bilious matter, are experienced. The breathing is irregular, and often hurried; and the patient has a feeling of oppression or weight in the epigastrium or chest, which causes him to sigh deeply. There is sometimes also a short, dry cough. The pulse is small, in some instances quickened, even very much so, in others slow, often irregular and feeble. The secretions are generally scanty; but the urine is usually pale, limpid, and copious.

The nervous system is much disordered. Independently of the tremors already alluded to, there is often severe pain, of a neuralgic character, in the back, loins, and extremities, and sometimes in the head. The temper is not unfrequently irritable, and the mind confused, dejected, and sometimes even wandering. Occasionally there is drowsiness, which, in some rare instances deepens into stupor, coma, and even symptoms of apoplexy.

On

The duration of the cold stage varies greatly. Sometimes it does not exceed a few minutes, sometimes extends to three or four hours or more. the average, it may perhaps be stated at about an hour.

Hot Stage.-Pyrexia.-The passage from the chill to the hot stage is not abrupt. Rigors for a time alternate with flushes of heat. The first sensations of warmth are rather agreeable than otherwise. A glow is felt about the face and temples, and the patient is conscious of increased heat of breath. Gradually the whole surface becomes hot; but even now, if a limb be moved into a cool part of the bed, sudden chills are felt, vibrating disagreeably through the frame. At length all traces of the cold stage disappear, and the patient is affected with a universal burning heat. The checks are flushed, the eyes sparkle, the surface is everywhere reddened, and the skin distended with blood. The evidence of increased heat is not confined to the sensations of the patient. The temperature of the body is positively increased. Fordyce found it to be 105° by the thermometer, and Mackintosh states that he has known it to be as high as 110° in Great Britain, and 112° in warm climates. The mouth is hot and dry; the tongue usually furred; and the patient generally complains of great thirst, though this is not invariable. There is an utter disinclination for food, and occasionally nausea and vomiting. The respiration is more regular than in the chill, but is still accelerated. The pulse is more frequent than in health, and is usually full and strong. In some cases, however, when the state of system is adynamic, it is at once frequent and feeble. All the secretions are diminished; the skin being dry as well as hot, and the urine scanty and often high-coloured. The head is almost always painful, sometimes very much so; and the suffering from this cause, as well as the general violence of the febrile reaction, is often greater than is usual in remittent or continued fever. The pain is frequently throbbing, with a feeling of distension in the temples, and seems to be deep in the head, unlike that of the chill, which is generally superficial. There is frequently also pain in the back and limbs. Convulsions are not uncommon in children, at the commencement of the hot stage. Sometimes there is a moderate delirium; but this is not common. In some instances, a rashlike, or a petechial eruption appears and disappears with the fever. The duration of the hot stage varies from two to eighteen hours or more, before it begins to abate.

Sweating Stage.-Perspiration generally appears first upon the face and breast, and gradually spreads over the surface. It is sometimes slight, but generally copious, and occasionally very profuse. Upon its first appearance, the patient begins to feel some relief; and the febrile symptoms gradually abate as it advances. The skin becomes cool, the excitement of the circulation subsides, the mouth is moistened, the headache disappears, and the patient frequently falls into a calm sleep, from which he awakes free from fever.

The kidneys now resume their function, and the urine which is discharged very often deposits a lateritious sediment upon cooling.

It has been stated by writers that each stage of the paroxysm, subsequent to the chill, is the immediate effect of the preceding stage, in other words, that the cold stage produces the hot, and the hot the sweating. But this is scarcely probable, at least with regard to the first two stages, which bear no proportion to each other; a protracted and severe chill being frequently followed by less fever than a very slight one, and the fever sometimes occurring without any preceding chill whatever. The probability is, that, while the depression of the cold stage is naturally followed by some degree of febrile reaction, as a necessary consequence, the morbific cause, whatever it may be, is capable of producing the hot stage by a direct influence.

The whole duration of the paroxysm varies greatly. In many instances, it does not exceed three or four hours; while in others it runs on to within a very short time of the succeeding paroxysm, lasting sometimes in a quotidian eighteen hours, in a tertian thirty-six, and in a quartan sixty. As a general rule, however, the paroxysm is longer in a quotidian than a tertian, and in this than a quartan. The average duration in the quotidian may perhaps be stated at ten or twelve hours, in the tertian at eight or ten, and in the quartan at five or six. But the paroxysms generally shorten, as the disease becomes of longer continuance.

The paroxysm is liable to other diversities. Sometimes the cold stage is very slight, and exhibits few of its characteristic symptoms. Cases are not uncommon in which the only discoverable signs are some blueness about the nails, and a little coolness of the nose, ears, hands, and feet. This is especially the case with young children. Occasionally, even these symptoms are wanting, and the paroxysm begins at once with the hot stage, without any preceding chill whatever. This is the form of the complaint called by the vulgar dumb ague, to distinguish it from the more common form, which is called shaking ague. Sometimes the sweating stage is wanting; the fever either gradually subsiding without any discharge, or the place of the perspiration being supplied by a diarrhoea, or a copious flow of urine. The idea has been advanced, and it seems plausible, that the dropsical effusion which occasionally attends an attack of intermittent fever, may be vicarious to the perspiration. It is asserted that the cold stage has, in some instances, passed into the sweating, without the intervention of febrile reaction; and that, in others, the whole paroxysm has consisted of perspiration without either chill or fever. But, in such cases, the disease, though it may be intermittent, can scarcely be said to merit the name of intermittent fever. In the double tertian, it sometimes happens that, of the two paroxysms, which serve as the prototypes of all the others, one may be regular in all its stages, while the other is destitute of chill, or in some other way peculiar.

Among the vagaries of the paroxysm, a very singular one has been noticed in which the affection is confined to a single limb, which passes through the several stages regularly, the remainder of the system being apparently undisturbed. Various affections, occurring at regular intervals, without any other resemblance to intermittent fever than their paroxysmal character, have been . considered as masked cases of the disease (febris intermittens larvata). Among these may be enumerated neuralgia, rheumatism, epilepsy, hysteria, hiccough, petechial eruptions, diarrhoea, and dysentery, all of which occasionally appear in the intermittent form, occurring daily or every other day at the same hour, with intervals of apparent health. But it appears to me that they have as little claim to be considered intermittent fever, as the same affections, in their continuous form, would have to be considered continued

fever. If they could be shown to be uniformly the result of miasmatic influence, there might be some foundation for this view of their nature; but the fact is, that they sometimes occur under circumstances in which miasmata could by no possibility have been the cause.

Intermission, or Apyrexia.-After the paroxysm has subsided, the patient, though without fever, is not usually quite free from signs of disease. General languor, facility of fatigue, pains in the back and loins, uneasy sensations in the head and epigastrium, with some fur upon the tongue, and a feeble appetite, are not unfrequently left behind, in greater or less degree. The patient, moreover, is apt to have a pale or somewhat sallow complexion, and a sickly look. These, or analogous symptoms, are most common after the early paroxysms. Sometimes they are very slight, sometimes so considerable as, in connexion with some heat of skin and frequency of pulse, to render the intermission imperfect. They generally diminish with the continuance of the disease; and at length the patient becomes apparently quite well in the intervals of his attacks; having, not unfrequently, the appetite, the digestion, and the general vigour, though not perhaps fully the aspect of health. To the above rule, however, there are exceptions. Cases occur in which the patient, even at the commencement, is as free from all signs of disease during the intermission, as in his most perfect health.

COURSE, TERMINATION, &c.-It has been stated that, in the several types of intermittent fever, the paroxysms return at the same hour of the day. There is, however, often some variation in this respect. The commencement of a paroxysm, instead of being precisely at the same time of day as that of the preceding, may be an hour or two earlier, or an hour or two later; and it not unfrequently happens that, if a little before the time upon one day, it is a little after it on the next, so that the mean between the extremes of divergence is the regular hour. In some cases, instead of thus fluctuating backwards and forwards, each succeeding paroxysm occurs an hour or two earlier than its predecessor, so that the length of the intermission is regularly diminished. In other cases, it occurs an hour or two later, so as regularly to lengthen the intermission. In the former, the disease is said to be an anticipating, in the latter, a retarding intermittent. One type may in this manner be converted into another. Thus, an anticipating quartan may become a tertian, and an anticipating tertian a quotidian; while a retarding quotidian is changed into a tertian, and a retarding tertian into a quartan. It is obvious that an anticipating quotidian may pass from the intermittent to the remittent form.

It is a remarkable fact, that the paroxysms seldom occur during the night. Perhaps sleep may in some way oppose a resistance to their attack. The rule is not universally, but generally true. In the vast majority of cases, the time of attack is between the hours of eight in the morning and eight in the evening; and it is worthy of observation that, in the anticipating and retarding cases, when the receding or advancing paroxysm reaches the period of darkness, it is apt either to be arrested in its course, or to leap over the night, backward into the evening, or forward into the morning. Thus, the paroxysm of an anticipating tertian, occurring first at noon, and recurring afterwards successively at the hours of ten, eight, and six, will, after attaining the last mentioned hour, either continue to recur at the same, or will return next time at about six or eight in the evening preceding the regular period. A retarding tertian, on the contrary, after reaching the confines of night makes its next attack in the morning, subsequent to the regular day of return. (Fordyce.)

It has been generally observed that, the shorter the intermission, the earlier is the hour of the day at which the paroxysm is disposed to appear. Thus,

the quotidian most frequently makes its attack in the morning, the tertian. about noon, and the quartan in the afternoon. It is true that there are very frequent exceptions to this rule. Thus, the quotidian and tertian may change places, or may either of them occur in the afternoon; but the paroxysm of the quartan very rarely appears in the morning. Another result of observation is, that the longer the duration of the disease, the later in the day are usually the returns. Hence, in old cases of intermittents, the paroxysms should occur in the afternoon.

Reference has been made to the change of one type into another in the course of an anticipating or retarding intermittent. But the same conversion sometimes takes place abruptly. The most common is from a type with frequent paroxysms, to another in which they are less frequent. Hence, a quotidian is more apt to become tertian, and a tertian quartan, than the reverse. Intermittents, if left to themselves, will not in general run on indefinitely. The milder cases not unfrequently terminate spontaneously with the seventh or eighth, and sometimes so early even as the fourth or fifth paroxysm. More than one-half of the tertian fevers which occurred in the infirmaries of the Salpêtrière of Paris, in the autumn of the sixth year of the Republic, terminated with the ninth paroxysm, or previously. The treatment employed was of the simplest kind, and calculated to have little effect upon the course of the disease. (Dict. de Méd., xvi. 589.) According to Fordyce, quotidians usually end spontaneously in about ten weeks, tertians in about four months, and quartans in six, seven, or eight months. But occasionally, these diseases continue for a much longer time, if not interrupted.

When an intermittent has been checked by any means whatever, it has a strong tendency to return, so that very slight causes will often provoke a fresh attack, and not unfrequently a recurrence will take place without any appreciable cause. Quartans are said to be most apt to relapse; but all the types are subject to the law. In these returns, there is a singular tendency to observe the septenary period. It has been said that quotidians are most apt to return at the end of a week, tertians of two weeks, and quartans of three. I have not noticed this peculiarity of the several types; but of the general fact there can be no doubt. In most instances, according to my own observation, the relapse takes place upon the fourteenth day from the occurrence of the last paroxysm; and, if this day be passed, then at the end of the third week, or at some future weekly period. An autumnal attack of intermittent is very frequently succeeded by another, at the opening of the warm weather, in the subsequent spring. The liability to the recurrence of the disease continues for one or two years, and sometimes much longer. In general, the subsequent attacks, without a fresh exposure to the cause, are milder than the original.

GRADES AND COMPLICATIONS.-Intermittent fever may be of a sthenic character, with a vigorous reaction, a full strong pulse, a florid surface, and a pure rich blood; it may be asthenic, with unusual depression in the chill, a slow and uncertain reaction, a feeble though frequent pulse, a dusky or purplish hue of the skin, and a depraved, impoverished, or scanty blood; or it may be of any grade between these two extremes. In the first mentioned form, it is sometimes though erroneously said to be inflammatory; for the condition may exist altogether independently of inflammation. In the second form, it may be called simply feeble, when the blood is not depraved, and the general energies not greatly depressed; typhoid, when along with the debility there is a peculiar contamination or depravation of the circulating fluid; and malignant, pernicious, or congestive, when the powers of the system are so much prostrated as to endanger a very speedy and fatal issue.

These differences depend, not on the peculiar character of the miasmatic cause, but upon the previous condition of the patient, or the influence of other causes acting conjointly with the miasmata. Most cases occurring in temperate latitudes have more or less of the sthenic grade; and the characters of this grade have been sufficiently detailed in the general description of fever. The merely feeble cases are known by a general deficiency of energy in the reaction, and the marks of debility in the intermission, without peculiar symptoms of derangement, or any very alarming signs of prostration. They are not uncommon among individuals reduced by previous indisposition. The typhoid cases may be recognized by the greater depression of the chill, the pungent heat of the skin during the reaction, the very frequent but comparatively small and feeble pulse, the more than ordinary dryness of the mouth, the brown colour of the tongue, the tendency to the production of sordes about the teeth, the dusky hue of the surface, and the greater frequency of nervous symptoms, as subsultus tendinum, jactitation, and low delirium. They are met with chiefly among persons previously exposed to the want of proper sustenance, fresh air, and the ordinary comforts of life, or at periods when an epidemic typhoid influence prevails in miasmatic districts. Of the malignant or pernicious intermittent I shall treat separately; as it differs from the other forms strikingly in some of its symptoms, and requires that especial attention should be called to it, in consequence of its terrible fatality when mistaken, and inefficiently treated.

Intermittent fever is not unfrequently associated with inflammation of an organ or organs of the body, and, in this state, has often been confounded with the higher grades of the ordinary sthenic form of the disease, under the name of inflammatory intermittent; the local affection having been overlooked or disregarded. The distinguishing general character of these complicated cases is the appearance of the buffy coat of the blood upon coagulation. Except in the pregnant state, and in anemic cases, which are in general readily recognized, this sign may be considered as conclusive of the existence of inflammation. When this attends the sthenic state of the fever, a peculiar hardness of the pulse is superadded to its strength of impulse. But the inflammation may also be coincident with the typhoid character of the disease, in which case this hardness may be wanting.

The organs most frequently affected are the stomach and bowels, the liver, the lungs, and the brain, or its investing membranes. To enumerate here all the symptoms characteristic of the phlegmasia of these structures, would be to anticipate what must be stated fully hereafter. It will be sufficient to notice a few prominent symptoms, which may serve to fix attention upon the inflammation when it shall exist. When the stomach is inflamed, there are usually burning pain and tenderness upon pressure in the epigastrium, a craving for ice or cold drinks, and a more than ordinary degree of nausea and vomiting; substances which are ordinarily acceptable to the stomach, being often promptly rejected. Inflammation of the bowels is manifested by colicky pains in the abdomen, more or less tenderness over some particular part of its surface, and diarrhoea, or dysenteric symptoms. The liver may be considered as the seat of inflammation, when there are pain and tenderness in the right hypochondrium, difficulty of lying on the left side, pain in the right shoulder, nausea and vomiting, discoloured evacuations from the bowels, yellowness of the skin, conjunctivæ, or tongue, and a deep-brown colour of the urine. These inflammations are most frequent in the summer and autumn. The symptoms of thoracic inflammation are different, according as the bronchial membrane, the parenchyma of the lungs, or the pleura, is affected. In the first case, the ordinary catarrhal symptoms are presented;