became easy and normal. The Spleen was found to be enlarged and tender, and there was also some ten- derness over the region of the Liver. The Skin, even in the Chinese, was noticeably yellow, as were also the conjunctiva. The urine was not increased in amount, it shewed a slight increase in urates, but no blood or albumin was present. Apart from these symptoms and signs, none presented themselves that called for particular comment, and were such as usually accompany elevation of temperature-except in one instance which will be detailed further
OIL.
An important note in connection with these three cases is to be made. Two cases. remitted on January 14th, the third on January 24th: the Office-boy of the hospital who saw the patients frequently, and helped to coax mosquitoes to feed on them, but who had nothing to do with the nursing, was taken suddenly ill on January 30th. He was a known malarial subject and I had no reason to suspect that this attack was other than a malarial attack. On examination, however, of his blood numerous spirilla grere discovered, and he passed through a typical attack of relapsing fever of a very severe nature. His fever fell on the 6th day, the remission lasted 5 days; the first relapse then set in and lasted 10 days, then a remission of 9 days was followed by a second relapse which lasted 3 days and he took about 21 days more to convalesce. He complained of severe pain, backache and head- ache. His tongue was very foul and flabby. Just before the crisis of the first relapse he suffered from great distress of breathing and had a lively fear of impending death. Then the crisis occurred and he got better again, to have another relapse later on, During the first relapse his condition was very serious. His tongue was foul, and the backache was especially severe, and he was constipated. On the fourth day he developed a peculiar mental state. He was at first apathetic and then remained in a state of deep unconscious- ness from which he could, however, be aroused for a few moments at long intervals. Then he lost control of his sphincters, diarrhoea supervened, and the condition of unconsciousness deepened to such a degree that nothing could arouse him. This continued for three days, and during this time examination of the blood shewed that spirilla were absent, nor were they to be found in the centrifugalised urine. After a somewhat prolonged convalescence he recovered fairly well, a moderate degree of deatness however having set in which may possibly have been due to some injections (hypodermic) of quinine.
These cases are interesting, not only because Relapsing Fever is rare in Hongkong, but also because the fourth case shews hoy easily and rapidly it is transmissible and perhaps may point to a possible inole of transmission, The Office-boy used to assist in procuring films of blood for examination, and also in catching mosquitoes for me and coaxing them to feed. He never went near the patients at any other time, nor did he lend helping hand in nursing them. Yet the disease suddenly develops in him, the typical spisochetæ are found in his blood, and he passes through a very severe and a characteristic attack. How did he contract it ?
A
The Spirillum Obermeicri, the organism which is present in the disease and which causes it, is of varying length. In this series of cases it reached a length of from 24 to 30 microns they are said however to sometimes reach a length of 42 microns. It is wavy and spirally curled on staining, and when seen alive is very active, the principal movement being of a corkscrewy nature and sometimes of a lashing nature. It is very transparent and to be seen when living requires a darkened stage of the microscope. Its ends are pointed and its subs- tance stains uniformly. It is stated by one observer that fine transverse strice are to be