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.
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.