435
fallen to 101.8°, and at 11 P.M. it was 100° F.; ten grains of quinine were now injected hypodermically and during that night his temperature did not rise above 100 F.
23rd instant, 6 A.M. temperature registered 99° F., ten gains of quinine were injected hypoder- mically and a five grain quinine pill was ordered every hour; the wet-sheet was discontinued this morning, it having been applied continuously for seventy-six hours. This day the highest temperature
was 100.4°.
In the evening as patient was suffering from retention his urine was drawn off.
24th, urine had to be drawn off again this morning; the quinine pill was still given every hour excepting when patient was asleep; his temperature only rose above 100° F., at 6 PM. when it was 100.2°.
From this date he continued to improve; the retention continuing until the 26th instant, after which he passed his urine normally.
On the 25th, the following medicine was ordered in addition to the quinine pill :--
Re Liquoris Strychniæ
Aqua Chloroformi Aquæ aã
.m. iv.
3ss. ter die sdm.
On the 26th instant, the quinine pill was reduced to once every two hours, and on the 27th instant to once every four hours; on this latter date he was placed on half diet, and a mutton chop was added to his diet on the 29th. He was discharged cured on the 7th July.
REMARKS.
This is a typical case of the most severe form of what is termed "Hongkong Fever."
The type is really that of unusually malignant Remittent Fever, the onset is very sudden and the tendency is for the fever paroxysin to be excessive i.e. the temperature rises as high as 107° or 108° F. and can only be reduced by the application of external cold by the use of the graduated bath, the wet-sheet, or "ice-packing in the extreme cases.'
}}
There is generally distressing bilious vomiting and the nervous system is much more affected than in the milder cases of Malarial Fever.
In this case the fever was reduced in the first instance by the graduated bath; however, this reduction was only temporary, and the temperature that day rose again. No active measures were taken for some time with the hope that the crisis marked by profuse perspiration would set in tinct. Aconite in small doses frequently repeated in a diaphoretic mixture were given with the object of promoting this.
However, as this did not occur it was found useless to delay matters any more, and with the temperature registered (in the axilla) 108°, ice-packing was commenced and by this means in an hour and a half, the patient's temperature was reduced 8.2°, the hydrobromate of quinine was then injected hypodermically, as much as thirty grains being injected, during the following hour.
A rise above 104° F. occurred that day, but this was controlled by the continuous application of the wet-sheet for seventy-six hours.
In several of these severe cases retention has been met with, in this case it occurred on the 23rd June, (seventh day of illness) the question arises whether this is due to the fever or to the large doses of quinine given, as in these cases the retention is cured by small doses of strychnine, I am led to the conclusion that this is due to the direct effect of the malarial poison on the spinal cord.
Great care is taken to use a fresh solution of the hydrobromate of quinine (1 in 6), and the syringe is provided with a platinum needle.
In this case there was slight stiffness of some of the muscles of the forearm, which disappeared in a short time evidently due to the direct irritation of the muscle fibres by the hypodermic solution. The places selected for the injections are the calves of the legs, the shoulders (deltoid muscles) or the muscles of the forearm.
I attach to this a temperature chart of the case.
Appendix D.
CASE OF MALARIAL FEVER.
Mixed Intermittent and Remittent; High Temperature; Recovery.
A. W..
ÆT. 22, Sailor.
Admitted August 5th, 1889, 10.45 a м.
On admission patient stated that he had been feeling unwell for the last two days, his temperature was 103.2° F., the following was prescribed :-
Re Tr. Aconit
Mixt. Diaphoret
m. iv.
3i. horis sdn.