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As the patient was now delirious he was ice-packed; at 11.54 P.M. his temperature had fallen to 105° F. and he became sensible and was conscious of what was transpiring around him.

The ice-packing was continued, and at 12.15 A.M. his temperature had fallen to 101°-sixty minims of the hypodermic solution of the neutral hydrobromate of quinine (10 grains) were now injected and at 12.30 A.M. his temperature had fallen to 99.8°; the ice-packing was now discontinued and he was replaced in bed and 10 grains more of the neutral hydrobromate of quinine were injected. At 1.15 A.M. his temperature was 99° F., and another ten grains of the quinine were injected. He now slept for a few hours and, as on awaking at 4.30 A.M. his temperature was found to be 101.8° and skin dry, the aconite and diaphoretic mixture was now given every half hour; profuse perspiration set in, but his temperature however rose slightly and at 5.30 A M. was 102.4°.

Distressing vomiting now commenced and at 6 A.M. a mustard plaster was applied to the epigas- trium; this controlled the vomiting, but the temperature still continued to rise, and at 7.30 A.M. was 104°. Wet sheets were now applied, the aconite still being given; at 9.20 A.M. his temperature was 103.6°, and at 10.30 a.m. 102.8°, by 1.30 P.M., it had fallen to 101° when sixty minims of the bypo- dermic solution of the neutral hydrobromate of quinine were injected. At 4 P.M. his temperature was 100.6°; at 5.30 P.M. another ten grains were injected, the wet sheet still being applied, at 7.15 P.M. his temperature was 101° F., and at 10.30 P.M., it having fallen to 99° F., ten grains more of the quinine were injected. He now slept until 2 A.M. (21st) when his temperature was 100° F., and the wet sheet was continued; he slept on and off during the night, at 5.40 A.M. his temperature being 100° F. His temperature this day did not rise above 101.2° (6 P.M.); at 11.30 A.M. 10 grains of the neutral hydrobromate of quinine were injected and a similar injection was given at 10 P.M.

22nd instant :-This morning his temperature fell to 99.6° (7.5 A.M.) and five grains of quinine in the form of a pill was now ordered to be given every hour. As at 3 P.M. his temperature had risen to 102.4° this was discontinued and the aconite mixture substituted. At 8 P.M. his temperature had 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., 10 grains 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 P.M. 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.

..388.

ter die sdm.

On the 26th instant, the quinine pill was reduced to once every two hours, and on the 27th inst. 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 paroxysm 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 reduc- tion 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 tinet. 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 tem- perature registering (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.

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