Notes on Mediterranean or Malta Fever / by David Bruce, [M. Louis Hughes and Sinclair Westcott].

  • David Bruce
Date:
[date of publication not identified]
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Licence: Public Domain Mark

Credit: Notes on Mediterranean or Malta Fever / by David Bruce, [M. Louis Hughes and Sinclair Westcott]. Source: Wellcome Collection.

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    Medical Journal Experiment v.—Monkey, male, species bonnet, was under observation for three months previous to inoculation. Two days after the injection of a pure culture of the Micrococcus Melitensis obtained from the blood of Experiment iv he developed pyrexia, which lasted 2£ months, and ended in recovery. The temperature chart is very similar to that of Experi¬ ment vr, and is withheld on account of want of space. Experiment vi.—Monkey, female, species bonnet; inoculated with a pure culture obtained from the spleen of Experiment iv. She suffered tor more than three months from a very typical attack of this fever, ulti¬ mately recovering completely. The foregoing chart illustrates the chronic course of the disease, and is remarkably similar to what obtains in man. From these experiments it will be seen that the injection of pure cultivations of the Micrococcus Melitensis into monkeys gave rise to a disease bearing a strong resemblance to that found in man, and caused death in three experiments out of six. Further, it will be noted that from the three fatal cases the same micro-organism was again recovered in a state of pure culture. From the above considerations sufficient evidence has, in my opinion, been brought forward to show that in all proba¬ bility the micrococcus above described is the proximate cause of Malta fever, and is the strongest evidence yet adduced to show that this disease is a specific fever, quite distinct from typhoid or malaria. In regard to the important question as to how this micro¬ organism gains access to the human subject, whether by the air, in the drinking water, or in the food, absolutely nothing is known up to the present, and on account of the high tem¬ perature required for its growth, the length of time which elapses before the colonies appear, and the absence of any well-marked morphological or cultural characteristics, the search for it outside the body will be found very difficult. II.—Its Behaviour at Malta.4 By Surgeon-Captain M. LOUIS HUGHES, A.M.S., Malta. (Ill charge of Military Analytical Laboratory, Valletta.) “ Mediterranean, Malta, or rock fever,” officially returned in the army statistics as “simple continued fever,” presents far larger admission and invaliding rates in certain Mediterranean garrison towns than any other disease. I. Quantity.—The Maltese sutler proportionally less from it than British troops, but it is said to be increasing in fre¬ quency among the civil population of Valletta. It does not, however, appear to show that special predilection for new¬ comers that is so commonly noticed in the case of enteric fever. In quantity it has, however, on the whole, slowly but steadily decreased among the troops in Malta during the last seventy-five years, owing, doubtless, to the constant sanitary improvements in barracks. While the admission rate per 1,000 for enteric fever has during the last thirty-three years remained fairly constant, except at certain periods when some definite and widespread cause has been at work, that of simple continued fever has regularly risen and fallen in seven- year cycles between the maximum of 269.5 per 1,000 of strength in 1859, and the minimum of 71.2 in 1888. Marston, as quoted by Bruce, has mentioned an alternation of this fever with enteric fever, in epidemic form ; but, speaking generally for Malta, I do not find this borne out by statistics ; and though it has occurred in individual barracks, yet the epidemics have little relation to one another. II. Quality.—The case mortality has decreased from 3.08 in the sixties to 2.60 in the seventies, and 0.93 per mille in the eighties. Epidemics of note have become rare since 1873, and rapidly fatal cases are in the present day few. The admission and mortality rates during each seven-year cycle have risen together to a maximum, but the death-rate has fallen earlier and faster than the admission-rate. Finally, the admission- ?ate for rheumatic affections (in most instances the character¬ istic sequelse of Mediterranean fever) has, as far as quantity is concerned, shown the same variations and general decrease as the fever in question. HI. Seasonal Prevalence.—Though ague (that is intermittent •ever) does not exist as an endemic disease in Malta yet the seasonal prevalence of Mediterranean fever exactly corre¬ sponds to that of the so-called malarial poison. Becoming * Abstract of a paper read to the Malta Branch of the British Medical Association. fairly prevalent in April the attack-rate reaches a maximuni in July, August, and September, the hottest and driest months, and then falls until, in the wet and cold months of December, January, and February, a few sporadic though often extremely fatal cases occur. Enteric fever, on the other hand, becomes most prevalent after the first heavy rains, con¬ tinuing during the autumn and early winter months. IV. Localisation.—It has always been distinctly endemic in (1) the barracks, houses and hovels built by the Knights be¬ tween the beginning of the sixteenth and end of the eighteenth centuries—all these buildings have for years been in an overcrowded and insanitary condition though at present subject to yearly improvements ; (2) in the ships at anchor in the harbours of Malta. The fever is certainly not contagious from man to man, and both in localisation and general clinical characters it has a close analogy to enteric fever. In one instance lately three fatal cases of fever were admitted from a barrack containing eighty men, though no cases of fever had occurred there dur¬ ing the preceding twelve months. Clinically they were some¬ what analogous, but the post-mortem appearances and bacterio¬ logical tests clearly indicated that one was enteric and the other two Mediterranean fever. Bacteriological facts in no way negative the theory of faecal transmission of infection, and hygienic authorities and my own experiments point to a suitable reaction of faeces sewage, and more especially of rock and sea water contami¬ nated by sewage, for the growth of the special micro¬ organism of this fever, though owing to the high tempera¬ ture necessary and the length of time elapsing before the colonies appear, the specific growth has not as yet been isolated definitely. In the harbours of Malta, in spite of recent improvements by which most of the sewage is pumped out to sea, large sewer outlets exist in the Quarantine Harbour, and the excreta of some 5,000 to 8,000 sailors employed on ships of war and mercantile vessels, are being continually poured into the enclosed and tideless harbours, converting their basins into one large cesspool, which is never cleaned out, and must hold the accumulations of ages. The offensive state of the water becomes apparent to both sight and smell at the sewer-outlets at all times, and in the enclosed creeks and docks on rough days, yet in summer soldiers and sailors may be seen bathing daily all round these very places. Moreover, this same water is used for washing down decks, etc., so that when drying it has ample opportunity of giving off in an enclosed space such miasmata as it may contain. There is no evidence in favour of infected food or drink¬ ing water having any causal connection with this fever, and the introduction of a pure water supply under pressure lias not lessened its prevalence in Valletta. The facts point dis¬ tinctly to a probable air-borne virus on shore, as does the fol¬ lowing account of a recent epidemic : A regiment was quartered on a small island in the Quarantine Harbour, Valletta, from January 2nd, 1892, until October 10th of the same year, during which period it suffered severely from “ simple continued fever,’ 197 cases being admitted from a strength of 760 men. The regiment had suffered severely from this fever elsewhere during its first year’s service in Malta, had been seasoned by a three years’ residence, and was com¬ posed 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 1725. A careful analysis of the fever admissions divides them into two classes:— 1. Cases of true Mediterranean fever. 2. Relapses and slight cases of the same fever (the latter possibly due to special individual power of resistance), cases of simple ardent fever (febricula), and other obscure but slight febrile ailments. The last class of cases were in hospital but a short time, and there is little to note of consequence except that the numbers were higher than those from other barracks, and that in proportion to strength the number of admissions from the fort was double that from the huts. The admission rate per mille for true Mediterranean fever in Valletta district (strength 3,511, in¬ cluding the island in question) in 1892 was 52.2, while those of the huts and fort in question were 46.3 and 178.6 respectively, showing that some local cause of fever must exist in the fort. In the fort, 38 men, 2 women, and 5 children of this regiment were affected, and of the men, 1 died, 6 were invalided, 14 were sent to the sanitarium, and 17 returned to duty straight from hospital, the average stay in hos¬ pital being 99.3 days.5 The majority of these rooms are dark, close, and damp, and were never intended for barracks. 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 5 Since the above was written news has come from Gozo that some ot these men have suffered from relapses, and even been invalided home, accentuating the seriousness of this outbreak.
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