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Appendix A.
CASE OF REMITTENT FEVER, HIGH TEMPERATURE, ABSCESS OF
SPLEEN, RECOVERY.
The most interesting of the fever cases during 1890 was that of P. C. JAMES ALEXANDER. was admitted on the 5th of June, suffering from Intermittent Fever and Enlarged Spleen.
He
The splenic dulness was enlarged and the spleen could be felt just below the border of the ribs. His temperature for four days previous had been going up to 101° F. or so in the afternoons. This was his first attack of fever.
He had a 5 grain pill of quinine thrice daily to start with and ung: hydrarg: biniodid: to rub in over the enlarged spleen. On the 6th he had a 5 grain quinine pill every four hours, but as this did not have any effect on the fever, he had one every hour on the 9th. His bowels all this time had to be regulated by aperients; while antipyrin had also to be given when the temperature was high. On the afternoon of the 15th, it went up to 104.6, and after this the fever became decidedly remittent in character, bilious vomiting being rather severe. On the 14th, he commenced to take gr. 10 of quinine every hour when his temperature was below 100° F. At this stage the quinine could only be kept down after the administration of opium or effervescing mixture. On the evening of the 16th, the temperature again rose, and at 11.27 P.M. had got to 107°. He was immediately ice-packed and the temperature was brought down to 100°.4 at 12.20, champagne and soda being given frequently during the process, while an ice bag was kept on his head and another on the nape of the neck. During the next twenty-five minutes, he had 105 minims of the solution of neutral quinine hydrobromate (1 in 6) hypodermically. On being put to bed, his temperature again began to rise in spite of large doses of Warburg's Tincture, antipyrin and, later on, aconite until at 7 A.M., on the 17th, it was 108°.3 when ice-packing had again to be resorted to.
At 8.13 he was removed to bed with a temperature of 97° F. having had 80 m. of quinine hypo- dermically during the preceding twenty minutes. Two hours later, the temperature again started on its upward journey and gradually rose through the day notwithstanding large quantities of the ordinary antipyretics till at 5.20 P.M. 107°.4 was reached, when ice-packing was again commenced. At 6.10 P.M. he was removed from the pack when he had gr. morphia hypodermically, having had since 5.58 P.M. 120 m. of quinine solution hypodermically as well. As long as the temperature kept below 101° he had 10 grains of sulphate of quinine by stomach every hour also. The morphia quieted him consi- derably and gave him some sleep during the evening. About 10 P.M., however, the fever commenced again, and at 1.30 A.M. had got to 106.2. At 2.10 A.M., after packing, the temperature was 98°.5 when he had another 60 m. of quinine by skin and also gr. morphia. He had a fairly good rest till 6 A.M. when the old story began again, at 7.30 his temperature being 105°.6. He was put into a tepid bath this time and it was gradually cooled down to 75° F. At 8.55 A.M., the temperature was 97o.4 when he had another 60 m, of quinine hypodermically.
The temperature kept down till noon when it again went up, and at 4.15 P.M., it was 107°.2. Ice-packing again brought it down to 97°.6, at 4.55 P.M. where it remained for over an hour. He had only 20 m. hypodermically this time, as also 10 gr. by stomach every hour while the temperature was below 100° F. as well as 20 gr. by enema. The temperature again went up at 9 P.M. when it was 101° F. The patient at this time had 40 m. quinine hypodermically. On the 19th, the temperature kept hovering between 104° and 106° all day despite large quantities of aconite and antimony-one minim of tr. aconite, and 3 m. of vin: antimonial being given every ten minutes through the day.
At 5 P.M., the temperature being 106°, he was again placed in a tepid bath which was gradually cooled down till at 6.15 P.M., the temperature had fallen to 98.8., 180 m. of quinine were given hypo- dermically between 6 P.M. and 7.5 P.M. At 9.35 P.M., temperature being again on the rise, a wet sheet was put over him to be changed frequently. He also had by skin gr. morphia and another 60 m. quinine solution at 11.10 P.M. Although the temperature kept up, he had a fairly good night's rest. The wet sheet was kept on the patient off and on during the next three days during which he had quinine frequently hypodermically. For a long time between the 23rd June and 6th July, the tem perature kept moving up and down between 98 and 102°. Between July 6th and July 28th, it ranged between 98° and 104°, 105°, or 106° every day. During all this time the spleen had been enlarging until it almost reached the middle line. The liver dulness was normal all the time. During this period he had antipyrin, quinine and purgatives in almost enormous quantities.
Strength had been gained on Brand's Essence, eggs, fish and champagne in large quantities, a mixture of brandy and champagne proving of excellent value during a long period of the case. The chest and abdomen were examined carefully time after time to try and find out a cause for the temperature as the amount of quinine that he was now having had really no effect.
On 25th of July, however, matters became explained to some extent as, at noon, just after morn- ing visit, when he had been carefully examined and no lung mischief found, he began to spit up large quantities of pus and blood and, on being examined again a few hours after, dense crepitations could be heard all round the base of the left lung, which was slightly dull. Next day (26th), the expecto- ration continued; the exact quantity could not be measured owing to vomit and other inatter being