INFECTION IN INTERMEDIATE HOST: QUARTAN 
191 
infections may be with a single, double, 
or triple arrangement of paroxysms but 
most frequently with single or double. 
The complete quartan paroxysm pre¬ 
sents the three classical stages, namely, (a) 
the cold, or stage of rigor, (b) the hot, or 
febrile stage, and (c) the sweating, or 
stage of defervescence. 
The cold stage, in our experience, has 
most frequently begun with a temperature 
below 100° F. Infrequently the tempera¬ 
ture has been subnormal at this time, which 
appears to be to a large extent a character¬ 
istic dependent upon the individual. Oc¬ 
casionally the cold stage has been ushered 
in with a fever as high as 103° or 104° F 
but this is not common. This stage is 
usually initiated by chilly sensations, gen¬ 
erally beginning in the extremities. They 
may then extend in area and increase in 
degree until an actual rigor occurs with its 
accompanying cyanosis, particularly of the 
lips and finger nails, cold extremities, rapid 
and small pulse and quick but brief respira¬ 
tions. Headache may be severe. 
On the other hand, the patients may 
have rigorless paroxysms. The severity of 
the latter may be confined to chilly sensa¬ 
tions and a subsequently elevated tempera¬ 
ture or there may occur merely a slightly 
elevated temperature. Our experience re¬ 
garding the incidence of rigors has been 
almost the opposite of Marchiafava and 
Bignami (1901) who state that they are 
“not apt to be absent.” As Boyd (1940b) 
pointed out, (a) rigors most frequently in¬ 
itiate simple quartan paroxysms, (b) in the 
case of double quartan fevers the rigor 
more frequently precedes only one of the 
two paroxysms and (c) when the par¬ 
oxysms are quotidian, the incidence of 
rigors is likewise most often quotidian. 
While, as mentioned before, the indi¬ 
vidual paroxysms of quartan infections 
tend to be regular, one cannot as a rule 
say the same for their incidence throughout 
an attack. As illustrated in Fig. 3 (No. 
B-2813), by an additive process, a double 
quartan course may become triple (quo¬ 
tidian) in type, and conversely, by a sub¬ 
tractive process, a quotidian course may 
revert to a simple form. Also through the 
Fig. 1. No. B-2814 (P. malariae ) : Postponement 
of one cycle eventually results in its fusion with a 
second cycle. No. B-2815 (P. malariae ): New 
cycle appears (14th, 17th, etc., days) as old cycle 
(15th, 18th, etc., days) disappears. 
substitution of a new cycle for one that 
has dropped out, the clinical type (single, 
double, triple) will remain unchanged 
(Fig. 4, No. B-2802). The appearance of 
new cycles or the reappearance of dropped 
cycles and the disappearance either of 
original or added cycles has been charac- 
further breaking up of the chief paroxysms into 
several minor ones (two a day on the 15th and 
16th days). No. B-2832 (P. malariae ) : Parasites 
showed extreme invasiveness in this instance. Un¬ 
usually high parasite densities. Note two parox¬ 
ysms on 12th and 14th days with terminal remit- 
teney. Fatal termination. 
