Il6 TROPICAL MEDICINE AND HYGIENE 



Clinical Course : Severer Type. The onset of the disease 

 is sudden, but not invariably with a rigor. The tempera- 

 ture rises rapidly, there is violent headache, most intense 

 over the frontal region. The eyes are much injected and 

 often described as ferrety. Jaundice soon appears, but 

 not as early as in blackwater fever ; the conjunctiva and 

 skin are at first lemon-coloured, but soon deepen to a 

 bright yellow colour. Vomiting is a prominent symptom ; 

 at first, merely of food, then watery, then '* acid vomit," 

 and later almost black " black vomit." 



The act of emesis is performed with little or no effort, 

 and the amount ejected is surprising. The vomit seems 

 rather to gush out than to be forcibly expressed. There 

 is a feeling of marked and decided relief after each 

 evacuation of the stomach. 



Epigastric pain and tenderness occur early and are 

 intensified by pressure. There is usually an intensely 

 acid or bitter taste in the mouth. 



The course of the disease is best considered divided into 

 three stages as described by Blair. During the first stage 

 the temperature is high and the pulse quick and bound- 

 ing. The headache and epigastric pains are severe, and 

 the vomit is free from blood till towards the close of this 

 period. The urine contains albumin about the second 

 day, and the jaundice appears and progressively deepens. 

 The duration of this stage is from three to four days. 



The passage into the second stage is rapid, though not 

 exactly by crisis. The temperature falls to normal or 

 subnormal, the pulse-rate is much reduced, and the rate 

 may be 40 or even less per minute, the restlessness, 

 pain, and delirium disappear, and the patient feels much 

 relieved, and often quite well. The general appearance 

 of well-being in the second stage is deceptive, and death 

 may occur in such a patient, and he, even while he is 

 sinking, may feel quite well. 



In some cases the mild ones (yellow fever simplex) 

 this remission is the end of the disease and the patient 

 steadily continues to improve, and passes into the stage of 

 convalescence without secondary fever (fig. 34). 



