initial paroxysm; usually it is milder and seldom lasts so long. During its continuance the secretion of urine is considerably increased; sweating also is profuse and prostration marked.
With the defervescence of the first relapse the patient enters on the second period of apyrexia, which is usually coincident with convalescence. But in some patients a second relapse may occur, usually about the twenty-first day counting from the commencement of symptoms. This second relapse rarely lasts longer than three days, and is generally milder than the previous paroxysms. In rare instances three, four, five, or even more relapses have been observed. Convalescence may be protracted, and complicated with such sequelæ as nephritis, ophthalmia, otorrhœa, pneumonia, neuritis, parotitis, adenitis. In pregnant women abortion is the rule.
African type.— The African tick-conveyed spirillum fever, although as regards the type of fever resembling the classical European and Indian forms, differs from these in some important particulars. The initial fever is not usually so prolonged, generally terminating in crisis within three days. Diarrhœa and dysenteric symptoms are not uncommon. The apyretic intervals are of very irregular duration, being, according to Philip Ross, sometimes as short as one day, sometimes as long as three weeks; and instead of only one or two relapses, as in ordinary relapsing fever, there may be as many as eleven, five or six relapses being the rule. The fever, though shorter, is as severe in the relapses as in the initial paroxysm, but the intervals tend to become longer. In some instances the reverse is the case, perhaps in both particulars. Sometimes the fever may assume a low chronic form, it may be with severe headache and vomiting. Iritis is not an uncommon complication or sequela. As already stated, the parasites are usually very scanty in peripheral blood and may be hard to find.
In the natives of the endemic districts the disease, as generally observed, is not nearly so severe as in Europeans and strangers, being usually limited to
