The icterus is more marked about the face, neck and upper parts of the trunk. The albuminuria precedes the jaundice.
Blackwater Fever.—In a typical case of this disease we have within a few hours a marked jaundice which tends to deepen. It is usually more or less marked according as the haemoglobinuria may be. It does not show the tendency to persist as does the jaundice of yellow fever.
Bilious Remittent Fever.—The jaundice appears rather earlier than that of yellow fever but is rarely seen on the first day of the paroxysm as with blackwater fever.
Of great diagnostic value is the early appearance of bile-colored urine as different from the haemoglobin-tinged urine of blackwater. The albuminous urine of yellow fever is not apt to show any bile coloring in the first three or four days of the disease.
Relapsing Fever.—There is a clinical type of relapsing fever associated with jaundice and a high death rate which was first described by Griesinger from Egypt. This icteric type is not infrequent in Asia. This jaundice is late and the disease much resembles yellow fever. The enlarged painful spleen and the finding of spirochaetes in the peripheral circulation are essential to differentiation.
Weil’s disease.—Much interest has been recently aroused in Weil’s disease, or epidemic jaundice, on account of the frequency of the disease in soldiers in the Balkan campaign. While a spirochaete has been shown by Inada and others to be the cause, yet many workers have isolated paratyphoid B organisms from the blood of such cases. Frugoni obtained cultures of this organism from the duodenal fluid of 11 cases from 48 cases investigated. The accepted cause of true Weil’s disease is Leptospira icterohaemorrhagiae. The jaundice begins about the third day of an irregular fever. Like yellow fever these cases showed injection of the conjunctivae and albuminuria. There were, however, usually a leucocytosis and enlarged spleen.
In severe cases of spotted fever of the Rocky Mountains we may have a generalized jaundice. Rarely cases of typhus fever may show jaundice.
Alterations in Size of the Liver
There is only a slight enlargement in the ordinary case of tropical liver but in some cases it may extend 3 or 4 fingers’ breadth below the costal cartilages or rarely to the umbilicus.
In liver abscess the enlargement is a rather late feature, and the condition should be diagnosed before we have the assistance of protruding ribs and distention of the intercostal spaces. As the abscess is usually located in the upper portion of the right lobe the enlargement is usually upwards and is best made out with the X-ray, showing the cupola-like projection.