are then morbid heat of the skin, thirst, loathing of food, a bad taste in the mouth, extreme weakness, and languor; headach, sometimes frontal, at other times general, increased by mental exertion, light, and noise, particularly the noise of persons speaking or reading aloud, less so by that of machinery or any other not calling into operation the mental faculties. There is at times slight delirium, mostly at night. During the early part of the disease there is sleeplessness, latterly succeeded by the opposite state of drowsiness. The pulse is weak and quick; the bowels costive; sometimes vomiting of greenish or yellowish fluid. In occasional cases there is pain in the right or in the left hypochondriac region or in other parts of the abdomen; in some instances pain in the chest, with slight cough. These chest-symptoms I have seen only in persons who previously had some affection of the lungs or bronchial membrane; and of urgent local symptoms, those connected with the head are the only ones constant in the disease.

Many cases occur where the head symptoms are not so severe as above mentioned, where there is only slight headach throughout the disease, and little or no delirium; and, on the other hand, there are a few instances of ardent heat of skin, intense headach, followed by drowsiness, sopor, and coma; and the degree of intensity of disease ranges by insensible gradation, from that of mild common continued fever to that of typhus gravior.

After ten, twenty, or thirty days of these symptoms the disease terminates in one of several ways. 1. When it is fatal, the chief morbid state is effusion on the surface, or within the ventricles of the brain. 2. The state of continued pyrexia ceases, the patient complains of nothing except weakness, and in about a fortnight or more is restored to health. 3. The continued fever passes into remittent, generally of the quotidian, sometimes of the tertian type, and, when this change has taken place for about a week, it is followed by convalescence. 4. The fever changes first to remittent, and after a few weeks turns to intermittent, which, after several paroxysms, terminates in recovery. 5. The continued pyrexia changes directly to intermittent. 6. It passes directly into irregular periodic attacks of either a remittent or an intermittent character, or of these blended. Of those ways in which the disease may terminate, the first is rare, the fourth and fifth are most frequent, and the others are about equally common.

State of the Mind.-Sometimes, before the affection displays a distinct character, there is, as already noticed, an unusually capricious and irritable disposition; in other instances, where this change takes place to a greater degree, the friends are apt to think it the beginning of insanity. The delirium during the disease is the same as that of other fevers. After the fever is over, there is

observed, in a few rare cases, a mental alteration for the worse, approaching almost to stupidity; this may go off gradually in a few months, or it may last for a year.

Sequelae. After recovery, in other respects besides the mental state above mentioned, there is, in some instances, impairment of vision or hearing for a few weeks.

Complications. Sometimes there is affection of the liver, and, if the patient has frequently had ague or remittent fever, there is likely to be enlargement of the spleen. I knew of a case of malarial continued fever, where some chest-symptoms were supposed to be the chief if not the only malady, but, on the exhibition of quinine, the patient quickly recovered; the same was the case where there was affection of the liver, and jaundice; and in another instance, where there was supposed to be some disease of the abdominal aorta.

Causes. This fever is produced by the combined agency of great heat and a moist soil, as the muddy banks and edges of marshes, lakes, rivers, and canals, liable to changes in the height of the water; it is also occasioned by the first few years' cultivation of a soil containing some inches of very rich mould. A person who has had an attack is predisposed, if living in a malarious district, to other attacks and to remittent and ague; if living in a non-malarious country, he is liable to attacks of ague after exposure to cold and wet.

Diagnosis.-This fever appears to differ from common continued fever in the following particulars.

Prognosis.-A removal to a healthy part of the country is likely to be followed by recovery. When the fever becomes remittent, the prognosis is rather favourable, and when intermittent, recovery

is almost certain. Unfavourable cases are those where the fever remains continued, and where, also, removal is impossible from weakness, local situation, or pecuniary inability; likewise, where an attack follows a few weeks only after a former one.

Treatment.-The best measure is removal from the malarious neighbourhood. A popular and correct idea is, that a voyage on the lake is very beneficial, and from most places a patient can easily get water-conveyance. Thus, from most parts on the shores of Lakes Ontario and Erie, he can be easily removed by water to Drummondville, near the Falls of Niagara, a spot free from malaria, and in other respects, also, an excellent place for a sick person. For invalids at Amherstburg and Sandwich a visit to Windsor on the Detroit, or Sarnia on the St Clair is the most convenient. Of travelling in a steamer, the advantage is the quick passage, and the disadvantages are the noise, heat, and internal motion, so that in some cases a sailing-vessel may be preferable. In the public service this change of air is often inconvenient or impracticable, and in private practice also, from the severity of the illness, or the patient's pecuniary inability to remove from home, the disease must often be treated at the spot where it was contracted. When the patient is very ill and also far inland, it is next to impossible to remove him, on account of the present bad condition of Canadian roads.

At the commencement of the disease a single emetic may be prescribed. For the heat of skin cold sponging ought to be employed, and confined to the face and limbs if any chest or abdominal symptoms appear. For the thirst, iced-water drinks are useful, acidulated drinks are grateful; but as they may tend to promote constipation, they had better be avoided. After but little effect from the previous remedy, there may be tried in succession for the headach, cutting short the hair, cold affusion, shaving the scalp, purgatives, venesection, a blister, or leeches, or cupping the nape of the neck. Some patients object much to shaving the scalp, but their reluctance ought not to be indulged, if the headach is still considerable on the third day. Except at Toronto and Kingston, leeches are not easily procured in West Canada. By all the above measures the headach is not entirely removed, but continues in some degree throughout the whole course of the disease. Mental excitement and the irritation from light and sound must be guarded against. The bowels require to be acted on at first by cathartics, and then almost daily by purgatives or laxatives. During the state of continued pyrexia, half a grain of tartar-emetic may be prescribed thrice daily, from day to day, as long as no sinking appears. When there is much nausea and little vomiting an ipecacuan emetic may be prescribed; when the vomiting is of an ordinary amount, it may be left to itself; when too violent, it must be checked by opium or a sinapism or blister. Pain

in the chest is best treated by a sinapism, and this failing, by a blister. The same may be said of any abdominal pain.

When the fever has proceeded for twenty or twenty-five days, and there is great weakness, it is advisable to give a small quantity of wine five or six times a-day, and of wine in this province, sherry is to be preferred, as it is less adulterated than port. After the disease has continued for ten or fifteen days or longer, and when the violence of the fever has subsided, some experimental use may be made of quinine. If it appear that at any time of the day there is rather less pyrexia than another, a grain or two of it in solution may be given and its effect watched; and if any improvement seem to follow, a larger dose inay then be prescribed. This diminution of pyrexia may be looked for towards the middle of the day. When the disease assumes a remittent, or intermittent, or an irregular periodic type, quinine is to be given in the absence. of the paroxysms.

The above is the treatment required in whole or in part in most. cases; but occasionally additional measures are called for. Yellowness of the skin and pain in the liver may be treated by blisters over that organ, and the remains of this complaint by blue pill and rhubarb. During convalescence, uneasiness in the region of the spleen, and a feeling of distension and enlargement may be opposed by the use of tartar-emetic ointment or of iodine ointment over the part. A painful and irritable state of the kidneys may be soothed by the warm bath or treated with dry cupping. The impairment of hearing and vision may be left to time.

Remarks on the treatment.-There are two parts of the treatment respecting which medical men may differ. One is, the degree of necessity for venesection, some being more partial to it than others. In some cases, it seems to be immediately required by the severity of the head symptoms; but after shaving the scalp and the cold affusion these become milder, and the patient's weakness is apparently so great as, to some extent, to contra-indicate it. If after shaving the scalp, blood-letting, and the use of the cold affusion, the pain be still great, venesection ought to be employed; but for slight headach, it is not required. The other probable subject of difference is the propriety of giving quinine while the pyrexia continues,* which cannot be avoided if there is no apyrectic period in which to give it. Lind, in his work on hot climates,† quotes from Clark (on long voyages) the following sentence, without comment certainly, but still without any expression of dissent. Cinchona may be given "with advantage in malignant and remittent fevers in India, not only during the remissions, but even during the exacerbations of the fever; and when the fever is continual," though where there * This practice is found disadvantageous in the Mediterranean fever. Third edition. London, 1777, page 120.

is a remission there seems to be no occasion to give it in the paroxysm; and I am inclined to think that it is best never to use cinchona, but quinine only, and to give this, if it be deemed proper to give any, in a small dose in solution at that time, during the twenty-four hours when there is least pyrexia. The only probable ill effect is a slight increase of the headach for an hour or two; but this sometimes does not occur; and when it does, the temporary inconvenience may be endured, if any permanent advantage is expected to follow. If the headach be much increased after the quinine, the medicine is to be discontinued.

Cases. I shall now give the outlines of one or two cases to show the course of the symptoms.

At Port Colborne, Lake Erie, 1840, July 23, Mr Malcolm, R. D., aged twenty-six, royal navy; complains of great heat of skin; thirst; extreme weakness; pain in the head and limbs; tongue brown; nausea; anorexia; the pulse weak and quick. Hair to be cut short; cold affusion on the head; cold sponging of the limbs; an emetic to be followed some hours after by a cathartic.

July 24th. Slept badly; headach rather less; aversion to light and noise; the other symptoms continue, with vomiting of greenish and yellowish fluid. Purgative medicine and cold applications.

July 25th. Slept little; the same symptoms continue. He was bled to eight ounces, and syncope, with but little effect on the headach. Head to be shaved and a blister applied.

July 26th. Delirium in the night; less headach; heat of skin, and thirst continue; some pain in the left iliac region; slight cough, and pain near the middle of the sternum. To apply a blister to the chest, and to take a cough-mixture containing antimony.

July 27th. Some delirium in the night; headach somewhat less; is rather drowsy; skin hot; blister rose well; no pain of chest; less cough; still occasional pain in the left iliac region. To apply a sinapism to the part; laxative medicine.

July 28th-29th. Delirium at night; slight headach; a little cough.

July 30th. In the course of to-day his skin became pretty cool; no pain of head or chest; the cough is nearly gone. Pulse quick; feeble.

July 31st, Augt. 7th. During these eight days he had paroxysms of quotidian remittent, coming on about 11 or 12 P. M., and going off about 5 or 6 A. M. During the day time he felt cool and pretty comfortable, and took opening medicine and cinchona.

August 8th,-11th. During these four days he had two fits of tertian remittent, on the 8th and 10th.