The rhythmical course of the fever is characteristic. It begins apparently suddenly with chilliness or typical shivering, whilst the temperature of the body rises, the pulse becomes low and tense and the number of beats of the pulse increases considerably. After half to two hours the heat stage begins. The patient himself feels the rise of his temperature (shown by feeling of heat, dry tongue, headache, thirst). The temperature may reach 41°C or more. At the same time there is sensitiveness in the region of the spleen and enlargement of that organ. After four to six hours an improvement takes place, and with profuse perspiration the body temperature falls rapidly, not often below normal. After the attack the patient feels languid, but otherwise well until certain prodromal symptoms (heaviness in the body, headache) which were not noticed at first, denote the approach of another attack of fever, which proceeds in the same way. The intervals between the attacks are of varying length which permit of a distinction in the kinds of fever. If the attacks intermit one day, occurring on the first, third and fifth days of the illness and always at the same time of day, it is termed _febris tertiana_; if two days occur between fever days, it is called _febris quartana_. In the case of the fever recurring daily, later writers speak of typical _febris quotidiana_. But a quotidian fever may arise when two tertian fevers differing by about twenty-four hours exist at the same time (_febris tertiana duplex_). The patient has a daily attack, but the fever of the first, third and fifth days differs in some point (hour of occurrence, height of temperature, duration of cold or hot stage) from the fever of the second, fourth and sixth days. Similarly, two or three quartan fevers which differ by about twenty-four hours each may be observed together (_febris quartana duplex_ or _triplex_); in the latter case the result is also a quotidian fever. Two kinds of tertian fever are differentiated--a milder form occurring especially in the spring (spring tertian fever), and a more severe form appearing in the summer and autumn in warmer districts, especially in the tropics (_summer or autumn fever_, _febris æstivo-autumnalis_, _febris tropica_, _febris perniciosa_). The latter often becomes a quotidian fever. All the afore-mentioned infections are termed acute. They are distinguished from the very different _chronic malarial infection_ by the frequent occurrence of relapses, which finally lead to changes of some organs and particularly of the blood. The relapses are then generally marked by an irregular course of fever. The term masked malaria is used when any disturbance of the state of health of a periodic character shows itself and disappears after treatment with quinine.[194] Generally it is a question of neuralgia.