CLIMA TOLOG Y—DIA GNOSIS 



1509 



Climatology. — It was common in Gallipoli, the Balkans, Italy, and 

 France. 



etiology. — ^This is at present unknown. Certain authors con- 

 sider it to be of paratyphoid origin, but this is not so. Spirochsetes 

 have been described in the urine by several observers, including 

 one of us. These organisms are often not pathogenic to guinea-pigs, 

 and have not yet been demonstrated to be the cause of the disease. 



Pathology. — It would appear as though the jaundice was due to 

 obstruction to the common bile duct, either by swelling of the 

 duodenal mucosa or to mucus in the duct. 



Symptomatology. — ^The onset is gradual. The patient feels tired, 

 complains of aches in various joints and muscles for weeks, the skin 

 may appear to be normal, and the temperature is either normal or 

 not very high (99° to 100° F.). The patient has often the sensation 

 of suffering from very high fever, while on taking his temperature 

 he may find it normal or subnormal. During this stage very often 

 the urine is darker than usual and contains biliary pigments. We 

 have come across patients feeling fairly well, but complaining of 

 what they called rheumatism for months before the jaundice 

 appeared; others had remarked the staining of their shirts by 

 the urine. This stage may last for several weeks; in one of our 

 cases it lasted three months before the jaundice appeared. 



The Jaundice Stage. — ^First the sclerotics, then the skin, slowly 

 become icteric. The degree of jaundice is seldom so marked as in 

 cases of true obstructive j aundice. The patient generally feels abso- 

 lutely done up, often with pains and aches all over the body; as 

 a rule there is very little or no pruritus, in contrast to so many other 

 types of jaundice. He has no appetite, and may feel inclined to 

 vomit. The temperature is normal or subnormal, pulse usually 

 slow, but may be of normal frequency; the spleen generally is not 

 palpable, nor is the liver in most cases ; there may be pain on pressure 

 in the region of the gall-bladder, but this is not a constant symptom. 

 There is often constipation, and the stools may be whitish or of the 

 usual brownish colour; at times there are periods of diarrhoea, 

 alternating with periods of constipation. The urine is scarce and 

 very dark-coloured; it may contain a trace of albumen and casts. 

 The jaundice stage lasts between two and eight weeks. Recovery is 

 slow, and for weeks and months after the jaundice is over the patient 

 may feel very weak. 



Diagnosis. — ^The characteristic features of the disease are: — 

 (i) Its epidemicity; (2) its slow onset; (3) its long course divided 

 into a pre-icteric and an icteric period. 



With regard to the differential diagnosis, it can be separated from 

 catarrhal jaundice only by its epidemicity. 



From icterus castrensis gravis (Weil's disease) it can be differen- 

 tiated by the mildness of the symptoms, by the slowness of the 

 onset, and by the slightness or absence of the febrile symptoms 

 and the absence of haemorrhages. 



From enteric jaundice it can be separated by the absence of enteric 



