panying this stage are creepy sensations over the body, especially down the spine, yawning, and a certain amount of cyanosis. These symptoms are evidences of the contraction of the peripheral blood-vessels, causing absence of blood in the periphery of the body, with an increase in the visceral blood. Occasionally, there is nausea; sometimes there are vomiting, chattering of the teeth, and a rapid pulse, which is small and hard. The temperature, as registered by a surface thermometer, is subnormal, but the rectal and axillary temperature is high.

being severe anemia with jaundice. The complexion in this condition is muddy and of a grayish-yellow tint.

Symptomatology.-Tertian.-Prodromes are rare, and are characterized by periodicity, consisting of vague pains, slight nausea, and chilliness. The paroxysm consists of three stages: chill, fever, and sweating.

First Stage.-A few hours before the chill headache and a sense of uneasiness may be experienced. The onset is abrupt, with chilliness resulting in a distinct rigor; this lasts from fifteen to forty minutes or more. The symptoms accom

Second Stage.-The cold stage merges into the hot stage, which lasts from one to four hours. There are now sensations of heat, flushed face, injected eyes, full, bounding pulse, thirst, intense headache, restlessness, and even delirium. temperature rises to 103° F. or higher.

The

Third Stage. The hot stage is soon followed by the third stage that of sweating; this begins with sweating of the face, rapidly spreading over the entire body, terminating in a very profuse sweat, lasting from one to three hours. The temperature begins to fall, and at the end of this stage reaches the normal or subnormal. Headache persists for some time afterward, as a rule being frontal in character. Herpes is frequently seen, and albuminuria may be present.

Intermission. This is followed by a period of intermission lasting from thirty-six to forty-eight hours, during which time the temperature is normal or subnormal. The patient feels perfectly well, and is able to be about. This period continues until the next paroxysm, when the train of symptoms is again repeated. The regularity of these stages depends upon the uniform growth of the parasite, so that they sporulate almost simultaneously.

Occasionally, an individual is infected upon two successive days. In such an event there are two distinct groups of parasites that sporulate on consecutive days, causing a daily paroxysm (quotidian fever). In long-continued infections the growth of the parasite may become somewhat irregular, so that segmentation does not take place at a given time. As a result of this the chill may be prolonged or even absent. The fever may be somewhat irregular or, in rare cases, continued or absent. The sweating stage may show variation. In order to ascertain the variety of the type a blood examination is necessary.

Quartan Type.-This is the rarest of the malarial infections. It is found in parts of Italy, especially the Pontine marshes. The clinical manifestations of the paroxysms are similar to those just described in the tertian variety. The paroxysm occurs every seventy-two hours in the single infection. A double infection may occur, giving rise to a paroxysm on two successive days; then a day intervenes, and again two successive paroxysms follow, etc. The quotidian type of fever may also occur as the result of a triple infection.

ESTIVO-AUTUMNAL TYPE.

(SOMETIMES CALLED CONTINUED, Remittent, or IRREGULAR.)

Varieties. First, quotidian intermittent fever; second, tertian estivo-autumnal fever; third, pernicious estivo-autumnal malaria.

Estivo-autumnal fever is commonly found in the tropics, and rarely in temperate climates.

Quotidian Intermittent.-This is characterized by daily paroxysms, as described in the tertian variety. The regularity, however, has a tendency to vary.

Tertian Type. This is characterized by paroxysms every

Fig. 29.-Temperature-curve in a case of estivo-autumnal fever.

forty-eight hours that may resemble the tertian type, and show a tendency to become irregular.

Pernicious Malaria.-This type is commonly associated with the estivo-autumnal parasite-rarely with the tertian. It is produced either as a result of the severe infection, usually, of the estivo-autumnal parasite or of great abundance of parasites.

Different Groups.-Three distinct and well-defined groups have been differentiated: the algid, the comatose, and the hemorrhagic form.

Algid Form. The algid form is characterized by marked gastro-intestinal symptoms, vomiting, abdominal cramp, with

frequent stools. The urine is diminished, the pulse is feeble, and the temperature may be normal or subnormal.

Comatose Form.-The comatose form closely resembles an apoplectic stroke. The subject is suddenly stricken with unconsciousness or with acute delirium, with rapidly oncoming coma and chill. The unconsciousness continues, and the patient dies in coma. The temperature may be elevated at first, but in a day or two it falls to normal or subnormal.

Hemorrhagic Form.-The hemorrhagic type may occur in all the forms of severe malarial infections. Hemorrhage occurs most frequently from the kidneys, being either a hemoglobinuria or a hematuria. Suppression of the urine is occasionally met with, the patient dying from this cause. It is often called "bilious hemorrhagic fever."

Malarial Cachexia. It is the result of long-standing infection or repeated infections, causing severe anemia and characteristic discoloration of the skin, being of a muddy grayish color. The enlargement of the spleen is marked.

Combination of Type.-Some of the varieties just described may be combined.

Complications and Sequels.-Pneumonia, dysentery, nephritis, and enteric fever are sometimes concurrent affections. To the latter cases the term typhomalarial fever has been incorrectly applied. There is no mixture of type, the enteric fever running its course, the malaria being an intercurrent affection, or vice versâ. Other complications, such as tuberculosis, orchitis, or adenitis, may occur.

Relapses. Relapses are frequent, occurring after a period of weeks or months, sometimes of a year or more.

Diagnosis.-Diagnosis depends upon the finding of the parasites in the blood, and it may be said with accuracy that the type of fever may be determined, and with some certainty the time of the paroxysms. No diagnosis of malarial fever should be made in any fever showing irregular or regular type without the presence of the plasmodium. The therapeutic test should not be employed as a method of diagnosis.

Prognosis. In temperate climates the prognosis is good, the mortality being very low. In tropic and subtropic countries in which the severer infections by the estivo-autumnal parasites occur, the prognosis is unfavorable unless quinin can be administered early and in sufficient quantities.

Prophylaxis.-Thorough drainage and systematic cultivation decreases its prevalence. If one enter into a malarious

district, high ground should be selected for living purposes and the night air avoided. Mosquito-netting is of use. Quinin may be administered in small doses as a prophylactic.

Routine Treatment.-Rest in bed, if possible, is desirable, especially in the severer infections. Quinin is the specific, and should be administered in doses sufficient to produce its physiologic effect. In the ordinary tertian form fifteen to twenty grains a day, preferably given in solution, will be usually found sufficient. In the severer forms and in pernicious malarial fever it is always best to give quinin hypodermically. The treatment may be begun by the preliminary administration of a laxative dose of calomel, but the specific (quinin) should be employed as soon as possible. Arsenic and methylene-blue may be used. A spontaneous recovery rarely takes place.

Treatment in any case should be continued for a period of some weeks after all symptoms have disappeared, as relapses

are common.

Treatment of Malarial Cachexia.-Change of climate, a long sea voyage, and arsenic constitute the most favorable treatment of this condition. Quinin is of very little service. Warburg's tincture is often useful.

THE EXANTHEMATA OR ERUPTIVE FEVERS.

This group comprises scarlet fever, measles, German measles, variola, vaccinia, varicella, and, for the sake of convenience, erysipelas may be included. These fevers have certain well-marked characteristics. They are diseases of childhood, and are eminently contagious, having a known and well-defined period of incubation. They are all self-limited. Each is characterized by a well-defined eruption, appearing upon a certain day and in a definite manner. They have special sequels. There is no specific treatment, except in the case of vaccination, which is preventive in the variolous dis

eases.

SCARLET FEVER.

Definition. An acute, specific, contagious disease, characterized by a scarlet eruption that occurs early on the second day, with sore throat, high fever, and frequent implication of the kidney.