SYMPTOM A TOLOGY— VA RIETIES 



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them is seldom reddened. Of all the joints the hip, shoulder, ankle, 

 and knee appear most commonly affected. Inflammation or 

 neuralgia of the testes may occur, and at times the parotid also 

 becomes inflamed. 



The blood has been more particularly studied by Bassett-Smith 

 and Gabbi, who find a secondary anaemia with a loss of 20 to 40 per 

 cent, of the corpuscles, with some poikilocytosis and an even 

 greater reduction of the haemoglobin. The leucocytic count is 

 normal, but there is a decrease in the polymorphonuclears, and an 

 increase in the mononuclears up to as much as 80 per cent, in some 

 cases. Phagocytosis is said to be diminished, as is also the bac- 

 tericidal power of the blood. 



The urine is passed in fair quantity, and has a slightly acid 

 reaction, with a deposit of urates and phosphates, but there is very 

 seldom any albumen, though bile may be present in severe cases, and 

 the specific germ can be found in the urine even two years after an 

 attack. Albuminuria and nephritis may occur, and very rarely 

 haematuria. 



The patient is now anaemic, and prostrated by the repeated 

 attacks of fever, when gradually the symptoms begin to improve, 

 the intermissions lengthen, the attacks lessen in length and severity, 

 the temperature becomes normal or subnormal in the morning, 

 rising a little at night. Gradually the evening rise diminishes until 

 it stops, the tongue clears, the symptoms abate, and convalescence 

 begins after an illness of from 20 to 300 days, with an average of 

 90 days. 



Varieties. — ^Two varieties distinct from the typical description 

 given above are recognized by Hughes — ^viz., a malignant and an 

 intermittent — to which a third or ambulatory variety may be added. 



The Malignant Variety. — Suddenly, without warning, the patient 

 is attacked with high fever, the temperature rising to 104° or 

 105° F., with severe pains all over the body, flushed face, and all 

 the other symptoms already mentioned, but in an aggravated form, 

 and often associated with basal pneumonia, and diarrhoea with 

 offensive stools. 



After a little the symptoms abate somewhat, but instead of 

 improving, the pulse becomes intermittent, the breathing is laboured, 

 and vomiting becomes serious, and the patient gradually passes into 

 the typhoid state, when hyperpyrexia sets in, and death takes place 

 from the fifth to the twenty-first day of the illness. 



The Intermittent Variety. — ^The onset in this variety is very 

 gradual. When the attack is fully developed, the temperature is 

 about normal in the morning, but rises in the afternoon to 99° or 

 much higher, up to 105° F., this rise being accompanied by malaise, 

 irritability, and chilliness. During the night sweating occurs, and 

 the temperature falls to nearly normal. This fever continues usually 

 for about six weeks, but may be prolonged for about six months, and 

 is usually unasscciated with any serious symptoms — in fact, so 

 mild may the attack be that it is not discovered until the patient's 



