SYMPTOM A TOLOG Y—DIA GNOSIS 



and teeth. Vomiting may be present from the first, and hiccough 

 may also be troublesome. There may be pain and tenderness in 

 almost every part of the body. The neck may be stiff, andjin these 

 cases the cerebro-spinal fluid maybe under pressure and contain an 

 excess of polymorphonuclear cells and lymphocytes, as well as 

 albumen and bile. 



The conjunctivae may be injected, and herpes may be present 

 on the lips. 



Jaundice usually appears two or three days after the onset of the 

 symptoms, but may be later, though it is almost always present 

 before the temperature drops. Pruritus is slight or absent. 



The blood shows a diminution of red corpuscles and haemoglobin, 

 and an increase of leucocytes, while a very few spirochaetes are 

 present between the fourth and ninth day. The pulse is slow in 

 proportion to the temperature. The urine usually contains bile, 

 albumen, granular and hyaline casts, and sometimes a few red cor- 

 puscles, and the spirochaete can be found after the first week. 



Haemorrhages from the lungs, the stomach, or more rarely the 

 bowels, may occur, while epistaxis and purpura may be seen in 

 severe cases. 



Termination. — ^The temperature drops by crisis or rapid lysis from 

 the eighth to tenth day. 



Relapse. — ^There is often a return of the fever some few days after 

 it falls to normal, and the relapse may last from a few days to ten or 

 even fifteen days, but there is no increase in the symptoms. 



Convalescence. — ^This is often prolonged. 



Diagnosis. — ^The cardinal diagnostic points are: — 



1. The presence of the spirochaete in the blood between the fourth 

 and ninth day (it is difficult to see), and in the urine. Blood may 

 be inoculated into the peritoneal cavity of guinea-pigs, in which 

 iHness supervenes after inoculation of not less than six days. 



In order to discover the spirochaete in the urine, it is necessary 

 to adopt Castellani's method of centrifuging 20 c.c. and pouring 

 off the supernatant fluid, then adding another 20 c.c. and again 

 centrifuging, and so on until about 200 c.c. of urine has been centri- 

 fuged, after which the deposit may be examined. 



2. The severity of the symptoms and the sudden onset, the 

 severe pains, the jaundice, the enlargement of the liver and spleen, 

 the albumen in the urine, with casts and a few red blood corpuscles. 



3. The pulse is slow in proportion to the temperature. 



The differential diagnosis has to be made from camp jaundice, 

 enteric jaundice, septic jaundice, malarial jaundice, acute yellow 

 atrophy of the liver, typhus, blackwater fever, pneumonia with 

 jaundice, yellow fever, and relapsing fever. 



From camp jaundice [icterus castrensis levis) it can be diagnosed 

 by the sudden onset, the severity of the symptoms, and the short- 

 ness of the illness. 



From enteric jaundice, which is rare, it may be recognized by the 

 presence of the polymorphonuclear leucocytosis and the absence 



