184 TROPICAL MEDICINE AND HYGIENE 



Clinical Course. After a few hours of malaise the patient 

 is suddenly seized with chills, and in two or three hours 

 he is suffering from high fever, with a hot, dry skin, with 

 rapid pulse, severe frontal headache, and great pain in the 

 back and limbs. Bilious vomiting sets in, accompanied 

 by much thirst and by pain and tenderness of the upper 

 part of the abdomen. Considerable prostration ensues, 

 and by the second day of his illness, if not earlier, the 

 patient takes to his bed. Here he lies for about a week, 

 his tongue becomes dry and coated, his bowels consti- 

 pated, and his liver and spleen enlarged and tender. 

 Jaundice may supervene, and slight bronchitis is common 

 at this stage. 



The patient is troubled with sleeplessness (the insomnia 

 resembling that of a patient with delirium tremens) f 

 or he may be delirious. His aspect is weary, his face 

 livid, and his condition appears to be very serious. 

 On or about the seventh day, however, a crisis occurs. 

 Following a brief increase in the severity of the symptoms, 

 copious perspiration sets in, the temperature falls very 

 rapidly, and symptoms of collapse may follow, not infre- 

 quently accompanied by diarrhoea or even dysentery. 

 In a favourable case, however, the collapse is not serious : 

 the patient falls asleep and wakes after a few hours, 

 apparently convalescent. After about a week of this 

 seeming convalescence the patient is subjected to another 

 attack of fever commencing almost as suddenly as the first. 



The symptoms of the relapse are similar to those of 

 the initial attack, but milder, though the fever may be 

 higher and the debility more pronounced. The duration 

 is, however, shorter. A second crisis occurs on or about 

 the fifth day, and is usually followed, after a short con- 

 valescence, by complete recovery. Sometimes, however, 

 a second, and in decreasing frequency a third, fourth, or 

 fifth relapse may occur. On the other hand, there may 

 be no relapse. Some cases are cut short by death in the 

 first attack. 



The suddenness of the rise and fall of temperature is a 



