This form of the disease is marked by a diminished temperature and decreased sensibility of the whole surface of the body; the skin being at the same time, soft, contracted, and often clammy, or wet with a copious perspiration. When a partial reaction takes place, the heat is never considerable, and it is often confined to particular parts of the surface. There are considerable and universal lassitude and debility, with pain in the head and giddiness, the eyes are heavy, suffused and dull; the countenance is haggard and the face pale, and of a dingy muddy appearance; the pulse is small, frequent; the tone of the voice is often changed, the articulation being slow and drawling, or imperfect and stammering. The breathing is anxious and laborious, with frequent sighing. The tongue exhibits at first but little change, but soon becomes dark brown or black, especially in those cases in which the earlier stages of the disease has been marked by some degree of excitement. The stomach is occasionally irritable; the stomach and right side are tender on pressure, and more or less tumid; the bowels are torpid, and when stools are procured, they are dark-coloured and offensive, and often attended with griping and straining. The mind is generally dull, indifferent and confused, from the commencement of the attack, and, in the progress of the disease, sinks into a state of stupor, or of low muttering delirium. There is an absence of exacerbations and remissions of the fever, the disease presenting but little other change than a rapid or gradual increase in intensity. In fatal cases, death, which may take place between the fifth and fifteenth days, or even later, is often preceded by hiccup, twitching of the muscles, involuntary stools, hemorrhage from the stomach and bowels and petechiae.

The congestive form of bilious remittent fever may attack suddenly, when it is apt to assume a peculiarly malignant form, and to terminate rapidly in death; in many cases, however, it is pre ceded by the same symptoms as the milder and more open forma of the disease. In the more violent attacks of congestive fever, the system seems to sink at once prostrate before the invasion. The skin is cold, and covered with a clammy sweat, as in the collapse of cholera; the pulse is weak and fluttering; the stomach is very irritable, with frequent and painful, but often ineffectual efforts to vomit; the countenance is shrunken, and pale or livid; there is often low muttering delirium, with shivering and fainting. In some cases, no complaint is made, a lethargic insensibility seeming to oppress the patient; in others, the most extreme anguish is endured by the miserable sufferer, who in his agony often utters groans or loud cries. The vital powers are speedily exhausted by a few such exacerbations, although the remissions in this class of cases are usually well defined, and full of transient relief and hope. The third, fourth or fifth return of the train of symptoms described, for the most part, puts an end to the scene.

The convalescence from an attack of all the forms of bilious remittent fever is always protracted. Relapses from slight irregularities of diet, or too early exposure, are not unfrequent. After severe attacks, the hair often falls entirely off, and is only slowly and imperfectly renewed, or the patient remains permanently bald. The functions of the stomach and bowels are generally imperfectly performed for a long period after recovery, and require the utmost circumspection on the part of the patient. Jaundice is a very frequent consequence of bilious remittents.

Treatment

In the more decidedly inflammatory cases, with a hot skin, flushed and turgid face, severe pain in the head and back, great oppression at the chest, and a firm or corded pulse, when the patient is young, robust, and plethoric; it is recommended to take blood from the arm; and that a sufficient amount should be drawn off at once to reduce the violence of the fever. One sufficient bleeding at the onset of the disease is far more efficacious than repeated small bleedings afterwards.

Local blood-letting, by means either of leeches or by cupping, will be useful in many cases where bleeding from the arm may not be considered necessary. In all cases attended with intense pain in the head, throbbing of the temples or delirium, with pain or decided tenderness of the stomach or the right side, or pain or tightness about the chest, the application of leeches or cupping-glasses to the seat of pain, will usually afford relief. The very great suffering which many patients experience from pain in the back and loins, has frequently been relieved by the application of cupping-glasses along the sides of the spine. After the leeches or cupping, hot fomentations may be applied.

After the bleeding, or at once where bleeding is considered unnecessary, the bowels must be opened by purgatives. There is considerable difference of opinion amongst Medical Practitioners as to what cathartics are best to employ. Dr. Hartshorne says: "The use of large doses of Calomel is now almost entirely abandoned by American practitioners"; but he does not state what he considers a large dose; and medical opinions differ considerably on that point. Sir Thomas Watson says: "Calomel is probably one of our best cathartics in this disease. It may be given either alone, in a full dose, and followed by occasional doses of Castor Oil, Senna Tea, Calcined Magnesia, or by laxative injections; or the Calomel may be con-bined with Rhubarb or Jalap; or, what is frequently a more effectual plan, a full dose of the Calomel administered at first, and then every three or four hours, according to the effects produced, moderate doses of Blue Pill and Rhubarb, with the addition of a small portion of Ipecacuanha. By these means we shall generally succeed in freeing the bowels of the dark-colored, viscid matter with which they are often loaded, and procuring more regular and healthy stools, after which an occasional dose of the milder laxatives will alone be required."