The following description of Mediterranean, undulant or Malta Fever is taken from "The Encyclopaedia of Medical Treatment" Oxford Medical Publications, 1915.  

 The disease was very common in the period before and during WW1. The then Commander Jellicoe was on board HMS Victoria, but was in his bunk suffering from Malta Fever, when his ship was involved in collision with HMS Camperdown on 22 June 1893.  Jellicoe was able to escape from his ship before she capsized and sank but he was very weak and had to be supported in the water by an unknown midshipman before rescue. 

Dr Geoffrey Miller, Editor

Undulant or Mediterranean Fever

Distribution.- This disease is most common around the shores of the Mediterranean, but has lately extended into European countries (Portugal, Spain and France). Other endemic areas are present in. India, China, North and South Africa, America, and Peru; in fact, the disease has now become world-wide.

Aetiology.- It attacks all ages and both sexes, but generally has the highest incidence in women and young adults, occurring in all seasons, but particularly in the hot dry weather. The disease was frequently found in association with typhoid in the Mediterranean, a person recovering from the former suffered often from a prolonged fever due to the latter infection. The cause of the disease is the minute coccus, the M. melitensis, which produces an acute or chronic septicaemic condition. The organism may gain access to the body (1) by food, particularly in milk; (2) occasionally by infection through the skin and mucous membrane. Wherever goat's milk is a staple diet the disease tends to be endemic - goats being commonly affected though rarely showing any evidence of the disease. Cows also may be infected, and their milk can convey the dangerous organism. The infection is conveyed from man and animals chiefly by the urine, faeces and milk.

Symptomatology -The disease may commence as an acute fever simulating typhoid and malaria, or it may run a subacute or chronic course, producing intense cachexia with anaemia and persistent neuritis. During the febrile state rheumatic-like symptoms may be present with some gastro-intestinal disturbance, excessive sweats, constipation, endocarditis, orchitis, lobular pneumonia or pulmonary oedema; nephritis and haemorrhages are rare. The course of the disease extends on an average over three months, but it may be prolonged to two years. The nervous symptoms are generally marked: at first there are insomnia and slight delirium, then great depression and a tendency to nerve pains, such as sciatica and neuralgia, sometimes giving rise to a local paresis of groups of muscles. Cardio-vascular symptoms are common: irregular palpitations from slight mental or physical causes, rapidity of pulse with irregularity of force, volume and frequency. The changes in the blood are important; there is generally a reduction in the number of red cells and a low colour index-a marked reduction in the polynuclear cells and a relatively marked increase in the mononuclears giving rise to a general lowering of resistance to bacterial infections. Death may be brought about by hyperpyrexia, heart failure, and pulmonary complications.

The diagnosis may be made by the clinical symptoms : the long fever with rheumatic-like pains, sweats, constipation and cachexia, but most accurately by culture of the organism from the blood, or by agglutination reactions, which are present early and are given with high dilutions of the serum. The latter are specific in character if certain precautions are taken. Occasionally the organism may be isolated from the urine, and the diagnosis confirmed thereby.            

Prophylaxis. - As the exciting cause in the great majority of the cases is the entrance into the body of the micro-organism by milk, it is essential that in the endemic area this shall be rendered free from infection. In the Mediterranean and parts of South Africa, etc., goat's milk is almost universally used, and as this is now known to be so frequently infected, sterilisation must be effectively carried out. This can be done by boiling the milk, and that this has been effectively done can be ascertained by using the Ortol test. It must be remembered also that not only goat's milk, but cow's milk may be dangerous, and that the products of milk, such as cream, butter and cheese may convey infection; some cases have even been traced to ice-cream in Algeria. Infection in infants is conveyed by the mother's milk (Italy).

Treatment of the Disease.- Disinfection of all infected material from the patient must be carried out as in typhoid. In all cases of undulant fever it is important to remember that we are dealing with a specific disease over which we have no certain control and that it tends to run a very long course. It is of the very first importance so to conduct the treatment that the patient's strength shall be maintained by giving as much food as he can assimilate; we must also counteract the secondary anaemia, and symptoms must be relieved by appropriate measures. We may also attack the cause of the disease by means of vaccines.    

    With such a long and tedious disease good nursing is of great importance. In an acute case a comfortable bed in a well-ventilated room, which can be kept at an equable temperature with cheerful surroundings, is required.

A trained nurse is almost always necessary, for at first the course of the disease may be as severe as in a bad case of typhoid fever, giving rise to high pyrexia, gastric discomfort, slight delirium, insomnia, sweats and other symptoms of a severe toxaemia; here, then, a good nurse or nurses are required to carry out measures to keep down the fever, regulate the food, and attend to the comfort of the patient. The danger line of fever is often put at 103 degrees, when tepid sponging is necessary; if the temperature rises to 104 degrees cold sponging; and above that a wet pack may be required. Great attention should be paid to the pulse and the condition of the skin; if the former is weak a stimulant should always be combined with the antipyretic measure; great care must be taken never to cheek sweats, if present, by hydrotherapy. A continued type of fever lasting three to four weeks, if uncontrolled, produces a marked effect upon the cardiac and nervous system, so that tachycardia and persistent neuritis appear. Constipation generally is a marked and early feature; as soon as the diagnosis has been made, small doses of calomel, saline purges, or better still, cascara and enemata, may be used. Sweats are frequently very severe and distressing, either local or general; as in rheumatic fever, the patient should be kept between blankets and, the skin frequently dried and powdered; this will materially decrease the discomfort. If rheumatic symptoms affecting the joints appear, as they are apt to do, hot opium fomentations, or belladonna liniment associated with perfect rest, gives the most relief. One of the most distressing symptoms in acute cases is the persistent insomnia. The patient should never be allowed to pass sleepless nights. Trional, sulphonal or other mild hypnotic preparations should be given. At first, the patient should be kept upon a restricted typhoid diet until the diagnosis is assured, when light soups, eggs, custard puddings, Benger's food and Sanatogen may be given, always using the condition of the tongue as the main guide. If the tongue is fairly clean, the fever moderate, and the assimilation good, a very low diet is contraindicated. Stimulants are not required, and should not be given at first; in the third, fourth or fifth week they will probably be most useful, and should be reserved to help a flagging heart enfeebled by continued pyrexia.

As to drugs, quinine is useless in large doses, but, I have found that combined with chlorine (Burney Yeo's mixture) it did in some cases apparently shorten the pyrexia attacks; Hartigan recommends cyllin - but no drug has any specific effect. Digitalis, strychnine and ammonia may each render assistance in acute conditions when the toxaemia is most severe. Abundant cooling drinks are most gratifying; when the mouth and tongue are dry and foul, sulphurous acid as a wash is very beneficial, generally more so than boracic acid and myrrh, carbolic acid or Listerine.

Both the condition of the lungs and kidneys should be watched from day to day. Antipyretics like phenacetin and antipyrin are generally to be avoided.

After the primary wave has passed off, each recurring attack of pyrexia increases the anaemia, the tendency to neuritis and the general cachexia; the patient loses weight steadily, becoming more and more depressed, and is liable to orchitis, boils, etc. The careful feeding becomes more and more important, and efforts should be made to combat the anaemia by mild iron preparations such as dialysed iron, Blaud's pills, etc., and ferro-glidine given with milk or with strychnine. Diffusible stimulants, such as brandy and champagne, will be helpful now. Later, when a low, hectic type of fever comes on, as in the third month and after, arsenic and iron are called for either by the mouth or by intramuscular injections, and I have found preparations of yeast useful not only in increasing the number of white blood-cells, but also in reducing the tendency to neuritis; two drachms of fresh yeast may be given twice a day on bread and butter as a sandwich, or in milk; capsules of nucleic acid are also useful. In the chronic stages, massage of the wasted muscles should be used daily, and for the chronic neuritis high frequency treatment is sometimes very beneficial. If pain is persistent, a liniment of aconite, belladonna, or camphor gives relief. In convalescence some malt alcoholic drinks may be given with food, such as good stout and porter, or port wine if preferred.

During convalescence warm clothing, fresh air and sunshine, with gentle exercise, must be insisted on, and frequently a change of surroundings brings about a cure when other means have failed; but the patient must be warned that a chill or over-exertion is liable to induce a relapse. Serum therapy has not given satisfactory results. A nucleo-proteid serum has been prepared by Donzello-Trambusti and is said to be effective, but much more evidence is required. Vaccines made of dead emulsions of the M. melitensis have been fairly tried. From a large series of cases in Haslar hospital and elsewhere I have found that their use was of no advantage in the acute stages of the disease, but during the chronic toxaemia with a low, irregular fever they appeared to cut short the disease. Their administration is scientifically justifiable and reasonable, for we know that the organism can remain alive for long periods in the spleen and other organs; therefore any measures are called for which increase the phagocytic activity of the cells in the blood tending to destroy the infecting agent. The two most important means to this end are appropriate vaccine therapy and the administration of yeast or nucleic acid. Scardo (Francesco) from experiments carried out at Rome on goats artificially infected with M. melitensis, obtained some good results with intravenous injections of corrosive sublimate (using Bacefli's formula). This method he is now going to apply to human cases with great hope of cutting short the fever.

A micrococcus paramelitensis has lately been described which is probably the cause of several anomalous forms of fever in the endemic area in which the ordinary serum diagnostic test has failedi and for which a special vaccine would be required.  

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