INTERMITTENT FEVER. 683 



Under the head of congestive, pernicious intermittent, in the strict 

 sense, we must class those cases where the malignant course of the 

 disease is caused by hyperaemia, effusions of blood, inflammations, and, 

 perhaps, also by obstructions of the circulation in different organs, in- 

 duced by stoppage of the capillaries with pigment. Probably these 

 disturbances of nutrition and circulation in the central organs of the 

 nervous system are the origin of the maniacal, apoplectic, epileptiform, 

 and tetanic convulsions, which occasionally complicate the paroxysms, 

 and have led to the designations febris intermittens perniciosa, mani- 

 acalis, apoplectica, epileptica, tetanica. A rather frequent but rarely 

 dangerous complication of intermittent fever is a severe bronchitis, 

 which exacerbates with every paroxysm and remits with each apyrexia. 

 Febres intermittentes comitatae pneumoniacse and pleuriticae, or cases 

 of intermittent haemoptysis, are rare. In many cases of congestive in- 

 termittent, there is jaundice. Copious watery transudations from the 

 intestinal canal, violent vomiting, and profuse diarrhoea, may cause 

 thickening of the blood, and give the paroxysm a great resemblance to 

 the algid stage of cholera. In some cases there are also profuse inter- 

 mittent intestinal haemorrhages. (Among fifty-one cases of pernicious 

 intermittent, observed by Frerichs, there was profuse diarrhoea seven- 

 teen times, profuse intestinal haemorrhage three times.) The serous 

 transudations and haemorrhages into the intestinal canal may depend 

 on acute congestion due to obstruction of the hepatic capillaries by 

 pigment, but this has not been proved in all cases. Lastly, we have to 

 mention the complications of intermittent with diseases of the kidneys. 

 They evince themselves by albuminuria, haematuria, and in severer cases 

 by the suppression of urine. (In the fifty-one cases of Frerichs, albu- 

 minuria was seen twenty times, suppression of urine five times.) 



Pernicious intermittent fever occurs chiefly in tropical-fever regions, 

 it is true, but even with us, in places where intense malaria prevails, 

 it is not rare, and individual cases are seen in every large epidemic of 

 intermittent fever. The malignant character either appears at the 

 start, or does not manifest itself till the second or third paroxysm, or 

 even later. After malignant congestive symptoms have appeared, the 

 apyrexias are often so imperfect that the diagnosis is very difficult or 

 even impossible. In the epidemics observed by Frerichs, most patients 

 were sent into the hospital with the diagnosis of a typhus. 



III. Concealed Intermittent Fever. While, as a rule, intermittent 

 fever results from infection with malaria, we not unfrequently see ex- 

 ceptional cases where, instead of fever-paroxysms, there is neuralgia, 

 the attacks of neuralgia being separated by regular intermissions, cor- 

 responding to the apyrexias of a simple intermittent. These deviations 

 from the rule are inexplicable, it is true, but this is also true of regular 



