296 APPENDICES 



in the morning than in the evening. There may be 

 very severe headache, and pains in the back and 

 limbs. One of the most distressing symptoms is 

 the vomiting, which is often exceedingly severe and 

 difficult to stop. Diarrhoea is not infrequent. In 

 some cases after forty-eight hours, but more commonly 

 after three or four days, the temperature falls rapidly 

 to below the normal, and the symptoms are imme- 

 diately relieved. After a varying interval of from 

 four days to a week, and sometimes longer, there is 

 a recurrence of all the symptoms, occasionally as 

 severe as in the first instance, but generally less 

 severe. The relapse lasts for two or three days, and 

 after another interval it is followed by a third. There 

 is a tendency for the duration of the attacks to become 

 shorter, and for the intervals between them to become 

 longer, until they cease altogether. Five or six re- 

 lapses is not an uncommon number for an European 

 to suffer ; occasionally there are as many as twelve. 

 Amongst natives there is not always a relapse, and 

 there is seldom more than one. 



Although tick fever is not a very fatal disease — the 

 mortality is usually below 6 per cent. (Manson) — it 

 is a very disagreeable disease for Europeans in a 

 tropical climate, which is itself a hindrance to complete 

 convalescence. 



The diagnosis is not always eas}^ unless a micro- 

 scopic examination of the blood can be made. It may 

 be very suggestive of malaria, but the fact that it does 

 not respond to quinine ought to help the diagnosis in 

 this case; and the persistent vomiting is unlike malaria. 

 Some of the cases in which intestinal symptoms are 

 prominent somewhat resemble enteric fever. 



The treatment must be confined to treating the most 

 distressing symptoms, so far as is possible. There 

 is no drug which is known either to stop the disease 



