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3 0A
MEDITERRANEAN, MALTA
OR
UNDULANT FEVER

v _ _ ‘Rim M-’ ‘L_iE_ V
L. s. H‘ ,&;;;~.1. M. LEERARY
\_


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Photo (1000 diam.) by Mr. Pringle.
l.—Micrococcus Melitensis val Brucli, colonies from human spleen about 14 days old, less than
one-half natural size.
IL—Mic. Mel. from spleen of monkey (Exp. III . Chap. II .), colonies full grown, almost, natural size.
F10. [IL—Mic. Mel. from human spleen, colonies full grown, about half natural size.
Fm.
lV.—Mic. Mel. from colony on agar (x 1000), microphotogmph.
MEDITERRANEAN, MALTA
OR
UNDULANT FEVER
*‘VQWC' BY
MPVLOUIS gUGHEs
SURGEON-CAPTAIN, ARMY MEDICAL STAFF
'a'Lunnun
MACMILLAN AND (30., LIMITED
NEW YORK: THE MACMILLAN COMPANY
1897
All rights 'rese'rved
\ 1 1T]
Wk \f\%0\
MW“
TO THE
RIGHT HON. LORD LISTER, P.R.S., D.C.L., LL.D., ETC.
SURGEON EXTRAORDINARY TO ILM. THE QUEEN
THIS BOOK IS DEDICATED
IN ADMIRATION OF HIS GREAT TALENTS, AND IN
REMEMBRANCE OF MANY ACTS OF KIN DNESS TO THE AUTHOR
ERRA'I‘A.
In Contents, last line, for u nominorum” read u nominum.”
On pages 226 to 231, headlines, for u nominorum ” read u nominum.”
On page 163, seventh line from bottom, for u have” read “ has.”
a \
‘x
I“?
, .
PREFACE
WHEN the writer arrived in Malta towards the end of the year 1890,
for a six years’ tour of service‘ in that place, he found that his medical
work would chieﬂy consist, during the greater part of the year, of treating
a fever about which no two medical ofﬁcers appeared to agree, respecting
its cause, treatment, or even name. Some even doubted its speciﬁc
F‘ nature, calling it a variety of enteric or malarial fever, and until the
\.
(\\\
I
‘*x
M enteric nature.
writer had been present at a post-mortem examination on a fatal case,
he was himself prejudiced in favour of all serious cases being of an
The fallacy of this theory soon became apparent, and
L2) extended clinical and pathological experience showed how much there
\
‘o
was to learn, and how little to guide anyone, in the study of this
important fever. The majority of medical ofﬁcers, naval and military,
gain much valuable knowledge during their service in the Mediterranean,
but in most cases this goes away with them on the expiration of their
tour of service, and new medical officers have to take up the work ab
initio. Could these latter but begin where their predecessors left off,
we should in course of time, by accumulated knowledge, really know
much about this disease. It is with the idea of placing such little‘
knowledge as the writer has gained, during six years of almost constant
hospital and other practice amongst such fever cases, at the disposal
of those coming after him, that this small book has been compiled. Let
us hope that it will form a nucleus for a more extended and accurate
account at some future date, in which case, crude and disjointed as it
is, it may prove of service.
a busy life, at the headquarters of a large station, were available for
the compilation of these notes, which are therefore far from being as
systematic or complete as could be wished, and leave much for others to
correct and work out. Further, during the last summer of the author’s
service in the Mediterranean, he contracted this fever himself, and
had to be invalided to England. Though this proved a most practical
Only the hours that could be spared from '
X UNDULANT, jl/[ALTA 0R [MEDITERRANEAN FEVER

if unwelcome experience, it precluded him from carrying out research
into many points of interest, more particularly with reference to the
blood and the bacteriology of the urine and faeces.
Few but medical officers of the Army and Navy meet with this fever
in its endemic area, and all our-present knowledge about it has been
drawn from the accounts of the experiences which they have been able
to publish. Unfortunately their shifting and busy life affords but little
opportunity for systematic research. One of the greatest advances
towards gaining a knowledge of the fever, namely, its recognition as a
distinct disease, by the Committee appointed by the Royal College of
Physicians of London, by whom the last edition of the Nomenclature of
Diseases has been drawn up, has been acknowledged by that august
body, in their preface, as being “in consequence, more especially, of
representations made by officers of the Medical Department of the
Army.” This is not only a proof that such work has not been wasted,
but is a matter for which those who have the honour of the Army
Medical Staff at heart, may be pardoned for feeling some pride.
The etiology and treatment of this fever are of considerable import-
ance to Great Britain, for the Mediterranean is not only a winter resort
and important commercial centre, but is also a training-ground for a
large ﬂeet, and a half-way house in which regiments are acclimatised
before proceeding to India. It contains a permanent force of over
25,000 soldiers and sailors, and may at any time become the seat of
warlike operations, when every available man may become of vital
importance. All these troops are at present more or less exposed to the
effects of this endemic fever, both in the garrison towns and in the
various ports which our ﬂeet visit. Its lengthened duration causes an
enormous yearly ﬁnancial loss, from non-effective pay and invaliding,
while it may be said to be the most important, and next to venereal
diseases, the most prevalent form of sickness affecting our Mediterranean
forces. .
" To the French, Italian, and other Mediterranean nations, this subject
cannot but be of importance, while the limits of its geographical pre-
valence have yet to be ﬁxed.
The author, who together with his wife and two sisters have suffered
from the disease (average pyrexial duration, 140 days), feels only too
strongly the need that exists for discovering and removing its cause, it
being to Englishmen at present the scourge of the Mediterranean.
In the text, a date enclosed in brackets, following a name, refers to
the bibliography, a section of the work which the author has endeavoured
to make as complete as possible. All the matter he has been able to
PREFA CE Xl

collect has been included, Without reference to the particular views of
the individual Writers, so that it may be a guide to those who Wish to
make a systematic and exhaustive study of the disease. The author
Will always be grateful for further references, particulars of which any
reader may be Willing to furnish him. ’
Though the Writer has had an opportunity of seeing cases of this
fever in many parts of the Mediterranean, his practical experience has
been gained in Malta and among soldiers and their families. The
greater part of this book must therefore refer to that place, and to the
prevalence of the feverin the Army. He has, however, collected as
much general matter as may have come to his ‘knowledge, and doubtless
the experiences gained in Malta will be found to apply in great part to
this fever as it occurs elsewhere. .
In conclusion, the Writer has to especially thank Surgeon-Major-
General O’Dwyer, Surgeon-Majors Bruce and Manché, Surgeon-Captain
Ritchie, Dr. Thin of London, Prof. \Vright of Netley, Drs. Pisani,
Carruana Secluna, and T. Zammit of Malta, and many others, for much
valuable help and kind encouragement in his Work. Also Mr. Pringle
and Mr. Rosser for their excellent photographs.
' M. L. H.
c/o HOLT & C0.,
17 WHITEHALL PLACE, LoNDoN, S.W.
CONTENTS
CHAPTER I
Deﬁnition— Synonyms—5 Short description— S pecific nature of the fever——
Nomenclature — Historical sketch — Geographical distribution —— Biblio-
graphy
CHAPTER H
Bacteriology—~Predisposing causes—Method of propagation and dissemination
—Inﬁuence of age and sex—Incubation period—Seasonal prevalence—In-
ﬂuence of rainfall and atmospheric temperature—Question of immunity
from subsequent attacks—Changes in type, quantitative and qualitative .
CHAPTER HI
Symptomatology—Description of clinical types: malignant, undulatory, in-
termittent, etc. -—Physiognomy—Tegumentary system—Pyrexia—Nervous
system—Arthritic symptoms—Circulatory system—Respiratory system—
Alimentary systen1~—Urinary and sexual symptoms—Complications and
sequelae
CHAPTER H7
Diagnosis from enteric fever, paludism, tuberculosis, hepatic abscess, etc.—
Prognosis—Duration of pyrexia and convalescence——Mortality——Morbid
anatomy, naked eye and microscopic
CHAPTER V
Prophylaxis—Treatment—Invaliding and change of air
PAG E
94
154
INDEX RERUM
INDEX NOMINORUM
221
226
INDEX TO CLINICAL DESCRIPTIONS OF
CASE
1. Indian Remittent Fever ('4) .
. Fatal Result during a Relapse
. Fatal Result during a Relapse
. Malignant fatal Case . .
. Fatal Case with Cardiac Complications
. Malignant fatal Case .
. Malignant fatal Case . .
. Pericardial Eﬂ‘usion with fatal Result
. Malignant fatal Case
16. Fatal Result during a Relapse
. Prolonged and fataLIntermittent Case
12. Malignant fatal Case . .
. Death at late Stage with Cardiac Complications
14. .Pericardial Effusion with fatal Results
15. Death with Cerebral Symptoms . .
16—20. Instances of Attacks of Undulant and
Individual
. Pimples simulating Rose Rash
COOOQODCJ‘WOON)
Enteric Fever in the same
22. Subcutaneous Haemon'hages .
‘ . Illustrating pure Undulant Type of Pyrexia
24. Rapidly fatal Malignant Type . .
25. Case illustrating Cerebro-spinal Symptoms
26-36. Rheumatoid Symptoms following Undulant Fever
37—40. Rheumatoid Symptoms commencing Undulant Fever .
41. Late Neuritic and Arthritic Symptoms
42. Neuritic Symptoms : Intermittent Type followed
43. Gout complicating Undulant Fever
44 .
45. Early Arthritic Symptoms .
46-49. Orchitic Symptoms
by Undulatory Pyrexia
. Sacro-iliac Eﬁ’usion .
38,
39,
39,
CASES
PAGE
27
37
113
33
33
39
115
144
39
117
39
40
40,174
40,144
40,124
39,
84-86
102
‘104
103
115
124
123
129
130
130
140
140
141
151
INDEX OF TABLE S
TABLE
1.
2.
10.
11.
12.
13.
14.
. Time spent in Hospital by 844 cases
Admission-rate for Fevers—Gibraltar, Malta, and Ionian Isles, 1837-1847 .
Admission and Death rates for Simple Continued and Remittent Fevers in
Malta, 1817-1889
. Admission and Death rates for Non-tubercular Respiratory and Sympto-
matic Intestinal Diseases in Malta, 1817-1878
. Admission and Death rates for Rheumatic Affections, Malta, 1817-1888
. Admission-rate for Undulant Fever and Mean Temperature month by
month, showing the seasonal prevalence of 1839 cases
. Admission-rate for Undulant Fever, Rainfall, and Average Temperature
for each month in 1891, 1892, and 1895
. Admission-rate for Undulant Fever and Rainfall for each month in 1884.,
1885, 1886, and 1887
. Length of previous Mediterranean Service in 292 cases
. Death-rates, Civilian Population of Malta, in 1895, at various ages
Annual Admission-rate per mille (troops in Malta), for Simple Continued
Fever, with Rainfall from 1859-1895
Average Admission-rates for Simple Continued Fever, in Cyclical Periods,
from 1859-1895
Date of Death in 45 cases
Duration of 300 waves
Pyrexial duration in 372 cases
PAGE
15
17
17
18
77
108
166
167
INDEX OF CHARTS
CHART
1.
QDCDKTOD UTI-POGN
Experiment on a Monkey (Bruce)
. Experiment on a Monkey (Author) .
. Experiment on a Monkey (Author) .
. Experiment on a Monkey (Author) .
. Comparison of Monthly Admission-rates for Undulant Fever with Rainfall
(Malta 1891 and 1892)
. Typical Undulations of Remittent Pyrexia .
. Undulations of somewhat Continuous Pyrexia
. Undulatory ending with Intermittent Type
. Intermittent Type showing Waves .
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Undulatory Type with well-marked Waves .
Undulatory Type with Waves less clearly divided
Severe Wave at End of an Attack
Early temporary Falls of Temperature in Undulant and Enteric Fevers
Malignant rapidly fatal Type
Fall of Temperature followed by fatal Rise .
Death during a Relapse
Death during a Relapse
Diurnal Curve, 43rd to 51st Day of Chart 9
Intermittent Type passing into Undulatory (First Part)
(Second Part)
77 3, ,Q 3,
PAGE
45
46
47
48
80
108
109
111
112
113
114
114
115
115
116
117
118
119
131
134
CHAPTER I
Deﬁnition.—Synonyms .' (a) From its supposed resemblance to enteric (typhoid) or
malarial fevers ; (b) from its rcmittent character ; (e) from the occurrence of gastric.
derangements or other symptoms; (ll) from its lengthened course and indefinite
duration ; (c) From its geographical prevalence ; (f) from its supposed origin.—
S/rort (Zcserzfption.——,8§2eeeﬁe nature : Supposed resemblance to enteric and malarial
fevers; Differentiation from these fevers.——r\'rmzmclaz‘ure : Necessity for a suitable
name ; geographical names unsatisfactory ; fallacy of names connected with other
fevers ; consideration of other suggested names.—Undulant fever suggested as a
suitable name.—][£stom'eal Sketch: Accurate history begins 11.1). 1859; (0)
occurrence prior to 1859; Hippocrates, 11.0. 460; Demarco and Howard,
Al). 1722-87; Fauverge, 1798-1800; Cleghorn, 1744-49 ; Heastic, 1825-28 :
Burnet, 1800-10; Hennen, 1816-25; Davy, 18133-35; Parliamentary statistical
reports, 1817-59; Crimean \Var period. (b) More accurate history, Marston,
1859; Mackay, 1862; Pottinger, 1862; Royal Navy, 1872; Boileau, 1865;
Chartres, 1866 ; Guilia, 1871 ; Donaldson, Oswald \Vood, and Lane Notter, 1876 ;
'Ye-ale, 1879; Turner, 1884; Maclean, 1885; Bruce, 1886, ctc., Discovery of a
speciﬁc micro-organism; Motfet, 1889; Articles in text-books on medicine and
inclusion in the nomenclature of the Royal College of Physicians of London,
18915-97; Italian and other writers. Summary.—G’eogrop/rieaZ Disfribmﬁiow~
Malta and Gibraltar; Sardinia; Balearic Isles; Italy and Sicily; 'h'eccc;
Turkey ; Cyprus; Crete; Jerusalem; North African coast; Red Sea; France.
Somewhat analogous or possibly identical forms of fever occurring in China,
India, and America.—]}£Z)Z'i0gmp/zy.
Deﬁnition.—An endemic pyrexial disease, occasionally prevailing as an
epidemic, having a long and indeﬁnite duration, an irregular course
with an almost invariable tendency to undulatory pyrexial relapses.
It is usually characterised by constipation, profuse perspirations, and
accompanied or followed by symptoms of a neuralgie character. Often
accompanied by swelling and effusion of the joints and other rheumatoid
symptoms. After death, the spleen is found to be enlarged and often
softened, many of the organs congested, but Peyer’s glands neither
enlarged nor ulcerated, nor is ulceration present in other parts of the
small intestine. There is a constant occurrence in certain tissues of a
deﬁnite species of micro-organism.
Synonyms.——(a) From its supposed resemblance to enteric (typhoid) or
male/rial fevers. F ebbrieola tiﬁodea (Grimaldi, 187 2, etc.) ; Intermittent
typhoid(Borrelli, 1877); Adeno-tifo (Cantani, 1878); Febbricola tifosa (De
Renzi, 1884); Febbre tifoidea atipica (Capozzi, 1885); Ileo-tifo a forma
B
N
UND ULANT, M'AL TA ore

sudorale (Jaccoud, 1885-86) 3 Pseudo-tifo (Guiffré, 1893)3 Recurrent
typhoid 3 Illyphqinalarial fever (Maclean, 1875, Rho, 1895, etc.) 3
Feeco-malariaTfbvef (Donaldson, 187 6) 3 Subcontinuous malarial fever
(Baccelli, 1875, 18913 Drummond, 1888) 3 F ievre typhoide sudorale
italienne (Jaccoud, 1897),: Tifo atassico.
(6) From its 'rem-z'ttent character. Mediterranean gastric remittent
fever (Marston, 1861 3 Chartres 1866 3 Boileau, 1865) 3 Bilious remittent
fever 3 Remittent fever (so returned by Royal Navy and Malta Civil
Government up to 1896, and by Army from 1871 to 1885).
(c) From the occurrence of gastric derangenzents or other symptoms.
Mediterranean gastric remittent fever (Marston, 1861 3 Boileau, 1865 3
Chartres, 1866)3 La febbre gastro-biliosa (Guilia, 1871) 3 Febrile
dyspepsia. 3 Bilious remittent fever 3 Febris sudoralis (Tomaselli, 1880) 3
F ebbre miliare (Frederici, 1885, etc.)3 Recurrent fever 3 Febris compli-
cata (Veale, 1879) 3 Bilious continued fever (Typhaldos, 188~§)0I31*I?$ili5sa
‘derp‘sesi caldi 3 Undulant fever (Author, 1896).
(d) From its lengthened coarse and indeﬁnite duration. Febbre
subcontinua (Torti, 17123 Baccelli, 1866) 3 Common continued fever
(Hennen, Davy, etc. 1817-35)3 Simple continued fever (Military
returns, 1885-96) 3 Febbre continua epidemica (Tomaselli, 1886).
(e) From its geographical prevalence. Mediterranean fever (Burnett,
1810 3 Guiffre and others)3 Mediterranean gastric remittent fever
(Marston, 18613 Boileau, 1865 3 Chartres, 1866) 3 Rock or Gibraltar
fever (Turner, 1884. 3 Moffet, 1889, etc.)3 Malta fever (Oswald-“food
and Notter, 1876 3 Bruce, 1889); Neapolitan fever (Borelli, 1887 3
Fazio, 1879 3 Galassi, 1883) 3 Febbre delle fogna (Dominicis, 1875, etc.) 3
Febbre urbana; Cyprus fever (Carageorgiades, 1891) 3 Levant fever 3
Cretan‘ fever 3 Syriac fever.
(f ) From its supposed origin. Feeco-malarial fever (Donaldson,
1876) 3 Febbre infetiva atipica (Rummo, 1881) 3 Pythogenic septiccemia
(Moffet, 1889)3 F ebbre climatica (Pasquale, 1889, etc.)3 Sewage,
mephitic or cesspit fever 3 Febbre da idrotionemia.
(g) Other designations. Febbre innominata (Guifl’ré, 1888); New
fever (Crete) 3 Febricola nostrana (Fazio, 1879).
Short description—This endemic fever of the Mediterranean, both
clinically and pathologically, has very definite and constant features, which
enable it to be distinguished from other diseases3 more particularly
from enteric and paludic fevers. It has, however, a close clinical
relationship with these two febrile conditions, and occurs in many
localities side by side with one or both of them.
Clinically, the fever has a peculiarly irregular temperature curve,
consisting of intermittent waves or undulations of pyrexia, of a distinctly
remittent character. These pyrexial waves or undulations last, as a
rule, from one to three weeks, with an apyrexial interval, or period of
temporary abatement of pyrexial intensity between, lasting for two or
more days. In rare cases, the remissions may become so marked as to
give an almost intermittent character to the febrile curve, clearly dis-
ﬂiEDlTERkANE/IN FE VER 3

tinguishable, however, from the paroxysms of paludic infection. This
pyrexial condition is usually much prolonged, having an uncertain
duration, lasting for even six months or more. Unlike paludism, its
course is not markedly affected by the administration of quinine or
arsenic. Its course is often irregular and even erratic in nature.
This pyrexia is usually accompanied by obstinate constipation,
progressive anaemia, and debility. It is often complicated with, and
followed by neuralgic symptoms referred to the peripheral or central
nervous system; arthritic effusions; painful inﬂammatory conditions of
certain ﬁbrous structures, of a localised nature; or swelling of the
testicles.
Though the rate of mortality is very low, the invaliding rate is
high, and the duration prolonged, so that the average stay in hospital is
from seventy to ninety days.
The fever is endemic in certain places, and may become epidemic
within a limited area. It does not appear to be contagious directly
from man to man.
Pathologically, the spleen becomes at ﬁrst much enlarged and
softened, though subsequently it may shrink again. The alimentary
tract may be the seat of irregular patches of arborescent venous
congestion, which, though often excessive in the large intestine in rapidly
fatal cases, have otherwise no special localisation. They have no
relation to Peyer’s patches, which are macroscopically unaffected. The
microscopical appearances of the tissues are those brought about by the
continued action of an irritant poison. Altered blood pigment is not
deposited in the tissues, as in paludism. A
A speciﬁc micro-organism has been isolated from the tissues after
death, which when introduced into the tissues of healthy monkeys,
produces in those animals a similar pyrexial condition. From the
bodies of such inoculated monkeys, after death, the same micro-organism
has been isolated in a pure state and cultivated artiﬁcially. Moreover,
the micro-organism obtained from such monkeys has, when introduced
into the tissues of other healthy monkeys, again produced a form.
of prolonged pyrexia, similar in character to that of undulant (Medi-
terranean) fever in man.1
1 In the countries in which the author has had an opportunity of studying this fever, a
large number of cases of pyrexia of short duration have occurred side by side with this
and other continued fevers. These cases were most commonly met with during epidemics
of undulant or enteric fevers, and while coming from the same locality, were most numerous
at the beginning and towards the end of each epidemic. The majority of these short attacks
lasted but a few days, and appeared to belong to that class of fever known as simple ardent
fever or febricula, a most common affection in those countries. Other cases, lasting from
seven to twenty days, had in some instances the characteristics of undulant fever, in others
those of enteric fever. That they may be mild or abortive attacks of these fevers is possible
and even probable, but we have no data on which to base any deﬁnite theory. Under
these circumstances, the writer has, in this work, based his descriptions and conclusions only
on those cases which have lasted long enough, or in which post-mortem observation has
proved sufﬁcient for him to be sure of a diagnosis. In the statistics of admission rates, etc.,
all cases of under three weeks’ duration have been excluded, with the exception of fatal
cases with post-mortem veriﬁcation.
4 UND ULANT, .MAL TA 01?

Speciﬁc Nature—That undulant fever is a speciﬁc disease there
can be no doubt. There are, however, both in England and on the
Continent, members of our profession who still regard this disease as a
variety of either enteric or malarial fevers. Many of these have served
in India, and are among those who, until a comparatively recent date,
refused to recognise the existence of enteric fever as an endemic Indian
disease. Certain of these would even go so far as to call undulant fever
by the misleading and unscientiﬁc term “typho-malarial fever,” about
which the writer will have more to say in the section dealing with the
nomenclature of this disease. Many of these men belong to a class
termed “germ sceptics,” and hold that the clinical manifestations of this
disease are those of enteric or malarial fevers modiﬁed by climatic
conditions, or a mixture of both these fevers produced by peculiar
climatic conditions acting upon the human body. Others, more orthodox
and advanced in their views, accept the necessity of a casual and living
virus, but attribute the peculiar clinical characteristics of undulant fever
to either an altered mode of entrance to the body in the case of enteric
fever or to altered climatic conditions to which the malarial virus may
be subjected where this undulant fever exists. Newcomers to the
Mediterranean are often sceptical on arrival as to the speciﬁc nature of
this fever, especially as they are usually advised, as a matter of safety,
to treat these cases as enteric until they have become more experienced
in diagnosis and treatment. They soon, however, especially after a
post-mortem examination of an acute case, recognise the peculiar nature
of this fever. A few of the less scientiﬁc, however, cling to that common
opposition to new theories which characterises many who are unwilling
to acknowledge truths they have failed themselves to discover and
demonstrate.
The clinical resemblance between undulant fever and other pyrexial
conditions will be dealt with in detail under the question of diagnosis ;
it will merely be necessary at this stage to discuss its resemblance with
its closer neighbours, enteric and malarial (paludic) fevers.
Undulant fever has been classed with enteric fever, because—
(a) Cases of both diseases may occur side by side, and be even
attributed to a similar faecal origin. On the other hand, on careful
investigation it is found that the general and individual distribution of
cases, and the apparent life history of the poisons, is considerably and
markedly different.
(6) Severe cases of undulant fever have a tendency to assume the
so-called typhoid state, in which case, even if diarrhoea be not present,
they may closely resemble enteric fever of a somewhat uncommon type.
Under these circumstances, and especially near the commencement of an
attack, sure diagnosis is often difﬁcult and even impossible, as is not
uncommonly the case in the initial stages of other febrile diseases. The
number of these cases having a close clinical resemblance to enteric fever,
even during the early stage of an attack, is both small in proportion and
conﬁned to severe and fatal cases. Even these at a later stage, if not
[MEDITERRANEAN FE VEE 5

fatal, and the vast majority of cases at all stages, have very distinct
and characteristic differences, while a large number are so utterly differ-
ent as to preclude their having any connection whatever with enteric
fever. That the diseases have often some clinical resemblances there
can be no doubt, for if not they would long ago have been differentiated.
The same difﬁculty was met with in the cases of typhus and enteric
fevers, until their separate nature was clearly laid down by Murchison,
who himself says: “\Vith regard to the speciﬁc distinctness of typhus
and enteric fever it is right to state that I was taught to regard them
as mere varieties of one disease, and that with this impression 1 com-
menced their study in the London Fever Hospital.” The writer’s
acquaintance with typhus fever is limited to one epidemic, which occurred
at Benghasi (North Africa) in the spring of 1893, but he is of opinion
that, if the contagiousness of that fever is put aside, it resembles enteric
fever much more closely than undulant fever does. '
Besides these points of resemblance, there are other differences
which must be mentioned :—
Firstly, in undulant fever there is a total absence of those morbid
changes in Peyer’s glands so characteristic of enteric fever in England,
the Mediterranean, and indeed all the world over.
Secondly, there is usually present in the spleens of fatal enteric
fever cases,the bacillus of Eberth and Gaffky, a micro-organism believed
by many to be the proximal cause of the disease. This bacillus the writer
has isolated from the spleens of the only nine cases of enteric fever, in
which he has sought for it in Malta 3 but it has been invariably absent
from the spleens of fourteen fatal cases of undulant fever that the writer
has had the opportunity of investigating. Bruce also found this to be
the case. Moreover, this bacillus has been replaced by a deﬁnite micro-
coccus in the twenty-ﬁve instances of fatal undulant fever in which
Bruce, Gipps, and the writer have been enabled to investigate the spleen
soon after death. This micrococcus, when introduced in a pure state
into the tissues of healthy monkeys, has been found to produce a similar
pyrexial condition to that observed in men when suffering from undulant
fever. It has also satisﬁed those tests laid down for the establishment
of the speciﬁc nature of pathogenic organisms.
Lastly, the serum-reactions of these two fevers, with respect to their
casual micro-organisms, are such as could only exist in two distinct and
speciﬁc forms of fever.
To call this disease a variety of enteric fever would necessitate a
belief in the polymorphism, not only of the individual virus, but of the
clinical and pathological phenomena that this virus is said to produce in
the human subject, a belief which, if true, would alter and even upset the
whole basis on which bacteriology and nosology at present rest.
Undulant fever has been classed as a malarial fever (i.e. as paludism),
because—
(a) The remittent, and at times the intermittent character of the
pyrexial curve has led to its being returned as “remittent fever,” both
6 UND ULANT, MAL TA OR

by naval and civilian practitioners. In this way it came to be included
in the malarial group of fevers under the 1885 edition of the Nomen-
clature of Diseases. This remittence and intermittence is, however, of a
non-paroxysmal nature, and is not markedly affected by the administra-
tion of quinine. It is more like the remittence met with in some cases
of enteric fever, or the intermittence of phthisis, or of the hectic fever
of suppuration.
(b) The irregular course, uncertain duration, and tendency to relapses
after apparent subsidence, have been urged as betokening its malarial
nature. Whereas, however, in the case of true paludism, the irregularity
of course has a certain periodic and paroxysmal nature, this is not the
case in undulant fever. Again, a patient who has once become infected
with true paludism, may be subject to subsequent attacks on but slight
provocation, even years after he has totally removed from all chance of
re-infection. In the case of undulant fever, however, when once really
convalescent, a patient is completely free from febrile relapses of a like
nature 5 nor does one attack appear to specially predispose to a sub-
sequent one, but in the opinion of some writers it even confers immunity.
(0) The two fevers may exist side by side in the same locality, and
so lead to ambiguity. In Malta, however, paludism does not exist, in
these days, as an endemic disease, but only occurs in the form of relapses
in men who have been previously infected in India, Mauritius, or else-
where; whereas undulant fever is endemic, and unfortunately very
prevalent. There exist therefore in Malta special facilities for studying
this fever, apart from, and uninfluenced by paludic infection; and any
one who has had the opportunity of seeing and treating cases of these
two fevers side by side, the one imported and the other endemic, must
at once be struck by their great clinical differences. Again, Dr. Thin,1
the writer, and others who have sought for it, have failed, to ﬁnd
Laveran’s haematophyllum in the blood of cases of undulant fever, nor
has deposition of altered blood pigment been observed. Laveran’s
discovery has cast a flood of light on what has heretofore been chaos,‘
with regard to malarial fevers. The terms “ remittent” and “ inter-
mittent,” used in the official nomenclature of diseases (1885), have
become most inapplicable. Such terms classify together, by one clinical
characteristic common to various febrile disorders, various as yet undiffer-
entiated but speciﬁc diseases. At the same time they place apart, under
separate sub-headings, cases of a single disease, which (on account perhaps
of the quantity, quality, or variety of its virus 3 some resistance peculiar
to the patient, or other cause) may exhibit even in the same attack a
pyrexial curve varying from an intermittent to a remittent or even a
continuously high type. Even those who habitually return undulant
fever as “ remittent fever,” agree that it is not strictly a malarial disease,
but justify their action by pointing out that no better heading is avail-
able in the nomenclature of diseases. By the word “malarial” the
1 Report of meeting of Roy. Med. and Chir. Soc., London, in Bm't. Zlled. Jour. or Lancet
for 18th April 1896.
[MEDITERRANEAN FE VEA’ _ 7

writer refers to these diseases believed to result from infection by the
amoeboid bodies ﬁrst discovered by Laveran, and not to its literal deriva-
tion of mal aeria. Now that the heading “Mediterranean Fever” has
been added to the new nomenclature (1896) there is no excuse for
returning this fever as “ remittent fever.”
Finally, the seasonal prevalence of these three fevers under discus-
sion is not identical.
It may therefore be said that there are strong clinical, pathological,
and etiological reasons for believing undulant fever to be distinct from
either enteric fever or paludism, and though they may, scientiﬁcally and
geographically speaking, be somewhat near neighbours, it is impossible
that they can all three be one and the same disease. There are no other
diseases described at present in the leading works on medicine that can
be confounded with undulant fever.
Moreover, if our experiments are what we believe them to be, its
speciﬁc nature has been proved on the lines laid down by Professor
Koch, with a bacteriological completeness attained in few other instances.
For while this fever has such distinct and constant features, both clinic-
ally and pathologically, as enables it to be identiﬁed from other diseases,
a micro-organism, distinguishable from all others by its appearance and
mode of growth, has been discovered in those parts of the body where,
from clinical symptoms and post-mortem appearances, one would expect
to ﬁnd it. This micro-organism would appear to be present in every
case ; neither has any other organism been found under similar circum-
stances, nor is any other disease known in which this micro-organism is
present. It has been passed artiﬁcially through six generations of pure
cultures without change ; and when introduced in a pure state and with
due precautions into the tissues of healthy monkeys, has produced febrile
phenomena similar to those occurring in man, without causing any local
changes at the seat of inoculation. From the tissues of these monkeys
after death a similar micro-organism has been obtained, which also has
been passed through six generations of pure cultures, and which, when
introduced into the tissues of other healthy monkeys, has caused a
similar train of febrile symptoms.
All this points conclusively to the fact that this undulant fever is a
speciﬁc disease.
Nomenclature.—Having arrived at the conclusion that this fever is
a distinct and speciﬁc disease, the very important question of a suitable
and generally acceptable name, under which it may be ‘returned, arises.
This has proved a most difficult subject ; for, to come into general use,
the name should be so stamped with the identity of the disease as to
at once recall to the mind that disease and no other; while at the
same time it must not be based on any theory which later knowledge
may explode. Many names have been suggested, but none of them has
proved wholly satisfactory. At this early stage in the public literary
s UND ULANT, .MAL TA 01?

existence of this disease the choice of a suitable name is of great
moment, as when once in general use, however undesirable it may prove,
it will be exceedingly difficult to change.
Hitherto, for want of a better name, the writer has always termed it
the “Endemic Fever of the Mediterranean,” or more brieﬂy “Mediterranean
Fever.” For a similar reason, the committee appointed by the Royal
College of Physicians of London, in revising the ofﬁcial nomenclature of
diseases, has termed it “Mediterranean Fever” (synonym, “Malta.
Fever”). This name implies a theory of geographical limitation which is
neither an established fact, nor in the opinion of the writer a probable
condition. While cases of so-called climatic or typho-malarial fever, of
long duration and irregular course, neither enteric nor paludic in nature,
exist in the coast towns of the Red Sea and China, and even in parts
of India and America, it would be unwise to lay down any geographical
limitations for the prevalence of this fever, until the exact nature of
these cases is ascertained.
Bruce has always called it “Malta Fever,” while others have given it
equally local names, such as “Gibraltar or Rock Fever,” “Neapolitan
Fever,” “ Cyprus Fever,” etc. T 0 give it the name of a single town or
country, is to rather unfairly saddle that place with the responsibility
of a fever by no means peculiar to that special part of the world.
The excuse, that to call it “Malta Fever,” is to shed a scientiﬁc
radiance upon the island where ﬁrst it was accurately studied, carries
more weight with a scientist than an hotel proprietor. The name
micrococcus Melitensis, given by the writer in 1893 to the speciﬁc
micro-organism of the disease, and since adopted by others, has not the
same objectional characters.
Geographical names have in the past been responsible for much of
the confusion concerning “fevers,” which for so many years retarded the
progress of scientiﬁc medicine, preventive and therapeutical. Sir
William Aitken, when advocating the use of the ﬁrst general nomen-
clature of diseases in 187 2, wrote: “Except as matters of history and
as beacons to warn us from a greater danger to science, let these (geo-
graphical) and such-like names be consigned to oblivion.” Such names
are as a rule picked up, in the ﬁrst instance, by newcomers from the
empirics of the places where these fevers exist, and are never retained
after the disease has been carefully studied. Though it has been a
great advance to have this fever recently included in the leading text-
books on medicine, and in the oﬁicial nomenclature of diseases, even as
“Mediterranean or Malta Fever,” it is unlikely that these names will
prove permanently satisfactory.
In the returns of the Royal Navy, of the Maltese Civil Government,
and of the Army between the years 1871 and 1885, all cases of this
fever were described as “Remittent Fever,” a term which has necessi-
tated their being included among the malarial group of fevers, together
with all cases of paludic infection. In the military returns before 1871,
and from 1886 to 1896, these cases have been included, together with
.A’UEDZTEERANEAN FE VEE 9

all febrile attacks of indeﬁnite and doubtful nature, under the heading
“Simple Continued Fever,” a disease then officially deﬁned as “con-
tinuous fever having no obvious distinguishing character.” This name
was applied to very many and various febrile disorders, varying in their
duration from two to two hundred days, which were not diagnosed, or
which, though correctly diagnosed, could not be placed under any more
deﬁnite heading. Now this fever has some most “obvious distinguish-
ing characteristics,” and the only excuse for so misnaming the disease,
was that while military regulations lay down that every case of sickness
must be returned under some official heading, that of S. C. Fever
interfered least with the statistics of other better deﬁned diseases. It
therefore follows that the returns of the last hundred years throw but
little statistical light upon the prevalence of this fever. The intro-
duction of the disease into the new third edition of the nomenclature of
diseases has removed this difﬁculty, and will in time provide us with
much valuable information.
The British soldier, on account of its long and tedious course, with
unconscious punning upon the shortened term in common use (S. C.
Fever), has christened this disease “slow continued fever,” a cumber-
some though not inappropriate name.
Various names connected with enteric and malarial fevers have been
suggested, more especially 'by continental writers, such as “continuous
or subcontinuous malaria,” “feeco-malaria,” “pseudo-typhoic,” “,pseudo-
enteric,” “intermittent” or “adeno-typhoid,” and last but by no means
least often, the name “typho-mafarial fever.” All such hybrids are
hopelessly misleading. The last term, which has been even recently
advocated, though contained in the second (1885) edition of the nomen-
clature of diseases, has been happily omitted from the new edition
(1896).1 The term in English works has been used to denote:
(l) Atypical enteric fever occurring in hot climates.
(2) Enteric fever affecting a patient also infected with the virus of
paludism, the latter poison being supposed to modify the effects
of the former (Woodward, etc.) Or malarial fever simulating
enteric fever.
(3) Fevers identical with or resembling this undulant fever.
If these fevers are either enteric or paludic in nature, they should be
returned as such. If they are cases of acute enteric fever, occurring
with and modiﬁed by concurrent paludism, they should be included in
returns under that condition which at the time appeared the more
serious 3 and though it might perhaps be more accurate to include them
under both headings, this would scarcely be advisable from a hospital
accommodation point of view, leading as it would to a variance between
the number of men in hospital, and the number of cases of sickness ad-
mitted. The condition is comparable to that in which a syphilitic 2 or
1 See Squire (1886), Maclean (1875, 1876, and 1885), Duncan (1888), and Davidson
(1892), Geo. Path. (America). _
-2 For such a case see report of Surg.-Capt. MacNaught, A.M.S., Indian ﬁled. Gazette,
10 UND ULANT, MALTA 0R

tubercular1 subject contracts enteric fever or sustains an injury. In
such instances it is not thought necessary that compound names like
typho-syphilis, or tuberculo-enteric should be used, nor is any difficulty
complained of in such cases. If, on the other hand, as we believe, this-
endemic fever of the Mediterranean is neither enteric nor malarial in
nature, but is due to an entirely different cause, it would be a most
unscientiﬁc and retrograde step to apply a term to it, which when
literally translated implies “ a fever of malarial origin resembling typhus
(exanthematicus).”
We must remember, however, that in Italy, where the term “ pseudo-
tifo ” is used, the nomenclature of diseases differs from ours. There the
term tifo (typhus) refers rather to a group of fevers, than to any one
disease; individuals being distinguished by an additional qualiﬁcation
such as “ tifo enterico vel abdomenale,” and “ tifo petecchiale vel esante-
matico.” We may, however, in England, put away from our nosology
such hybrid names and variations on the word “typhus,” and by an
accuracy of nomenclature keep pace with our extended and deﬁnite
modern pathology.
The term recurrent fever is descriptive, but it has too close a resem-
blance to the Italian “febbre ricorrente,” and the German “typhus
recurrens,” both synonyms for our relapsing fever.
Pythogenic septicaemia (Moffet) is, in the present state of our know-
ledge, rather a leap into the darkness of its supposed origin.
Professor Veale suggested the name complicate fever, as he thought
that the attribute adjunct complicate, stated at once the most salient
feature of the disease, but implied no theory as to its nature or cause.
Like the term febbre sudorale (Tomaselli) it is descriptive, but neither
of these has been accepted as satisfactory.
It is one thing, however, while drawing a lesson from history, to dis-
card unsuitable synonyms and call for a new name, and quite another
to suggest a suitable substitute. The writer has had many discussions
and correspondences on the subject with Surgeon-Major Bruce and
others interested in this fever, but Without result. For six years,
while seriously considering the question, he has waited in hope that
a suitable name would be forthcoming, but in vain.
As the writer has taken upon himself the responsibility of placing
this book before the public, he feels keenly that it is his duty to deal
with this difﬁcult subject if he possibly can. At the same time he
knows, as only those who have worked at the subject are able, how
little there is to guide one in the right direction. He has determined
to call the fever, in this work at least, by the name “ UNDULANT FEVER.”
If this is a good name it will stand the test of time and use, if the
reverse, the sooner it is condemned the better. That it is not a perfect
name is self-evident, for to be so it “should be so characteristic and
v01. xxxi. No. 7, p. 252, 1896, and Sir Dyee Duckworth, B'rz't. Med. Jom'. vol. p. 896,
11th April 1886.
1 See Chantemesse, La. Se'nza'ine Medicale, Année 17, No. 30, p. 240, 23rd June 1897.
., [MEDITERRANEAN FEVER II

signiﬁcant that a person but slightly acquainted with the language and
subject should, on hearing it, immediately understand what is the nature
of the disease it designates ” (Plouquet). Sir \Villiam Aitken says : “It
should be composed out of the same elements as the deﬁnition of the
disease, in fact it ought to be the deﬁnition converted into a name, and
derived either from the symptoms of. the disease or from the supposed
proximate cause.” Now, in the deﬁnition of this peculiar blood
infection, the only constant features we meet with are pyrexia of un-
certain duration and peculiar undulating and relapsing course 3 certain
changes in the spleen; and the occurrence in certain tissues of a micro-
organism. Of its supposed feecal origin we scarcely yet have sufficient
data on which to base a name, while one derived from a leading clinical
characteristic, while appealing to the ordinary mind, is less liable to
error than one derived from a supposed proximate cause. Either
relapsing or splenic fever are terms which would have referred to
deﬁnite characteristics, but both names are already in use. It has
therefore appeared to the writer that the term undulant fever, by
referring to the peculiar pyrexial curve so characteristic of the disease,
might prove a usable name. The name appeals forcibly to the clinical
observer, who, standing in a ward surrounded by cases of this fever (as
one may do on any summer day in the military hospitals of Malta),
gazes at the temperature charts upon the walls, and notices the way in
which the recorded pyrexial curves undulate across the paper in waves
of varying size 3 especially when the temperature is allowed to run its
course unchecked by artiﬁcial means.
The advantages of the term “ undulant fever ” may be brieﬂy sum-
marised—
(a) It describes one of the most constant and characteristic clinical
features of the disease, namely the pyrexial undulations so apparent
upon the ordinary temperature records.
(1)) The term appears to be grammatically correct.
(0) The term is not one which can be applied to other febrile
diseases, which is the weak point with the terms remittent and inter-
mittent fever.
(d) It need not (as is the case with the heraldic term “ wavy”) be
held to mean a deﬁnite quantity or amount of intensity 3 but as in
nature, undulations vary from the gentle ripple or broader swell to the
chopping wave or overwhelming breaker, so may the expression be
applied to the various pyrexial waves of this fever, however much they
vary in length and magnitude.
(e) Its Latin synonym (febris undulans) renders it comprehensible to
scientists all over the civilised world, while it is easily translatable into
their various individual languages, in most cases with but little change.
(f) While the term is descriptive, has a familiar sound, and slips
easily and lightly from the tongue 3 and as it has not previously been
used by scientists in such a manner, its use should not give rise to
ambiguity.
12 UNDULANT, .MALTA 01? Q
B. c. 450.

Historical Sketch.——The accurate history of undulant fever com-
mences from the year 1859, when Marston wrote the ﬁrst description of
the fever as a distinct disease. This was published in the Army llfedical
Report for 1863, and has been the basis of most of the papers written
since that date.
A careful study, however, of the literature of the fevers of the
Mediterranean prior to 1859, leads one to believe that this particular
fever must have prevailed in many of the towns on its coasts during the
last century if not at an earlier period. Until the commencement of
the present century, and, indeed, during its ﬁrst quarter, “fevers” were
a very indeﬁnite quantity. We ﬁnd, however, on comparing those at
present prevailing in the Mediterranean with those of the past, so close
a similarity in their general type and seasonal prevalence, as to raise a
strong presumption, in the absence of evidence to the contrary, that new
types have not been introduced. Thus the presence or absence of true
malarial fevers in certain localities is well indicated; the occurrence of
enteric fever is apparent, either directly or indirectly, before it was
separately returned, by the number of cases of peritonitis, perforation of
intestine, etc., which disappeared from the returns when enteric fever
came to be considered as a deﬁnite disease. We ﬁnd also a large number
of cases of “simple or common continued fever” (including fatal ones),
and others returned under various symptomatic headings, which appear
to have been much like those fevers of the present day, which we are in
the habit of calling simple ardent fever, Mediterranean or undulant
fever, etc. Like the malarial and enteric cases, these seem to have
occurred at the same period of the year, and under similar favouring
circumstances as these fevers do now, except that they appear to have
been more severe, fatal, and on the whole more prevalent than at present.
The following extracts from authors, besides other references in the
bibliography, appear to throw some light on this subject.
As far back as Hippocrates (of Thasus, off the coast of Thrace, circa
13.0. 450) we ﬁnd in his Epidemics, in the words of Prof. Veale, two
passages “which, making allowance for the difference between his modes
of thought and expression and those of our time, might almost pass for
a brief description of this disease.”1 Adams, in his translation (A.D.
1849), at page 351 says: “The conclusions to which a patient study of
modern authorities on the subject have brought me, amount to this, that
the fevers described by Hippocrates in his Epidemics are exactly the
same as those which are now described as still prevailing in the land of
Greece; and that they correspond very well with those described by
Cleghorn as occurring in Majorca” (presumably meant for Minorca).
Until the present century, we ﬁnd few works in which clinical facts are
so carefully and accurately recorded as they are in the case descriptions
ascribed to Hippocrates. Now, at pages 408, 415, and elsewhere in the
same translation, we ﬁnd full accounts of cases of protracted fever (dura-
tion up to 120 days), which are not unlike undulant fever. The ﬁrst
1 See trans. by Adams, pp. 355 and 359.
MEDITERRANEAN FE VER 13

of these (p. 408), after four pyrexial waves, suffered from irregular and
intermitting fever. After the fortieth day “ apyrexia at times, at others
not ; for if the fever intermitted and was alleviated for a little, it
immediately relapsed again.” Death occurred upon the 120th day.
Of this case Adams says: “This is an example of one of those pro-
tracted fevers of an intermittent type which, as I have been informed
by an intelligent physician who practised for several years in the Ionian
Isles, are common in the climate of Greece.” Others of his recorded
cases are like enteric fever (pp. 411, 412, 418, and 420) and simple
ardent fever (p. 413) of the present day, whereas the malignant cases
are similar to those described by Cleghorn, Davy, and other more
modern authors.
During the eighteenth century we ﬁnd references to the occurrence
of continued and remittent fevers in Malta (Demarco, etc., 1722-1787
Howard (1786), in his Report on the Continental Hospitals, mentions
that fevers were prevalent in Malta, and describes a low form of fever
prevalent in the wards of the Great Hospital of the Knights of St. John.
Bonamici, who- died in 1680, and Boisgelin, who was present in Malta
before and after the French and English occupations of the island, both
describe an indigenous fungus, which was held to be a sovereign remedy
for “fever,” and a valuable monopoly of the Grand Masters.1 Fauverge
(1803), who served as a military surgeon during the French occupation
of Malta (1798-1800), says: “Les maladies bilieuses, les ﬁevres inter-
mittentes, les affections catarrhales et les hémorrhoides, affectant plus
particulierement les habitans de Malte.”
Cleghorn (17 51) describes cases of non-paroxysmal continued fever
in Minorca, occurring between the years 1744 and 1749. These were
of irregular type, incurable by “bark,” marked by excessive perspira-
tions, and followed by relapse after relapse. After death the spleen was
“so excessively soft and rotten, that it had more the appearance of
congealed blood wrapt in a membrane than of an original part.” Some
of his cases may have been of a paludic nature, others were distinctly
enteric in character, while such cases as those above described closely
resemble undulant fever.
The majority of the early medical writers of Gibraltar were so taken
up with the subject of yellow fever, that they neglected such homely
themes as their common endemic fevers (see Rey,‘2 Pym, Gilkrest,
\Vilson, Chervin, Amiel, Bancroft, etc.).
During the early part of the present century we ﬁnd that the same
classes of fever prevailed at Malta, Gibraltar, and Minorca (Port Mahon),
whereas in the Ionian Isles “malarial fevers” occurred “in addition”
(see Burnett, Hennen, Davy, etc.).
1 Fungus Melitensis, or Cynomorium coccineum, Balanophoraceze, 0rd. Rhizantheae,
mostly used as a styptic and astringent. See J. F. Bonamici, Disse-rtatto (Ze Face Sptcato
Ooeet'neo IlIeZz'ten-sz'. MSS. vol. xviii., Public Library, Malta. Also, Louis de Boisgelin,
Ancient and JIIodern 111 alta, 2 vols. 1805.
2 Rey, H. J ., M.D., Essaz' star la topographic 'nzécltcale dc Gibraltar.
(With references to the other authors.)
Paris, 1833.
1722-1800.
I4 LUVZDCZL¢4ZVZ§ 2M9411714 (91?
1800-1810.
1816-1825.

Dr. Heastie (1830), who served in various parts of the Mediterranean
from 1825 to 1828, says: “It is notorious, and well ascertained from a
series of practical observations, that the yellow fever, which lately proved
so fatal at Gibraltar, and occasionally appears in various parts of the
Mediterranean, has succeeded to the mild remittent which was long ago
known to exist in these places before the populations increased, and the
exciting local causes became so numerous, formable, and aggravated.”
Sir \Villiam Burnett, writing in 1810, and describing ten years’
experience of Mediterranean fevers affecting sailors, returns a very large
number of cases of a continuous nature. The high mortality and com-
paratively short duration of most of these cases point rather towards an
enteric origin. In some instances, however, the enteric element is, at
least from his description, not so conspicuous. Thus in the case of
ships ﬁtting in Malta dockyard (pp. 169-180), we ﬁnd an admission
rate of 777 cases, with a mortality of only 250 per cent 3 and that in
days of most heroic treatment. Again, on page 180, the same is found
in an account of fever at Palermo. Nearly all his cases occurred while
ships were ﬁtting in port.
It is still more interesting to note, that his general description of
fever cases occurring during the autumn and winter months, agrees
essentially with that of enteric fever 3 whereas his description of cases
occurring during the summer months agrees more with that of un-
dulant fever; a seasonal distinction which prevails to the present day.
Thus in cases met with towards the end of June and onwards, he says :
“ Considerable headache, deep-seated in the orbits, nausea and prostra-
tion, epigastric uneasiness, and even vomiting 3 through the whole course
a loathing for food, a bad taste in the mouth, tongue white and moist 3
there is commonly constipation of the bowels and loss of appetite.
Pains in the joints, back, and calves of the legs, profuse perspirations,
but skin usually dry 3 much head symptoms.” During the winter
months, however, he says: “Affection of the brain is not at all times
so prominent a symptom, nor the bowels so constipated, and there is
often a more anxious look at the beginning and severe pain on pressing
the abdomen. In some cases epistaxis, subsultus tendinum, picking at
the bed-clothes, and involuntary stools.” The post-mortem descriptions
of these latter also point to enteric fever. None of the cases were
contagious, they occurred mostly among those who went on shore, while
in his opinion the administration of quinine did more harm than good.
Dr. Hennen (1816-25), in his Medical Topography of the Mediter-
ranean, states that the mortality from fevers amongst the native
population of Malta, from 1818 to 1823, was 1 in 6671 of the total
population (96,404.), for the six year period, being over a tenth of the
total mortality from all causes. Though his detailed descriptions leave
much to be desired, especially with regard to case description, his stat-
istics are clearly arranged. These show a very small admission-rate
for malarial fevers (and even these cases are stated to have been mostly
imported from the Ionian Islands) 3 and a very large admission rate for
.MEDZTERRANEAN FE VER 15

common continued fever, intestinal inflammatory diseases, pneumonia,
bronchial catarrh, and rheumatism among the troops.
Dr. Davy (1842-62) who served in Malta from 1833-35, publishes, 1833-1835-
especially in his later work, graphic ‘clinical and post-mortem accounts
of the fevers he had met with there. Many of the fatal cases, with
intestinal Peyerian ulceration, must undoubtedly have been enteric in
nature, while others closely resembled undulant fever as met with in
these days. He gives the following admission rate per thousand, among
the troops, from 1837 to 1847 :—

Diseases. Gibraltar. Malta.1 Feb. intermit. 3'95 2'17 4491
Feb. remit. . . 1'53 '66 2629
Feb. com. contd. 73'76 20250 7529
Typhus . . . 1 '60 . .. ...
All other diseases . 857'10 90980 88389


If we study the ofﬁcial parliamentary statistics of sickness among To 1846.
the troops serving in the Mediterranean, for the years from 1817 to
1846, we ﬁnd much the same classes of fevers prevailing as at the
present day, though in greater amount. Thus in Malta we ﬁnd
malarial fevers conﬁned to certain years in which a number of men were
transferred from malarious countries, such as the Ionian Islands, while
in certain years no entries for these diseases occur. For common con-
tinued fever some 10,644 admissions are recorded, for synochus 125, for
rheumatic affections 2352, for non-tubercular pneumonic affections 2413,
and for intestinal complaints of a symptomatic nature a'very high rate.
From these fevers, equal to an annual admission rate of 1853 per
thousand of strength, 2'87 per thousand of strength died annually.
It is stated in these reports (1817 -3 6), that of these fevers “common
continued fever was the cause of by far the greater proportion of deaths
from this class of disease.” And later (1837-46) we ﬁnd “there was a
high fever rate, of which the chief is common continued fever.” See
also remarks by Captain Smyth, RN. (1854) referring to the years
1830-36.
In 1859, in a parliamentary sanitary report on barracks and To 1859.
hospitals, as follows: “During the entire period which has elapsed
since the ﬁrst hospital records were kept in Malta, the prevalent type of
fever has been common continued fever. Out of 22,969 cases of fever
admitted to hospital, of which we have accounts, 21,122 have been
registered as of this type (1817 -5 9), and though most were slight,
still ﬁve-sixths of the fever mortality has been caused by this disease.
The type next in frequency has been remittent fever, which has supplied
about 5'50 per cent of the fever admissions, and about 9 per cent of the
1 Malarial cases imported. 2 Malarial fevers endemic.
I6 UNDULANT, [lﬂ-JLTA 0R
1854.

fever deaths. Intermittent fevers have been so rare as to make it
probable that they were imported. . . . Natives and British troops
suffer alike from the usual zymotic diseases, and both suffer from the
same classes of disease.”
The actual quantity and severity of these continued fevers, taken as
a class, and of those symptomatic diseases under which they were often
returned, was proportionally much greater in those days than now ; but
the seasonal prevalence of both periods, as quoted in the various ofﬁcial
returns and private publications, has not varied since the beginning of
the century. These statistics bring us into the period of the Crimean
War, at which time Malta became a military base of some importance.
Soon after this time (1860), enteric fever was ﬁrst diagnosed and re-
turned officially in the records of military hospitals, and we ﬁnd that
fever at once replacing such diseases as peritonitis, haemorrhage of bowel,
perforation of intestine, enteritis, and pneumonia. At this time also
Marston published his paper upon enteric and other fevers prevalent in
Malta.
The fact that during the. Crimean War there was a very large
temporary increase in the admission rate for enteric and other continued
fevers in Malta, there being a largely increased number of troops of a
susceptible age there at the time, besides numbers of convalescents and
sick from the seat of war, has given rise to the belief among the Maltese
that the English imported both enteric and undulant fevers into the
island at that time from the Crimea. Marston in 1859 refers to this
theory : “ Of late years, it has seemed to me, that the prevalence of this
three days’ fever has considerably diminished, while other febrile diseases,
of a severer character and longer duration, have made their appearance.
The civil surgeons practising here consider that a very marked change
has taken place in the type of fevers generally. They are in the habit
of referring the date of such alteration to the period of the Crimean War.
However this may be, typhoid and fevers of long duration appear to
be more common than they were six or eight years ago.” It must be
noted that in 1859 continued fevers were more prevalent than they have
ever been before or after. The fact that these fevers were “ more common
(in 1859) than they were six or eight years before,” ale. previous to the
Crimean \Var, is not surprising when we also take into consideration
that while so many more susceptible persons were present in Malta at
that time, the years from 1855 to 1859 were those when, from statistical
experience of the past seventy-eight years, we should expect the preval-
ence of these continued fevers to be on the increase (see table 10).
Oswald 1Wood (1876) writes: “Some twenty years ago cases of
Malta fever were comparatively unfrequent and mild in their type ;
indeed it was by no means the formidable disease which it is now.” He
does not, however, mention any authority for his statement, and as he
was not many years in Malta, it is probable that his information was
derived from Marston’s paper. N otter, the same year, in the same
periodical, states : “That it has long existed is evident to anyone who
MEDITERRANEAN FEVER 17

will study the history of this fever. It appears to have been especially
prevalent in Her Maj esty’s Royal Navy half a century ago, for, on turn-
ing to the medical history for that period, we ﬁnd that rheumatism was
common and often extremely intractable, and that two-thirds of all the
invalids were classed under the head of inflammation with fever,—a vague
term, I acknowledge, but one easily understood by anyone who has
studied the disease.”
Whether or not these diseases became permanently more prevalent
after the Crimean War, not only did they exist in Malta before that time
(Davy), but since then there has been a steady decrease in the admission-
rates for continued fevers and their allies, which descredits the theory
that these fevers were ﬁrst introduced during the Crimean War. The
following statistics are available :—


Simple Continued and Remittent Fevers from 1871-1885 in Malta.
1817-36 Admission-rate per mille, 173 Mortality 2'90
1837-46 ,, ,, ,, 210'0 ,, 1'80
1847-56 ,, ,, ,, 256'0 ,, 2'50
1857-59 (The years 1857-58 are not available.)
1860-69 Admission-rate per mille, 181'5 Mortality 3'08 1
1870-79 ,,~ ,, ,, 168'1 ,, 2'60
1880-89 ,, ,, ,, 128'5 ,, '93


This is not due to the separation from these ﬁgures of enteric fever
(returned as a separate disease since 1860), for if we add the enteric fever
cases to the above it does not materially alter the admission-rates,
though it increases the death-rates. The increase in the death-rate is
due to enteric and undulant fever cases being included as such, instead
of under such headings as perforation of intestine, pneumonia, etc. It
is still more signiﬁcant that during the periods under discussion there
has been a still more marked decrease in the number of cases returned
under the various symptomatic headings allied with these continued
fevers. This is specially marked in the respiratory and intestinal
diseases :—


Admission and Mortality per Mille, Malta.
N on-tubercular Respiratory Diseases. Symptomatic Intestinal Diseases.
Years. l Admissions. Mortality. Admissions. Mortality.
!
1817-36 i 111'0 2'90 1092 3'40
1837-46 ' 130'3 1'40 1705 ‘84
1847-56 81'0 1'10 95 ‘3 '40
1859-68 420 '68 Not differentiated, and almost all in-
1869-78 424 ‘66 cluded under enteric fever.
187 9-88 I
1 Enteric fever ﬁrst diagnosed in military returns, and undulant fever recognised.
C
18 UNDULANT, [MALTA OR

The exception to this general decrease in prevalence occurs in the
case of the “ rheumatic affections,” which in Malta are usually to a great
extent the results of this fever. These increased slightly until 1877,
but this was accompanied by a marked decrease in the corresponding
death-rate :—

R-lieumatic Aﬁ‘ectious per Mille, Malta.

1817-36 Admissions 340 Mortality '20
1837-46 ,, 46'0 ,, ~14.
1847-56 ,, 38'0 ,, ‘10
1859-68 ,, 49‘0 ,, '04
1869-78 ,, 50'1 ,, nil
1879-88 ,, ,, ,,


During the time that the Crimean \Var was going 011 we have to
take into consideration the fact that not only was the material—M. the
cases—more abundant for purposes of clinical observation, but also there
were a much larger number of skilled observers in Malta at that time,
leading to a concentration of public interest in these continued fevers,
more particularly in those of a severe and fatal nature. It was at the
time also when enteric fever was being generally recognised and separated
from other fevers, and the clinical thermometer was coming into use.
There is a great tendency on the part of some medical men to believe a
disease must have recently appeared, because they themselves have
previously failed to recognise it. Indeed, the author has met with well-
educated Maltese physicians who have informed him quite recently that
this undulant or Mediterranean fever was not known in Malta ten years
ago, but that it originated when the new drainage was laid down in 1885 !
Lyons and Aitken mention, in their account of the pathological
appearances met with in fatal cases of fever in the Crimea during the
war, cases of typhoid or common continued fever in which no ulceration
was present. These cases, together with typical enteric ones, were
called “ Crimean Fever,” and although some of the long cases of remittent
fever, in which quinine was said to have been of no avail, might be held to
have some clinical resemblance to undulant fever, it would be jumping
at conclusions to use these facts as an argument in favour of the disease
having been imported from the Crimea to Malta. Malta was certainly
a depot for the Crimea in those days, and the disease might as easily
have been transported from there to the Crimea as in the opposite
direction. We ﬁnd that the statistics of Gibraltar, which go back into
the last century, closely resemble those of Malta with the same preval-
ence of similar types of fever. Moreover, although the disease does not
appear to have been recognised in Italy until after papers had been
published in 1861, 1865, and 1866 by Mar'ston, Boileau, and Chartres, still
it seems to have been present as an endemic disease before that time.
“There, then, did places so much nearer Malta, and in consistent inter-
ZIIEDZTERRANEAN FE VER 19

‘course with that place for centuries, such as Sicily, Italy, Crete, Greece,
and Gibraltar, obtain this fever? If they did not obtain it from Malta,
but possessed it before the Crimean period, Malta could scarcely have
escaped contamination from these sources. We do not ﬁnd that change
in the admission and death rates and in the seasonal prevalence of fevers
in Malta that would be expected, had either undulant or enteric fever
appeared there for the ﬁrst time between 1855-57, and still less than if
both had appeared together. We have, on the contrary, direct evidence
that one or both existed in Malta in 1833-35 (Davy). Lastly, had they
appeared for the ﬁrst time so recently, the native Maltese population
could scarcely have acquired the amount of immunity from these fevers
they at present possess. Many of the foregoing remarks, doubtless,
have bearing on other places in the Mediterranean less well known to the
author. ~
The author is therefore of opinion that undulant fever has existed
as an endemic disease, in Malta and Gibraltar at least, since the begin-
ning of the present century, and probably for much longer, but that
it was not recognised until 1859 as a distinct type of fever. .
The accurate history of this undulant fever, therefore, dates from 1859-
1859, when Marston, who graphically describes his own sufferings from
this fever, published in the Armq Zlé/ettjgal ___]_3Z_ue-B_oolt pojnh1863 a most
excellent and exhaustive account of the fevers which he had met with
previously in Malta. He states that he “had as far as possible made a
point of seeing all the cases of fever—whether occurring among the troops
or inhabitants—and of being present at the post-mortem examinations.”
First of all he gives a very clear and detailed account of enteric fever,
stating that it always commenced (as in these days) about autumn ; then
reaching its acme of prevalence soon after that season, continued through
the winter, but towards the spring ceased to prevail to any extent.
After a description of simple ardent fever, which he called “Maltese
Fever,” he described a form of fever which he termed “ Mediterranean
remittent or gastric remittent fever.” This latter, from the clinical and
post-mortem reports, cannot have been other than the fever with which
we are dealing. It has, he says, a very long course of from three to
ﬁve or ten weeks, marked by irregular exacerbations and remissions,
great derangement of the assimilative organs, tenderness in the epi-
gastric region, splenic enlargement, and no exanthematous eruption.
Pathologically it is marked by congestion or inﬂammation, with soften-
ing of the enteric mucous membrane, particularly that of the stomach
and duodenum ; but without any lesion of the Peyerian follicles, but with
hypertrophies of the liver and spleen. He adds: “The disease prevails
particularly during the spring and summer months (less so during the
autumnal months); it is not contagious; and is comparatively non-
fatal.” At the end are detailed accounts of special symptoms, cases,
and post-mortem reports.
About this period we ﬁnd in the Annual Medical Blue-Books of the
Navy descriptions of cases of pyrexia similar to those of undulant fever,
20 UND ULANT, MAL TA 01?
1862.
1865-1866.

but included under the names remittent fever, rheumatism, cachexia,
and bronchial catarrh, etc.
Thus in 1862 Dr. A. Mackay states: “In the Mediterranean the
term fever is not unfrequently applied to a train of symptoms of so
anomalous and obscure a nature as would justify their being classed
rather as cases of climatic cachexia than of fever so called.” Again,
Surgeon R. Pottinger states, when speaking of some typhoid cases:
“ Rheumatism accompanied and very much retarded convalescence in a
large number of these cases. Convalescence from this disease was
exceedingly slow, and a peculiarity connected with it was a gradual
coming on of a rheumatic affection, which sometimes attacked several
joints, but for the most part settled in one of the hips. This sequela
of fever was very intractable, and resisted the use of all the remedies
employed in the cure of rheumatism.” The admission-rate for rheu-
matism was, in 1862, 1048 per 1000, and in 1861 as much as 112'8 per
1000 3 and in the general remarks for the former year we ﬁnd: “In
last year’s Report it was observed that rheumatic affections very fre-
quently followed in the train of the various fevers common in the
Mediterranean, whether periodic or continued. The returns of this
year conﬁrm that observation in the strongest manner. The disease
appeared in a large number of cases either as a direct sequela of fever,
or it occurred in persons who had at some recent period suffered from
febrile disease. It is a very prominent feature also in that peculiar
form of cachexia which is liable to be begotten in the Mediterranean,
and not unfrequently, in one form or another, it was the most decided
symptom which that condition exhibited.” .
Even later, in 1872 (pp. 51, 52), we ﬁnd “cases of continued fever
with relapses. In no instance was fever attended by diarrhoea, or
followed by tertian or quartan sequelae. In all cases more or less
obstinate constipation coexisted, with a white, ﬂabby, indented tongue.
No individual appeared in the slightest danger, and nourishment could
always be given; but convalescence, even in the mildest cases, was very
tediously protracted, and rheumatic sequelae nearly invariably followed.
In a few instances the curious form of muscular rheumatism referred to
attracted attention 3 in four individuals the disease terminated favour-
ably in an unusual form of orchitis. . . . In three the right testicle
suffered 3 in one the left was. attacked. Duration of cases 81, 51, 77,
136, 36, 131, 89, 94, 107, 103, 117, 78, etc., days.” Such cases seem
to have been similar to undulant fever cases of the present day.
The next articles, published in English, were those by Boileau and
Chartres, also in the Army Medical Blue-Books, about 1865-66. The
paper of the former professes “to contain only carefully-observed facts,
faithfully set down”; and is based on 450 cases of “fever.” While
eliminating enteric fever and slight cases of febricula, he gives an
accurate account of undulant fever, under the name of Mediterranean
gastric remittent fever, together with reports of cases and temperature
charts. He deﬁnes the disease as “ a fever, most irregular in its course
rlIEDZTEZI’EANEAN FE VER 2I

and most protracted in duration ; characterised by dyspeptic symptoms ;
accompanied by profuse diaphoresis or sudamina; eventually and almost
invariably ending in complete recovery. . . . Its alliance with the par-
oxysmal fevers appears to me very doubtful. It has not the character-
istics of any of the intermittents or remittents that have ever been
correctly described 'as such. There is no alternation of cold, hot, and
sweating stages. It is as monotonous in its course as it is insidious
and gradual in its onset. . . . There is not even an approach to the
erratic forms of periodic fevers.”
Chartres gives a detailed account of an epidemic of “Mediterranean
gastric remittent fever,” which attacked the 100th Regiment when
quartered during the year 1866 in Verdala Barracks in Malta, a barrack
to this day infested with this fever. The men attacked had an average
service of 2'50 years in Malta, and seven in the army. The clinical
and post-mortem details are undoubtedly those of undulant fever.
Guilia, the only modern Maltese physician who has written on the 1871.
subject, published in 1871 a short account of the fever locally, adding
nothing, however, to previous reports.
In 1876, in the Army Medical Report, Donaldson describes the fever 1876,
as it prevailed at that time in Verdala Barracks; and during the same
year Oswald Wood and Notter, army surgeons, published short de-
scriptions of the fever in the Edinburgh M ediccd Journal.
In 1879, Surgeon-Major Veale, in the Army Medical Report, published 1879.
a paper, which, with those of Marston and Bruce, may be termed one of
the three classics concerning undulant fever. He graphically describes O
the symptoms seen, at the Royal Victoria Hospital at Netley, in febrile
relapses, occurring in cases which had been invalided home from Gib-
raltar, Malta, and Cyprus. Besides an accurate account of undulant
fever, he draws a clear line of distinction between cases of this fever
and cases of malarial fever from the Mediterranean and elsewhere.
Turner, on an experience of two years’ practice in the Civil Hospital 1884.
at Gibraltar in 1884, endeavoured but very unsatisfactorily (as was
pointed out by Professor Maclean in 1885) to prove the enteric nature
of “Rock fever.” He says that he was “led to believe that the bulk
of the cases differ in no essential respect from enteric fever as it is met
with in England and elsewhere; that although the mode of expression
and the severity of the fever may be modiﬁed by surrounding inﬂuences,
the extent of variation is not so great as would at ﬁrst appear; and
that the idea of a speciﬁcally distinct ‘Rock fever’ cannot be enter-
tained.” Though his clinical descriptions show that some of his cases
may have been Rock or Mediterranean fever, the special cases he mentions
in detail and one of his two post-mortem descriptions are undoubtedly
accounts of enteric fever cases and of nothing else. As these cases of
enteric fever are described by him as “a few samples of Rock fever,”
it is easy to see how the error arose. Enteric fever, unfortunately, is
also an endemic disease in Gibraltar, but undulant fever is less prevalent
there than in Malta.
[0
N
UND ULANT, MALTA 0R
1887-1889.
0
1895-1896.
. Journal the ﬁrst really detailed account of the fever.

\Vith the exception of short articles more or less based on the papers
already mentioned, little else of importance appears to have been
published in England, until Bruce discovered the speciﬁc and causal
organism in 1886, to which the writer later gave the name of “Micro-
coccus Melitensis.” In 1889 Bruce published in the British [Medical
In the same year
Moffet of Gibraltar described its prevalence in that place.
Since that time the disease has been recognised in England as a
separate form of fever; and during the last three years it has been
given a place in such standard works as Quain’s Dictionary, Allbutt’s
System of llledicine, and Davidson’s Hygiene of Tropical Diseases, etc., and
also in the 1896 edition of the Nomenclature of Diseases.
From the above account, and from a study of the literature of the
subject, it will be seen that the isolation and description of undulant
fever, and its acceptation as a separate and speciﬁc disease in England,
and indeed on the Continent also, has been brought about, the author is
proud to say, entirely by the exertions of various medical ofﬁcers of the
British Army 1 and Navy.
In Italy its existence was ﬁrst deﬁnitely described by Tomasi in
1874, since which many observers have published accounts of the fever,
among whom may be mentioned Copozzi, Rho and Galassi of Rome;
Borelli, Fazio, De Renzi, and Rummo of Naples; and in Sicily,
Tomaselli of Catania and Guiffre of Palermo. Other writers, there and
elsewhere, are mentioned in the bibliography.
It is interesting to note that as early as 1879 Prof. Eugenio Fazio
not only described this fever as it then occurred in Naples, but while
referring its cause to insanitation (more particularly to sewer emanations),
laid great stress on the distinct and speciﬁc nature of the disease, and on
the probability of its proximate cause being some micrococcus or other
microphyte (“micrococco, microﬁto,” etc.)
There is therefore unimpeachable evidence that undulant fever
existed in Malta in 1859, and was then established as an endemic
disease. Moreover, the writings of Davy (1833-35), the similar
character of the statistics of sickness and of the seasonal prevalence of
continued fevers in Malta and Gibraltar as far back as 1817, and the
tone of the medical reports of the fevers which prevailed in the
Mediterranean during the whole of the present, and to a less deﬁnite
extent during the last century, lead one to believe that this undulant
fever probably has existed as an endemic disease in the Mediterranean
(or at least in Malta and Gibraltar), as far back as the last century, if
not a great deal longer. Whether the occupation of Malta by the
French and then by the English caused any change in character of the
prevailing fevers it is impossible to say. There has been, however, but
1 See memorandum of sub-committee on classiﬁcation in A'omenclatnre of Diseases, Royal
College of Physicians of London, 3rd edit. 1896, p. xxv.: “ In consequence, more especially,
of representations made by oﬁicers of the Medical Department of the Army, Mediterranean
or Malta fever has been admitted as a distinct disease.”
MEDITERRANEAN FE VER 23

little change in the nature of the inhabitants, as the natives were as
now, Maltese; the garrison of the Knights of St. John being recruited
from the various countries of Europe, north of the Mediterranean, were
(from 1530-1798) strangers to the place. Their vows of celibacy
also prevented the establishment of a residential alien population,
which might have in time acquired a hereditary immunity. More-
' over, the Order came to Malta from Crete, where the same fever exists,
and individuals were constantly going backwards and forwards between
Malta and the various Mediterranean ports where the fever is now _
endemic. The old buildings that they constructed in Malta, now
utilised in many cases as barracks, have been during the English
occupation the seats of the greatest and most regular prevalence of this
fever since it has been recognised, and of “continued fevers” before
that time. \Ve know from documentary evidence that “fevers”
prevailed in Malta during the middle and latter end of the last
century.
From all accounts the sanitary condition of these buildings in the
time of the Knights must have been terrible, whereas modern improve-
ments have altered little of the stone or of the foundations originally
used in their construction. Malta has never been in an independent
position, but has for centuries been ruled by various alien races, and
been a sort of half-way house in the Mediterranean. There is evidence
to show that continued fevers existed there in the time of the Knights,
and subsequently during the occupation by the French 3 and ample
evidence that such fevers existed amongst both the natives and the
English garrison, similar in character to those of the present day, but in
greater abundance in proportion to the number of those present in the
island. It seems highly improbable, therefore, that the introduction of
undulant (and enteric) fever into Malta was reserved for the English,
considering the greater facilities and opportunities that our predecessors
possessed.
Geographical Distributiom—rlfalta and Gibraltar—The author can
state deﬁnitely, from personal observation, that undulant fever exists as
an endemic disease in both these places 3 and that Rock fever and Malta
fever are synonyms for the same disease. These facts are amply con-
firmed by the writings of Marston, Veale, Bruce, Moffet, and others, and
by the similarity of symptoms of fever cases invalided to Netley Hospital
from these two places.
Sardinia—Dr. Luigi Zauda, quoted by Bruce, states that this fever
is well known in Cagliari and elsewhere in the interior of the island.
Guiffre also notes its occurrence.
Balearic Isles—The writer has been informed on good and recent
authority that this fever is endemic in Minorca. There was a large
naval hospital at Port Mahon during the early part of the century,
where cases of fever from the ﬂeet, contracted in various parts of the
Mediterranean, were treated. Fevers contracted at this place were
described by Burnett (1800-1810) as being similar to those met with in
24 (7ND ULANT, .MALTA on

Malta.l Gaston Vuillier, describing Iviza, says: “Fever is epdemic at
Iviza. Besides such obvious causes as putrefying vegetable matter,
stagnant water, ﬁlthy streets, drain gutters which are no better than
open sewers, there is no doubt that the conﬁned and sedentary life led
by the people helps to foster epidemics.” 2
Italy—Its occurrence in Rome is described by Capozzi, Galassi,
Drummond, etc. In Naples by Borelli, Fazio, Capozzi, De Renzi,
Rummo, etc. 'Guiffré states that it is endemic in Naples, and other
places in the neighbourhood (Caserta, Benevento, Campobasso, etc.);
and in middle and upper Italy (Rome, Ariccia, Terano, Fermo, Padua),
with a frequency decreasing as the latitude increases towards the north.
The fever became epidemic in Naples in 1872. Cardarelli described its
occurrence in southern Italy (Cittanova) in 1879.
Sicily—Tomaselli describes its common occurrence in Catania, where
it prevailed in epidemic form in 18.7 2, 1878, and in 1884. Guiffré
states that it occurs as an endemic disease in Palermo and Catania, and
is also to be met with in Taormina and other villages on the south side
of Mount Etna. Prof. Cassiola also informed the author, when at
Taormina, that this fever occurred at that place.
Greece—Prof. P. Typhaldos (1882) describes a similar form of fever
to be met with in Athens. Dr. G. Inglessis (of Naples), in 1882, stated
that he had observed in Cephalonia cases of fever likely to be identical
with “Neapolitan fever.”
Tnrhey—Guiﬂ‘ré mentions its occurrence in Constantinople and
Smyrna. Dr. Paterson describes it as common in the former place. Dr.
Moore, R.N., describes cases of fever similar to this contracted at
Smyrna in 1872. Dr. Davids, of the German cruiser LOTGZQ’Z], quoted by
Bruce, stated that he had the opportunity of observing ﬁfteen cases of
this fever at Constantinople and three at Smyrna.
Cyprian—Dr. J. G. Carageorgiades, of Limasol, has published a small
monograph on the subject, proving the existence of this endemic fever
in the towns of Cyprus. Guiffré also mentions its occurrence. Malarial
fevers are also met with.3
Crete—Dr. A. Capetanakis, of Candia, reports that it has become
frequent in occurrence in this place since 1880. Guiffré also quotes
this place.
Jerusalem—Dr. Thomas Chaplin, in 1864, described cases of fever in
Jerusalem very like this undulant fever. He also gave a graphic
account of the insanitary condition of the “ Holy City,” built, he says,
upon the rubbish of 3000 years. Later, in 1885, he published a paper
on cases of “ Malarial Typhoid Fever” occurring in the same place, and
appearing similar to undulant fever. It is, he says, uninﬂuenced or but
1 See also Cleghorn (1744-1749).
2 Impressions of Travel in the Balearic Isles, by Gaston Vuillier (trans. by Frederic
Breton), London, 1897.
3 See also Davidson’s Geographical Pathology, Cyprus, p. 261 et seq. ; Veale (1879);
Lancet, 20th July and 8th December 1878 ; ﬁled. Times and Gazette and Health of the N aog/
both for 1878 ; Heidenstein (1886) ; and Sullivan (1878).
ﬂ-[E D] T E RRA NEA 1V FE VER 25

slightly influenced by quinine or other drugs ; severe and fatal cases last
from 30 to 120 days, mild ones from 4 to 8 weeks; non-contz-igious and
non-exanthematous ; onset like enteric fever, but the course differing
from that disease in the infrequent occurrence of diarrhoea and tympan-
ites, the tendency for the temperature to run on for many weeks, and to
show during the second month great diurnal ranges of temperature
without there appearing to be much the matter with the patient.
The temperature of one case is given, but though it is of an undulant
fever character it is not of sufﬁcient length to be of much value. Un-
fortunately he was unable to make any autopsies, so that his remark
that “Peyer’s glands are apparently not affected” is an unconﬁrmed
surmise. He states that in this place both malarial and enteric fevers
exist in their typical form, and that enteric fever attacking malarial
subjects is proportionally modiﬁed, but that “malarial typhoid fever” is
apparently a separate form of fever from these two. \Vhatever this
fever is, it has the seasonal prevalence and many of the characteristics
of undulant fever, and as Jerusalem is not an unlikely place in which to
ﬁnd the disease this evidence is valuable.
North Africa.1—-The author has frequently been informed that cases
of this fever occur in Alexandria, but has failed to gain reliable infor-
mation on this point. Most of the cases prove to be relapses in men
transferred from Malta, where they have suffered from the fever.
Surgeon-Captain F. G. Morgan (1892), however, mentions a few instances
of this fever attacking men in Alexandria who had not served previously
in other parts of the Mediterranean. ,
Guiffré mentions its occurrence in Tunis and Algiers. Dr. Perini,
from twenty years’ experience in Tunis, informed Bruce that in 1879 he
had the opportunity of observing the ﬁrst case of this fever which
occurred there. He further states that when the French occupation
took place an epidemic of this fever broke out at Golletta, a muddy
seaport in the vicinity, and that since that time it has become endemic.
Bruce says : “ This fever does not appear to be known at Tripoli.” A
Maltese doctor, with long experience in that place, had not ,met with
the fever there. “Then visiting Benghasi and Derna, on the same coast,
in 1893, the author failed to ﬁnd evidence of its occurrence in these places,
but at the same time evidence gained in such primitive places is unreliable.
Red Sea—Dr. Hutchinsoii-IVIilnes states that he met with this type
of fever at Suakim and Massowah, where it differed in no way from that
met with in Malta, Naples, and Crete. Drs. Pasquale, Rho, and other
Italian physicians, describe somewhat similar cases as occurring at Suakim
and Massowah. Recent discussions in the medical journals on the
subject of whether Aden is really malarious, point to the likelihood of
this fever being endemic in that place.'2 Dr. Squire has also described
1 In South Africa cases of typho-malarial fever were reported during the Zulu \Yar, but
without much foundation, A31. 1'). Report, 1879, Appendix ; also recently in Matabeleland,
Brit. .lIerZ. Joar. vol. i. p. 1105, lst May 1897.
'3 Surgeon-Major Colson, Brit. ﬁled. Joar. vol. i. p. 1019; 1896.
26 CNDL’LANT, MAL TA on

cases of typho-malarial fever in Suakim in 1885, which might seem
similar to undulant fever attacks elsewhere.1
F ranca—J accoud states that it is only met with in Paris as an im-
ported disease in persons lately from Italy. The exact northern limits
of the geographical distribution of this fever have yet to be ﬁxed. From
information the author has received from various towns on the French
Mediterranean coast, and from Genoa, Venice, and Trieste, he is of opinion
that the disease is not of common occurrence in these places, but is
unable to either exclude or deﬁnitely conﬁrm its existence in these
latitudes.
China—Fevers of a somewhat similar type have been described as
occurring in Hong Kong by Durand-Fadel and Mitford-Atkinson. At
a recent discussion on this subject, at the Royal Medico-Chirurgical
Society, Dr. Patrick Manson said that he had probably seen cases in China
similar to those described.‘2 Army medical ofﬁcers have met with cases in
Hong Kong they consider similar to this fever. Prof. \Vright, of Netley,
has met with a case of continued fever from Hong Kong, which showed
a serum reaction to the micrococcus Melitensis similar to that met with
in the blood of cases of undulant fever from the Mediterraneanﬁ
India—In various reports upon the diseases of India we read
accounts of cases of fever which, without being either malarial (paludic)
or enteric in nature, have a certain clinical resemblance to both these
diseases. Such cases are, however, unaffected by quinine. In the belief
that they were caused by a combination of the malarial and enteric
poisons in the human body at one and the same time, they have
occasionally been termed “ typho-malarial fever.” 4 Many of these cases,
in both India and Burmah, have a number of the clinical characteristics
of this undulant fever. As the climatic and topographical conditions in
many parts of India and Burmah are apparently suitable for the exist-
ence of this fever, it is worth while discussing the question that others
may be led to go into the subject locally. Cur reasons for believing in
the possibility of its existence in these places may be brieﬂy mentioned.
(1) These cases are described in published works either as anomalous
forms of continued fever which can be placed under no deﬁnite type 3 as
atypical enteric fever 3 or as typho-malarial fever, a disease which in the
Mediterranean has proved to be undulant fever.5 The clinical accounts
of these cases are quite as much like undulant fever as those written in
the Mediterranean before that fever became an established disease.
Thus Surgeon-General Moore, in his JIIannal of the Diseases of India,
describes “undeﬁned climatic fever.” Such cases, he says, “begin like
other fevers until the temperature rises to 1010 or 102° F., from which
period until the date of death or recovery is from a fortnight to three
1 See also Health of the Navy, 1884, pp. 104-7.
‘3 Ville Brit. ﬁled. Jon/x (18th April) vol. i. p. 973 ; 1896.
Lancet, vol. i. p. 656 3 1897.
See back, section on nomenclature. typho-malarial fever.
I517].
“I A;- :41
ﬂ/EDZTEA’A’ANEAN F5 VEZL’ 27
weeks ordinarily, occasionally shorter, but often much longer, extending
even to 120 days. During this time there are always morning and
evening variations, the range of temperature being sometimes as much
as 90, frequent but variable remissions, and often amelioration about
every ninth day, when the appetite may return and the inexperienced
be led to believe there is little the matter. . . . Thus, in the thermo-
metric range the fever‘ somewhat resembles remittent, in the duration
of the febrile stage it most resembles typhoid, while in the tendency to
periodical amelioration and the occasional abrupt cessation it simulates
relapsing fever. . . . The disease may sometimes most resemble re-
mittent, at others typhoid or relapsing, yet not be found fairly dis-
tinguishable as either, according to the dicta enunciated by the
exponents of fever types, but yet a blurred image of all. Any ‘com-
plication or sequelee which occur during or after any other phase of
fever may be present during or after undefined climatic fever, but pneu-
monia is the most common complication.”
See also Surgeon Limit-Colonel Crombie, I.M.S., in the }')residential
address at the recent Indian Medical Congress ,1 Dr. Mitra in the last
number of the Zlferlz'caZ AVML'ZMZ,‘ Sir Joseph F ayrer in his work upon
the Climate and Fee'ers of India; and Dr. P. Rho in 1894.
(2) In an account of two outbreaks of fever, by Marston, in 1879
(Army ﬁled. Reports), one of true enteric fever at Ranikhet, the other,
in close vicinity, of so-called remittent fever at Choubattia, we find
accurate clinical and post-mortem accounts and temperature charts.
The cases at Ranikhet were similar to enteric fever elsewhere.
As pointed out by the writer in 1892,?‘ the clinical and post-mortem
descriptions of those from Choubattia are indistinguishable (to one who
has not actually seen the cases) from cases of undulant fever in Malta};
Squire mentions a similar occurrence at Dinapore, Lower Bengal, in the
70th Regiment in 1883.
The writer has met with a case of acute fever, landed in Malta
from a troopship homeward bound from India, which was said to be at
the beginning of the second week of enteric fever (see Case 1). The
disease had commenced seven days after leaving Bombay. Though
many of the symptoms were severe and adynamic in character, they re-
sembled those met with in severe undulant fever more than those of
enteric fever. Quinine had no beneﬁcial effect. The case proved fatal
on about the fourteenth day of the disease. At the post-mortem ex-
amination twenty-four hours later no signs of enteric lesion were
present, but the appearances were those met with in acute and fatal
cases of undulant fever. Unfortunately the writer did not have an
opportunity of making any bacteriological experiments, nor of examin-
ing the blood for malarial organisms.
Case 1.——C-'ase of fever, said to be of the Indian remittent type.—
Sergt. S., age 30, service 10 years. Admitted to hospital (10-11-1892)
1 Lancet, vol. i. p. 187; 1896. ‘3 Lancet, vol. ii. p. 1265 ; 1892.
3 See also remarks on these outbreaks by Squire in 188 6.
28 UN!) ULAJVT .IUA L T A OR

on board ship soon after leaving Bombay, with fever of asthenic
type. N o abdominal symptoms or diarrhoea. Said to be due to resi-
dence in the climate of India. The case was diagnosed enteric fever,
and transferred from the ship to Valetta Hospital, when passing Malta,
in an adynamic condition (17-11-92). As the case progressed the
symptoms became more grave and typhoid in character, but were not,
in the opinion of the medical officers of the hospital, in keeping with
the diagnosis of enteric fever. Delirium set in, and was succeeded by
coma, and he died at 12.10 PM. much cyanosed (24-11-92).
Treatment.——Milk, eggs, and beef-tea. Brandy. Ice to suck and
externally to the head. Quinine without effect, antipyrin and sali-
cylate of soda.
Post-ntortcm.—-—Twenty-four hours after. Body well nourished and
covered by a good layer of adipose tissue. Heart 11'5 ounces, normal,
but with much external fat. Lungs l9 and 20 ounces, with slight
hypostatic congestion. Kidneys enveloped in fat, but normal. Liver
and brain normal. Spleen very small, but soft and diﬁluent (rotten).
Intestines normal, no congestion nor inﬂammation of Peyer’s patches.
Mesentery contained much fat.
Account extracted from the records of the hospital. Though the author
was not in medical charge nor present at the post-mortem examination
he had frequent opportunities of seeing the ease up to the last moment;
also the intestines and spleen were kept in spirit for his inspection.
(4) A large number of medical officers who have served in India
and Burmah before coming to Malta have expressed decided opinions,
when questioned by the writer, that many cases of fever they had met
with in the former places were identical in nature with undulant fever.
These had been returned as enteric fever, though in fatal cases the
speciﬁc lesions had been absent from Peyer’s patches, and in some
instances the primary attack had been followed by as many as ﬁve
relapses. For the powers of clinical observation of many of these
medical ofﬁcers the writer can vouch.
A medical officer, whose knowledge of clinical medicine is sound,
wrote to the author in 1892 from Lucknow as follows :—
“I send you an assortment of charts. We get cases here evidently
not malarial, which run on for weeks, which get very debilitated, lose
flesh, hair, etc., but don’t die. These sort of cases are not mentioned in
any work. Quinine, arsenic, etc., have no eﬁ‘ect, and they simply get
well in process of time, and are rarely complicated. The senior medical
officers generally call them enteric modiﬁed by malaria, and going on to
malarial fever, but none of the juniors believe in this, but are of an
opinion that they resemble ‘Malta fever.’ I have seen half a dozen
cases of over 100 days’ duration, and I now have a case of 79 days.
He eats a most liberal diet and is very anaemic and thin, gets evening
headache, but complains of nothing. He has been twice badly cin-
chonised, has taken enormous doses of arsenic, iron, and opium, but is
none the better.”
[MEDITERRANEAN FE VER 29

It is only right to mention also that other medical officers, in whom
reliance can be placed, deny this resemblance between Mediterranean
and Indian fevers, but these will generally be found to have served in
different parts of India from those previously mentioned. India has, as
we well know, a large variety of climates and topographical conditions
in the million and a half square miles of its territory 3 and we must
expect to ﬁnd as many variations of disease prevalent. The existence
or otherwise of this fever in India and Burmah is, however, a subject
which is worthy of investigation.
('5) Lastly, but by no means of least importance, are the experi-
ments recently carried out at N etley by Professor Wright and others.1
They have obtained a serum reaction in relation to the micrococcus
Melitensis, with the blood of cases .of so-called enteric fever invalided
from India (Subathu), the reaction being similar to that met with in
cases of undulant fever invalided from the Mediterranean. Many of
these cases, having had no previous Mediterranean service, suffered at
Netley from febrile relapses, swollen testicles, etc., which symptoms
were indistinguishable from those met with in cases of undulant fever.
America—As we have drawn attention to the possibility of the
existence of undulant fever in India, it is equally important for us to
discuss the occurrence of certain types of fever which occur in America.
These cases have been termed “typho-malarial fever” by Woodward
(1876), Maurel (1879), Bartlett (1881), and Webb (1883). In the
valley of the Mississippi they were called “malarial continued fever”
by Maury (1881), who has published some interesting temperature
charts. At the General Medical Congress (1893) at Washington, fevers
occurring in Venezuela were described which Dr. Rho (1895) has com-
pared with the fever of Malta and Gibraltar, as described by English
military doctors. See also remarks by Stewardson (1841), Fife (1888),
accounts of continued fever in the [Medical History of the War of Rebellion,
and in Davidson’s Geographical Pathology.2
In the parts of America mentioned we again ﬁnd a suitable climate
for the existence of this fever, and without theorising further, would
draw the attention of our American colleagues to these at present un-
deﬁned forms of fever, which to a certain extent resemble this undulant
fever.
BIBLIOGRAPHY

' 460-357 13.0. HIPPOCRATES. Epidemics. Translated by Adams, Syden. Soc. vol.
i. London, mu. 1849.
1709. BATES, T., Naval Surgeon. An Erwhiridion of Fevers incident to Seamen in
the..zllcditerranean, 2nd edition, London.
1 Brit. Jled. Journal, 1897, vol. i. p. 911. See also Freyer, VVelch, and Macartney,
1897.
.2 Typho-malarial fever in the valleys of the Mississippi,iPotomac, Ohio, and Chickahominy
rivers, p. 830 ; Remittent fever, U.S.A., p. 829; Mountain fever by Koher of California,
p. 833.
30 UND ULANT, .MALTA OR

1712. TORTI. Theraputice spec. ad febres perniciosas, periodicas, etc. (Febbre sub-
continua.)
1744-49. CLEGHORN, G., Army Surgeon. Epidemical Diseases in Minorca. London,
1751.
1763-87. DEMARCO, GUISEPPE, M.D. Fasti ﬂIorboru/n Melitensis; also Discr-
tatio Academica dc Febre, vol. xxxvi. MSS. Pub. Lib. Valetta ; also De Febribus Acutis.
May 25, 1786, vol. Xxxvii. MSS. Pub. Lib. Valetta; also Inglott MSS. No. 2, 1722-
1737, same library.
1786. HOWARD. The Lazaretos of Europe, Section on Malta, p. 58.
1798-1800. F AUVERGE, J. P., Chir. Major. Des maladies gui ont regne a lllalte,
pendent le Bloeus, Paris, 1803. He also quotes ROBERT, “Mémoire sur la topographic
physique et médicale de Malte . . . . parmi 1es troupes francoises,” pub. in the 4th
vol. of rllémoires sur l’Egypte, by Prof. Desgenettes, Paris, 1803.
1800-10. BURNETT, Sir W., M. D. A Practical Account of Mediterranean Fevers.
London, 1816.
1810. IRVINE, W., M.D., Army Physician. Observations upon Diseases in Sicily
(Continued Summer Fevers). London.
1816-25. HENNEN, J., M.D., Inspector of Mil. Hosp. Medical Topography of the
ilfediterranean, London, 1830; also quoted in Montgomery Martin’s History of the
British Possessions in the illediterranean.
1820. BURN, G., Naval Surgeon. Defebre M'editerranea.
1821. BAXrER, A., Military Surgeon. De febre Remittcnte (Mediterranei). Edin..Univ.
Graduation Essays. Also CLARK, J ., Military Surgeon, similar essay on same subject.
1824-35. DAVY, M.D., F. R.S., Insp.-Genl. Notes on the Ionian Islands and illalta,
vol. ii. p. 262 et seq. 0n the Fevers of Alalta, London, 1842. Also see Diseases in the
Army, article on Malta, 1833-5, London, 1862.
1825-28. HEASTIE, A., Naval Surgeon. Observations on Fever as it generally occurs
along the Coasts of the Zllediterranean and on Shipboard, being Part ii. of a work on
yellow and other fevers. Edin. 1830.
1836. MAILLOT. Traite des ﬁevres, Ajaccio, Algiers, and Rona. Paris. See also
Boudin, 1842, and Bonnet, 1853.—CRAIG1E. Elements of the Practice of Physic, vol. i.
‘Fevers.” Edin.
1817-36. Parliamentary Statistical Reports on the Diseases of the Army, including
Zllediterranean Stations. London, 1840.
1830-36. SMYTH, Capt, R.N'. The lllediterranean. London, 1854.
} The Health of the Navy. Annual Parliamentary Return.
1837-46. Parliamentary Statistical Reports on the Sickness, Mortality, and I nvalid-
ing among the Troops in the Mediterranean, etc. London, 1854.
1841. JOHNSON, J., M.D., and MARTIN, J. RANARD. The Inﬂuence of Tropical
Climates on European Constitutions, 6th edit. pp. 390-399.—STEWARDSON, American
Journal for April.
1849-59. Parliamentary Report on the Sanitary condition of the ﬁIcditerra/iean
Stations, drawn up by Capt. Douglas Galton, RE, and J. Sutherland, Esq., M. D., In-
cluding tables of fever prevalence. London, 1861.
1852. HAsPEL, A. Maladies de l’Algcria, Paris. See also Brit. and For. Med. and
Chir. Gas. October, p. 349.
1856. LYONS and AITKEN. Parliamentary Report on the Pathology of the Diseases
of the Army in the East.
1857. Parliamentary Report on the Zlfedical and Surgical History of the Crimean
War, vol. ii. part i. sect. vi. ; also review in the Brit. and For. Med. and Chir. Gas.
for Jul .
18538. ARNAND. Hist. me'd. chir. de la guerrc dc Crime’a—JAGQUOT. Du typhus
de l’arme'e cl’ Orient. Paris.
1860. CAZALAS. Maladies de l’armée ol’Orient. Paris.
1859-95. Army Medical Reports. Published annually for the War Office by Harrison
and Son, London.
1861. MARs'rox, J. A., M. D., Assist. Surg., R.A. "Report on Fever (Malta).”
Army Medical Report, pub. in 1863, vol. iii. p. 486.
1862. Health of the Navy. Parliamentary return, pp. 41 and 59.
1863. CASORATI. Tratato (lelle febbri intermittenti. Pavia and Milan. See also
Brit. and For. rlfed. and Chir. Car. 1864, vol. ii. p. 34.
111E D! T E RRA IVE A .N FE VE R 3 I

1864. CHAPLIN, T., M.D. “The Fevcrs of Jerusalem,” Lancet, 27th Aug, 3rd
Sept, and 10th Sept. Syriac Fer-‘er, vol. ii. pp. 236, 263, and 289, see on 1885.
1865. BOILEAU, J. I). H., Assist. Surg. 29th Regt. “Remarks on Fever in Malta,
with Cases,” Army riled. Report, pub. in 1868, p. 478.
1866. CHARTnEs, Surgeon 100th Regt. “Gastric Remittent Fever,” Army .Uccl-ical
.Ileport, pub. in 1867, p. 527. -— BACCELLI. Dellc fcbbri subcontinua, Rome, and
again in 1875 and 1894.——GUIDIGI. Sullafebbre tifoiclea. Torino.
1868. GnIESIN-GER. lizfcctionslcranh. Italian edition pub. in Milan. Dclle
malattie (l’infceione, p. 90 and seq. -—-DUT110ULAN, A. F. Traite' (les malr'a‘lirs (les
Europeans (lans les .PaQ/s Ohaucls, p. 15.
1870. BonnnLLI, Prof. D. Dcllafelbre. N apoli.
1871. GITILIA, G., M. D. “ Sulle febbri Endemiche di Malta,” [l Darth, Gazzctta (ll
rlleclicina, N o. 1, Lugio 25th. Malta.
1872. BonnELLI, D. “ Della febbre a tipo intermittente,” Jtcrista clin. (It Bologna.
—~GRIMALDI, G. S'al life, Napoli—Arrknx, Sir W., M.D. Practice of radar-m, vol. 1.
p. 595 (Simple Continued Fever).——l\loor.E, Staff-Surgeon, R.N. Health of the New”,
p. 49. _
1873. CANTANI, A. “Sull’ Infezione da Malaria,” Lczione clinichc (Qualunque
febbre non-malarica), ride Il Earth, Nov. 15th, Malta.
1874. TOMASI, S. ivotarella sulla cura (lel tifo, Morgagni.
1875. FIACLEAN, Prof., C.B., M.D., I.M.S. “ 011 Malta Fever, with a Suggestion,”
Brit. rllccl. Journ. vol. ii. p. 224, August. —TOMASI, S. Nola sul tifo, Morgagni.
1876. MACLEAN, Prof. (see above). “ Sequel to a Note on Malta Fever,” Brit. Jlcrl.
Journ. vol. i. p. 190 (February).——\VO0D, OSWALD, M.B., Surgeon, A.M.D. “Malta
Fever,” Eat-in. Merl. Journal for July, xxii. p. 40.——NOTTER, LANE, B.A., 1\l..S..
D.P.H.. Surgeon A.M.D. “On Malta Fever,” Eclin. Meal. Journal for October, xxii.
p. 289.-—DONALDSON, J. Y., Surgeon-Major, A.M.D. “On the Diagnosis and Causa-
tion of Frisco-malarial Fever” (Malta), with note by Prof. Maelean, in Army 11137.1.
1.?cport, published in 1879, p. 238.-—DOMIN 101s, N. La febbrc (la fogna, N apoli, 1876 and
1883 (v. pure il suo Trattato di Pathologia e Therapia speciale medicale, N apoli, 1887.
p. 633).—-\VOODWAP.D. Outlines of the Chief Camp Diseases ,- Typho-malarial Fever,
Philadelphia.
1877. BORRELLI. “La febbre di Napoli,” Ricista Ulinica (Zi Bologna, No. 225,
Argosto.
1878. AITKEN. “ Malarial Fever at Rome,” Brit. Merl. Journ. April 27th, vol. i.
p. 597.——GANTANI, A. Inter/no acl un case cli acleno-tifo, Morgagni, p. 395.-—SULLIVA.\',
J., M.D., F .R. C.P. “ The Malarial F evers of Cyprus,” .Mecl. Times and Gazette, vol. ii.
p. 539, Nov. 9th.
1879. FRANCO, Dr. D. “ F ebbre di N apoli,” La Scuola 1Ifecliea Napolz'tana, fasc. 3,
anno ii. See also Giorna-lc Intcrnaz. Naples, 1880.—1713.41.15, H., Surgeon-Major, M.D.
“ Remarks on the Cases of Fever from Cyprus, Malta, and Gibraltar, treated at Netley,”
Army Jllccl. Report, vol. xxi. p. 260, published in 1881.—FAZIO, Prof. E. “Febbre
napolitana,” Associazione N aturalisti e Medici, 8 Maggie, rlfort-mcnto 'mcclico-chirurgico,
p. 239. Napoli—Mans'rox, J. A, Brig.-Surg., A.M.D. “Remarks on Entcric (and
Remittent) Fever, Bengal,” Army rlfccl. Report, published in 1881, vol. xxi. p. 238--
.\I.\UP.EL. “ Typho-malarial Fever in the French Convict Settlement, Cayenne,” Goa.
hcbcl. (to meet. N0. 4.—DUP.AND-F.=1DEL. “Typho-malarial Fever in China,” Full. (Zr
l’Aeacl. (lc we'd. do Par-"is, No. 5.
1880. CANTANI, A. La (liversita clci q-uarlri clinici nclle malattie (la infe-z'ionc.
Also, Uh caso cli aclcnotifo tli tliﬁicile (liagnosi, Morgagni.
1881. RUMMO, G. Una for-ma cli febbre infetti'va, NapOli.—-.M.~\.URY, R. B., M.D.
of Memphis, Tennessee. “F evers of the Mississippi Valley,” American Journal of
.Mcclical Sciences, April, vol. clxii. art. 9.——BAR’1‘LETT. History ancl Treatment m” the
Feccrs of the United States QfAmer-ica. Philadelphia, 1842, 1856, and 1881.
1882. Canaenoncranns, J. G., M.D. A lcthcia Journal, January, No.58, published
in Limasol, Cyprus—TYrHALDos, Prof. P. “On Bilious Continued Fevers,” Galen,
Nos. 48-51, pp. 337-418 ; and in 1883 in Nos. 20, 21, pp. 305-330, published in Athens.
——FAYRER, Sir J. On the Climate ancl Fercrs of Inclia. London.
1883. GALAssI, L. “Sulla considdetta febbre napolitana,” Rivista clinica e tera-
pculica.—-El Genie .lfeclico Qui-rurgico for January 15th (DaVidSOn).——INGLESSIS, G.
Galen for April, p. 268, published in Athens—\VEBB. “Typho-malarial or Continued
Malarial Fever,” American Journal Of American ,S'cicnccs for April.
32 UIVDULANT, [MALTA OR

1884. TURNER, “7., M.A., M.D. “ On the Nature of the so-called Rock Fever of
Gibraltar,” Practitioner for April, vol. xxxiii. p. 305.—-DE CHAUMONT, Prof., M.D.
“Lecture on Military Hygiene,” Journal of the United Service Institution, p. 762,
London. —DE RENZI, E. “ Sulle febbricola,” Rivista clinic-a e terapcutiea ; and Riforma
illedica, 1885, n. 165.
1885. MACLEAN, Prof., M.D., C.B. “The Fever of Malta and Gibraltar,”
Practitioner for January, xxxiv. p. 78.——CHAPLIN, T., M.D. “On Malarial Typhoid
Fever ” (Jerusalem), Lancet for September 19th (see 1864, p. 31), vol. ii. p. 518.~——CANTANI,
A. “Ancora dell’ ileo-tifo, della cosiddetta febbre napoletana,” Rifor'ma medical, n.
127.——CAPOZZI, D. “Della febbre tifoidea atipica,” Lezioni nel Medico practico con-
temporaneo, 1885 - 1887.—-FEDEEIoI, C. “ Sulla febbre miliare di Palermo,” Speri-
mentale, 1885, 11.——GALASSI, L. “Della febbre napoletana o febbricola del Prof. de
Renzi,” Sperimentale 1885, ii.—JACCOUI), S. Lecons de clinigue me’dicale, 1883-84.
Paris, Delahaye et Lecrosnier.——LEPIDI-CHIoTI, G. Sulla cosiddetta miliare di
Palermo, lilorgagni—Cnare. “Rock Fever,” Lancet for November 28th, vol. ii. p.
1028. —HIEsoH. Handbook of Geographical and Historical Pathology, New Syd.
Soc. vol. i. p. 620 (Typho-malarial Fever).
1886. MooEE, W. J., Surg. -Genl., C.I.E. [Manual of Diseases of India, 2nd
edit. p. 275 (“Undeﬁned Climatic Fever”). See also editions of 1841, p. 145 (“Rheu-
matism ”).—ToMAsELLI, S. “ La febbre continua epidemics. dominante in Catania dal
settembre 1878, all’ Aprile 1879,” Negli Atti del’ Accademia Gioenia, vol. xiv. 1879,
3rd edit. 1886, 4th edit. 1895.—JACC()UD, S. Lecons d’overture. Paris, Delahaye et
Lecrosnier.—HEIDENSTEIN, M.D. “Cyprus Fevers” in Colonial Report for Medi-
terranean, No. 23 (Carageorgiades and Davidson).——SQUIRE, J. E., M.D., F.R.C.P.
“Typho-malarial Fever,” Transactions Epidemiological Soc. London, vol. vi. p. 24.
Also Lancet for January 1887 (abstract).
1887. JAGOE, H., Surg.-Major. “Notes on Enteric and Typho-malarial Fever,”
Lancet, vol. i. p. 119, Jan. 15th.—BEUOE, D., Surg.-Captain, M.D. “Note on the
Discovery of a Micro-organism in Malta Fever,” Practitioner for September, xxxix.
). 161.
l 1888. BRUCE, D. “The Micrococcus of Malta Fever,” Practitioner for April, x1.
p. 241.——DUNCAN, A., Surg—Major, I.M.S. The Prevention of Disease in Tropical
Climates (Typho-malarial Fever), London.—DEUMMOND, E., M.D. “Fever at Rome,”
Practitioner for October, vol. xli. p. 256.——DE BLAsI. “Le febbri continue
epidemiche di Palermo,” Giornale della R. Aecademia di Medicina di Torino, Nos. 4
and 5.-—GUIFFRE, L. Sullefebbri continue epidemiche, etc., Torino, Ermanno Leescher.
-—FIEE. Report of the 51st Ann. Sess. Med. Soc. of Tennessee—Medical and Surgical
History of the War of Rebellion, Part 111. vol. i. pub. at Washington.
1889. BRUCE, D. “Observations on Malta Fever,” Brit. IIIed. Jour. 18th May
(also leading article in same), vol. i. p. 1101 ; Riforma Medica, 1° semestre, p. 811.—
SINCLAIR, J ., Surg.-Genl. “Diseases Prevalent in Malta,” Brit. Med. Jour. 5th
January, vol. i. p. 9.—-MoEEET, G. E., Surg., A.M.S., M.B., C.M. “Notes on the
Endemic Fever of Gibraltar,” Army lIed. Report, pub. in 1891, xxxi. p. 403.—~PASQUALE.
“ On the Fevers occurring at Massowah,” Giorn. illed. del R. esereito R. ZMarina, Maggio,
e giugno. Ibidem, luglio 1891. Also quotes Fiorani, 2° semestre 1885; marzo 1886;
Panara, maggio 1886; Rho, dicembre 1886 3 Cognetti, luglio 1887; Barbatelli,
ottobre 1888. —-DE CONCILIIS. “Contributo allo studio della febbri climatiche di
Massaua,” I bidem, febbraio 1889.—KELsoH and KIENER. Traité des maladies des
pays chauds. Paris.
1890. BRUCE, D., Assist. Prof., Netley. “ On the Etiology of Malta Fever,” Army
JIed. Report, pub. in 1892, vol. xxxii. p. 365.—G1rrs, A. G. P., Surgeon, RN. “ On
Malta Fever,” Trans. of the Epidemiological Society of London, vol. ix. p. 76.-—ELLIs,
H. M., Staff-Surgeon, R.N. Note in Naval Annual Report, p. 41.-—-BozZoLo, C. Com-
munication to the International Congress of Berlin.
1891. CHANTEMESSE. Article in vol. i. Traite' de médecine, Charcot, Bouchard,
and Brissaud. Paris—GoDDING, C. C., Staff-Surgeon, R.N. “Malta (Remittent)
Fever,” Brit. .Med. Jour. 16th May, vol. i. p. 1065.——BRUCE, D. “Note on Malta
Fever,” a criticism of the last in Brit. Med. Jour. of 13th June, vol. i. p. 1281.—CARA-
GEORGIADES, J. G., M.D. Cyprus Fever or Febris Uomplicata. Limasol, Cyprus.—-RHO.
“ Delle febbre predominanti a Massaua,” Riv. Olin. Arch. Ital. di clin. med. puntata
2° 1891.—MARAGLIAEO. “ Febbre simulanti la febbre Typhoidea e Geneva,” Riforma
illeclica, 1891, ii. p. 181 (Guiffre’).
MEDITERRANEAN FE VER 33

1892. PASQUALE. See 1889, p. 32, and Lancet, 25th May 1892. ——~MILNES, H., M.D.,
R.N. “Note on the Fevers prevalent on the Shores of the Mediterranean and Red
Seas,” Lancet, 18th June, vol. i. p. 1359.——OLIVER, T., M.D., F.R.C. P. “Danubian
(?) Fever,” Lancet, 18th August, vol. ii. p. 361.—BOND, C. Knox. “ Danubian Fever,”
Lancet, 27th August, vol. ii. p. 507.—HUGHES, M. LOUIS, Sing-Captain A.M.S. “ In-
vestigations into the Etiology of Mediterranean Fevers,” Lancet, 3rd December, vol. ii.
p. 1265.-—PETELLA. “ Le febbri climatiche de Massaua,” Giorn. jlfed. del R. esercito e
R. Marina, Agosto, and Suttembre. —DAVIDSON. Geographical Pathology, Edin.
(section on Spain and Gibraltar) vol. i. p. 198.——MORGAN, F. T., Sung-Capt. A. M.S.
“Notes on the F evers of Alexandria,” Army Med. Report, pub. 1894, vol. Xxxiv. p. 380.
1893. BRUCE, D. “ Sur une nouvelle forme de fievre rencontrée sur les bords de la
Mediterrannée,” Annales de l’Institut Pasteur, avril, vol. vii. p. 289.—HUGHEs, M.
LOUIS. “ Sur une forme de ﬁevre fréquente sur les cétes de la Mediterrannée,” Annales
de l’Institut Pasteur, aout, vol. vii. p. 628, and in Riforma llled. vols. i. and iii.—
Idem. “Natural History of Mediterranean Fevers,” Medit. Naturalist, Jan. Feb.
and March, vol. ii. No. 20, p. 299, No. 21, p. 325, and No. 22, p. 332.—BRUOE, D.,
HUGHES, M. LOUIS, and WEsco'r'r, SINCLAIR. “Notes on Mediterranean or Malta
Fever,” Brit. Jlfed. Jour. of 8th July, vol. ii. pp. 59 to 62.—BRUCE, HUGHES, and
FAZIO. “ La febbre mediterranea e la febbricola nostrana,” Rivista internaeionale
d’igiene, Octobre, No. 10, p. 394 ; also Riforma Medica, Nos. 1 and 3, N apoli.—GUIEFRI-':,
L., and SILVA, B. “ F ebbre Mediterranea, pseudo-tifo, ” Trattato di Medicina di Charcot,
Bouchard, and Brissaud, 22° del, vol. i. Paris and Milan—BRUCE, D. “ Malta Fever,”
article in Davidson’s Hygiene and Diseases of PV arm Climates, Edin. p. 1265.—KLEI:\‘,
E., M. D., F. R.S. “Malta Fever,” article in the Treatise on Hygiene and Public Health,
by Stevenson and Murphy, vol. ii. p. 170.
1894. BACCELLI. “La subcontinua tifoide,” 1875, republished 1894 in Le scuole
ital. oli clin. medica, Milano, vol. 1. p. 138.—-—l\IITFORD-ATKINSON. “The Malarial
Fevers of Hong Kong,” Lancet, 28th April, vol. i. p. 1054.-——MAOAETNEY, J ., M.D.,
Surg.-Col. “Mediterranean Fevers,” letter to the Brit. lied. Jour. 16th June, vol. i.
p. 1332.—HUGHEs, M. LoUIs. “The Diagnosis between Enteric Fever and the Re-
mittent Fever of the Mediterranean,” llledical Magazine for August, vol. iii. No. 2, p.
152; Brit. Med. Jour. 28th July, eta—BRUCE, D. Article in Quain’s Dictionary
of Medicine, vol. ii. p. 10, “Malta Fever.”—RHO, F. Sguardo Generale sulla Patologia
di rlfassua, etc., Rome, Tipograﬁa Nazionale di G. Bertero, Via Umbria (especially note
appendiX).—RHO, F. “Delle febbri tifoidee atipiche e della cosiddetta febbre tifo-
malarica,” Sperimentale, fasc. 28° and 29°, anno xlviii. p. 545.—American Journal of
Zlledical Science for September.
1895. CROMBIE, Surg.-Lt.-Col., I.M.S. Presidential Address, Indian Medical Con-
gress, Lancet, 9th Jan. vol. i. p. 187.—HUGHEs, M. LOUIs. “The Fevers of India and
the Mediterranean,” Lancet, 2nd March, vol. i. p. 574.——CLIMO, H., Surg.-Col., A.M.S.
“ Malta Fever in relation to Local Sanitary Conditions and the Hermite Process,”
Lancet, 18th June, vol. i. p. 1510.—RIIO, F. “ Malattie predominanti nei paesi caldi e
temperati,” Annali di Medicina Navale. Rome—International Medical Magazine, vol.
iii. . 740.
2113896. MITRA, M. C., M.A., M.D. “Indian Remittent Fever,” Medical Annual.
BristoL—HUGHEs, M. LOUIs. “The Endemic Fever of the Mediterranean,” Trans. of
the Royal Med. and Chir. Society, London, 14th April, vol. lXXiX. p. 279.—Nomenclature
of Diseases, drawn up by a committee appointed by the Royal College of Physicians of
London, 3rd edit., 17(a).—HUGHEs, M. LOUIS. “ Undulant (Malta) Fever,” Lancet, 25th
July, vol. ii. pp. 239 and 518.—STERNBERG, M.D., LL.D. Note on “Malta Fever” in
a Text-book of Bacteriology, pp. 528 and 597 ; see also American Year-Boole of jlledicine
and Surgery, p. 53.
1897. WRIGHT, A. E., Prof., M. D., and SEMPLE, Surg—Major, A.M.S. “Note on
the Technique of Serum Diagnosis of Acute Speciﬁc Fevers,” Brit. Med. Journ. 16th
Jan. v01. i. p. 139 ; also 30th Jan. vol. i. p. 258 ; also “On the Employment of Dead
Bacteria in the Serum Diagnosis of Typhoid and Malta Fevers,” Ibid. 15th May, vol. i.
p. 1214.—JAOOOUI), Prof. “De la typhoide sudorale,” Clinique médicale, H6pital de
la Pitie, La Semaine me’dicale, Février 10, 1897, 179 année, No. 6.—WRIGHT, A. E.,
Proﬁ, M.D., and SMITH, F., Surg.-Capt., A.M.S. “On the Application of the Scrum
Test to Differential Diagnosis of Typhoid and Malta Fevers,” Lancet, 6th March, vol. i. p.
656 ; also “A Note on the Occurrence of Malta Fever in India,” Brit. Med. Jour. 10th
April, vol. i. p. 911.-—MAGLEOD, G. E. “Case of Purpura Heemorrhagica following
D
34 UNDULANT, .MALTA OR [MEDITERRANEAN FEVER

Malta Fever,” Lancet, 22nd May, v01. i. p. 1410.—FREYER, Surg.-Major, A.M.S.
“ Occurrence of Malta Fever in India,” Brit. ﬁled. Joma 22nd May, vol. i. p. 1319.—
NOTTER, Prof. LANE, A.M.S. Article in A New System ry” llledicine, Clifford Allbutt,
F.R.S., L0nd0n.—-—MAOARTNEY, J ., Brig.-Su1*g.-Lt.—Col., A.M.S. “On the Occurrence
of Malta Fever in India,” Brit. Med. Jour. 29th May, vol. i. p. 1384.--“Mediterranean
Fever in Gibraltar,” Brit. Med. Jam". 29th May, vol. i. p. 1381.—WELCH, Surg.-Col.,
A.M.S., F.R.O.S. “The Occurrence of Malta Fever in India,” Brit. ﬁled. JO’LLT. v01. i.
p. 1512, 12th June.—GR0000. “Sul decorso della febbre nelle infezione tifoidea,”
Seltimana med. dcZZo sperimentalc, Jan. 9th and 16th.
CHAPTER II
Etiology—Bacteriology : Disco very of a micrococcus ; its isolation from the tissues after
death ; Method of isolation ; Description of the micrococcus ; Inoculation experi-
ments on animals ; Pathogenic nature of micrococcus.—Po'edisposing Causes.—
Zllethocl of propagation and dissemination: Non-contagious ; Elimination of such
causes as inoculation, polluted aqueduct or well water, milk, mineral waters, grog-
shop and canteen drinks, ice, and food; Discussion of fsecally polluted air_as a
cause, in connection with insanitation; Extracts from authors ; Factors usually
present ; Examples of outbreaks connected with insanitation ; Faecal pollution of
harbour water as a suggested cause ; Non-faecal telluric exhalations and dust con-
sidered in relation to cause ; Micro-organisms in air ; Soil zones ; Micro-organisms
in sewer gas ; Effects of climatic conditions upon prevalence ; Drainage of Valetta ;
Air-borne enteric fever; Reaction of faecal matter, Diﬁiculty with plate cultiva-
tions ; The cesspit populations of Malta ; Mode of entrance into the human sub-
ject—Age and sen—Incubation period—Seasonal pTevaZenca—Zn/tuence of rain-
fall and temperature.— Immunity from subsequent attacks considered—Changes in
type (quantitative and qualitative) : Need for statistics to cover a suﬂiciently long
period ; Rumoured increase in prevalence since 1885 discussed ; Difference be-
tween urban and rural prevalence ; Its limited occurrence in G020 ; Recent increase
in the number of susceptible persons exposed to infection; A discussion on the
past military statistics for simple continued and remittent fevers, the only avail-
able ones procurable, which deal with the past prevalence of this fever.
Bacteriology—Although undulant fever has existed in the Mediterranean
as an endemic disease for so many years, it was not until 1886 that a
micro-organism was discovered, to the effects of which the phenomena of
this disease could be attributed. This has been owing partly to the fact
that naval and military medical officers are seldom long enough in one
place to be able to undertake scientiﬁc investigations ; partly that early
post-mortem examinations are rarely attainable by civilian medical men,
on account of the religious tenets of the nations inhabiting the Mediter-
ranean littoral; and partly on account of the comparatively recent
date of recognition of this disease as a separate and speciﬁc form of
fever.
The discovery of this micro-organism at Malta was the result of the
researches of Surgeon-Major David Bruce, A.M.S., since Assistant-
Professor of Pathology in the Army Medical School at Netley.
In a case of this fever, which died on the 15th day of the disease,
Bruce found, nine hours after death, in splenic sections, “enormous
numbers of single micrococci ” scattered through the tissues. This led
36 UND ULANT, MALTA ole

him to believe that a micrococcus might be the cause of this fever, and
in May of the following year (1887), with Dr. Carruana Secluna, he
made between thirty and forty inoculations into sterilised agar-agar with
blood aseptically taken from the ﬁngers of ten cases of this fever, but
without result. One of these cases, however, proved fatal, and less than
one hour after death eight tubes of agar-agar were inoculated with the
usual precautions. These were kept at the temperature of the air
(25° C.) for 16% hours, after which six were placed in an incubator at
37 ° C. Colonies of a micro-organism, which the writer has called the
Micrococcus Melitensis, appeared in all the tubes; in those placed in
the incubator sixty-eight hours after inoculation, but in the remaining
two tubes not until after 168 hours.
In his next case Bruce was unable to make an autopsy, but seven
hours after death, by means of a sterilised trochar and canula, he obtained
some splenic pulp with which he inoculated six tubes of agar-agar. In
four of these tubes, placed next morning in the incubator, colonies of
the micrococcus Melitensis appeared in eighty-four hours. In one tube
kept at the temperature of the air, but somewhat higher than in the
preceding instance, the same micrococcus appeared in 110 hours, while
the remaining tubes proved contaminated. In his fourth case of six
tubes of agar-agar inoculated directly from the spleen and placed at once
in the incubator, colonies of the same micrococcus appeared in sixty-
seven hours in four of the tubes, the remaining two proving con-
taminated.
The next case gave positive results in all six tubes inoculated, in
ninety-seven hours—the greater length of time being accounted for by
the fact that the gas burner of the incubator was accidentally turned out
for twenty-four hours. These growths were cultivated through genera-
tions of pure cultures. A fragment of fresh splenic pulp, in sterilised
water and x 500 diams, showed “the ﬁeld of the microscope literally
crowded with myriads of micrococci dancing in about in the most
active manner.”
The sixth case was somewhat peculiar (see on p. 171, Chapter IV.)
and out of six tubes inoculated from the spleen, liver, and kidneys, and
kept at a temperature of 25° Q, but one contained a growth, and that
not until after 336 hours. Bruce, however, states: “This growth was
subjected to a most rigorous examination microscopically and by staining
reactions, with the result that I fully convinced myself of its identity
with the micrococcus of Malta fever.”
Details of the above cases may be found in the Practitioner for
September 1887 and April 1888.
Three more cases, in which this micrococcus was obtained from the
spleen after death, were published by Bruce in the Annales de l’Institut
Pasteur, in 1893, making nine cases in all.
In 1890, Surgeon Gipps, R.N., described two cases in the Trans. of
the Epidemiological Society, in which he believed that he had isolated a
similar micrococcus, of which he gives a drawing. He does not appear,
[MEDITERRANEAN FE VER 37

however, to place much conﬁdence in its causal connection with the
disease.
In 1891 Bruce was able in two cases to cultivate the micrococcus
from blood aspirated from the spleen during life.
In one fatal case only did Bruce (in 1891) fail to obtain the
characteristic micrococcus. This was subsequently proved to be due
to the excessive alkalinity of the culture media. Colonies subsequently
obtained by the writer from other cases refused to grow on this alkaline
agar.1
In 1891 the writer began to work at the bacteriology of this fever,
since which time he has been able to cultivate artiﬁcially, from the spleens
of fourteen fatal cases of undulant fever after death, pure colonies of a
micrococcus similar in every respect to that discovered by Bruce. In
no cases has the micrococcus been absent.
DETAILS OF FOURTEEN CASES
Case 2.——Illaste'ating a fatal result during a relapse—Admitted 27th
July 1891. Age 22; service two years. Previous health good.
Admitted with the usual febrile symptoms, onset being sudden.
On the 10th day the symptoms partook of a typhoid character,
the tongue became dry and brown, the pulse quick and feeble, the
abdomen tympanitic, there was also subsultus tendinum and
abundant crops of sudamina. This continued until the 24th day,
when he began to improve, the disease being characterised by constipa-
tion and rheumatic symptoms to the end, whereas from the 13th to the
26th day there had been a tendency to diarrhoea. From the 40th to the
45th day there was an apyrexial period, after which there was a severe
relapse. The condition gradually became worse, tympanites set in and
was a prominent symptom. There were signs of hypostatic congestion
at the bases of the lungs at the back. He died much exhausted, at
2.30 A.M., on the 73rd day of the disease. The pyrexial curve was
similar to that of Case 3, except that the ﬁrst or primary wave lasted
39, and the second (fatal) wave 27 days.
Treatment—No solid food; stimulants, antipyrin, salicylate of soda,
diaphoretics. Quinine in various doses from two to ﬁfteen grains three
times a day.
Though not in clinical charge of the case, the writer had constant
opportunities of visiting it during life, and there was no doubt as to the
diagnosis of undulant fever. At the post-mortem examination four
hours after death, six army and three civilian medical officers were
present, who all conﬁrmed ‘the diagnosis. The body was fairly well
nourished and the heart normal. The lungs showed some hypostatic
congestion of both bases, with sero-purulent exudation in the bronchioles.
1 See Davidson’s Diseases of Warm Climates, p. 267 ; and Army illedz'cal Report for
1890, published in 1892, vol. xxxii. p. 365.
38 UNDULANT, JIIALTA 0!?

Liver weighed 7 4 ounces, was slightly fatty. Kidneys normal. Spleen,
12 ounces, enlarged and dark, but ﬁrm in texture. Stomach and
duodenum normal; the jejunum had a patch of congestion, 4:}; inches
long, a foot below the duodenum. The ileum, Peyer’s patches,
and the solitary glands were all normal. In the large intestine
the caecum was normal, but just below this for one foot in extent, and
again for six inches at the upper part of the sigmoid ﬂexure, were
patches of congestion and exudation. There was no sign of ulceration
along the whole extent of the alimentary tract.
Experiment—The spleen was removed as aseptically as possible, and
without tearing its capsule, at once wrapped in a towel soaked in a solution
of perchloride of mercury, and removed to the laboratory. There three
cuts were made in the spleen with three sterilised knives, each out being
through and at right angles to the plane of the preceding one. The
innermost out being used for inoculation purposes, the cuts being
allowed to fall together between each operation. Three tubes of agar-
agar were inoculated by a small drop of blood removed on a sterilised
platinum ooze, two tubes were at once placed in the incubator at 990 F.,
and one left at the temperature of the air (about 7 5° Character-
istic colonies of the micrococcus Melitensis appeared in both the tubes
placed in the incubator after 124 hours, but the tube left at the tempera-
ture of the air remained sterile. These growths were passed through
six generations of pure cultures on agar-agar and were used for inocula-
tion of monkeys. One primary and two secondary cultures forwarded
to Bruce at N etley were identiﬁed by him as the same micro-organism
that he had found.
Case 3.-—-Was somewhat similar in character, proving fatal during a
relapse, on the 54th day of the disease. (For details and chart see
Chapter III.)
Cover-glass preparations of fresh splenic substance showed micro-
cocci here and there. Three tubes of nutrient agar-agar were inoculated
from the spleen with the same procedure as in the last case, and were
placed in the incubator at 99° F. Characteristic growths appeared in
every tube within 120 hours from inoculation.
Case 4.—A malignant one, proved fatal on the 23rd day from
hyperpyrexia. He was the only fatal case that occurred in the
epidemic mentioned on p. 59. At post-mortem examination the lungs
were found to be much congested at the bases, the spleen congested,
friable, and weighing 15 ounces, the liver congested, but Peyer’s patches
and the mesenteric glands normal. Inoculations were made in broth and
on agar-agar ; characteristic colonies appearing on the seventh and sixth
days respectively at 99° F.
Case 5.-—Also a malignant case in a delicate subject which proved
fatal from cardiac failure on the 12th day. At the post-mortem there
were mitral vegetations with fatty degeneration and inﬁltration of the
heart. The spleen weighed 13 ounces and was extremely congested,
liver enormously enlarged (88 ounces), but Peyer’s glands and the
MEDITERRANEAN FE V51? 39

mesenteric glands normal. The spleen was removed one hour after
death, and three tubes of agar-agar inoculated, characteristic growths
appearing on the ﬁfth day at 99° F.
Case 6.—Died on the 18th day of continuously high pyrexia in
a comatose condition. At the post-mortem examination seven hours
after death the lungs showed basal congestion, the liver (73 ounces)
was congested and friable, the spleen (21 ounces) was almost in a
state of liquefaction, its substance breaking up on the slightest
pressure. The mesenteric glands were slightly enlarged, but Peyer’s
patches were normal. The great gut for 18 inches, including the
ceecum, was deeply congested, somewhat swollen and thickened, and
the solitary glands were prominent. Characteristic growths were
obtained from the spleen on agar-agar in ﬁve days.
Case 7 .—-Died of collapse, vomiting and exhaustion on the 35th day
of the disease, the temperature having fallen the day before death only
to rise again. After death the bases of the lungs and the spleen (18
ounces) were found to be congested; the mesenteric glands slightly
enlarged, but Peyer’s patches and the intestines normal. Characteristic
growths on agar-agar were obtained from the spleen in 130 hours at
99° F. (See Chapter III.)
Case 8.—Died of heart failure and pericardial effusion on the 19th
day of a very remittent case, see on p. 144. This and the preceding
case are mentioned in the instances of outbreaks. After death the
lungs showed lobular consolidation of the lungs, the spleen (12 ounces)
congested, the liver nutmeg, and the heart with mitral vegetations ;
Peyer’s patches and the mesenteric glands normal. The micro-organism
was visible in cover-glass specimens of splenic substance, and was
obtained from the spleen on agar-agar in pure growths on the 6th day.
(See Chapter III.)
Case 9.—Died of hyperpyrexia on the 24th day of continuously high
pyrexia, after admission to the hospital. After death there was basal
congestion of both lungs, the spleen (12 ounces) was congested, the
large gut much congested, the mesenteric glands slightly enlarged, but
Peyer’s patches normal. One hour after death-the micro-organism was
visible in cover-glass preparations of fresh splenic substance, and charac-
teristic growths were obtained on agar-agar on the 5th day.
Case 10.—A long case with short undulations (see Chart No. XVII.)
died of sudden hyperpyrexia on the 57th of the disease. After death the
lungs were oedematous and congested at the bases ; the liver (80 ounces)
intensely congested; spleen (11 ounces) congested, but ﬁrm; mesenteric
glands and Peyer’s patches normal. Micrococci visible and growths
obtained as in the last case. (See Chapter III.)
Case 11.—A somewhat unique case, was admitted to hospital for
three weeks’ fever, and then discharged apparently cured. Four months
afterwards he was again admitted with fever of a typically intermittent
character, which proved fatal from cardiac failure on the 154th day
of this attack. After death the heart was ﬂabby, there was a small
4o UND ULANT, MALTA 0R

aneurysmal dilatation above the posterior left semilunar valve, and all
three of these valves had vegetations on them. There was much serous
ﬂuid in the pleural cavities, the bases of the lungs being congested and
oedematous. The liver (76 ounces) was nutmeg, the spleen (14 ounces)
congested, but Peyer’s patches, the mesenteric glands, and intestines
were normal. Six tubes inoculated from the spleen all showed charac-
teristic growths on the 6th day.
Case 1 2.——Died of hyperpyrexia on the 24th day of acute fever. After
death there was considerable congestion of the bases of both lungs ; the
liver was nutmeg ; the spleen (14 ounces) engorged with venous blood ;
there were patches of congestion here and there in the intestines, most
marked in the colon. Peyer’s patches and the mesenteric glands were
normal. Characteristic colonies were obtained from the spleen as in
the other cases.
Case 13.——Had served for three years in Gibraltar and for ﬁve
months in Malta. He died suddenly of cardiac failure, after a slight
mental excitement, on the 111th day of the disease. At the post-mortem
examination warty vegetations were found on the mitral valve, there
were recent pleuritic adhesions at the base and posterior parts of the
right lung, the lower lobe of which was consolidated. The spleen (15'5
ounces) was congested, soft and friable, the liver congested. The kidneys
showed the characteristic appearances of “large white kidney.” The
intestinal walls were attenuated, but were otherwise healthy. The
spleen was removed three hours after death, and from it characteristic
growths were obtained, while sections were made of portions of the
different organs. (See Chapter III.)
Case 14.——Died somewhat suddenly, on the 62nd day of the disease,
of effusion into the pericardium, during a relapse, and after his tempera-
ture had been normal for 17 days. (For details see on p. 145.) At
the post-mortem examination 17 ounces of ﬂuid were found in the peri-
cardium, the right pleura was obliterated by organised lymph, the right
lung oedematous and congested, the liver nutmeg, the spleen (15 ounces)
congested, but the intestines, Peyer’s patches, and the mesenteric glands
normal. Characteristic growths were obtained from the spleen on the
ﬁfth day after inoculation. (See Chapter III.)
Case 15.—Died on the 117th day from cerebral symptoms. (For
details see under nervous symptoms, Chapter III.) Characteristic
growths were obtained from the spleen and brain.
These cases, together with those of Bruce and Cripps, make altogether
twenty-ﬁve instances in which this micrococcus has been successfully
isolated from the spleens of fatal cases of undoubted undulant fever.
From the clinical symptoms and postmortem appearances met with in
this fever, the spleen, in the last case the brain, and in other cases the
kidney, are, moreover, the places where it might be expected to be present.
N 0 other micro-organism has been found present under similar circum-
stances, nor has a similar organism been found present in the tissues of
fatal cases in Malta, which have died from causes other than undulant
[MEDITERRANEAN FEVER 41

fever. Thus Bruce states1 that the micrococcus Melitensis was absent
in several cases of enteric fever, dysentery, tuberculosis, pneumonia, and
other diseases in which he sought for it. The writer has isolated from
the spleens of nine fatal cases of enteric fever occurring in Malta pure
cultivations of Eberth’s bacillus ; but in no case was there present any
organism at all similar to the micrococcus Melitensis.
The micrococcus has not been isolated from the blood of cases
suffering from this fever, a condition met with in enteric fever (Roux
in Epitome, British Medical Journal, May 23rd 1896, vol. i. p. 84, also
Stern, Jan. 15th, 1897, vol. i. p. 9, etc.). The writer has not sought
for it in the kidney of man, but it has been isolated from this organ by
Bruce once (see Pratt. vol. xl. p. 244). The organism has been twice
isolated from the spleen during life.2 In only one case has it appeared
absent from the spleen, when sought for after death, and in this case
there existed ample reason for the failure in isolation of the micro-
organism artiﬁcially, even if it had been present in great quantity.3
It would therefore appear to be reasonable for us to believe that this
micro-organism is invariably present in the spleen, and possibly other
organs, of cases suffering from undulant fever.
Method of procedure—The following procedure has been adopted
in obtaining the micro-organism from the spleen (or other organ) after
death. A clean towel is ﬁrst soaked in a solution of corrosive
subli1nate(l in 1000), wrung out, and doubled over once. This doubled
towel is folded three times upon itself and placed on a plate, previously
washed with the same solution. After rendering the hands aseptic, a
median incision is made with sterilised instruments in the cadaver, as
soon after death as practicable, through the abdominal wall from the
ensiform cartilage to the left of and a little below the umbilicus. The
hand is thrust into the abdominal cavity (the operator standing on the
cadaver’s right and using the right hand), and passed along the inner
surface of the abdominal wall to the spleen. This organ is then ﬁrmly
grasped and brought forward and through the opening in the abdomen,
any adhesions being easily broken down by the ﬁngers. The vessels are
then severed, and the spleen at once placed within the folded towel and
conveyed to the laboratory. Inoculations have not often been made in
the dead-house on account of the impurities present in the air, and the
absence of the various adjuncts suitable for such experiments; but
with the aid of a spirit lamp they can and have been so conducted on
two occasions.
Three incisions are now made in the spleen by means of a pair of
forceps and three new knives, which have not been used for such a
purpose before, and which have been previously sterilised in the naked
ﬂame of a Bunsen burner. The ﬁrst incision is made vertically,
longitudinally, and to one side of the middle line, through the splenic
substance. The second horizontally through the plane of, and at right
angles to the ﬁrst cut, and in the direction of and through the middle
1 A..M.D. Report, 1890. 2 See Davidson (art. by Bruce), 1893, p. 267. 3 See back.
42 UND ULANT, MALTA 01?

line of the organ. The third is made vertically through the middle of
the plane of the second. Each cut is made with a freshly sterilised and
different knife. The centre of the third cut at some distance from the
capsule is used for inoculation purposes. A drop of splenic blood is
taken in the loop of a sterilised ooze and transferred to the broth or
to the surface of the nutrient agar-agar in the usual way. The
surface of the cuts in the spleen are allowed to fall together and the
ooze is sterilised between each inoculation, so as to be exposed to
accidental contamination as little as possible. The inoculated tubes
are then placed in an incubator at 99°-100° F. When the tubes are
inoculated, cover-glass smears may be made by taking a cover-glass,
previously cleaned in alcohol, with a pair of forceps and lightly touching
the surface of the inner cut with it. This must then be laid, face down-
wards, on a similar cover-glass, the two slid apart, one placed on a
ﬁlter-paper under a sterilised glass shade to dry, and the fellow placed
face downwards on a slide, and the edges painted with petroleum (to
prevent evaporation) when it is ready for immediate microscopic examina—
tion. The former when dry can be ﬁxed, stained, and examined at
leisure. Any number of these can be prepared by even an unskilled
operator and forwarded to experts for examination.
Small portions of the organ may next be removed with sterilised
instruments, and placed in alcohol for future investigation.
Other organs may be similarly examined.
This detail which to the bacteriologist is but simple every-day
technicality, has been given in detail for two reasons. Firstly, to show
that the element of doubt which might arise from want of simple
precautions against contamination has been eliminated; and, secondly,
as a guide to others who, as beginners, may wish to carry on the good
work of investigation here initiated.
In ﬁve of his cases1 Bruce extracted the spleen ten minutes after
death, in four the writer removed the organ within an hour of death.
In other cases the interval varied up to eight hours. In one case
the author obtained the microorganism from the brain, together with
other but slight contaminations as late as twenty hours after death, but
from the spleen of the same case he had been enabled to obtain pure
cultivations from inoculations one hour after death.
Description of the micro-organism.—This minute micro-organism
the author in 1893 named the “Micrococcus Melitensis,” to which he
would add the name “ vel Brucii.” It grows best in nutrient material, the
alkalinity of which is slightly less than that of the human blood, and
at a temperature of about 37° to 38° C. At temperatures between 40°
and 42°C. growth is suspended; above 42° C. artiﬁcial growths die.
Below 185° C. growth is also suspended, while if they are kept at a
moist heat of 156° C. for long they die. Colonies that were allowed to
dry completely were found to be dead when tested three years after.
Cultivations forwarded to England during the winter died on the way.
1 Annales de Z’institut Pasteur, 1893, vol. vii. p. 289.
[MEDITERRANEAN FE VER 43

On the sloping surface of 1'5 per cent peptone agar-agar, at a tem-
perature of 37 ° C., its colonies become visible to the naked eye in from
120-125 hours from the primary inoculation from the human spleen.
They appear ﬁrst as minute transparent colourless drops on the surface
of the agar, but slightly different in colour from the agar itself. In
about 36 hours more they become of a transparent amber colour, and
increasing very slowly in size, on the fourth or ﬁfth day of their appear-
ance become opaque. At this stage they most resemble split pearls
lying upon the agar surface. Under a low power and by transmitted
light such colonies appear to be orange in colour, quite round, with a
deﬁnite but granular margin. If kept on moist agar they slowly
increase in size, and, while retaining their circular shape individually,
may gradually coalesce. In the course of three months these colonies
turn to a buff or even orange colour in naked-eye appearance; and at
the same time increase in thickness by heaping up material in the centre
of the colony. Individual colonies do not attain to any great size, when
compared with other growths, ceasing to increase when little larger than a
split pea, which old colonies often resemble. No liquefaction takes
place. Though they do not increase in size after two months’ growth,
the colonies retain their vitality at a suitable temperature for over three
months. \Vhen a comparatively large amount of living material is
transferred from a primary growth on agar, with an ooze, to the surface
of a new portion of agar, a streak appears in from two to three days,
composed of innumerable small colonies. These are barely visible to
the naked eye at ﬁrst, but soon coalesce, and form a ﬂat, slightly opaque
gray streak, which does not, however, tend to spread to any extent
beyond its original boundaries. Not only does the large amount of
growth transferred mathematically increase the apparent rate of growth,
but at the same time the micro-organism seems to acquire by education
a slightly increased power of growth on artiﬁcial food. This readiness
of growth does not, however, continue to notably increase with subse-
quent cultivations.
The micrococcus will not grow on agar, the alkalinity of which is
much in excess of that of the human blood, nor would it grow on acid
agar which had not been neutralised with alkaline solution. If culti-
vated on successive media of increasing alkalinity, they can be educated
to grow on very alkaline media. In such case, however, they are longer
in appearing and grow more slowly, and in very diffuse manner on the
agar surface, with only abortive attempts at the formation of deﬁnite
colonies. Such diffuse growths, however, when transferred to agar,
having a suitable alkalinity, again revert to their original characteristic
mode of growth.
In making primary inoculations on agar, the best success is ob-
tained with new material that has not had time to dry off its moisture.
When old dry agar is used, the blood transferred from the spleen, by
drying in a small clot, occasionally interferes with the growth of the
colonies. \Vith new agar, in which there is a residue of moisture at the
44 UND ULANT, MAL TA OR

lowest point of the sloping surface, we often ﬁnd that while only a few
colonies appear on the upper and drier portion, very numerous small
colonies appear on the lower portion as the moisture dries up, from
evaporation in the incubator. The most successful method of obtaining
growths from the spleen and other tissues is to make the primary
inoculations into broth, and to make secondary ones from this to agar a
few days later.
The micrococcus grows also on gelatine and in bouillon. On the
former it grows very slowly at 22° C. without liquefaction. In the
latter it gives rise to a general and increasing opaqueness, com-
mencing on the ﬁfth or sixth day, afterwards forming a white pre-
cipitate consisting of these cocci, but without forming a surface
pellicle. On potatoes at 37° C. no apparent growth takes place
(Bruce).
Microscopically in the hanging drop they appear as very minute
cocci, measuring '33 la in dried specimens (Bruce), ovoid in shape, and in
rapid molecular (Brownian motion. Many are seen in pairs, and a
few in temporary short chains of four, the latter more especially when
they have been grown on alkaline agar. No chains are visible in cover-
glass or dried specimens. They stain very readily with all the usual
aniline dyes, but lose their colour very rapidly when treated with alcohol
or other decolorising agent. The absence of a ﬁxation agent makes the
bacteriological examination of tissue sections at present an impossibility.
Serum from the blood of patients recently attacked with this undulant
fever, or of monkeys that have been experimentally inoculated with the
micrococcus Melitensis, has been found by Prof. Wright to have an
agglomerating effect on pure cultures of the micrococcus Melitensis in a
ﬂuid medium, an effect not possessed by the serum of other persons or
uninoculated monkeys (oicle “Diagnosis,” Chap. IV.).
The slow growth, peculiar appearance of colonies on the surface of
nutrient agar, the small size that the individual colonies attain, the
minute size of the coccus, and the readiness with which the micro-
organism stains and decolorises, serves to differentiate it from others.
Having proved the constant presence of this micro-organism in the
tissues of cases of undulant fever, it next became necessary to investi-
gate its pathogenic powers on the lower animals. The following
inoculation experiments were made by Surgeon-Major Bruce in 1887 ,
which he has kindly permitted me to include here :—
Eaperiment I.—A male monkey (Bonnet species) was inoculated in
the left forearm with a pure growth obtained from the spleen of a case
after death, by means of a perfectly clean Pravaz syringe, the growth
having been grown on artiﬁcial media in a pure condition for a month
previously. The temperature of this monkey for a fortnight before
inoculation ranged between 998° F. and 100'5° F. He ate well, was
very active, and to all appearances healthy. The virus was mixed with
ten drops of sterilised water. 011 the day after inoculation the tem-
[MEDITERRANEAN FEVER 45

perature began to rise (see Chart), and reaching 106°-107° F., he died
21 days after inoculation.
On post-mortem examination the lungs showed no signs of tuber-
culosis; the liver and spleen were enormously enlarged. On opening
the intestine the mucous membrane was found to be free from ulceration.
Six tubes of agar-agar were inoculated from the spleen and two from
CHART I.


the liver, with full precautions. In all those from the spleen, and in one
from the liver, the micrococcus Melitensis was isolated, the colonies
appearing after 168 hours. In the remaining tube from the liver no
growth appeared.
Experiment IL—Another male monkey (Bonnet species) was simi-
larly inoculated. The temperature rose rapidly, and he died on the
13th day. Growths were obtained from the internal organs, making
their appearance after four days.
Bruce found that rabbits and mice gave negative results. From one
rabbit killed 23 days after inoculation, and from another after 26 days,
the characteristic growth was obtained 3 but from many others no growth
was obtained. Of nine mice inoculated but one died. The culture had
been introduced beneath the root of the tail, and he died apparently
from septicaemia, as in addition to the characteristic micrococcus other
forms of bacteria were also present. From one only of the remaining
eight mice could the micrococcus be recovered from the tissues.
In two guinea-pigs inoculated no change of symptoms appeared,
though kept for two months under observation.
Since then the writer has had the opportunity of making the follow-
ing conﬁrmatory inoculation experiments :—
Eaperiment III—A small male monkey, of the Bonnet species, was
kept under observation for two months, during which period his appetite
was good and his temperature stationary (average about 99°). He was
inoculated on 1st November 1891 by the injection of a colony of micro-
coccus Melitensis, obtained from the spleen of Case No. 2, Chapter II.,
into the muscles of the forearm. The site of the inoculation had been
46 UNDULANT, .MALTA 0R

previously shaved, cleaned with soap and water, and washed with a
solution of perchloride of mercury. The syringe and all other apparatus
had been carefully sterilised 3 while the colony had been mixed with
1 0.0. of sterilised bouillon, that had been under observation for one
month previously. The colony had
CHART 11' been visibly growing 14 days.
' 2 3 4 5 6 7 8 9 'l ‘2'3 '5 Forty-eight hours afterwards the
temperature began to rise, and
daily increasing with a remitting
curve, reached 1060 F. on the 15th
day. For the ﬁrst 10 days the
monkey was lively and continued
to eat his food, but after that he
lay about and refused almost all
food. He was killed 362 hours
after inoculation. No change


took place at the seat of inoculation.
A post-mortem examination was made ﬁve minutes after death. The
body was fairly well nourished, and the heart apparently normal. The
lungs contained sero-purulent exudation in the bronchial tubes, but were
otherwise normal. No tuberculosis, etc. The liver was congested, and
the spleen was also congested, and very large in proportion to the total
body-weight. The intestines were slightly congested at the ileo-ceecal
valve, but Peyer’s patches were unaffected, and no other pathological
condition was noticeable.
Seven tubes of agar-agar were inoculated from the spleen in the
usual manner. Two tubes were inoculated from the cardiac blood in
the following manner :—
The pericardium was aseptically opened, and the large vessels
ligatured with sterilised gut and divided above the ligature, the heart
being removed entire together with its contained blood. A sterilised
hollow needle ﬁxed in a glass tube, guarded above by a sterilised cotton-
wool pad, was thrust into the cavity of the ventricle, and the contained
blood drawn into the tube by means of an attached syringe. The ﬁrst
and last drops were discarded and the remainder was at once passed
into tubes of agar-agar.
All these tubes were at once placed in the incubator at a tempera-
ture of 37° C., and resulted as follows :—
Cf seven splenic cultures: ﬁve showed numerous colonies of mic.
Melitensis 168 hours after inoculation 3 two showed contamination with
mic. albicans.
Of two from the cardiac blood: one showed numerous colonies of
mic. Melitensis 168 hours from inoculation 3 one contained no growth
of any kind.
These growths were identical with those obtained from human
spleen, macroscopically and microscopically, and specimens forwarded
to Bruce at Netley were identiﬁed by him. The growths were cultivated
MEDITERRANEAN FE VER 47

also in bouillon, and were carried through six generations of pure
cultures on agar-agar, without change.
Experiment IV.—A small male African monkey was inoculated in
the muscles of the left forearm, with the same precautions as were
taken in the preceding experiment. The virus was taken from a
growth obtained from the intra-cardiac blood of the monkey in
Experiment III. The following day the temperature began to rise, and
for eleven weeks he suffered from pyrexia of a distinctly remittent
type (see Chart). He lost weight considerably, and at rare intervals
CHART III.
I234-56789 IIIQI3|4|6|GI7I8|9

suffered from diarrhoea, but as a rule was rather constipated. No
change took place at the seat of inoculation. The monkey completely
recovered, and lived for a year in good health, when he died of acute
poisoning from something he had eaten. The temperature was taken
carefully three times a day in the axilla by the same two people from
ﬁrst to last.
Experiment V.——A female African monkey (Bonnet species), under
observation and in good health for three months previously, was
similarly inoculated in the muscles of the right thigh, with virus from
a growth obtained from the spleen of the monkey in Experiment III.
This, like the preceding growths used for inoculation purposes, was
kept for a suﬁiciently long time in the incubator to ensure its purity.
The monkey suffered from pyrexia, consisting of intermittent waves of
remittent character, for over 94 days. She ultimately completely
recovered, and lived in good health for three years until killed by a
dog. No local symptoms appeared at the seat of inoculation. She
48 UNDULANT, [MALTA 01?

lost weight and seemed to suffer from pain or rheumatism of the
extremities at irregular intervals. The waves of temperature and the
long duration of the pyrexia remind one forcibly of undulant fever
occurring in man.
CHART IV.

These monkeys were more or less tamed before they were bought,
but needed a great deal of patience, and a considerable expenditure of
thermometers at ﬁrst, in order to obtain correct temperature records.
After a time, however, they became so accustomed to having their
temperature taken, that there came to be quite a competition for the
accompanying petting and grape or other bribe. Their normal
temperatures before inoculation were as nearly as possible 99° F.
Experiment VL—A very savage and impatient monkey was also
inoculated with virus obtained from the spleen of BM. Case No. 3,
and his temperature was taken at irregular intervals. It was elevated,
while no local changes occurred at the seat of inoculation. He
ultimately recovered, but little more can be said about the case.
Conﬁrmatory experiments of a similar character have been carried
out at Netley, with cultures obtained by the writer, in/Malta, from
human spleen after death, with conclusive results.
Summary—Thus by direct experiment we have been able to produce
in monkeys (though not so far in other animals), by inoculation with
pure cultures of the micrococcus Melitensis vel Brucii, obtained from
men suffering from undulant fever, a pyrexial condition analogous to
that of undulant fever in man. We have, moreover, isolated pure
cultures of this micrococcus from the tissues of monkeys (Bonnet
[MEDITERRANEAN FE VER 49

species) so affected, which when inoculated into other similar monkeys
have again produced a similar febrile condition.
As the micrococcus in question is morphologically distinct from
other known pathogenic micro-organisms, and has completely fulﬁlled
the postulates laid down by Professor Koch, we have strong evidence
in favour of it being the proximate cause of undulant fever in man 3
moreover, it reacts to the serum test with blood obtained from those
suffering from that fever.
The writer regrets that, owing to lack of spare time and money, he
has been unable to carry these investigations further, but hopes that
others will carry on the work, so that the question may be placed upon
the ﬁrm and certain basis that more conﬁrmatory inoculation experi-
ments can only supply.
It is next necessary to endeavour to ascertain the manner in which
this micro-organism enters the human body, and the circumstances which
exert a direct or indirect inﬂuence on its life history.
Predisposing causes—These are many and various 3 as is the case
with other diseases, and especially with fevers, they are usually given
the credit of being the actual cause.
As may be expected “chill” has had to bear the responsibility of
most attacks in the past. This term is a convenient one, as it usually
raises no outside responsibility beyond the carelessness of the patient
himself. Most patients can remember a “ chill” to which they attribute
the disease, and the busy practitioner is bothered no more. The “chill”
referred to is usually the effect of the fever, after the infection has
taken place, and has probably less connection with exposure to actual
cold, than many unremembered ones previous to the insidious onset of
the fever. In these days it is unnecessary to discuss this subject,
suffice it to say that the fever is most prevalent during the period of
hot and equable temperature, and least prevalent when the weather is
most cold, wet, and unequable. As a predisposing cause, to those
exposed to the infection of this fever, chill may by its depressing effect
upon the system aid the virus in its onslaught.
The same may be said of “exposure to sun,” which the writer has
often been given as a cause of this and even of enteric fever! He
especially remembers a case of fatal enteric fever with extensive
ulceration, attributed by a local doctor to playing polo in the sun, a
few days before admission, in apparently the second week of the attack !
The depressing effects of the climate, the sirocco winds and heat of the
Mediterranean summer, may also be predisposing causes, without our
being justiﬁed or satisﬁed in attributing this fever to climatic causes
over which we mortals have no control. As our knowledge of disease
causes increases we hear less and less of climatic diseases.
Unsuitable food, overwork, bodily fatigue, overcrowding, want of
ventilation, damp rooms, and other unhygienic causes, all have their
E
50 UND ULANT, MAL TA 0]?

bearing on the case in aiding and abetting the poison where it is
present. Again, in the subject attacked we may ﬁnd such predisposing
causes as tend towards an increased susceptibility, such as youth, extra-
Mediterranean birth and origin, special idiosyncrasy, etc. Many others
might be mentioned, but they are all matters bearing on the question
of prophylaxis, which will be dealt with later.
The great point necessary, if we are to cope with the ravages of this
fever successfully, is to remember that the essential factor which
occasions its occurrence is the presence of a speciﬁc virus (requiring for
its existence a certain degree of atmospheric temperature, etc.) within a
measurable distance of a susceptible human being.
Mode of propagation and dissemination—That the disease is not
propagated by direct contagion from man to man is a fact that is
agreed to by all observers (Marston, Bruce, Tomaselli, etc.) Patients
suffering from other diseases, occupying beds next to cases of undulant
fever, do not develop this fever, nor do the military sick attendants in
fever wards suffer from this fever more than those working in other
wards, or so much as the soldiers in many of the barracks in Malta,
who have not entered the hospital previous to the onset of their attacks.
When members of a family are attacked one after another it is due to
the presence of a common infective cause, and not to contagion. It is
difﬁcult to say, in the present limited state of our knowledge, what is
the exact mode by which the virus enters the human body, but by
collecting all the pros and cons of circumstantial evidence at our
disposal it will be possible to build up a theory which time alone can
prove or disprove.
On the various theories which attribute its occurrence to chills,
climate, exposure to sun, intemperance, etc., we need not waste our time,
but refer readers back to the section on predisposing causes in which
place these inﬂuences have been dealt with.
There does not appear to be any evidence in favour of entrance
being by inoculation through the broken skin, as has been performed
artiﬁcially in the case of monkeys. There is no connection, as is the
case in tetanus, between attacks of this fever and accidents associated
with broken skin. Those who suffer most from mosquito bites during
their ﬁrst summer in Malta are by no means specially subject to this
fever, nor do patients or sick attendants bitten by these insects in the
fever wards of the hospital develop this fever as a result; mosquitoes
are said also to bite but once (Manson).
By a process of exclusion we have therefore to look to the sub-
stances which enter the body by way of the alimentary canal or air
passages drink, food, and air, and such accidental substances as
they may contain) for the cause of this fever.
As regards drink, the soldiers in Malta are supplied with aqueduct
water for drinking and cooking purposes, with mineral waters made
from aqueduct water, and with milk obtained nominally under adequate
supervision. They have also access in some cases to an inferior class of
[MEDITERRANEAN FEVER 51

water used only for ﬂushing and washing purposes, and in a very few
instances to well water; but not only are they warned not to drink
such water by notices on the taps or wells, but there are taps of good
water at most of such places to prevent their using inferior water
through laziness. Besides these they drink good English beer, tea, etc.
and in many cases various wines and inferior drinks in the local grog
shops. Though the distribution of enteric fever in Malta follows the
distribution of water-supplies found accidentally polluted, this is not
the case with undulant fever. Valetta Barracks have been almost
entirely free from enteric fever, other than imported cases, during the
past ﬁve years, and the same may be said for barracks situated in
Floriana; but these barracks have been far from free from undulant
fever. The immunity from enteric fever is due to the excellence of the
drinking water, which comes through iron pipes from large covered
settling tanks in the country, supplied from underground springs in the
hills. These barracks have no wells, but have separate inferior aque-
duct water-supply for washing and ﬂushing purposes. Were this latter
the cause of the fever, in spite of the absence of enteric fever, we should
expect the inhabitants of private houses in the same area supplied only
with the good water to be immune from undulant fever; but this is
very far from being the case. Again, when a very large portion of
another water-supply became polluted and enteric fever became general
over that water-supply area, undulant fever remained localised, among
the soldiers, to the same blocks of buildings and in the same quantity
as before and after the pollution occurred. Again, epidemics of undulant
fever occurring in any particular barracks have not been attended by
an increased prevalence of the disease in other barracks on the same
water-supply area.
The fact that well water in many of the Maltese houses, where cases
of “remittent fever” occur, has been found polluted, has led some of
the Maltese to the belief that polluted well water is the cause of the
disease. There is a fallacy, however, in this theory, in that most cases
of enteric fever which occur among Maltese are returned as “remittent
fever,” and an enormous part of the English garrison, and even of the
Maltese, who suffer severely from this fever have no access to well
water of any kind. Even, therefore, if such water causes certain cases,
they are but a very small portion of those met with in Malta, and it is
far from being the common cause. In Gibraltar, where the main supply
is collected rain water from tanks, this fever is less prevalent than in
Malta. Though it has been noticed in Malta that soldiers who are
teetotalers (i.e. water drinkers) are especially liable to attacks of enteric
fever, this is not the case with undulant fever. Also, the writer has
found undulant fever occurring amongst families who drank nothing
but the best aqueduct water which had been previously well boiled.
Again, at one period when all drinking water was ordered to be
boiled on account of the prevalence of enteric fever at the time, though
the effect of this proceeding on the prevalence of enteric fever was most
52 UNDULANT, [MALTA OR

noticeable, it did not appear to decrease the prevalence of undulant
fever, even at an early date, when fear of infection led to the order being
properly carried out.
Lastly, the localisation of attacks to individual barracks and build-
ings, and more particularly to individual rooms in those barracks or
buildings, irrespective of the water-supply of these places, and the
total want of connection between the prevalence of fever and the dis-
tribution of the various water-supplies general and local, is strongly
against a water-borne cause in this disease.
The question of milk-supply is intimately connected with that of
water, most infections carried by milk being communicated by means of
contaminated water fraudulently or purposely added, or used for clean-
ing vessels, etc. Besides this the writer has known undulant fever
attack families who used only Swiss condensed milk, regiments in
which no other milk was allowed in barracks, and families whose milk-
supply was always milked from goats on their own premises, into their
own vessels, under reliable supervision. He has met with no fact that
would favour a causal connection between milk-supply and this fever.
In instances where milk contamination has undoubtedly caused localised
outbreaks of enteric fever, undulant fever has not shown increased pre-
valence in the same area.
The question of mineral waters also depends upon the water—supply,
and no causal connection has ever appeared, though the supplies are
numerous enough to have made a distinct difference in prevalence among
the different consumers, had there been any connection. Undulant
fever also has attacked regiments which have made their own mineral
waters under supervision, using only aqueduct water that has been
previously boiled. The author has had the opportunity of visiting all
the mineral water factories supplying the troops, and has ascertained
their condition, and the fact that all had during his experience aque-
duct water laid directly into their machines, there being no other supply
of water on the premises available for use.
The local grog shop, evil and undesirable though it be, has been
made responsible for nearly all the diseases that soldiers are subject to,
as it is the easiest means of transferring sanitary responsibility from
military to other shoulders. Though a very large number of those
situated outside Valetta are still without a sound water-supply laid on
to the premises, this is not the case with those in Valetta, and even at
its worst, if this were a cause, it only brings us back to the same ques-
tion of water-supply which we have already discussed. That actual
alcoholic drinks, even of the most inferior kind, can cause fever other
than from added pollutions, is a theory more worthy of discussion by
rabid teetotalers than by scientiﬁc investigators. Moreover, a large
number of ofﬁcers, ladies, women, children, and even soldiers are
attacked who have never entered a grog shop, so that any cause derived
from these places can scarcely be of a peculiar nature, but common to
other more respectable places.
MEDITERRANEAN FE VER 53

On the whole there seems little reason to connect the cause of this
fever with articles of drink, and, as the writer will show later, there is
much to connect the cause with other factors.
That the disease is not usually propagated by food is fairly certain,
as the soldiers’ food is a well-known and deﬁnite quantity, bought and
prepared under close supervision. It is most exceptional for soldiers to
eat out of barracks, or to indulge in green uncooked vegetables, or other
food liable to contamination.
Lastly, ice is but a form of water-supply, nor has its use in hospital
or by the large numbers of individuals who use it habitually in their
drinks during that hot period of the year when this fever is especially
prevalent, appeared to be attended by fever prevalence.
By a process of exclusion we are brought to the discussion of polluted
air as a cause of this fever. The writer has certain evidence to put
forward in favour of such a cause, but as somewhat similar opinions
have already been stated by others, it will be advisable ﬁrst of all to
brieﬂy refer to their remarks. Unfortunately they have in most cases
published their opinions only, without recording the facts or reasons
which led to their conclusions.
Leaving out of the question the remarks of writers during what
might be called the prehistoric age of this fever, we ﬁnd the following
remarks in the literature of the past thirty-ﬁve years :—
Marston in 1861 says: “I fancy that we may perceive the opera-
tion of two agencies : (1) The effects, whatever they may be, induced by
residence in a hot, moist climate; (2) Certain localised conditions con-
nected with drainage and dampness.
“ If I were asked to indicate the cause of this disease, I would
suggest the defective house-drainage.”
Boileau in 1865 attributes four of his cases to fsecal emanations,
giving no cause for the other cases.
Chartres in 1866 says : “The causes most active in the production
of this fever were, I consider, the following, viz.: (1) Special peculiar-
ities of locality; (2) Sanitary defects of barracks, more especially those
of bad drainage and insufﬁcient ventilation; (3) The effects of climate
and a long residence in the Mediterranean; (4) Intemperance.”
Donaldson in 187 6 says: “I look upon enteric, fzeco-malarial undulant) fever and febrile dyspepsia (febricula) as but different ex-
pressions of a similar cause, viz., the breathing of an air or the drinking
of a water polluted by sewage or its emanations, the former being due
to the introduction of the poison through the drinking water, and the
two latter to its entrance through the air.” \Vith regard to the latter,
he gives his opinion on Verdala Barracks and the connection between
undulant fever cases and sewer-gas emanations.
Oswald \Vood in 187 6 says: “I state my belief that one of the
chief causes, if not the sole cause of Malta fever, is the unsanitary con-
dition of the island.”
The italics are his own.
54 UN!) ULANT, MAL TA 01?
Prof. Notter, writing in 1876, says: “The drainage is extremely
bad, the sewers are nothing but long cesspools, and from the porous
nature of the stone the ground is in many places reeking with ﬁlth, and
the ground saturated like a sponge with sewage ﬁlth, the rock dis-
integrated and foul to a degree. During my service in 1872, one of the
worst outbreaks of this disease took place in Fort Ricasoli, where the
system of drainage was known to be imperfect, and the smell pervading
the place was at times sickening. This arose from the system adopted
of hand-ﬂushing of the water-closets, which was not properly carried out,
the result being accumulation of soil in the sewer. . . . To sum up,
this disease may be stated to be essentially a ﬁlth disease, intensiﬁed
by the climate and moisture present in the air. . . . The cause
essentially consists in defective drainage, in having to sleep in houses
and breathe air impregnated with foetid organic vapours given off
from saturated subsoil or ﬁlthy water- closets, aided by climatic
conditions.”
The late Prof. de Chaumont (1884) regarded this disease as a blood
poisoning due to defective sewerage and saturation of the soil with faecal
matter.
In Italy opinions are divided, except that those who discredit its
faecal origin give no other explanation of its cause.
Fazio, Capozzi, and Rummo have noticed in Naples that the disease
developed itself more when the cleaning of cesspools was abandoned and
the sewage drains were put in communication with the rain-water drains
and the sinks. They also noticed its prevalence in the vicinity of latrines,
and particularly where there was stagnation in the ﬂow of sewage.
Borelli and Dominicis also admit its faecal origin in Naples, while De
Renzi denies it. Galassi of Rome, Cardile and Guiffré of Palermo
more or less deny it also.
Thus Fazio, in 187 9, says: “Concludendo ripeto che la cosi detta
febbre napolitana costituisca una entita nosologica distinta e che non
debbe confondersi con le ordinarie infezioni. Ch’ essa trae movenza dal
meﬁtismo delle fogne, e che, come nel caso da me riferito, puo contenere
elementi speciﬁci sia della malaria, sia del tifo; e come si e svolta appo
noi similmente potra manifestarsi anche in altri paesi, i quali si trovino in
condizioni identiche.” 1
Tomaselli, in Catania, in the ﬁrst edition of his monograph, con-
sidered that its cause and occurrence had some connection with local
sanitary conditions, but in his later editions he seems less certain.
Guiffré bases part of his argument against a faecal origin on the fact
that it occurs in places very healthy in all respects. From what the
author has seen in one of the places mentioned, he can only say that
whereas the hotels were clean and well drained, the houses of the lower
classes were in anything but a sanitary condition.
Schriin and A. de Martini look upon it as a typho-malarial fever,
Cantani as an atypical form of enteric fever.
1 Vide Fazio, 1879 and 1893.
[MEDITERRANEAN FE VER 5 5

Duncan in 1888 writes : “ I cannot help thinking that some form of
faecal poisoning is at the bottom of it. It is less common in Gibraltar
than in Malta, for Gibraltar is better drained and on harder rock. Now,
in both Malta and Gibraltar, but especially in Malta, there is danger of
fwcal contamination of air and water, and Malta must be saturated with
feecal detritus. To me it seems that the constant breathing of a faecally-
polluted atmosphere—that is to say, in which the faecal element exists
widely diffused, and is so little concentrated as not to be perceptible by
the senses—would result in such an affection.”
Bruce, in 1889, says : “There is no mention anywhere of water
contaminated by sewage being the vehicle.”
Surgeon Moffet, at Gibraltar (A .M.D. Rep. 1889), says : “ The
disease is intimately related to enteric fever as regards etiology at least,
which is apparent from the following facts :—-Both diseases exist side by
side, occurring as localised epidemics together or alternately with each
other. Cases of both are furnished by the same barracks, often from the
same rooms, the number of cases of one kind of fever bearing a marked
proportion to those of the other, and while certain barracks in one year
furnish a large number of cases of both diseases, the following year
those remain tolerably healthy, whilst others, which during the previous
year had been healthy, now become the foci of violent epidemics.”
In 1886 the south wing of the Town Range Barracks, occupied by a
company of the Royal Engineers, furnished forty-one cases of fever,
twenty-one of which were returned as simple continued, the remainder,
more severe in type, as enteric fever. All cases presented many
symptoms in common, and it is probable that the number returned as
enteric fever was over-estimated. Those who had an opportunity of
watching the epidemic in all its details had no difficulty in assigning all
the cases to a common origin. The following account of the sanitary
defects in connection with this epidemic is taken from the report of the
medical ofﬁcer in charge of the station hospital :—“ When the back yard,
which was covered with asphalt, was opened up, a nine-inch earthenware
sewer pipe leaked at every joint, saturating the soil with sewage, which
also passed into a catch-pit, and thence into the tank containing rain
water, which was used by the men. The drain from the men’s ablution
room also leaked, and allowed the escape of its contents into the drink-
ing-water tank. The sewer gas which escaped found an exit up the
rain-water pipe which opened just below the window of a room, from
which the fatal case of enteric fever (2 so returned) was admitted into
hospital.” The water of this tank was found to be polluted in an ex-
treme degree, and condemned as quite unﬁt for use. The only fatal case
was that of a man well known to be of intemperate habits, and who,
according to his own account, never drank water, but he slept in a small
room upstairs, the window of which opened immediately above the rain-
water pipe, which had not been disconnected from the catch-pit of
the tank, and which therefore acted as an escape pipe for the
sewer gas generated in the catch-pit below. “This man’s disease, at ﬁrst
56 UND ULANT, [HAL TA 0R

returned as simple continued, was, as the symptoms became more
serious, changed to enteric fever, but the postmortem lesions did not
bear out the latter diagnosis.” He states that this was the only epidemic
in which there was any suspicion of the disease having been conveyed
by drinking water, while the bulk of evidence in this as well as in other
epidemics strongly points to aerial contamination as the chief factor in
the transmission of the disease poison. He adds that the defects were
remedied, the tank cleaned out, and every precaution taken to prevent
a recurrence of the disease. The following year this barrack furnished
only ﬁfteen cases of fever, two of which were severe, and returned as
enteric.
He says “of its (i.e. undulant fever’s) relation to certain localised
sanitary defects there can be no doubt. In every barrack whence cases
are furnished there existed grave defects, the remedying of which was
invariably followed by a diminution or cessation of the disease.”
\Ve have therefore a number of opinions of men who have studied
this fever, all more or less believing that the fever is due to an
aerial faecal poison. The writer has endeavoured during his service in
Malta to follow up the cases which have occurred in the barracks under
his sanitary care, and to group them with reference to locality and
possible causation. With the exception of certain sporadic cases, they
have all come from the same rooms, and have occupied beds in the same
parts of those rooms in the barracks in question. At the same time
certain other rooms have yielded no cases year after year. The rooms
which have yielded cases have had one or more of three factors not
common to the healthier ones. These have been: (a) Some insanitary
condition connected either directly with drainage or with ﬂooring of an
absorbent nature which has had probabilities of contamination with
human excrement (urine or faeces). (b) Dampness, especially of a vary-
ing nature. (0) Suitable climatic and topographical surroundings.
Even in the sporadic cases above excepted, items ((9) and (e) have
been present, while in rooms (with soft stone ﬂooring) which were
formerly used by the Knights and since used as barracks, the ﬁrst item is
not improbable, especially when one sees the ﬁlth which is to be found
beneath the stone ﬂags of such rooms on the ground ﬂoors of the build-
ings, and remembers the ambulatory nature of so many cases.
Where the disease has been epidemic these causes have been
most pronounced. Moreover, the rectiﬁcation of the insanitation has
been invariably followed by a cessation of fever prevalence more or
less complete according to the thoroughness or otherwise of the work
done. Other factors seem to favour the dissemination of the poison,
notably drying of the infected surface following the pollution, the
presence of air currents, deﬁcient ventilation, overcrowding, and the
close proximity of the susceptible human subject. The ﬂooding of the
ﬂoors with sewage, a choked house-drain which has burst, an overﬂowing
cesspit, an escape of sewer gas from an adjacent drain ventilator, a
direct communication between sleeping-rooms and drains by means of
[MEDITERRANEAN FEVER 57

untrapped sinks or cupboard latrines seem common causes of this
fever.
Of numerous cases where such conditions seemed to be probable
causes, the following are of a more certain character :—
EXAMPLES OF UNDULANT FEVER OUTBREAKS ASSOCIATED
WITH INSANITATION
1. A row of houses was hired by Government for the use of married
soldiers in Malta. These houses had cesspits, situated, as a very large
number are in that country, under the rooms. The former Maltese
occupants had allowed but little water to pass into the cesspits, in order
to save frequent emptying. The English soldiers, used to a water
drainage system, very soon ﬁlled these cesspits and caused them to
overﬂow, soaking the flooring of the rooms with faecal matter, etc.
This was followed by an outbreak of undulant fever affecting every
family exposed to this insanitation, and the houses had to be evacuated.
The cesspits were removed and the ﬂoors cemented with marked result.
2. During the years 1892-3 only three cases of fever were admitted
from an airy, well-built barrack in Valetta, holding 80 men. These
three cases were admitted on 18th November 1892, 27th December
1892, and 5th January 1893 respectively. All three died, and post
mortem and bacteriological examinations were made, with the result
that two proved to be suffering from undulant fever and the other
from enteric fever (see Cases 7 and 8). The only apparent cause
was that during November and December the barrack drain from the
latrines, running through the yard to join the main drain in the street
outside, had become choked and broken, and was discharging its sewage
into the porous rock channel in which it ran, in an enclosed space under
the windows of the canteen and close to the barrack-room door. The
stench from this break and during its repair was very bad. The work
was completed shortly after the admission of the last case, and no other
case has occurred since. The milk and water supplies were excellent,
and these men did not bathe in an insanitary place. These 80 men
belonged to the same regiments that, while occupying other barracks
close by, were by no means free from cases of this fever, though using
similar milk and water supplies.
3. In a large building in Valetta, three bedrooms occupied by
officers, and three only, had a reputation for producing undulant fever
cases, which was put down to their insufficient ventilation. Further
investigation in 1895 discovered a most insanitary water-closet in the
dark and enclosed passage from which these bedrooms opened. On
account of its faulty construction it had been locked up, and in its
unused state it acted as a ventilator for sewer gas, which it discharged
into the passage. This was rectiﬁed, and since -then no further cases
have occurred.
4. For three years, while stationed in Valetta, a staff ofﬁcer resided
58 UNDULANT, MALTA OR

in a large official residence in one of the best parts of the town. The
inmates (all English) consisted of four males, three adult and four young
females. Two of the girls only were attacked with undulant fever in
1892, and both suffered from typical and severe attacks, the elder from
100, and the younger from 80 days’ pyrexia, and both were a consider-
able time longer before convalescence became fully established. The
elder had suffered from a severe attack of enteric fever in Brussels two
years previously, complicated by a relapse. Both girls occupied the
turret room, and were the only occupants of that room. On investiga-
tion it was found that the windows of this room were on a level with a
neighbouring main drain ventilator, and that the smell from this not
only entered the room in question, but affected the houses on the
opposite side of the road, a much greater distance away. The house-
drain ventilator also opened on to the roof of this room, and was very
offensive at the time. Inquiry elicited the information that former
occupants of the house, who had used this room as a bedroom, had
suffered from the fever. The room was shut up, and no case has
occurred since among the remaining occupants of a susceptible age,
though four years have elapsed.
5. A certain house, hired as a Government quarter, had the follow-
ing history :—First an ofﬁcer, who occupied it, lost his wife and was
himself invalided home on account of undulant fever. The next ofﬁcer
had both his children attacked—one died, while the other suffered
severely from the fever and had to be taken to England. The next
three ofﬁcers were invalided home with the fever, though two of them
had resided in the island in other houses for three years previously,
during which time they had enjoyed good health.
Another medical ofﬁcer moved in, when he found that his wife and
children were suffering from frequent sore throats and slight febrile
attacks, and had the drains examined. It was then found that, instead
of the supposed modern connection with the main drainage system, the
sewage of the house had for a long time been passing through house-
drains made of porous stone. There was considerable faecal extravasa-
tion under the ﬂooring of the lower rooms. The house was evacuated
for repairs, and has not yet been reoccupied.
6. In a new and well-constructed ﬂat in Valetta the ﬁrst occupant
was invalided home with this fever. The next also suffered from the
same fever, together with his wife and child; the child died and the
man and wife were invalided home. The next occupant was a man,
with a wife and sister. The sister suffered severely and the wife
slightly from this fever. An inspection of the quarter disclosed a leak-
ing pan-latrine on the verandah off the bedroom, and a leaking drain
ventilator running in a circular turret staircase, communicating with
the same room. The smell from both, neither of which was ten feet
distant from the bed, entered the room and was most offensive. People
of the same rank in life, occupying other portions of the block, were
unaffected. The water-supply was excellent and common to the whole
MEDITERRANEAN FE VER 59

of Valetta; the milk was obtained from goats milked at the door. The
latrine was rectiﬁed, and the ventilator placed outside the building,
with excellent results.
7. A regiment was quartered on a small island in one of the har-
bours of Valetta, from 2nd January 1892 until 10th October of the
same year. During this period it suffered severely from “simple con-
tinued fever,” 197 cases being admitted from a total strength of 760
men. The regiment had suffered severely from this fever elsewhere
during its ﬁrst year of service in Malta, had been seasoned by three
years’ residence, and was composed of men whose ages were not below
the average of the station, yet their fever rate for 1892 far exceeded
that of any other regiment. Of these men, 480 were quartered in
wooden huts, and the remaining 280 in an old fort close by, which had
been built by the Knights in 17 7 5. A careful analysis of the fever
admissions divides them into two classes—
(a) Cases of true Mediterranean or undulant fever.
(b) Relapses or slight cases of the same fever cases of simple
ardent fever (febricula), and other obscure but slight febrile ailments
without localised symptoms.
The latter class were in hospital but a short time, and there is little
to note, except that the numbers were greater than from any other
barracks in the island, and that in proportion to strength the admis-
sions from the fort were double those from the huts.
The admission-rate per mille for true undulant fever in Valetta dis-
trict (strength 3511, including the island in question) in 1892 was
522, while those of the huts and fort in question were 468 and 17 8'6
respectively, showing that some special local cause of fever must exist
within the fort. The men in the fort and huts, belonging to the same
regiment, were of the same age and class, and under identical conditions
as regards food, milk, and water supplies, the latter being common to a
very large area of unaffected population, civil and military. In the fort
38 men, 2 women, and 5 children were affected ; and of the men 1 died
(see Case No. 11), 6 were invalided, of whom I was ﬁnally discharged
from the service, 14 were sent to the sanitarium, and 17 returned to
duty straight from hospital, but were in many cases readmitted with
relapses after leaving Valetta district in October. The average stay in
hospital was 109 days each for the men. The majority of the rooms in
question were dark, close, and damp, and were never intended for bar-
rack-rooms. Round the back of the rooms ran large channels, cut in
the extremely porous rock, and passing on each side of the fort down to
the sea. From 1870 these channels were used as sewers, until the sub-
stitution in 1885 of the present dry-earth system. Undulant fever
occurred in the fort as an epidemic in 1870 and 187 2, and though
sporadic was not excessive from 1885 to 1891. During the latter
period a quantity of sewage remained boxed up, with the result that
the stone became soaked with sewage even through the walls and ﬂoor-
ing to the adjacent rooms. Analysis of portions of the walls of the
60 UNDULANT, [MALTA 0R

channels and rooms showed not only a larger percentage of chemical
constituents of sewage, much organic matter, and a very large number
of putrid and non-pathogenic organisms when compared with similar
but unpolluted stone. Again, though unpolluted stone was highly
alkaline, the stone of these walls was neutral or faintly alkaline, form-
ing therefore a suitable nidus theoretically for the micrococcus of this
fever. Between September and December 1891 a thorough overhauling
of the drains took place, these channels being cleared and converted
into surface-water drains, gratings being placed at intervals almost on
a level with, adjacent to or even opposite the windows of the barrack-
rooms. Owing to their situation and construction there was a varying
yet constant current of air from the sea, travelling up these channels
and passing out of the gratings into the fort, the porous walls at the
same time being wet or dry according to the state of the atmosphere
and the amount of rain. There was ample opportunity for miasmata
to pass from the rock channels into the barrack-rooms, and it is a sig-
niﬁcant fact that these 45 cases slept in beds grouped in close and
definite relation to the rock-channels and sewage-soaked walls, and in
direct proportion to the amount of varying dampness present. The
ﬁrst case was admitted four days after the cessation of the heavy rain.
There was no other apparent cause for the outbreak, and obvious
sanitary measures have resulted in a cessation of this fever prevalence.
8. In a large modern and well-built hospital, built on one of the
best sites in Malta, a number of cases of this fever (20-40) have for
many years past been constantly treated in wards on the top ﬂoor,
without the disease spreading to others in the same wards. The
hospital had always been considered a very healthy one until recently,
when a few cases of this fever began to occur among venereal patients
on the middle ﬂoor, and the patients and sick attendants occupying the
ground ﬂoor suffered severely and even fatally from this fever. In the
kitchen behind the hospital two cooks died of its effects, and patients
suffering from slight ailments such as sprains, etc., and who occupied
tents immediately behind the building, also developed the fever. Many
of the sufferers had been in hospital over a month, while others had
resided in the building for many months previously. The water-supply
was good and common to a large district, the milk-supply was above
suspicion. On investigation it was found that the hospital drain-pipe,
which ran along the back of the hospital, between the main building
and the ground occupied by the kitchen and tents, had been blocked
for some time, beyond the main building, and that the faecal sewage,
from the fever and other wards, had forced the joints of the pipe, and
leaked in all directions under the hospital foundations and through the
ground on which the kitchen and tents were situated.
At the same time, in three officers’ quarters in the same grounds, but
well detached and for many years considered to be among the healthiest
in Malta, six cases of this fever occurred in one year. In this case the
main and house drains were found blocked, and the backﬂow of sewage
[MEDITERRANEAN FE VER 61

caused offensive odours of sewer gas to enter the back rooms from
adjacent drain ventilators.
A similar condition existed at the other end of the same drain, in
some adjacent barracks, with the result that of two occupants of a
married quarter there, one died and the other suffered from a severe
and prolonged attack of this fever. Many other cases were also ad-
mitted from the rooms near.
Though the details are not exactly laid down in this last instance,
the writer has preferred it to many other smaller instances with exact
details, on account of the large number of cases occurring in an English-
built hospital, which had for a number of years been healthy.
9. In some married quarters in Valetta cases of true Mediterranean
fever occurred from time to time 3 on investigation it was found that
there was a large tunnel, built during the last century, running up
under these quarters. Down the centre of this ran a leaking drain,
which had sinks and ablution rooms from these quarters running
straight into it. No one seemed to be aware of its existence, and
certainly it had not been opened for twelve years. On opening, six
cartloads of escaped house sewage were found. It was cleaned out,
ventilated, redrained, and cut off, and no cases occurred during the
following twelve months.
10. In the same barracks the schoolmaster suffered from a long
attack of this fever. His room was over a drain-pipe that smelt whenever
anything passed down it from the quarter above. The sink-pipe also
passed straight into the drain without any intervening trap. This was
remedied and the quarter became a healthy one.
11. In the same barracks cases had come continually from a certain
end room. On investigation it was found to communicate by means of
a wooden door (erroneously supposed to be nailed up) with a closed
space under the staircase in which the ablution-room drain had burst.
This drain was the upper end of the main latrine drain.
12. In a block containing officers’ quarters, only the occupants of
two rooms were attacked with this fever during the period 1892-95.
In one room a drain-pipe passing down the wall had burst, at the
time four cases occurred. In the other room nothing appeared wrong,
though the only two officers occupying it were attacked; one died and
the other was invalided home. It was, however, the only room which
received all its air from the inner court, the surface drains of which
were untrapped, and led straight into the main drain. These were
trapped and no other case has occurred since.
13. Among the sick attendants in the Valetta Military Hospital,
the annual daily sick-rate in proportion to strength had in 1890 been
1833 in 1891, 0933 in 1892,1'073 in 1893, 1'37; in 1894,1'523 or
an average of 135 per cent.
In 1895 this rate rose to 4'48. The excessive sickness was due to
an outbreak of S. C. fever, a disease which had but little affected these
men previously, indeed they were considerably less often attacked than
62 UND ULA N T, 111A L TA OR

the soldiers in barracks, in spite of the fact that they were continuously
nursing cases of this class of fever in the wards. \Vith the exception
of two slight cases of eleven and eight days’ pyrexia, these cases were
all cases of true undulant fever. This fever attacked a staff sergeant
and his family (of whom more), and thirteen of the rank and ﬁle, but
did not affect any others above the rank of corporal. The proportion
of those attacked with undulant fever to strength (54) was over 25 per
cent, an enormous rate when compared with that of the whole of Valetta
district, which in spite of this being an unusually severe year, with an
epidemic in a regiment in Floriana, only amounted to 7'3 per cent of
strength (3522). The average stay in hospital of the rank and ﬁle, not
counting the time spent in England by one invalid, was eighty days;
two were invalided (of whom one died), seven were sent to the sani-
tarium at Citta Vecchia, only four returned straight to duty. The
disease attacked those who slept in a certain room when on night duty,
and its onset was contemporaneous with the opening of this room,
which for many years before had been used as a drug store. \Vith the
exception of the staff sergeant it did not attack those who did not sleep
in this room. There were 110 causes for fever present, other than this
room, that had not been present in other years, nor that were not
common to the other attendants above the rank of corporal, or
indeed to all the patients in hospital, some 200 in number.
The room in question was very small, and the occupants slept on the
ﬂoor or on bedsteads raised 2 feet above the floor, and was found to be
damp from water which soaked through the wall and ﬂoor from an
adjacent road at a higher level (2 feet)—at a place, too, where urine and
house 'slops had been thrown. In the centre of the ﬂoor of the room
was a circle of stone, closing an old porous drain, the remains of which,
cut off at the outer wall, was found running through the damp portion
under the ﬂat porous stones which formed the ﬂooring. Reliable
records proved that for a very long time this room had been the dead-
house of the hospital, where some years ago all post-mortem operations
had been carried out. There is little doubt that a considerable amount
of infective material must have passed on to the floor, and soaked
through the porous drain under the ﬂooring, in days gone by. The
outbreak stopped on the use of this room being discontinued, nor have
cases occurred since, though after the ﬂooring was removed, and that and
the walls covered with good cement, the room has again been used. The
drain and central stone of the ﬂoor, pierced by a round hole connected
with the drain, shows that the ﬂoor had not been renewed when the
room ceased to be a dead-house.
The staff sergeant who was attacked at the same time occupied a
two-room quarter a few rooms away. He was eighty-one days in
hospital, after which he was invalided to England. His wife and child
also suffered, and the previous occupant was invalided to England for
the same disease, though up to that time the quarter had been healthy.
On investigation, it was found that the wall of his bedroom was damp,
[MEDITERRANEAN FEVER 63

and had been so for some time, and that this was due to the drain-pipe
of a latrine next to his room having burst and allowed an extravasa-
tion of its contents to escape into the very porous wall of his room.
14. In a private house in Valetta where two previous occupants
had been attacked with this fever, the writer was called in May 1896
to attend an officer and his wife who were suffering from this fever, and
were sent to England. He found that their bedroom was built off a
small passage (5 feet square) containing a latrine of an insanitary
nature. The doors between had been kept open for coolness. There
was no other cause apparent. The officer stated that he had had a new
latrine pan put in on taking the house the winter before, and that its
previous condition had been “most insanitary.”
15. A doctor and his wife were attacked with undulant fever after
the former had spent ﬁve and a half years in the Mediterranean, the
latter one and a half years, all of which latter period they had spent in
one ﬂat. They were attacked within a fortnight of moving into a back
bedroom (June 1896). Subsequent investigation discovered a disused
and leaking latrine beneath their window (about 10 feet below), in a
corner of a neighbouring yard, where on account of iron bars in the
window, it had been invisible from the bedroom. A case had previously
occurred in the ﬂat immediately above. Their pyrexia lasted 310 and
31 days respectively. The smell from this latrine reached the room, and
no other cause was apparent.
Numerous sporadic cases have occurred where either men slept in
barracks under foul air outlets next main drain ventilators, or families
were attacked in houses, the drains of which were subsequently found
to be leaking into the ﬂooring of certain rooms. In the latter cases, as
the leaks were not noticed until some time after the outbreaks, they
might be objected to as not having existed previously, but they occur
so often that there would appear to be connection between the two.
In large houses a few members only, often those sleeping together in
the same room, are usually affected; but in small one or two-roomecl
quarters it is not uncommon for a number of members of the same
family to be affected. This would appear to depend on the sleeping
distance from the local infective cause.
Many naval medical officers have attributed its prevalence on board
ship to the condition of the harbours of Malta.
Thus, 1. Burnett (1810) states : “ To the inﬂuence of marsh
miasma, aided by causes hereafter mentioned, has been assigned the
appearance of this disease in most of the ships where it has occurred,
and many circumstances induce me to believe that it has a very con-
siderable share in producing an attack. . . .
“At Minorca and Malta, the two places where from the nature of my
duty my principal observations have been made, there are at the head
of each harbour marshes of this description which during the summer
and autumn months emit very offensive exhalations. . . .
64 UNDULANT, MALTA 0R

“ The harbour of Mahon (Minorca) is divided by an island on which
stands the Naval Hospital. Ships anchored during the summer or
autumn above the hospital island for any length of time rarely escape
without a number of men being attacked with fever, while the ships
anchored below are commonly entirely free from it. Independent of
the crews being within the inﬂuence of the marsh by lying above the
hospital island, the common sewers of the town of Mahon, considerably
elevated above the sea, pour their contents into the upper part of the
harbour, and doubtless have an unsalutary effect on the atmosphere.
The ﬂux and reﬂux is solely inﬂuenced by the winds, and in summer
there is always much calm weather, and water in the upper part of the
harbour becomes perfectly black and stagnant, often continuing so for a
week together. . . .
“In Malta it has always been remarked that ships ﬁtting at the
dockyard, situated at the upper part of one of the arms of the harbour,
are more subject to attacks of fever than those lying out at their
anchors, and on moving a ship where it was present, to Bighi Bay, the
disease has uniformly ceased.1 The reﬂux and ﬂux of Mahon equally
applied here.” (Also the sewer outlets. Author.)
With regard to Malta, the marsh referred to has for many years been
drained and converted into ﬁelds, and has ceased to affect the health of
the garrison, whatever its inﬂuence may have been in years gone by. In
the early part of the century (Hennen), and indeed during the last
century (temp. Grand-Master Pinto), we ﬁnd accounts of fevers caused
by exhalations from this marsh, and Curmi was then said to be noted
for its malarial fevers while the Capuchin monks of St. Francis,
Floriana, were granted dispensation from nightly devotions on this
account. \Ve do not ﬁnd, however (see back), that the troops suffered
from the malarial fevers, but from those of a continued type, and the
occurrence of these malarial fevers has been much disproved by Davy
(1833). Since 1885, when the sewage of the towns on either side of
the Grand Harbour ceased to ﬂow into its basin, and was diverted into
the open sea, this harbour has vastly improved in its sanitary con-
dition. Before 1885 it has been described as “ one huge cesspool,” and
many references to its condition are to be found in the annual naval
blue-books since 1840, and elsewhere.2 Still, however, a large open
sewer from Curmi enters its lower end, while the sewage of the many
hundreds of sailors on the various naval and mercantile vessels in port
is discharged daily into its conﬁned and tideless basin, the presence of
which is very evident in the enclosed creeks in rough weather. In the
Quarantine Harbour a very large amount of sewage ﬁnds its way into its
basin, at Misida, Marsamuscetto, and Lower St. Elmo, its discharge
being very evident to the eye and nose. A scheme is under considera-
tion for diverting this matter into the open sea.
1 See also Surgeon Heastie. R.N., 1825-1828.
2 See also It Barth. Gaz. dt Medici/ta, No. 5 of 23rd Gennajo 1872, Malta ; and Donald-
son (1876).
IIIEDITERRANEAJV FE VER 65

2. Marston (1861) mentions the cases of two men who developed
severe and fatal attacks of this fever ten days after bathing in a dirty
part of the harbour.
3. Bruce (1889) mentions the case of an officer attacked with this
fever, who attributed its occurrence to long exposure to the foul emana-
tions in one of the ﬁlthiest parts of the Quarantine Harbour, nine days
before.
4. Surgeon Gipps, RN. (1890) states: “From my own observa-
tion I should unhesitatingly call it dirt fever, due to long-continued
stagnation of sewage, both in the harbour from the shipping, and the
fact that from days immemorial the whole porous stone of which the
island is composed has been saturated with sewage, long previous to
the introduction of the improvements in carrying the sewage out to sea.
. . . The disease is not only much more frequent among naval officers
and men than among the military, but the fever with the former is of a
much more severe type. . . . Almost all cases occur either at or shortly
after leaving Malta. . . . When away from Malta for any length of
time there is almost a complete freedom from fever of any sort, except
those cases which occur within some two or three weeks after leaving
the island.”
5. Fleet-Surgeon Ellis, R.N., in the Naval Annual Blue-Boole for
1890, gives the following account of an outbreak :—
“All cases returned by Orion excepting one (strength 150
men) were cases of so-called ‘ Malta fever,’ and occurred in the persons
of thirty-two individuals between March 19th and May 20th, some of
whom suffered from relapses. On March 14th the ship was placed in
dock at the head of Dockyard Creek, to undergo repairs, and after the
water had been pumped out of this dock a large quantity of very
foetid mud was exposed which had to be removed in buckets.” The
ship had arrived in Malta on March 7th, and the “proportion of cases far
exceed those of any other ironclad at that time lying in Malta harbour.”
Though there are similar polluted tideless harbours at Naples and
elsewhere in the Mediterranean, this fever occurs in many inland villages
and other places where no such polluted water exists. It was the
fashion for some few non-professional persons to attribute the whole
prevalence of this fever in the garrison of Malta to the condition of the
harbours. This theory became widely disseminated in England. How-
ever much naval sickness it may be causally connected with, it cannot
be the whole cause, nor even have much or any connection with a vast
number of cases occurring among soldiers in Malta, Gibraltar, and else-
where.
The evidence in favour of this pollution of harbour water as a cause
of undulant fever is :—
(a) That cases on board ship occur mostly, if not altogether, while
in Mediterranean ports, or when ﬁtting in dock, and are not therefore
due to causes inherent in the ships themselves. (Gipps and other naval
surgeons.)
F
66 UNDULANT, [MAL TA 0R

(1)) That cases occur in ships whose only water-supply is distilled
before use.
(0) That men who have not visited or slept in houses on shore have
been said to be attacked.
(01) That the harbour water is undoubtedly polluted with human
dejecta from persons infected with this fever.
(e) That the water of the creeks and round the ships in port
contains a much larger number of germs than that in the open
part of the harbour and in the open sea, and that the reaction of
sea-water is suitable theoretically for the growth of the micrococcus
Melitensis.
(f) That sailors bathe in the water of these creeks round their
ships, and that soldiers bathe in many cases near sewer outlets, and take
this polluted water into their mouths. This water is also used for
washing down decks, where on drying it may give off poisonous ex-
halations.
That this is a plausible and convenient theory there is no doubt ;
and it is difficult to see where else the sailor catches his fever. The
latter is, however, a question which the writer must leave to his naval
colleagues, who are in a better position to judge, and conﬁne his
remarks to a theoretical examination of this theory. That it is not the
whole cause goes without saying, when we reﬂect that the disease
attacks soldiers who have neither bathed nor been in the harbour, and
also inhabitants of inland villages who have not been near the sea for
months or years before. We know from direct experiment, and indeed
from practical experience, that micro-organisms do not rise from water
or wet surfaces, unless “ there is at the time a spurting up of the ﬂuid
by waves, or by violent agitation, or by the formation of bubbles, that
particles of water and with them bacteria can be carried by currents of
air over short distances ” (Nageli quoted by Fliigge), or after the moist
surface has ﬁrst dried. If the fever is therefore really contracted from
polluted harbour water in certain cases, it is by reason of swallowing or
absorbing it through accidental cuts or superﬁcial abrasions when bath-
ing, of breathing exhalations from decks washed with the water, or from
eating oysters or insufficiently cooked ﬁsh caught in its waters, only too
often round the mouths of the sewers. It is unlikely that any drying
process at the water’s edge can aﬂ‘ect the inmates of ships in this tide-
less water at a time of year when there is an almost continuous calm,
and it is a signiﬁcant fact that the English inhabitants of houses on the
borders of Dockyard Creek have not suffered from this fever, when
those on ships at anchor close by have done so. There are at any rate
ample means of avoiding the possibilities of infection mentioned, and of
at the same time proving or disproving the theory in question by simple
precautions.
The writer has failed experimentally to isolate the micrococcus
Melitensis from the sea-water in question, or to grow it artiﬁcially in
sterilised sea-water. Such experiments are, however, of little negative
[MEDITERRANEAN FE VER 67

value on account of the diﬂficulty of isolating so slow growing an
organism from amongst other much more rapid growths, and from the
changes which necessarily occur in sterilising sea-water.
This cause, if such it be, must therefore remain sub jadz'ce, and
await further investigation, without, however, it is hoped, delaying in
any way the good work of cleansing the harbours from their present
objectionable pollution. The writer has not heard of cases arising
among passengers on troopships or mail steamers, individuals from
which weekly spend a few hours on shore when passing through Malta
or Gibraltar, and who eat and drink on shore, and occasionally spend a
night.
Its connection with the turning up of new clean soil, from which
the human faecal element is absent, has been mooted by those who hold
that it is malarial in origin, but no such connection appears to exist.
The countrymen who work all day in the ﬁelds are less subject to the
fever than those who spend all their time in the towns and villages;
and soldiers who are employed in the country do not suffer so much
from this fever as those in barracks. Soldiers encamped on clean
ground in the country do not suffer, but do so if on old and polluted
ground near barracks, or on barrack squares. The Maltese of the large
towns, from living in so small an island, have a peculiar habit of
scarcely ever leaving their own town except to drive to certain country
places, such as Notabile, Sliema, and St. Paul’s Bay. The soldiers conﬁne
themselves to their recreation grounds and to the towns. These two
classes of people are the ones which suffer most from the fever. The
writer has not found that those oﬂicers and their friends and families
who are in the habit of exploring the country valleys, and spending
much of their time there, are in any way more subject to the effects of
the disease. Officers and men at Gozo in tents and barracks seldom suffer
(see p. 89). An outbreak is mentioned as occurring in 1844 during the
excavation of a new dock at Cottonera 3 the works took place, however,
in one of the most thickly populated, unhealthy, and dirty parts of Malta,
and not in new ground. A medical officer, who was in Malta in 1884,
has described to the writer an outbreak of most severe and fatal undulant
fever which attacked some Royal Engineers employed in building
fortiﬁcations in the country on the site of an old Roman (l) cemetery.
No details are, however, available beyond three post-mortem reports,
which were those of typical undulant fever. We can safely dismiss the
subject, and feel justiﬁed in believing that the turning up of virgin or
clean soil, clean from a human faecal point of view, has no connection
with the causation of this fever. Troops under canvas on cultivated
or uncultivated ﬁelds in Malta have been most healthy and quite free
from fever.
The inﬂuence of dust, polluted with human faeces, as a cause of
enteric fever and other diseases in India, Egypt, and other dry and
dusty places, has not in the writer’s opinion been sufficiently in-
68 UNDULANT, MALTA OR

vestigated. We read of a French cavalry regiment1 which contracted
a number of cases of enteric fever (112 in 1600 men, 12 fatal) from
manoeuvring on a ploughed ﬁeld recently manured with human faeces.
Of course in well-kept roads the chances of human faeces containing
the speciﬁc virus of any given disease must be small. Though in a
fever of such an ambulatory type as the one under discussion the
chances are increased, it is just as prevalent in those streets of Valetta
that are paved as in other unpaved and dusty ones.
It is well, however, to bear this possible, if improbable, cause in
mind, when dealing with excavations connected with old sewage drains,
or the foundations of old houses, and not to allow faecally polluted
earth to lie about, where winds and breezes may carry it to the human
mouth.
We have therefore, from an eminently practical point of view,
reason to connect the occurrence of certain cases of this fever with
faecal pollution of air near the person affected. The bed in which the
soldier sleeps is but 24 inches from the ground, so that when the
pollution is in the ﬂoor of the room it has not far to go. In the cases
where sewer gas has been thought to have caused the disease, the dis-
tance that the poison must have travelled downwards, or through the
house in the direction of direct draughts, has varied from four to twenty
or thirty feet. In all the instances mentioned there have been deﬁnite
air currents to account for the carriage of the virus through the
atmosphere. The deﬁcient ventilation of certain rooms in which it has
occurred has been most marked, tending to increase the strength of the
dose of the poison inhaled, from absence of dilution with purer air.
The inﬂuence of overcrowding and over-population has also been noted,
increasing as it does the liability of the soil to pollution.
The organism is an exceedingly small one, even among its minute
brother micrococci, and though spores and the miasmatic infection of
paludism are often carried to considerable distances through the air, we
know too little of at least the latter, to compare them with this disease
germ. Fliigge states: “Nothing certain is known as to the distances
to which dry but living bacteria can be carried by the wind: from the
extraordinary distances over which other particles of dust can be
carried, we may conclude that when opportunity offers the bacteria
may be carried over very considerable areas.”
Now dust from the Mount Vesuvius eruption was found 400 miles
off. Though as a rule the outside air contains but few micro-organisms,
in the “air of dwelling-rooms they are found in very small numbers,
even when all movement of the air has been avoided as much as
possible for some time, while they are present in large numbers when
the dust has been raised by movements and other disturbances. It is
found that bacteria when once they have passed into the air ﬂoat or
are carried about by currents of air for a varying time ” (Fliigge).
1 Lancet, vol. i. p. 307, 1896 (abstract from Dr. Henrot, Revue d’Hg/giene).
[MEDITERRANEAN FE VER 69

From practical experiments in laboratories there is not much
difficulty in accepting the passage of this disease virus through the
atmosphere to the patient’s mouth, throat, and possibly further, when
once it has entered the air.
We have next to discuss the reasons for believing that it can rise
from the polluted soil in which we believe it to exist. We know from
experiment and from practical epidemiological experience, that germs
do not rise spontaneously from moist surfaces, and that even strong
currents of air are unable to detach them from such situations. Hoff-
mann (Archie fiir Hygiene, vols. i. and ii. pt. ii.) has pointed out
that there is in porous soils what he terms a superﬁcial zone of
evaporation, in which the moisture varies from saturation to zero. In
hot weather the zone is considerable in extent, and when rain descends
on it after a period of heat and drought, it is often capable of retain-
ing the whole of the latter without its lower border becoming wet. In
such there is always a dry layer, between the surface part which is
temporarily wetted by the rain and the deeper strata in which the
water lies. Under these conditions the impurities which reach the
soil become deposited in the dry zone. Under this zone is situated a
layer which is always wet. When the upper zone is ﬁlled with rain the
amount of water in the second zone remains constant, for any excess
which it may receive passes down into a third zone or that of the
underground water. Any micro-organisms present in the ﬁrst zone are
alternately immersed in water or air. In the former case they remain
in the soil, in the latter case they may be transferred to the atmosphere
by air currents. The outermost layer of soil may be kept moist by
slight and long-continued rain, in which case, however large the dry
‘ zone, its organisms would not easily escape into the air.1
The fact that the air2 in well-ﬂushed English sewers, in which
decomposition and evolution of gases is not going on, does not contain
an excessive number of micro-organisms (Frankland), when compared
with outside air, does not invalidate the possible causal connection
between sewer gas and this fever. It is not the quantity but the
quality and pathogenic nature of the germs which are all important
questions here. Enteric fever (Cameron, etc.),3 diarrhoea, sore throats
(tonsillitis), and other diseases have been traced to such a cause. Again,
the number of germs found in cesspit air, and in air in the neighbour-
hood of sewage pollution of soil, has been found to largely exceed those
of sewers or ordinary air. Arthur has shown that bacteria can un-
doubtedly grow up the sides or walls of the damp nutrient sewers, and
if these latter become at all dry, air currents readily detach and disperse
them. The temperature of sewers in the Mediterranean is higher than
1 See also Cavendish Lecture in Brit. Med. Journal, June 11th, 1892.
2 Arthur, “Bacteriology of Sewer Air,” Sanit. Record, Nov. 10th, 1894. See also
Robertson, “Study of the Micro-organisms in Air, especially in Sewer Air,” Brit. [Meet
Journal, Dec. 15th, 1888, vol. ii. p. 1340.
3 Tichbourne (R. Academy Med. Ireland), Lancet, vol. i. p. 1416, or Brit. llfecl. Jour.
vol. i. p. 1285 (May 22nd, 1897). See also on p. 71.
70 UNDULANT, MALTA OR

that in England (average 55° F.),1 and therefore more favourable to
germ growth.
Now in Malta, besides the great inﬂuence of air temperature, from
the point of view of actual heat, on the growth of the virus of this
fever, we have clear evidence of the controlling power which rainfall
has on the prevalence of the fever. While the surface of the ground
is wet the fever lies dormant, ready to burst forth with dry weather,
provided there is at the same time a suitable amount of warmth for its
development. Dry summers have always been the most severe “fever
years” with respect to undulant fever. The fever does not occur in
any amount during spring or until the rains have ceased. The undulant
fever prevalence curve follows the inverse ratio of the rainfall, month
by month. In this respect a moderate but continued rainfall is better
for prevention than an interrupted fall of similar amount. Moisture
also seems to be necessary to the growth of the virus in the soil, but
at the same time the virus does not leave the soil until the superﬁcial
layer has dried up. This would seem to explain how it is that rooms,
the walls and ﬂoors of which are alternately wet and dry, give the
greatest number of cases of this fever when infective causes are present,
and how the question of dampness, so often connected with the
occurrence of cases of this fever, comes in. It also explains the
liability to fever on the part of those living in ground ﬂoor rooms
with uncemented ﬂoors, and the undoubted efficacy of cementing ﬂoors
in unhealthy ground ﬂoor tenements.
Until 1885 Valetta (one of the healthiest parts of Malta) was
drained by means of large conduits, dug by the Knights in the porous
stone, and running beneath the streets. These were directly connected
with the houses by means of pipes made of porous stone. These
covered ditches were in some cases as much as forty feet deep, and in
all cases wide enough for a man to walk in. They were unﬂushed,
and the sewage passed along them in a stagnant but constant stream
which must have soaked into the porous foundations of the city in all
directions. In 1885 new sewers were laid on modern principles along
the bottoms of these conduits, the upper part of the gallery being
utilised for storm water. The new main drains are well laid, but the
means of ﬂushing are insufficient. Moreover, the majority of the house
closets, at any rate in Maltese houses, are hand ﬂushed, and as water, in
excess of a certain limited quantity, is charged for, the economical
householder neglects to supply his share of ﬂushing water. Owing to
the enormous population crowded into a small space (Valetta is said to
be one of the most thickly populated places in the world, 75,883
persons to the square mile), every available foot of ground is utilised
for building purposes, and to arrange for a sufﬁcient number of closets
for so many people without having them unduly close to the living
rooms, has proved an impossibility. Consequently bedroom cabinet
1 See Lancet, vol. i. p. 1313 1897.
[MEDITERRANEAN FEVER 7I

closets abound. To provide air and light to a small extent to the
numerous small rooms found in the modern reconstructed buildings,
small shafts are built varying from six to twenty feet square, While
others are built round an enclosed yard. Many rooms have no external
opening except into a passage or into such a shaft. In these shafts
or yards, two, three, or more closets are placed one above another, on
bracketed balconies. Room brick-ventilators often open from above a
bed, straight into these closets, while in the majority the bedroom opens
directly into the closet, or into a small passage and within a few feet of
it. Each soil-pipe runs into a vertical pipe running up one side of the
shaft, and opening as a ventilator on the roof at various heights above
it. On calm days and when the sirocco wind is blowing, little air rises
from these shafts, while exhalations from the ventilator appear to fall
into them. The closets are rarely sewer-gas proof. Moreover, on
account of the variability in altitude above the sea of the different
portions of Valetta, main drain and house drain ventilators that may
be carried well above the roof on which they are placed, are often on
a level with the windows of adjacent houses. The same may be said
of Gibraltar and many other Mediterranean towns. In some barracks
also we ﬁnd main drain ventilators and room louvred ventilators side
by side. It is true that the latter are theoretically foul air outlets,
but practically this depends greatly on the direction of air currents
from time to time. The upper part of the old conduit, now used for
surface and storm water, is wet in winter and dry in summer, and
though trapped, the traps soon dry up in hot weather and cease to
have any effect. The above remarks apply also to the Three Cities on
the Cottonera side of the harbour.
That the writer does not attach any fever-producing power to smells,
per se, goes without saying, for indeed in such case few dwellers in the
Mediterranean would escape, but at the same time a smell is often an
indication of sewer gas escape, and of the direction in which it travels.
That enteric fever can arise from air pollution from sewers there seems
little doubt,1 but there we are dealing with a bacillus, and not with a
micrococcus. In the case of this minute micrococcus we have much to
make out before laying down anything deﬁnite on the question of its
portability, but not only is it as minute as many aerial spores, but the
writer has met with so many cases of this fever occurring next to such
closets or drain ventilators, in otherwise healthy houses, as to believe
ﬁrmly that their occurrence is more than accidental, and as much con-
nected with sewer exhalations as many sore throats occurring in similar
places.
It has been urged that direct experiment in England has proved that
the air of sewers contains few micro-organisms ; but it must be remem-
bered that in these the wetted perimeter is a fairly constant factor,
1 Army ﬁled. Report, 1876 (Malta), p. 64; Ziemssen’s Encyclopedia of rlledicine, vol.
i. p. 56; Uffelmann, Indian Gazette, Jan. 1, 1896; Tichbourne, Brit. ﬁled. Jour. vol. i.
p. 1285; 1897 ; etc.
72 UND ULANT, MALTA 0R

owing to adequate general and individual ﬂushing. In Malta, on the
other hand, the ﬂushing is very inadequate, and there is a condition of
alternate wet and dry surfaces. The higher temperature in the Mediter-
ranean also favours decomposition and germ life. It has also been
said that sewage is too alkaline to allow of the growth of this micro-
coccus. This is not the case. Not only have a large number of un-
dulant fever stools and specimens of sewerage effluent, which the author
has tested, proved neutral or faintly alkaline in reaction, but also the
walls and stone ﬂoors that have become soaked through with escaped
sewage, in rooms where this fever has been especially prevalent, have
proved of a faint and suitable alkalinity, whereas stone from clean walls
and more especially newly-quarried stone of a similar nature have proved
very strongly alkaline. The strongest argument in favour of the surmise
that this fever is due to the effects of an aerial virus from infected soil
(or drains), rests upon the basis of its localised and seasonable preval-
ence, and on the fact that there is, on the one hand, no other more
strongly grounded theory of causation, nor, on the other side, any evi-
dence to negative the theory. That it cannot be deﬁnitely proved
until the almost insurmountable diﬂiculties of obtaining plate cultiva-
tions of this slow—growing, heat-loving micro-organism are overcome, is
granted 3 but the theory is one which will repay investigation, for its
proof or disproof will equally lead to the path of truth, and towards the
important goal of prevention.
In Sliema and other towns and villages, the cesspit system is still in
vogue. The cesspits are, according to law, imperviously rendered, but
this regulation is evaded by knocking holes in the cement after it has
been passed by the Government inspector. That these cesspits drain
into the porous foundations of the houses there is no doubt, a fact self-
evident when their position and their capacity, with the infrequency
with which they are emptied, is taken into account. They are placed
in a large number of cases under the foot-path and front door, and their
odour is most offensive to passers by. In this cesspit population un-
dulant fever is most common, a condition to be expected if our former
deductions are correct. In certain cases the house drain passes into
natural clefts or caverns in the porous rocky foundations 3 a coveted
condition on account of the saving of original expense in construction
and subsequent emptying, which latter is never done. It need hardly
be noted that these houses are the constant habitat of this fever. For-
tunately, it has at last been decided, after years of discussion, to drain
Sliema and neighbouring places, but it is a great pity that it was not
done in the ﬁrst instance, before the porous rock became inﬁltrated with
ﬁlth, in which case this place might have been one of the pleasantest,
most convenient, and healthiest of places to live, in Malta. Let us
hope this will be realised in the future. The mistake that is made in
overcrowded Malta, is to allow every new house outside Valetta and the
Three Cities to build a cesspit under its foundations, instead of organis-
ing a general system of sewage removal. If such a plan was adopted
MEDITERRANEAN FE VER 7 3

in the early stages of suburban building the expense would be slight,
gradual, and borne to a large extent by the builders. In the present
case things are allowed to go on until the magnitude of the pollution
and sickness calls for urgent and costly redress, at a time when the
vested rights of the landlords make them averse to contributing towards
the necessary outlay 3 without taking into account the ﬁnancial loss
entailed by attacks of this fever on individual bread-winners, a no small
item.
The author has particularly noticed that the cases occurring when
the faecal soil pollution, to which an outbreak is attributed, is of long
standing are the most severe. This may imply that the virus increases
in virulence during a saprophytic assistance in soil. It is to be noted in
connection with this fact that the monkeys inoculated with virus from
man suffered more severely than those inoculated with virus obtained
from monkeys. This is the case with certain other poisons.
The cases which the author has believed to arise from drain or sewer
emanations have, as a general rule, been less severe than those from cess-
pit exhalations, or more especially from faecal pollution of soil. Out-
breaks from the last cause have been more extended in their effects, have
produced a greater number of cases in proportion to the number of
persons exposed to the infection, and such cases have, on the whole,
been mere severe in character. In houses where drain exhalations have
been blamed, there has often been a marked interval between the onsets
of the individual cases. In instances where soil pollution has been in
question a number of cases have been admitted from one hut, room, or
block of barracks Within a short time of one another. In one ﬂat con-
taining two occupants one suffered severely from this fever in 1894, and
went home to England 3 of the two succeeding occupants, one suffered
severely during the following summer and also went to England.
Of the next two occupants in the spring of 1896, the husband had a
mild, though long attack, in the early part of May, the wife a similar
attack commencing at the end of May. In this case the bedroom and
dressing-room opened on to a small landing some ﬁve yards square con-
taining a water-closet. The last occupants, who only were under the
writer’s medical charge, described this closet as being in a most insanitary
condition when they entered the ﬂat, and though they had replaced it
by a modern one it was then far from satisfactory.
So far we have arrived at the conclusion that there are reasons for
believing that undulant fever is caused, in the majority of instances, by
a speciﬁc micrococcus emanating, during hot dry weather, from a saphro-
phytic existence in soil polluted with the faeces of those suffering from
the same disease.
From the fact that the infection apparently travels through the
air, and that the initial symptoms are, as has been recently noticed in
certain other diseases, tightness in the throat, redness and tenderness of
the tonsils with often a coating of translucent fur, a furred tongue,
slight swelling of submaxillary and cervical lymphatic glands, epigastric
74 UND ULAZVT, MALTA 0R

tenderness, anorexia, nausea, and even vomiting, pain and stiffness of the
muscles of the neck and back, it is not unlikely that the virus gains
entrance to the human body by means of the inspired air. Though
these local symptoms are, however, not strongly marked in many of the
cases, we must remember that the virus does not usually produce
strongly-marked local symptoms. In the case of inoculation, though a
comparatively large amount of the virus was injected into the monkey’s
forearm, no local results were noticed. It has not produced local
suppuration in any case that the writer has seen. Moreover, while
there does not appear to be any other means of entrance which so fully
ﬁts in with the facts we have at our disposal, there is evidence against
other usual modes of entrance.
That it enters the body tissues, and is not a toxic intestinal or
bronchial parasite, is evident from the ineffectiveness of intestinal and
respirative antiseptic remedies, and more particularly from the ex-
ceedingly varied and localised nature of many of the symptoms, implying
a local action of the living virus rather than a general action of a circu-
lating toxic agent.
It also seems probable that the living virus is excreted with the
faeces and urine, and so returning to the soil is able to infect the air of
a deﬁnite and circumscribed area and so re-enter the human subject.
Age and Sex—All ages are liable to this fever. As in these short
service days the majority of soldiers are under thirty years of age, we
ﬁnd this fever in the army in Malta between the ages of ﬁfteen and
thirty. Infants rarely suffer. The average age of 500 non-fatal cases
collected by the author was twenty-three years and four months (sixteen
to forty-seven) ; that of thirty fatal cases recorded in the books of the
military hospital at Valetta was twenty - three years (nineteen to
twenty-eight). Bruce states that of the cases treated by him in 1886,
two were under twenty, seventy-six under thirty, and six under forty.
Chartres states that in an epidemic in Malta in 1866, six were about
thirty, forty-ﬁve over and ﬁfty-seven under that age (nineteen to
thirty-seven). Moffet, in Gibraltar, gives its military prevalence among
men as 94 per cent under and 6 per cent over thirty years of age.
Among the inhabitants of Italy and Sicily, Guiffré gives between
ﬁfteen and forty years as the most susceptible ages, and states that
children under six and adults over ﬁfty are relatively exempt. Notiﬁca-
tion of this disease has only recently been instituted for the civil popula-
tion of Malta, but the accounts given of its occurrence seem to agree with
the above, except that as the disease in children is of a mild character
and has few deﬁnite symptoms, it is probable that many such cases are
missed. Native practitioners give from six to thirty as the most
susceptible period. Marston, at Malta in 1860, stated “it affects par
excellence young men under thirty-ﬁve, particularly those of rheumatic
diathesis ; next in frequency children; most unfrequently the aged.”
Tomaselli of Catania is of opinion that the greatest number of cases
occur between the ages of six and thirty, less frequently from two to
MEDITERRANEAN FE VER 7 5

six, and from thirty to ﬁfty 3 very rarely above ﬁfty. Rummo of
Naples is of the same opinion.
Sex appears to have little or no inﬂuence, any apparent differ-
ence being due to age, occupation, and surroundings. In a given
number of married families in the army, the writer has for these reasons
found the women if anything more subject than the men.
Incubation period—In a fever whose onset is in many cases so
markedly insidious, it is very difficult to collect evidence on this point.
In the inoculation experiments upon monkeys the incubation period was
about twenty-four hours. Here the poison being introduced directly
into the tissues, had not to ﬁrst overcome the resistance of the mucous
membranes and other natural barriers to infection.
Chartres (1865) states that of forty-one cases occurring in one
month, the ﬁrst commenced six days after the regiment entered Verdala
Barracks,
Marston (1861) mentions the cases of two men who were attacked
ten days after bathing in a dirty part of the Grand Harbour.
Bruce (1889) gives the case of an officer who attributed his attack
“ to a long exposure to foul emanations in one of the ﬁlthiest parts of
the Quarantine Harbour,” nine days before. He also states that the
disease has developed in England in persons who have been from fourteen
to seventeen days away from Malta. He gives the probable duration as
from a few days to twenty or thirty days, stating that there is no
evidence that it exceeds two months.
Moffet ( 1889) gives reasons for believing it to be from six to forty-
nine days.
Ellis (1890) states that the ﬁrst case, in the outbreak on H.M.S.
Orion, occurred ﬁve days after entering dock, and twelve days after
arrival in Malta.
Guiffré (1893) gives six to ten days or more 3 J accoud (1886), who
studied the disease in Paris, in persons who had come recently from
Italy, makes the incubation not less than ten days.
Many persons are described as developing the fever at varying periods
after arrival in England from Malta. All such cases that the author
has personally met with have been reduced on investigation to within a
fortnight, and many have appeared to have had the fever on them
before leaving. There is no doubt that cases develop on board ship on
the way to England, the author having met with cases of from one to
ﬁve clear days, and one less certain of ten days. The two following are
instances of cases said, but erroneously, to have developed after arrival
in England, and are samples of a class of cases which have led to state-
ments of long incubation periods. A colonel went on leave, and twelve
days after leaving Malta consulted a doctor in England, who pronounced
him to be suffering from this fever, from which he did not recover for
nearly two years. He had, however, been feeling “seedy and liverish”
all the voyage, and two days before embarking at Malta informed the
writer, during a casual conversation, that he was “off his feed,” had
76 UND ULANT, [MALTA 012

been suffering from headaches in the evening, and thought it was time
he went on leave. This officer had doubtless been suffering from slight
pyrexia even before leaving Malta. The other case was reported to
have had an even longer incubation period (over fourteen days), but as
he had been sick in his quarters for nearly a fortnight before leaving
Malta (though not officially on the sick list), with a temperature every
evening, the report must have been an erroneous one.
Where there is often a long latent period between the undulations
or relapses, a variable onset, and a very large difference in the action of
the virus (virulence or susceptibility) on different persons, there is
doubtless a variable incubation period. The author has met with cases
of fever commencing eight, ten, fourteen, and many within thirty days
of their arrival in Malta. He is inclined to think that it may be as
short as three days in some cases. Probably three to ten or ﬁfteen days
is near the mark, in cases where the ﬁrst febrile onset is noted.
Seasonal preva1ence.——In the military hospitals in Malta, where
every case which occurs among the troops is necessarily admitted, the
admission-rate is lowest during the ﬁrst quarter of the year, rises rapidly
in May to a maximum in July, August, and September, after which it
soon falls until a low rate is again met with in December, January, and
February.
The rate during the last quarter is higher than that of the ﬁrst
quarter for the following reasons :-—(1) Certain relapses and ambulatory
cases, which become infected earlier in the year, are admitted during
this quarter 3 (2) the annual occurrence of enteric fever (which com-
mences from two to three weeks after the ﬁrst heavy rains) takes place
at this time, and a few cases of this fever most probably are included
among the undulant fever cases through error in diagnosis 3 (3) the
average temperature during the last quarter is some 7 ‘84° F. higher than
that of the ﬁrst quarter, and the average temperature of October and
November is 106° F. higher than that of the succeeding four months
(December to March inclusive), when the fever rate is lowest. This
difference in temperature (reckoned from daily observations at 9 A.M. for
ten years, taken in the official observatory) has been proved experiment-
ally to have a distinct effect on the growth of the virus of the disease in
question.
A similar mode of prevalence has been noted over and over again in
the published Army Medical Reports since 1817 and in Naval Reports
since 1840. Marston, writing in 1859, states: “The disease prevails
particularly during the spring and summer months.” A similar mode of
prevalence is also met with in Gibraltar (Moffet), Palermo (Guiffré),
Rome (Galassi), and Cyprus (Carageorgiades).
In the following table will be found the actual admissions for un-
dulant fever into one hospital in Malta, from a body of men whose
average strength for each year remained practically constant (compiled
by Bruce and by the Author) contrasted with the mean monthly temper-
ature (at 9 am.) for ten years (1881-1890):——-
MEDITERRANEAN EE VER 77


TABLE V.
Admissions.
Ratio Mean Monthl ' Tel e at
Months of the Year‘ Bruce 1 Hughes Total‘ per cent. at 9 A.M. fdr lOlilpealisure
11 Years. 6 Years.
January . . . 12 40 52 4'1 56‘74° F.
February . 13 3O 43 3 '4 57 ‘06°
March . . . 20 44 64 5'0 59'64°
April . . . 23 55 78 5'2 62'76°
May . . . 75 77 152 11 -5 (so-94°
June . . . 80 83 163 123 72'81° M
July . . . 102 118 220 16'5 7943' _ aix'
August . . . 52 119 171 128 so-17° P16” ence-
September . . 42 116 158 118 78'96°
October . . . 38 73 111 8'4 72'73°
November . . 32 46 68 5'2 64'88°
December . . 12 37 49 3'8 59'35°
Total . . 501 838 1339 1000 67'82°

Though the actual monthly variation in the admission-rate for this
fever varies slightly from year to year, the above table gives the
average of a number of years, and it moreover agrees with the experi-
ence of others in former years. The author is of opinion that a certain
number of cases of undiagnosed enteric fever may have been included in
his ﬁgures for the last three months of the year (October-December),
as that fever was prevalent outside Valetta three times during those
months, and to a less extent perhaps in January. It will be clearly
seen, however, that undulant fever especially prevails from May to the
middle of October, and is least prevalent from November to April in-
clusive—facts of import to those intending to visit Malta or other
Mediterranean towns, and to residents able to spend a portion of the
year away in England or elsewhere.
Climatic inﬂuences—(a) Rainfall—In Malta and Gibraltar the attack-
rate of undulant fever has been found to increase in an inverse ratio to
the amount and continuance of the rainfall from month to month. While
the surface of the ground is kept constantly wet by rainfall, the attack-
rate is low, but the cessation of rain in warm weather is at once followed by
an increased activity on the part of the fever poison, and the attack-rate
rises very rapidly, its fall being delayed until the commencement of the
autumn rain, when it is well marked and often sudden.
This statement is based on the monthly admission-rate for undulant
fever at Cottonera military hospital for the year 1891, and at Valetta
military hospital for the years 1891, 1892, and 1895; collected in both
1 Vide British rlledical Jour. vol. i. p. 1101 ; 1889.
78 UNDULANT, MAL TA on

places by the writer, by excluding from the admissions for “Simple
Continued Fever,” as far as possible, all non-fatal cases in hospital for
less than 20 days, and all cases subsequently proved to have been
incorrectly diagnosed. The admission-rates so obtained have been com-
pared with the rainfall collected daily on the roof of Valetta military
hospital, at a spot not more than a mile and a half from the farthest
barrack from which the cases were admitted, particulars of which are
yearly published by Government in the Army Medical Reports.
This ratio is further conﬁrmed by a comparison between the
admission-rates to Valetta hospital for the years 1884 to 1887, kindly
supplied to me in 1893 by Surgeon-Major Bruce, and the oﬂicial
monthly rainfall return for those years.
Tables VI. and VII. give some of these ﬁgures in detail, and Chart
V. the same results in more graphic form for the years 1891 and 189 2.
It is, moreover, interesting to note that in the past we ﬁnd that
recorded epidemic or excessive prevalence of this fever has, as a rule,
occurred during unusually dry years 31 and that the annual admission-
rate for simple continued fever (which, as will be shown later on, has
some bearing on the question), has during the last thirty-seven years
varied inversely with the rainfall with but one exception. The
exception occurred in the year 187 6, when a comparatively low
admission-rate was combined with a small amount of rainfall. Two
factors were, however, at work that year, namely, a most unusually
large number of rainy days occurring during the warm weather, and the
fact that this year was midway between two periods of excessive pre-
valence, and should in the ordinary course of events have reached a
much lower point on the scale than it actually did. It therefore
appears that the rainfall was not without effect even during 1876.
1 Chartres (Army Medical Report for 1866) describes an epidemic as occurring during
that year in Malta, “ after an unusually dry winter, so scanty a fall of rain not having been
experienced in the island of Malta for many years,” etc. See also AAMD. Reports for 1837,
1840, 1841, 1865, 1867, 1872, 1885, and 1895.
[TABLES
[MEDITERRAIVEAN FE VER
79
TABLE VL—Aclmissions for U ndulant Fee-er contrasted with Rainfall
and Temperature


1891. 1892. 1895.
Months.
Admis- Rain- Average Adnlis- Rain- Average Admis- Rain- Average
sions. fall. temp. slons. fall. temp. sions. fall. temp.
January . 4 4'58 520° 7 2'84 608° 61 1'85 55'3°
February 6 4'72 51 '0° 12 1 '36 59 ‘1° 1 1 '01 56 ‘9°
March 10 '11 57'6° 12 '11 61 ‘9° 10 '39 58'2°
April 9 '55 61 ‘5° 4 2'40 63 ‘6° 30 '15 63 ‘3°
May 11 '14 64 ‘5° 16 3'21 66 ‘5° 39 '65 66 ‘2°
June 18 '01 727° 8 74 ‘6° 37 72'1°
July . 22 78'8° 21 ‘38 79‘1° 46 80‘6°
August . . 38 79'7° 33 802° 32 '15 80'0°
September . 20 ‘52 777° 28 3'61 75'8° 40 ‘37 77'8°
October . . 23 2'96 717° 16 1'62 73‘7° 10 1'23 74'3°
November . 20 1 '46 656° 5 7'16 65'7° 5 2'19 68'0°
December 12 3 '09 61 ‘5° 161 1'84 61 ‘6° 1 3 '63 59 ‘5°
Total 193 18'14 66 ‘2° 178 24 '53 68'6° 258 11 '60 67 ‘7o


1 Enteric fever prevalent at this time.
TABLE VII—From Figures supplied by Surgeon-Major Bruce


1884. 1885. 1886. 1887.
Month. 0 _ _
ﬂog?‘ Rainfall. Rainfall. Rainfall. Rainfall.
January 4 10'87 .. . 4'07 6 4'93 6 2'92
February . 3 '64 '26 1 3'28 3 1'89
March . 6 1'39 1 '10 5 '73 5 '23
April . .. . '45 1 ‘55 2 ‘60 2 1'40
May 2 '48 38 30 7 '18
June 6 '16 28 .. . 16 '05 12 '15
July . 8 19 '02 8 30 August 3 '20 7 '08 11 . . . 19 '23
September 3 '24 8 '30 5 3 '5 9 17 ‘35
October 2 1 '42 4 '68 9 ‘55 3 11 ‘42
November 6 5 '65 3 3 ‘39 5 6 '83 4 1 '38
December 1 3'58 2 2 '65 2 4'31 3 '97
Total. 44 25 '05 111 12 '15 100 24 '87 121 21 ‘12


80 UND ULANT, MALTA OR

It is interesting also to note that while the fever prevailed in
epidemic form in Naples and Catania in 1872, it also prevailed in
most unusual quantity in Malta,1 and with a severity that has not been
exceeded since. This was an unusually hot and dry year (rainfall 135
in.). A similar state of affairs occurred again in 1885.
It is evident that meteorological conditions have a great deal to do
with the amount of prevalence of the fever. In 1895 there was an un-
usual number of cases, whereas the rainfall (11'6 in.) was very small,
and had the temperature been greater, doubtless the prevalence would
have been greater. In the following spring of 1896 very few
cases occurred, while there was unusually cold weather, and almost
constant (though not heavy) rainfall; but in June, when it became dry
and hot, the fever at once broke out.
CHART V.
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J
(b) Temperature—That the virus of this fever requires a certain
temperature for its artiﬁcial existence and growth has been already
mentioned in the section on the bacteriology of this fever. That a
similar factor is necessary for its saprophytic existence, and to enable it
to produce effects upon the human body, is further proved by the
relationship which exists between atmospheric temperature and the
geographical prevalence of the disease.
Thus north of latitude 46° N., which roughly corresponds to the
isotherm of 55° F. (average annual temperature), this fever does not
appear to exist except as an imported disease. South of this line the
fever is met with as an endemic disease, whose annual prevalence
becomes of increasing importance as the average annual temperature
rises above 60° F. It has usually been described as a subtropical
disease, though experiments would lead us to believe that it may be
able to exist in countries whose average daily temperature does not rise
above 109° F., and according to some authors it would appear to exist
as far south as Massowah in the Red Sea, which, being situated about
latitude 15° N., is within the boundaries of the tropical isotherm of
800 F. This is said to be one of the hottest places in the world, with
an actual average annual temperature of 905° F2
1 See Notter (1876) and A.M.D. Reports.
2 .Manual of Hygiene, Notter and Firth, 1896, p. 722.
[MEDITERRANEAN FEVER 81

In Malta but a few sporadic cases (and relapses) occur in the winter,
and during January, February, and March they are rarely seen in the
wards, but the number of admissions rapidly increases as the daily
average temperature reaches 60° F. This usually occurs in May, but if
this month be unusually cool (as in 1896) but few cases occur until
June. The converse is also true. In the Navy we ﬁnd the same state
of things.1 The limitations of its tropical existence must be left to
future investigators.
Length of residence—In Malta we do not ﬁnd that residents acquire
immunity from this fever, and whereas enteric fever specially favours
newcomers, undulant fever attacks even those who have been in resi-
dence for six or more years. When a regiment is ﬁrst placed in an
unhealthy barrack the susceptible element is usually very great, and it
suffers accordingly, nor does previous Mediterranean service confer an
immunity. Moreover, though the younger soldiers (who usually have
but short service in the locality) suffer a great deal on account of their
youth, older soldiers with long local service also suffer, and to a much
larger extent than is the case with enteric fever.
Thus the regiment mentioned in the epidemic of 1892 had been
three years in Malta; and the majority of the men attacked had been
all that time with the regiment. Again Chartres, in his account
of an epidemic in Malta in 1866, says: “The men attacked (41)
had all of them a continuous service of over seven years in the
Mediterranean, two years and a half of which were spent in the
island of Malta.”
The average service in the Mediterranean of 270 cases in 1895 was
205 years (one month to 11 years). The writer has known this fever
attack English residents after a stay of over twenty years in Malta.
The apparent immunity enjoyed by many European residents is probably
due to their having inhabited healthy houses during their stay in
Malta, as those who are long in the place rarely change their houses;
and to a certain survival of the insusceptible. There is no doubt that
although the native Maltese suffer from this fever, they do not do so to
anything like the extent to which European visitors suffer. This has
been attributed to their having acquired an insusceptibility by having
gone through an attack, mild or otherwise, during childhood, and to the
fact that their parents have transmitted to them an hereditary power of
resisting the encroaches of the poison. However this may be, they
suffer most severely from non-endemic diseases (such as measles, etc.),
whenever these are introduced from without, both of which facts are
comparable with many instances of susceptibility of natives to endemic
and non-endemic diseases all over the world.
The length of time previously spent in the Mediterranean (i.e. in
Gibraltar and Malta) by 292 consecutive cases was as follows :—
1 Health of the Navy, 1887, etc. 3 also Trans. Epid. Soc. vol. ix. p. 87 (Gipps).
G
82 UNDULANT, [MALTA 0R

TABLE VIII.
Previous Service. Cases.
1 month . . . . . . 4
2 months . . . . . . 10
3—4 ,, . . . . . . 15
5-6 ,, . . . . . . 24
7-12 ,, . . . . . . 12
Total under one year . . . . . 65
1 year but under two . . . . . 19
2 years ,, ,, three . . . . . 35
3 ,, ,, ,, four . . . . . 88
4 ,, ,, ,, ﬁve . . . . . 8
5 ,, ,, ,, six . . . . . 8
6 ,, and over . . . . . 4
2192
The large number attacked during their fourth year of residence is
probably due to their having moved as a large-sized unit into an infec-
tive area at such a period in their service.
Acclimatisation, as applied to undulant fever, is therefore, in
regiments or large bodies of men, simply a survival of the ﬁttest
(most insusceptible), or a weeding out of the susceptible 3 and is not
acquired by those llnattacked, by simple residence in countries where
this fever prevails in healthy houses or barracks. The writer knows of
three English residents who contracted this fever after twenty, seventeen,
and twelve years’ residence in Malta. He himself contracted the disease
after ﬁve and a half years, and a brother officer after over six years’
residence. Few of the regular English permanent residents appear to
escape an attack at some period or other, but do not seem to have
suffered twice from long attacks.
Immunity from subsequent attacks—Though the writer and others
have carefully examined the recorded medical histories of many thousands
of soldiers serving in the Mediterranean, they have failed (with one
exception) to ﬁnd mention of a second attack of true undulant fever
affecting one individual. This may, however, be owing to the fact that
in these “short service” days, soldiers stay but a few years exposed to
its inﬂuence; and that a large number of those who have suffered from
this fever are invalided to England and do not return. The only excep-
tion was in the case of an oﬂicer, who, together with his wife, suffered
from an attack of this fever in August 1895 in a small quarter in Malta,
where the drain-pipe had burst and leaked into their room. Both
individuals were about ﬁfty years old, and the pyrexial and other
symptoms were unmistakably those of undulant fever. In April 1871,
when previously serving in Malta, this oﬂicer had (when in the ranks),
suffered severely from fever when quartered in Isola Gate, for which he
was invalided to England after ninety-three days’ illness.
From his graphic description of his symptoms, both during the
pyrexial period and during his subsequent convalescence in England,
the writer is of opinion that he suffered at that time from a typical and
[MEDITERRANEAN FE VER 83

severe attack of this fever. This would amount to two attacks in the
same individual with an interval of twenty-four years.
It is not uncommon in Malta for cases, with every appearance of
their being attacks of undulant fever, to be apparently cured in
from one to four months, and to be discharged to duty, returning to the
same barrack-room and bed from which they were originally admitted,
only to again develop fever of an unmistakable, lengthy, or even fatal
character, after a month or more of apparent good health. During
their ﬁrst admission these cases were certainly not suffering from mild
enteric or other speciﬁc fever, nor from the common febricula of the
place. In a disease whose duration is an unﬁxed quantity, it is not
impossible that many of the cases of seven to fourteen days’ fever, so
often met with, may be abortive attacks of true undulant fever;
but what is certain, is that these short attacks do not confer immunity
from more severe ones occurring subsequently. Again, it is impossible
to say in such cases (in which the apyrexial period does not much
exceed a month in duration), whether the patient is suffering from a
relapse from his original infection, or from the effects of a fresh dose of
the poison. By the expression “true undulant fever,” the writer in
this work refers to cases whose pyrexia is typical and has lasted at
least three weeks, or in which a post-mortem examination has been held.
Guilia (Malta, 1871) states that this fever has often been manifest
more than once in the same individual, instancing a case in which an
English lady had three separate attacks, but he does not give particulars
of their length. Guiffré is of opinion that one attack does not confer
immunity, and mentions that persons have suffered from it a second and
third time in Naples, Palermo, and in Malta. Carageorgiades (Cyprus,
1891) states that as a rule one attack does confer immunity, and that
he has “seen persons who had suffered from this fever ten or ﬁfteen
years ago protected from a second attack.” Bruce says: “In my
opinion one attack does confer immunity.”
Many naval surgeons are of opinion that one attack rather predis-
poses to a second, and for this reason those invalided from the Medi-
terranean are not sent back until after a long ‘period. Thus Gipps
(1890) says : “ I would here take the opportunity of calling in question
the statement made by Surgeon Bruce as to one attack conferring
immunity from a second. This is distinctly contradictory to the
experience of naval medical and other ofﬁcers ; and so strongly is this
held to be the case that ofﬁcers and men who have once had this fever
are not sent back to the station till after a long time has elapsed. In
fact, in the naval service, exactly the opposite view is held to that just
quoted, and so far from one attack granting immunity, it is looked on
as predisposing very strongly to a second and third attack; and I havc
myself seen many men who have had more than two separate attacks.”
The writer has often been told of cases of two or three separate
attacks, which, on investigation, prove to be short febriculas, or relapses
of one attack. The comparative immunity of the native adult population
s4 UND ULANT, MALTA on

of Malta has been ascribed to individuals having suffered from the
fever during youth (see death—rate tables), and though, in the writer’s
experience, many adult Maltese suffer from the fever, it cannot be
denied that the native population have (as is the case with most endemic
diseases) acquired a certain protective immunity. It is probable, from
the facts at our disposal, that an attack of this fever does confer
immunity, at any rate for a number of years; but that this immunity,
like that of enteric fever, is by no means absolute in every individual;
also it is impossible at present to lay down the period after which he
becomes proof against relapses.
TABLE IX.——M0rtality Rates .- Civilian population of Malta, 1895,

per mille
Place. Under 5. Over 5. All Ages. Population.
Malta . . . 267‘35 100'05 14'43 25'41 153,399
Valetta . . 276'09 100'62 13'11 21 '85 24,132
Floriana . . 21081 6831 14'41 2337 6,076
Cottonera . 271'88 92'83 11'49 21'89 28,450
Villages . . 267 '74 10455 1567 27°51 94,741
Gozo . . . 277'18 94'98 13'51 24'30 19,545
Victoria . . 33816 10253 2088 3156 6,337
Villages . . 258'89 91'31 10‘22 21'12 13,208 ‘


The fact that a patient has suffered from enteric fever does not in
any way protect him from a subsequent attack of undulant fever, nor
does an attack of undulant fever confer immunity from subsequent
enteric fever. On this point Guiffré, Bruce, Rummo, and Carageorgiades
are very deﬁnite, and Maltese physicians are of the same opinion. Bruce
states: “Several patients have come under my charge suffering from
Malta fever who have previously had enteric fever.”
Moreover, the serum of blood from patients suffering from (or who
have recently suffered from) enteric fever has no agglomerative effect
upon pure cultivations of the micrococcus Melitensis.
The writer has met with the following instances in his practice :—
Case 1 6.—Enteric fever followed by undulant fever two years later.
The writer’s sister suffered from an attack of enteric fever with a
relapse during the autumn of 1890, when at school in Brussels (aged
seventeen years). In the autumn of 1892, together with a sister sleep-
ing in the same room, she suffered from an unusually severe attack of
undulant fever in Malta, the pyrexia of which lasted a hundred days.
Between the attacks there was perfect convalescence, a year of which
was spent in Malta, and a perfect convalescence was made from the
second attack, the patient continuing to reside in Malta for two years
afterwards.
MEDITERRANEAN FE VER 85

Case 17 .—Mediterranean fever followed by fatal enteric feoer four months
later.
An officer of the Royal Artillery suffered from unmistakable un-
dulant fever from 26th November 1891 to 15th January 1892, when
he was sent on leave to England and apparently recovered. He did not
suffer from relapse, but returned to duty in Malta some two months after.
On 5th May he was admitted to hospital suffering from acute enteric fever
which proved fatal. At the post-mortem examination typical enteric
ulcers were found, nor was there evidence of any previous Peyerian
disease having existed. Eberth’s bacillus was obtained and cultivated
from the spleen.
Case 18.-—-Enterio feoer followed by Mediterranean fever four years later.
A sergeant of the Welsh Regiment was stated in his medical history
sheet to have suffered from enteric fever in Cairo in February 1889 3
duration of time in hospital, ﬁfty-nine days. He assured me that there
was no doubt at the time as to the nature of the disease he was then
suffering from. In June 1893 he was under the writer’s medical charge
suffering from undoubted undulant fever, the pyrexia of which lasted
for ﬁfty-six days, after which he was invalided to the sanatorium at
Citta Vecchia, where he completely recovered.
Case 19.-—Mediterranean feoer followed by fatal enteric fever with an
apparent interval of less than one month.
A corporal of the Royal Scots Regiment was in hospital under the
author’s care from 10th April to 10th May 1891, suffering from irregular
temperature and constipation. He returned to duty apparently cured,
but was readmitted to hospital on 6th June. On this second occasion he
suffered from a similar form of irregular pyrexia with obstinate con-
stipation until the 6th July following. In both cases the clinical
symptoms were like those of many cases of undulant fever, and quite
unlike those of enteric fever. He was transferred to the sanatorium,
and his temperature remained normal until the end of the month, when
it began to rise daily, proving fatal on 12th August. At the post-
mortem examination typical early enteric ulceration was found, but no
signs of previous Peyerian disease. The interval between the two
attacks is in this instance so short that it cannot be considered as con-
clusive, yet it is of value, as it has the appearance of a case in which the
two poisons either coexisted, or followed one another very closely.
The writer has also met with a case which for the ﬁrst month ex-
hibited the intermittent pyrexia of undulant fever, and during the second
month a continuous temperature in which he died. The latest symptoms
and post-mortem appearances were those of acute enteric fever, but with
no signs of previous (healing) ulcers.
Cases of apparent enteric fever becoming undulant fever after the
primary wave will be dealt with later.
Many cases of this fever are at ﬁrst erroneously diagnosed as enteric
fever, and such cases must be clearly separated from the above examples.
The following is such a case :—
so UND ULANT, MAL TA 0R

Case 20.—Pte. “7., K.R.R. Mediterranean Service one year. Ad-
mitted 20-12-92 for enteric fever, and discharged 7 -2-93 (ﬁfty days), but
readmitted for undulant fever twenty days later (lasting 120 days).
This was really a case of undulant fever incorrectly diagnosed at ﬁrst.
A previous attack of malaria does not confer immunity from sub-
sequent attacks of this fever, as has been thought by some. The writer
has met with cases of this fever affecting men who have previously
suffered from paludism in India or in Mauritius. Chartres, in his
account of an epidemic in 1866 in Malta, says of 108 cases: “ Thirty-
two had previously suffered from ague and intermittents in Canada and
elsewhere.” Guiffré, Bruce, and Carageorgiades are of the same opinion,
while Rummo considers that previous attacks of malaria predispose cases
to the effects of this fever. The writer has met with one case where
previously contracted paludism appeared to complicate undulant fever
pyrexia.
The three to ﬁve day febricula (simple ardent fever), of such common
occurrence in the summer in the Mediterranean, appears to have no bear-
ing on this question, nor has syphilis. Attacks of undulant fever un-
doubtedly pave the way in many instances for tubercular sequelae, while
patients suffering from gonorrhoea have on many occasions developed
concurrent undulant fever. Cases have contracted gonorrhoea and primary
syphilis a fortnight after discharge from hospital after severe undulant
fever; nor do these diseases protect. Patients who have previously
suffered from rheumatic fever or rheumatism are exceptionally prone to
the rheumatic symptoms of this fever, while some have gone so far as to
say that such cases are specially predisposed to attacks of undulant fever
in the ﬁrst instance. Rheumatic fever, if it exists at all as an endemic
disease in Malta, is most uncommon.
Marston (1859) has described a peculiar alternation in certain
localities of undulant and enteric fevers in epidemic form. In Malta
the writer has neither found this borne out by statistics nor by his
personal experience. Such occurrences would appear to be a matter of
coincidence.
Changes in type (quantitative and qua1itative).-—The question of
changes in type with respect to the prevalence of this fever is a very
difﬁcult one, owing to the absence of reliable statistics, cases of this fever
having been always included with other fevers, or under various
symptomatic headings. These headings under which the fever has been
returned during the past have, however, one and all decreased both as
regards numbers and case mortality. But with this fact we must
remember to consider the decrease which has also taken place in the
prevalence of dysentery, enterica, and other (doubtless preventible)
diseases. If we carefully study the accounts of continuous fevers in
those places where endemic malarial fevers do not exist, we ﬁnd a most
notable disappearance of malignant and fatal cases of continued fever
(other than enterica). One is, on the whole, led to believe, at any rate
in Malta and Gibraltar, that on account of better treatment, more skilful
[MEDITERRANEAN FE VER 87

diagnosis, increasing care as to sanitation and general hygiene, or it may
be from some actual change in type for the better, undulant fever has
decreased in its case severity with the growth of the present century.1
We must not, however, be led away by accounts of these fevers written
early in the century into thinking that there were not then a proportion-
ate number of mild cases also, as such authors were apt to base their
descriptions upon their most noticeable and severe cases, neglecting or
failing to recognise their milder cases. There is a general impression in
Malta at the present time among civilian practitioners that this undulant
fever is increasing in prevalence in that place, a theory which reminds
one of similar opinions held in Malta in the days of Marston and N otter.2
The theory may be correct, and can only be disproved by actual
statistics, covering a sufficient number of years. These cannot become
available for some time to come. It must be carefully borne in mind
that this fever varies in prevalence from year to year, appearing to
follow some periodical cyclic inﬂuence. Hence it comes that the official
reports and opinions of senior medical ofﬁcers who have only spent from
two to ﬁve years continuously in its endemic area, have varied greatly
as to this point, being based on their personal experience, which in point
of time is necessarily limited. Moreover, the majority of medical
practitioners in Malta have only during the past seven or eight years
begun to recognise and accept the existence of this endemic fever, and
few are aware that it was well described before the year 1886. It is
not surprising that such men are meeting with more and more cases
every year, as it is only during the last ten years that the disease has
been brought prominently forward in the medical journals. Many date
its introduction from the year 1885-86, when a new drainage system
was laid down. Thus Bruce says, when writing in 1889 : “It is
curious that the introduction of the system of removal of excreta by
sewers has been looked upon, rightly or wrongly, as coinciding with an
excessive development of this fever in Valetta, Naples, and Catania.
Eugenio Fazio,3 in writing of the Neapolitan fever, states that from the
time the old-fashioned emptying of cesspools was suppressed and the
house drains were carried into the main sewers, which had previously
been used for the carrying off of rain water, the hygienic condition of
Naples was changed. The faecal materials being collected in a cloacal
system which was not well constructed, being not only deﬁcient in down-
fall, but also in water for ﬂushing, there stagnate and inﬁltrate the
sub-soil, especially as this is a porous rock, whence are poured into the
atmosphere the products of putrid fermentations. Tomaselli4 writes in
1 The case mortality for S. C. fever in Malta has fallen from 3'08 per mille in the sixties
to 2'60 in the seventies and 0'93 in the eighties. The majority of these fatal cases were
probably undulant fever, as it has been more common to miscliagnose such cases enteric fever
than the reverse, while diagnosis has become more accurate.
2 See Chap. I. p. 16.
3 Fazio (1879) ; also same author, I l ehima e la salubritcl di Napoli, 2nd ed. Naples,
1891, pp. 30-33.
4 1886, etc.
ss UND ULANT, MAL TA 01?

the same manner concerning the fever in Catania. He states that its
occurrence and causation seemed to have some connection with local
sanitary conditions, which had been modiﬁed by the introduction into
the public streets of the sewer system, and the ﬁrst outbreak corre-
sponded in fact with the epoch of this reform. . . . He is certain
that, under the existing circumstances, in which there is a scarcity of
water for flushing purposes, the city of Catania lies under the malign
inﬂuence of a poisonous miasma, which is continually given off from
these subterranean sources. In like manner it was the fashion in 1886,
in Valetta, Malta, to blame the introduction of a general system of
drainage for the great increase in the number of cases of this fever
during the two years in which the system had been in operation.
Among soldiers this increase had certainly been very marked, and it
appears that the sewers were in operation before an efficient method of
ﬂushing was introduced. Tomaselli’s words in regard to Catania might
have been applied to Valetta.
Tomaselli, in a later edition of his pamphlet, seems to place less
stress upon this cause for an increase of prevalence.
Those who put forward the theory base it on the idea that a source
of infection which in the cesspit days was conﬁned to a single house,
or to certain houses, became by means of a general, but insufficiently
ﬂushed, drainage system a more widespread cause of fever. This,
as will be shown later on, does not altogether apply to Valetta, as a
system of conduit drains was laid down in that place by the Knights.
Again, the year in question (1885) was one in which the usual cycle
of prevalence of S. C. fever was at its highest. It was a very hot
and rainless one, similar to others in which there has been excessive
prevalence of this fever. The same type of undulant fever was also
very prevalent in Sicily at that time. Numerous cases of enteric fever
were invalided to Malta from Egypt by the Army and Navy at that
period. Moreover, while the new drainage was in progress, there were,
we are told, heaps of sewage and other putrescent material from the old
conduits lying on the roads beside the open drains. There is little
wonder, therefore, that enteric, undulant, and other continued fevers
were prevalent at the time, and that special attention was directed to
their existence.
Dr. Pisani, chief Government medical officer at Malta, who had
practised in that place since the Crimean War, states that the disease,
in his opinion, was at ﬁrst almost conﬁned to the neighbourhood of
military barracks, and that it spread at a later date to the civil popula-
tion and villages. Very little information is to be gained from civil
statistics upon this point, as notiﬁcation has but recently come into
force. The oﬂicial death-rates are of little value, as not only is the
death-rate of this fever exceedingly low, but the majority of the deaths
from this cause have been returned under the heading of enteric fever,
or under symptomatic headings. Moreover, few post-mortem examina-
tions are held. It is a fact, however, that this and other continued
MEDITERRANEAN FE VER 89

fevers are and have always been more prevalent among the soldiers and
other visitors than amongst the indigenous population which has had
the opportunity of acquiring a certain immunity. We ﬁnd that Dr.
Hennen mentions that from 1821-23 fevers in the civil hospital accounted
for over 14 per cent of the total deaths, and that from 1818-23 they
accounted for 10'6 per cent of the deaths among the civil population
(96,404). These fevers were of the continued type, were non-malarial
in character, and were at that time the most prevalent diseases in the
island.
At present, in Malta, we ﬁnd this undulant fever prevailing in Valetta
and the Three Cities, at those villages where the inhabitants of Valetta
chieﬂy visit, i.e. Sliema, Notabile, Lia, Balsan, Attard, Birchicara, Nasciar,
etc. ; and also at Zabbar and Zeitun, which, besides being near the Three
Cities, are inhabited by the men who coal the ships in harbour. In the
other villages it is little prevalent, and enters but rarely into the
official returns of such outlying villages as Melleha, Dingli, Gargur, etc.
In Gozo it occurs in Victoria, the chief town, but scarcely ever in the
villages, and with much less frequency among the troops than is the
case in Malta. In fact, the greater number of cases of undulant fever
which have occurred amongst the Gozo garrison have apparently been
importations from Malta.
Surgeon-Major Robinson, A.M.S., who has been for four years in
medical charge of troops in Gozo (average annual strength for that
period, 540 men), says :—
“Attacks of this fever among men sent straight to Gozo (without
previous residence elsewhere in the Mediterranean) are so rare, that,
with the difficulty of being sure that even the few men attacked have
not visited Malta since their arrival, I am inclined to doubt its endemic
occurrence in the barracks of Gozo. I have made it a rule to ask all
fever cases about their movements prior to admission, but unfortunately
I have not recorded their answers, and cannot be certain of the move-
ments of any individual case, as a number of men visit Malta from time
to time on duty or pleasure.
“ While attacks or relapses occur among bodies of men immediately
after their transference from Malta, such attacks tend to become exceed-
ingly rare, or cease entirely, after a certain time; as if these men had
exhausted the stock of fever brought with them. Companies of men
that have remained for a long time free from the fever in Gozo produce
cases on their return from a course of musketry in Malta (duration two
to three weeks).
“From 1892 to 1896, out of an average strength of about twenty
women and thirty-four children occupying married quarters in barracks
in Gozo, but one case of this fever occurred, and this in a child who
was suffering from the disease when transferred from Malta. Amongst
the ofﬁcers’ families for the same period (average strength three ladies
and six children, all living out of barracks), three cases occurred. Of
these two were transferred from Malta while suffering from the fever,
90 UNDULANT, [MALTA OR

and the remaining one had recently arrived from Egypt, where she had
resided for some months. From November 1894 to November 1895
some twenty-six additional women and fourteen children arrived straight
from England, and resided in the villages of Ghain Seilan and Migiaro,
and in houses in the neighbourhood where sanitation is either absent or
rudimentary. They inhabited with natives the small, badly-ventilated
and overcrowded houses of the poorer classes. Though they suffered
(especially the parturients) from ophthalmia, diarrhoea, sore throats,
anaemia, etc., and were so heavily handicapped from a sanitary point of
view, not a single case of this fever occurred amongst them. Other
families have lived from three to six years in Gozo without suffering.
Now the members of these families, unlike the soldiers, rarely, if ever,
visit Malta. In barracks there are dry earth latrines, the urine and
slope being carried off by water drainage to the sea. The water-supply
is good, but excessively hard. Milk is obtained from goats, as in Malta.
It would, therefore, appear that in Gozo during the last few years,
situated only ﬁve miles from Malta, in similar barracks and houses,
built upon similar porous rock, men and families of the same regiments,
age, etc., living under similar climatic and domestic conditions as those
met with in Malta, enjoy an enormously greater immunity from this
particular fever, even though they in certain instances live under what
might be considered most unfavourable sanitary conditions.”
The places where it is at present most prevalent in Malta are those
which for centuries have been the centres of the greatest mercantile
activity. Those from which it is said to be absent, or in which it
rarely occurs, are isolated agricultural villages, little or never visited by
the inhabitants of the infected towns. Few of the houses in these
villages have any sanitary arrangements, the native using an adjacent
ﬁeld for necessary purposes ; while in those in which middens are built
there is sufﬁcient space to allow of their being away from the dwelling-
rooms. The villagers also come but little to the towns, and then only
for a few hours to sell their country produce ; and as the distances are
so short they can always return on the same day. It is possible, and
indeed probable, that the outlying towns, and those villages in which
the fever occurs, have received it from the mercantile cities around the
Grand Harbour in the ﬁrst instance. Although the troops have been
massed about this harbour for many years, it scarcely justiﬁes a belief
that they are responsible for its occurrence, but rather they suffer from
being strangers, obliged to live amid the closely-packed native popula-
tion in the worst part of its Maltese endemic area.
There are many facts which might account for an apparent increase
in prevalence, which might not at the same time be a real and actual
increase of a permanent nature in the proportional amount of sickness
from this cause. For instance, the civil population has nearly doubled
itself in numbers since 1820, so that while a great many more persons
exist within the infective area, there is also a proportional increase in
the sources of infection. The garrison has also increased in numbers
[MEDITERRANEAN FE VER 91

year by year, and at the same time, owing to the present short service
system, and to the short period now spent by individual regiments in
one place, the average age and service in the Mediterranean of individual
soldiers has very considerably decreased. In these days, therefore, a
much larger number of young susceptible British soldiers are annually
exposed to the infection of this fever than was formerly the case.
Though the total admissions per thousand of strength for S. C.
fever in Malta have been on the whole steadily decreasing during the
past eighty years, the actual number of cases of undulant fever may
have increased among the troops, and so any individual medical officer,
by having more cases to treat, may have imagined that the disease was
really more prevalent, unless he at the same time considered other
attendant circumstances. More cases seem to have been admitted into
the Valetta Military Hospital during the last six years (1891-1896)
than were admitted during the thirteen years mentioned by Bruce
(1876-1888) in his paper published in 1889.
The author is of opinion that the increase is more apparent than
real, and that if the attack rates per thousand of susceptible people
could be compared for sufficiently long periods, the increase would be
absent from among the urban residents, and if present among the troops
would prove to be due to the youth of the men and to the frequent
arrival of new regiments in the command.
There is reason to believe that the statistics in the official military
returns, referring to S. C. fever and remittent fever in Malta, since
1817, may throw some light upon the past prevalence of undulant
fever. The reasons for so thinking are—
(1) That whenever undulant fever has been sufficiently prevalent to
be remarked upon specially, the occurrence of S. C. fever and remittent
fever has been proportionally great (1859, Marston 3 1865-8, Boileau
and Chartres; 1872, Notter; 1878-9,1 Veale; 1885, Bruce; 1892,
author. See also Army Medical Department Reports for these years).
That whenever undulant fever has been epidemic in any special
local area, it has been accompanied by an increase in the number of
cases of febricula from the same area.
(3) That during the nine years in which statistics of undulant fever
have been collected by Bruce and by the author, and the years in which
its monthly prevalence happens to have been separately mentioned in
the official reports, the seasonal prevalence and relation to climatic
conditions have been roughly similar for both undulant and simple
continued fevers.
(4) That from 1871 to 1885 cases returned as remittent fever were
instances of attacks of this undulant fever.
(5) That the annual admission-rate for rheumatic affections, which
in Malta are usually the sequelae of undulant fever, has followed the
same curve as that of simple continued fever.
Now, if we analyse the admissions to hospital among soldiers in
1 See also Health of the Navy.
92 UNDULANT, [MALTA OR

Malta which have been included under the name “Simple Continued
Fever,” we ﬁnd that these consist of—
(a) Cases of a short speciﬁc febrile disease, often called simple ardent
fever or febricula, whose pyrexial duration is from one to ﬁve days, which
form the great bulk of these admissions. The prevalence of this fever
seems to be governed a great deal by climatic conditions, of which
temperature would appear to be an important factor, though not the
only one. It is, and has been for very many years, an extremely
common disease in Malta during the warmer months, occurring often in
apparent waves of prevalence and attacking the same individual year
after year, frequently affecting him about the same month in each year.
Few of the garrison escape an attack of this fever, but in many cases it
is so slight that but little notice is taken of it. Whatever form of
poison is concerned in the production of this disease, there is every
indication that it is separate and distinct from that of undulant
fever. There is, however, a close resemblance between the seasonal
prevalence of the two fevers, so that an increase in the activity of one
is accompanied by a similar increase in the other.
(b) Cases of abortive or undiagnosed enteric fever, which previous
to 1860 formed a larger proportion of these admissions than they do now.
Enteric fever, however, in Malta occurs mostly during the autumn
and winter months, when undulant fever is uncommon. We are,
therefore, able to judge of the extent to which these cases may cause
error in any individual year. Moreover, while the prevalence of enteric
fever is very small when compared with that of simple continued or
undulant fevers, its yearly prevalence since 1860 has been fairly
steady, except during certain years when some known cause of infection
has been at work. We ﬁnd also, on comparing the admission-rates of
enteric fever with those of simple continued fever, that there is no
variation that would lead one to believe that undiagnosed enteric fever
had caused an appreciable error in the curve of prevalence of the
so-called simple continued fever.
(c) Cases of more or less remittent pyrexia of from six to twenty
days’ duration, which but for their extremely short duration have
every appearance of being cases of undulant fever. These cases are
particularly common when undulant fever is at all prevalent, and
occur at the same time of year as that fever, and are admitted from
the same barrack-rooms. That they are abortive undulant fever we
are not at present justiﬁed in saying, but this class of case does not
appear to interfere with the proportional admission-rates of simple
continued and undulant fevers.
(d) Cases of slight pyrexia due to undiscovered local conditions, or
to slight ailments, which form so small a proportion of these cases that
they may be disregarded in a rough estimate.
(e) Cases of true undulant fever, which form about a third of
the admissions for simple continued fever each year, and fresh ad-
missions for relapses of undulant fever in men who have been dis-
[MEDITERRANEAN FE VER 93

charged from hospital apparently cured, which latter form a large number
of these cases.
Of the above we may disregard classes (12), (c), and (d), while class (a)
appears to follow a similar annual prevalence curve to that of
undulant fever (class 6), the activity of its poison depending prob-
ably on somewhat similar factors. On these grounds it is possible
that the annual prevalence curve of simple continued fever for Malta
(and indeed there is reason to believe that the same may be said for
Gibraltar), taken on the admission-rate per thousand of strength since
1860, may help us in estimating the behaviour of this fever year by
year with regard to climatic conditions and changes in quantity.
Subsequent observations, with the more accurate statistics which will
become available when this fever is returned under a separate heading,
can alone settle this point; and in the meanwhile the writer will
merely state the facts as a guide for subsequent investigations.
TABLE X.—Admission—Rate (Malta) per Mille of Strength for Simple
Continued Fever (Military Garrison), compared with the Rainfall
in Valetta, 1859-1895.

Year. Rate. Rain. Year. Rate. Rain. Year. Rate. Rain.

1859 1 2695 1872 1 233‘4 13'5 1884 1145 154
1860 1 2086 16 '2 1873 170‘5 239 1885 1 ‘1 181 '9 121
1861 1416 20 '4 1874 197 '0 236 1886 3 ‘1 154 '1 248
1862 1417 155 1875 1407 27'0 1887 2 103 '6 21'1
1863 1146 23 '7 1876 136'1 142 1888 71 '2 14'8
1864 1869 21 '0 1877 157'1 262 1889 836 260
1865 1 2104 164 1878 1 1892 179 1890 85 ‘5 217
1866 1 1981 100 1879 1 2095 265 1891 109'1 181
1867 1 2287 128 1880 1734 193 1892 1 172'0 251
1868 1 2057 24 '0 1881 165'1 146 1893 1308 236
1869 1798 20 '3 1882 1117 283 1894 104'1 278
1870 1319 16.0 1883 96 '3 196 1895 1 1689 11 '6
1871 115'’? 169 t


1 Epidemics of undulant fever noted. 2 New water-supply to Valetta.
3 New drainage in Burmola, Isola, and Ricasoli. ‘1 New drainage in Valetta.
TABLE XL—Averaye Rates (from above) for Cyclical Periods.1


I‘IOC -
(Bass
1859-1867 9 188 '9
1867-1872 6 1825 6'4
1872-1879 8 1792 3'3
1879-1885 7 1503 289
1885-1892 8 120'1 302
1 A cyclical period here extends from one maximum year of prevalence to the next
maximum year, extending, therefore, from the summit of one wave of prevalence to the
summit of the next.
CHAPTER III
Symptomatology.—(a) General remarks, with description of three types and irregular
cases :—(1) Malignant type. (2) Undulatory type. (3) Intermittent type. (4)
Irregular cases.——(b) Physiognomy.——(c) Tegumentary system: Non-exanthemat-
ous 3 Prickly heat, boils, purpuric spots, etc., may occur; Diaphoresis 3 Desqua-
mation and loss of hair; Distinctive odour, etc.—(d) Pyrexia: Pyrexial waves;
Nature and duration ; Variations ; Diurnal Wave, nature and duration 3 Effects of
external and internal inﬂuences.—(e) Nervous system .' Fever pains, headache,
general nervous irritability, impairment of mental functions and of special senses,
cerebro—spinal symptoms, neuritic pains, paralysis and atrophy of certain muscles.
—-(f) Arthritic symptoms: Acute; Subacute—(g) Circulatory system: Pulse,
palpation, valvular disease, weak action, pericardial effusion.—(h) Respiratory
system: Bronchitis, catarrhal pneumonia, hypostatic congestion at bases, cough,
expectoration, Mediterranean phthisis—(lo) Alimentary system: Mouth, tongue,
gastritis, constipation and diarrhoea—(Z) Urinary and sexual system: Epididy-
mitis and orchitis, vesical irritability, retention, albuminuria, menstruation.—-(m)
Complications and sequelw.
Symptomatology.-—So variable are the symptoms and so uncertain is the
duration and course of this fever, that it is impossible to give a description
to which all cases can be referred. The various local symptoms would
appear to be due to the action of a living virus upon the tissues, having a
constant but comparatively mild irritative action. The more severe local
and general symptoms met with in malignant cases appear to be due to the
action of large quantities of the virus (with probably greater virulent
power) in the tissues than are met with in mild cases. In the mildest
intermittent cases, and in the later stages of other cases preceding con-
valescence, the disease appears to have a certain diurnal latency, which
disappears in proportion as the disease increases in severity. In all
cases there are periods of more or less abatement of symptoms, often
marked by intervals of absolute but temporary latency between relapses.
Where the virus rests during these latent periods we cannot say,
though in many cases localised rheumatoid symptoms lead us to believe
that a portion of the virus may remain in the locality of these
symptoms. As a rule, however, when local symptoms are present
pyrexia is also present. We can only compare this latency with that
met with in syphilis, paludism, and tubercle; and with that lately
observed in other fevers of more certain duration. Its irregular course
and uncertain duration are somewhat like those of paludism, but
MEDITERRANEAN FE VER 95

unfortunately we have not a speciﬁc remedy like quinine with which
to cut it short. In some of its clinical symptoms this disease has a
connection with the effects on the body of the disease causes of typhoid
and rheumatic fevers. Except that this virus never appears to cause
suppuration in its local manifestations, it seems to have many of the
general and local actions of that of pyaemia, falling short, however, of
that disease in the severity of its action. Whatever its life action
within the body proves to be, clinically the disease has every appearance
of a blood infection, commencing in the mucous membranes of the mouth,
throat, or possibly of the stomach and air passages; and from hence
passing into the system and the various tissues, causing symptoms due
to its general and local action on the body tissues and economy. Its
chief and most constant clinical manifestation is pyrexia, and from this
point of view must its clinical description and clinical variations be ap-
proached. Putting aside those short (abortive and indeﬁnite cases of
fever lasting from seven to twenty-one days, which are more severe than
simple ardent fever and unlike enteric fever, we meet with three varieties
to which all cases of this undulant fever seem to approximate clinically.
These, however, are not necessarily distinct from one another, but must
be looked upon as due to variations in the severity of the action of the
virus, brought about by causes dependent upon the organism or the
individual himself, or his surroundings. Any one variety or type may
pass into any other.
As long as the patient is liable to pyrexia, so long is the virus still
present in the body, and so long is it theoretically able, under suitable
circumstances, to burst out at any time into an attack of any severity.
When pyrexia has ceased entirely, the symptoms met with are those due
to anaemia and debility of the various tissues, making them temporarily
less able to carry out their usual functions, and to resist the action of
any adverse surrounding circumstances.
As the various local symptoms are variable in constancy, writers of
limited experience must necessarily vary in their accounts of the fre-
quency of their symptoms.
The following descriptions are based upon notes of over a thousand
cases which the writer has had the opportunity of seeing or treating in
Malta and elsewhere in the Mediterranean, during six years of almost
continuous hospital practice. These were selected, from the many
hundreds of cases of continuous fever admitted to the military hospital
“for simple continued fever,” on account of their clinical or post-
mortem appearances having left no doubt as to their nature.
1. Malignant type.—(a) The onset in many cases seems most sudden.
The patient, often a strong, muscular man, is admitted to hospital
suffering from severe pyrexia, stated to be of only one or two days’ '
standing. He complains of severe headache, “ pains all over him,” dis-
taste for food, thirst, nausea, and even vomiting. His face is ﬂushed, his
tongue thickly coated with whitish gray or yellow fur, pink at the tip
and edges, moist, very swollen, and indented by the teeth laterally.
96 UNDULANT, [MALTA 0R

His temperature may be 104°-105° F. or more. There is epigastric, splenic,
and perhaps hepatic tenderness on pressure, while the area of splenic
dulness is increased. The patient’s breath is unusually offensive. If
left to take its course, after four or ﬁve days of constantly high tem-
perature, signs of basal pneumonic congestion, with bronchial rales all
over the chest, appear, and these may pass on to lobular consolidation.
The pulse remains strong, or responds to stimulants, and the mind is
unusually clear. The urine is decreased, dark in colour and loaded
with lithates : the stools are most offensive. Diarrhoea may be present
from implication of the great gut, a condition which adds materially to
the gravity of the case. In such cases the stools are profuse and fre-
quent, excessively offensive, usually brown in colour, and varying in
consistency.
The temperature may abate slightly for a few days, but remains
usually well under 1030 F. After a varying number of days the
pulse begins to ﬂag and become intermittent, the breathing next
becomes laboured, and obstinate vomiting may be present. The
tongue becomes brown, dry, and cracked, the teeth are covered with
sordes, and other symptoms of the so-called “typhoid state” set
in. At this time there is a most offensive odour about the patient,
more especially about his breath and skin; his whole appearance
is that of a man saturated with the fever poison, as if it were attack-
ing and rotting every tissue in his body. The respirations now
become shallow and fast, with signs of increasing pulmonary con-
gestion 3 delirium supervenes and passes into coma ; the faeces are passed
involuntarily; the temperature rises steadily ; the heart gives way, and
the patient dies of hyperpyrexia. At death the temperature in the
mouth is about 110°, F., but may continue to rise, so that 112°-115O F.
have been registered in the internal organs shortly after death. Death
in such cases occurs as a rule between the ﬁfth and twenty-ﬁrst days of
the disease, but rapidly fatal cases are happily rare in these days of
improved treatment.
(b) In a few cases the temperature may abate after the ﬁrst few days,
and remain between 1020 and 103° F., but at the same time a condition
of extreme nervous excitability sets in. This is soon followed by
pronounced nervous exhaustion, resulting occasionally in death, due
apparently to direct toxaemic poisoning of the higher nerve centres.
These cases are uncommon, but need most careful management.
(c) In some instances the patient passes safely through the primary
pyrexial undulation, the temperature abates at the end of two or three
weeks for a few days, followed by the gradual rise of a second pyrexial
undulation. This following the same course as the primary attack, but
in a patient weakened by the previous fever, may cause a fatal result
similar in every respect to those already mentioned.
(d) In two cases the writer has met with a temporary fall to normal
combined with great exhaustion, lasting from six to eighteen hours,
preceding death from hyperpyrexia (vide Cases 6 and 21).
[MEDITERRANEAN EE VER 97

(e) In cases which prove fatal at a later stage (70th-150th day)
of the disease, death is usually due to sudden cardiac failure, pericardiac
effusion, pleuritic or empyaemic mischief, to debility, exhaustion, or to the
supervention of phthisis or some other intercurrent disease.
In 45 cases in which the day of the fatal result was noted, it occurred
as follows :—


TABLE XII.
From 1- 7 days 6 cases or 1333 per cent
-,, 8-14 ,, . . . . 7 ,, ,, 15'56 ,,
a: n ' ' ' - 9 a, n n
,, 21-30 ,, . . . 5 ,, ,, 11-11 ,,
During ﬁrst month . . . 27 cases or 60'00 per cent
, second ,, . . . 11 ., ,, 24'44 ,,
7 n 3 n a: n
., fourth ,, 3 7, n 6'67 a:
, 7, 1 a, :9 :7
Total 4_5 100'00
2. Undulatory type—This may be considered to be the usual course
of this fever, other types being but variations brought about by differ-
ences in severity of individual cases. The febrile course is marked by
intermittent waves or undulations, of more or less remittent pyrexia, of
variable length, separated from one another by periods of temporary
abatement or absence of symptoms. In typical uncomplicated cases
conﬁned to bed there is usually a premonitory stage of low spirits,
mental worry, sleeplessness, anorexia, with dyspeptic symptoms, with
headache and slight pyrexia each evening. The temperature next rises
gradually, remitting each morning about half the amount of the previous
evening rise. With this are combined slight headache, pains in the
neck, back, and limbs, moist furred tongue, swollen and indented
laterally, a bad taste in the mouth, epigastric tenderness and constipa-
tion. Most patients do not at ﬁrst report sick, trying to ﬁght off the
fever. The result is that all these symptoms become exaggerated, and
on admission the temperature is high and the headache most severe.
The temperature having reached 103°-105° F. in the evening, accom-
panied by some bronchial catarrh or hypostatic congestion of the lungs
in proportion to the severity of the case, after a variable period gradually
falls to normal or thereabouts in the morning, and though it may rise
higher in the evening, the patient feels much better and probably wishes
to get up, a wish which, if gratiﬁed, is at once followed by a severe
relapse. The primary wave of pyrexia may now be said to be over.
For a few days the temperature may remain at or about normal, after
which it again begins to rise and a relapse ensues similar to the primary
attack, but usually less prolonged and less severe. This subsides only
to be followed by other relapses forming the undulatory temperature
charts so characteristic of this fever. Such pyrexia is almost always
H
98 UN!) ULANT, MAL TA 0R

accompanied by obstinate constipation, though diarrhoea may occur
temporarily in very severe cases, more especially during the primary
attack. Each remission of temperature is accompanied by profuse
sweating.
Anaemia and muscular wasting are progressive and often severe.
At any stage, but usually late in the attack, or during convalescence,
symptoms of localised interstitial neuritis may occur, leading to ob-
stinate sciatica, intercostal neuralgia, etc. In other cases peripheral
symptoms may point to irritation of the central nervous system, followed
by more central symptoms, or by loss or impairment of function of the
nerves of special sense. In many cases effusion into one or more joints
may occur, often of a sudden, transitory and metastatic nature, but
causing extreme tension and pain ; or painful orchitis may appear.
Finally, the patient is reduced to an emaciated, anaemic, and bed-
ridden condition; subject to attacks of bronchial catarrh, lobular
pneumonia, cardiac palpitation, rheumatic or neuralgic complications on
the slightest exposure to chill, excitement, or change in the weather.
Disappointed at each relapse, his whole expression is the picture of
despondent apathy, his only wish to get away to England. His
emaciated appearance, his profuse night-sweats, often intermittent
pyrexia, and cough, remind one forcibly of the last stage of phthisis.
Gradually, however, his temperature, after showing more and more
tendency to become intermittent towards the end of the second or third
month, becomes normal or subnormal in the morning, and but slightly
above normal in the evening. Next, the evening rise occurs only at
increasingly long intervals, then ceases, and usually gives place to a few
days of subnormal temperature, after which convalescence is established.
This subnormal period is one of the surest signs of approaching con-
valescence, especially when it is accompanied by a clean tongue and other
signs of mitigation of symptoms. The strength now slowly returns, the
cheeks ﬁll out, and the patient gets up for an increasing period every
, day) After a few weeks, if not invalided home, he is sent to a sani-
torium, or perhaps may be strong enough to return to duty, but for
months he is liable to attacks of neuralgic pain, to swollen joints or
testicles, combined often with a return of mild pyrexia. Final recovery
cannot be said to take place for many months, and until the anaemia has
disappeared, and the mucous membranes have regained their complete
functions. When, however, the patient is completely free from the
disease, it does not, like paludism, recur. The pyrexial duration, which
averages some 60 days, varies within such wide limits as from 20 to
300 days or more; while the total stay in hospital, which averages
some 90 days, may extend to two years, where sciatica or other sequelae
are present.
3. Intermittent type—In these cases the onset is generally extremely
insidious, the general course mild, and the duration less than in the
previous types mentioned. There is usually a premonitory stage, during
which the patient suffers from a sense of weariness and lassitude in the
[MEDITERRANEAN FE VER 99

evening, a feeling of worry and irritability about the details of his
daily occupations, and possibly slight headache in the evening. At the
same time his appetite is diminished—he wakes each morning with a
“nasty taste” in his mouth and a slightly coated tongue. If his tem~
perature is taken at this stage, it is found to be normal or subnormal in
the morning, about 99° F. in the afternoon, and normal again about ten
or eleven at night. Usually he thinks it is “liver or biliousness,” takes
an aperient, and often, urged on by his friends, attempts to work it off
by hard exercise. After a game of polo, a stiff walk or other exercise,
he returns with a racking headache and retires early to bed, where he
spends a somewhat restless night. Next morning, feeling better, he
returns to work, but sooner or later seeks medical advice, generally in
the evening. He now complains of bad headache in the evening, sleep-
lessness, pains in the muscles of the neck and back, loss of appetite and
night-sweats. His tongue is furred, swollen and marked laterally by
the teeth, he has epigastric tenderness and possibly pain, there may be
slight redness and relaxation of the tonsils, uvula, and pharyngeal pillars,
and the submaxillary, cervical or sublingual lymphatic glands may be
slightly tender and enlarged. His temperature will be found to vary
between normal and 100° F. in the morning and 99°-101° F. or more
in the evening, its height depending a great deal on the extent to which
he has endeavoured to ﬁght off the fever. Possibly, but not necessarily,
he may complain of effusion into a joint or of an attack of sciatica or
neuralgia. After a good night’s rest following a sleeping draught, an
absence for some hours of mental worry and unsuitable food, with the
warmth of bed, he feels much better. If he does not suffer from
arthritic or neuralgic complications or high pyrexia, he will complain of
little or nothing on the ﬁrst or second morning following his retirement
to bed. About 2 PM. each afternoon, or possibly earlier, he will com-
plain of a creepy feeling in the back, a sensation of general irritability
and malaise. His temperature will be found to be rising to a maximum
of 99° to 105° F. slowly and steadily until between 2 and 5 19.11., but
without rigor or paroxysm. During the night it will again fall
gradually to normal or thereabouts, at which time the patient will be
subject to a perspiration proportional in amount to the diurnal variation
of temperature and the debility present. A
This daily intermitting temperature has a close resemblance t
hectic fever, and may continue for months without other symptoms than
daily afternoon malaise, nightly perspirations, constipation, increasing
anaemia and debility. On the other hand, it may at any time, especially
if the patient is not well looked after, and endeavours to continue at
work, develop into the remittent or continuously high type of pyrexia
of the undulatory or malignant varieties already described. It may
also be accompanied by any of the complications or sequelee met with
in those types, or those types may by a mitigation of severity pass
into this intermittent type, a not uncommon ending of many un-
dulatory cases.
a‘‘'.!.
I
..‘Or
...-ll
0
‘a
QIO""
I
o”..(
100 UND ULANT, [MALTA 0R

The remarkable point about this pyrexia is the curious way in which
it often goes on day after day without any serious complications. Except
in the afternoon and evening, when his temperature is highest, the
patient eats well, and complains of little, while drugs have little or
no effect upon its course or duration. At any moment, however, the
slumbering fever may, so to speak, burst into ﬂame.
If the temperature be accurately taken, so as to register the true
daily maximum and minimum, these are found to form waves or un-
dulations of pyrexial intensity similar to those already described, the
daily remittence being exaggerated into an intermittence. On the ordi-
nary chart, where the temperature is taken at ﬁxed times, without refer-
ence to the times of maximum or minimum, these undulations are not
necessarily clearly marked, and as there are rarely absolute apyrexial
periods other than the daily intermissions, there is less despondency than
with the well-marked and disappointing relapses of the undulatory
type. The amount of pyrexia may vary within wide limits, but how-
ever high the evening temperature rises, this elevation is of a distinctly
non-paroxysmal nature, shivering being conﬁned usually to children
or persons of marked nervous excitability. Its duration is most
variable, but usually the pyrexia is seldom prolonged beyond the sixth
week in purely intermittent cases, though in exceptional cases it
has been known to continue for as long as six months.
It is always well in the Mediterranean to take the temperature of
every case reporting sick with symptoms of dyspepsia, debility, etc., as
a preliminary measure, and if there is any doubt to take it during the
afternoon or evening. Fever is often overlooked for want of such pre-
caution, and cases treated for slight symptoms for some time before the
real condition is discovered, to the detriment of the patient’s health and
the doctor’s reputation.
Irregular and mixed types—Between the undulatory type with its
continuous or remittent temperature, and the intermittent type, we
meet with every variety of curve that can be said to approximate to the
descriptions given, or to any mixture of both. There is always, how-
ever, that tendency to the formation of waves or undulations of pyrexial
intensity if the curve is accurately registered, a feature not common to
other types of fever. The differences are of a pyrexial nature, and will
be dealt with in detail under that heading.
Intermittence is a not infrequent mode of ending in cases of an
undulant type, while an intermittent case may pass into the undulant
type, this latter being, however, a much less common occurrence.
Certain cases, in which diarrhoea has been present during the
primary wave, have been thought to have been enteric fever passing on
to undulant fever, and due to a double infection. So many severe cases
have a resemblance at times to enteric fever, that it is impossible to
state deﬁnitely whether such a double infection can take place.
In such cases in which the writer has been able to make a post-
[l/EDITENNANEAN FE VER 101

mortem examination no signs of previous enteric fever have been
present.
In one case already mentioned, a month of intermittent pyrexia
similar to that of undulant fever, was followed by a continuously high
temperature, diarrhoea, and considerable haemorrhage. The case proved
fatal, and at the post-mortem the typical ulceration of the third week
of enteric fever was present, but no signs of previous Peyerian ulcera-
tion that could be referred back to the ﬁrst month of the attack. It
would seem possible that both poisons existed in the body at the same
time, as has been observed with other fevers.1
Tomaselli (1886-95) describes four types of undulant fever :——-(1)
Forma gastrica ; (2) Forma indeterminata; (3) Forma nervosa; (4)
Forma letale o paralitica.
SYMPTOMS IN DETAIL
Physiognomy.—-The ordinary case, in which the onset is insidious,
and the patient does not report sick until the fourth or ﬁfth day, when
he has a languid air and a washed-out and somewhat pale countenance,
and on the malar eminences an almost hectic ﬂush.
In the more severe onset, with high temperature, the face, the
mucous membranes of the gums, the mouth and fauces, and the con-
junctivae, are at ﬁrst somewhat congested, while in rapidly fatal cases
they are often extremely cyanosed before death. The dull, heavy
expression of enteric fever is rarely present. Later on in the attack
the skin and exposed mucous surfaces become anaemic, and the former
occasionally somewhat bronzed, the expression dull and apathetic.
This listless resignation is replaced by an expression of extreme pain
and anxiety when a large joint becomes suddenly inﬂamed, such as the
hip, vertebral joints, or the sacro-iliac synchondroses ; or by an un-
mistakable expression of mental Worry and irritation, when there is
pronounced cerebro-spinal irritation. As the anaemia increases the
skin becomes gradually of a dull clay colour, and becomes tightly drawn
over the face, the limbs shrink, and the muscles of the neck stand out
like cords, and an expression of extreme listless apathy comes over the
patient, who has suffered perhaps for three or four months from this
protracted and disappointing form of fever. The outward appearance
of many patients at this stage of the attack may be compared to that
often seen in cases of phthisis with pyrexia.
During convalescence, if there are no rheumatic or neuralgic sequelae,
the body weight is gradually if not rapidly increased, but the anaemia,
breathlessness, and debility take a considerable time to disappear, so
that there is often for a long time an unhealthy-looking fatness of
face, combined with a puffy, anaemic look. The eyelids and ankles
often remain swollen and puffy for months during convalescence,
1 Vide Chap. I. p. 10, Chap. IV. p. 160, and Brit. filed. .Iour. vol. i. pp. 129, 148 ; 1897.
102 UNDULANT, MALTA 011’

though there be no albumin in the urine. When rheumatic or
neuralgic sequelae occur during convalescence, the patient drags
himself about, and looks a most miserable individual, an appearance
heightened in the extreme by the loss of hair which occurs in this
disease. Patients suffering severely from this fever appear to age very
rapidly during the attack, an appearance which does not entirely dis-
appear on recovery. The sallow, anaemic complexion, the gray hairs,
and new wrinkles, cause the patient of from twenty to twenty-ﬁve to
appear over thirty-ﬁve years of age.
The decubitus is lateral, except in exceptional and very severe cases,
or when the vertebral joints are affected, when it may be dorsal.
Tegumentary system—This fever is not an exanthematous disease.
In a very few severe cases pimples have been met with on the
anterior surface of the abdomen, which have been at ﬁrst sight mis-
taken for the rose spots of enteric fever. Though their appearance
may have been deceptive, they did not come out in crops, nor was their
duration in any way typical. Their extreme rarity, and their similarity
to pimples which occur in those who are in otherwise good health, point
to their occurrence being accidental in this disease. In England the
typical rose rash is said by Murchison and other authorities to occur in
from 70 to 80 per cent of cases of enteric fever; but in Malta it is
more often absent or slightly marked, than clearly present, in cases of
undoubted enteric fever of all varieties of severity. The writer has
rarely in Malta met with those decided crops of copious spots that he
has frequently met with in more temperate climates. Not only does
the exanthem of enteric fever become a very small factor in diagnosis in
Malta, but it is well to be cautious when declaring spots occurring with
pyrexia to be enteric in origin, and to watch them for a day or two
before giving a decided opinion as to their nature.
Case 21.—Illustratiny pimples which were mistaken for the rose-rash of en-
tericfever.——Pte. K., Connaught Rangers, aged 21, previous medical history
very good, except that he had suffered from pneumonia two and a half
years previously. Onset sudden on the 1st of August 1891, pyrexia
not severe until the 8th day, when it rose from 102° F. in the morning
to 104° in the evening, and remained high, with the exception of those
periods when it was brought down by cold pack or sponging, until the
19th. About the 13th day he developed diarrhoea of a light yellow
colour and very loose in character, combined with general abdominal
tenderness, and a few rose spots on the anterior surface of the abdomen.
This diarrhoea lasted until the 23rd day, when he became somewhat
better. The condition had been very similar to that met with in
enteric fever, where perforation was threatening, and this opinion was
strengthened by the remarkable way in which the patient improved
under large doses of opium. The rose spots were few in number and
soon disappeared, and they were not at all typical in appearance after
the ﬁrst day. They were probably sudamina. On the 26th day signs
[MEDITERRANEAN FE VER 103

of severe congestion, and, later on, consolidation of the right lung were
apparent, and the temperature rose from 102° on the 26th to 104° on
the 29th 3 and on the 32nd day, though the right lung was clearing, a
similar condition was present in the left. On the 34th day the
temperature fell, reaching normal on the 35th, and he seemed much
better but extremely exhausted, and the writer handed the case over
to another medical officer. He was subsequently informed that his
temperature began to rise suddenly and steadily on the evening of the
next day, and he died of hyperpyrexia at 3 A.M. on the 38th day of the
disease. The post-mortem appearances were those of undulant fever,
and there were no changes visible in Peyer’s patches, the writer being
present at the examination.
Sudamina are not uncommon during and after the third week,
occurring on the back and chest, especially when the perspiration has
been profuse and the skin not suﬂiciently well attended to nor kept clean.
In summer a common and most distressing symptom is prickly heat,
which, however, occurs at the same time among healthy persons and
among those suffering from other diseases. In a few instances it may
become pustular, and resembling in that stage the pustular rash met
with beneath strong mercurial dressings. This condition must be
carefully looked after, especially when it occurs upon the back, as
otherwise, and more particularly when scratched, boils or ulcers may
complicate matters and lead to tiresome bed-sores.
In spring and autumn boils may occur in various parts of the body,
either singly or in crops. They are not especially connected with this
disease in any way, but are a fertile source of bed-sore in neglected
patients, as they often appear on the backs or gluteal regions of
debilitated cases at a late stage in the disease. The great point to be
remembered is that they are apt to spread along the skin by direct
transference of infective matter, and must therefore be dressed care-
fully, the surrounding skin being disinfected with some mild antiseptic
at each dressing. The author has seen, for instance, boils occur on the
inner side of one thigh by inoculation from a burst boil on a similar
position on the opposite thigh.
Subcutaneous abscesses occasionally occur in debilitated cases during
the progress of the fever. They cause a slight increase in the pyrexia,
but are apparently accidental and unconnected with the virus of the
fever, and heal readily when evacuated and suitably dressed. Small
temporary subcutaneous nodules are very occasionally met with on the
face and extremities, such as the anterior surface of the leg. They last
about a week and then disappear spontaneously, never exceeding an
orange pip in size.
Subcutaneous haemorrhages, with or without scorbutic symptoms,
occasionally occur in debilitated subjects late in the disease. The
author has only met with this condition twice, and in neither case were
the subcutaneous hzemorrhages severe or connected with scorbutic
symptoms.
104 UND ULANT, MAL TA 0R

Case 22. —Illustrating purpnric symptoms. ——Pte. J ., King’s R.
Riﬂes, aged 22, was admitted to hospital on May 26th 1895,
suffering from a severe attack of undulant fever. He was sent
to the sanitarium from August 5th to September 27th, when he
returned to hospital in Valetta. During the whole of this time he
had been subject to intermittent attacks of remittent pyrexia. He
continued to suffer from nocturnal pyrexia, varying from 99° to 1020 F.,
with usually a normal temperature in the morning, until November,
when pyrexia was limited to occasional slight nocturnal rises every
three or four days, without, however, any regular periodicity. On the
22nd of December, while still subject to occasional rise of temperature
at night, and seven months after the onset of the disease and his ad-
mission to Wumerous spots of haemorrhagic extravasation
appeared on his legs below the knee. They varied in size, but did not
exceed a quarter of an inch in diameter. They were scattered about
the skin from an eighth to half an inch apart, being very closely arranged
on the front of the leg and instep, but less so at the back. They were
less numerous on the right than on the left side, and appeared to come
out in crops for three days. In colour they were dark red, which did
not disappear on pressure. There was no increase in pyrexia. About
the same time his nose bled whenever it was picked. About the 26th
of December the spots began to fade from dark to light red; next a
slightly yellow spot appeared in the centre of each patch, after which
they passed through the various shades of yellow and gray common to
these conditions, and most familiar to us in the ordinary bruise. No
further symptoms appeared, and he lost all signs of pyrexia soon after-
wards. The condition appeared to depend upon anaemia, hydraemia, and
debility, following long-continued fever (seven months).
About the fourth week desquamation occurs, being most noticeable
on the soles of the feet, where the skin peels off in large ﬂakes, leaving
the skin of the feet soft and tender for a considerable time, so that
boots are irksome during early convalescence. As is the case in enteric
fever, a certain amount of bronzing takes place as the anaemia pro-
grosses; but there is never any approach to the excessive pigmentation
met with in paludism.
A distinctive and disagreeable odour, emanating apparently from the
skin and breath, is present in nearly all cases, and is best marked in
severe cases, when it may be almost offensive. This odour is most
noticeable at post-mortem examinations, and the same smell is not met
with in enteric fever cases, though such cases are said to have a
peculiar odour of their own. The distinctive odour referred to in un-
dulant fever does not depend upon dyspepsia or uncleanliness, as it is
present in cases where these conditions are absent, in hospital patients
and gentlefolk who receive every attention, in as great a degree as in
those who are under reverse conditions. It is comparable to the odours
emanating from cases of typhus or rheumatic fever, and though quite
distinct from these, is more disagreeable, and perhaps from its nature
[MEDITERRANEAN FE VER I05

less easily recognisable in the sick-room. It is one of the points which
often unconsciously aid the experienced physician and nurse in dis-
tinguishing between cases of this and other febrile conditions, while its
presence in marked degree in a doubtful and severe case has often been
the only clinical sign of difference from enteric fever during the ﬁrst day
or two after admission to hospital.
During the fourth month, towards the end of long attacks, or even
during early convalescence, the hair falls out extensively. Though this
also occurs after other fevers, it is much more the rule than the excep-
tion in severe or prolonged attacks of this fever. Though the shedding
of the hair is extensive, it is gradually and completely replaced during
convalescence, unless the general condition of the patient remains below
par. It is well, therefore, to warn patients of this fact when their
attack is prolonged, while there need be no hesitation about cutting the
hair, or even shaving the head, in the case of female patients if it con-
duces to their comfort, as they are not only cooler without it, but
besides doing away with the necessity of brushing, it appears to tend
towards strengthening the new hair when it comes. Dark hair fre
quently becomes mixed with numerous gray hairs even in young men of
twenty-three, a condition which may not completely disappear with
recovery.
In long cases the nails often have a grooved or longitudinally
striated appearance.
\Vhile the temperature remains continuously high the skin is hot
and dry. Each remission is, however, followed by diaphoresis, which
tends to be most profuse in cases in which there is an inter-
mittence or a very marked remission. The more moderate diaphoresis
following moderate remissions at the beginning of severe attacks with
high temperature, is refreshing and to be encouraged as a sign of a
temporary or permanent amelioration of the disease; but this is a very
different condition from that following greater intermittent variations in
the height of the temperature curve.
So profuse is the latter diaphoresis in most cases, that following no
paroyxsm, it comes to be one of the peculiar characteristics of the
disease; and in fact the fever has been named in Italy “febbris
sudoralis” (Tomaselli) on account of this symptom. It may be com-
pared with the night-sweats of phthisis, and those accompanying the
hectic fever of other suppurating conditions, but it is much more pro-
fuse. The condition is most debilitating and depressing, and seems to
increase in severity as the disease progresses and the patient becomes
weaker.
These profuse perspirations follow the diurnal fall of the temperature,
their time of onset being governed, therefore, by the pyrexial curve of
each individual case. In the greater number of cases it occurs between
11 RM. at night and 2 or 3 A.M. the next morning. At the time the
sweat literally rolls off the patient’s face in large drops, soaking through
the pillow; while at the same time that coming from the surface of the
106 UNDULANT, [MALTA 0R

body soaks through his clothes, the sheets, and even the blankets.
This may go on for an hour or two, necessitating two, three, or more
changes of clothes and sheets. The sweat is acid in reaction.
Besides these profuse perspirations, smaller ones may occur at any
time during the day or night, owing to slight variations in the
temperature curve, or they may be brought on by any emotion, excite-
ment, or exertion. In fact, as the case progresses, the nervous element
of the thermogenic apparatus appears to become more and more sus-
ceptible to excitation, and to react disproportionally to any stimulation.
This characteristic of undulant fever seems to depend to so large an
extent upon the action of the poison on the nervous system, and to
vary so much with the individual nervous excitability of each patient,
that it would appear to be more in its proper place among the nervous
symptoms than here. It is the custom, however, to deal with it more
as a local tegumentary symptom, and it comes very well before the
consideration of the pyrexia, with which it is closely connected.
In a few cases diaphoresis appears to be temporarily localised to
certain portions of the body, such as the face, or it may be more profuse
on one side of the body than on the other. One arm may be covered
with perspiration and the other quite dry.
Pyrexia—This is the chief and often the only clinical manifestation
of the disease, while many of the common symptoms and post-mortem
appearances are but due to functional derangements, the result of the
febrile condition present. Other characteristic clinical symptoms there
are, but none of these are so uniformly present as pyrexia of a
characteristic nature, while many of them are due to local manifestations
of the action of the virus closely connected with the direct production
of this pyrexia.
In all the acute diseases termed fevers, the phenomenon of excessive
production or elevation of the body temperature is met with.
Moreover, in each of these fevers this elevation of temperature
follows a somewhat different course, due to causes dependent upon the
action of the virus or to products elaborated by the virus of the par-
ticular disease in question, the exact nature and mode of action of these
causes being at present a matter of doubt. We believe, however, that
two factors are concerned in this excessive body temperature: (1) A
disturbance in the process of oxidation and nutrition within the tissues
of the body 3 and (2) An alteration in the normal relations between the
(restraining action of the nervous system and these last-mentioned
processes, and an interference with the nervous mechanism of heat
regulation. The exact quantity and quality of the action of these
processes of the virus of each individual disease marks to a great extent
the character of the resulting pyrexia.
Speaking generally, we ﬁnd in undulant fever that the action of the
poison on the nervous mechanism of body heat regulation has a marked
effect on the character of the pyrexia present in very many, if not all of
[WEDITERRANEAN FE VER 107

the cases. This is on a par with other symptoms due to the action of
the poison on other portions of the nervous system. \Ve ﬁnd in many
mild (intermittent) cases that the temperature rises in the afternoon to
104mo or 105° without any great constitutional disturbance ; that while
some cases may be seriously and even dangerously ill at a constant
temperature of 103°, others may be but little affected by a continued
temperature of 104°-105° ; that paroxysms are absent, and rigors rare ; -
that the temperature is highest in children and nervous and excitable
patients; that it is affected by anything that affects the nervous system,
such as emotion, fatigue, excitement, worry, etc., the presence of the
depressing sirocco wind, and indeed anything of a mentally depressing
nature; and that these manifestations are in excess of those met with
in the case of other fevers.
Again we ﬁnd in those cases in which the central nervous system
appears especially affected, characterised by symptoms referable to
cerebro-spinal irritation, that the temperature may remain continuously
high (103°-104°) even for a month, without there being the usual and
proportional accompanying symptoms of dry or brown tongue, con-
gestion of internal organs, derangement of function of these organs, etc.
Speaking generally, there is some relation between the height of the
temperature and the activity of the disease causes, but to a different
degree in each individual case, so that the exact pyrexial severity is not
necessarily an index of the urgency of the symptoms, nor of the prognosis
in any abstract case. In each individual case, however, there is a
relationship between the temperature curve and the satisfactory pro-
gress or otherwise of that particular case which it is necessary for the
medical officer who treats the case to accurately realise.
The chief characteristics of the pyrexia of this fever when compared
with that of others are—( 1) The variability which exists in the amount
and duration of the pyrexia of different cases. The duration is quite
indeﬁnite, and follows no rule applicable to even a majority of cases.
The daily pyrexial curve may vary between a continuously high
temperature and an intermittent one in different cases, or even in the
same attack. The tendency of the daily maximum and minimum
temperatures to form waves or undulations of intensity, of varying
character and length in different cases, but with a tendency in indi-
vidual cases to resemble the primary wave, while generally decreasing
in length and severity as the case progresses.
The most regular and, so to speak, typical wave of pyrexial intensity,
in uncomplicated cases conﬁned to bed, rises like the ideal curve of
enteric fever, and subsides in an equally regular manner. The daily
temperature is usually remittent in character, the evening temperature
being about two degrees higher than that of the same morning. The
average length of 300 waves was about ten days, the primary wave being
usually longer (average 18 to 23 days), while in a few cases it even
lasted almost the whole pyrexial period. The duration of 300 well-
marked waves occurring in 95 cases was :—
1 08 UND ULA N T, [MAL TA 0R
TABLE XIII.
One week and under . . . . 70 waves.
Between one and two weeks . . . 97 ,,
Between two and three ,, . . . . 60 .,
Between three and four , , . . . . 23 ,,
Between four and ﬁve ,, . . . . 42 ,,
Between ﬁve and six ,, . . . . 3 ,,
Between six and seven ,, . . . . 3 ,,
Between seven and eight ,, . . . . 2 ,,
300 ,,
The average number of these waves in an attack was three (1-7
The interval between waves is marked by a period of apyrexia and
absence of morbid symptoms, lasting from one to ten days or more
(average 3-4 days) ; or simply by a period of comparative remission of
pyrexial and other symptoms of variable degree.
CHART VI.

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1234-68789
N 0250. —-E : Enema administered .
Typical undulations of remittent pyrexia in undulant fever.
The typical temperature curve of this fever, for the sake of descrip-
tion, may be said to be a series of intermittent waves or undulations of
remittent pyrexia.
Case 23.—Illustratiny such a curve—Capt. P., admitted to hospital with
undulant fever of 20 days’ standing on the 26th of December 1890, after
[MEDITERRANEAN FE VER 109

having been under treatment ill private lodgings ill Vittoriosa, Malta. He
suffered from obstinate constipation, progressive anaemia and debility,
CHART VII.
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Undulations of somewhat continuous pyrexia.
Unusually long case, with somewhat continuous‘ temperature, marked apyrexial periods, and
falls to normal at the endings of waves, treated by the expectant method. This was thought
at first to be a case of enteric fever.
dyspeptic troubles, loss of weight, and pyrexia (see Chart VI.). He was
never dangerously ill, but became much debilitated, and was invalided to
England on March 28th, 1891, where he continued for three months to
IIO UN'DULANT, MALTA OR

be subject to occasional rises of temperature and the rheumatic com-
plications of this fever. He ultimately recovered and returned to duty
with his regiment in Malta in January of 1892. Since then, except
for a slight attack of febricula in July 1892, lasting three days, he has
remained in good health.
This regularity in pyrexial undulations, which has by some been
likened to enteric fever with from one to ﬁve or more relapses, is not,
however, by any means the rule, every variation in the duration and
character of the waves, apyrexial periods, and daily temperature curves
being met with. The daily temperature may vary from continuously
high pyrexia to intermittence. The attack may consist entirely of
pyrexial undulations or of intermittent pyrexia ; may commence with
pyrexial undulations, and pass later into an intermittent type; or com-
mencing with intermittence, pass into the undulatory type with waves
of remittent or continuous pyrexia. In all these cases, however, where
the true maximum and minimum daily temperatures are accurately
ascertained, these show a tendency, by their increase and decrease in
height, to form more or less marked undulations of pyrexial intensity.
At the beginning of a wave the pyrexial curve may steadily rise without
remittence, or it may rise suddenly, though this latter is not common.
At the end of a wave a fall to normal may occur gradually but without
remittance, or the fall may be a sudden one, by crisis. This last ending
is most uncommon, while as a permanent ending to an attack the writer
has only met with it on two occasions. In such recorded risings and
failings, however, the maximum daily temperature (which occurs usually
in the afternoon) may have been missed, and the temperature may have
fallen by the time of the evening visit to a point near that of the next
morning and below that of the same morning, and so masked any slight
remission which may have been present. Most commonly, however, the
ascent and descent of the temperature curve in these pyrexial waves is
gradual and associated with more or less remittence or intermittence.
The length of an individual wave follows no rule, so that the
primary wave may last the whole attack, or the attack may consist
of a series of short waves (ride Chart XVII.), in some instances almost
simulating the curve of relapsing fever. These two extreme conditions
are not common, nearly all cases conforming roughly to three types :—
(1) Cases with well-marked moderately long undulations of remittent
or continuous temperature (ride Charts VI., VII., and ; (2) Cases of
intermittent or extremely remittent pyrexia, with waves only marked,
and then not always clearly, by the maximum and minimum daily
temperature records (ride Charts VIII. and IX.) ; (3) Cases in which
these two preceding types succeed one another, the intermittent usually
(though not invariably) following the undulatory type, and indeed
being a not uncommon ending to all varieties of attacks of this fever
(m'de Charts VIII. and XIX. and Case 42).
As has been said, most cases end with a longer or shorter period of
intermittence, which, in a large number of cases, may be drawn out by a
[MEDITERRANEAN FEVER III

period during which the only symptom is an occasional rise of temperature
in the afternoon or evening of a slight nature (99°-101°) at irregular
intervals. As long, however, as a patient is subject to these slight
CHART VIII.
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77
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91
Note. —P : Purgative administered.
Undulatory passing to intermittent type.
noctural rises, he is liable to a relapse of any severity, even fatal in
character. In such cases the virus seems to be lying hidden somewhere,
ready at any indlscretion to burst forth and produce more serious effects.
112 UNDULANT, [MALTA 0R

In cases where relapses occur after long intervals (one to three months)
of apparent convalescence, it is generally found that the patient has at
times felt seedy, or suffered from headache, shivering, or diaphoresis on
certain days, when, if his temperature had been taken in the evening, it
would have been found to be slightly elevated. There is no periodicity
about these slight irregular rises. Other relapses occur after periods of
apparently complete recovery in men who, after their discharge from
CHART IX.
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3ll23456789 ll|2l3|4|5|6l7l8l9
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Intermittent type showing waves.
hospital, have returned to the same bed in the same barrack-room they
inhabited when the original infection took place, and to the same mode
of life. In such cases is it possible that a re-infection took place? In
cases that have quite recovered, and have been a year free from fever,
or who have left the infective area after recovery, we do not meet with
recurrences of pyrexia such as are met with in paludism. Once, there-
fore, completely free from the fever the patient may consider himself
cured. A not uncommon ending in acute attacks is a wave of a short
but unusually severe nature immediately preceding permanent cessation
[MEDITERRANEAN FE VER I I3

of the pyrexia. The slumbering fever appears to suddenly ﬂare up into
a strong ﬂame and, as it were, burn itself out (see Charts XII. and XIX.).
One of the surest signs of permanent cessation of pyrexia is a period
of subnormal temperature lasting from one to six or more days with a
clean tongue. Without this subnormal period an apyrexial interval can
never be trusted to remain permanent, while in those cases where, on
CHART X.
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Undulatory type with well-marked waves.
account of debility or other cause the temporary apyrexial periods be-
tween waves are subnormal in character, it is found that the permanent
cessation of pyrexia is marked by a still lower point or longer period
below the normal line.
The apyrexial periods between waves (taking pyrexia to mean ex-
cessive temperature above normal) vary in length as much as the waves
of pyrexia, though they are considerably shorter as a general rule. In
some cases they are most clearly marked (Charts VII. and X.), while in
others they are only replaced by a comparative abatement in the severity
of the symptoms (Charts VI. and XI). Or one wave may seem to overlap
the next with only a slightly marked abatement.
A sudden fall of temperature (or accidental intermission) during a
wave, and lasting only a few hours, is often met with. When occurring
during the ﬁrst few days after admission during the primary wave, it is
comparable with the fall accompanying haemorrhage in enteric fever.
I
114 UND ULANT, MAL TA 0R

At this period, in the absence of heemorrhage or other accountable
symptom, it is a most valuable diagnostic sign in favour of a doubtful
case being one of undulant fever (vide Chart XIII.)
CHART XI.
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Chart with undulations not clearly differentiated.
The continuously high temperature curve met with in certain
malignant and fatal types has already been described. Also the tend-
CHART XII.
9|


24003011210120.344600141I020
Severe wave at end of an attack. See also Chart XIX.
ency to extreme hyperpyrexia in such cases, the temperature continuing
to rise after death, so that 112° and 115° F. have been registered in the
internal organs.
MEDITERRANEAN FEVER 115

The following is a specimen case, for the notes of which I am
indebted to Surgeon-Major Bruce :—
Case 24.—Illustrating extreme and rapidly fatal pyreaid—Pte. G.,
admitted to hospital 28th August 1888, on the third day of severe
pyrexia; previous history good; age 23. On admission his face
was dusky, his hands tremulous, his tongue dry and brown, his pulse
weak, and there was a tendency to delirium. His condition became
gradually worse, and he died of hyperpyrexia on the tenth day of the
disease. He was on milk diet with a suitable amount of brandy, com-
bined with stimulating drugs (see Chart XIV.).
At the post-mortem examination the lungs were found to be con-
gested at the bases, the liver congested, and the spleen (weight 19
CHART XIII. CHART XIV.
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July 3 7 IO
P PPPP P
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N ote.—P : Purgative administered.
Early temporary falls of temperature in undulant and Stools I e 4 2 2 | e s
enteric fevers.

Malignant rapidly fatal case.
ounces) deeply congested. Peyer’s patches were quite normal through-
out, and but for a few patches of congestion the intestines were also
normal in appearance. Colonies of the micrococcus Melitensis were
obtained from the spleen after death.
In a few fatal cases, after a period of high pyrexia, the temperature
may fall gradually to normal in an apparently satisfactory manner, but
the patients show most unsatisfactory signs of exhaustion, possibly with
muttering delirium, and after a few hours this temperature may begin to
rise and attain to fatal hyperpyrexia. Even if attempts be made to
check this ﬁnal and fatal rise by external cold it is found to be of no
avail, the nervous pyrexia-restraining mechanism appearing to have
completely lost its power of responding even to external stimulation.
These cases are always those in which the temperature has been allowed
to remain high for a long time previously without artiﬁcial interference.
Such an end is met with occasionally in other acute fevers, notably in
cases of enteric fever.
Case 7. -— Illustrating decline of temperature with extreme exhaustion,
followed by uncontrollable hyperpyreaia.—Pte. C., R. Berkshire Regt.,
116 UNDULANT, [MALTA OR

aged 22, admitted to hospital in Valetta, 11th January 1893,
on the sixth day of the disease. He was a quite temperate man,
who had been serving in Malta for nearly two years. Previous
health good, but for attacks of slight febricula in July 1891 and
December 1892. This and Case No. 8 occurred near burst drain, as
has been mentioned in the chapter on etiology. Accompanying the
extremely high pyrexia were diarrhoea, dry brown tongue, catarrhal
pneumonic symptoms, extreme nervous prostration, and a tendency to
pass into the so-called “typhoid state.” The case was thought by
many to be one of enteric fever. There was general abdominal tender-
ness at times, and towards the end persistent vomiting of every form of
nourishment. When his temperature fell to normal on the 35th
day he was extremely debilitated, exhausted, and collapsed, and the
next day uncontrollable hyperpyrexia of a fatal character set in. Had
the temperature been treated by external application of cold from the
CHART XV.
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Fall of temperature followed by fatal hyperpyrexia.
beginning it is probable that a different result would have been
attained (see Chart XV.).
At the post-mortem the lungs were found to be extremely congested
and consolidated in patches at the bases. The spleen weighed 18
ounces, and was excessively congested. The intestines were congested
in patches, but were not ulcerated, while Peyer’s patches were all
normal in appearance. The mesenteric glands were somewhat enlarged.
The micrococcus Melitensis was isolated from the spleen in pure
cultivations on agar after death. See also Case 21.
Case 3.-—Illustrating a fatal result during a relapse—Case 3
similar to No. 2 in character. Admitted July 10th, 1892. Age
20; service six years, two of which had been in Malta. This man
slept in a bed from which a comrade in his room said that other cases
had been admitted to hospital. The bed in question was under a roof
ventilator, placed next a main drain ventilator, the smell from which
was complained of in the room.
Precious history—Had suffered from slight attacks of febricula and
bronchial catarrh in Cairo in 1887 ; from gonorrhoea four times in Malta
between October 1891 and June 1892. Habits latterly intemperate,
physique on admittance fairly good.
' [MEDITERRANEAN FEVER 117

Clinical history—Onset somewhat sudden, admitted on the third
day of the attack with pains in the back and limbs, epigastric tenderness
and some vomiting, the latter relieved by bismuth. Primary attack
lasted 24 days, during which time there was a tendency to diarrhoea,
but no other symptom of an enteric nature. After an apyrexial period
of about ﬁve days the second wave began on the 25th day of the disease,
the temperature ranged high and the patient became daily worse.
On the 49th day he suffered from subcutaneous heemorrhages over the
sacrum and buttocks, but no bed-sores appeared. There was tenderness
on pressure in the epigastric, splenic, and left iliac regions; a tendency
to diarrhoea with loose yellow stools throughout the relapse 3 while
during the last four days the stools were passed involuntarily. Death
occurred on the 54th day at 7.15 P.M., from heart failure and
exhaustion (see Chart XVI.)
CHART XVI.


1 - 2 2 2
Death during a relapse.
Treatment—Careful dietary and free use of stimulants. Gastric
sedatives and antipyrin. Lead and opium internally, and opium and
starch enemata for diarrhoea.
Examination one hour after death—Body emaciated. Heart normal.
Lungs showed hypostatic congestion of both bases. Spleen weighed 14
ounces, was very dark in colour and soft in consistency. Liver weighed
59 ounces, was slightly congested. Stomach distended with gas and
ﬂuid food, but was otherwise normal. Duodenum normal. Small
intestine contracted and shrunken, and about 221; feet from the
caecum it was hyperaemic with arborescent congestion, in the course
of the vessels. Peyer’s patches and the mesenteric glands were all
normal. The large intestine, for two feet from the ileo-caecal valve, was
intensely congested and offensive, which explained the presence of
diarrhoea during life.
Case 10.-—Illustrating short irregular waves and death during a relapse.—
Admitted April 18th, 1892. Age 26 ; service ﬁve years.
Previous history very good ; no previous illness during army service.
Clinical history—Onset sudden on day before admission. Severe
pyrexial symptoms for 18 days, after which they became of an adynamic
character, combined with delirium, a dry brown tongue, tendency to
118 UNDULANT, [MALTA 0R

diarrhoea, splenic tenderness, and much sleeplessness. On the 21st day
there were symptoms of impending death, with involuntary passage of
feeces; but the patient rallied. On the 23rd day there were symptoms
of lobular consolidation of the right lung, which became extreme about
the 38th day and endangered life. There were extreme dyspnoea,
cyanosis of skin, and symptoms of oedema of the right lung, from whlch,
however, he again rallied on the 45th day. On the 50th day he was
much better, but on the 56th day the temperature began to rise again.
On the 57th day he became very exhausted, with laboured breathing, and
died on the morning of the 58th day (see Chart XVII).
Treatment—Careful dietary and free use of stimulants. Dry cup-
ping, poultices and turpentine to chest. Expectorants, astringents, etc.
Examination one hour after death.——Body emaciated. Heart normal.
Lungs oedematous, congested, and with lobular consolidation of both
CHART XVII.
4 d


Short irregular pyrexial waves, with death during a relapse.
bases. Intestines normal except for slight duodenal hyperaemia,
Peyer’s patches and mesenteric glands normal. Liver weighed 80
ounces and was extremely congested. Kidneys, 8 ounces, and also con-
gested. Spleen, 12 ounces, congested, but ﬁrm in texture.
Experiment—Cover-glass preparations of fresh splenic substance
showed many micrococci. Pure cultures of characteristic micro-organism
obtained from the spleen as in former cases.
Another, but uncommon form of temperature curve in fatal cases,
is one in which an originally high temperature falls gradually and
satisfactorily to within what is usually considered a safe limit, by the
second week 3 but the fall is accompanied by symptoms of extreme
nervous exhaustion of increasing severity. The condition appears to be
one of acute poisoning from toxic substances distinct from those causing
the pyrexia. One might almost consider that there was present in the
alimentary canal some toxic alkaloid similar to those met with in
acute ptomaine poisonings, over and above the fever virus. Such cases,
happily not of frequent occurrence, complicated as they are by serious
nervous and adynamic symptoms, are most difficult to treat successfully,
and are of a most fatal character.
Of cases which die at a later date there is little to be said, as they
MEDITERRANEAN FE VER- 119

either die during a relapse under circumstances comparable with death
during the primary attack ; or at a late stage in the disease from some
complication, or intercurrent or succeeding disease, when there is little
to be said of special nature about the temperature curve.
The daily temperature curve is usually remittent in character, i.e.
the morning temperature is as a rule one or two degrees lower than that
in the evening, without actually touching the normal line or thereabouts
except during the apyrexial intervals. As has been mentioned, this
curve may, however, in difficult cases assume any type between inter-
mittence and a continuously high temperature; or pass from one to
another type in one and the same attack.
To understand the course of the daily pyrexial curve, it is best to
ﬁrst take the intermittent temperature of mild cases. In these it is
usually at or near normal during the morning visit (8 A.M.), and begins
CHART XVIII.
44TH- 45TH. 46TH. 47TH. 48TH. 49TH. 60TH. 518T.


Diurnal curve (43rd to 51st day) of Chart 9.
to rise steadily a little before 11 AM. to a maximum between 2 and 3
RM. From this it gradually falls to half-way about 6 RM. (the time
of the evening visit), and reaches normal again about 10 or 11 P.M.,
or later; after which profuse diaphoresis occurs. Occasionally slight
supernumerary rises of temperature are added to this curve, a common
one being just after the evening visit and bedmaking. This diurnal
curve is accentuated by any mental emotion or excitement, by exertion,
injudicious dietary or medicine, excessive constipation or the reverse, by
the damp, enervating sirocco wind, or by the appearance of any special
localised symptom. It is not an uncommon occurrence to ﬁnd all the
‘temperatures of a ward unusually high on the evening following a bad
sirocco wind, or the afternoon on which friends are allowed to visit
patients. Though a similar rise is met with in enteric and other
fevers, it is rarely so constant or well marked as in the undulant fever
cases in hospital. The relief of constipation, or a change in the weather,
often prove to be excellent antipyretics. This daily curve is quite non-
paroxysmal in nature, resembling more the hectic fever of phthisis than
the paroxysms of ague. The rise of temperature is associated with the
feeling of chilliness in the hands or feet and malaise, a creeping, crawling
120 UNDULANT, [MAL TA 0R

feeling in the back. Bigors are most rare, and conﬁned to children
and patients with a specially nervous temperament.
The maximum and minimum may be postponed (or less often
anticipated), so that in a few extreme cases the morning temperature
becomes the high one and the evening the reverse. In all these mild
cases the temperature is apt to reach a far higher point than the general
condition and other symptoms would usually warrant, and this fact is
accentuated in children, and those of nervous and excitable temperament.
From the above mild type the daily temperature curve may be
increased in duration so as to postpone the fall well into the night and
the diaphoresis to the early morning, while at the same time the
morning rise is anticipated. Thus though the height may not increase
very much, the amount or duration of pyrexia is increased considerably.
With this increase in the duration of pyrexia, there comes an increase in
those symptoms due to interference with the oxidation, nutrition, meta-
bolism, and excretion in the body. These materially increase the severity
of the case. In more severe cases one day’s curve appears to run into
and overlap that of the next, until with less and less remittence the
temperature comes to be continuously high, and the daily variation less
than one degree—a condition leading to danger of death from sudden
hyperpyrexia.
At the end of an attack the daily pyrexia may be conﬁned to a
slight rise of temperature scarcely exceeding 99° F., at 2 RM. or there-
abouts, falling to normal again about 5 or 6 RM. In these cases the
patient can usually get about in strict moderation and eat his meals,
except that his lunch must be limited to soup or milk, and he must'
lie down during the early part of the afternoon. During such time,
however, he is liable to a relapse on any indiscretion.
Nervous System.--The action of the virus on the, nervous system,
as evinced by the common clinical phenomena of the disease, is next to
pyrexia one of the most constant and characteristic features in this
fever.
Speaking generally, the disease poison seems to have an irritative
action on the cerebro-spinal system, evinced by exaggerated reﬂexes, if
not by more evident symptoms. We cannot say whether this is due to
the action of the virus or of its products on the central and peri-
pheral nervous tissues or on the ﬁbrous sheaths of these structures, but
are inclined to attribute it to a mixture of both. Whether it produces
a neuritis, a perineuritis, or some other pathological condition, the results
are of a typical neuralgic character, whether the exciting cause be '
central or peripheral.
While many local symptoms may be referred to its direct action on
special parts of the nervous mechanism, many other constant but more
general symptoms doubtless have their origin in a similar action. The
action of the virus would appear to be of two kinds, direct and indirect.
The virus (or its products) in certain cases appear to directly attack the
[MEDITERRANEAN FEVER 121

central and peripheral cerebro-spinal nerve tissue. By means of certain
toxic substances formed during the life cycle of the virus within the
human body, an indirect action is brought to bear upon the higher
nerve centres, notably those regulating the thermic mechanism (including
the perspiration), the heart and lungs, etc. By its action upon the
ﬁbrous structures of the body, including apparently the ﬁbrous
coverings of the various nerve structures, it appears to have also
local effect upon certain parts of the cerebro-spinal and peripheral
nervous system. This latter action would seem to be closely
analogous to its action upon other ﬁbrous structures, such as the
aponeuroses, the joints, the pericardium, pleura, etc. These latter are
localised and variable in distribution, and though common in occurrence
are by no means essential symptoms, though a tendency to nerve irrita-
tion appears to be always present in some degree. Their localised and
metastatic nature, the fact that they occasionally leave their effects
behind after the actual fever has disappeared, and that they usually
occur during the later and less severe stages of the fever, lead one to
the belief that they are due to the direct action of the virus on local
structures.
“Fever pains,” headache, general malaise and weakness, are the
initial symptoms that most patients complain of when ﬁrst seeking
medical advice.
(a) The so-called “fever pains,” though not specially characteristic
of; this particular fever, are rarely absent. The patient usually com-
plains of “pains all over him,” and when pressed to particularise, lays
special stress on his neck and the middle of his back and behind his
eyeballs. The muscles of the neck and back are the seat of slight but
numerous darting pains when stretched or moved 3 and these pains seem
to radiate round the abdomen, and along the upper and lower ex-
tremities, or into the face or scalp, following the course of the nerves, and
giving rise to slight tingling, localised and varying hyperaesthesia of the
skin and much stiffness in the muscleé. These pains are most severe in
those who have been trying to work off their “stiffness” by exercise.
They are greatly relieved by warmth and rest in bed, being rarely com-
plained of after the patient has been twenty-four hours in a comfortable
bed in hospital. Ill intermittent cases they may recur to a slight ex-
tent when the temperature is rising in the afternoon, causing that
peculiar “creepy feeling ” in the back which, combined with a feeling
of dryness of the skin, are to the patient infallible indications of the
onset of his daily non-paroxysmal rise. The pain behind the eyeballs
is felt whenever the eyes are quickly turned in any new direction.
(b) The headache is usually present in direct proportion to the
severity of the pyrexia and the amount of muscular and mental work
that the patient has undergone since the onset of the pyrexia. Thus it
usually disappears after a day or two of rest and quiet in bed or after
a good natural or artiﬁcial sleep. In malignant cases it may be most
severe, while in mild, intermittent ones, who have refrained from exertion,
122 UND ULANT, MALTA 0R

mentally and physically, it may be absent or conﬁned to the onset of the
afternoon rise of temperature. It is cerebral in nature, usually frontal,
less often occipital. When it returns during treatment in hospital
it is usually associated with a sudden rise of temperature, or with
constipation.
(c) Wakefulness and sleeplessness are common early symptoms.
The mental faculties are usually clearer at ﬁrst than in enteric fever
cases of equal pyrexial severity, the general muscular and nervous pros-
tration being much less marked at the commencement of the disease.
Rigors are very rarely met with. In some few cases general ner-
vous irritability referable to the cerebro-spinal system is present. In
such cases mental irritability and sleeplessness are combined with
cutaneous hyperaesthesia of variable or varying extent, girdle pains,
hemianaesthesia, alteration in the function of the nerves of special
sense, etc., though these symptoms are rarely constant or severe.
Delusions and delirium are uncommon except in severe cases, or
occasionally in cases when the temperature, which has maintained a high
level for some days, begins to fall permanently. In these latter instances
they rarely last more than a few days. They are more marked when the
fall is rapid or great. Thus, a sergeant who, during a very severe primary
attack, had retained his mental faculties, about the 27th day became
subject to delusions for four days at the beginning of an amelioration
of his condition, of a marked and permanent nature. During these
four days he believed that he had received a commission as an officer,
and tried to get up and perform the duties appertaining to his new
rank in life. Another sergeant of equal standing in his own regiment
had lately received such a commission, hence the delusion in his case.
After four days he recovered his mental equilibrium.
Nearly all patients become low spirited when their temperature
returns to normal at all quickly, after remaining high for any time. A
lady who kept up her spirits most cheerfully through a severe attack
lasting ninety days, was reduced almost to despair, passing into ﬂoods
of tears on the slightest provocation, after a somewhat sudden and
permanent fall of temperature before convalescence. This latter is a
most common condition, the pyrexia seeming to act as a false stimulant
to the nervous system, its removal being followed by an absence of
nervous excitation, necessitating stimulating and sympathetic treatment
until the nervous equilibrium has been re-established. It is a somewhat
favourable symptom in many cases. It should be borne in mind
though, as it often alarms the patient and his friends, who think he is
worse instead of better. It must not, however, be mistaken for that
nervous prostration occasionally present with a moderate temperature
in a few very serious and even fatal cases, where a condition somewhat
similar to that met with in cases of ptomaine poisoning is met with.
With reference to this depression, it has been shown that, though
as a rule, when the body-weight falls 40 per cent the patient dies of
inanition, life may be sustained under greater loss when pyrexia is
[MEDITERRANEAN FEVER 123

present, the body heat being sustained (Chossat), the pyrexia acting as
a kind of stimulant.
In very severe cases with high temperature delirium may be
present and pass on to coma before a fatal issue from hyperpyrexia, if
suitable and energetic treatment be not adopted.
Nervous prostration is very marked at the end of prolonged attacks,
and even for some time during convalescence. In such cases the power
of concentration of ideas or of following out a train of thought, the
remembrance of names or ﬁgures, and similar ﬁne mental actions, are
often temporarily impaired, and only very slowly return.
Common sensation sometimes remains impaired for a long time;
deafness, not due to quinine, is often met with but ultimately gets all
right, though it takes time. Hyperaesthesia with acute pain on pressure
or even exaggerated reﬂexes may occur, so that even the weight of
the bedclothes may become unendurable. These pains and neuralgic
symptoms when present often disappear when the temperature rises at
all high. Aberrations of sensations to touch may occur, and taste
become deﬁcient. General cutaneous hyperaesthesia or hemianaesthesia
may occur.
The memory may become impaired for some length of time,
especially with respect to dates, names, and the chronological order of
events. A clergyman found difficulty in preaching for some months
after an attack, a doctor in remembering doses, etc.
Tremulous condition of the hands may persist. Some weakness of
vision may occur, but this disappears with recovery. Retention of urine
may occur during the acute stages. Slight weakness of the sphincter
urinae has followed attacks and remained permanently. Involuntary
passage of faeces only occurs in the last stages of most severe cases,
usually before death.
The writer has not met with actual mania or imbecility following
attacks of this fever ; but hysterical symptoms may occur.
The decubitus is lateral until the patient becomes very seriously or
dangerously ill.
There is in all cases a certain irritability of the nervous system
characterised by increased reﬂexes, more particularly of the patella and
plantar reﬂexes, and in one case ankle clonus was present. Periosteal
reﬂexes do not appear to be increased. In a large percentage of cases
there are neuralgic pains which will be described later. In other cases
mental irritability and sleeplessness are combined with actual signs of
cerebro-spinal irritation, such as cutaneous hyperaesthesia, anaesthesia,
alteration in function of certain nerves of special sense, girdle pains,
optic neuritis, etc. The chief and most constant characteristic about
these symptoms is their variability in the same individual from hour to
hour, or from day to day. \Vhereas some of these symptoms appear to
be due to the direct action of the virus on the nervous tissues, others
seem also due to serous effusion into the ventricles of the brain and
beneath the cerebrospinal meninges, comparable to the effusions into
124 UND ULANT, MAL TA OR

the joints, tendons, pleurae, pericardium, etc., and like these usually
late symptoms. Intense burning pain in the soles of the feet is not an
uncommon symptom in such cases, while it also occurs in other cases
during desquamation of these parts.
Case 25.—With cerebro-spinal irritation early in the attach—Pte.
H., admitted to hospital July 31st, 1895, on the fourth day of the
attack. The usual symptoms of headache, fever pains, furred tongue,
and epigastric tenderness were present. Morning temperature 101°,
evening 102° E. On the evening of the 6th day temperature fell
to 984°, and remained beneath 100° until the evening of the 10th day,
when a long but remittent wave began, lasting until the 65th day,
during which period the temperature varied between 100°-104'4° F.
The temperature varied between 98° to 101° until he was invalided on
the 90th day. After this there was no return of the pyrexia, and he
made a good and uninterrupted recovery.
During this long wave lasting 56 days, he suffered at times from
hyperaesthesia of the lower part of the abdomen and of the extremities,
varying in locality and degree. Towards the end of the wave he
suffered from most severe hyperaesthesia of the soles of the feet, relieved
by soaking them in cold water 3 desquamation also occurred at this
period. He also complained from time to time of girdle pains, and of
pains shooting down the nerves of the legs. He suffered from frequent
headaches, at times of a continuous character. From being of a bright
and lively disposition, he changed at this time to an extremely irritable
and often sulky nature, and was continually arguing or quarrelling
with the hospital attendants. His sight at one time became somewhat
affected and reading made his head ache. Bromide of potassium, rest,
and quiet gave great relief to these symptoms, which all passed
away with the cessation of the pyrexia. When the writer met him
some two months later he had entirely recovered his original lively
disposition and gave no trouble whatever.
Case 1 5.—-0f cerebro-spinal irritation with fatal intercranial pressure.—
Sergt. R., age 23, army service ﬁve years, arrived in Malta Feb. 2nd,
1895. Previous medical history good, only one entry in medical
history sheet for a mild attack of measles in 1891 at Aldershot. No
other foreign service.
Admitted to hospital Jan. 16th, 1896, on the third day of an attack
of undulant fever, temperature 105'4° F. at 6 PM. Tongue thickly
coated, bowels constipated. The bowels were relieved by ﬁve grains of
calomel with powdered jalap, followed next morning by an enema. He
complained of intense frontal headache and the usual pains in the back
and limbs. The temperature remained high until the 10th day,
necessitating frequent artiﬁcial reduction by means of cold water
sponging; after which it fell a degree a day (the difference between
morning and evening being about 2°) until the 13th day, when it again
rose above 103°, necessitating similar treatment. The temporary fall
was accompanied by diarrhoea, easily controlled by a lead and opium
MEDITERRANEAN FE VER 125

pill. Until the 25th day the temperature remained high, the tongue
became dry and brown, the breath foul, and only beef juice, peptonised
milk, albumin water, and champagne, could be digested. After this
his temperature became more remittent, varying between 99° in the
morning and 102° in the evening until the 45th day.
The amelioration of pyrexial symptoms on the 27 th day was
accompanied by delusions lasting for four days, though he had retained
his mental faculties previously. On the 33rd day he complained of
“rheumatic pains” following the course of the nerves of the legs, dull
and aching with occasional shooting pains. With ﬂannel drawers and hot
applications these began to disappear on the 36th day, and were com~
pletely gone by the 39th day. Throughout the whole of the remainder
of the attack he suffered from obstinate constipation, requiring frequent
doses of liquorice powder, calomel and jalap, compound senna mixture,
or enemas.
On the 45th day the temperature reached normal, and continued a
mild intermittent character until the 102nd day, with no other
symptoms except constipation, nocturnal diaphoresis, and, for three
days about the 55th day, some neuritic pains in the shoulders and
arms.
On the 102nd day his temperature rose, and the intermittent
character changed to a more continuous type between 1000 and 103°
until the 111th day. At this time also he began to complain of pains
shooting down the legs, and some dull aching pain in the anterior
portion of the legs. From a quiet, uncomplaining man, he changed to
an irritable one, complaining that his “nerves had all gone wrong.” He
talked a great deal at this period, and on the 107th day complained of
a pain shooting through his head when he tried to think of an answer
to any question put to him. He suffered from sleeplessness. He had
during the previous months various antiseptic and other drugs, none of
which cut short the attack, and on account of his anaemia and debility
he had passed an invaliding board, and was awaiting passage to England.
His hair was falling out, and his feet peeling in large ﬂakes, and he
suffered from intense burning pain at times in the soles of his feet. On
the 112th day the headache became very severe, his reﬂexes were found
to be enormously exaggerated, and he began to make many purposeless
and nonsensical remarks, while there was hyperaesthesia of varying
amount on the left side and girdle pains. On the 113th and 114th
days he became unconscious, but could still be roused into semi-
consciousness at times. Constipation was marked, and only slightly
relieved by strong measures. His pulse remained good. On the 115th
day he was found to be blind of the left eye, the pupil of the same side
was slightly enlarged, there were slight ptosis and divergent strabismus
of the same side of varying amount, slight facial paralysis (left), some
rigidity and stiffness of the muscles of the back of the neck, with pain
when the head was moved. These symptoms varied in amount during
the 115th and 116th days, becoming most marked about 7.30 P.M. on
126 Uivp ULANT, MAL TA on

the latter, when he became comatose, while retention replaced an in-
voluntary passage of urine which had existed for the two previous
days, his breathing became stertorous, his pulse for the ﬁrst time weak
and soft, mucus collected in his throat and lungs, and death seemed
imminent, his temperature having risen from 100'6° at 2 RM. to 104'4°.
During the last few days, besides ordinary treatment, he had had
strong aperients without much effect, blisters to the neck and head, and
full doses of bromide and iodide of potash. He was now treated with
mercury ointment inunction over the abdomen, groin, and thighs, which
was followed by marked but temporary improvement. The temperature
fell to 100'8°, at 9.30 PM. the breathing became deeper, the pulse
slightly fuller, the “death rattle” disappeared, power of swallowing
returned, and the skin became moist. He suffered, however, from
occasional convulsive spasms, his hands were passed frequently over the
abdomen and pubis; he moaned a good deal. Signs of facial paralysis
had disappeared the next morning, but the amaurosis and divergent
strabismus and ptosis remained, though the pupils were equal. On the
morning of the 117th day his temperature was 101'8°, and he appeared
better, except that his pulse was weak and thready, and he remained
quite unconscious. About 10.30 AM. the difficulty in swallowing
returned, the breathing became stertorous, the pulse weaker and weaker,
until, with failure of circulation and respiration, he died quietly at 1
P.M., his temperature steadily rising before death.
Postmortem—The spleen was removed two hours after death, and
inoculations were made in the usual way in the laboratory on nutrient
agar-agar, from which numerous pure cultivations of the micrococcus
Melitensis were obtained subsequently. Cover-glass smear preparations
were made and portions preserved in alcohol for further investigation.
The organ weighed 12 ounces, was fairly ﬁrm in consistence, and
not markedly congested. Twenty hours after :——Heart muscle ﬂabby,
weighed 105 ounces, otherwise normal; ante-mortem clot in both
ventricles. Right lung (32 ounces), left lung (29 ounces), both bases in
a state of hypostatic congestion. Liver (68 ounces) congested and nut-
meg. Kidneys congested, capsules peeled easily. Alimentary tract
normal except for a few patches of arborescent or dendritic venous
congestion. Peyer’s patches and the mesenteric glands normal.
Brain, both membranes and cerebral tissue much congested. On
section the “puncta vasculosa” were very marked, the cerebral tissues
were extremely soft, especially at the base, where they also appeared
to be oedematous. There was a considerable excess of cerebro-spinal
ﬁuid beneath the membranes and in the lateral ventricles, while in the
latter and on the choroid plexus were small ﬂocculi of exudation
(lymph). Specimens of the liver, kidney, cerebrum (optic thalamus,
cortex, and decussation), cerebellum and anterior crural nerve were also
kept for investigation. Cover-glass smear preparations and inoculations
of the brain were made on to agar-agar, cultivations of the micrococcus
Melitensis being obtained. (See section on “Morbid Anatomy”)
[MEDITERRANEAN FE VER 127

(d) Neuralgic and neuritic pains—These are met with in some form,
as symptoms or sequelae, in some 75 per cent of cases. They may
occur at any stage of the attack, but are rarely present during the
primary acute pyrexia of severe cases. Like the arthritic eﬁusions
these symptoms are most commonly met with at a late stage in the
attack, when the pyrexia has, so to speak, become chronic and mild in
character, or in cases whose pyrexia has been mild from the beginning.
They often disappear on the onset of high pyrexia. For these reasons
they are considered by some persons as a favourable sign, indicating an
abatement in the severity of the attack or a step on the road to
recovery. They are, however, the most painful symptoms met with in
the disease. In all cases the nerves appear to be in a state in which
the slightest exposure to chill is followed by an attack of neuralgic
pain and tenderness; and they remain in this state during Econ-
valescence, so that attacks of neuralgic pain are not uncommon after
the pyrexial condition has entirely ceased. As a rule a deﬁnite nerve
or a set of nerves is attacked. The pain may take the form of severe
facial, frontal, or occipital neuralgia 3 of lumbago, sciatica, or of pain
following the course of any nerve, or cutaneous hyperaesthesia may be
present. The pain may be acute or chronic in nature, may follow a
deﬁnite exposure to chill very rapidly, or may arise apparently without
cause.
(1) When acute, their course is accompanied by slight increase in
the quantity of the temperature, amplifying slightly its daily length
and elevation. They last from one to ten or more days, and are
usually amenable to treatment. There is acute intermittent shooting
pain down the branches of the nerve affected, more especially on moving
the limb, constant dull pain and marked tenderness in the trunk of the
nerve itself, and often slight localised cutaneous hyperaesthesia. These
symptoms would seem to depend upon acute invblvement (inﬂammatory
congestion l) of the ﬁbrous sheath of the affected nerve. Pain of a
similar character may be referred to the aponeuroses, muscle or tendon
sheaths, joints, etc. ; all appearing to be dependent upon a similar
pathological action on ﬁbrous structures. They usually occur during or
just after the decline of a pyrexial wave, during the late chronic stages
of the pyrexia, or as the chief symptom of an otherwise mild attack.
When chronic or subacute in nature theseipains are less amen-
able to treatment. They occur in some form or other in about 60 per
cent of cases, nearly always late in the attack or during convalescence,
and even after return to duty following apparent recovery. They are
extremely common during the late relapses of severe and prolonged attacks.
When occurring during convalescence or during a slight relapse, after
apparent recovery, their presence is usually marked by an elevation of
temperature, varying from 99° to 100° F., or this may be absent or
conﬁned to the onset of the pains. When they occur during pyrexia, a
similar amount appears to be added to the previous amount of tempera-
ture. Clinically, their appearance is that of a localised action of the
128 UNDULANT, [MALTA OR

virus, with slight secondary pyrexia, occurring after the phenomena of
the general infection have passed away. Possibly there is some sub-
acute inﬂammatory action going on in the ﬁbrous nerve sheath, leading
to exudation and pressure on the nerve tissue proper. The condition
may last from a week to many months, but recovery is the rule. There
is generally in this fever a slight hyperaesthesia of the peripheral
nervous system, and an undue susceptibility of the sensory nerves to the
effects of heat, cold, pressure, and other stimuli. This may become
exaggerated in the case of any particular nerve, in which case localised
symptoms of neuritis arise.1 The nerve the writer has found most
often affected has been the sciatic. In such cases the onset has usually
been sudden and accompanied by pyrexia, however slight, its ﬁrst
appearance being while the poison is still present in the tissues of the
body. The cases may be relieved in a fortnight, or may continue for
months after all pyrexia has ceased, or recovery may be followed by
relapses of sciatica following any exposure to cold, fatigue, etc., the
susceptibility, however, decreasing with time.
The symptoms consist of varying tenderness over the course of the
nerve, pains of a shooting, tingling, and variable nature over the
branches of distribution, and aching pain in the region of the sciatic
nerve itself. These pains are decreased by rest and equable warmth,
increased by movement and variations in atmospheric temperature.
Occasionally there is localised hyperaesthesia of certain parts of the
thigh or leg, contact with the bedclothes being even intolerable. In a
few cases there is temporary atrophy or paralysis of certain muscles of
the leg, but this is rarely associated with sciatica directly, being more
often a separate symptom conﬁned to the pedal extensors or deltoid.
The left sciatic is not more often affected than the right; and its occur-
ence is not due to constipation. Both sides may be affected simul-
taneously or successively. Any other nerve or nerves may become
similarly affected.
The writer has not met with intercurrent herpes, though that con-
dition occurs in Malta apart from this fever.
It is a very common thing to ﬁnd entries for “rheumatism” in a
soldier’s medical history sheet following an attack of undulant fever,
even months after apparent recovery from that fever. Such entries
usually refer to neuritic symptoms, with or without pyrexia, and are
strictly speaking sequelae of and directly connected with the attack of
undulant fever.
Thus we ﬁnd in looking through the medical history records of any
regiment such cases as the following :—
Cases 26-36.--Pte. E., admitted to hospital in Gibraltar, Dec. 1st
1893, suffering from Mediterranean fever, for which he was discharged
to duty 107 days after. Five days later he was readmitted for
“rheumatism” which lasted 13 days.
1 For symptoms of neuritis during typhoid fever see Dr. 0sler, Johns Hopkins Hospital
Reports, vii., vol. v. p. 397-
[MEDITERRANEAN FEVER I29

Pte. T., admitted to hospital in Malta for Mediterranean fever on
August 2nd, 1895, and discharged to duty 88 days after. Seven days
later he was readmitted for “rheumatism ” lasting 15 days.
Pte. B., admitted to hospital, Nov. 6th, 1895, with Mediterranean
fever lasting 69 days. Readmitted 7 days after being discharged, for
“ rheumatism ” lasting 55 days.
Pte. H., admitted to hospital, June 14th, 1895, for Mediterranean
fever lasting 123 days. Readmitted 10 days after discharge to duty,
for “rheumatism” lasting 83 days.
Pte. L., admitted to hospital in Gibraltar for Mediterranean fever
lasting 149 days, June 14th, 1894. Readmitted 15 days after discharge
from hospital, for “ rheumatism ” lasting 10 days.
Pte. N., admitted to hospital in Malta, July 13th, 1895, for Medi_
terranean fever, and discharged to duty 94 days after. Readmitted for
“rheumatism” 24 days later, which lasted 19 days.
Pte. E., admitted to hospital, May 20th, 1895, suffering from Medi—
terranean fever, and discharged to duty 169 days later. Readmitted for
“rheumatism ” 35 days after, for which he remained in hospital for 61
days longer.
Pte. E., admitted to hospital, June 10th, 1895, with Mediterranean
fever, and discharged to duty 106 days after. Readmitted with a re-
lapse, Dec. 10th, for 36 days. Readmitted 22 days later for “rheuma-
tism,” which lasted 29 days.
Pte. L., admitted to hospital, May 20th, 1895, for 71 days with
very severe Mediterranean fever. Readmitted, 41 days after discharge
from hospital, for 10 days with “ rheumatism” and sciatica.
Pte. E., admitted to hospital, May 31st, 1895, for Mediterranean
fever, and discharged to duty 69 days later. 140 days later, readmitted
with “rheumatism ” for 23 days.
Pte. M., admitted to hospital, July 6th, 1895, for 108 days suffer-
ing from Mediterranean fever. Readmitted, after being at duty for 118
days, for “rheumatism,” and was in hospital for 39 days with sciatica,
pains in the legs following the course of the nerves, and slight oedema
of the ankles. No albuminuria.
Less commonly we ﬁnd swollen joints and neuritic pains at the
beginning of an attack, in which case the pyrexia is usually mild and
intermittent in type. Thus we ﬁnd in a few medical history sheets,
such entries as these :—
Cases 37 -40.-—-Pte. C., admitted to hospital in Malta with “ rheuma-
tism” and pyrexia on June 6th, 1895, and discharged to duty 19 days
later. Eeadmitted with Mediterranean fever of a pronounced type 10
days later, for which he remained in hospital for 89 days.
Pte. W., admitted August 2nd with “rheumatism” and pyrexia for
36 days, ultimately proving to be Mediterranean fever. Readmitted
43 days later for a febrile relapse lasting 21 days.
Pte. H., admitted to hospital, July 24th, 1895, with “rheumatism,”
which proved to be Mediterranean fever, lasting 52 days. Readmitted
K
13o UNDULANT, MAL TA OR

for 12 days in November, and for 22 days in December and January,
with the characteristic “rheumatic ” symptoms.
Case 41.-——Illustrating the later neuritic and arthritic symptoms of the
fever.—Pte. B., King’s R. Riﬂes, aged 22 3 service abroad, three years at
Gibraltar and ten months in Malta; was admitted to hospital in
Malta on June 2nd, 1895, on about 14th day of an attack of Mediter-
ranean fever. His temperature, which was high on admission, fell
steadily until it reached normal on the 21st day of the disease. After
an apyrexial period of ﬁve days it again rose, and from the 26th to the
39th day was irregularly intermittent. After this he suffered from
three well-marked pyrexial undulations of remittent temperature from
the 40th to the 49th, from the 58th to the 66th, and from the 72nd to
the 87th days. His temperature was normal or subnormal for the next
14 days, and he was sent to the sanitarium on August 26th on the 99th
day of the attack.
During this period he had no neuritic or arthritic symptoms, but
while at the sanitorium he suffered for a fortnight from rheumatic
pains in the right hip and knee. On the 7th of October he was dis-
charged to duty apparently cured, but ﬁve days later he was again
admitted to hospital suffering from slight nocturnal pyrexia and rheu-
matic pains in the right hip and knee. After 17 days he returned to
duty apparently cured.
Twenty-eight days later he was again admitted to hospital with
pyrexia lasting 12 days, and varying between 100° in the morning and
102° F. in the evening. He also suffered pain and tenderness along the
right sciatic nerve, pain in the right hip and knee, great anaemia,
debility and swelling of the ankles after exertion. These symptoms
disappeared about the 7th of December, and he began to convalesce
steadily, and was invalided to England.
Case 42.-—Intermittent type passing into undulant type with neuritic symp-
toms—Dr. M. L. H., aged 29 years. Previous Mediterranean service (in
Malta) ﬁve and a half years. Previous health very good; since 1877
only suffered from tonsillitis in 1887, mild inﬂuenza in 1893, and slight
attacks of febricula (two or three days in duration) annually during
service in Malta. During the ﬁrst week of June 1896 the patient felt
irritable and worried during the afternoon, and was told by others “ that
he was not looking well.” He had moved with his wife for the ﬁrst
time, a fortnight before, into a back bedroom where insanitary sur-
roundings were subsequently found to be present (vide outbreak 15,
Chapter II.). On June 3rd his wife developed undulant fever (vide Case
45). On June 7th the patient returned from a ﬁve-mile bicycle ride
with a bad headache and a temperature of 100° F. in the evening. On
the morning of the 8th after sleeping in a direct draught on duty,
patient awoke with severe neuralgia of the left or exposed side of the
head which passed oﬁ about midday. The onset was most insidious, and
during the ﬁrst week of pyrexia he suffered from soreness and stiffness
of the throat, redness of the tonsils, and increase in size of the
[MEDITERRANEAN FE VER I3 I

cervical and submaxillary glands. The patient was removed to an
airy house overlooking the sea. At this time his tongue was coated,
and his evening temperature 998’ F. During the night of J une 9th a
high wind arose after the patient had gone to sleep, and came directly
on his head. On the morning of the 10th he awoke with very severe
neuralgia of the frontal and occipital nerves of both sides of the head,
and “fever pains” in the muscles of the back. The latter lasted only
one day, but the former for three days, while the pain was very severe,
each hair seemed painfully ﬁxed to the scalp, and the patient vomited all
food. During this time the temperature had varied between 99°-101° F.
By June 13th the neuralgia had disappeared, having been greatly
relieved by warm applications and by wearing a cap. From June 13th
CHART XIX—First Part.
l23456789|Oll|2l8|4l5|6l7l8l9 ‘2|
7896

Note. —P : Purgative administered.
Chart of third month of pyrexia of Case 42.
to the 28th the temperature in the afternoon varied between 99°-100° F.,
while in the morning it was normal or slightly under normal, and but
for occasional and rather vague pains about the hips, and a somewhat
coated tongue, no other symptoms were present. On July 2nd he
returned to light duty, and from that date until July the 12th, though
at work, his temperature was always about 99° F. in the afternoon, and
he suffered from pain on lateral movement of the left maxillary articula-
tion. On July 13th he suffered from stiffness of the elbow joints with
slight pain on movement ; while the maxillary pain began to disappear.
On the 14th he returned at 8 P.M. from a short bicycle ride, with pains
in the lumbar region, a great sense of fatigue, and a temperature of
100° F. The lumbar pain passed off during the night, but returned most
severely next evening, the temperature being 101° F., and he was again
placed upon the sick-list. From this date until the 19th he suffered
from very severe neuralgia of the lumbar portion of the spinal cord,
with shooting pains down the nerves of the legs (anterior crural and
sciatic), round the abdomen, and on one occasion into the left testicle.
I32 UNDULANT, MALTA 0R

These were treated with rest, warm applications locally, and with
salicylate of quinine and morphia internally. The tongue was furred,
and the temperature continued the mild intermittent character it had
exhibited from the beginning of the attack but was somewhat higher
(99°-100'2° in the morning and 100'2°-100'8° in the evening). Each
night the patient sweated profusely. The condition appeared to have
commenced in the intervertebral joint ligaments, and to have extended
later to the spinal cord or its membranes, the pain being always severe
but most intense upon the slightest movement. The spinal pain
passed off on the 19th and 20th. From the 20th to the 26th there was
only pain on movement and tenderness on pressure in the left anterior
crural and to a less extent in the right sciatic nerves. The bowels were
kept open, and had been so during the whole period of the neuritic
symptoms. The temperature varied between 99° and 100'2° F., and he
began to be up and about and to take light solid food. On the after-
noon of the 28th the patient took too much exercise, and on the 29th
was conﬁned entirely to bed again with very severe pain in the
anterior crural nerve (left) and its branches. The nerve was tender to
pressure, the seat of dull aching pain at all times, and of occasional
shooting pains down the leg. The patient found great diﬁiculty, even
with the aid of cushions, in placing his leg in a comfortable position
of rest, while the catching of the toes in the bedclothes when moving
it caused intense pain down the whole course of the nerve. On the
31st he was transferred to hospital, a few days after which his right
acromio-clavicular joint became affected. There was pain on stretching
the ligaments of the joint, and on pressure on the ligaments from above,
but none on pressing the ends of the bones together. These neuritic
and rheumatoid symptoms continued until August 10th, together with
constipation, night sweating, and intermittent temperature between 99°-
101'4°. On August 10th the temperature began to rise, and formed a
wave of six days’ duration (immediately following the administration of
liq. arsenicalis, which drug was discontinued upon August 12th),
reaching normal on the evening of the 15th, and then continuing an
intermittent course until the end of the month (between 98°~100°2° lVith the rise of temperature on the 10th the neuritic and arthritic
symptoms disappeared entirely. On the night of the 18th of August
the patient slept with the right knee uncovered, and exposed to the wind
blowing in at an open window. In the morning there was much oedema
and swelling round the inner and outer hamstring tendons, pain on
pressure and movement. This gradually subsided, but did not ﬁnally
disappear until the 31st. On August the 26th an acute inﬂamma-
tory swelling appeared upon the posterior surface of the left olecranon,
which in three days had all the appearances and sensations of an acute
tense bursal abscess. With hot applications and rest in a sling the
pain and tension subsided, and the redness, peri-bursal swelling, and
tenderness slowly disappeared in about fourteen days from the onset.
A few days after the worst period of this swelling a similar one
[MEDITERRANEAN FEVER 133

appeared upon the right olecranon, and ran a similar course. On
September 3rd another similar but less severe swelling appeared on the
tendons and fascia of the extensor brevis digitorum of the right foot,
lasting about ﬁve days.
During July and the ﬁrst half of the month of August the patient
suffered from excessive pulsation of the abdominal aorta, giving the
sensation and appearance of an aneurysm, except that no tumour was
present. The pulsation was easily felt on the surface of the abdomen,
between the ensiform cartilage and the umbilicus, especially on deep
pressure, while the bedclothes were visibly moved by it. The condition
entirely disappeared towards the end of August.
On the 30th of August the patient left Malta for England by sea.
His health and strength improved daily during the voyage, and he was
able to be on deck from 11 AM. to 5 P.M. There was a slight rise of
temperature each afternoon about 2 P.M., which subsided again by 6
P.M., and he was able to take his usual food without ill effect, excepting
lunch and tea, for which soup and milk were substituted. On arrival
in England on September 8th all acute symptoms, including pyrexia,
had disappeared.
For three weeks the temperature remained normal, and the patient
was able to eat and take exercise as usual, and appeared to have quite
recovered from the effects of the fever, except for muscular debility and
shortness of breath on exertion. At the end of September he suffered
from slight sore throat, and a temperature of 99°-101° of an evening,
which ended in a heavy cold in the head. He had been in Guildford,
and at this stage went to Leamington. By the 12th of October, 128
days from the onset of the fever, the cold subsided, but the temperature
began to rise in a typical relapse of undulant fever, and followed a
course of well-marked undulations of distinctly remittent pyrexia (vide
Chart XIX.).
The pyrexial undulations were at ﬁrst short and well marked, being
associated with few local symptoms beyond constipation and diaphoresis.
About the 150th day he suffered from paroxysms of coughing, without
expectoration, especially in the early morning. This dry irritable cough
continued until the beginning of January, or the 217th day. Added
to this was a morning expectoration, which was proportionate in
amount to the height of the temperature. The sputum was soft, semi-
transparent, and, when the temperature was high, slightly blood-stained.
This blood-staining was bright in colour, and limited to a small ﬂeck of
blood in each lump of sputum. At the same time, and again in
February and March, he suffered from palpitation on the slightest exer-
tion, even when turning at all quickly in bed. From the 218th to the
243rd day he was much better, and gained strength and weight. He
was able to get up during the afternoon, take gentle exercise in the garden,
and eat solid food for breakfast and dinner. He spent December and
January at Frodsham in Cheshire. On the 3rd of February he was
carefully moved by train to Colwyn Bay, in North Wales. This
I 34 UND ULA N T, [MAL TA OR

move was followed by a severe relapse (ride Chart). The temperature
had to be frequently reduced by means of cold water towels and sponging,
CHART XIX—Second Part.
123456789
123456789
Undulations of pyreua folloiung four months of intermittence, passing into internuttence and ending
wlth a ﬁnal sex ere pyrexial \\ ave.
-—a course which had been adopted whenever the temperature exceeded
103° F. After this he suffered from intermittent pyrexia until the 326th
day. From the 256th to the 266th day he suffered from very severe
sciatica of the left side. This was treated with salicylate of quinine,
[MEDITERRANEAN FEVER I35

internally and externally, with belladonna and menthol plasters. The
disappearance of neuritic symptoms occurred synchronously with the
increase of pyrexia following the 266th day. From the 276th to the
283rd day he complained of most severe pain in the left side on the
slightest movement of the chest wall. Breathing was painful and
coughing very painful when lying on that side ; while in a sitting
position breathing was insupportable agony for the ﬁrst three days. The
pain was referred to the diaphragm, on the left side under the margin of
the ribs, along the upper margin of the anterior portion of the spleen.
The spleen was not noticeably enlarged at this stage, though it had been
at an earlier stage in the attack. The pain was considerably relieved
by morphia, and after three days began to gradually disappear, so that
he was able to sit at stool. At this time (284th day) a large round
worm was seen in a stool, and a dose of santonin was given, followed by
a second on the 289th day, but without bringing away any more worms.
The second dose, given at 9 P.M., was followed at 2 AM. by a very
severe shivering ﬁt, lasting for half an hour. This was the only
approach to a rigor during the whole attack. The breath, which had been
offensive at times, improved from this period. From the 316th to the
326th day he suffered from neuritis in the left arm and forearm, which
disappeared with the rise of temperature on the 327th day. About
the 316th day the tongue began to clean, and steadily improved until
the cessation of pyrexia on the 337th day. This ﬁnal burst of
pyrexia was restrained by ﬁve-grain doses of phenacetin whenever the
temperature exceeded 103° F., the patient having previously gained in
strength enough to justify its use. Each dose was followed by profuse
perspiration, a fall of temperature of from 2° to 3° F. and an ameliora-
tion of cerebral symptoms due to the pyrexia. Its use was not, how-
ever, followed by any strengthening in force or decrease in rapidity
of the heart’s action, while the temperature usually rose again to nearly
its former height a few hours after the administration, necessitating
a second dose. With cold water towels and cold sponging, on former
occasions, the pulse-rate was always decreased, even as much as from
120 to 84 beats a minute. After the final burst of pyrexia the tempera-
ture remained subnormal in the mornings and for most of the day for
nearly two months, rising, however, a few points above normal after long
walks or bicycle rides, but not exceeding 99° F.
During early convalescence he suffered considerably from tenderness
of the soles of the feet, pain and stiffness in the muscles of the legs and
in the tendons round the knees and ankles, and pain in the hips, knees,
and ankles on movement, more especially after periods of rest. At the
end of a month of more or less subnormal temperature he was moved to
Guildford. Though he suffered from palpitation on the slightest exer-
tion at ﬁrst, this together with the stiffness and pain in the joints
gradually disappeared towards the end of the second month of con-
valescence. His appetite was good, and he soon reached and then ex-
ceeded his normal weight. Anaemia was not very marked. During the
I36 UNDULANT, MALTA 0R

ﬁrst two months of convalescence he was given Blaud’s pills and small
doses of quinine daily. During the attack he was variously treated with
numerous drugs, including quinine, arsenic, and mercury. These, far from
improving the condition, appeared if anything to do harm. The ﬁnal
cessation of pryexia was synchronous with a period of three weeks,
during which all medication had been stopped, but during which the
weather had improved considerably. During the attack he was given
as much variety in diet as possible, solid diet of a light nature being
given whenever the temperature was normal and the tongue fairly clean.
This, combined with bismuth and pepsin, did much to keep up the
patient’s strength and weight, so that he was not unduly handicapped
when convalescence was ﬁnally established. During convalescence he
spent as much time as possible in the open air, but was not able to take
much exercise or do much mental work for the ﬁrst two months, though
the daily improvement was marked. He returned to work on 20th
August 1897.
Paralysis and atrophy of certain muscles—This is distinctly a late
symptom of long attacks, and for this reason it is less commonly met
with in Malta than among invalids after their arrival at Netley
(England). The writer has met with it once affecting the extensor
muscles of the leg, simulating the foot-drop of alcoholic neuritis, and
three times in the deltoid muscle. Unlike the paralysis of lead and
alcohol poisoning the reﬂexes are not lost. When affecting the leg, the
big toe drops in a most characteristic manner from paralysis of the ex-
tensor proprius pollicis, and the patient is unable to lift his toes from
the ground when standing with his heels together. When affecting the
deltoid he is unable to raise his arm above a right angle. The affected
muscle slowly atrophies, and as slowly regains, ﬁrst its function and
then its proportions. Recovery appears to be complete, though it may
take two or more months to become established. Surgeon-Captain
Westcott, who has specially investigated the condition of these muscles,
states: “This symptom is a late manifestation, seldom appearing
within four months, but in one case it occurred as early as the end of the
second week of the disease. The alterations in the electrical reactions
are both quantitative and qualitative. Diminution in the muscular
response is the only quantitative alteration that I have noticed. The
qualitative alterations are both nodal and serial; the former consists in
a sluggish contraction with marked duration of tetanus 3 in some cases
this is the only change, but in those of long duration there is an
overtaking of the cathodal closing contraction by the anodal closing
contraction.” 1
Patients experience much pain and tenderness in the muscles of the
calves of the legs after walking, etc., for some time, after being long in
bed in a recumbent position.
1 Brit. ﬁled. Jour. vol. ii. p. 60, 1893.
MEDITERRANEAN FEVER I37

Arthritie symptoms.—Effusion into one or more joints occurs in
some 40 per cent of cases, and may be acute or subacute in nature. In
either instance the onset is usually sudden, and in the greater number
of cases there appears to be no ostensible cause for its occurrence. Acute
attacks may arise during a wave of pyrexia, or more often during its
decline. Subacute attacks occur generally later on in an attack,
during a relapse, or at the beginning of certain mild and intermittent
cases, in which the slight pyrexia appears to be secondary to the
arthritic condition. Thus cases have been admitted to hospital in the
morning suffering from effusion into the knee-joint, without traumatic
history, and with a normal temperature, but with a furred tongue. In
the evening the temperature has been found to be from 99° to 101° F.
This may persist for a few days, when the effusion may disappear from
the knee-joint, reappearing in other joints. The patient may recover in
a week or a fortnight, temporarily or permanently, or may continue for
weeks or months with a slight though varying amount of pyrexia at
night time, from which, however, he is never quite free, and from which
he may at any moment pass into a severe pyrexial condition of an even
fatal nature. The symptoms in these mild attacks are similar to those
met with in the late stages of severe ones, and seem to be cases in
which the primary waves of severe pyrexia have been absent. Every
grade of severity is met with connecting the malignant case with one
such as has just been described. The effusion does not appear in the
joints in any regular order, nor is it symmetrical in its distribution.
Occurring during the latter stages of the disease, this condition is very
commonly met with among invalids, among the patients drafted to the
sanitarium, and during relapses among those sent to duty after apparent
cure. As long as a patient is liable to a nocturnal temperature of 99°
or 100° F. during any ten consecutive days, so long must he be con-
sidered liable to arthritic or other symptoms ; for apparently he still has
the poison in his tissues and the potential element of any phase of the
disease, the virus being only kept in check by the inherent or acquired
resistance of the tissue cells. Any reduction in their ﬁghting power,
caused by fatigue, insufficient or unsuitable food, exposure to cold, etc.,
is at once followed by an exacerbation of the disease and a temporary
triumph of the virus.
(1) The acute effusion, occurring somewhat early in the disease, is
usually conﬁned to one joint, is very sudden in onset and acute in
character. The patient may be suddenly attacked in the middle of the
night by acute pain in one hip, shoulder, knee, or other joint.
This pain, considerable even when the joint is at rest, becomes
excruciating on the slightest attempt at voluntary movement, and taxes
the strength and patience of the attendant to procure for the patient the
least painful position. There is swelling, effusion of ﬂuid into the joint,
heat, extreme tension with throbbing pain, but rarely any redness. The
symptoms are those of acute non-suppurate synovitis. The application
of hot fomentations, warm blankets, and the administration of morphia
13s UND ULANT, MALTA 011’

may soon relieve the pain and tension, which would otherwise have
tormented the patient for many hours. Usually after ﬁve or six hours
the pain and swelling subside, but it is three or four days before all pain
and tenderness disappear. In some cases the relief of one joint is
followed by a similar condition in some other joint. The pain is in
proportion to the amount of tension present, being most intense and
intolerable when it attacks the vertebral or sacro-iliac joints. In such
cases the condition of the patient is miserable in the extreme, the
slightest jar or shaking of the bed, changing of sheets or clothes, the
use of the bed-pan, or in fact the slightest movement, being attended
by excessive pain. Happily these joints are rarely affected, and
these acute conditions are amenable to treatment. These acute arthritic
attacks are accompanied by an appreciable increase of pyrexia
(2°-3° E), which increases and decreases with the severity of the local
symptoms.
Salicylates have not the same effect on these complications that they
have in the case of rheumatic fever, and it is doubtful whether they have
any effect at all. Suppuration has never occurred in any case that the
writer has seen or heard of, nor is the condition followed by ankylosis,
and though some temporary stiffness of the joint may remain, recovery
is the rule. Occurring as they so often do during the decline of the
primary acute pyrexial wave, it is well to warn the attendants, for
they not uncommonly occur after a more than usually hopeful prog-
nosis has been given, and on a night on which the physician has omitted
his evening visit on account of the improved condition of the patient.
Subacute effusion into one or more joints is a common but by no
means necessary condition. It is usually met with—(a) During the
later stages of the febrile attack; (5) During febrile relapses after
apparent recovery; (0) As an early and chief symptom in certain mild
and intermittent cases as has been already described. The onset and
progress of the effusion is accompanied by slight nocturnal pyrexia, 99°
to 100° F., or by a slight increase in any pre-existing pyrexial condition.
In the former case the pyrexia appears to be secondary to a local action
of the virus on the individual joints. Their common occurrence at a
late stage in the attack, often passing from large joints to smaller ones,
and ﬁnally ending with the phalangeal joints of the face or hands, has
given rise to the popular theory that their appearance is the beginning
of the end, the disease tending to pass out of the body through the
ﬁngers and toes. The condition attacks joints without regard for
symmetry or order, nor does it usually remain long with any particular
joint (2 to 7 or more days), but its subsidence in one joint is usually
followed or anticipated by a similar condition in some other joint on
the same or opposite side. This metastasis often passes from large to
smaller joints. When affecting the small joints of the hand or foot it
usually extends to several adjacent ones.
In the writer’s cases the joints have been affected in somewhat the
following order of frequency: hip, knee, shoulder, ankle, wrist, ﬁngers,
MEDITERRANEAN FE VER 139

toes, elbows, intervertebral joints, sacro-iliac synchrondrosis, lower
jaw, etc.
As ill the acute condition, neither suppuration nor ankylosis occur,
though in a few cases an affected joint has become the seat of tuber-
cular deposits at a subsequent date. Stiffness of the joints remains for
some weeks or months in may cases, preventing soldiers from assuming
the kneeling position when ﬁring, etc. This disappears at a later date,
so that complete return of function is the rule. The stiffness is probably
due to slight synovial adhesions and to prolonged rest in bed. The
clinical features are swelling and ﬂuctuation in the joint, pain increased
by movement, and occasionally some exudation into the surrounding
tissues if the condition is at all long continued.
The condition is somewhat similar to that met with in rheumatic
fever, but unlike that disease, the arthritic condition is by no means a
necessity nor so usual a symptom. It has often been noticed, too, that
those who have previously suffered from rheumatic fever or rheumatism
before arriving in the Mediterranean are especially prone to these
symptoms when they contract undulant fever. So like rheumatic fever
are acute cases with early arthritic symptoms, that the writer has seen
such cases erroneously diagnosed as such by medical officers new to the
Mediterranean. Other cases have been diagnosed “synovitis of knee,”
etc., when on admission to hospital in the morning with effusion in one
joint their temperature has been found to be normal, in spite of the
absence of a traumatic history. Such cases are found to have more or
less evening temperature, while the subsidence of the eﬂ’usion is followed
by effusion in some other joint.
The condition of arthritic and tendon effusion may again be com-
pared with that met with, but, on the other hand, much less often, in
gonorrhoea, scarlet fever, inﬂuenza, and even in enteric fever. In
these diseases, however, there is reason to believe that the arthritic
symptoms are not necessarily caused by the speciﬁc virus of the
disease itself. Again, in chronic pyeemia, where a somewhat similar
type of micro-organism has found entrance to the body tissues, we
ﬁnd the same swollen joints, but with the difference that in this case
the virulence of the poison is sufficient to cause suppuration and its
results.
The exact pathology of the arthritic symptoms needs working out,
but there is a certain connection between these symptoms and chills
received during an attack of this fever that is worthy of notice. In the
majority of cases no such connection exists, but in many they follow like
cause and effect (vide Case 42). Patients who suffer from this fever
become most susceptible to changes in external temperature, and seem
to feel “ every breeze.”
The difference between patients who sleep in woollen material and
those who wear cotton or linen bedclothes and linen sheets, in the occur-
rence of arthritic symptoms (and the same may be said of neuralgic pains)
is most marked, as is also the comfort derived from ﬂannel next the skin
14o UND ULANT, MAL TA OR

by those already suffering from such symptoms. Again, the writer has
noticed that private patients, convalescents, and others treated out of
hospital are especially subject to effusion into the hip-joint (and to
sciatica), while those in hospital seem less subject to such symptoms,
but suffer from effusion into the ﬁnger-joints, and to rheumatic pains
and stiffness about the head and neck. The greater tendency of the
former class of patients to hip troubles he would attribute to exposure
while using the chamber ewer, or polished and often draughty water-
closet seat, in place of the bed-pan used in hospital. The tendency to
similar conditions affecting the hands, head, and neck in all classes of
patients he would attribute to variation in covering to which these parts
are subject in bed. An effusion into the tendon-sheaths of the right
knee, from which the writer suffered, was distinctly caused by an ex-
perimental exposure to cold.
In some cases “rheumatism” and stiffness is complained of in the
inter-muscular aponeuroses, the sheaths of the muscles, bursae, and in
the periosteal coverings of the tibiae, ulna, etc. The latter may be
combined in rare cases with subcutaneous nodes and acute swellings,
with all the local signs of periosteal or bursal abscess, but without any
suppurations occurring.
In subjects with gouty diathesis or hereditary history the onset of
the fever may be accompanied by a typical attack of gout.
Case 43.—Gouty diathesis with undulant feuer.——Capt. B., Lincolnshire
Regt., age 29; Mediterranean service one year; developed un-
dulant fever of a mild intermittent type on 10th May 1896 ;
furred tongue, severe head and back ache and shooting pains
down the legs and arms. On the third day these pains subsided,
and he was attacked with acute gout in the left great too lasting four
days, and on the fourth day in the right toe lasting three days. It
was relieved by warmth applied locally, and by colchicum and
alkalines internally. He had a very strong family history of gout,
and had previously been attacked. The undulant fever lasted six
months. On admission the temperature was 101'6° F., above which
it did not go until the fourth month, when he suffered from a severe
relapse.
Case 44.—Illustratiny sacro-iliac eﬂusion at a late stage. ——Pte. S.,
aged 24, with a good previous medical history, arrived in Malta
in the middle of January 1895, after nearly three years’ service in
Gibraltar. He was admitted to hospital on the 29th of June 1895
suffering from severe undulant fever, with a tendency to extremely high
pyrexia out of all proportion to the urgency and severity of the other
symptoms. He remained in hospital for seventy-two days, after which he
returned to duty apparently cured. On the 9th of January 1896, more
than three months later, he was again admitted with a similar form of
pyrexia, its height being excessive when compared with other symptoms
and with its effect upon his constitution generally. The temperature
gradually fell until it reached normal on the morning of the 27 th, being
MEDITERRANEAN FE VER I41

under 100° in the evening. On the 31st he complained of severe pain
in the sacral region, which became excessive on the slightest movement,
rendering the use of the bed-pan or even a change of position in bed
most excruciating. There was great pain on pressure over the muscles
covering the sacroiliac joint. This began to subside on the 6th of
February, but had become more bearable under hot fomentations and
morphia soon after its onset. By the 8th he was able to move in bed
without much pain, and though stiff in the back for some time, all acute
symptoms had disappeared about ten days from the onset, but was
followed by a less acute attack of a similar nature in the left hip ten
days later. His temperature did not become permanently normal until
the end of March, when he was invalided home to England, nine months
after the ﬁrst onset of the fever. He did not return to duty until after
fourteen months from the primary onset of the fever.
Case 45.—Illustrating early arthritic symptoms—Mrs. H., of Malta,
complained on 3rd June 1896 of pains in the left hip, temperature
apparently normal; on the 4th pain more severe, temperature at
6 RM. 99°. On the 5th, hip somewhat swollen, painful and tender.
On the 6th all the symptoms of synovitis of left hip; evening
temperature 100'2°. Rest in bed, belladonna plaster and ﬂannel
bandage, salicylate of quinine, gr. v., three times a day. The tempera-
ture remained normal every morning, and rose to 99° or 1000 each even-
ing. About 10th June the hip recovered, but the temperature continued
an intermittent and undulant course until the last week in June, when
it rose to 103'4° in a wave, and falling gradually became normal on 30th
June. This was followed by complete recovery, but for occasional
rheumatic pains following exposure to chills in England during August.
The patient left Malta on 28th July.
The affection appears to be situated in the ﬁbrous tissues and liga-
ments around the joint, the bony and cartilaginous structures being un-
affected. Pressure on and stretching of the ligamentous structures is
most painful, while this is not the case when the ends of the bones are
pressed together, unless such a proceeding increases the intra-articular
tension. \Vhen the tendons become affected there is usually some
swelling and oedema in their sheaths and in the surrounding tissues,
with local pain and tenderness on pressure or voluntary movement.
The tendons most commonly affected are the extensors of the hands and
feet, and the hamstring tendons. These conditions of the joints and
tendons are doubtless closely connected pathologically with the con-
ditions affecting the nerves, pleura, bursae, pericardium, aponeuroses, etc.
Circulatory system.—The pulse is usually slow and ﬁrm at ﬁrst
(80-90), even out of proportion to the number of the respirations and the
amount of pyrexia present, when these are uncomplicated by other
serious symptoms. Later on, especially in malignant cases, the pulse
becomes rapid (120-140) and intermittent; and with increasing lung
congestion may become small, thready, still more intermittent until the
overburdened heart gives out entirely. In malignant cases the condition
I42 UNDULANT, [MALTA OR

of the pulse and the force of the heart’s action, taken with the condition
of the lungs, should engage the constant attention of the medical
attendant, for the key to his patient’s general condition rests in such
watchfulness.
In long-continued cases the pulse often becomes constantly increased
in rate (110-120). In these cases nervous cardiac irritability of other
parts of the nervous system is of common occurrence, the heart being
subject to attacks of palpitation on the slightest exertion, or even
under the inﬂuence of some triﬂing emotion.1 Other symptoms referable
to irritability of the nervous vase-motor system may be present, such as
abnormal abdominal (aortic) pulsation.
Haemic murmurs are met with in anaemic and debilitated subjects
towards the end of long attacks and during convalescence. Organic
disease is said to be set up in some cases, but the author has only
met with it in four fatal instances, where it was not known to be
present before the onset of the pyrexia. These cases proved fatal on
the 19th (Case 8), 62nd (Case 14), 111th (Case 13), and 154th (Case 11)
days of the disease.
In the second case (see “ Histology ”) the disease might not have been
antecedent to the fever, but in none was there any reason to connect the
post-mortem appearances with the fever in question. In the ﬁrst two
cases the fatal result was directly due to coexisting pericardial effusion,
in two it was due to sudden cardiac syncope. Cardiac valvular disease
is a most serious complication, though not necessarily fatal, as in malig-
nant cases death is usually due to failure of the heart to carry on the
circulation.
Swelling and oedema of the ankles and legs is a common and even
severe symptom during convalescence, and much aggravated by standing.
It disappears gradually as the anwmia and debility decrease. The writer
has only once met with phlegmasia dolens complicating a case of this
fever, and occurring during the eighth week of a pyrexial attack lasting
fourth months. Resolution was but slowly effected.
The spleen can nearly always be made out on percussion and palpa-
tion below the margin of the ribs, and occasionally is considerably en-
larged, especially in malignant cases. During the ﬁrst acute stage it is
tender to pressure, and may be painful, but after and towards the end
of the second month of long attacks it often shrinks again. The speciﬁc
organism has been isolated from the spleen by puncture and aspiration
during life. Localised but slight swelling of the lymphatic glands may
occur. They do not suppurate. Those in the neck and groin are most
often affected.
1 In many cases this irritable condition of the cardiac nerves is most marked and lasts
long into convalescence, and it is to be met with to a lesser degree in all cases of over sixty
days’ duration. In one case (duration 111 days), the news that the patient had been placed
under orders to go home to England proved a fatal excitement, and death took place
suddenly from syncope, though, except for great anaemia, debility and long-continued but
slight fever and a slight mitral murmur, the patient had no serious symptoms at the
time.
[MEDITERRANEAN FEVER I43

Epistaxis occurs in a few cases early in the attack, but is most
uncommon. Intestinal haemorrhage is limited to spots of fresh blood in
the stools in cases where the lower bowel is affected.
When the pyrexia is at all severe or of long duration the menses are
suppressed, and this continues well into the convalescent period. Pre-
existing pregnancy is not necessarily interrupted. The lymphatic glands
are occasionally swollen and painful, but do not suppurate.
The blood has been microscopically examined by Dr. Thin, the
writer, and by numerous other observers, and culture experiments have
been made, but no organisms have been found to be present. The
coagulability of the blood is said to be somewhat diminished. The
red corpuscles diminish rapidly at ﬁrst, from 5,000,000 to 3,000,000
per cubic millimetre (Bruce), more slowly but steadily later on through-
out the pyrexial period, leading to the pronounced anaemia which so
prolongs convalescence.
Scorbutic symptoms, during the progress of long cases, have been
described. The writer has only seen them occur in one instance, the
spongy and haemorrhagic condition of the gums being due to an excessive
use of mercury. He is of opinion that the free use of fresh lemonade,
and when possible of fruit, during the long period of attacks has been
the means of abolishing these symptoms so rarely met with now. (See
“ Alimentary System.”)
In long cases constipation and continued abdominal congestion may
set up a haemorrhoidal condition of the mucous membrane of the lower
part of the rectum. This usually disappears when convalescence becomes
established.
Pericardial eﬂusion—The writer has twice met with instances of
pericardial effusion occurring in the course of this fever. Both
cases proved fatal, one on the 19th and the other on the 62nd day of
the disease. In both cases there were vegetations present upon
the mitral valve; in both cases the effusion consisted of clear serum
and partook of the nature of hydrops pericardii. No pus was present,
but little ﬁbrin, while the pericardium was but slightly congested. The
condition was overlooked until the symptoms became suddenly urgent,
when the nature of the complication was obvious. It was not relieved
by any of the usual remedies, and aspiration was not tried, though it is
apparently the treatment to be employed in any future case. The
condition was remarkably similar to the common arthritic effusions of
this disease, death resulting directly from the amount of serous effusion
present, there being no other urgent symptom present of a dangerous
nature. Consequently the hope of a favourable result following aspira-
tion should be great. In both cases the writer saw the cases only at
the last moment, when they were both quite conscious and sensible.
They were sitting up in bed, suffering from extreme dyspnoea, pain in
the cardiac region, with restless countenances, on which were written
that anxious look of impending death. The pulse was small and feeble,
the heart sounds almost inaudible, the area of cardiac dulness largely
I44 UNDULANT, MALTA OR
~04.

increased. In both instances there had been a rise of temperature
during the previous few days, probably associated with the pouring out
of the effusion.
Case 8. ——Private W., Royal Berkshire Regiment, age 23, was
admitted to hospital on 29th December 1892, suffering from acute
undulant fever of about three days’ standing, contracted with another
case near a burst drain (see “ Instances of Outbreaks ”). Health during
ﬁve years’ previous service had been very good. On admission his tem-
perature was 103° F., and all through the attack, until his death on
15th January 1893, his temperature was most remittent in character,
varying between normal on the mornings of the 7th, 10th, and
16th days, and 1040 F. on the evenings of the 8th, 10th, 12th,
13th, 14th, and 18th days of the disease. On admission he
suffered from pain in the chest, palpitation, and signs of eatarrhal
pneumonic consolidation, with profuse expectoration. On the 10th
day he suffered from vomiting and increased lung symptoms. On
the 14th day he became rapidly worse, suffering from frequent loose
light yellow stools, and his temperature rose to 104° F. at 3.30 P.M.,
from which it was reduced by sponging to 101° F. It began to rise
again at 6 P.M., while at the same time he complained of great peri-
cardial pain, dyspnoea, and anxiety. His lungs were considerably
congested at the bases with signs of consolidation, his pulse was small,
thready, and intermittent. His temperature reached 104'6° F. at
8 P.M., from which it was reduced by sponging to 102'4° F., but the
cardiac symptoms increased, and the diagnosis of pericardial effusion
was made, but too late for any satisfactory result, and he died some-
what suddenly of heart failure. An apical systolic murmur had been
audible from the ﬁrst, and treatment had been directed towards helping
the action of the heart, which was at no time strong, much of the lung
stasis being doubtless due to the presence of this condition, and the
local symptoms to a great extent at ﬁrst being put down to this
cause.
At the post-mortem examination the lungs were found to be
extremely congested, with patches of basal consolidation. The spleen
(weight 12 oz.) was extremely congested, and colonies of the micro-
coccus Melitensis were obtained from it. The liver (weight 50 oz.)
was congested and slightly nutmeg. The heart contained a large
ante-mortem clot in each ventricle, and there were thickening and vege-
tations on the mitral valve. The pericardial sac contained 13 oz. of
clear serum ; the serous surfaces were not inﬂamed.
Case 14.—Private J., age 22, was admitted to hospital on
8th August 1895. His previous medical history was good. The
primary wave was severe, and lasted until the middle of September,
when the temperature fell to normal, and remained there for sixteen
days until 7th October, when it rose suddenly to 104° F. During
this apyrexial period the patient was up and about, and had even for a
few days been having solid food. On the 8th his tongue was furred
[MEDITERRANEAN FE VER I45

slightly, but he complained of no pain. His temperature was reduced
slightly by sponging, and perspiration was encouraged by diaphoretic
mixture. On the 9th he seemed better, and on the 10th his tempera-
ture fell to 101° F. after a good night, and he seemed to be much
improved. On the afternoon of the 11th he for the ﬁrst time began to
suffer from pain in the chest, but did not complain of anything until
6.30 P.M., when his temperature was found to be 103'6° F. He
also complained at this time of great pain in the cardiac region
and dyspnoea, while his pulse was found to be weak and his heart sounds
inaudible. He became very rapidly worse, the dyspnoea increased,
the pulse became small, intermittent, and very rapid 3 he became
extremely collapsed, his temperature at 7.30 P.M. being subnormal, and
in spite of treatment he died soon after of cardiac failure. Aspiration
was not tried.
Temperature from 5th October to 11th October

Date. Day of Disease. Teﬁgglligtlgra Evening Temperature. Bowels.
5th October 56th 976° F. 98'4° F. 2
6th ,, 57th 97-s° es-s° 2
7th ,, 58th 98 ‘8° 104 ‘0° 2
8th ,, 59th 103 ‘0° 103 ‘4° 2
9th ,, 60th 102 ‘6° 103 ‘0° 1
10th ,, 61st 100'0° 101'O° 1
, o 103'6° at 6.30 P.M.
11th ,, 62nd 100 0 97,20 at 7,30 P'M } 2


At the post-mortem examination the right lung did not collapse on
opening the chest, the left one did so imperfectly. The entire right
parietal sac was obliterated by adherent lymph, sufficiently organised to
contain distinctly marked blood-vessels in it. The right lung (weight
33 oz.) was congested and oedematous 3 the left (weight 23 oz.) slightly
emphysematous, the lower lobe being congested. There were 17 oz. of
clear serum ill the pericardial sac, which was not inﬂamed. The heart
was relaxed and ﬂabby, but the valves were normal. The liver (weight
70 oz.) and the spleen (weight 14 oz.) were congested. The kidneys
were congested, and their capsules somewhat adherent.
Should the writer again meet with such a case of pericardial
effusion, apparently uncomplicated by other dangerous symptoms, he
will most certainly feel justiﬁed in resorting to aspiration or other
operative measures for its relief. He would refer his readers especially
to a recent paper by Dr. William Ewart on some twelve “Practical
Aids in the Diagnosis of Pericardial Effusion,” reported in full in the
British Medical Journal,1 and warn them to be on the look-out for this
rare but dangerous complication. The sudden onset of dangerous
1 21st March 1896, vol. i. p. 717, and 23rd January 1897, vol. i. p. 185.
L
146 UND ULANT, MALTA 0R

symptoms shows the necessity for prompt action, for in neither of the
cases reported was the condition suspected until a short time before
death, nor was there time in either instance for the medical officer in
actual charge of the case to be summoned in time to take action before
death ensued.
The site usually chosen for aspiration is the ﬁfth intercostal space
on the left side, close up to, or from one to two inches out from the
eternal margin, the aspirating needle being inclined upwards and
towards the middle line. Others choose the fourth, sixth, or seventh
interspace, left side, or even the right side of the sternum, but it will
be well to be guided by circumstances after carefully mapping out the
extent of the effusion.
Respiratory symptoms—About the beginning of the third week,
or earlier in severe cases, some bronchial cooing becomes audible on
auscultation, being most marked posteriorly at the bases of the lungs.
Later on, in some 95 per cent, there is evidence of basal congestion,
varying in amount according to the severity of the general condition.
In malignant cases this is apt to go on to lobular consolidation and
hypostatic pneumonia; so much so that this condition is nearly always
present in post-mortem examinations of rapidly fatal cases, and has a
large inﬂuence in bringing about the fatal result. In a large number
of cases bronchitis with frothy or more often sticky mucous expectora-
tion is present, and a certain amount of this symptom may persist
throughout the pyrexial period of long cases. In such cases it may
only be marked by a few ﬁne crepitations, often only at the apices, a
few rhonchi, and expectoration of sticky and even blood-stained sputum.
These symptoms, with the hectic kind of temperature of such cases, and
the copious night-sweats, are often mistaken by the unwary for
phthisis. The sputum is, however, not nummular, and does not contain
tubercle bacilli, while the pneumonic physical signs are not typical nor
progressive. The writer has, however, seen such cases diagnosed as
phthisis, invalided as such, and recover before embarkation for England.
Others have hurried home to consult specialists with a belief, supported
by local medical advice, that they had contracted tuberculosis of the
lungs. Indeed, in years gone by writers were in the habit of describing
a “Mediterranean phthisis,” which yielded wonderfully and generally
entirely to treatment.
These pneumonic symptoms, though to a certain extent possibly
caused by the direct action of the virus, are due largely to congestion,
from inefficient pulmonary circulation, and are therefore most common
and severe in those who have previously suffered from pleurisy or
pneumonia, or who suffer from organic cardiac disease.
A nervous cough, unaccompanied by expectoration or physical signs, is
present in some cases, being worst at evening when the temperature rises,
while dyspnoea may occur without any ostensible cause, but is less common.
A form of pleurisy without effusion is not uncommon, leading to
[MEDITERRANEAN FEVER I47

permanent adhesions; while pleurisy with effusion may accompany
pneumonic trouble, but is not commonly marked. Very rarely excessive
effusion into a pleural cavity may occur, but it has never in the writer’s
experience gone on to suppuration.
Intercostal neuralgia is not uncommon.
In even the mildest cases from the beginning of an attack we ﬁnd
that all patients expectorate some sticky mucus from the lungs, though
there be no physical signs present. This is especially notable in the
morning, when the accumulation of the night is brought up. This
symptom is usually proportionate in severity to the temperature, and
varies in amount directly as the pyrexial undulations rise and fall.
Where the sputum contains slight streaks or ﬂecks of bright blood, the
temperature has usually reached the summit of a wave late in a long
attack, and the condition disappears soon after the temperature has
reached normal again.
In some cases where cardiac and pulmonary irritability and distress
are marked, out of proportion to the amount of the pyrexia, the disease
seems to be specially affecting these organs locally or through their
nervous supply.
In all cases where such symptoms are present, and very especially
in cases where organic cardiac disease is present, or where the pyrexia
remains continually high, a close watch must be kept on the lungs, and
any tendency to congestion dealt with at once.
Alimentary system—The tongue on admission is usually swollen,
thickly coated with whitish yellow fur on the dorsum, pink at the tip
and edges, moist, ﬂabby and indented laterally by the teeth.
These points are accentuated in those who have been for some time
suffering from pyrexia, and have been eating unsuitable food before
reporting sick. In severe cases the dorsum becomes covered with thick
ragged fur, and may for a few days become dry and brown, and even
in very severe cases may become ﬁssured and a little blood issue from
the ﬁssures. In long-continued cases, during or after the second month,
the tongue often becomes glazed, of a dull, raw meat appearance, with
patches of its surface denuded of epithelium. The condition of the
tongue is roughly an index of the severity of the case, and of the
importance of any given rise of temperature. It is an accurate index
of the suitability or otherwise of the diet in use, and often gives warn-
ing of the necessity for the exhibition of stimulants. High temperature,
with serious constitutional disturbance, is accompanied by a dry brown
tongue, while, when there is a tendency to hyperpyrexia, the tongue is
usually proportionately foul. In the high temperatures accompanying
symptoms referable to the central nervous system, there is often little
constitutional disturbance, and the tongue remains comparatively clean
in spite of continued high pyrexia. The tongue rarely, if ever, becomes
quite clean until the disease is over, remaining lightly furred during
long but temporary apyrexial periods. It may, therefore, be taken as
I48 UNDULANT, MALTA OR

a rough but useful rule that a fall of temperature to normal will rarely
prove permanent unless at the same time the tongue has also become
clean. This has an obvious bearing on the question of an increase of
diet, or permission to get up for an apparently convalescent patient.
At the end of very long and protracted cases, in which the disease is
limited to slight nocturnal pyrexia with little or no constitutional
disturbance and a clean tongue, it is occasionally found that solid food
may be given that would upset other patients whose gastro-intestinal
mucous membrane was still in an irritable condition, as evinced by the
furred condition of the tongue. This power of assimilating solid food
at the end of long attacks is in great contrast to the general gastro-
intestinal irritation present in severe cases, and indeed during the initial
stages of nearly all cases. Besides the condition of the tongue, other
signs of gastric irritation are constantly present during the early and
severe stages of the attack. These are loss of appetite and desire for
food, foul taste in the mouth, inability to digest any but suitable food,
epigastric tenderness in almost all cases, occasionally nausea and even
vomiting. Both these last symptoms are increased by unsuitable food,
and in a few cases have proved most serious. The epigastric tenderness,
and occasionally also pain, is marked, and contrasts with the iliac tender-
ness of enteric fever. It is felt on pressure over and to the left of the
sternal notch, and is increased to the left when, as is usually the case
during the ﬁrst month or six weeks, the spleen is enlarged and tender
to pressure. In such cases the area of splenic dulness is proportionally
increased, while the spleen may often be felt on palpation below the
margin of the ribs, on inspiration and expiration, during the ﬁrst
month or so.
The liver is often tender to pressure and slightly enlarged down-
wards in severe cases, at an early stage and also towards the end of
prolonged attacks, when from continued back pressure congestion, it has
become somewhat “nutmeg” in character. Occasionally patches of
intestinal congestion may give rise to localised tenderness at various
points over the abdominal surface, but such are rare in occurrence.
Epistaxis1 has occurred in ﬁve of the writer’s cases ; it is an
uncommon but early symptom. Bleeding from the gums, combined
with a spongy condition, has been described, but has been only met
with once by the writer in a case in which the exhibition of calomel
was unduly pushed. Its absence is probably due to the use of fresh
lemonade and fruit.
‘Bruce (1889) mentions a case where “on the 94th day of the
disease the gums were found to be spongy 3 the lower half of a dark
claret colour, the upper pale and livid.2
The pillars of the fauces, the uvula, and tonsils are usually red,
relaxed, slightly congested, and dry at the onset of the disease, while
1 For profuse epistaxis during the eighth week see MacLeod (1897).
2 See also Davidson’s Geo. Path. (1892), vol. i. pp. 262 and 264, Veale (1879), and
Macleod (1897).
MEDITERRANEAN FEVER 149

the patient complains of a feeling of constriction. An aphthous ﬁlm, or
grayish translucent coating with small white points over the follicles, is
often noticed at the same time over the tonsils. The breath is usually
foul, and remains so in proportion to the condition of the tongue and
stomach, and to the suitability of the food. There is often some
swelling or tenderness, with hardening of the cervical or submaxillary
glands. These can be distinctly felt, and vary in size from a pea to a
hazel nut.
In non-malignant cases constipation is the rule. In the writer’s
experience it was marked in 81 per cent of cases ; while of the remaining
19 per cent it was combined with diarrhoea in 3 per cent ; 12 per cent
were normal, and in only 4 per cent was diarrhoea markedly present.
In fatal cases, owing to the frequent involvement of the large gut,
diarrhoea has been present in 13 out of the 22 cases in which the
state of the bowels was noticed, and in many of these it was excessive,
the stools being loose and watery in consistence, light in colour, most
offensive, and at the end passed involuntarily. In other cases the
stools are usually brown, somewhat offensive, and even in severe cases
are as a rule more or less formed, and in many cases very hard, scybalous,
and yellow or almost white in colour.
Bruce (1889) says: “In 65 cases in which the condition of the
bowels was noted, in 48 there was constipation and in 17 diarrhoea.”
In severe cases the condition of the teeth and gums may become
offensive, from collection of sordes, as in other fevers. In Malta, ﬂies
are apt to collect round the mouths of such cases and prove annoying.
This occurrence is looked upon as a bad sign by nurses and sick
attendants.1
The stools are usually, and especially in mild cases, brown, and
hard in character. In many cases they are lighter in colour and even
scybalous. In all cases they are offensive, and in severe cases excessively
so. When diarrhoea is present they become loose in character, but
have usually a darkish colour, and a great tendency to be more or less
formed, even in cases with many of the characteristics of enteric fever.
In certain severe cases, especially when there is involvement of the
lower bowel, there may be loose yellow stools, passed frequently and
even involuntarily, but they rarely have the pea-soup appearance of
those met with in enteric fever.
Tympanites is rarely met with, and is but seldom marked. Occa-
sionally the common tenderness on pressure met with over the epigastric,
splenic, and at times over the hepatic regions, may extend downwards,
being presumably due to intestinal congestion. It is mostly met with
over the sigmoid ﬂexure in cases in which the large bowel is involved,
and is with gurgling most rare in the right hypochondrium.
The appetite and powers of digestion decrease almost directly in
1 See Baxter (1820) who includes “ muscae circa 0s volitantes ” among his serious prog-
nostic signs.
150 UN!) ULANT, MAL TA 01a

proportion to the severity of the disease. In severe and malignant
cases the digestion is almost in abeyance, while in very mild cases, and
in the ﬁnal chronic and intermittent stages of long attacks, the patient
often can digest the most unlikely diet, apparently with impunity.
The return of the appetite is gradual, and is rarely so marked as is the
ravenous desire for food after enteric fever. Its return, combined with
the cleaning of the tongue and abatement of pyrexia, is a sign of
commencing convalescence. The re-establishment of the digestive
powers is very slow after prolonged attacks, and the greatest care must
be taken with regard to dietary for a long time after the actual pyrexia
has disappeared. Much of this is doubtless due to anaemia, but besides
there is much attenuation of the intestines, wasting of their mucous
membranes, and loss of function by the digestive glands and organs of a
temporary nature, in long cases of this fever.
Urinary and sexual system—The urine is decreased in amount at
ﬁrst, and in severe cases dark in colour and loaded with lithates. Later
on, unless there is much diaphoresis, it may be increased in amount,
light in colour, and of low speciﬁc gravity. It is acid in reaction, except
in a few instances when temporary irritability of the bladder is present.
Albumin is rarely present, even in fatal cases. In very prolonged fatal
cases a condition of commencing large white kidney has been met
with. Albumin is absent from the urine of those suffering from oedema
of the ankles during convalescence, the condition depending upon
anaemia.
As has been mentioned before, retention may occur in severe cases ;
and slight weakness of the sphincter vesicae has been met with during
convalescence. Also a temporary difficulty in starting micturition.
In very mild cases sexual desire may be increased, the sexual organs
partaking in the generally increased nervous susceptibility. Menstrua-
tion only disappears in severe cases, and in those in which anaemia is
marked. Attacks of this fever have not caused abortion in pregnant
women, in the few instances which have occurred in the practice of the
writer.
Attacks of this fever, especially when combined with epididymitis,
have been accused of causing sterility. This has not been proved by
any facts, while the Maltese are a most proliﬁc race. It is certainly
not the case with females. The writer has met with an instance in
which a wife became impregnated a month after recovery from a mild
attack of this fever (40 days’ pyrexia) when her husband was in the
middle of a severe and prolonged attack of the same disease, but during
a temporary apyrexial period. The pregnancy went on successfully
to term.
Epididymitis and orchitis (usually single), occur in about 4 to 5 per
cent of cases, and are late symptoms. Such conditions are met with
more commonly during relapses after apparent convalescence has been
established, and may be acute or subacute in character. Suppuration is
[MEDITERRANEAN FEVER 151

most uncommon, but occurred in one of the writer’s cases, accompanied
by a superﬁcial abscess over the ensiform cartilage, both being appar-
ently accidental and due to causes other than the fever virus.
When acute in nature, the testicle and epididymus swell, in from 24
to 48 hours, to the size of a small orange, are very painful and ex-
tremely tender. There may be some redness of the skin and effusion
into the‘tunica vaginalis. The condition has no connection with ante-
cedent attacks of gonorrhoea, and very many men who have suffered
from gonorrhoea previously, go through an attack of Mediterranean
fever without any testicular trouble. The acute inﬂammation usually
subsides in the course of a few days, leaving the organ hard and slightly
tender. Gradually the hardness disappears and the normal condition
is returned to, but this often takes a considerable time. The subacute
variety is merely a less acute form of the above, the patient complaining
of pain and a feeling of weight about the testicle, especially after
exertion or exercise. On examination the epididymus is found to be
enlarged, and the whole organ somewhat tender when squeezed even
gently. A few days’ rest and support relieves the distress, though it
may return if exercise is taken before it has quite recovered.
As is the case with the arthritic attacks, a certain amount of pyrexia,
proportionate to the acuteness of the symptoms, accompanies attacks of
this kind.
Cases 46-49.-—Illustrating orchitic symptoms—Pte. E., admitted in
Malta, June 28th, 1895, suffering from Mediterranean fever, for
which he remained in hospital for 125 days. Seven days after
his return to duty he was again admitted to hospital with
similar pyrexia complicated by acute orchitis, and pains in both hips.
During his ﬁrst stay in hospital he had suffered from effusion into the
hip and elbow joints. The orchitis (with epididymitis) ran an acute
course, with remittent pyrexia lasting a fortnight, after which the
testicle slowly recovered, but he continued to suffer from pyrexial
symptoms every now and then for two months longer. Eventually he
completely recovered, returning to permanent duty on Feb. 17th, 1896,
seven and a half months from the ﬁrst onset of the fever.
Pte. A., admitted to hospital, August 29th, 1895, with Medi-
terranean fever complicated with swollen joints, being discharged to
' duty 43 days after. Five days later he was readmitted for orchitis
following the fever, and did not again return to duty until 24 days
later.
Pte. M., admitted to hospital, June 23rd, 1895, with a mild attack
of fever for 12 days. Readmitted 79 days later with orchitis and
pyrexia lasting 13 days. Again admitted with severe Mediter-
ranean fever 12 days later for 70 days, followed by complete
recovery.
Pte. F., admitted on July 27 th, 1895, with Mediterranean fever for
59 days. Readmitted with orchitis and pyrexia 36 days later, lasting
35 days. Readmitted a fortnight after with rheumatism lasting 19 days.
152 UNDULANT, [MALTA OR

Pte. E., admitted September 4th, 1895, with mild Mediterranean
fever lasting 22 days. Admitted three months afterwards with orchitis
lasting 17 days.
Ollivierl mentions 27 instances of orchitis occurring in the course of
enteric fever. In 7 it set in during the primary pyrexia, in 20 during
convalescence, but not later than twenty days from the cessation of the
primary pyrexia. In one-ﬁfth of the cases suppuration occurred.
Murchison and other works do not mention this symptom, but it is
noted by Velpeau (1844).
Complications. —Hyperpyrexia, uncombined with other serious
symptoms, may occur at the onset of an attack, at the summit of a
pyrexial wave or late in a long case. In these instances it can generally
be successfully coped with, unless the patient is very debilitated. It is
then not very serious, and is usually followed by a more or less perma-
nent fall of temperature. When combined with pulmonary congestion
or consolidation, and with symptoms of failure of the cardio-respiratory
circulation, hyperpyrexia is, however, an extremely dangerous and fatal
complication at any stage of an attack. This condition usually follows
a period of continuously high temperature where antipyretic treatment
has been neglected, either early in a malignant attack or during a
severe relapse. Only too often in such cases the cardio-respiratory
circulation fails to support life in spite of temperature reduction. In a
few cases hyperpyrexia is accompanied by severe nervous prostration,
and may immediately follow a fall of temperature to normal (accom-
panied, however, by no improvement in the general condition of the
patient) well on in an attack. In these two last instances the pyrexia
too often proves uncontrollable to drugs or external application of cold,
the patient’s extremities and nose become cold and white, his body very
hot and probably cyanosed, while his temperature rises steadily from
106° to 108° F. and after death, to even greater heights (1120 to 1150 These cases almost always prove fatal.
Pulmonary congestion, passing into consolidation, is present in
nearly all malignant cases and in all early fatal ones. The bases of the
lungs and heart’s action should therefore always be carefully watched in
all severe cases with high temperature, and treatment of a suitable
nature begun early on the ﬁrst sign of stasis in the pulmonary circula-
tion. In severe cases this condition of the pulmonary circulation often
determines the fatal issue. It must, of course, be borne in mind that
the state of the heart’s action is the great factor to consider in such
cases.
Pleuritic effusion may occur and need tapping, but it is rarely in
itself dangerous. Empyema the writer has not met with, though it is
said to occur.
1 Revue de médecine, Paris, Oct. and Nov. 1883, and in Practitioner, May 1884, vol.
xxxii. p. 375.
[MEDITERRANEAN FEVER 153

Cardiac failure may occur, weakness and irregularity of the heart’s
action are not uncommon. Care must therefore be taken to watch the
pulse, and meet by adequate stimulation any ﬂagging, especially when
there are any signs of pulmonary congestion, during relapses in long
cases or when signs of general nervous prostration are present.
The presence of organic cardiac disease is a serious element of
danger, weakening as it does the power of the heart to carry on the
circulation, and leading in long debilitated cases to danger of sudden
death from syncope.
Pericardial effusion is a very dangerous, but happily uncommon
complication. In the only two cases the author has met with, the
condition was not noticed or complained of until a very short time
before death. In both mitral organic cardiac disease was present,
though not in any severe degree. Aspiration may in future give better
results.
Renal disease has as yet been seldom present, but has proved a
serious complication in prolonged cases, and if present would doubtless
add greatly to the danger of serious cases.
Anaemia, debility, and bed-sores materially lengthen the periods of
both pyrexia and convalescence while leading to danger to life from
exhaustion.
Uncontrollable vomiting is a most serious and dangerous complication,
happily but seldom met with. In lesser degrees it may seriously
complicate severe cases, and need very careful dietary and medication.
It is most prone to occur with high temperatures combined with over-
feeding.
Diarrhoea, especially when due to involvement of the large gut and
when the stools are frequent, offensive, and passed involuntarily, is a
serious symptom. Cases in which it is marked not infrequently prove
fatal.
Symptoms associated with the “typhoid state,” especially dry brown
tongue, delirium, and nervous prostration, are serious but not un-
amenable complications.
Constipation and portal congestion may give rise to haemorrhoids,
but these tend to disappear with convalescence. Anal ﬁssure, of a most
painful nature, complicated a case in Malta. A slight operation for the
relief of pain, during a somewhat high pyrexia, proved fatal from
haemorrhage, in spite of every attention in hospital. There was no his-
tory of haemophilia.
CHAPTER IV
Diagnosis : From enteric fever; Paludism; Tuberculosis; Hepatic abscess; other
suppurative diseases; Rheumatic fever, etc.—Prognosis.—Duration.' Pyrexlal
duration; Stay in hospital in a non-effective condition.—Mortality.—-[Morbid
anatomy: Naked-eye appearances based upon accounts of 62 post-mortem
detailed examinations, on cases whose duration varied from 4 to 160 days;
Division into two classes ;- Class 1., rapidly fatal cases 3 Class 11., longer cases 3
Descriptions by other authors ; Microscopic appearances.
Diagnosis. From enteric fever.—Though the writer has had the oppor-
tunity of personally observing a considerable number of cases of enteric
fever both in England and Malta, besides many hundreds of cases
of undulant fever, the following remarks are based on the carefully
recorded notes of three hundred cases of the latter fever, whose later
history or post-mortem appearances have left no doubt as to the correct-
ness of the diagnosis. This diagnosis in typical cases is sufficiently
clear, even to an inexperienced observer. There are, however, cases,
and these are unfortunately of the more serious and fatal class, in which
there is a great tendency towards passing into the so-called “typhoid
state.” In such instances it is only by long experience, daily watching,
and by carefully weighing every available fact, that a correct diagnosis
can be arrived at.
In the ﬁrst instance, many facts of collective value may be gleaned
from the history of the patient. With many exceptions, undulant fever
favours individuals in their second, third, or fourth years of residence,
and these indiscriminately up to and even over 35 years of age, the
23rd being the most frequent and fatal ‘year among the troops. It
occurs mostly during the hot dry months from June to October, when
the average monthly temperature is over 60° F.; its prevalence having
an inverse ratio to the amount and continuance of the rainfall.
Individual cases may as a rule, and more especially during an epidemic,
be traced to certain rooms in certain buildings. Enteric fever, on the
other hand, favours new-comers between the ages of 15 and 25, occur-
ring mostly after the ﬁrst heavy rains, and continuing to prevail during
the autumn and early winter months. As a rule this prevalence has
relationship with some deﬁnite area of milk and water supply, distinct
I
[MEDITERRANEAN FEVER 155

from that of undulant fever, except in certain epidemics, when a dual
cause appears to be at work.
Passing to clinical points we ﬁnd that the pyrexial curve is on the
whole the most accurate guide. The intermittent waves of remittent
pyrexia, varying in number from one to seven (usually three), with a
more or less marked apyrexial period between, are very characteristic of
undulant fever. Moreover, these waves are of an irregular character,‘ being
often combined, especially in the case of the shorter ones, with periods
of intermittent (but non-paroxysmal) pyrexia of variable duration—
while each successive wave of temperature bears no necessarily deﬁnite
relationship to the character of the primary attack or to intervening
waves. These waves vary in duration from three days to eight weeks,
the average being about ten days. The total duration of the pyrexiaT
condition is most iridefihiteINarying from 20 to 300 days or more, the
average being about nine or ten weeks, the only reliable indication of
convalescence being a p’éfiodmdfwsfiibnormal temperature. The resulting
anaemia and debility 7are extreme, causin'gwaniiavé'fagiézstay in hospital of
over 90 days.
This condition is very different from the occasional irregularities
from the recognised type met with in enteric fever fféTlfdwevefmany
relapses may occur, such relapses as a rule bear a deﬁnite relationship
in character to the primary attack. _Nolr'_1mﬁffentﬁiéffeﬂver
often of so prolon ed a character, thoTiglTthe writer was once deceived
by a‘cttSé'b‘f unuslfally remittent enteric fever, which died in a relapse,
on what appeared to be the 64th day of the disease. At the post-
mortem examination there were, besides recent enteric ulceration, signs
of previous healed and healing ulcers. Such a case is, however, of most
unusual occurrence.
The chief difficulty in diagnosis always arises durin “the”, ﬁrst
fortpaight of continuously high temperature" in severe cases. In “the'
Twi'iter’s experience, a fall in temperature approaching to normal, though
only of a temporary nature, if it occur during the ﬁrst ten days of the
disease, and without adequate apparent cause (such as entorrhagia), is
in adults a most valuable indication of undulant fever (see Chart XML).
The occurrence, two or three times, of slight epistaxis during the
early stages of an attack would raise a presumption of _e_r_1teric__ foyer,
while the occurrence in an adult of entorrhagia to any notable amount
is a sure sign that the case is not one" of rundlilant fever. It must be
remembered, however, that a spongy haemorrhagic condition of the gums
is occasionally present, at a late stage, in cases of undulant fever, and
that haemorrhoids or colitis may cause a few drops of bright blood in a
stool, conditions easily distinguishable from the above.
When the temperature in undulant fever begins to remit there is a
great tendency to profuse diaphoresis. This takes place about one
o’clock in the early mb‘r'riing, as a gerieral rule, and is sufficiently profuse
to necessitate one or more changes of clothes. Though more common
at a late stage in the attack when the patient is much debilitated, it is


156 UNDULANT, [MALTA 0R

somewhat characteristic at all stages, being uncombined with any rigor
or paroxysm.
Constipation, with more or less formed, and even very hard stools,
is th'e'ru'l‘mdulant fever, while diarrhoea is exceptional in non-fatal
cases (three times in 100 cases). In fatal cases diarrhoea is common (13
times in 20 cases) ; the stools then, however, are usually daTrker in colour
and less ﬂuid in consistency than in enteric fever. As constipation“
occurs also in about 4 per cent of enteric fever cases, the presence of
numerous “ pea-soup ” stools can be of diagnostic value only in mild and
uncomplicated cases.
In undulant fever there is usually an absence of that tumid, swollen
pondition of abdomen so common in enteric fev'er°(79~per scent), while“
tlﬁdp'a'mfeﬁness in the right iliac fossa, so characteristic
of the latter disease, is generally rep’lmly'asimiiar condition in the
_ep_igastric region, due, it is believed, to a common tendency to gastritis.
This may be combined with even nausea and vomiting. The tongue is
moist, swollen, and more uniformly furred than in enteric fever, with an
absence of the peculiar reddened edges. The areak of gsplen-ikdnlnpess is
more extensive, the spleen more tender, and itsHower border more
obvious on palpation below the margin of the ribs, the liver being at
the same time often slightly enlarged and tender. The face is frequently
excessively ﬂushed, and even cyanotic, while there is an early tendency
to severe headache and neuralgic or muscular pains. Though slight
swelling of the joigtsxmay very occasionally occur in enteric fever, it is
a common symptoin‘ifi~ undulant fever, more especially in the later stages
of the disease, passing from one joint to another, but especially affecting
the extremities, combined with effusion and occasional redness. Trouble-
some rheumatic and neuralgic symptoms are very common complications
and sequelae of undulant fever, while orchitis and mastitis may occur.
In undulant fever during life, and more especially during post-mortem
examination, the writer has observed in severe cases a characteristic goat-
like 0 our not present in enteric fever, but comparable to those present
In typhus and rheumatic fevers. During life this is noticeable about the
skin and breath.
Undulant fever IIWISWJT‘EIEEIEIOH, but on the other hand
the peculiar rose-rash is seldom we eve oped in enteric fever cases in
Malta, though present in some 70 per cent of English cases.
The reaction given by Ehrlich’s sulphanilic acid test for urine has,
in the at present limited experience of the writer, given aid in questions
of diagnosis. In enteric fever this test has given in twenty instances
(including a fatal case with post-mortem veriﬁcation) a crimson-red or
port-wine colour, especially noticeable as a salmon tint in the froth when
shaken. This reaction is most intense during the primary fever of the
ﬁrst fortnight, but gradually disappears during the third week. This
crimson is precipitated on standing as a greenish rusty-brown mass. In
undulant fever, in over 1 60 instances, the reaction has varied from orange
to mahogany-brown, and although the latter has occasionally in reﬂected
MEDITERRANEAN FE VER 157

light a pink tinge, there has always been a total absence of the enteric
red or rather crimson, both in the ﬂuid and in its froth, in crmf'faf'yl
‘ing severity and at all stages of the disease. The precipitate, too, has
no green tin e. As this test is applicable to the rs and most difficult
vQEETFciI'n-Egdiagnostic point of view, it should, ifTt‘ﬁmMtiffil'ésf't'o'give
such satisfactory results, prove of utility. Unfortunately, however, it
has two disadvantages, which for the busy practitioner will mitigate
its general usefulness. Firstly, it needs freshly-made solutions, which
take up time to make, but after a little practice this is reduced to a
small minimum. Secondly, the test rests in most cases on a distinction
between various shades of one primary colour, these shades depending
on its admixture with very small amounts of other colours. This,
especially as the colour is red, has proved an insurmountable difficulty to
some persons, who, without being colour blind, lack the necessary
appreciation of colour.
The following is the method of application the writer has employed :—
SOLUTION A.1
Sulphanilic acid . . . . 5 cc. (sat. solution).
Hydrochloric acid . . . . 50 cc.
Water . . . . . 1000 cc.
SoLUTloN B.
Nitrite of Soda . . . . . . 95 cc.
Water . . . . . . . 1000 cc.
Keep in separate stoppered bottles.
At time of testing add 200 cc. of solution A to 5 cc. of solution B,
add to this mixture an equal part of the urine, and render alkaline
with ammonia. Shake well and observe (a) the colour of the ﬂuid, (b)
the colour of the froth, (c) after standing for twenty-four hours the
colour of the precipitate. A standard red enteric tube may be made
with red ink or fuchsine for purposes of comparison.
The sodium nitrite solution should be freshly prepared, the sample
of urine freshly passed and acid in reaction, and the fact that morphine
gives a similar reaction borne in mind. Hewlett mentions various
modiﬁcations of this test. Thus Ehrlich mixes the urine with ﬁve times
its volume of absolute alcohol, ﬁlters and tests the ﬁltrate as previously
described. Simon adds the ammonia by means of a pipette, so that it
forms a layer on the surface, and a coloured ring is produced at the
junction of the liquids. Rutimeyer makes his test solution by adding to
200 parts of a saturated aqueous solution of sulphanilic acid, 10 parts of
pure nitric acid, and 6 parts of a 0'5 per cent aqueous solution of sodium
nitrite. Green claims that the reaction is much more reliable if the test
solution be prepared by mixing A and B in the proportion of 100 to 1
1 See also V. Taksch’s Clinical Diagnosis; Lancet, 6th Jan. 1894; Practitioner for
March 1894 ; and Brit. riled. J0ur., 18th Jan. 1896, vol. i. p. 136, etc.
158 UNDULANT, MALTA 0R
instead of 40 to l, as originally recommended. He has also established
the fact that the addition of various drugs does not interfere with the
reaction.
That the crimson reaction has been met with also in cases of advanced
phthisis, tuberculosis, extensive malignant disease, and occasionally in
measles, pneumonia, typhus fever, acute rheumatism and septicaemia, is
true, but as the abs cc of the reaction is the important point in this
question, the usefulness of the test is not materially weakened, but if
anything rather strengthened.
The serum reaction'test (Vidal), which has been recently employed
in the diagnosis of enteric fever,1 has also been applied to undulant fever
by Professor Wright of Netley. He employs serum sedimentation
tubes, in which serum from blood, obtained from the patient’s ﬁnger,
diluted with normal salt solution and intimately mixed with a living
culture of enteric or undulant fever bacteria. After twenty-four hours
the agglomeration and sedimentation of a similar culture, or the diffuse
growth of a different one, settles the nature of the disease. The details
of the reaction are fully described in a paper by Professor Wright2;
also a method of applying the test with dead cultivations which can be
forwarded in capsules from a laboratory, and so do away with the
necessity for the cultivation of the bacteria by individual medical ofﬁcers
in various stations.3 The technique is as follows :—
A blood-capsule is made by drawing out the ends of a piece of glass
tubing (of about a quarter of an inch in diameter) to capillary ﬁneness,
in the blow-pipe ﬂame, in such a manner as to leave about a quarter of
an inch of the original tubing in the centre. Blood is then obtained in
the usual manner by pricking the ﬁnger of a patient near the nail.
This blood is drawn into the capsule and its capillary ends sealed in the
blow-pipe ﬂame. The capsule is then set aside or sent to a laboratory
for examination. As soon as the serum has separated from the clot it is
ready for use. A capillary pipette is now made by drawing out the
end of a piece of glass tubing in the blow-pipe ﬂame. One extremity of
the blood capsule is nipped off and the contained serum drawn into the
capillary pipette, a mark being made on the tube at the upper margin of
the serum to indicate the amount obtained. This serum is then blown
into a watch-glass, and is diluted, ﬁrst, ﬁve-fold by ﬁlling the capillary
pipette four times in succession with normal salt solution (to the same
extent as it was ﬁlled with serum), and by blowing this salt solution
into the watch-glass containing the serum. In this manner any desired
dilutions are obtained. It is convenient to work with 5, 10, 25, 50,
and 100~fold dilutions of each sample of serum.
An emulsion of living typhoid bacilli or of the micrococcus Melitensis
1 Vide American Journ. of rMeol. Science, March 1897 ; Lancet, 1895, vol. i. p. 1459 and
p. 1464 ; 1896, 19th Sept. and 19th Dec. ; Brit. Med. Joan, 5th and 12th Dec. 1896, Jan.
1897, vol. i. pp. 147, 231 ; and .New York Med. Jour., 31st Dec. 1896, etc.
2 Brit. Med. Jour., 1897, vol. i. pp. 139, 258. Serum sedimentation tubes can be
obtained from Mr. A. E. Dean, jun., 73 Hatton Garden, EC.
3 Brit. Med. Jour., vol. i. p. 1214 ; 1897.
[MEDITERRANEAN FE VER 159

is made in another watch-glass (or that of dead bacteria, sent in a cap-
sule from a laboratory, may be used).
Equal parts of the diluted serum and of this emulsion are now mixed
together. This may be done by running a certain amount of the
diluted serum into the capillary pipette, and making a mark at its upper
margin to indicate the amount run in. A small air bubble may then be
drawn into the tube, and next the bacterial emulsion run into the tube
to the point already marked. The capillary pipette will now contain
equal parts of the diluted serum and of the emulsion, separated from one
another by an air-bubble. These are then blown into a watch-glass and
intimately mixed.
A drop of this mixture placed on a cover-glass and inverted over a
hollow-ground slip may be examined under the microscope. The re-
mainder is again run into the capillary pipette, the capillary end sealed in
the blow-pipe ﬂame, and the pipette placed on one side for observation (for
convenience in an ordinary glass test-tube). A control tube, containing
equal parts of the bacterial emulsion and of normal salt solution, may also
be prepared and placed by the side of the original tube for comparison.
Under the microscope the bacteria will soon lose their motility and
become agglomerated into clumps, if they have been mixed with the
diluted serum from a person who is undergoing, or who has undergone,
the speciﬁc fever which corresponds to the variety of bacteria which has
been employed. In the capillary pipette this agglomeration is shown
by a precipitate formed of these agglomerated masses of bacteria, which
in about twenty-four hours forms a pellet near the lower end of the
capillary tube of the pipette, plainly visible to the naked eye, while the
ﬂuid above is clear. In the control tube, or in a tube where the serum
has been obtained from a patient who is neither suffering nor has
suffered from the speciﬁc fever caused by the bacteria employed in the
emulsion, no such change occurs. Even where dead bacteria are
employed which are eventually deposited at the lower end of the tube,
they form a different and evenly-disposed non-ﬂocculent deposit of
individual bacteria.
This technique is simple and easily carried out, though a written
description may seem so full of details. Where capsules of dead bacteria
are used no special bacteriological apparatus or knowledge is required,
but only a blow-pipe ﬂame, watch-glasses, and some slight manual
dexterity. Professor Wright has described (Brit. Med. Jour., 15th May
1897) a method in which, by the substitution of methylated spirit for
ether, the ordinary freezing spray used in hospitals may be employed
to obtain a blow-pipe ﬂame. The spray must be ﬁnely divided and the
spirit fed into the spray with regularity and in suﬂficient quantity.
The glass tube must always be removed from the ﬂame before being
drawn out into capillary pipettes and blood capsules.
Diagnosis from paludism.—Undulant fever differs essentially from
paludism in being non-paroxysmal, by having no periodical or regular
160 UNDULANT, MALTA OR

apyrexial intervals, by being unaffected by quinine to any great extent,
and by leaving the system free from relapses in after years when once
the disease has ceased to manifest clinical phenomena for any consider-
able period. The cases which approach most closely to paludism,
clinically speaking, are those cases in which there is a daily intermission,
more especially when they occur in countries where ague also exists.
There is in Malta no diﬁiculty in distinguishing such cases, and even the
question as to whether the patient has previously visited a paludic
country or not, is almost a foregone conclusion to one who has witnessed
the symptoms of both diseases. In undulant fever of an intermittent
type the temperature rises so steadily and slowly that the patient often
makes no complaint, or complains of but slight headache and general
malaise. There is no paroxysm, and rarely any attempt at a rigor,
though when the temperature falls profuse and continued sweating may
take place.
In undulant fever the haematophyllum malariae is invariably absent
from the blood.
It has been said that undulant fever and paludism can simultaneously
coexist in the same subject. The writer has seen cases of undulant
fever, in subjects who had previously suffered, in former stations, from
paludic infection, exhibit suddenly every alternate day an unusually high
temperature of a paroxysmal character. These periodic paroxysms and
excessive temperatures disappeared after the administration of quinine,
leaving only the pyrexia characteristic of undulant fever. Unfortun-
ately the organism peculiar to paludism has not yet been sought for in
these rarely seen cases, but an analogy exists in the relapses of ague
which frequently occur in England in paludic subjects after operations
or accidents.1 If the organism is ever found in such cases, its discovery
will strengthen the differentiation between these two fevers.
In Malta, where undulant fever is unfortunately far from uncommon,
paludism does not exist in these days as an endemic disease, though
slight relapses are met with among such of the troops as have previously
served in Mauritius, Cyprus, India, and in other countries where that
disease is prevalent. Such relapses are readily cured by quinine, and are
quite distinct clinically from cases of fever contracted in Malta.
In 1800-1810 we ﬁnd cases of “malaria” referred by Burnett to
emanations from the marsh at the end of the Grand Harbour, but he
also points out that large sewage drains opened there also, and stated
that he considered that they had much to do with the matter. Hennen
in 1825 also speaks of “malarial fevers” arising from this marsh, and
from a similar one at Misida, at the end of the Quarantine Harbour,
though Davy (1835) throws doubt on this assertion.2 He mentions that
the Capuchin monks of the convent at Floriana, which overlooked the
1 The writer has seen a case of tubercle of lung with hectic pyrexia similarly complicated
by paludism. See also Dr. Patrick Mason in Brit. Med. Jour. for 6th Jan. 1896.
2 1827, MacCulloch, rllalaria, London. Note on Malta, said by Davy ill 1835 to be
erroneous.
MEDITERRANEAN FEVER I6I

former marsh, had a special dispensation from nightly devotions on
account of the exposure that these necessitated. These marshes have
since been drained, and are now in an innocuous condition. Whatever
their effect on the troops may have been in those days, it can never have
been great, as we ﬁnd only very slight admission and death rates from
malarial fevers since 1817 (i.e. quotidian, tertian, and quartan fevers),
and whenever these rates reached a little above the average there was
invariably a note attributing these admissions to imported cases from
the Ionian Isles or elsewhere. (See back.)
Certain it is that paludism is not at present an endemic disease of
rocky Malta, though visitors arriving there seem frequently to possess
an opinion that undulant fever is a “malarial disease,” and gaze at those
who have had experience of the disease with incredulous pity when they
attempt to disprove such a theory.
From phthisis, liver abscess, and other suppurating diseases com-
bined with hectic pyrexia, we have to depend principally upon the
presence of local symptoms for our diagnosis. The temperature charts
of many chronic intermittent cases of undulant fever are undistinguish-
able from many which occur in the course of pulmonary tuberculosis.
Moreover, in many cases of undulant fever a condition of alveolar and
bronchial catarrh is set up, which with slight nocturnal pyrexia may per-
sist for three or four weeks or even months, before actual convalescence
is established. This, together with the profuse night-sweats, anaemia,
emaciation, and debility so often present, is apt to lead the unwary
astray, especially as there may be apical crepitations on auscultation.
The writer has seen such cases diagnosed phthisis, and invalided for that
disease, but completely recover before they had even embarked for
England. In these cases there is an absence of dulness, localised apical
ﬂattening and pain, and tubular breathing. The condition is more
generally distributed over the lungs on both sides, and is not pro-
gressive; the expectoration is strictly mucous, and though even blood-
stained is not hard and nummular, and contains no tubercule bacilli.
Often it is due to enfeebled circulation and the recumbent position in
bed, in which case it is marked by excessive physical signs at the basis
of the lungs behind, marking hypostatic congestion. This condition has
been called “Mediterranean phthisis.”
It must, however, be borne in mind that phthisis is a not uncommon
sequela of undulant fever, occasionally appearing to overlap that
infection, or follow after it with but a short interval between, and
such a condition must be distinguished from that described above.
Cases of chronic hepatic abscess have frequently been overlooked
to the detriment of the patient, the case having been considered as one
of undulant fever. This is accounted for by the similarity of the
pyrexial curve, and the fact that the liver is occasionally enlarged and
tender to pressure in the latter disease, while vague ('2) pains of a
rheumatic and temporary nature are not uncommon in both diseases.
M
162 UNDULANT, [MALTA OR

Hepatic abscess is occasionally met with in the Mediterranean,
though it is much less common among English troops than it used to be
ﬁfty years ago. The liver should always be carefully examined for
tenderness or enlargement in cases of continuous or intermittent pyrexia,
and constant pain or uneasiness referred to that organ be carefully gone
into, lest that early moment so often suitable for successful operation in
the case of liver abscess be missed.
Empyema and other suppurating diseases accompanied with tempera-
ture are usually easily distinguished from undulant fever, if their cases
are properly inquired into, by their localised symptomatology and the
history of the case.
The writer has not met with acute croupous pneumonia as an
endemic disease in Malta, though he has met with many cases trans-
ferred from troop and merchant ships outward bound from England. If
the disease exists it is not common, but catarrhal (broncho) pneumonia
is a most common and severe complication of undulant fever. As to
the existence of acute croupous (lobar) pneumonia elsewhere in the
Mediterranean the writer can give no opinion, but does not think that
a diagnosis should be difficult to establish, especially when a single lung
only is attacked. He has, however, seen cases landed from ships whose
temperature after the fall by crisis has on account of pleurisy or
empyema simulated the intermittent pyrexia of this fever. The history
and physical signs were sufficient for diagnosis to be certain.
An effusion into a single joint can be readily distinguished from
traumatic synovitis, by the presence of pyrexia at least in the evening,
and the absence of a history of traumatism.
The early gastric symptoms are distinguished from simple dyspepsia
by the presence of pyrexia, though the writer has frequently known a
mistake made in diagnosis owing to neglect in omitting to take the
patient’s temperature.
The rheumatoid and neuralgic symptoms following attacks of this
fever must be carefully distinguished from other conditions associated
with similar painful symptoms, as the latter are apt to be overlooked
unless a careful physical examination be made in each case. The
writer has known extensive spinal caries thus missed; while he was
once handed over a case of sarcoma extensively involving the ischium,
anterior muscles of the thigh, and extending noticeably into the abdo-
minal cavity under the peritoneum of the iliac fossa. This case was
said to have recently suffered from undulant fever, and to be at present
attacked with sciatica, the result of that fever. The physical examina-
tion made on transfer of the case at once disclosed, both to his former
attendant and to the writer, the real nature of the case, which was still
more evident on the post-mortem table somewhat later, in both this and
the preceding case.
The writer has not met with true rheumatic fever in Malta, though
he has more than once seen cases diagnosed as such, which subsequently
proved to be undulant fever. He has only personally met with two cases
[MEDITERRANEAN FEVER 163

of undulant fever which could be said to resemble rheumatic fever,
in which early joint effusion was combined with somewhat high pyrexia,
a condition not often met with in undulant fever. Even in these two
cases a correct diagnosis was not diﬂicult.
As a general rule in undulant fever, the joints are rarely affected
early in the attack, but when this is the case the temperature is usually
low, intermittent, and bears little proportion to the amount and severity
of the arthritic condition. The joints, when affected, are rarely so painful
as in rheumatic fever, except in those cases where one joint is acutely
swollen and the temperature is high. In this later event the pain and
tension soon gave way to appropriate treatment. The patient has not
that dread of movement, or of having his bed shaken, so characteristic
of rheumatic fever patients. There is not the same constant sweating
and acrid smell about the patient 3 the sweating in undulant fever,
though often profuse, being associated with deﬁnite falls of temperature.
Cardiac and pericardiac affections are rare in undulant fever, and even
when organic cardiac disease has been present, there has been reason to
believe that it existed prior to the onset of the attack. Pericardial
effusion has not been mentioned by other writers, and was only present
in less than 0'2 per cent of the author’s cases. Cardiac murmurs were
present in less than 0'5 per cent of his cases, while they are said to
occur ill 20 to 80 per cent in cases of rheumatic fever in England
(Fagge). Lastly, salicylic acid and its salts have little or no effect upon
the pyrexia or other symptoms of this fever.
Prognosis—With regard to danger to life and hope of ultimate
recovery the prognosis in this fever is a very favourable one, the case
mortality being about 2 per cent.
A previous history of tubercular, cardiac, or pulmonary disease
(pneumonia, pleurisy, etc.), or the presence of organic cardiac or renal
disease, of concurrent anmmia, phthisis, syphilis, etc., or of great nervous
excitability, all indicate a serious prognosis. The great majority of
deaths occur during the ﬁrst or second month of the disease, and are
mostly due to a train of circumstances which has led to hyperpyrexia,
pneumonic congestion (with perhaps consolidation), and failure of the
heart’s action. Of those dying at a later date (less than 25 per cent),
many die in a severe relapse associated with a similar combination of
hyperpyrexia and cardio-respiratory failure, others from syncope.
Hyperpyrexia when uncombined with failure of the cardio-respiratory
circulation can usually be controlled, but a combination of these two
conditions, unless energetically treated from their ﬁrst appearance, have
only too often proved fatal. This is very evident in the reports of
post-mortem examinations on severe cases. We cannot, therefore, but
view any condition likely to interfere with or retard the cardio-respira-
tory circulation, as a serious symptom, becoming the more so as the
pyrexia increases in amount and severity.
In other cases which have proved fatal at a later date, we meet
164 UND ULANT, MAL TA 0R

with organic cardiac disease, pericardial effusion, pleuritis, or empyema,
anaemia, debility, exhaustion, and intercurrent phthisis as causes of
death.
The cases which most often prove dangerous are either those which
commence with a tendency to continuously high pyrexia, with early
signs of pneumonic congestion, or those in which the patient is anaemic
with a highly excitable nervous temperament.
Obese plethoric patients more often suffer from malignant symptoms,
bear the fever worse, and are more prone to pneumonic’ congestion and
consolidation than those of a spare and lean build.
It has been said that those who have previously suffered from a
tendency to “rheumatism ” are more prone to the rheumatoid and
neuritic symptoms of this fever.
The appearance during an attack, of feeble, insufficient, irregular or
intermittent cardiac action, of pericardial effusion, pneumonic congestion,
pleuritis, renal disease, persistent vomiting, severe diarrhoea from in-
volvement of the large gut, excessive or continuously high pyrexia with
a tendency to dry brown tongue, and other symptoms of the so-called
typhoid state, of great anaemia, debility or bed-sores, one and all call for
constant attention and a guarded prognosis.
A dry tongue at any stage of the disease is always a serious
symptom; a cleaning tongue, especially when associated with a fall of
temperature, a most satisfactory condition.
Arthritic and acute neuritic symptoms rarely last long, and ulti-
mately subside. The former may, however, leave some temporary stiff-
ness, and though the joints never suppurate, they have been known to
become the seat of subsequent tubercular deposits ; the latter may leave
a tendency to neuralgic symptoms on exposure to chills, etc. Gouty
arthritis may be brought on in persons subject to that diathesis.
Chronic neuritic affections may persist for some time (1-12 months), even
after pyrexia has disappeared, and thus give rise to after admissions to
hospital for sciatica, neuralgia, rheumatism, etc.
Pyrexia that is uncontrollable by cold applications (generally the
result of want of early treatment) is almost invariably fatal.
Convalescence is usually rapid when once fairly established,
but anaemia, oedema of the ankles, nervo-muscular debility, cardiac
irritability, shortness of breath, and feeble digestion may remain
for some time in cases in which the pyrexia has been unusually severe
or prolonged.
With regard to the length of time that a patient may expect to be
incapacitated from active work, prognosis is unfavourable and unre-
liable. The average time spent on the sick list by soldiers treated in
hospital (including time spent at the sanitarium or in hospital in England
after invaliding) has been from 70-90 days, but this duration varied be-
tween wide limits. While some patients returned to duty at the end of a
month, many who were invalided to England were away from duty for a
year, others from a year and a half to two years, before ﬁnal recovery.
'-
[MEDITERRANEAN FEVER 165
No deﬁnite rule can be laid down, but the pyrexia of cases of the
undulant type with severe onset may usually be expected to end during
the second month, and be ﬁt for work between the end of the third and
the sixth month, but there are many exceptions. Very severe cases,
though more dangerous to life, are on the whole less prolonged. In-
termittent and mild cases vary within very wide limits, while they are
unfortunately just the cases that are usually the most anxious to know
when they may expect to recover.
Thus the writer has separately treated the husband and wife of two
separate families simultaneously attacked during the spring. Both of
the husbands were ofﬁcers, of similar rank and mode of life ; and all four
individuals suffered during the ﬁrst two months from pyrexia of a similar
type and severity. With one family this pyrexia lasted, in the case of
the wife for two months, in the case of the husband for ten months.
\Vith the other family, in the case of the wife for one month, in the
case of the husband for eleven months. The wives suffered from mild
intermittent pyrexia, some arthritic effusion, were conﬁned to bed, and
dieted early in the attack, and were transferred to England before the
hot weather. The husbands did not at ﬁrst wholly give up work, were
not sent to England until the hot weather was nearly over, and arrived
for an unusually damp and wet September. Their temperature was
intermittent and mild for the ﬁrst three months, and then became
undulatory and severe, returning to an intermittent type before
recovery.
In all outbreaks of this fever the individual cases have varied greatly
in type, duration, and severity.
It is therefore never advisable to give an opinion upon the probable
duration of any individual case. At the same time, while inculcating
and encouraging patience, the patient’s spirits should be stimulated by
the hope that it may soon end. As a general but not invariable rule, a
gradually falling pyrexial undulation with markedly remittent tempera-
ture is more favourable than a rapid fall. A subnormal temperature
lasting for a day or two, and following an intermittent temperature or
gradual fall, when accompanied by a clean tongue and general improve-
ment, is very often a sign that pyrexia is to cease, even though the
patient himself may not feel in very excellent spirits. The afternoon
and evening temperatures are the only ones on which an opinion can be
based, as the morning temperature may be subnormal for days or weeks
while the later ones vary in their height above the normal line.
What the remote effects of this fever are it is impossible to say,
without further data than are at the disposal of the present writer. We
ﬁnd, from microscopical examination of the tissues of prolonged cases, that
changes occur, due to the constant and prolonged action of an irritant
poison, producing a “ﬁbrosis” in certain organs. Though this is not
great in amount, yet it is a change that cannot be beneﬁcial, and which
in greater amount leads to danger in such conditions as chronic alcoholism
and paludism. Whatever its effect may be on the ultimate prolongation
166 UNDULANT, MALTA OR

of health and life, it is one that has not been complained of as yet
among ofﬁcers and long service soldiers, or among civilians living in its
endemic area. In these days of short service but little is known of the
old age of the private soldier, but though very many cases of undulant
fever are annually invalided to England, but very few are discharged
from the service on account of permanent unﬁtness.
Duration—There are two points connected with this question,
namely, the duration of the active disease, i.e. the pyrexial duration, and
the length of time spent in hospital on account of the effects of the
fever.
Disregarding doubtful non-fatal cases of under three weeks’ duration,
the author has found the pyrexial duration of 372 cases in which it was
noted to be as follows :—
TABLE XIV.
{ 1-20 days (fatal cases) . . . . 51 #5
21-30 ,, . . . . 70} "
31-40 ,, 65
41-50 ,, 50 154
51-60 ,, 39
J 61-70 ,, 36
71-80 ,, 34 as
1 81-90 18
91-100 ,, 20
101-110 ,, s so
111-120 ,, 11
121-130 ,, s
131-140,, . . . . . 14
141-150 ,, . . . . . of
151-160 ,, . . . . . 2
To the above must be added, in certain cases, the unnoted relapses
for which they were subsequently admitted into other hospitals, or from
which they suffered at the sanitarium, or after being invalided from the
island. It may be safely said that the average pyrexial duration
exceeds 60 or 70 days, while cases have been known to exceed 300
days. (Bruce, one case, 18 months 3 Veale, one case, 2 years 3 author,
one case, 277, two cases over 300 days, and two for 2 years.)
On a similar principle the time spent in hospital in Malta by 844
cases has been :—
1 A verage pyrexial duration about ﬁfty-eight days.
MEDITERRANEAN FEVER 167

TABLE XV.
f 1-20 da s(fatal cases) . . . 10}
\21-30 ,,y . . . . . 204 214
' 31-40 ,, . . . . . 153
{ 41-50 ,, . . . . . 119}378
51-60 ,, . . . . . 106
I 61-70 ,, . . . . . 72}
71-80 ,, . . . . . 57 159
l81-90 ,, . . . . . 30
J 91400 ,, . . . . . 26
101-110 ,, . . . . 21 ,- 59
111L120 ,, . . . . . 12;
121-130 ,, . . . . . 12}
131-140 ,, . . . . . 5 28
141-150 ,, . . . . . 11
Over 150 ,, . . . . . 6
844
In these are included 26 fatal cases, of which 10 died at an
early stage in the disease. Also 401 cases sent to the sanitarium at
Citta Vecchia for change of air (average stay there one month); and
142 cases invalided home to England. Moreover some of these cases
subsequently relapsed in other stations.
Taking these three latter items into consideration, it would appear
that the average time spent in hospital by cases of undulant fever
contracted in Malta is from 70 to 90 or more days, while cases with
sciatica have remained non-effective over a year and a half. Long
cases can scarcely be said to have completely returned to their original
state of health until an interval of from 12 to 24’ months, while many
seem to take years to completely shake off its effects. Of these 844
cases only 275 were sent straight back to duty from hospital, and many
of these relapsed.
Bruce gives the time in hospital as an average of 90 days, Moffet 9
to 12 weeks, Guiffré between 15 days to 28 weeks.
Mortality—Bruce and many others estimate the death-rate at about
2 per cent of cases attacked. During the six years spent by the
author in Malta, the mortality varied greatly from year to year in
relation to the strength of the garrison, but averaged fairly constantly
slightly over 2 per cent of cases attacked.
Morbid anatomy—The following remarks are based on the reports
of 62 post-mortem examinations on soldiers (duration of disease 4 to
156 days), recorded in the military hospitals in Malta, at 15 of which
the writer was present.
These morbid appearances depend, apparently, to a great extent on
the direct effects of the virus or its products on tissues of the human
organism. The post-mortem naked-eye appearances in acute and rapidly
I68 UNDULANT, [MALTA 0R

fatal cases are those of intense congestion, especially marked in the
internal organs. While those met with in chronic cases, fatal at a later
stage in the disease, are those of long-continued irritation of the tissues.
In the following description the writer will endeavour as far as possible
to divide the cases into two such classes.
Of these 62 recorded cases, 27 belong to the rapidly fatal class, 18
to those fatal at a later stage, and in 17 the duration was not men-
tioned.
CLASS I.—A cute and Rapidly Eatal Cases (27)
These comprise nearly all the cases which die during the ﬁrst four
weeks of the disease (some 60 per cent. of fatal cases), the fatal result
being apparently due to the direct action of the virus, or of its products,
on the patient.
Brain—In ten cases in which this organ was examined, the
meninges, superﬁcial veins, and choroid plexus, were congested in nine,
the greatest intensity being in early cases. In a few cases there was
effusion into the ventricular spaces. In one the condition was described
as normal.
Heart—The muscular walls are described as normal in all except
one case, when they were said to be “ﬂabby” (duration 12 days).
In three cases there were vegetations on the mitral valves, presumably
in two, and probably in one case, of previous origin. In one of the two
cases there was also fatty inﬁltration present, and in the last case
extreme pericardial effusion was present (duration 19 days).
Lungs—These were invariably congested at the bases, especially
behind. In many cases this hypostatic congestion had gone on to
lobular consolidation and oedema, but though small portions might sink
in water, the whole lung ﬂoated in those cases tested by the author.
Of ﬁfteen cases in which the condition was clearly noted, there was
considerable congestion with lobular consolidation of the bases of both
lungs in eleven 3 a similar condition of the left lung, with congestion
only of the right in one case 3 the remaining three cases having their
lungs congested without consolidation. The condition is one of hypo-
static congestion passing into broncho-pneumonia, with consolidation in
lobular patches, with much serous exudation into the bronchial tubes,
which latter are often injected. The bronchial glands were enlarged in
proportion to the pulmonary lesion.
Pleuritic adhesions are mentioned in six cases, in three of which
they are described as “old” (duration of cases 4, 7, and 8 days);
in three they are described as of “recent origin” (duration 8, 13, and
14 days).
Liver.——Congested, and somewhat enlarged and increased in weight,
in very acute cases 3 in a few cases not altered in appearance.
Spleen—Enlarged, the average weight of twenty-six cases being
199 oz. (10-44). It has always an extremely congested appearance,
[MEDITERRANEAN FE VER 169

being dark red or even red-black in colour, and of these twenty-six
cases nine were much congested, eleven were soft and extremely friable
in texture, while six were so broken down as to appear almost diffluent.
This latter condition is very characteristic, the spleen in some cases
appearing like a large clot of venous blood, ill other and more extreme
cases as a bag of semi-ﬂuid blood. This appearance has been described
as “ broken-down and rotten.”
Alimentary canal—Patches of congestion were present in twenty-four
cases out of twenty-seven. These were present in the stomach in six,
in the duodenum in six, in the jejunum and ileum in nineteen (one very
severe), and in the colon in eleven instances (two very severe). This
congestion followed the arborescent distribution of the vessels of the
stomach and intestine, and produced a dendritic appearance when held
up to the light, the congested veins, some a quarter of an inch apart,
looking like leaﬂess trees. It is not conﬁned to, nor constant in any
particular spot, and has no relationship to Peyer’s patches, though
occasionally one of these patches may happen to be situated on a
congested area. Similar congestive patches have been met with in
enteric and other forms of abdominal disease of an acute nature, and
while they form part of the general internal congestive condition, they
can scarcely be considered as typical lesions, nor specially characteristic
of this fever. The mucous membrane is often swollen and softened.
Peyer’s patches are unaffected, except that when there is extreme
intestinal congestion one or two of these glands may appear to be
slightly prominent (twice in twenty-seven cases), but there is no condi-
tion present in any way approaching the lesions found in enteric fever.
In no case was ulceration present.
The congestion met with in the colon is more characteristic of the
disease, being occasionally of an inﬂammatory character and combined
with oedema of the mucous membrane. It appeared in some cases to
decide the fatal issue, and in the sixty cases, in many of which the
duration is not given, it was noted as being present in twenty-two
instances, in eleven of which it is described as very severe. A similar
condition was specially noted by Oswald Wood in 187 6. The condition
reminds one of the early stages of dysentery, but the clinical course of
such cases, fatal or non-fatal, is different. The mucous membrane is
swollen, softened, and oedematous in large patches, livid and even
purple with congestion, and the solitary glands may be prominent. In
long cases which present this condition we have usually to attribute
death to the effects of a severe relapse complicated by this local lesion,
which approximates such cases to the acute rapidly fatal cases of
Class I.
In six cases only were the mesenteric glands enlarged, in which the
duration of the disease is noted, and in these cases such enlargement
was probably due to the excessive congestion of the large and small
intestines present in all these cases. Enlarged glands are mentioned
in thirteen of the sixty cases, in each of which cases intestinal con-
170 UNDULANT, MALTA 0R

gestion was present, and in ten of these the congestion may be said to
have been excessive.
Kidneys—These are in some cases congested, especially about the
pyramids and Malpighian corpuscles, in others apparently normal.
CLASS II.—Cases Fatal at a Late Period in the Disease (18)
In these cases the fatal issue is generally the result of heart failure
from intercurrent mitral disease; of broncho-pneumonia or other com-
plication acting on a debilitated and enfeebled constitution; or of a
sudden exacerbation of acute febrile symptoms. Such cases, besides
the signs of the local and immediate cause of death, show signs of
chronic irritation of the tissues similar to that met with in certain forms
of chronic poisoning. The duration of these cases was from 32
to 156 days, so that some of the cases which died during the acute
stage of their ﬁrst relapse are included.
Brain—In only ﬁve instances does this organ appear to have
been examined; in one (duration 117 days) there was effusion and
softening; in another (duration 44 days) “there was slight serous
effusion into the arachnoid space and lateral ventricles”; in another
(duration over 31 days) the “meninges were congested”; while the
remaining two were normal. There is an absence of mention of the
intense congestion met with in acute and very early cases.
Heart—This, though usually described as normal, is in ﬁve instances
termed “pale and ﬂabby”; in one there were mitral vegetations (111
days); in another (156 days), in which the organ was “soft, ﬂabby,
and small” ; there was a small aneurysmal dilatation above the posterior
left semi-lunar valve, vegetations on all the semi-lunar valves, and
some old pericardial adhesions ; in another (62 days) there were
17 oz. of clear ﬂuid in the pericardium, without any apparent cardiac
lesion. In the last three cases death occurred suddenly on account of
heart failure.
Lungs—As in the former class, these are usually congested at the
bases, and in four cases patches of consolidation were present.~ The
condition is not, however, nearly so severe as is the case with short
acute cases. In only two cases are the lungs returned as normal.
In ﬁve cases there were pleuritic adhesions of long standing, in two
adhesions of recent origin, and in two cases there was pleuritic effusion
present.
Spleen. —This organ is invariably congested in appearance and
increased in weight. Leaving out two cases whose time in hospital
only just exceeded one month, we ﬁnd that the average weight of the
spleens of fourteen long cases was 144 oz. Of these three were ﬁrm in
texture (duration 58, 72, and 53 days; weights 9, 12, and 11 oz.),
eight softened, and of these two were “diffluent.” The softer spleens
occurred in those who died during acute relapses.
[MEDITERRANEAN FEVER I71

Liver—Of twelve cases in which the condition of this organ is noted
it was described as normal in two, congested in ﬁve, pale in three, fatty
in one, and nutmeg in two, both of which were complicated by cardiac
disease. It was in nearly all cases increased in weight.
Alimentary canal—Of eighteen cases (duration 32 to 156 days),
but four were free from mention of congestion. These are scattered
about indiscriminately, and though somewhat constant in their pre-
sence, were not as a rule nearly so intense as in the former class.
In two cases there was the severe congestive appearance of the colon,
that has already been mentioned in Class I.; in a few long-continued
cases the intestines were sunken and attenuated.
In one case (duration 88 days) there was a small superﬁcial ulcer
in the caecum, and a shelving ulcer with irregular and ragged edges in
the colon 3 three or four of the Peyer’s patches were slightly congested,
and one mesenteric gland had suppurated, this latter condition probably
depending upon an abrasion or small ulceration which was present.
A case published by Bruce in the Practitioner of April 1888 (duration
53 days) had also ulceration present, and was thus described: “The
ulcerated condition was found 36 inches from the ileo-caecal valve
upwards. In this space there were four patches of ulceration. The
ﬁrst 4%- inches above the valve and opposite the mesenteric attachment
was oval in shape (one-third by one-quarter of an inch), and divided into
two by a bridge of mucous membrane. The edges were thickened and
undermined, and forming the ﬂoor could be seen the circular muscular
layer. This ulceration did not seem to correspond to a Peyer’s patch,
but was evidently formed on a loop of blood-vessel. No change could
be seen on the peritoneal surface. The other three patches of ulceration
were in Peyer’s patches. They had each the same character. There
was no thickening of the edges or undermining, but the substance of
the gland had fallen out in small oval and round patches, so as to give
a serpiginous character to the ulceration. In addition to these four
patches there were many minute losses of substance evidently corre-
sponding to solitary glands. It was noted that immediately above the
ileo-caecal valve there was a large Peyer’s patch which was neither
thickened nor ulcerated, and appeared to be healthy.” In addition to
these, Peyer’s patches are described as slightly enlarged in one case
(duration 40 days), but no ulceration was present. In another case
(duration 58 days) Moffet, at Gibraltar, says : “A few of Peyer’s patches
were prominent in lower third of ileum, while one or two higher up
presented a ‘shaven beard’ appearance, the mucous membrane was
soft, and the coats of the small bowel were attenuated and atroph'ied;
no ulceration nor cicatrices of old ulcers were seen.” This case died
during the ﬁrst acute relapse, on the 58th day. Another case in
Malta had an ulcer upon the posterior wall of the anal sphincter
(duration 46 days).
Of 62 cases, these are the only ones that had any ulceration resembling
enteric fever, and in only two of these was the ulceration suﬂiciently
172 UNDULAIVT, [MALTA OR

like to need discussion. In the ﬁrst case the ulcers had neither the
locality nor the appearance of enteric ulcers, and in the second case
(Bruce) the ulceration appeared to depend upon accidental causes other
than the true enteric virus. Moffet’s case, of which full notes with tem-
perature chart are published in the Army [Medical Report for 1889, was
certainly not enteric in nature. Besides these cases, Chartres mentions
one (duration 18 days), in which the intestines were normal except for
“two very minute points of abrasion of the apices of Peyerian glands
which were somewhat more pronounced than usual.” This case, together
with one of short duration in which the author found two small super-
ﬁcial ulcers (like abrasions) not situated on any Peyer’s patch, have not
been included among the 62 cases quoted, on account of the element of
doubt that they might introduce.
The losses in continuity in these cases were more of the nature of
abrasions than of speciﬁc ulceration, and taking into consideration the
softened and congested condition of the mucous membrane, and in the
long cases the atrophied and debilitated state of the intestinal tract
during the long-continued pyrexia associated with intestinal irritation
and marked constipation, we have not far to go for a solution of their
cause. \Vhile remembering that enteric fever has a peculiar speciﬁc
and typical form of intestinal ulceration, we must therefore bear in
mind that non-speciﬁc losses of continuity of surface of the intestinal
mucous membrane may occur in undulant fever, being in these cases (as
was doubtless the slight enlargement of Peyer’s patches in the case
mentioned) of accidental occurrence, and like bed-sores, having no
direct speciﬁc connection with the disease. In the many post-mortem
examinations that the writer has made on cases of enteric fever in
Malta, he has never had any difficulty in identifying the speciﬁc in-
testinal lesions of that disease, which lesions differed in no way from those
met with in England and elsewhere ; and he has no hesitation in saying
that the case he mentions above, in which two small ulcers were present,
had none of the characters of true enteric fever; while sixty of the
total quoted cases had not the slightest trace of ulceration apparent in
the alimentary tract.
Squire (1886), when describing cases of so-called typho-malarial
fever at Suakim, mentions that intestinal ulceration, when present, was
“not such ulceration either in site or character as that of enteric
fever.”
In four cases the mesenteric glands were said to be somewhat
enlarged.
See also ten or eleven cases mentioned by Guiffré (1893), collected
from various sources.
Squire (1886) gives the general pathological appearances in cases of
typho-malarial fever at Suakim, as follows :—
“ General injection of the mucous membrane of the alimentary canal,
often most marked in the duodenum and upper jejunum, but affecting
at different times the whole length of the tract. With this fulness of
[llEDITERRANEAN FEVER 173
the vessels there may be ecchymoses under the mucous membrane at
various parts in the intestine.
“ 'When ulcers are found they are generally irregular in shape, and do
not select the closed glands of the intestine.
“ The mesenteric glands are often enlarged.
“The spleen is generally enlarged; and the liver frequently con-
gested.”
For detailed descriptions of post-mortem examinations see Cases Nos.
2 to 15, Chapter II.; Nos. 3, 7, 8, 10, 14, 15, 21, 24, Chapter III., and
N o. 13, Chapter IV.
Microscopic appearances—With the exception of the spleen there
is nothing to be seen microscopically in the tissues that can be said to
be characteristic of this disease. The appearances in acute rapidly fatal
cases are those of acute pyrexia, with local congestions and hyper-
anaemias, the result of the irritating poison circulating in the body. In
long chronic cases the appearances are those of long-continued toxic
irritation of the body tissues. Owing to the high temperature of the
Mediterranean, during the summer months, when these cases occur,
section cutting is very difficult, so that there is a great want of further
and more accurate histological investigation.
Bruce states: “On making a section through a Peyer’s patch and
examining it under a low power, the serous, muscular, submucous, and
mucous layers are foun to be unthickened and almost normal in
appearance. The epithelial layer is continuous over the surface of the
gland. Under a high power morbid changes are found restricted to the
mucous and submucous layers, and consist in a slight proliferation of the
cellular elements. On examining the large endothelioid plates of the
glandular tissue they are seen to be somewhat swollen and proliferating,
and there is a slight proliferation of the adenoid tissue. There is pro-
liferation of the cellular elements of the lymphoid tissue of the mesenteric
glands, the reticulum is very delicate, and appears in places to be almost
obliterated by the increase in the number of the cells; there is some
proliferation of the endotheliod plates, and they are in a condition of
cloudy swelling. The Malpighian bodies of the spleen are enlarged from
an apparent increase in the number of the round lymphoid cells; the
endothelioid plates of the marginal sinuses are proliferating and swollen ;
a condition of intense congestion is seen in the section; the sinuses
being enormously distended with blood; there is marked exudation of
small round cells along the lines of most of the venules. The liver is
congested, the cells in a condition of cloudy swelling, and there is an
inﬁltration of small round cells in the interlobular ﬁssures. The kidney
is also congested, and in a state of glomerular nephritis.”
Bacteriologically he mentions the appearance of single micrococci
scattered throughout splenic sections in enormous numbers; while
micrococci similar in appearance to these are found in smaller numbers
in the liver and kidneys.
The writer has also observed the micro-organisms peculiar to this
I74 UNDULANT, [MALTA OR

fever, in cover-glass preparations of fresh splenic substance, shortly after
death, in ﬁve instances, in two of which they were extremely numerous.
In other cases they were not noticeable, though cultures on agar-agar
were obtained by inoculation. As no agent, by which the stain can be
ﬁxed in the micrococci while the tissues are being decolorised, has yet
been discovered. These cocci have not been carefully studied in situ, but
when they were visible they appeared to be in a free state in the extra-
cellular ﬂuids. As they have been grown as pure cultures from the spleen
by inoculation on agar-agar in twenty-ﬁve instances, from splenic blood
obtained during life in two instances, and from the spleens of inoculated
monkeys after death in three instances, there can be little doubt that
the spleen is one of the places where the micro-organism is invariably
present in cases of this fever, a fact further probable when we consider
the naked-eye appearances of the spleen at post-mortem examinations.
In the liver and kidney it has been found, and we must next search for
it in the lung, intestine, cerebro-spinal system, and in the swollen
joints, before its pathology can be placed on a sound footing. It has
been found in the circulating blood of the inoculated monkey, but not in
that of man.
In acute cases examined by the writer he has observed the micro-
scopical appearances described by Bruce as present in the spleen, liver,
Peyer’s patch, and mesenteric gland.
With regard to chronic cases, Dr. Hewlett, of the British Institute
of Preventive Medicine, has very kindly cut and stained sections of the
organs of Case N o. 13 (duration 111 days), from specimens sent to him
by the author.
Case 13.—Aged 25 years. Mediterranean service two years. Admitted
14-5-95 from a barrack where an outbreak of this fever was occurring
at the time. Previous history good. Admitted with the usual symptoms
of Mediterranean fever of sudden onset. On May 24th signs of hypostatic
basal pneumonia of the right lung appeared and persisted until June 9th,
when resolution set in, and there was a temporary abatement of symp-
toms until June 18th, when there was a pyrexial relapse of about a
month in duration. On June 29th a large abscess formed in the left
groin and was opened. Between June 18th and July 14th another
abscess formed on the back of the head and was evacuated, and many
boils in various regions of the body required incision. At the end of
July these abscesses had healed and the patient was better, while no
more boils or abscesses occurred. On August 20th he was emaciated,
debilitated, and extremely anmmic, his lips being almost colourless. He
also suffered from intractable sciatica. A systolic murmur, thought to
be haemic, was audible at the apex of the heart. About August 24th
he became worse; muscular tremors were constantly present, and the
pulse became ﬂapping in character. On the 29th he died suddenly of
cardiac failure, after 111 days of pyrexia.
Post-mortem examination three hours after death. Body greatly
emaciated, post-mortem rigidity well marked. Hypertrophy of the left
[MEDITERRANEAN FEVER I75

ventricle of the heart, with warty vegetations on the mitral valves;
weight, 12 ounces. There were recent adhesions between the parietal
and visceral pleura at the base and posterior part of the right lung.
The lower portion of the right lung was consolidated to some extent
and weighed 265 ounces 3 the left lung was healthy and weighed 17
ounces. The right bronchial glands were enlarged. The liver (weight,
72 ounces) was much congested. The kidneys (weight, 10'5 ounces
each) showed the characteristic changes of “large white kidney,” there
being strands of connective tissue between the pyramids. The spleen
(weight, 15'5 ounces) was much congested, soft, and friable. The
intestines were much attenuated as regards their walls, bllt were other-
wise quite healthy, there being no congested patches. A few mesenteric
glands were slightly enlarged, but Peyer’s patches appeared normal.
The pericardium contained from 4 to 5 ounces of serous ﬂuid. Small
portions of the lung, liver, spleen, kidney, mitral valve, mesenteric
gland, and a Peyer’s patch, were placed in equal parts of alcohol and
water for twelve hours. They were then transferred to absolute alcohol
(frequently changed) for three days, and then sent in absolute alcohol
to Dr. Hewlett.
The case was of the undulatory type, the pyrexial waves lasting
30, 27, 7, 13, 6, and 8 days, with some irregularity towards the
end.
Dr. Hewlett embedded the specimens ill paraffin in the ordinary
manner, cut sections with a rocking microtome and stained them with
Ehrlich’s heematoxylin and eosin.
They show the following appearances :—
Heart.-——The small vegetation on the mitral nerve has become
nearly fully organised into ﬁbrous tissue, and though it is still in-
ﬁltrated with round cells undergoing change, it cannot be of very recent
on in.
gLung—The perivascular and interalveolar tissue is inﬁltrated with
round cells (leucocytes). The air vesicles contain large catarrhal cells
and shreds of ﬁbrin, indicative of catarrhal pneumonia.
Liven—N either fatty nor ﬁbroid changes are present. There is
cloudy swelling of the liver cells, which have stained badly and show
granular degeneration of their protoplasm.
Spleen—Beyond a larger proportion than usual of lymphoid tissue
there is apparently nothing abnormal.
Peyer’s patch. The epithelium is continuous over the surface of
the gland. There is slight inﬁltration and increase in the lymphoid
cells. Otherwise the section of the intestine through a Peyer’s patch
appears to be normal.
Kidneys—There is cloudy swelling, granular degeneration and loss
of nuclei in the lining epithelium of the tubules, pointing to tubular
nephritis. In places there is inﬁltration of round cells into the inter-
tubular connective tissue, with commencing interstitial change. The
glomeruli are normal.

I76 UNDULANT, [MALTA OR MEDITERRANEAN FEVER

These appearances are not in any way specially characteristic of
undulant fever, but are rather those of severe and prolonged pyrexia,
acting on the tissues of the body.
Professor A. E. Wright, of Netley, has also cut sections of the
spleen, liver, kidney, and brain, of Case No. 14 for the author. These
showed the same signs of continued tissue irritation, much marked
in this case in the brain, and in and around the tubules of the kidney.
CHAPTER V
Prophylaxis: Period of prevalence in endemic area; Nature of suitable clothing;
General hygienic measures; Notiﬁcation; Disinfection of stools; Prevention of
pollution of soil; Flushing and disconnection of house-drains 3 Avoidance of
proximity to drain ventilators; Extravasation from house-drains; Flushing of
main drains 3 Cementing of ground-ﬂoor, living-rooms, etc.; Leaking cesspits in
porous soil 3 Discharge of sewage into tideless harbours 3 Dry-earth system, super-
vision of 3 Disconnection of rain-water pipes, sinks, etc., in the open air 3 Avoid-
ance of polluted ground for camping purposes; Prophylaxis on board ship;
Vaccination. —- Treatment: No speciﬁc drug known; Remove patient from in-
sanitary surroundings ; Dust from soft stone ﬂooring 3 Nursing and night attend-
ance 3 Cotton sheets, etc.; Conﬁne to bed during acute stages; Avoid fatigue,
worry, and chills 3 Fresh air 3 Absorbent clothing 3 Bed-pan and night stool;
Dietary; State of tongue; Severe cases not to be overfed; Milk, source of, and
amount; Peptonised milk; Lemonade, lime-juice, and fruit; Eggs and albumin
water; Beef juice, beef tea, etc. 3 Soda-water, lime-Water, tea, coffee, etc. 3 Ice 3
Calves’ foot jelly, chicken quenelle, soups, light puddings, etc. 3 Tobacco 3 Stimu-
lants 3 Drugs 3 Constipation 3 Diarrhoea 3 Record of stools 3 Bladder 3 Teeth and
gums; Mosquitoes and ﬂies; Prickly heat, sudamina, boils, bed-sores, etc.;
Diaphoresis and change of patient’s clothes; Pneumonic, pleuritic, and cardiac
symptoms 3 Fever pains, headache, sleeplessness, cerebro-spinal irritation, neuritis,
arthritic effusion, hyperzesthesia of the feet, and atrophy of muscles; Moderate
regulation of temperature; not to exceed 103°F. unchecked ; Antipyretic drugs
condemned 3 External use of cold water advocated 3 its advantages 3 apply early
in attack, and with regularity 3 Patients differ in response to external cold 3 Mode
of application 3 Amount of supervision necessary 3 Excessive reduction of tempera-
ture deprecated 3 Results of application 3 Friction of extremities combined ; Tepid
daily sponging of skin 3 Management of convalescence 3 Certain drugs ; Quinine,
bismuth, arsenic, hydrocyanic, carbolic acid, boracic acid, chlorine, mercurial
preparations, aconite, colchicum, eucalyptus, turpentine, Salicylates, antipyrin,
antifebrin, phenacetin, resorcin 3 Invaliding with change of air and scene.
Prophylaxis—Until the disease has been eradicated, those who visit
localities in the Mediterranean where this fever prevails, for mere pleasure
or in search of health, will do well to limit their stay to the period from
November to April (inclusive), during which period there is little~or no un
dulant fever. From the beginning of the hot weather, which usually com-
mences during May, until the sirocco winds of September and October
are over, all children and women who can afford a change are better
away from the infective area, in the more bracing climate of Switzer-
land, the Italian Alps, England, or elsewhere.
When business, duty, or pleasure calls strangers to the Medi-
N
178 UND ULANT, MALTA 0R

terranean at any time of the year, there are a few simple points which
they rarely realise, but which natives regularly practise. The sleeping
suit (be it pyjamas or night-dress) should be composed of absorbent
material, such as ﬂannelette, Jaeger, cotton-wool fabric, or ﬂannel.
Wear also similar material next the skin during the day, however
little else is worn, and remember that the dampness of the climate and
its sudden changes of temperature make the Mediterranean a cold and
chilly place, a fact little realised by those who have not visited it.
When visiting its shores in winter, do not leave rugs, furs, and warm
clothing behind. When likely to be out after sundown, especially when
driving, warm wraps should be taken, as the change from bright and
warm sunshine to the evening cold is sudden and often great. The
same is necessary when the harbour has to be crossed at night. Into
the ordinary hygiene of every-day life it is unnecessary to enter, as
every one should understand the necessity of avoiding excessive ex-
posure to sun, fatigue, etc., the supervision of their milk and water
supplies 3 the avoidance of overcrowding, and the necessity for an
adequate supply of fresh air in dwelling-houses. It is not, however,
out of place to remark that those of the garrison who take exercise in
the fresh air of the country during summer, are healthier and less liable
to attacks of fever than those who habitually remain in the vicinity of
their barracks, oﬁices, or houses in town.
The main point to dwell upon, if indeed we are correct in our sur-
mise, as to the actual cause of the fever, is the avoidance and subsequent
eradication of existing localised infective areas. For this purpose
every case admitted to hospital or notiﬁed as existing in private houses,
should be as carefully inquired into by their attending or district
medical officers, as is at present done in the case of enteric fever
among the troops. Notiﬁcation, which is in force in Malta, should
be made compulsory in all places where the fever exists. For this
purpose a printed form should be used and ﬁled for future compila-
tion of results. In the Army each district medical oﬂicer should keep a
book or plan in his inspection room, having a space for every room in
barracks, in which the simple entry of the date on which each case was
admitted would cause little trouble, and be a guide to the localised
distribution of cases, and soon lead to the detection and eradication of
infection foci. The writer, by roughly’following out such a plan, and
by tracing each case occurring in the barracks under his medical charge
to the bed it occupied, has not only discovered unsuspected insanitary
conditions of a gross nature, but has found his opinion of the faecal
nature of the fever conﬁrmed over and over again. This system with
some variation, if applied to many other diseases also, would soon lessen
their occurrence and the inefficiency and expense they involve. There is a
great tendency in military medical reports to give the sickness which
occurs in various regiments and corps, rather than that which occurs
within the deﬁnite areas which they occupy. The fact, so carefully
recorded in our published annual blue-book, that this or that regiment
MEDITERRANEAN FE VER 179

when in Malta seven years ago, suffered severely from enteric or S. C.
fever, etc., is of little value to us now, since we do not know what
barrack they then occupied. What is urgently needed in each garrison,
is a record of the sickness in each barracks and barrack-room, with its
probable cause, a brief account of remedial measures taken, a plan of
the drainage, watensupply, and an account of the milk-supply, etc.,
kept up to date. This would be a sort of medical history sheet for each
barracks, similar somewhat to that at present kept for each soldier.
These and other sanitary records should be kept in some central office
such as that of the principal medical officer, and be available for the
inspection of those concerned, while in large districts or stations a special
sanitary medical ofﬁcer (who, for a very slight addition to his pay would
soon qualify for a diploma in public health) in charge of such records,
and with a separate office and clerk, would investigate and eradicate
much of this and other preventible disease.
The notiﬁcation report should specify—
(1) The number, name, rank, age, army and Mediterranean service
of the sufferer, as is at present done in Malta.
(2) The barracks, room, and bed he has occupied during the two
months previous to the onset of the disease, and what previous
admissions have been noted from the same locality. If
married, whether any other member of the family has been
attacked.
(3) The general habits, occupations, and character for sobriety of the
sufferer.
(4) Any insanitary conditions to which he has been exposed, which
may have a bearing on the case.
(5) Date of apparent onset.
Any small extra expenditure that may be necessary to work such
a system would soon be repaid over and over again in the Army by
saving lives of officers and men, the replacement of whom, to say the
least, is a serious ﬁnancial loss; the saving in non-effective pay, and
in diets, extras, and stimulants in hospital; and in civil life by saving
the bread-winners of families from long periods of absence from work,
etc.
A modiﬁed form of this scheme might equally apply to civil com-
munities, and by the knowledge gained by such notiﬁcation, the
efforts of the civil sanitary department in preventing the occurrence of
this disease, by sanitary advice and control, would prove most beneﬁcial
both to individual families concerned and the community at large.
If the theory of the causation of this fever by aerial emanations from
soil (or drains, etc.) previously contaminated by the evacuations of thosel
suffering from the disease prove correct, there are many prophylactic
measures that we should adopt. The evacuations of those suffering from
the fever should be disinfected before being discharged into the house-
drains, or should be burnt. This will prove a large question, as we have
I80 UNDULANT, [MALTA OR
to deal with a disease having an extremely long duration when compared
with enteric fever. Moreover, owing to its often insidious onset, its
occasionally long apyrexial periods, and to the fact that patients are often
up and about, though still liable to slight rises of temperature, it follows
that many cases of this fever are leading for various periods an ordinary
life, though possibly their evacuations are of an infective nature. Care
must be especially taken that such ambulatory cases do not make a habit
of fouling ground in and around houses, barrack-rooms, and camps.
Such habits are unfortunately not uncommon among both the native
inhabitants of these parts of the Mediterranean garrisoned by England,
and among the soldiers themselves. The only way of guarding against
such pollution is to prevent both the healthy and unhealthy from such
habits. This is provided for in Malta by law among civilians, and a little
more activity on the part of the police would work great improvements.
It is further prevented in many places by paving such spots as are liable
to frequent pollution, and many of the streets, pavements, and squares,
with asphalte or cement, suited to the climate; and more especially
by providing urinals, etc., in suitable quantities, in the towns, for public
use. These improvements to the porous and dusty soil of the towns of
the Mediterranean, are beneﬁcial for many reasons besides that under
discussion, and should not be stinted. In the Army the same pre-
cautions can be even more easily applied, and are most important, for
there we have a community of men all more or less of a susceptible age,
and who are constantly being encamped on ground close to and around
barrack-rooms or on which troops have been previously encamped.
Facilities should be given to men to carry out instructions, by providing
urinals in suitable places, instead of placing them all together at one end
of the barracks, as is often the case. This particularly applies to large
barracks, and to such places as the canteen and sergeants’ mess. Again,
the urine tubs for night use should, besides being themselves kept clean,
be placed in such a position as not to contaminate the ground beneath
them. At very small expense indeed the space on which they are
placed can be cemented, and if possible be supplied with a slope and
a small trapped drain, disconnected outside. This allows of the ground
being properly washed down every day. Those who have seen the ﬂat
paving stones (usually themselves of a porous nature) taken up, dis-
closing the ﬁlth which collects beneath them in such situations, will not
doubt the necessity of this measure. A light should also be placed near
the spot on which these tubs are kept, so that men may be able to see
their position, and use them instead of the ground between, as is
too commonly the case where they are placed in the dark, outside the
barrack-room. They should further be emptied under very reliable
supervision, as the soldier will invariably use the easiest means of
getting rid of their contents, rather than the most suitable, unless well
looked after. Usually the nearest surface-water drain is made use of,
and the writer has even seen them emptied down grids, collecting water
for tanks set apart for ablution and cooking purposes.

[MEDITERRANEAN FE VER 181

It should be hardly necessary to point out the need for adequate
ﬂushing and disconnection of house-drains, but unfortunately in these
countries water is not too abundant during the hot weather, while the
crowded nature, at any rate of Malta and Gibraltar, leads to a close prox-
imity between dwelling-rooms and latrines. Flush-out apparatus with
waste-preventing ﬂushing gear, arranged with a sufficient fall to procure
the maximum of work with the minimum quantity of water, are
being gradually introduced and give excellent results. Unfortunately
ﬂushing is too often done by emptying water down the latrine by hand,
in the houses of the lower classes. From laziness where water drainage
is in force, and from a desire not to ﬁll the cesspit in other situations,
this proves a most faulty method. The disconnection of the house-
drains from the general drainage system is a most important point in
the crowded cities of the Mediterranean. Latrines are for want of space
often ill close proximity to bedrooms, placed in enclosed air-shafts or
yards, on the small verandah of the only window, or actually communi-
cating with bedrooms by a door or (as the writer has seen on several
occasions) by a room brick-ventilator intended for a fresh air inlet! In
hot weather there is a considerable amount of sewer-gas to escape, and
if precautions-are not taken, syphons may be forced. While providing
free ventilation to cesspits, house, and main drains, it is very necessary
that shafts should be carried well above the roofs of houses and kept
away from all neighbouring windows. In towns such as Valetta and
Gibraltar, where a very large number of houses are crowded into a small
space, and where from the hilly nature of the ground the roof of one
house is very often on a level with the windows of those in front or
behind, much difficulty is experienced in effecting this. So many cases
have, in the opinion of the writer and others, occurred in rooms opposite
such drain ventilators that visitors and others should be careful to
ascertain when taking a house, ﬂat, or rooms, that no such dangerous
and possible cause of infection exists in their proximity. Where house-
drains are unavoidably carried across yards or under cellars, any damp-
ness that might indicate leakage should at once be inquired into. Main
drains cannot be too well ﬂushed in hot weather, and where fresh water
is scarce or limited ill amount, and salt water close at hand, it would
appear reasonable that some means of utilising the latter might be made
available as has been done in many of the English towns lately. As
leaking and ruptured drain-pipes have so often contaminated the
subsoil of houses and yards in Malta, owing to the extremely porous
nature of the soil, it has proved practically advantageous in many
places to have the ﬂoors of cellars, ground-ﬂoor rooms, and yards
rendered with cement or other impervious material. The writer is
of opinion that all ground-ﬂoor rooms used for sleeping purposes should
be so treated, and in many of the barrack-rooms so treated this has
proved of great value in lessening or removing sickness from this
fever. In many cases this has been applied to streets, pavements,
and public squares with advantage. As has been mentioned already
182 UND ULANT, MAL TA OR

it is a great improvement in hospital wards over the usual dusty
paving of soft stone.
In the porous soil of Malta cesspits have not proved a success in
neighbourhoods where there are any number of houses close together, as
however carefully they are built in the ﬁrst instance, the temptation of
allowing or producing leakage has proved too strong to the native, on
account of its saving the cost of frequent emptying. Unfortunately,
however close these houses may be to the open sea, they continue to
build cesspits, until by their number and close proximity a subsoil pollu-
tion of so great an amount has taken place as to cause a danger to the
community at large. At this stage the institution of a general water-
drainage system has become a costly matter, and one to which the
existing landlords are not inclined to contribute. It seems a pity that
in the case, at least, of growing watering-places and suburbs of large
towns, some system is not instituted when these are in their infancy, at
which time there should be little if any difﬁculty in getting each land-
lord to contribute his share of the expense when building a new house.
We must remember, however, the lesson of the past, and carry all such
systems to the open sea, and not into the tideless harbours of the Mediter-
ranean, as has been too often the case.
Where the dry-earth system is in use, it must be under careful
supervision, not only as regards the cleanliness of the pails in use, but
also as to ﬁnal disposal of the material. The writer has found
a covered surface-water ditch full of such matter, which a contractor, to
save himself the trouble and expense of removing, had thrown down a
neighbouring grid in barracks. This covered ditch ran behind some
married quarters, where unaccountable cases of fever were occurring. In
barracks the contractor for emptying dry-earth pails usually visits at an
early hour, and before the men are about, so that special supervision
must be arranged for. The ultimate disposal of this material in crowded
places and in such a place as Malta, where the soil usually only has an
average of from six to ten inches thickness, needs consideration. This
soil also has but little activity in the dry hot weather. It is necessary
that the power of growth and future mischief of such germs as those of
enteric and undulant fevers, which appear to be able to lead a sapro-
phytic existence in some soils, should be carefully ascertained. It is
only with such knowledge in our possession that we can scientiﬁcally
discuss the possible merits or demerits of disposal of sewage by mea s of
the dry-earth system, or of sewage farms on any large scale. Of this
knowledge we at present are deﬁcient.
Rain-water pipes from roof, etc., must be disconnected from foul
drains, in the open air, over suitable traps, or they may prove dangerous
in dry weather by becoming drain ventilators. The same may be said
of sink, bath, and overﬂow pipes, which only too often are either con-
nected directly with drains, or are disconnected indoors instead of in the
open air, or have only a forceable syphon between. People living in
England scarcely realise the closeness of these to living rooms in such a
[MEDITERRANEAN FE VER 183

town as Valetta, where the average population is estimated officially
as 75,883 to the square mile; while that of the whole of Malta is as
much as 1600 to the square mile. To a less degree this is the case with
Gibraltar.
Care must be taken not to camp on ground liable to pollution, and
this especially applies to those tents used in barracks in’ Malta during
hot weather to relieve the barrack-rooms, which must not be placed on or
near to ground liable to pollution, nor near to drain ventilators. The
writer has seen many cases of this fever admitted to hospital from tents
unsuitably erected in such situations.
As- to prophylaxis on board ship the writer can give no opinion,
but must leave to his colleagues in the Royal Navy and mercantile
marine the elucidation of this subject. As all cases of this fever (other
than relapses) are said to occur within a reasonable period of leaving
port, it seems probable that the disease is not causally connected with
the ship itself nor with its food or water supply. It would, therefore,
follow that the prevalence of undulant fever on board ship is due to
some factor connected with either the situation of the ship in harbour
or to the visit of its occupants to the shore. It would be interesting to
know whether Burnett’s remarks on the difference of fever prevalence
in ships in dock or in the creeks, from that of ships in Bighi Bay (see
back, Chapter II. p. 63), still holds good ; and whether those who sleep on
shore when in harbour suffer more than those who remain habitually on
board. The possibility of danger arising from eating harbour shell-ﬁsh,
from bathing in polluted harbour water, and from using it for washing
down decks, etc., has already been pointed out (Chapter II. p. 65).
Lastly, it is possible that some form of vaccination may be discovered
that may render susceptible troops immune from attacks of this fever, if
only for a time, as in these days they do not remain as a rule long
within the endemic area of the Mediterranean. In this hope we are
much encouraged by recent experiments made on monkeys by Professor
‘Vright of Netley, in which he has, by artiﬁcial inoculation of dead
cultures of the micrococcus Melitensis, been able to confer upon monkeys
not only a high serum sedimentation power with regard to that micro-
organism, but also a power of at least inhibiting the growth of the micro-
organism of that disease in their system. Moreover, these dead though
still poisonous cultures, without being in any way dangerous, appear to
confer on monkeys as effectual an immunity as living ones.1
Treatment—There is no drug of a speciﬁc nature at present known
which will cut short an attack of this fever by its action on the virus, as
does quinine in ague, and mercury in syphilis. \Ve have, therefore,
primarily to treat a pyrexia which, except perhaps at the end of an
attack, we can do little to directly shorten by means of drugs. Not
infrequently when the pyrexia is dying out, and the virus is apparently
making its last stand, its ﬁnal disappearance is synchronous with the
1 Brit. IMed. Journal, 1897, vol. i. p. 258, and note on p. 259.
I 84 UND ULA N T, [MAL TA ' OR

administration for a few days of quinine or some other germicidal drug.
\Vhether this is accidental coincidence, or due to the action . of-the drug
administered, it is difﬁcult to say. We ﬁnd, however, that for this reason
various drugs are vaunted as speciﬁcs, which not only fail to cure other
cases at a similar stage in the disease, but which, when administered
during the acute stages, when the virus is, so to speak, in possession of
its full ﬁghting powers, not only have no effect upon the virus itself, nor
are able to shorten the duration of the attack, but in most instances
actually increase the severity of local alimentary symptoms, and also the
general febrile condition. In numerous cases, after much ineffective
medication, recovery has followed the cessation of all medicinal treatment.
We can, however, do a very great deal towards mitigating both the
general and local effects of this pyrexial condition, and towards the
lessening mortality due to hyperpyrexia. 1 We have, secondly, to treat
the various localised morbid conditions which arise. Lastly, we have to
consider the best means of recovery from the anaemia, debility, tissue
irritability, and other conditions left by the fever, after all pyrexial
symptoms have disappeared and the virus has been completely subdued.
Our ﬁrst aim should, therefore, as is the case with enteric and many
other acute fevers, be to place the patient under the most favourable
circumstances for nature (i.e. the individual tissues of the affected
subject) to effect her own cure, and at the same time to alleviate and
ward off complications and sequelae.
Although many cases will do well with careful nursing and dietary
alone, it is a great mistake to think that this is all that is necessary 3
for we each ﬁnd that as our experience increases our deaths decrease or
are postponed, our cases become milder and shorter, while complications
become less frequent and severe. Expectant treatment is very apt to
develop into laissez-faire in so prolonged a disease.
On arriving in Malta, Army medical officers have, as a rule, to treat
numbers of cases of this fever almost at once, and not unnaturally ask
those with former experience for advice in the matter. They rarely
obtain more than a suggestion that they should consider them as cases
of enteric fever, and treat them as circumstances should appear to
require. As it is these severe cases with a tendency to the “typhoid
state” that require the most active treatment, in the absence of any
authoritative advice on the subject, this suggestion comes to be useful,
under the system that half a leaf is better that no bread, but leaves
much to be found out at the expense of each medical ofﬁcer’s early
cases. The writer’s treatment, as detailed below, leaves much to be de-
sired, for while dealing with a fever which, like paludism, has an in-
deﬁnite duration, he is unable to cut short or restrict that duration
within ﬁxed limits, and is only able to a certain extent to control and
curb its virulence. This, however, is a valuable power to possess,
and the fact that the writer has more conﬁdence and satisfaction and
less anxiety in treating his present cases than he had six years ago, leads
him to hope that the following remarks, while assisting new comers
[MEDITERRANEAN FE VER 185

to the Mediterranean, may be a nucleus on which others with more
experience may build up a more perfect system of treatment in the
future.
It is, ﬁrst of all, advisable that the patient should be removed from
the neighbourhood of any insanitary surroundings which may have been
connected with the origin of his attack. If, as the writer believes, this
fever is caused by an aerial organism of a faecal nature, which enters the
body by way of the inspired air, it is evidently unwise to let him inspire
a larger dose than is necessary. Theoretically speaking, until a patient
has acquired absolute immunity from the disease, a new dose of the
poison would be supposed to predispose him to a relapse. Practically
speaking, it is found that patients who show no signs of improvement
while treated in their own beds in their own insanitary rooms, improve
rapidly when removed to another house, or room, or to an hospital.
Again, as has been already mentioned, patients who go back to the same
bed in the same barrack-room in which they developed an attack of this
fever, often have subsequently to be admitted to hospital with symptoms
of the same fever, after from one to three months of apparent recovery.
Many of these cases look suspiciously like instances of re-infection.
Soldiers when attacked with this fever are at once invariably sent to
hospital, with the best results.
Officers do best in hospital, while women who are treated in hospital,
do better than those treated in their own quarters. Though a great
deal of this may be due to the better nursing and care which is met
with in hospital practice, there is something more than this, and the
writer has often been able to date improvement in a case from the day
on which the individual changed a room or house. This is a preventive
rather than a remedial measure.
The room in which a case is treated should, if possible, be large, so
as to allow of plenty of fresh air being available. This is not a mere
platitude, but a necessity proved by experience. As the patient has to
remain in the same bed or room for eight or more weeks, during that
time his pyrexial condition will be materially affected by the tempera-
ture, moisture, etc. of the air he breathes. The lofty ceilings of many
of the hospital wards and private rooms in Malta make them admirably
suited for the treatment of these cases, though unfortunately the ex-
treme density of the population makes large and lofty rooms the excep-
tion, except in the houses of the rich. The soft stone ﬂoors so generally
met with in Malta are exceptionally badly suited to the treatment of
these cases, for not only are they extremely absorbent and difﬁcult to
keep clean in a sick-room, but give rise, when swept, to a cloud of ﬁnely
powdered stone dust, which predisposes cases to the common pneumonic
troubles so often dangerous to life in this fever, and aggravates such
symptoms when present to an extreme degree. This was most marked
in the large Military Hospital in Valetta, where the ﬂoor of the fever
ward was formerly of soft stone, giving rise when swept to a cloud
of dust. In 1894 the ﬂoor of this ward was relaid in cement, and
186 . UND ULANT, MAL TA OR

the improvement in the decrease in frequency and severity of pneu-
monic complications in undulant fever cases, occupying the same beds,
was most marked. When, as is often the case, it is necessary to
treat cases in rooms with soft stone ﬂoors, these should be either oiled,
painted with silicate or other paint, or carefully sprinkled with damp tea
leaves before being swept. While promoting free ventilation, and pro-
viding for as much fresh air as possible, precautions must be taken
against draughts, on account of the tendency to rheumatic or neuralgic
complications which frequently follow exposure to sudden chill in the
course of this fever. A trained nurse is advisable in all cases, and is
indispensable in severe cases, and it is especially during the night and
early morning that an attendant is required in even mild cases. All
sheets and pillow-cases should be of cotton and not linen. It need
scarcely be mentioned that a single bed, with a ﬁrm spring wire mattress
under the hair matress, without sides or foot-piece, is the most suitable 3
that it should be approachable from all sides 3 while unnecessary furni-
ture would be better elsewhere than in the sick-room. An air or water-
bed is often necessary in severe or emaciated cases.
The patient should be conﬁned entirely to bed during the acute
stage, and while the tongue remains furred, or acute neuralgic symptoms
combined with pyrexia are present. Usually it is best to keep the
patient in bed until pyrexia has ceased for some ten days, and the clean
tongue and temporary subnormal character of the temperature curve
gives promise of permanent recovery. Many a relapse may be traced to
the patient having been allowed up prematurely and injudiciously.
Thus a case in 1892 relapsed almost fatally after being allowed up for
a short time in the afternoon of Christmas day, though before that time
she was improving daily. It is often extremely difﬁcult to persuade the
friends of a patient to keep him in bed during an apyrexial period,
though the patient is generally more amenable, and only experience can
teach the medical attendant when a relapse is not to be anticipated.
There is, however, a not uncommon exception to this rule. In the
late stages of ,some cases that have dragged out their monotonous length,
and show little variation from normal in the morning and 99°-100° F.
in the evening, when the tongue is fairly clean and the patient has
some appetite, it is often advisable to allow him to be up in a chair or
sofa for a short time each morning, or later in the afternoon between
4.30 and 7 RM. The exhilarating feeling of being “ well enough to be
up ” is beneﬁcial, and more than counteracts any depressing feelings if
the patient is not allowed to tire himself. When the weather is suitable
the patient may in such instances often be placed in a chair, on a sofa,
or have his bed moved on to a verandah; but on no account must this
be allowed in acute stages, or in a draught, nor must he be left in the
open air as late as sundown. The writer has seen most severe relapses
and distressing rheumatic symptoms arise from neglect of these pre-
cautions. It may practically be said that in the absence of draughts
the more fresh air the patient gets the better. The writer has been in
[MEDITERRANEAN FE VER 187

the habit of advising his patients not only to keep their windows open,
but to be actually in the open air as much as possible during the
milder and more chronic stages of the fever, and especially during
convalescence. Great care must be taken, however, that in follow-
ing out this advice the patient does not fatigue himself when
moving out of doors. 'When the weather is warm, it is‘ better for him
to lie on a couch out of doors than to move about in a bath-chair or
carriage. Not only is it more fatiguing to sit up ill these conveyances,
but when the patient leaves his home, he is not able to return at once
to bed when he feels at all tired. All through the treatment of this
fever there is a happy medium to be achieved between healthful stimula-
tion of the nervous faculties and the depression which follows fatigue or
tissue irritation from injudicious medicine, dietary, or other treatment.
This happy medium can only be achieved by experience combined with
common sense, applied to each individual patient 3 nor can any rules be
laid down that will be found suited to any large section of cases, unless
the physician is prepared to modify his treatment according to circum—
stances and personal idiosyncrasies. The excessive severity of the
initial symptoms met with in those who have attempted to “ﬁght off
the disease,” is comparable with those relapses which follow over-exertion
during the progress of an attack, or with the temporary rises of tempera-
ture which follow the afternoon on which friends are allowed to visit
their friends in hospital, or the depressing dampness of a sirocco wind.
In short, the leucocytes have their battle to ﬁght, and we must be care-
ful not to draw their attention from the work by other calls on their
exertions, but assist them to expel the foe we are unable ourselves to
subdue. ‘The writer’s cases have suffered much less from the distressing
neuralgic and rheumatic symptoms of this fever since he has made thin
ﬂannel, ﬂannelette, or the new forms of cotton wool or J aeger, the routine
clothing of those under his care. The soldier in hospital wears what is
given to him without complaint, while most officers abroad wear ﬂannel
pyjamas, or are willing to do so if such are recommended to them. With
ladies, women, and children the case is different, and the most tactful
and ﬁrm persuasion is necessary before they can be induced to discard
the linen or cotton night-dress for one of woollen or other absorbent
material. Besides the strong feeling of habit and precedent, there is the
awkward fact to combat against, that the latter can rarely be made to
look as pretty as the many forms of elaborately trimmed cotton or linen
night-dresses. This feeling should, however, not be allowed to interfere
with this most useful point in treatment, for not only are the acute
arthritic or neuralgic symptoms most painful, but intractable sciatica
has been known to cripple strong men for a year or more after the
pyrexial condition has entirely ceased. For men the usual suit of
pyjamas, made large, is suitable, while for women and children some
form of combination garment is really the most useful. The combina-
tion form of garment is invaluable for children, as they are very apt to
throw 06 the bed-clothes and remain uncovered, though it has the
188 UNDULANT, MALTA OR

disadvantage over the pyjama suit of being more difficult to change.
Though many women positively assert that their skins will not stand
ﬂannel, ﬂannelette, or other absorbent material worn in this way, it is
found that any feeling of discomfort complained of at ﬁrst wears off
with wonderful rapidity, and the majority of patients continue to wear
these absorbent night-dresses permanently after recovery, at any rate
while :abroad. The comfort of this form of garment, be it night-dress
or suit, will be most evident when the profuse and debilitating night-
sweats of this fever begin, for a linen or cotton garment will be saturated
in a moment, nor will the patient be comfortable until after the dia-
phoresis is over, in spite of constant changing. An absorbent garment
reduces this discomfort to a minimum, prevents chills after changing,
and is most grateful and comforting to the patient whose temperature
has recently fallen with the outbreak of the perspiration. On account
of these profuse night-sweats, not only will an attendant require to be
ready to change the patient’s night-clothes and sheets during the night,
or early morning, even several times, but a good supply of these articles
should be in readiness for this purpose. Here, again, the superiority of
woollen or other absorbent material comes in, for articles of this descrip-
tion can readily be dried or washed in the house, and again be ready
for use, thus minimising the number of garments necessary. The
greater the number of night-clothes and sheets available, the greater the
comfort experienced by the patient. It is difficult to insure comfort
to the patient unless he has at least six, or in long cases eight or
more night-suits, four to six sets of sheets, six pillow-cases, and
a spare blanket and pillow, besides those in use on his bed, while
under these circumstances he will require to have facilities for
drying and washing these at home when necessary. In summer a light
blanket should be folded and placed at the foot of the bed, so that the
patient can pull it up at any time. In certain cases with neuralgic
or arthritic symptoms, as will be mentioned again, it is desirable to
discard the sheets and place the patients between blankets.
The use of the bed-pan should be enforced in severe cases, and
during the acute stages of all cases. Later on, when the patient can be
safely allowed to use the night-stool, he must not be compelled to go to
it through draughts or the outside air, and he should protect his hips
with a blanket from the cold, as these joints are so often the seat of
acute effusion and pain, of sudden onset, and attributable in many cases
to direct chill. An enema syringe is often required, and the usual
feeders, lamps, and other paraphernalia of a well-regulated sick-room.
During convalescence a comfortable arm-chair will be used for
some time, while in hospital the writer’s cases have derived the
greatest beneﬁt from a chair in which the patient has been able to
wheel himself about, as it combines an interesting and larger amount
of exercise with a minimum of exertion.
The general principles of dietary laid down for enteric fever cases
are applicable to a very large extent to cases of undulant fever.
[MEDITERRANEAN FEVER 189

Though ulcers are not present in the intestines, the mucous membranes
are in a very irritable condition, and the digestive functions are out
of order, in proportion to the severity of the pyrexia. Moreover,
any foreign bodies present in the alimentary canal, such as undigested
food, unsuitable and unnecessary drugs, etc., considerably increase any
irritability present. On the other hand, want of food or suitable
nourishment has a most depressing and harmful effect on the patient.
Here again we are placed between two ﬁres, and have to ﬁnd that
suitable middle course between over-feeding and starvation, the attain-
ment of which is one of the most important points in the successful
treatment of this fever. A rough rule of great value is that a patient’s
power of digestion is usually inversely in proportion to the severity of
his symptoms. It may seem almost unnecessary to mention that the
patient’s tongue is the surest guide to the state of his alimentary
mucous membrane, and therefore an index of his digestive powers, but
it is strangely true that this important point is frequently forgotten.
Thus the writer has often seen cases whose tongues were brown, dry,
and cracked, in the condition well known as the “ typhoid state,” with
or without vomiting being present, plied with milk and other forms of
nourishment at intervals of increasing frequency, with a painfully
mistaken kindness on the nurse’s and physician’s parts. Such cases he
has found at the post-mortem examination to have their stomachs enor-
mously distended with undigested food, a condition which must have
seriously handicapped the action of the adjacent heart and lung, at a
time when these were battling their hardest to keep the failing circula-
tion at work. Experience has taught us the nature and amount of
food that fever cases can digest, and though many improvements may
be made in the food-stuffs available, there is no doubt that it is quite
wrong to suppose that the worse the patient becomes and the higher his
temperature rises, the greater should the amount of food be. In fact
the reverse is the case with regard to the quantity of food required.
The writer would lay special stress upon this point, not only because
its importance has been proved over and over again by clinical experi-
ence, but because there is a great tendency to this practice on the part
of many nurses and of all untrained friends. They feel an increasing
necessity for action as the patient becomes more seriously ill, while this
is the part of the treatment that they have more especially under their
control. It is, therefore, well for the physician to lay down deﬁnitely
not only the nature of the food to be given, but also the exact amount
that should be suﬂicient for the twenty-four hours, with the time of
administration. Many cases whose breath has been unusually foul,
whose tongues have been undesirably dry and brown, or who have been
subject to vomiting, and whose general condition and pyrexial elevation
has been unsatisfactory, have at once improved on the amount of their
nourishment being lessened, or its character made more suitable to their
digestive powers. Any excess of milk and undigested curd, besides
acting as an irritating foreign body, also gives rise to fermentative
I90 UNDULANT, MALTA OR

changes in the alimentary canal, which cannot but increase the already
irritable condition of the mucous membrane.
In practice it is found that ﬂuid food is the best during the acute
stages of the fever. Milk, as fresh and pure as possible, should form
the chief part of the patient’s diet. Solid food should be withheld in
ordinary cases until there is an absence of gastric irritability, and an
indication of a probable cessation of acute pyrexia of a permanent
nature. A clean tongue, an attempt at an appetite, if combined with a
subnormal temperature for one or two days, followed by a normal
temperature of ten days’ standing, is a fairly sure sign, and would
justify a return to solid food ill moderation. An exception may be
made to this rule in long-continued cases, whose tongues are clean, and
whose only disabilities are debility, anaemia, and a slight rise of
temperature every evening to 99° or occasionally to 100° F. To allow
such patients up for part of the day, and to give them some interesting
and light though solid food in moderation, promotes a hope of recovery
which is in itself a powerful and beneﬁcial mental stimulant. To such
patients poached eggs, well-boiled chicken or white ﬁsh, bread and milk,
or milky pudding are often beneﬁcial, and at any rate do no harm.
They must not, however, be given potatoes, crusts, pastry, or other
forms of indigestible food, while the tongue must be watched for any
indication that food is improperly digested. The patient’s inclination
for food follows very closely his capabilities for digesting it, especially
from a quantitative point of view. Such a course of action in well-
chosen cases, when combined with stimulants and a careful avoidance of
fatigue, often enables patients to throw off the remnants of the pyrexial
condition, which before seemed unending. Ill acute stages, however,
such treatment would invariably be followed by a relapse, hence it must
be only exceptionally allowed and cautiously applied. In the countries
where this fever occurs, goat’s milk is always obtainable, cow’s milk
being less commonly used. As goats can generally be brought to the
patient’s house, or to the hospital, and there milked under supervision,
their milk is to be preferred to the more doubtful cow’s milk, which is
only obtainable from a distance. In Malta there are many more
persons drinking reputed cow’s milk than there are cows in the island
for this supply, and as cow’s milk and the milk of goats milked away
from the house is usually cheaper than that obtained under supervision
at the door, there is little doubt that it is better and safer to use milk
that has been milked straight into private vessels at the door, under
personal supervision, than any other. In the latter case we are able also
to inspect the goat and its milker, and are only subject to the trick of
giving the goat salt in its water, so that by increasing its thirst and
causing it to drink a large amount of water the vendors sell inferior
milk in larger quantity. Goat’s milk thus obtained, ill clean and well-
scalded vessels, is excellent in quality and admirable for the purpose.
It does not taste unpleasantly of the goat unless kept for an unusually
long time, or allowed to ferment. This milk should be given fresh,
MEDITERRANEAN FE VER 191

while any that is to be kept should be pasteurised or sterilised,1 and
kept in the ice chest (especially in summer and during sirocco winds)
until wanted. In hospital this is easily managed, while in private
practice a simple form of steriliser may be readily procured (Soxhlet’s,
Aymard’s, etc.), or made locally at small expense. The lengthy dura-
tion of this fever, the necessity of having the milk free from fermenta-
tion, and the great digestive superiority of milk pasteurised at a
comparatively low temperature over boiled milk, makes such an outlay
of time, trouble, and expense trivial when compared with the results
obtained.
Having procured a supply of fresh pasteurised or sterilised goat’s
milk, we come to the question of the amount required by the patient in
the twenty-four hours. As a general rule three pints of good milk is
sufﬁcient for a very severe case, in its acute stages, for twenty-four
hours. This may be increased in amount in less severe cases until a
maximum of ﬁve pints is reached. This is not meant to include the
total ﬂuids given, but only the amount of milk necessary. In very
severe cases even three pints of milk may not be digested, and in some
cases pure milk does not seem to be digested at all with case. In such
cases peptonised milk (combined with beef juice and similar food-stuffs),
in small quantities at a time, seems to meet the case. It would appear
in such cases as if the digestive functions were almost in temporary
abeyance, when the temperature is very high.
In ordinary mild cases, however long in duration, milk is well
borne and digested (up to four or ﬁve pints), and when the tongue is
cleaning, and the patient begins to take an interest in his food, and
shows even some attempt at an appetite, rice milk may be given. This
is prepared by boiling two ounces of best Bengal rice with three pints
of milk. To this may be cautiously added bread and milk, custard
pudding (equivalent to half an ounce of sugar, one egg, and half a pint
of milk), sago, rice, and other milky food.
When vomiting is present the greatest care has to be taken to give
the patient only such food as he will be able to retain.‘ In these cases
peptonised milk is especially useful, and with it bismuth in large doses,
beef juice, albumin water, and champagne are, as will be further
explained, our chief remedies. A portion of milk should be given to
the patient the ﬁrst thing in the morning. This should be the rule as
long as any temperature or debility remains, and it will be especially
appreciated when the patient is showing signs of recovery, at which
time he will be found to feel miserable and low-spirited at that time
of the day.
Next to milk, fresh lemonade, or some such substitute, is necessary.
Not only is the patient likely to be for a long period without vegetable
food while milk is his staple diet, but a scorbutic condition has been
described by many early writers as occurring in the later stages of long
1 See articles on this subject by Drs. Johnstone-Campbell and Hunter-Stewart in the
British Medical Journal, 6th September 1896, vol. ii. p. 623, for details.
192 UNDULANT, MALTA 0R

cases. This scorbutic condition has also been associated with purpura.
The writer has only once met with a scorbutic condition among the many
cases treated by various medical officers in Malta, and in this case the
condition of the gums appeared to be due to an excessive use of
mercury. The absence of such symptoms he would attribute to the
universal system of giving these patients two or more pints of lemonade,
made with freshly squeezed lemons, every day 3 each pint being equiva-
lent to one large lemon and three-quarters of an ounce of sugar. When
lemons are unobtainable two ounces of lime-juice have been substituted.
Besides this, the writer has been in the habit of allowing very mild
cases, convalescents, and cases that have reached the late and chronic
intermittent stages of the pyrexia, fresh grapes, oranges, strawberries,
bananas, and other fruits in season, skins and stones being, of course,
discarded.
Added to these articles of food, eggs are valuable in various ways.
During the acute stages egg ﬂip, made with the yoke of an egg beaten
up with milk, with sugar, and brandy, and ﬂavoured if desired with a
pinch of nutmeg, is a valuable and acceptable form of nourishment. This
may be given twice a day with beneﬁt. The white of these eggs, mixed
with water and ﬂavoured with cinnamon, peppermint, or other aromatic,
makes a useful form of albumin food of a ﬂuid character. In the later
stages eggs lightly poached or scrambled may safely be used as a
stepping-stone between ﬂuid and solid dietary. During convalescence
eggs for breakfast cooked in various ways are most acceptable to
patients after their long course of milk.
Beef juice is a most valuable form of nourishment for those severe
cases whose digestive faculty is almost in abeyance, or who suffer from
obstinate vomiting. In bad cases it is occasionally the only form of
' food that can be retained, and in many cases the writer has seen great
beneﬁt follow its use. In cases of obstinate vomiting this form of food
has tided over a crisis, until an abatement of symptoms has been
accompanied by an increased tolerance for food, and a return of diges-
tive activity. The writer has prepared it as follows :—
One pound of fresh beef, free from fat, and ﬁnely minced, is mixed with
eight ounces of soft water, six drops of hydrochloric acid, ﬁfty to sixty grains of
common salt, and after being well mixed is allowed to stand for three hours in
a cool place. It is then pressed through a hair sieve, and taken cold or
slightly warmed.
Beef tea, beef essence, beef extract, etc., though stimulating, can
scarcely be called nourishment,1 as there is little but the extractives and
meat salts left in them. They appeal, however, to the popular mind,
and, if well made, are stimulating, and form a change from the dull routine
of milk and egg ﬂip, greatly appreciated by those who have had to undergo
a course of such diet. They appear to have no bad effect on ordinary
1 Practitioner, Nov. 1881, p. 343, etc.
.M'EDITERRANEAN FE VER 193

cases, unless there is a tendency to diarrhoea, in which case they are
distinctly prejudicial, and where this is at all excessive, such food may
even be termed dangerous. In those cases ill which a congested or inﬂamed
condition of the great gut is present, where vomiting occurs at all
frequently, where excessive pyrexia is accompanied by failure of
digestion, foul breath, and dry brown tongue, or where diarrhoea is
present, beef tea is incompatible with successful treatment. With
regard to the various essences of beef, chicken, etc., none are so well
borne as beef and chicken jelly. The best are neutral in reaction,
pleasant in taste, and have a jelly-like consistence when kept at a
sufficiently low temperature. The alkaline essences that are issued to
army hospitals are not so well borne. Ill mild cases, beef tea in the
evening about 7 P.M., when the temperature is falling, is a welcome form
of stimulant, and during convalescence may be given at 11 AM. with
advantage, varied by strong soups. The amount of ﬂuids taken should
not be restricted, as the surface loss from perspiration is generally great.
Soda-water in a syphon may be placed by the bedside for use as
required both by day and night. Lime water added to the milk is of
value where there is gastric irritability, but is undesirable in other cases
on account of its constipating effects. Tea, coffee, and other beverages
may be given as desired.
Ice in small pieces is grateful in the hot weather, when sucked at
intervals, especially where the mouth is inclined to be dry. It will also
be needed in warm and sirocco weather, for preserving milk and other
food; and where there are severe cases, for direct application, as will be
described later. ,
Calves’ foot jelly, though possessing little or no nutritive value, helps
to vary the diet, and is a harmless form of solid food.
In intermittent cases, and during the period just before recovery ill
long cases, food is generally taken well during the morning, and during
the evening, when the temperature has fallen previously, but solids are
badly borne during the rising and maximum of pyrexia, usually between
1 P.M. and 6 P.M. As the patient’s digestion begins to become stronger
in its action and his appetite to be established, chicken broth and soups
with bread or toast may be added to the poached eggs, custard and
farinaceous puddings. These may be cautiously increased to chicken
quenelle, chicken cream, bread and butter without crust, crumb-bread
soaked in milk or soup, white ﬁsh, and well-boiled chicken or fresh game.
Chicken panada or quenelle is made by soaking the crumb of a French roll,
a few rusks, or some stale bread-crumb in hot milk, and placing it in a clean
stew-pan with an equal quantity of the breast or wing of a roast or boiled
chicken (or a chicken that has been used for broth) previously pounded in a
mortar. Add a little chicken broth and stir over the ﬁre for ten minutes or so.
Crusts of bread, potatoes, and oatmeal ‘should be withheld until con-
valescence is undoubtedly established. In regulating the diet, the state
of the tongue and bowels should be carefully noted, for these will
0
:94 UND ULANT, MALTA 0R

infallibly indicate the wisdom or otherwise of the course adopted. The
greatest care must be taken in serious cases, as one day of injudicious
dietary may make a great difference in the patient’s general condition,
or in a case that is mending, may cause a serious relapse. It is easier
to regulate the diet of convalescents in this fever than it is in enteric,
as there is usually an absence of that ravenous appetite which is
occasionally the undoing of promising cases of the latter disease. A
great deal of care is, however, necessary in dieting convalescents, as the
anaemic and enfeebled state of the mucous membranes of the alimentary
tract renders them deﬁcient in function for a considerable period after
the pyrexial condition has subsided ; and it is only by judicious dietary
that they can be educated into health, nor will the general anaemia
and debility of the body decrease unless this point be carefully
attended to.
Tobacco is best withheld from the majority of cases until con—
valescence is well established, and in all cases where cardiac irritability
is present.
Stimulants—These are very necessary in severe cases, where the
digestion being in abeyance, artiﬁcial support other than that to be
obtained from food is necessary. Under such circumstances a larger
amount of alcohol is oxidised in the system than is the case during
health; but the amount given in each individual case should not be
in excess of that amount which the patient is able to oxidise without
having to noticeably excrete alcohol by the lungs or kidneys. When
the temperature runs high stimulants are generally needed, and in
those cases where signs of nervous exhaustion with a moderate tempera-
ture are present they may require to be pushed. Where cardiac failure
is present, or the pulse is feeble, stimulants are needed, and a favourable
result is often due to their judicious administration. No deﬁnite
amount of stimulants can be laid down, the condition of the pulse and
tongue in each individual case being the best guide to the amount
necessary for that particular case, and the effect of stimulants on the
rate and character of the pulse should always be carefully noted. In
long chronic cases a small amount of alcohol daily is very beneﬁcial,
and also during convalescence. The most valuable form in which to
administer it is undoubtedly brandy, provided it is good in quality.
It may be given in milk, arrow-root, egg ﬂip, soda-water, etc., com-
mencing with two ounces a day and increasing as desired. The early
morning (26 AM.) is a time when stimulants may be given with
advantage, though this is often overlooked. If brandy is not liked,
whisky, moselle, or champagne may be substituted, the last being
one of the most valuable forms of stimulants we possess for these
cases. Where there is obstinate vomiting or extreme exhaustion, good
light dry champagne with a little soda-water may tide over a crisis and
save a patient when-in an almost hopeless condition. In cases where only
beef juice and iced champagne can be retained, there is hope while the
circulation is kept going and the lungs are not choked up with passive
[MEDITERRANEAN FEVER 195

congestion. As the case progresses and improves, port, wine, Graves, or
claret may be gradually substituted for the brandy, and when con-
valescence is established good stout, ale, or burgundy is beneﬁcial.
When we realise that most severe cases die from failure of the
circulation, with consequent passive congestion of the lungs, we see
plainly that much may be done to accelerate the circulation by increasing
the force of the heart’s action and so clearing the lungs, and ultimately
lessening the work that the heart has to do. On the, judicious adminis-
tration of stimulants (alcohol and ammonia) we greatly rely when en-
deavouring to attain this necessary object.
In the early morning and at any time when the temperature is sub-
normal or the patient seems fatigued, a small dose of ~whisky or brandy
is beneﬁcial. Also before sponging or packing.
From a drug point of view there cannot be said to be any speciﬁc
form of treatment applicable to this fever, as no drug or other medical
agent, having a germicidal action on the organism, has been discovered.
From its clinical analogy to paludism one should anticipate the
discovery of some such drug, but many and various have been tried
without effect. There would appear to be a possibility in favour of the
future discovery of some antitoxin treatment.
The fact that the administration of quinine, calomel, carbolic acid,
and other germicides has frequently been followed by convalescence
within a reasonable period in certain cases of this erratic fever, has led
to the advocation of many speciﬁcs. These have generally been ad-
vocated by comparative new-comers, and have unfortunately failed to
hold their own in any way. 'When the writer began to treat these cases
he administered iodide of mercury to three cases of chronic intermittent
pyrexia which had for a considerable time withstood treatment. All three
cases recovered at once in a most satisfactory manner, and a speciﬁc
appeared to have been discovered. The writer has failed, however, to cure
any further cases with the same remedy. It is a fact, however, that the
date of recovery of some chronic cases, dates from the day on which
quinine, arsenic, or other germicide has been administered ; whereas these
drugs have no effect on the majority of these chronic cases, and have a
most prejudicial effect on acute cases by aggravating pre-existing gastric
irritation. The only explanation is that those cases which recover on
the administration of a germicide, would have recovered in any case, or
that, either by its tonic or germicidal action, the drug in question may
have been of some slight assistance to the human organism, without
having any irritating effect on the mucous membrane, in a case which was
on the eve of recovery. Individual drugs will be noticed later on.
So far therefore we have laid clown-—
(1) That the patient should be transferred from insanitary to
sanitary surroundings, and supplied with a suitable nurse.
That he should be conﬁned to bed during the acute stages of
196 UA’DULANT, [MALTA OR

the disease, be clothed in absorbent material, and be pro-
tected from chills.
(3) That it is of the utmost importance that food and stimulants
should be judiciously administered.
It will be further shown that it is necessary-—
(4) That the natural processes of excretion, the respiratory,
and cardio-circulatory equilibrium should be carefully
maintained.
(5) That the temperature should be moderately regulated.
(6) That special treatment is necessary to meet certain symptoms
when they arise.
(7) The effects of certain drugs will be discussed, and the
advisability or otherwise of change of air and climate dealt
with.
In the great majority of cases constipation is present and should be
relieved. In a few cases, and those usually of a severe and often fatal
type, there is diarrhoea, which if at all persistent is a symptom requiring
much consideration.
On admission to hospital any existing constipation should be at once
relieved. For this purpose nothing works better than a good dose of
calomel combined with powered jalap, or pulv. jalapae co. If, however,
there is any doubt as to the diagnosis between this fever and enteric
fever, a caster-oil or simple enema should be used instead. This will
often bring a high temperature permanently down. The bowels should
be further kept open every other day by the above means, or by doses of
compound liquorice powder, cascara sagrada, Hunyadi water, enemata of
glycerine or soap, etc. Castor-oil internally is not satisfactory on
account of the constipation which so often follows its use. The free use
of these remedies at an early stage in the disease seems to mitigate
its severity, and to lessen the necessity for their constant use during
later stages of the fever. As diarrhoea seems to he often associated with
a congested condition of the large or small bowel, such treatment
tends rather to prevent than to produce diarrhoea, if used with due
caution. '
In late stages, when the tongue is fairly clean, stewed prunes, baked
apples, etc., are useful in relief of constipation.
Slight diarrhoea, dependent on the condition of the small bowel,
is often due to improper food, such as beef tea, excess of milk, etc.,
or of drugs, such as quinine. In both cases it may be cured by remov-
ing the cause and giving lime water with the milk, arrow~root, and
if necessary some astringent, with a small dose of opium, or if more
severe a pill of lead and opium. Occasionally it is combined with a
foul tongue and mouth, possibly tympanites and evidence of gastric and
intestinal fermentation, in which case small doses of calomel (i— to ~3— a
grain) or grey powder (gr. with sugar of milk, twice or three times
a day, often sufﬁces.
[MEDITERRANEAN FE VER 197

The mixture used in Malta for slight diarrhoea dependent upon the
condition of the small gut is z—R; Pulv. cret. aromat. gr. xviij., Tinct.
catechu gr. xxv., Tinct. opii. ITLvj, Aqua chloroformi ad M. et F.
misturam, to be given as required.
When dependent on the condition of the large bowel this diarrhoea is
harder to treat. The diet having been attended to, enemata of starch
and opium must be frequently administered. These enemata should be
made with sufficient boiled starch to produce a consistency like cream,
be given warm, and retained as long as possible. At the same time a
Dover’s powder at night is beneﬁcial. Irrigation with a solution of
boracic acid has been advocated.
A record of all stools, with colour, amount, and character should be
kept by the nurse, as their appearance, especially in early stages, is a
valuable guide to diagnosis, and in all stages as to the state of the
intestinal mucous membranes.
The bladder must be watched in severe cases lest retention be
missed; while any irritability which may be present is usually removed
by the administration of acetate of potash, soda-water, saline diuretics,
and attention to diet.
The teeth and gums must be attended to, especially in severe cases,
when the breath has a tendency to become foul, the tongue brown and
cracked, and the teeth covered with sordes. Such a condition is mostly
met with where the diet has not been judiciously regulated, or the
temperature has been allowed to remain continuously high. In the
'former class of case undigested and unsuitable food ferments in the
stomach and gives rise to these symptoms. The remedy is to regulate
the amount and nature of the food, and to give the patient bismuth,
while small doses of calomel, about i to a grain, two or three times
a day, or salicylic acid in 5 or 10 grain doses, have been recommended
to bring about a more healthy condition of the stomach. In these cases
the stomach is usually very irritable, and does not tolerate stronger
forms of antiseptic treatment, such as boracic acid or iodide of mercury,
quinine, arsenic, etc. They are very badly borne, and appear to do
more harm than good. Reliance should be placed on methods of treat-
ment which tend to improve the condition of the stomachic mucous
membrane, the most important of which are bismuth and suitable dietary,
such as peptonised foods, fresh beef juice, champagne, etc.
A return to a more normal condition on the part of the mucous
membrane proves the strongest and most reliable form of antiseptic
treatment we possess.
The local use of glycerine and borax, lemon juice, etc., to the
tongue and gums, or of mouth washes such as rose Water, Condy’s ﬂuid
in weak warm solution, or a solution of carbolic acid (1 in 100) mixed
with tincture of myrrh, glycerine and water, are useful as deterrents
against local fermentative growths. Where tartar collects on the teeth
and they become loose in the gums, a weak solution of sulphate of
copper may be used with a tooth-brush.
198 UNDULANT, MAL TA or

In summer a mosquito net is often necessary to keep off the swarms
of ﬂies which inevitably collect round patients whose mouths and
breath are not sweet. A plate of quassia chips in water helps to reduce
their numbers if placed on the bedside table. In clean and well-kept
hospitals in the Mediterranean, the common house-ﬂy can usually be
kept down, except about these severe cases, when their numbers are
almost an indication of the severity of the case. In the country
houses, and in the less clean houses of the lower classes, they prove a
worse pest than the notorious mosquito, and breed with enormous
rapidity during the summer months in any house refuse or roadside
ﬁlth that may exist. In Valetta and other towns where the roads are
paved and regularly swept, these and the venomous sand-ﬂy are less
numerous, and may be kept from the sick-room by attention to cleanli-
ness, and by carefully arranging for the room to be darker than the
outside air during the ﬁrst half of the day, by closing the blinds or
jalouses from 6 A.M. to about 4 RM. according to the direction of the
outlook from the windows. Those who are new to the Mediterranean
must also bear in mind that mosquitoes breed with great rapidity in
any water that is allowed to stand about during the hot weather 3 so
that the jugs and water-bottles must be emptied every morning and
reﬁlled, indoor tanks kept covered, ﬂower-pot saucers banished from the
neighbourhood of the sick-room, and garden tanks stocked with gold-
ﬁsh. Though long familiarity breeds contempt, one musical mosquito
within the net, will often prove a great nuisance to a patient, and
bring about a sleepless night, while the effect of their bites on new
comers is often most unpleasant. Worse still is the sand-ﬂy, as its
minute size gives it access through most netting, while small-meshed
netting, by restricting the ﬂow of pure air, is very hot. The various
incense-burning cures are only eﬂicacious while actually burning, while
little short of anointing the exposed surfaces and the feet and ankles
with eucalyptus or paraﬁin oil will stop them from biting. At night a
light within an open window attracts both mosquitoes and sand-ﬂies,
which when numerous may keep the patient awake for hours.
Prickly heat and sudamina may be largely prevented by due
attention to the skin, by careful changing of clothing after perspiration,
and by daily sponging of the surface with tepid water to which vinegar
or acetic acid has been added, and afterwards dusting with powder.
\Vhen present the affected surface should be frequently washed with
soap and water, bathed with boracic acid solution, and carefully dried
but not rubbed. If the irritation is excessive, it may often be allayed
by a surface coating of some unirritating soap, applied by damping
a cake of soap and gently passing it over the affected part. This
coating should be left on until the next washing with boracic acid.
Such treatment will often procure sleep for a patient, when otherwise
he would be the victim for hours of increasing sleepless irritation.
When sudamina become pustular they should be pricked, squeezed,
and washed frequently with boracic acid solution, care being taken
[MEDITERRANEAN FEVER 199

that the surrounding skin is well washed. \Vhen boils appear they
are the result of an infection, by a separate organism, on an en-
feebled constitution, and should be treated on sound surgical principles.
Evacuation, followed by a dressing of boracic acid lint, soaked in warm
boracic acid solution, and kept damp by a covering of gutta-percha
tissue and a bandage, proves most satisfactory. The great point is to
get rid of the pus, to deter the growth of the organism without using
antiseptic solutions whose strength will ill any way irritate or lessen
the ﬁghting power of the enfeebled and anaemic skin. At the same
time the healthy skin all round the boil should be well washed with
boracic or even stronger antiseptic solutions, to prevent the not un-
common spread of the organism to other spots along the surface of the
skin. Thus the writer has seen a crop of boils on the inside of one thigh
affect the opposite thigh, by direct contact for want of a protective
dressing. It is very necessary that boils be attended to, for though of
slight consequence in themselves in healthy individuals, in subjects who
have become enfeebled and debilitated in the course of this fever, they
may become the starting-point of bed-sores of a most intractable nature.
The same treatment is useful in the case of the small abscesses which
are occasionally met with.
The greatest care should be taken to guard against the formation of
bed-sores, for so emaciated may patients become, in the course of this
fever, that the skin covering their bony prominences is very prone to
suffer, and must therefore be carefully watched. It is well to institute
a routine practice by which all patients are rubbed with spirit and
water or other hardening agent, and treated with oxide of zinc, starch,
etc., from the beginning of the attack. When emaciation is present,
air or water beds and suitable cushions should be employed, suspicious
points protected from pressure, and actual sores treated early.
In severe cases, in the acute stages, the patient’s skin is often hot
and dry, when it is advisable to promote elimination by means of some
diaphoretic mixture. This should be given warm at night with a little
brandy, and an attempt made to promote a perspiration at about the
time at which it would occur if the case were less severe. In these
cases also a routine practice of sponging the surface of the body with
tepid water, with some ammonia, vinegar, or acetic acid added to it,
two or three times a day, is comforting and beneﬁcial.
In the majority of cases, however, there is more to complain of from
excessive sweating than from the reverse. When this occurs (usually
but not necessarily in the middle of the night) the patient’s sleeping
clothes, sheets, and pillow-case will require changing once, twice, or
oftener. A supply of these articles, well dried, aired, and warmed ill
cold weather, should be ready at hand. A spare dry pillow should be
kept in reserve until the sweating has quite ceased, and then substituted
for the one in use. The patient should on no account he allowed to
remain in his damp clothes, and he should be protected from chill
during any changing operations. It is not advisable to attempt to
200 UNDULANT, [MALTA OR

check the perspirations by means of drugs, as they appear to be beneﬁcial
in their action, except perhaps in long-continued cases where much
debility is present, in which case they have a depressing effect. Want
of cleanliness and attention to the dryness of the patient’s buttocks, and
to the changing of soiled sheets, are common sources of bed-sores.
Lung troubles are aggravated by dust and draughts, and by feeble
circulation or heart’s action, as has already been mentioned. The
maintenance of an equable temperature of the air of the sick-room is
advisable, and even the variation in temperature and air humidity
which accompany the use of punkahs over the beds of patients, has
been found in Malta to increase the frequency of neuralgic and lung
complications, nor does the freshening of the air achieved by the use of
punkahs compensate for their prejudicial effect 011 these cases. Con-
gestion of the lungs is best treated by stimulating expectorants such as
sal volatile, alcohol, etc., and by the application of a ﬂannel jacket to
the chest. When severe and when consolidation is present, jacket
poultices followed by a cotton-wool jacket, have a most beneﬁcial
effect, but it must be remembered that this condition is usually the
result of stasis from enfeebled circulation, and should be treated early
by appropriate means. The lungs should, therefore, be carefully
watched and measures taken directly congestion appears, to prevent
matters going further towards consolidation. In some cases it may be
that the virus directly attacks the lungs, as pneumonic symptoms are so
very common in this affection, and it is in these cases that warm
applications, by their stimulating effects, work the greatest relief. Cold
sponging, by reducing temperature and stimulating the lungs and heart,
indirectly aids in preventing pneumonic congestion.
The chest should be strapped when intercostal neuralgia or pleuro-
dynia are present, and a warm woollen vest worn next the skin. It is
always advisable for patients to wear a short ﬂannel jacket during the
day, at which time their chest and arms are not covered by the bed-
clothes as at night. Pleuritis should be treated on general principles.
The dry irritable cough occasionally met with is very difficult to
alleviate. Ipecacuanha, squills, and small doses of opium may be tried.
TVhen organic cardiac disease is present great care is necessary.
The heart and lungs must be carefully watched, and stimulants applied
early, before pneumonic congestion appears. The same care must be
taken when the heart shows signs of weak action or ﬂagging. In these
cases much may be effected by the judicious use of alcohol. Stimulants
should not be given until some symptom clearly indicates that they are
needed, and then with some deﬁnite object in view, and in suﬁicient
quantities to effect that object. They are too often given as an almost
routine practice in this fever, and when most required have not the
same effect as when they are reserved until really required. General
principles must guide in their administration, but they will be found
most useful when symptoms of heart failure occur during the summit of
a pyrexial wave. If the heart can be kept at work for a few days it
MEDITERRANEAN FE VER 201

will usually recover its equilibrium again when the temperature falls.
The slowing of the pulse, following cold sponging and the internal
administration of alcohol in these cases, is a valuable rest to the heart.
Small doses of strychnia and digitalis are also useful in these cases,
especially when signs of palpitation or intermittent heart’s action
are present. In many cases the writer has known digitalis improve"
the pulse and tide over a most critical period. Strychnia and iron are
also good cardiac tonics in long cases, where there is a tendency to
irregular action of the heart on slight exertion.
The initial cephalalgia, and that occurring during an attack whenever
the temperature rises higher than usual, should be treated by local
application of cold-water rags or ice.
The so-called fever pains, the headache, and sleeplessness so often
met with at the beginning of an attack, are best treated by a draught
of bromide of potassium and morphia at night for the ﬁrst two or three
days. It increases the comfort of the patient, allays the pain, anxiety,
and mental irritation attending the onset of severe attacks; and while
by inducing sleep it improves the general condition of the patientin
many ways, it need seldom be continued, as the habit of sleeping under
novel pyrexial circumstances is soon acquired. A small dose frequently
increases the nervous excitability, and fails to produce sound dreamless
sleep, so that a full dose should be given, when a draught is given at all.
For the ordinary soldier a drachm of liq. morph. hydrochlor. with 20 to
30 grains of bromide of potassium, in water, is suitable. For officers and
females a smaller dose may sufﬁce.
During the course of an attack, mostly when the temperature is
rising at the beginning of a wave, hypnotics are occasionally necessary.
In the majority of cases sulphonal or a Dover’s powder will be found
the most suitable remedies. In very severe relapses, however, and
when there is a tendency to “typhoid symptoms,” the ﬁrst-mentioned
draught may be given 3 and when there are marked abdominal or
intestinal symptoms, opium may prove of value.
WVhen peripheral or other symptoms are referable to central cerebro—
spinal irritation, bromide of potassium should be given in fairly
frequent doses. When such symptoms are due to an acute attack on a
deﬁnite portion of the nervous system, morphia gives great relief when
given during the few days on which the pain is most acute, for by
lessening the acute pain it allows the patient to rest in some ﬁxed
position and obtain sleep. Those who have lain awake at night, with
the throbbing, gnawing pain of such attacks, altering their position in
bed every few minutes without gaining relief, can only thoroughly
appreciate the blessing of sleep during the height of an acute attack of
this nature. Where there have been symptoms of severe cerebral
irritation or intercranial pressure, the use of the ice-bag with iodide of
potassium have given relief. In a very severe case the inunction of the
trunk with mercury ointment produced marked but only temporary
relief. A catheter may be necessary in such cases.
202 UN D ULAN T, [MAL TA OR

Acute neuralgia of peripheral nerves, due apparently to local in-
ﬂammation, the acute inﬂamed bursal swellings, and swollen joints,
are best treated by at once placing the patient between blankets, and
locally by hot fomentations, hot arm or foot baths, etc. This applica-
tion of moist heat, as hot as the patient can bear it, should be continued
until the pain and tension are relieved or bearable. After this, local
applications of opium and belladonna, or equal parts of the liquid extract
of belladonna and glycerine, give relief. The whole of the affected
part should be wrapped in cotton-wool or ﬂannel bandages, and placed‘
in a position of rest in such a way as to prevent these muscles from
acting which are inserted into, or adjacent to the inﬂamed parts.
When the nerves of the limbs are affected, ﬂannel drawers, or vests
with sleeves may be worn.
Flannel or woollen material next the skin and warm clothing
should be worn for some months after the pyrexia has ceased, especially
in cold and changeable climates, as patients are liable to attacks of
neuralgic pain on exposure to cold, for a considerable period after
apparent recovery.
When the pain and tenderness ' of inﬂammations of nerves,
joints, bursee, etc., remain in a chronic condition, massage, counter-
irritation with liniments or blisters, electricity and warm baths, are
useful. A visit during convalescence to some warm mineral or sulphur
baths has proved beneﬁcial. Such patients also like to have some sort
of liniment to rub with; those used mostly in Malta have been the lini-
mentum sapon. co.; equal parts ‘of the linimentum bellad. and lini-
mentum camph. co.; or equal parts of the linimentum opii. and
linimentum sinap. co. ’
If joints continue to give pain on movement, or do not return readily
to their normal size, a Scott’s dressing (ung. hydrarg. co. on strips of
lint, under strapping) often does good. Passive motion, massage, or
rubbing with some simple form of stimulating liniment, serve to relieve
stiffness. Some pain, however, often remains in certain nerves, such as
the sciatic, until the general health has improved and the anaemia
disappeared. Attention should, therefore, be especially directed towards
this point, and the patient suitably dieted, given plenty of fresh air,
and some form of tonic. Cod-liver oil, Blaud’s pills, small doses of ‘
arsenic (provided no gastric irritability exists), or iodide of potassium.
may be beneﬁcial. I
For the excessive pain and hyperaesthesia which occasionally affects
the soles of the feet, nothing has given so much relief as soaking the
foot or feet in cold water, or in a wrapping of cold-water bandages. If
a basin of cold water is securely ﬁxed at the bottom of the bed, or on a
chair close by, the patient, without leaving his horizontal position in
bed, can by bending his knees place a foot in the basin and keep it
there as long as necessary.
Regulation of temperature—“In a moderate regulation of the
temperature ” lies the secret of safe and successful treatment, until the
[MEDITERRANEAN FEVER 203

discovery of some speciﬁc germicidal remedy. The temperature should
never be allowed to remain continuously high for any length of time, for
in such cases, when dangerous symptoms actually appear, the patient will
be found to have lost the strength necessary for combating with the
disease. A fatal result due to hyperpyrexia at an early stage in the
disease is almost always due to an early neglect of this precaution.
Pyrexia is only one of the symptoms of this disease, and though it is
the most constant one, it does not appear to be in itself-dangerous when
not excessive, that is to say, when it does not rise above 103° F. Above
103° F., especially if it remain continuously above that point, pyrexia of
itself becomes a source of danger, either by reason of its exhausting
effect upon the nervous system when long continued, or by reason of its
excessive height being incompatible with life, causing death from the
direct effects of hyperpyrexia, as is the case in a large proportion of
fatal cases treated by the expectant method. We ﬁnd by experience
that a routine practice of keeping the temperature below 103° F. and so
approximating severe cases as far as possible to those of a milder type,
abolishes mortality early in the attack, largely diminishes the total mor-
tality, avoids to a great extent the more serious complications, and does not
add any had symptoms to our cases when due care is taken in carrying
out the treatment. When antipyretic treatment is carelessly or un-
scientiﬁcally carried out there is often much harm done, but this may
be said of many other forms of recognised treatment. Again, there
appears to be a certain amount of liability to shock and other undesir-
able symptoms when such treatment is carried to excess, by the
temperature being brought down too much or too quickly at any one
time. This can, however, be easily avoided if proper care be taken.
Cases whose temperature remains below 1030 F. rarely give cause for
alarm, but when severe symptoms do arise in such instances the cases
belong to one of two classes :-——(1) Cases of long standing, with possibly
cardiac complications, which are suffering from extreme anaemia with
nervous and cardiac debility. In such cases any strong emotion,
excitement, or nervous shock may cause serious and even fatal symptoms.
Cases comparable with instances of ptomaine poisoning, in which
the alarming symptoms are due to the presence in the blood of non-
pyogenous, but even more fatal toxins. Whether these substances are
formed by the micrococcus of undulant fever, or by other microorganisms
in the tissues, or whether they are formed in the intestine and absorbed
into the blood from there, we cannot say. In such cases we have to
support the circulation and general strength of the patient by every
means in our power,‘ and any attempt at the administration of anti-
pyretic treatment against a symptom not at the time excessive, is not
only unscientiﬁc in the extreme, but is followed by serious if not fatal
nervous depression and collapse.
In ordinary cases, in which the temperature does not rise above
103° F., direct antipyretic interference is, in this fever, in the present
state of our knowledge, theoretically uncalled for, and while practically
204 _UNDULANT, MALTA 0R

it does not appear to advance matters, it may obscure the early pyrexial
indication of the onset of some local complication. Cantanil even
suggests (as indeed Sydenham taught) that moderate pyrexia has a
beneﬁcent effect in the progress of a fever 3 and that by diminishing the
virulence of the cause and aiding phagocytosis, it has a kind of sterilis-
ing effect.2 Hare says that “moderate fever has been proved to be in
itself harmless. Hyperpyrexia is of itself harmful. Moderate pyrexia
has a useful function to perform in the body in the presence of an
infection.”3 It is the experience of all those who have suffered from
severe or long attacks of this fever, that they feel much more comfort-
able and less depressed in the afternoon when their temperature is
moderately high, than during a period of normal or subnormal morning
temperature, and that a fall to normal of a permanent nature is
most depressing. As we have already mentioned starvation can be
carried to greater lengths in those suffering from pyrexia than in those
with normal or subnormal temperatures. Moderate pyrexia would
therefore appear to the author, both personally as a sufferer and in his
patients, to have a direct or indirect stimulating effect, while a reduction
of marked amount is followed by temporary nervous depression, a con-
dition we wish to avoid in those suffering from acute “pyrexia, and who
have still their battle to ﬁght.
Although it has not yet been proved that moderate pyrexia, per se
(apart from the action of the virus and its non-pyogenetic products),
has an injurious effect upon the tissues, or that a certain amount of
temperature is necessary for the production of immunity, the writer can
scarcely think that pyrexia, even if necessary in fever infection, is more
useful or less harmful to the tissues than is inﬂammation to the healing
of a wound, though, like the latter, it may be necessary to combat micro-
organisms when present. Certain it is, however, that high temperatures
are injurious to the delicate central nervous tissues, and that very high
temperatures are incompatible with life. We must therefore steer a
rational course between needless and harmful interference and life-
preserving treatment. As long, therefore, as a case remains mild, from
a pyrexia point of view, it will be better to withhold symptomatic
antipyretic treatment, until some germicidal antipyretic is discovered,
in the realms of materia medica or serum-therapy, for this fever,
with an action similar to that of quinine in ague or mercury in syphilis.
In cases‘whose range of temperature exceeds 103° F. there is danger
to the patient from, the action on his nervous and other tissues of
this pyrexial symptom alone, in direct proportion to the height of that
temperature and to the length of time during which it is maintained.
Such danger, it may be to life, can only be avoided by early and syste-
1 Trans. Int. Med. Congress, Berlin, 1890. .
2 Hale White, Brit. [Med Journal, November 17th, 1894, vol. p. 1093. Dr. Munk, in
a lecture by Sir Dyce Duckworth, Brit. [Med Jour. vol. ii. p. 258, August 1st, 1896.
3 Therapeutic Gazette, Feb. 15th, 1896. See also Roy, “Protective Mechanisms,” Brit.
.lIed. Journ. vol. p. 310.
[MEDITERRANEAN FE VER 205

matic reduction of temperature by artiﬁcial means. Of the various
means at our disposal nothing answers so well as the external application
of cold by means of water, nothing is more unsatisfactory than the
action of the various antipyretic drugs at present in use. For we must
remember that mere elevation of the temperature is not to be attacked
as if it were itself the disease, but to be considered rather as a rough
index of the intensity of the activity of the virus or of the sensibility
of the individual to its action. Nothing is more certain than that the
administration of depressing, and even toxic, antipyretic drugs as a
routine practice is to be most strongly condemned. These drugs
should be conﬁned to two conditions, and even then, as will be shown
later on, with certain restrictions ill the case of different drugs. (a)
During the ﬁrst few days before the patient has, so to speak, become
accustomed to his pyrexia, when a dose of some antipyretic drug,
while reducing the temperature, also brings on a refreshing perspiration,
followed by a relief of headache and the much-needed sleep—a condition
which can also be obtained by means of tepid or cold_water sponging..-
(b) With certain exceptions in some conditions of hyperpyrexia early in
an attack. Individual antipyretics will be dealt with ill the section on
drugs.
Ill the method of temperature reduction by the application of
external cold by means of water, we have a most ﬂexible agent, capable
of being applied in various ways, at various temperatures, and applicable
to every case. This method has all the properties of the various anti-
pyretic drugs, has none of their many disadvantages, and above all,
besides reducing the temperature, it goes farther, and by its stimulating,
effects upon the respiration, circulation, metabolic and eliminatory
processes, it has a direct action upon the cause of the fever, thereby
having a somewhat speciﬁc effect. By aiding in the removal of toxic
substances from the blood it leads to an abatement in the severity of
the attack, an increased resistance and ﬁghting power on the part of
the patient, and a state of equilibrium among the various organs of the
body, thereby giving the patient an absence of dangerous symptoms in
the present and a reasonable chance of recovery in the future. In fact,
this useful form of treatment may be said to have the following pro-
perties when employed to obtain a moderate and safe range of pyrexia.
Besides the small amount of actual heat it removes from the surface of
the body, by its action on the large capillary and glandular integu-
mentary surface of the body it promotes excretion and elimination. By
its powerful reﬂex action upon the numerous cutaneous nerves it
stimulates the respiratory centre, producing full and strong respirations ill
place of frequent and shallow ones, so helping to clear the lungs and
increase the oxygenation of the blood. By the same action it also
stimulates the cardiac centre, gives rest to the over-burdened heart by
causing a stronger and less frequent action, and by accelerating the cir-
culation, removes stasis in the lungs and other internal organs. The
improved circulation and oxygenation of the blood promotes metabolism,
206 ' UND ULANT, MAL TA OR

and carries the leucocytes to all parts of the body, while the increase in
blood-pressure and local capillary blood~supply in the kidneys, lungs,
etc., promotes elimination of noxious products. This last point has
been proved in other fevers by the experimental researches of Juerg-
ansen, Roque, VVeil, and others. They ﬁnd that the amount of urea and
toxicity of the urine and of carbon dioxide in the expired air are largely
increased during such treatment, which is not the case with antipyrin.
The improvement in the condition and clearness of the mental faculties,
the refreshing sleep, the improved digestive powers, and the permanent
abatement of excessive pyrexia which follows this treatment in undulant
fever, cannot but be due to a similar action. Lastly, the avoidance of
the dangerous toxic effects of hyperpyrexia upon the higher nerve
centres is a most valuable property of the cold-water treatment.
During the last six years the writer has employed this treatment
extensively, and though he has to regret many instances in which he
either neglected it or began its application at too late a point in the
attack, he has not once met with a case in which he regretted its
rational application, but, on the contrary, believes that many of his
severe cases have to thank such treatment for their recovery. He has
not used baths, as they necessitate a considerable amount of labour on
the part of attendants and are more worrying to the patient, while
sponging, ice-water towels or sheets, and packing, have been found to
adequately meet all cases.
In applying the antipyrexial cold-water treatment do not wait until
a fatal result is anticipated, but begin the treatment as early as possible,
and let it be carried out systematically and whenever necessary, avoiding
a spasmodic or intermittent administration. In many cases it is suﬂicient
to lay down that the temperature be taken three times a day, viz. at
9 A.M., 2-3 P.M., and 6 P.M. ; or at 9 A.M., 5 P.M., and 8 P.M. ; and that
the patient be then sponged with tepid, tap, cold, or iced water accord-
ing to circumstances, if his temperature be at or above 103° F., and until
it has been reduced to 102° F., or slightly below. It is found by
experience that all patients do not respond to the application of cold
with equal readiness or rapidity. Thus while tepid sponging is sufficient
in one case, tap, iced water, or even ice packing is necessary to produce
similar results in others. In some cases the temperature falls slowly,
in- others more rapidly, and in rare cases with such extreme rapidity
that unless care be taken, before it is anticipated it may fall
below normal, and warm blankets, hot bottles, and stimulants be
necessary to bring about reaction. It is therefore wise to restrict
iced water and the use of ice packs to experienced and reliable persons
only, though the majority of nurses may safely sponge with tap or
tepid water. A little brandy may be given, before sponging or packing,
to many patients with advantage. The temperature should be taken
immediately before the sponging is begun, and every three or four
minutes during the operation, unless the effect of external cold on the
particular individual is well known, when it need probably not be taken
[MEDITERRANEA.V FE VER 207

quite so frequently. As soon as the temperature has fallen two or
three degrees, provided it be below 103° F., the sponging should be dis-
continued, the patient dried and placed in a warm, dry sleeping suit.
In any case the temperature should be brought down to about 102° F.,
but not below 101° F. In ordinary cases of high temperature a great deal
more success is obtained by bringing it down two or three degrees at a
time than by bringing it down a greater amount, the maximum amount of
advantage being reaped with the least amount of disadvantage. Certain
it is that success is not gained by bringing the temperature down to
normal or thereabouts, whereas the moderate course, without causing any
bad symptoms, refreshes the patient, braces his nervous system, relieving
headache and delirium, promotes tegumentary, respiratory, and urinary
excretion, causes the heart’s action to become stronger and less frequent,
increases the force of the respirations, avoids the dangers of hyperpyrexia,
and is usually followed by a refreshing sleep. Usually this artiﬁcial reduc-
tion of temperature is followed by a slight reactional rise from an hour to
an hour and a half afterwards. This is more marked in cases where the
artiﬁcial reduction has been excessive, while in those in which it has
been moderate as recommended, the after-rise is rarely much or long
continued, but is followed by some perspiration, sleep, and a permanent
reduction of pyrexia.
The clinical appearances would lead one to believe that a
certain amount of pyrexia is a necessary and so to speak normal
condition in this fever, and that the constitution is able to success-
fully combat with such a condition. \Vhen, however, for some reason
or other the pyrexia gains the upper hand, the balance of equilibrium
is destroyed, and it becomes an open question as to whether the
patient or the fever will prove the stronger. By bringing the tempera-
ture down by artiﬁcial means within safe limits, we give the patient’s
heart and other tissues rest and renewed strength, and at the same time
restore equilibrium. The rest which is given to the heart is a most
valuable point in the treatment, for if the failure of this organ to pump
the blood through the lungs, and indeed to beat at all, that is the
immediate cause of death in cases whose fatal issue is dependent on
high temperature. A lessening in frequency of one heat a minute is
equal to 1440 beats in the twenty-four hours, which is equivalent
to a valuable rest when the diminution in the number of beats per
minute can be expressed in two ﬁgures. The stimulation of the respira-
tory centre and increase in the strength of the cardiac action not only
help to clear the lungs, and by raising the blood pressure and increas-
ing the circulation to carry off waste and noxious products by stimu-
lating excretion, but also by so doing causes a lessening amount of
cardiac work to be necessary, and so leads to the establishment of
a permanent state of equilibrium between the heart and its work.
The beneﬁcial action of the treatment on the nervous system is
shown by the replacement of delirium, nervous excitement, or insomnia,
by a refreshing and quiet sleep; while the return to consciousness from
208 ' UNDULANT, [MALTA OR

hyperpyrexial coma is too well known in, other diseases to need descrip-
tion here. -
The writer has obtained excellent results by sponging his cases with
tepid, tap, or iced water according to the height of the individual’s tem~
perature and the manner in which it reacts to treatment ; while in severe
cases, and when acute hyperpyrexia has been present, he has employed
ice packing. The actual manner of application and the form of
treatment applied is a matter of experience and opinion, and the
medical attendant must be guided as to whether he will employ
sponging, packing, or bathing, by his own knowledge of the treatment,
by the reaction of the individual patient to cold, and above all by the
amount of reliance he is able to place in the nurse or other attendant at
his disposal. The writer has made a rule of invariably being present
when the ice-pack is to be used, but has been able, in the case of hospital
patients, to trust sponging with tap or even iced water to a reliable
nurse. Too much care cannot be taken when giving directions in these
matters, and the effects of treatment on the‘ pyrexial curve should be
most carefully registered on the chart as a guide to further treatment.
The effects of following out published forms of treatment in an irrational
and dangerous manner was most apparent in a case of this fever, com-
plicated with double catarrhal pneumonia, which, the writer was told,
was treated with ice on one lung and hot jacket poultices on the other!
Though both are acknowledged forms of treatment, the combination of
the two at one time was followed by fatal results.
It is well at all times to avoid chill when applying this treatment,
and as patients are prone in this disease to pneumonic troubles, the
writer usually avoids applying ice or ice water to the chest except in
severe cases where prompt and heroic treatment is necessary. Usually
the legs, arms, and abdomen prove sufficient surface for the application
of sponging or ice-water towels. In some cases the application of
towels to the arms and legs is soon followed by a reduction of tempera-
ture, while a few cases are met with in which one ice-water towel on the
arm or leg has made a difference of two or three degrees in short time.
With these last-mentioned cases the susceptibility to antipyretic treat- -
ment is so great, that a full ice-pack or a moderate dose of antipyrin
may be followed by serious collapse. Though these cases are uncommon
they should be borne in mind.
As an aid and guide to treatment, the writer has been ill the habit
of drawing a dark line along that marking the level on the chart of a
temperature of 103° F. This marks the point between a safe and unsafe
temperature, and though arbitrary in nature, proves useful. It is better
not to mark it in red ink, nor to tell the patient much about its use, as
in this fever patients are apt to watch their chart, when allowed, with
absorbent interest, and to suffer detrimental worry on account of its
many fluctuations and relapses. The addition of a “ danger line” to their
calculations would not add to their comfort. From the same point of
view all mental worry and excitement should be avoided, such as thev
MEDITERRANEAN FE VER 209»

frequent or unnecessary visits of friends, business and official work, etc.,
for, as has been shown, these all tend to elevate the temperature. The
effects of the damp sirocco wind in elevating the temperature has been
also mentioned.
When applying this treatment, whether sponging, pack, or baths be
the method in use, friction in the form of surface massage or rubbing
is a useful addition, as it assists in promoting the cutaneous capillary
circulation and excretion. '
Patients vary very much in the way in which the pyrexia of this
disease affects them. One patient may be seriously ill at 1020 F., another
may not appear to be much affected by a temperature of 1040 F. These
points must be borne in mind and allowance made for special idiosyncrasies
when moderating pyrexia, though as a general rule the arbitrary line at
103° F. will be found to divide moderate from excessive temperature.
This moderate regulation of temperature must not be confounded with
the tepid or warm—water sponging which every patient should undergo
each morning. It replaces the morning bath when the patient is con-
ﬁned to bed. It is most necessary, onaccount of the profuse diaphoresis,
to keep the skin in order and to promote its healthy action. In hot
weather and during the moist Mediterranean sirocco (or Levanter, etc.)
Winds it may often be beneﬁcially repeated in the evening, as it makes
the patient comfortable and ready for sleep. As pyrexial symptoms
diminish, and the morning temperature remains normal, the patient may
be allowed to take a warm bath, at his leisure, about 10 A.M., if the
weather is cold, before a ﬁre.
The chief point during early convalescence is to guard against
relapses. It is impossible to say when a patient is safe in this respect,
‘as relapses have been known to occur after one or two months of
apparent convalescence. ’
Over-exertion, either mental or physical, is probably the most frequent
cause of relapse ; chills, accidental catarrhs, sore-throats, etc., less common
exciting causes.
The ﬁrst aim should be to provide the patient with clean country
air. The locality should be inland and somewhat bracing, but sheltered
from the coldest winds, and free from damp on account of the tendency
to neuralgic sequelae in this disease. Change, of scene and locality, often
proves a valuable mental stimulant. With due regard to the avoidance
of fatigue, damp and cold, the patient should be in the open air as
much as possible. This can usually be managed where there is a garden,
and abroad where there are usually verandahs to the hospitals and
houses. In the Mediterranean the weather is warm enough for this at
mosttimes‘of the year during some part of the day ; but in England it
is difﬁcult during the damp cold weather of autumn and winter. In the
former place, again, the heat of summer and the depressing sirocco
winds are prejudicial to convalescence. This question is again dealt
with in the section on invaliding. A great number of patients improve
largely in health and often lose their fever during a voyage to England.
P
210 UNDULANT, [MALTA OR

Besides the mental stimulation of going home, these patients spend
a great part of their time on deck, in clean fresh air, in a situation where
fatigue can be altogether avoided. The writer cannot help feeling that
this has all to do with their improvement in health, the actual fact that
they have left the place where their fever was contracted, a point
insisted on by many Maltese practitioners, having but a small signiﬁ-
cance. Patients sent home to England from the Mediterranean during
the depressing heat of the summer (i.e. before September) do well, but
of those sent home during the autumn and winter, the same cannot be
said. The most favourable months for recovery in England are from the
beginning of June to the end of August, to which may often be added
the month of May. The corresponding favourable months in the
Mediterranean, especially in the sanatoria of Italy and Sicily, are from
the middle of October to the end of April.
Diet must be carefully attended to especially in prolonged cases, in
which the anaemic and irritable mucous membranes and torpid liver
must be gradually coaxed into activity. Too great a quantity of food
should not be taken at one time, To a liberal supply of milk, eggs,
fruit, game and ﬁsh, should be added the usual plain meals in moderation.
A glass of milk before rising, a cup of soup in the middle of the morning,
and a glass of milk by the bedside, should be provided. Above all, let
meals be supplied punctually at ﬁxed times. An occasional whisky with
water or soda, when indicated, is useful, and burgundy or stout are often
beneﬁcial with meals during convalescence.
Mental work should be put aside if it causes the slightest tendency
to worry, irritation, headache, or even difficulty in mental concentration.
Exercise is very beneﬁcial in strict moderation, and like food it should
be taken in small quantities at a time. Riding and cycling should not be
indulged in until convalescence is well established. There is a great
temptation when cycling to go too far from home, to over-work up hill,
etc. Again, when there is the least tendency to occurrence of pyrexial
rises, these by masking the sense of fatigue lead to the patient doing
more than he would otherwise do, and so increasing the pyrexia and
risking a relapse. Gentle walking exercise is best at ﬁrst, and inﬁnitely
better than driving or bath-chair exercise. The walk can be accurately
measured from a hundred yards onwards, while when driving, the patient
is apt to ﬁnd the sitting position fatiguing when some way from home,
whereas when walking he will scarcely get far from home when liable to
such fatigue. He can rest at frequent intervals, and even arrange to be
driven the short distance home if necessary. Walking, moreover, has a
therapeutical effect on the circulation, the muscles, bowels, etc. Person-
ally, when convalescing after a long attack the writer preferred rest in
the open air with short walks, to any carriage or bath-chair exercise.
While exercise is being taken in small quantities as often as advisable,
rest, both mental and physical, should be taken in large quantities. All
meals should be taken in bed at ﬁrst, and breakfast also, until the patient
is quite strong. His reading should be of a light nature, and while his
[MEDITERRANEAN FEVER 211

temperature is above normal he should be read to rather than read
himself. Many patients ﬁnd wool-work, embroidery, or games of
patience with cards, help to pass the time without causing undue mental
fatigue.
Warm clothes should be worn (especially when there is a tendency to
subnormal temperature) with woollen material next the skin. Patients
sent home from the Mediterranean must be provided with warmer clothes
for wear when nearing England. For a considerable time they will feel
every change in the weather, and unless due care be taken to protect them
from chills, obstinate sciatica or other neuralgic condition may be set up
and prove most intractable. They must study the weather, and dress
accordingly. Pain and stiffness in the joints and tendons, especially
after remaining long in one position, cause much trouble at ﬁrst in'
patients who have been long conﬁned to bed. It is much relieved by
wearing warm clothes, boots rather than shoes, massage or soaking in
hot water at night. It gradually wears off with moderate exercise,
especially cycling, at a latter stage in convalescence. Tenderness of the
soles of the feet is also very marked-at ﬁrst after a lengthened stay in
bed. They may be hardened by soaking in alum and water.
Hair that has fallen out will gradually return with improved health.
The scalp should not, however, be allowed to get too dry, and should be
treated with some stimulating and mildly oleaginous wash.
Preparations of iron are useful when anaemia and tendency to oedema
of the ankles are present. The writer usually administers iron in the
form of Blaud’s pills to convalescents, with apparently good results.
Easton’s syrup is also useful. The last preparation, or strychnia alone in
small doses, will be found beneﬁcial where there is a tendency to palpita-
tion on exertion or to nervous exhaustion. Stomachic and bitter tonics
often improve the appetite and general health, a useful one being nitro-
hydrochloric acid (freshly prepared) with the compound tincture of
gentian, before meals. The writer has been in the habit of administering
small doses of quinine (two to ﬁve grains of the bisulphide three times a
day before meals), after all tendency to active pyrexial symptoms and
gastric irritation have disappeared. This drug, which during the acute
stages of the fever does more harm than good, during real convalescence
appears to have its uses. There is then no gastric irritability to aggravate,
while as a tonic it seems to give tone to the stomach, heart, and nervous
systems in these small doses. It appears to have a further action on the
temperature curve of a steadying nature. If the temperature be carefully
taken during convalescence, it is found, especially after long attacks, to
vary during the day even in cases in whom the body-weight has reached
or exceeded the normal. In the morning it will be found to be below
98° F., and in the evening, and more especially after cycling or such other
exercise, to reach even 99° F., the total variation of from 1° to 2° being as
great as is often present in intermittent cases during active disease.
This variation is, however, mostly below the normal line, and may continue
for months after all pyrexia due to actual infection has quite disappeared,
212 UNDULANT, MALTA OR

and in persons whose temperature before the attack had been found by
actual and prolonged observation to maintain a constant level. The
amount of this variation is proportionate to the physical (and in some
cases the mental) exercise taken; the maximum height following the
exercise, the minimum height (or maximum of fall) following this rise as
a sort of reaction. This variation is also associated during and after the
fall by a proportional amount of fatigue or nervous exhaustion. It does
not appear to depend upon the pyrexial effects of infection, nor to be due
to the action of the micro-organism of the fever in any way, but to a
weakening of the nervous mechanism of body-heat regulation, when it is
acted upon by external conditions. The exact pathology of this pyrexial
variation would prove a' difficult question to determine, but the inability
to maintain an exact level under all circumstances, after being, so to
speak, out of regular working order for a long period (from three to
twelve months or more), is comparable with the debility of the rest of
the body, and its inability for a time to resist strain upon any of its
mechanism whether simple or highly complicated.1 \Vhatever it is due
to, these small doses of quinine seem to have a steadying effect and so to
be beneﬁcial. The writer has also an opinion, based upon a number of
cases treated with and without this drug, that it helps in preventing
relapses to a certain extent. In the form of compressed tabloids it is
easily carried about and administered.
Again, when all signs of gastric irritation have disappeared the writer
has administered small doses of arsenic to a number of cases. They
increased in weight and their anaemia decreased, no untoward symptoms
arising. In these the drug appeared to be responsible for some of the
improvement, when their progress was compared with the cases left with
out drugs during convalescence.
Action of Certain Drugs
Quinine.—So prevalent is the idea that there must be a “malarial”
taint at the root of Mediterranean fever, and so universal has the use of
quinine for “fever” become among the laity, that it is not surprising
that this drug should have been frequently tried as a remedy for this
fever, in spite of failure after failure. The writer has employed it in
various doses and ways without any speciﬁc result being obtained, the
fever going on unchecked in spite of continued administration, and in
acute cases its administration has usually been followed by an increase
in severity of the symptoms. This has been ‘the experience of other
observers, who with the writer limit its use to the convalescent stage,
when it may occasionally be useful as a tonic.
Marston (1861) says: “Quinine almost invariably disagrees with
the patient during the earlier stages of the disease.” Guilia (1871)
says much the same.
1 For somewhat similar variation in temperature during health, see Croonian Lectures
1897 (Dr. Hale White), Brit. Med. Journ. June 26th, etc.
[MEDITERRANEAN FEVER 213

Boileau (1865) says: “Quinine was given occasionally during
convalescence. I believe, however, that this medicine might be banished
from Malta without much loss to the station.”
Chartres (1865) says: “In prescribing quinine in this disease, and
having fairly tried it during remissions under many forms and in
various combinations and doses, I confess to have met with much
disappointment; its antiperiodic power was almost nil; its tonic or
restorative properties extremely doubtful. In heroic doses it was
positively detrimental.”
Oswald Wood 187 6) says: “Quinine appears to possess no
remedial qualities in this fever.”
Veale (187 9) says: “Quinine has been given in doses varying
from three to eighty grains per diem, but without beneﬁcial effect.
Indeed, the large doses do more harm than good.”
Surgeon Gipps, RN. (1890) says: “Quinine in this disease is
absolutely useless, and in fact worse than useless. This is agreed to by
all observers. There is already sufficient gastric irritation present
without administering a bitter drug dissolved in an acid; added to
which it has not the slightest effect on the fever.”
Bruce (1893) says: “As the result of many observations on the
action of this drug in Malta fever, I can assert that quinine has abso-
lutely no beneﬁcial inﬂuence whatever, and if pushed, as is too often
the case, is deleterious.”
Many others who have treated this fever in Gibraltar, Cyprus, Italy,
and elsewhere, have published similar remarks, while the opinion of
medical officers that the writer has met with in the Mediterranean have
with few exceptions coincided with these views. The tendency to
spontaneous cure, when it has coincided with the administration of this
or any other drug, has led some persons with a limited experience to
lay stress on a particular drug, the more extended use of which has
proved its inefﬁcacy. The writer is convinced that this has been the
case with the above few exceptions, an opinion based on a personal
acquaintance with the practitioners in question.
In the writer’s experience quinine in its various forms has had no
speciﬁc action on the virus of this fever. In acute cases with gastric
irritability large doses are vomited, while moderate doses increase the
irritability and general depression, and so do more harm than good. In
less acute and intermittent cases it appears to have no beneﬁcial effect,
while its continued absorption into the blood has a paralysing effect
upon the leucocytes, limits oxygenation, metabolism, and excretion
(Mitchell Bruce). Its antipyretic effects in this fever are slight, tran-
sitory, and in most cases unmarked, while its antiperiodic effects are nil.
\Vhere in severe cases it does good, there is apparently a certain amount
of septic absorption from the intestine going on, its antipyretic effects
being in inverse ratio to the pureness in type of the fever. This is the
case whether the drug is administered by the mouth, rectum, or hypo-
dermically. Its action in this fever is somewhat similar to its action on
214 UNDULANT, MALTA OR

the pyrexia of so-called hectic fever. The only instances in which the
writer has found it of use have been in the very late stages immediately
before convalescence, in which the appetite has been established, the
patient allowed to have certain solid food, and to get up for a time each
day, when small doses (two to ﬁve grains at most, twice or three times a
day) have assisted'in steadying the temperature, and stopping the very
slight nocturnal rises which seem to almost have become a habit. 111
such cases, without causing gastric disturbance, it has had a tonic effect,
improving the appetite and digestion, stimulating the heart and circula-
tion, and by so increasing the general bodily health has aided the
patient in throwing off the small remains of the fever. Quinine has a
similar tonic action during convalescence when the febrile stage has
ceased.
Bismuth in the form of the subnitrate (most easily taken in capsules),
is a most valuable remedy in the gastric derangement that is to be met
with almost invariably in acute cases of this fever. . It has a sedative
and astringent action on the mucous membrane locally, and so by allay-
ing the gastric irritation promotes digestion, and by this means improves
the general health and strength of the patient. It should be given to
all cases in which there is a foul, coated tongue, with offensive breath,
pyrosis, and other signs of imperfect digestion. Many of these gastric
symptoms appear to be due to fermentation of imperfectly digested
food, as does much of the occasional diarrhoea. The remarkable way in
which this condition often yields to doses of from ten to twenty grains
of the subnitrate of bismuth given three times a day, combined, in very
severe cases with high temperature, with small doses of pepsin or with
peptonised milk, has led the writer to believe that this drug has some
further action than that of a local mechanical sedative. This experience
has received support from the recent writings of Carles,1 Gayon, and others;
and by the fact that such small doses as ten to ﬁfteen grains repeated
three times a day have almost if not quite as much effect as very large
ones. Carles explains its action as follows :—“In contact with water it
has a tendency to split up into the oxide of bismuth and nitric acid.
In the stomach, the oxide, which is ill excess of the acid, has ﬁrstly a
detergent effect upon the mucous membrane, precipitating the mucus;
and secondly, a germicidal power. The nitric acid has a tonic, astrin—
gent, and special antiseptic action (Duclaux). In the intestine it meets
with sulphuretted hydrogen gas, which converts it into black sulphide,
liberating a further portion of its acid, which is partially transformed
into nitrous fumes, the antiseptic action of which has been proved by
Giraud and Pabst. For this action to take place satisfactorily, the
subnitrate must be pure and unmixed with the carbonate, and should
be as ﬁnely powdered as possible.” 2
Whether this adequately explains the undoubted beneﬁt met with
clinically from the administration of this drug it would be rash to
1 Archives Cli-nigue de Bordeaux, February 1896.
2 Brit. [Med. Journal, 14th December 1895, p. 1483, and 4th April 1896.
[MEDITERRAIVEAN FE VER 215

surmise, but the writer can strongly recommend its use. The effects
which follow its administration are almost as great as those following
the use of many internal antiseptic remedies in this fever, so that
whether it acts directly as a germicide, or indirectly by aiding the
germicidal action of the tissues, it matters little clinically. As it does
not by its direct action stop the course of the fever, but only mitigates
its intestinal or gastric symptoms, it is probable that its action is on
the accidental fermentative organisms rather than on the virus of
undulant fever proper, so that without being a speciﬁc drug it has its
uses. It is of no avail in the late chronic stages of protracted cases,
whose pyrexial range is low, and whose gastric symptoms are slight. It
has the great advantage of being unirritating, and therefore does no
harm, which cannot be said of many drugs often given in this fever.
Arsenic acts as a gastric irritant, and has no antipyretic or anti-
periodic effects on this fever, but rather the reverse (see Case 42). Its
use is contra-indicated in all cases during the febrile stage. It has
occasionally been used as a tonic, and for sciatica after convalescence
has been well established.
Hydrocyanic acid should not be given for gastric irritation, as locally
it only paralyses the stomachic nerve endings, and rather hinders than
encourages improvement in the digestive powers of that organ; while
internally it acts as a depressant on the respiratory and cardiac centres,
the reverse of what is required in severe cases.
Carbolic acid, carbolates, and iodide of potassium, have all been used
without speciﬁc effect.
Boracic acid internally has been given by the writer in many
instances with doubtful effect in a few, and with none in others. Its
good effects were probably due to the promotion of intestinal asepsis
rather than to any speciﬁc action on the virus. In solution it has been
advocated as a remedy, in the form of local irrigation, for involvement
of the large bowel.
Chlorine has not appeared to do any good.
Salol has no effect on the pyrexia, as might be expected in a local
intestinal antiseptic.
Aconite is contra-indicated from its depressant effect upon the heart
and circulation generally.
Colchicum does no good, and is a gastric irritant and respiratory
depressant, but has proved useful in small doses, combined with an
alkali, in attacks of gout complicating this fever. _,
Eucalyptus has been tried by Tomaselli and Bruce, but neither found
it of any use. The same may be said of turpentine.
Salicylic acid is a stomachic irritant and a cardiac depressant, sali-
cylate of soda or quinine much less so. On account of the arthritic and
neuralgic symptoms of this fever and its consequent clinical resemblance
to acute rheumatic fever, for which disease these drugs are held to
be speciﬁc remedies, there has been a great tendency to administer
them in cases of undulant fever. They have, however, no speciﬁc
216 UNDULANT, MAL TA 0]?

effect on the virus of the fever, and a doubtful effect on the local
rheumatoid symptoms, and their use has been condemned by Rumno,
Tomaselli, and Bruce. In small doses salicylate of soda has appeared of
use in cases where fermentative changes were going on in the gastro-
intestinal canal, while salicylate of quinine is well borne, and its
administration in numerous cases has been followed by no appreciable
ill effects. The writer has been in the habit of giving the latter in
small doses three times a day, under the impression that it has kept off
and alleviated the rheumatoid complications. The administration of
salicylic acid or the salicylate of soda as a speciﬁc routine treatment for
this disease is not only unscientiﬁc, but has proved actually harmful in
severe cases.
Antipyrin (phenazone) has been largely employed. Though it
reduces the temperature it has no effect upon the cause of the fever ; it
does not rest, but often has a powerfully depressant action on the heart,
especially in severe and critical cases, and at the same time it reduces
the urinary and respiratory excretions. It is an uncertain and even
dangerous drug in this fever, and its use should be conﬁned to single
doses in strong subjects during the ﬁrst few days of the attack. At
this period, although it reduces temperature, promotes perspiration,
relieves headache, and procures sleep, the same results may be obtained
with even greater advantage by means of the external application of
cold water, while a more exact effect and measurable reduction of pyrexia
can be obtained and the heart’s action improved.
Antifebrin (acetanilide) should not be used.
Phenacetin is preferable to antipyrin, and may be employed in cases
where that drug is inadmissible with greater safety. It produces
profuse perspiration, fall in temperature and general (but temporary)
relief from discomfort, but the heart’s action is not improved, while the
temperature frequently rises again to its original level a few hours
after.
Resorcin has been used by the author without result.
Invaliding.—In Malta out of 844 cases of this fever among soldiers,
401 (47 '51 per cent) were sent to a sanatorium, 142 (1682 per cent)
were invalided to England, and 275 returned straight from hospital to
their duty. Among officers the proportion was much higher. In the
Royal Navy a much larger proportion of men are invalided to England
for the effects of .this fever. The question of the advisability or other-
wise of leaving the country in which the disease prevails, as a remedial
measure, is therefore one of importance. The naval authorities and
many of the local practitioners advise patients to at once leave for
England. Many others deny the necessity of change or its efficacy as a
remedial measure.
Thus we ﬁnd in the Naval Annual Blue-Boole for 1886: “A large
proportion of the cases sent to hospital were subsequently invalided.
Indeed, according to my experience, when a man has suffered severely
MEDITERRANEAN EE VER 1 217

from this fever he becomes liable to constant relapses, and is not likely
to make a complete recovery or be ﬁt for his ordinary duty until he has
been removed from the station.”
Again in 1887 : “Indeed, according to my experience, when a man
has suffered from a severe or moderately severe attack of this fever it is
hopeless to attempt to keep him on the station, and the sooner he is
sent home the better it is for himself and for the efficiency and economy
of the service.”
This was practically the opinion of those naval medical officers
present in the island during the writer’s stay in Malta, who had
to do practically with the subject. It ‘must be remembered, however,
that such a practice is less troublesome to carry out than that of
continuing to treat the cases, that it is most suited to the limited
naval hospital accommodation, and that there are greater facilities
in the Navy for sending men home at all times than there are in the
Army. A rigid adherence to the letter of such treatment is liable,
however, to carry inexperienced medical officers into grave trouble
through errors in diagnosis. Two such cases have come under the
writer’s notice, where such an error led to most unfortunate and fatal
results. In the ﬁrst case a woman was sent for change of air to Gozo,
where on arrival the expected accommodation was found to be deﬁcient.
This necessitated a somewhat prolonged drive, in the course of which
she fainted, and soon after died. Then and then only it was found on
post-mortem examination that she had been suffering from enteric
fever, a perforation having brought about the fatal result. The other
was the case of a civilian gentleman, who, believing that he was
suffering from undulant fever, left Malta hurriedly after a few days’
pyrexia, only to die of enteric haemorrhage a day or two after arrival
in England.
The custom in the Army is to give local hospital treatment a fair
trial ﬁrst, and only to invalid such cases as appear to be unable to shake
off the effects of the fever without a change. They are rarely sent away
duringthe ﬁrst two months of the disease, while the majority are kept
longer in Malta. This is due to a great extent to the fact that ac-
commodation in troop-ships for invalids is only available ill the winter
months, at which time the fever is little prevalent; while passages are
only provided in private packets when certiﬁed as absolutely necessary.
This is the other extreme, and frequently invaliding is either left until
a very late stage, or invalids who have passed a Board, for change to
England, are kept waiting for a Governmentlpassage for so long a time
that the change comes too late to be beneﬁcial. -. 3 3
Those who treat the disease among invalids sent to England de
scribe many of them, especially during damp and cold weather, as
dragging out a weary indoor existence of relapses and rheumatic com-
plications, often for months. Other cases are described as recovering
after a few days at sea. Certain it is that cases neither do well ill
England in the cold of winter, nor in the Mediterranean during the
218 UNDULANT, MALTA OR

heat and the enervating sirocco winds of the summer. Much of the good
effect of change depends on the exhilarating effect on the mind of
leaving foreign service for home, on the bracing effect of the fresh air
at sea, and on removal from the area of infection.
The last effect can usually be obtained by removal from the infected
area to the hospital or elsewhere. One of the writer’s sisters, who was
sent for six weeks to Italy for change, without material result, recovered
from the day she arrived back in Malta. It is certainly not justiﬁable
to send acute cases away from the comforts and attentions of home or
hospital to the fatigues of travelling, the doubtful comforts of foreign
hotels, and away from skilled and friendly advice and help, for the sake of
an over-estimated speciﬁc treatment by change of air. Many patients
have been recommended change to places where the same fever is known
to exist, being told that they cannot recover until they leave Malta!
The beneﬁcial effects of change of air and environment, especially during
convalescence, is not to be denied, but the trials of a sea voyage or over-
land journey should not be encountered until the acute stages are over,
nor until an enteric diagnosis has been excluded. During the winter
new attacks, and those still suffering from attacks contracted during the
autumn, do very well in Malta, provided they are moved away from the
immediate neighbourhood of infection. During convalescence a change
to the dry atmosphere of Cairo, or to the hill towns of Italy or Sicily,
is most beneﬁcial. During the autumn and winter cases are best
away from the rigors and indoor conﬁnement of the English climate.
During the spring and summer cases do not do well in Malta when at
all severely attacked. At such times every case of over a month or six
weeks’ duration should be inquired into, and everyone who appears to
be bearing the fever badly should be invalided and sent home as soon
as he is in a ﬁt condition to travel safely. At this time of year the
effect of even a few days at sea is most noticeable in the improved
general condition of the patient. Those of long duration (three months
and over), with much anaemia and debility, will get well much quicker
and more thoroughly if sent away to a cool climate at that time of year.
When they have arrived in England or elsewhere, a dry and slightly
bracing inland place should be chosen, which is not at the same time
exposed to cold winds. Patients do not throw off the fever satisfactorily
in relaxing or low lying seaside places, and are liable to neuralgia or
rheumatic complication and sequelae in damp or cold places. The duty
of Army medical officers is to avoid reduction of the ﬁghting strength of
the Army 011 account of sickness, as far as is possible, with due regard to
the rights of the individual and the expenditure of public money. The
writer believes that this would be best effected by invaliding to England
during the spring and summer, all cases of this fever, in which at the end
of ﬁve or six weeks (an enteric diagnosis having been carefully excluded),
the fever appears to have a strong hold upon the patient, and to show
no signs of cessation, or in whom there is much anaemia or debility. A
change to a sanatorium would suffice during the autumn and winter,
[MEDITERRANEAN FE VER 219

provided the above course was adhered to from May to September.
Could a hospital ship be available for conveyance of naval and military
invalids from the Mediterranean to England during the spring and
summer, after the usual trooping season, it would repay expenditure and
be of ‘the greatest service.
To sum up :—
(a) Do not invalid patients until a sure diagnosis has been made 3 nor
until the most acute stage is over.
(b) Invalid freely during the spring and summer months to England
or such similar climate, choosing a dry inland place, bracing without
being cold.
(c) Treat patient during autumn and winter in the Mediterranean,
in sanitary surroundings, sending them if necessary during convalescence
to some dry, bracing place within the neighbourhood. A change to
Civita Vecchia or Gozo is often of use during convalescence in Malta;
or further aﬁeld to Taormina or Gergenti in Sicily, to the Italian lakes,
Switzerland, the Tyrol, or the Nile. '
(d) It is very necessary that change of air should be accompanied by
relief from mental work, worry, or physical discomfort. This with
careful dietary and cheerful surroundings are the chief beneﬁcial items
of the change.
INDEX
ABscEss, hepatic, diagnosis from, 161
Abscesses, subcutaneous, 103
Absence of mic. Melitensis in other diseases,
7, 41
Absorbent night-suits and clothing, 139,
178, 187
Accurate period of history, viole History
Acetanilide, action of, 216
Aconite, action of, 215
Admission rates, vide Tables
Age, inﬂuence of, 74
Air, polluted, as a cause, 53
Albumin water, 191, 192
Alimentary system, symptoms connected
with, 147
Anaemia, 143, 211
Anatomy, morbid, 167-176
Ancient history, vide History
Animals, lower, experiments upon, 44-49
Antifebrin, action of, 216
Antipyrin, action of, 216
Antiscorbutic treatment, 191
Appetite, 148, 190
Apyrexial intervals, 108
Arsenic, action of, 216
Arthritic effusions, 137-141, 202
Atrophy of muscles, 136
Attacks, immunity from second, 82
BAOILLUS of enteric fever, 5, 41
Bacteriology, 5, 35-49
Baths, trapping of, 182
Bed, conﬁne to, during acute stages, 186
Bed-pan, use of, in severe cases, 188
Bed-sores, prevent, 103, 199
Beef juice, 192
Beef tea, 192
Bibliography, 29-34
Bismuth, action of, 191, 214
Boils, occurrence of, 103, 199
treatment of, 199
Boracic acid, action of‘, 215
Brain, morbid anatomy of, 168, 170
CAMPING on polluted ground, avoid, 180, 183
Carbolic acid, action of, 215

RERUM
Cardiac symptoms, 141-146
Carriage of organisms through the air, 68
Cases, index of, xv.
Causative factors present in outbreaks, 56
Causes, predisposing, 49
Cementing of ground-ﬂoor rooms, 62, 70
Cerebro-spinal symptoms, 123-136
Changes in type, 86
Changing night-suits after diaphoresis, 187
188
Charts, index of, xvii.
Chicken quinelle, 191
Chills when using night-stool, 140, 188
Chlorine, action of, 215
Circulatory system, symptoms, 141-146
Colchicum, action of, 215
Cold sponging, advantages and method of
application, 202-209
Complications, 152
Congestion, pulmonary, 146
treatment of, 200
Constipation, 149
treatment of, 196
Convalescence, management of, 208
Cough, 146, 200
Crimea, introduction of fever into Malta
from the, 16
Cyclical periods, S. C. fever, 93
DAILY tepid sponging of skin, 198, 209
Damp ﬂoors, 56, 70
Danger of over-feeding severe cases, 189
Date of death (45 cases), 97, 168
Death-rates (various, vide Tables)
of undulant fever, 97, 163, 167
Decreased prevalence of S. C. fever, 87
Decubitus, 102, 123
Deﬁnition, 1
Delirium, 122
Delusions, 122
Depression, mental, following fall of tempera-
ture, 122
Description, ﬁrst accurate, by Marston, 19
Description of mic. Melitensis, 42
Description of disease, short, 2
Desquamation, 104
222
UNDULANT, MALTA OR [MEDITERRANEAN FEVER

Diagnosis from (1) enteric fever, 154
(2) paludism, 159
(3) phthisis, 161
(4) hepatic abscess, 162
(5) empyaema, etc., 162
(6) pneumonia, 162
(7) rheumatism, rheumatic fever.
traumatic synovitis, 162
Diaphoresis, 105
change of clothes after, 187, 188
Diarrhoea, 149
treatment of, 196
Dietary, 188-195
Differentiation from (1) enteric fever, 4
(2) paludism, 5
Diﬁiculty in micturition, 150
Digestion, derangement of, 148, 189
Discovery of mic. Melitensis by Bruce (1886),
35
Dissemination of poison, 50-74
Distinct disease, acceptance as, due to work
of medical oﬂicers of’ the army, 22
Distinctive odour, 104
Diurnal temperature curve, 119
Drainage of Valetta, 70
of Sliema and villages, 72
new, supposed dissemination by, 87
Drains, efficient ﬂushing of. 181
eﬂicient ventilation of, 181
ventilators of, to be well raised, 18]
Draughts to be avoided, 186, 200
Duration of hospital treatment, 167
pyrexial, 166
Dust, faecal pollution of, 67
Dyspnoea, 146, 200
and
EARLY history, vide History
Effusions, arthritic, 137-141, 202
pericardial, description and treatment, 143
Egg-ﬂip, 192
Eggs in dietary, 192
Elimination as causes of—
(1) inoculation, 50
(2) water-supply, 50
(3) milk, aerated waters, ice, and other
drinks, 52
(4) grog-shops, 52
(5) food-supply, 53
Empyaema, diagnosis from, 162
Enteric and undulant fevers occurring to-
gether, 4
fever, bacillus of, 5, 41
connection with dust, 67, 68
diagnosis from, 154
differentiation from, 4
Erhlich’s test in, 156
neuritis in (Osler), 128
orchitis in (Ollivier), 152
severe cases of undulant fever resembl-
ing, 4, 184
Entrance of virus to human tissues, 50-73
Epididymitis, 150

Epigastric tenderness, 147
Epistaxis, 104
Erhlich’s test for urine, 156
Examples of 15 outbreaks, 56-63
Existence prior to 1859, reasons for, 12, 16,
19, 23
Exit of virus from human body, 74
Expectoration, 146
Experiments, post-mortem, on spleen, by
Bruce (9), 35
by Gipps (2), 36
by author (14), 37-41
on lower animals (Bruce), 44
(author), 45
Eucalyptus, action of, 215
FACTORS, causative, present in outbreaks, 56
Faecal origin, extracts from writers (18), 53-
6
Fall of temperature, early, aid in diagnosis,
115
Fauces, redness of, 73
Feet, hyperaesthesia of, treatment of, 124, 202
Fever pains, 121
treatment of, 201
First described accurately by Marston in
1859, 19
Floors, (lamp, 56, 70
dust from soft stone, 185
Flushing of drains necessary, 181
Food-supply, vide Elimination
Fruit, fresh, in dietary. 192
in constipation, 196
GAsTRiTis, 147
Geographical distribution, 23-29
names condemned, 8
Grog-shops, vide Elimination
Ground-ﬂoor rooms, cementing of, 62, 70 '“
HIEMATOPHYLLUM (Laveran), absence of, 6
Haemic murmurs, 142
Haemorrhages, subcutaneous, 103
Haemorrhoids, 143
Hair, falling out of, 105, 211
Harbours, insanitation of, 63-67
Headache, 121, 201
Hepatic abscess, diagnosis from, 162
Historical sketch, 12
History, ancient—Hippocrates, B. o. 460, 12
early—Demarco, 1722-87 3 Howard, 1786 3
Fauverge, 1798-1800; Cleghorn, 1744-
493 Heastie, 1825-28; Burnett, 1800-
10 3 Hennen, 1815-25 3 Davy, 1833-35 3
official reports, 1817-59, 13-19
accurate—Marston, 1859 ; MacKay, 1862;
Boileau, 1865 ; Chartres, 1866 3 Guilia,
1871 ; Donaldson, Oswald-Wood, and
N otter, 1876 3 Veale, 1879 3 Turner,
1884; Bruce, 1886-89; Moffet, 1889'
Italian and other writers, 19-23
INDEX RE R UM 22 3

Hydrocyanic acid, action of, 215
Hyperzesthesia, 123
of feet, and treatment of, 124, 202
ICE (vide Elimination), 193
Immunity from subsequent attacks, 82
in connection with other diseases, 84
Impairment of memory and special senses,
123
Increased prevalence, rumour of, 87
Incubation period, 75, 76
Index of charts, xvii.
of tables, xvi.
to clinical description of cases, xv.
Inﬂuence on prevalence of—
(1) age and sex, 74
(2) air temperature, 80
(3) length of residence, 81
(4) rainfall, 77
(5) season of year, 76
Inoculation, vide Elimination
of monkeys, 44-49
Insanitary condition of harbours, 63-67
surroundings, move patient from, 57, 185
Insanitation, outbreaks connected with (15),
Intermittent type, 98
Intestines, morbid anatomy of, 169, 171, 173
Introduction into Malta, local theory of, 16,
23
Invaliding, 216
Irregular or mixed types, 100
Isolation of mic. Melitensis from the spleen,
35-42
KIDNEY, large white, 150
morbid anatomy of, 170, 173
LARGE white kidney, 150
Lemonade, 191
Lime juice, 191
Liver, morbid anatomy of, 168, 171, 173
Lungs, congestion of, 146
treatment, 200
morbid anatomy of, 168, 170
MALARIAL fevers, diagnosis from, 159
differentiation from, 5
not endemic in Malta, 6
Malignant type, 95
Mediterranean, when to visit the, 77
phthisis, 146
Memory, impairment of, 123
Mental depression following fall of tempera-
ture, 122
Method of isolation of mic. Melitensis, 41
Micrococcus Melitensis, absence of, in other
diseases, 7, 41
discovery of, by Bruce in 1886. 35
description of, 42-44
method of isolation of, 41
photographs of, F rontispiece

Micro-organisms in sewers, 69
Microscopical histological appearances, 173
Micturition, difficulty ill, 150
Milk, diet, quantity and quality, 190
in connection with cause, vide Elimination
peptonised, 191
Mineral waters in connection with cause,
vide Elimination
Mixed types, 100
Mode of entrance of virus to human body,
50-73
of exit of virus from human body, 74
Morbid anatomy, 167-176
Mortality, 97, 163, 167
Mosquitoes, sand-ﬂies, etc., 50
Muscles, atrophy of, 136
NERVOUS system, 120-126
N euralgic and neuritic symptoms, 127
treatment of, 201
Neuritis in enteric fever (Osler), 128
Night - suits and clothing of absorbent
material, 139, 178, 187
Night-stool, chills while using, 140, 188
N odules, subcutaneous, 103
Nomenclature, 7
N on-contagious, 50
N on-exanthelnatous, 1 02
N otiﬁcation of cases, 178
Nurse ill severe cases, 186
ODOUR, distinctive, 104
(Edema, subcutaneous, 101
Orchitis in undulant fever, 150
in enteric fever (Ollivicr), 152
Organisms, carriage of, through air, 68
Outbreaks associated with insanitatioll (15),
57-63
Overcrowding, 49, 56, 68
Overfeeding, danger of, ill severe cases, 189
PAINs, fever, 121
Paludism, diagnosis from, 159
differentiation from, 5
not endemic ill Malta, 6
Paralysis of muscles, 136
Pathological anatomy, 167-176
Peptonlsed milk, 191
Pericardial effusion, 143
treatment of, 143
Periods, cyclical, S. C. fever, 93
Peyer’s patches, absence of ulceration ill, 5
morbid anatomy of, 168
Phenacetin, action of, 215
Phenazone, action of, 216
Phthisis, cases resembling, 98, 101
diagnosis from, 161
Mediterranean, 146
Photographs of mic. Melitensis, Frontispiece
Physiognomy, 101
Pimples simulating exanthem, 102
Pleuritic symptoms, 146, 200
224 UNDULANT, [MALTA OR [MEDITERRANEAN FEVER

Pneumonia, diagnosis from, 162
Polluted air as cause, 53
ground, avoid camping upon, 180, 183
Population, Valetta, 70
Postulates of Prof. Koch fulﬁlled, 40, 49
Predisposing causes, 49
Prevalence, inﬂuence of air temperature on , 80
inﬂuence of rainfall on, 77
in Gozo, 89
of S. C. fever, decreased, 86, 87, 93
in Malta, rumoured increase in, 87
seasonal, 76
Preventive measures, 177
Prickly heat, 103
treatment of, 198
Prognosis, 163
Prophylaxis, 177
Pulmonary congestion, 146
treatment of, 200
Pulse, 141
Pyrexia, a stimulant, 122, 204
description of, 106-120
QUININE, action of, 212
salicylate, action of, 216
RAINFALL, inﬂuence of, on prevalence, 77
Reaction, Erhlich’s, for urine, 156
of building stone and stools, 72
serum, 5, 44, 49, 84, 158
Regulation of temperature by external cold,
202-209
Residence, effect of long, 81
Resorcin, action of, 216
Respiratory symptoms, 146
Retention of urine, 150
Rooms, damp, 56, 70
ground ﬂoor, cementing of, 57, 62, 70
SALICYLATES of quinine and soda, action of,
215
Salicylic acid, action of, 215
Salol, action of, 214
Sand-ﬂies, mosquitoes, etc., 198
Scorbutic symptoms, 103
Seasonal prevalence, 76
Sequelae, 152
Serum-reaction, 5, 44, 49, 84, 158
Severe cases simulating enteric fever, 4, 109,
110
Severity, possible decrease in, 87
Sewage, reaction of, 71
Sewers, micro-organisms in, 69
ﬂushing of, 181
Sex, inﬂuence of, 75
Sexual organs, 151
Sheets should be cotton, 188
Short description, 2
Sinks, trapping of, 182
Simple continued fever, cyclical periods, 93
decrease in prevalence, 87
statistics, 17

Sketch, historical, 12
Skin, tepid sponging of, daily, 198, 209
Sleeplessness, 122, 201
treatment of, 201
Sliema and villages, drainage of, 72
Soft stone ﬂoors, dust from, 185
Soil, turning up of virgin, 67
zones of moisture in, 69
Special senses, impairment of, 123
Speciﬁc remedy, not known, 183
nature, 4
Spleen, enlargement of, 1, 3, 142
morbid anatomy of, 168, 170
Sponging, tepid, daily, 198, 209
cold, advantages of, 202, 209
Sputum, 146
Statistics of S. C. fever, 17
Stimulant, pyrexia a, 122, 204
Stimulants, 194
Stomach, morbid anatomy of, 169, 171
Stone in buildings, reaction of, 72
Stools, appearance of, 149
disinfection of, 179
reaction of, 72
record of, 197
Subcutaneous abscesses, 103
haemorrhages, 103
nodules, 103
Sudamina, 103
Symptomatology, 94-153
Synonyms, 1, 2
TABLES, index of, xvi.
Tegumentary system, 102
Temperature as a stimulant, 122, 204
diurnal curve, 119
clinical description of, 106-120
moderate regulation of, 202-209
of air, influence of, on prevalence, 80
Tenderness, epigastric, 147
Tepid sponging of body daily, 198, 209
Tongue, 147
Tonsils, 148
Treatment. general, 183-219
Trapping of baths, sinks, etc., 182
Turpentine, action of, 215
Type, changes in, 86
Types, clinical, 95-102
Typhoid fever, see‘Enteric fever
Typho-malarial fever, 2, 9, 26
ULCERATION of Peyer’s patches, absence of,
5, 169, 171, 173
Undulant and enteric fevers occurring side
by side, 4
fever, a suitable name, 10
Undulatory type, 97
Urinary system, 150
Urine, retention of, 150
Uvula, 148
VALETTA, drainage of, 70
INDEX RER UM 225

Ventilation, deﬁcient, 49, 56, 68 Water-supply, vide Elimination
Ventilators of drains should be well raised, \Vaves, pyrexial, average length of, 107
180 average number of, 108
Vesical irritability, treatment of, 197 description of, 107
Virus, mode of dissemination, 50-74 Wheel-chair during convalescence, 188
WAKEFULNESS, 122, 201 ZONES of moisture in soil, 69
Warm clothing in winter, 178, 211

Q
INDEX NOMINORUM
ADAMS :
Translation of Hippocrates, Syden. $00.,
12, 29
Aden :
Geographical distribution, 25
Africa:
Geographical distribution, 25
Aitken, Sir W. :
Bibliography, 1856, 1872. 30, 31
Crimean War, 18
Nomenclature, 8, 11
Aitken :
Bibliography, 1878, 31
Allbutt, Clifford :
Bibliography, 1897, 34
Historical, 22
Algiers:
Geographical distribution, 25
America:
Geographical distribution, 29
Arnaud:
Bibliography, 1858, 30
Arthur:
Micro-organisms in sewer air, 69
Atkinson, Mitford- :
Bibliography, 1894, 33
Geographical distribution, 26
Aymard:
Milk steriliser, 191
BACCELLI, Prof. :
Bibliography, 1866, 1894. 31, 33
Subcontinuous malarial fever, febbre sub-
continua, 2
Balearic Isles :
Geographical distribution, 23
Bartlett :
Bibliography, 1881, 31
Fever in America, 29
Bates :
Bibliography, 1801, 30
Baxter :
Bibliography, 1821, 30
“ Muscae circa os volitantes,” 149
Benghasi :
Geographical distribution, 25
Typhus epidemic in 1893, 5

Boileau :
Bibliography, 1865, 31
Faecal origin, 53
Historical, 20
Mediterranean gastric remittent fever. 2
Quinine, action of, 213
Boisgelin:
Fungus Melitensis, 13
Bonamici:
Fungus Melitensis, 13
Bond:
Bibliography, 1892, 33
Bonnet:
Bibliography, 1853, 31
Borrelli, Proﬂ:
Bibliography, 1870, 1872, 1877, 31
Fever in Naples, 24
Historical, 22
Intermittent typhoid, 1
Neapolitan fever, 2
Boudin:
Bibliography, 1842, 30
Bozzolo :
Bibliography, 1890, 32
Bruce :
Age susceptibility,
Bibliography, 1887, 1888, 1889, 1890,
1893, 1894, 32, 33
Causal connection with harbours, 65
Constipation, 149
Experiments on monkeys, 44
Fever in Malta, 23, 79
Historical, 22
Immunity, 83
Incubation period, 75
Intestinal ulceration, 171
Introduction of water drainage and fever,
87
Malignant fatal case, 115
Malta fever, 2
Mic. Melitensis absent in other diseases,
41
Mic. Melitensis, discovery of, 35
Microscopic appearances, 42. 44
Mortality, 167
Non-contagious, 50
Pyrexial duration, 166
INDEX N OMIN OR Uﬂ/f
227
Bruce—continued .-
Quinine, action of, 213
Red blood corpuscles, diminution of, 143
Seasonal prevalence, 77, 79
Spleen, micrococcus in, 36
Spongy gums, 148
Water-supply, non~connection with, 55
Burmah:
Geographical distribution, 28
Burn :
Bibliography, 1820, 30
Burnett, Sir W. :
Bibliography, 1800-1810, 30
Causal connection with Harbours, 63, 64
Historical, 13, 14
Malaria in Malta, 160
Mediterranean fever, 2
CAMERON, Sir W.:
Aerial enteric fever, 69
Candia, see Crete
Cantani:
Adeno-tifo, 1
Bibliography, 1873, 1878, 1880, 1885,
31, 32
Function of pyrexia in fever, 204
Capetanakis :
Fever in Crete, 24
Capozzi :
Bibliography, 1885, 32
Febbre tifoidea atipica, l
Fever in Rome, 24
Faecal origin, 54
Historical, 22
Carageorgiades :
Bibliography, 1882, 1891, 32
Cyprus fever, 2
Fever in Cyprus, 24
Immunity, 83
Seasonal prevalence, 76
Cardarelli :
Fever in Naples, 24
Cardile:
Fzecal origin, 54
Cailes :
Bismuth, action of, 214
Carruana Secluna :
Bacteriology, 36
Catania:
Epidemics in, 54, 80, 87, 88
Geographical distribution, 24
Casorati:
Bibliography, 1863, 30
Cassiola:
Fever in Taorrnina, 24
Cazalas :
Bibliography, 1860, 30
Cephalonia:
Geographical distribution, 24

Chantemesse :
Bibliography, 1891, 32
'I‘ubercle and enteric fever simultaneously,
10
Chaplin :
Bibliography, 1864, 1885, 31, 32
Fever in Jerusalem, 24
Chartres :
Age susceptibility, 74
Bibliography, 1866, 31
Effect of residence, 81
Faecal origin. 53
Historical, 21
Immunity, 86
Incubation period, 75
Intestinal ulceration, 171
Mediterranean gastric remittent lever, 2
Quinine, action of, 213
Rainfall, connection with, 78
China:
Geographical distribution, 26
Chioti, Lepidi- :
Bibliography, 1885, 32
Chossat:
Death following loss of body weight,
23
Choubattia :
Fever in, 27
Clark :
Bibliography, 1821, 30
Cleghorn :
Balearic Isles, fever in, 13, 24
Bibliography, 1744-49, 30
Historical, l3
Colson:
Fever in Aden, 25
Constantinople :
Geographical distribution, 24
Craig,r :
Bibliography, 1885, 32
Craigie:
Bibliography, 1836, 30
Crete :
Geographical distribution, 24
Crimean War :
Historical, 16-19
Crombie :
Bibliography, 1895, 33
Fever in India, 27
Cyprus:
Geographical distribution, 24
Seasonal prevalence, 76
DAVIDS:
Fever in Constantinople and Smyrna, 24
Davidson:
Bibliography, 1892, 33
Fever in America, 29
Fever in Cyprus, 24
Historical, 22
Spongy gums, 148
Typho-malarial fever, 9
228 UNDULANT, MALTA OR MEDITERRANEAN FE VER

Davy :
Bibliography, 1833-35, 30
Common continued fever, 2
Historical, 13, 14, 22
Malaria in Malta, 160
De Blasi :
Bibliography, 1888, 32
De Chaumont :
Bibliography, 1884, 32
Faecal origin, 54
De Conciliis :
Bibliography, 1889, 32
De Renzi :
Bibliography, 1884, 32
Febricola tifosa, 1
Fever in Naples, 24
Historical, 22
Demarco :
Bibliography, 1722-87, 30
Historical, 13
Dinapore :
Geographical distribution, 27
Dominicis :
Bibliography, 1876, 31
Febre delle fogna, 2
Donaldson :
Bibliography, 1876, 31
Faeco-malarial fever, 2
F aecal origin, 53
Historical, 21
Drummond :
Bibliography, 1888, 32
Fever in Rome, 24
Subcontinuous malarial fever, 2
Duckworth, Sir Dyce :
Function of pyrexia in fevers, 204
Concurrent syphilis and ague, 10
Duncan :
Bibliography, 1888, 32
Faecal origin, 55
Typho-malarial fever, 9
Dutroulan:
Bibliography, 1868, 31
EBERTH and GAFKY :
Bacillus typhosus, 5
Egypt :
Geographical distribution, 25
Ehrlich :
Test for urine, 156
Ellis:
Bibliography, 1890, 32
Causal connection with harbours, 65
Ewart :
Symptoms of pericardial effusion, 145
FADEL, DURAND-:
Bibliography. 1879, 31
Geographical distribution, 26
Fayrer, Sir J .:
Bibliography, 1882, 31
Fever in India, 27

Fazio :
Bibliography, 1879, 31
Febricola nostrana, 2
Fever in Naples, 24
Faecal origin, 54
Historical, 22
Fauverge :
Bibliography, 1798-1800, 30
Historical, 13
Fife :
Bibliography, 1888, 32
Fever in America, 29
Flugge:
Bacteria in air, 68
Franco :
Bibliography, 1879, 31
Frankland :
Micro-organisms in sewer air, 69
Frederici:
Bibliography, 1885, 32
Febbre miliare, 2
Freyer:
Bibliography, 1897, 34
Fever in India, 29
GALAssI :
Bibliography, 1883, 1885, 31, 32
Febricola nostrana, 2
Fever in Rome, 24
Historical, 22
Seasonal prevalence, 76
Gibraltar:
Fever prevalence, 1837-47, 15
Geographical distribution, 23
Historical, 13
Seasonal prevalence, 76
Yellow fever in, 13
Gipps :
Bacteriology, 36
Bibliography, 1890, 32
Causal connection with harbours, 65
Immunity, 83
Micrococcus Melitensis in spleen, 36
Quinine, action of, 213
Giraud :
Bismuth, action of, 214
Godding:
Bibliography. 1890, 32
Gozo:
Fever in, 89
Greece:
Geographical distribution, 13
Historical, 13
Green :
Ehrlich’s test for urine, 157
Greisenger:
Bibliography, 1868, 31
Grimaldi:
Bibliography, 1872, 31
Febricola tifoidea, 1
Grocco :
Bibliography, 1897. 34
INDEX 1V GAIL/V 0R UM 229

Guidici:
Bibliography, 1866, 31
Guiifré:
Age susceptibility, 74
Bibliography, 1888, 1893, 32
Febbre innominata, febbre mediterranea, 2
Fever in Sardinia, Italy, Sicily, Smyrna,
Cyprus, Crete, and Tunis, 24, 25
Historical, 22
Immunity, 83
Incubation period, 75
Morbid anatomy, 172
Pseudo-tifo, 2
Pyrexial duration, 167
Seasonal prevalence, 76
Guilia:
Bibliography, 1871, 31
Immunity, 83
Historical, 21
La febbre gastro-biliosa, 2
Quinine, action of, 212
Gayon:
Action of bismuth, 213
HARE :
Function of pyrexia in fevers, 204
Heastie : a
Bibliography, 1825-28, 30
Historical, 14
Haspel:
Bibliography, 1852, 31
Heidenstein :
Bibliography, 1886, 32
Fever in Cyprus, 24
Hennen:
Bibliography, 1815-25, 30
Common continued fever, 2
Historical, 13, 14
Malaria in Malta, 160
Henrot:
Enteric fever conveyed by dust, 68
Hewlett:
Ehrlich’s test for urine, 157
Microscopical appearances, 175
Hippocrates :
Bibliography, 13.0. 460-357, 29
Historical, 12
Hill-Clino:
Bibliography, 1895, 33
Hirsch:
Bibliography, 1885, 32
Hoﬂ'man :
Bacteria in soil, 69
Hong-Kong:
Geographical distribution, 26
Howard:
Bibliography, 1786, 30
Historical, 13
Hughes, M. Louis:
Bibliography, 1892,
1896, 33
1893, 1894, 1895,

Hunter-Stewart :
Sterilisation of milk, 191
INDIA:
Geographical distribution, 26
Inglessis : '
Bibliography, 1883, 31
Fever in Greece, 24
Ionian Isles:
Fever prevalence, 1837-47, 5
Irvine:
Bibliography, 1810, 30
Italy:
Geographical distribution, 24
Historical, 22
J ACOOUD :
Bibliography, 1885, 1886, 1897, 32, 33
Geographical distribution, 26
Ileo-tifo a forma sudorale 0r ﬁévre tifoide
sudorale italienne, 2
Incubation period, 75
J acquot :
Bibliography, 1858, 30
J agoe :
Bibliography, 1887, 32
Jerusalem :
Geographical distribution, 24
Johnson and Martin :
Bibliography, 1841, 30
Johnstone-Campbell :
Sterilisation of milk, 191
J uergansen:
Advantages of external cold applications
in fever, 206
KELSCH and KIENER :
Bibliography, 1889, 32
Klein:
Bibliography, 1893, 32
Knights of Malta (or St. John) :
Historical, 23
Koch:
Postulates of, fulﬁlled, 40, 49
LAVERAN:
Haematophyllum of malaria, 6
Levant :
Geographical distribution, 24
Lyons and Aitken:
Bibliography, 1856, 30
Crimean War, 18
MACARTNEY:
Bibliography, 1894, 1897, 33, 34
Fever in India, 29
MacCulloch :
Malaria in Malta, 160
Mackay :
Historical, 20
Maclean, Prof. :
Bibliography, 1875, 1876, 1885, 32
23o
UNDULANT, MALTA OR [MEDITERRANEAN FEVER

Maclean, Prof—continued .-
Historical, 21
Typho-malarial fever, 2
Macleod :
Bibliography, 1897, 33
Purpuric symptoms, 148
MacNaught :
Concurrent syphilis and enteric fever, 9
Maragliano :
Bibliography, 1891, 32
Maillot :
Bibliography, 1836, 30
Malta :
Age prevalence, 74
Death-rates, 84
Fever in dockyard, 14
Fever prevalence, 1837-47, 15
Geographical distribution, 13, 23
Historical, 13-23
Non-tubercular respiratory, symptomatic
intestinal diseases and rheumatic aﬂ'ec-
tions, 17, 18
Simple continued and remittent fever
prevalence, 1871-85, 17
Simple continued fever, 1817-95, 93
Seasonal prevalence, 76
Manson, P. :
Geographical distribution, 26
Tuberculosis and paludism, 160
Marston:
Age susceptibility, 74
Bibliography, 1861, 1879, 30, 31
Causal connection with harbours, 65
Fever in India, 27
Fever in Malta, 16
Faecal origin, 53
Historical, 16, 19
Incubation period, 75
Mediterranean gastric remittent fever,
N on-contagious, 50
Quinine, action of, 212
Martin and Johnson :
Bibliography, 1841, 30
Massowah :
Average temperature of, 80
Geographical distribution, 25
Maurel :
Bibliography, 1879, 31
Fever in America, 29
Maurey :
Bibliography, 1881, 31
Fever in America, 29
Milnes, H. :
Bibliography, 1892, 33
Fevers on Red Sea and Mediterranean
littorals, 25
Mitra:
Bibliography, 1896, 33
Fever in India, 27
Minorca.:
Geographical distribution, 13, 23

Molfet :
Age susceptibility, 74
Bibliography. 1889, 32
Fever in Gibraltar, 23
Faacal origin, 55
Historical, 22
Incubation period, 75
Intestinal ulceration, 171
Pyrexial duration, 167
Pythogenic septicaemia, 2, 10
Rock or Gibraltar fever, 2
Seasonal prevalence, 76
Moore, Surgeon-General :
Bibliography, 1886, 32
Fever in India, 26
Moore, Staff-Surgeon, RN. :
Bibliography, 1872, 31
Fever in Smyrna, 24
Morgan :
Bibliography, 1892, 33
Fever in Egypt, 25
Munk :
Function of pyrexia in fevers, 204
Murchison :
rl‘yphus and enteric fevers, 5
NAPLES :
Geographical distribution, 24
Historical, 22
N otter, Prof. :
Bibliography, 1876, 1897, 31, 33
Fzecal origin, 54
Historical, 16, 21
Malta fever, 2
N ageli :
Bacteria from moist surfaces, 66
OLIVER:
Bibliography, 1892, 33
Ollivier :
Orchitis in enteric fever, 152
Osler, Prof. :
Neuritis in enteric fever, 128
PABST :
Bismuth, action of, 214
Palermo:
Fever at, 14
Geographical distribution, 22
Seasonal prevalence, 76
Paris :
Geographical distribution, 26
Pasquale:
Bibliography, 1889, 1892, 32, 33
Febbre climatica, 2
Fever in Massowah, 25, 80
Paterson:
Fever in Constantinople, 24
Perini:
Fever in Tunis, 25
Petella:
Bibliography, 1892, 33
INDEX NOM! NOR UIM 23 1

Pisani :
Prevalence in Malta, 88
Plouquet :
Nomenclature, 11
Pottinger :
Historical, 20
QUAIN :
Historical, 22
RANIKHET:
Fever in, 27
Red Sea :
Geographical distribution, 25
Rey :
Yellow fever at Gibraltar, 13
Rho :
Bibliography, 1894, 1895, 33
Fever in America, 29
Fever in India, 27
Fever in Massowah, 25
Historical, 22
Typho-malarial fever, 2
Robertson :
Micro-organisms in sewer air, 69
Robinson :
Undulant fever in Gozo, 89
Rome :
Geographical distribution, 24
Historical, 22
Seasonal prevalence, 76
Roque :
External cold applications in fevers, 206
Roux :
Bacilli in blood, 41
Roy :
Function of pyrexia in fevers, 204
Rummo :
Age susceptibility, 75
Bibliography, 1881, 31
Febbre infetiva atipica, 2
Fever in Naples, 24
Faecal origin, 54
Immunity, 83
Rutimeyer :
Ehrlich’s test for urine, 157
SARDINIA :
Geographical distribution, 23
Secluna, Carruana:
Bacteriology, 36
Semple :
Bibliography, 1897, 33
Sicily :
Geographical distribution, 24
Simon :
Ehrlich’s test for urine, 157
Sinclair:
Bibliography, 1889, 32
Sliema :
Drainage of, 72

Smyrna :
Geographical distribution, 24
Smyth:
Bibliography, 1830-36, 30
Historical, 15
Smith:
Bibliography, 1897, 33
Soubathu :
Fever in, 29
Soxhlet :
Milk sterilisation, 191
Squire :
Bibliography, 1886, 32
Fever in India, 27
Fever in Suakim, 25
Morbid anatomy, 169
Typho—malarial fever, 9
Stewardson :
Bibliography, 1841, 30
Fever in America, 29
Sullivan :
Bibliography, 1878, 31
Fever in Cyprus, 24
Suakim:
Geographical distribution, 25
Sydenham :
Function of pyrexia in fever, 204
TAKSCH :
Ehrlich’s test for urine, 156
Taormina:
Geographical distribution, 24
Tichbourne :
Micro-organisms in sewer air, 69
Ae'rial enteric fever, 71
Thin:
Absence of malarial organisms in this
fever, 6
Tomaselli:
Age susceptibility, 74
Bibliography, 1886-95, 32
Diaphoresis, 105
Drainage, supposed connection with, 54, 88
Febbre sudorale, febbre continua epi-
demica, 2, 10
Fever in Catania, 24
Historical, 22
Not contagious, 50
Tomasi :
Bibliography, 1874, 1875, 31
Historical, 22
Torti :
Bibliography, 1712, 30
Febbre subcontinua, 2
Tripoli:
Geographical distribution, 25
Tunis :
Geographical, 25
Turkey :
Geographical distribution, 24
Turner:
Bibliography, 1884, 32
232 ‘ UNDULANT, MALTA 0R MEDITERRANEAN FEVER

Turner—continued .-
Historical, 21
Rock or Gibraltar fever, 2, 21
Typhaldos :
Bibliography, 1882, 31
Bilious continued fever, 2
Fever in Greece, 24
UFFEUMANN:
Ae'rial enteric fever, 71
IJALETTA:
Death-rates, 84
Drainage of, 70
Veale:
Bibliography, 1879, 31
Febris complicata, 2, 10
Fever from Cyprus, Gibraltar, and Malta,
23
Historical, 21
Pyrexial duration, 166
Quinine, action of, 213
Spongy gums, 148
Velpeau :
Orchitis in enteric fever, 152
YVEBB:
Bibliography, 1883, 32
Fever in America, 29
Weil :
External cold applications in fever, 206

Welch :
Bibliography, 1897, 34
Fever in India, 29
Westcott:
Bibliography, 1893, 33
Muscle atrophy, 136
White, Hale: ,
Function of pyrexia in fevers, 204
Wood, Oswald:
Bibliography, 1876, 31
Colitis in undulant fever, 169
Faecal origin, 53
Historical, 16, 21
Malta fever, 2
Quinine, action of, 213
Woodward:
Bibliography, 1876, 31
Fever in America, 29
Typho-malarial fever, 9
Wright, Prof. :
Bibliography, 1897, 33
Fever in India, 29
Microscopical appearances, 176
Serum reaction, 44
Protective inoculation, 183
ZAUDA:
Fever in Sardinia, 23
Ziemssen :
A'e'rial enteric fever, 71
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