NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
4
The cases of Mediterranean fever which have come under our investigation
at the present time naturally fall into two groups :
(a) those in which M. Melitensis was isolated from the spleen during life ; and,
(b) those in which no splenic puncture was made, the diagnosis resting solely
on the clinical history and the serum agglutination reaction.
Group a .—The cases in this class number eleven. In these cases a few
drops of blood removed from the spleen during life with a sterile syringe were
spread over several agar tubes. This simple operation was done under our
written instructions by the medical officer in charge of the case. The agar
tubes thus inseminated were at once returned to the laboratory, where the
further examination of the growths was made. In nearly every instance a pure
culture of a coccus, presently to be described, was obtained. In one or two
cases only were there any contaminating organisms and these were evidently skin
cocci of different kinds. No difficulty, however, was ever met with in isolating
the specific organism from these tubes.
From all the cases which gave a serum agglutination reaction with
M. Melitensis and in which splenic puncture was made there was isolated from
the spleen, by the method described, a small coccus which presented the following
characteristics, which are regarded by the workers on the Commission for the
investigation of Mediterranean fever as justifying the organism being with
confidence regarded as M. Melitensis :—
(1) A slow growth at 37° C. on agar slopes ; discrete colonies are circular,
transparent and dew-like ; the complete surface-growth is greyish-
white and moist ; when cultures are old the growth often acquires
a yellowish-brown colour.
(2) Stained by weak carbol-fuchsine shows a small coccus or cocco-bacillus,
appearing mostly as diplo-cocci and in short chains.
(3) Stained by Gram-Weigert method does not retain its stain.
(4) Grown in litmus milk, there is no development of gas, acidity or coagula-
tion, but there is a production of alkalinity.
(5) Grown on glucose-litmus agar there is no production of acidity, but
production of alkalinity.
(6) Agglutinated and sedimented with the serum of an animal immunised
with a pure standard growth of M. Melitensis.
(7) In the case of two of the races isolated a typical infection of a monkey
was produced.
To points 6 and 7 we shall return later. Having, therefore, stated that the
various strains of M. Melitensis isolated by us responded to the above tests, we
may now consider the cases from which this organism was isolated more or less
in detail.
5
Case I.—Sher Hussain; aged 24, Sepoy, 27th Punjabis, Multan. Patient
was admitted into hospital on the 4th March 1905. From this date fever of a
remittent type (vide chart I) continued for six weeks, when he died of exhaustion.
There were no marked symptoms except constipation and profuse sweating.
No joint pains were complained of. Quinine even in large doses was without any
influence.
The agglutination reaction of the serum with M. Melitensis was tested
on two occasions, namely, at the beginning of the third week and in the middle
of the sixth week. On the first occasion a complete reaction with stock
M. Melitensis was got in dilution of 1 in 1200. On the second occasion the reaction
was tested both with the stock strain and with the race isolated from the patient's
own spleen. This latter organism will hereafter be known as Multan I. The
following was the result of this examination:—
Dilution of serum.
Stock.
Multan I.
1 - 4 0 0
, .
.
.
Complete sedimenta-
tion.
Complete sedimenta-
tion.
1—800
..
.
.
-
Complete ,,
Complete ,,
1 — 1 6 0 0
. .
Well marked ,,
Complete ,,
1 — 3 2 o o
. .
.
.
Trace of ,,
Well marked ,,
1—6400 •
.
•
No ,,
No ,,
Blood was taken from the spleen on two separate occasions, namely, in the
middle of the fifth week and at the end of the sixth week. On both occasions
a pure culture of M. Melitensis was obtained (Multan I). This organism was
used for the inoculation of a monkey to be referred to hereafter.
Case II.—Hakim Singh; aged 22, Sepoy, 27th Punjabis, Multan. Patient
was admitted into hospital on 11th March 1905. He was at first treated as a case
of malaria, but the fever failed to yield to the administration of large doses of Quinine.
From the chart (vide chart II) it is seen that the temperature was very erratic
throughout. It came to normal about the end of the sixth week, the man being
sent on furlough soon afterwards. During the third week patient complained
of acute pain in the left hip-joint. There were no other characteristic
symptoms.
The serum reaction with M. Melitensis was tested on two occasions,
namely, about the end of the fourth week and again one week later. On the first
Dilution of serum.
Stock.
Multan.
1—40
•
•
.
.
. Complete sedimenta-
tion.
Complete sedimenta-
tion.
1—80. . . . Well marked „
Complete ,,
1—160
.
.
.. No ,,
No ,,
6
occasion it gave a complete reaction with the stock M. Melitensis in dilution
in 640. On the second occasion the following was the result:—
Dilution of serum.
Stock.
Multan I.
1—40 . . . . .
Complete sedimenta-
tion.
Complete sedimenta-
tion.
1—8o . .
.
.
Complete ,,
Complete
1—200 . . .
Well marked ,,
Complete ,,
1 — 4 0 0
.
.
.
.
Trace of ,,
Well marked,,
1—800. . . . .
No ,,
Trace of,,
Blood was withdrawn from the spleen about the end of the fifth week. A
pure culture of M. Melitensis was obtained (Multan II).
Case III. —Tej a Si ngh; aged 36, Sepoy, 27th Punj abi s, Mul tan. Pati ent
was admitted into hospital on the 24th March 1905 suffering from high fever.
The temperature (vide chart III) fell gradually and reached normal on the 12th
day. Patient was then discharged to duty. After an apyretic interval of about a
fortnight's duration, a relapse, which lasted for several weeks, began. The tem-
perature during this relapse was markedly remittent. No other noteworthy
symptoms were present.
The agglutination reaction of the serum with M. Melitensis was tested on
two occasions. On the first occasion, five days after the onset of the initial attack,.
a complete reaction in dilution of 1 in 60 was obtained with an emulsion of stock
M. Melitensis. On the second occasion, namely, at the end of the fourth week
and shortly after the beginning of the relapse, the following result was got:—
Blood was taken from the spleen at the beginning of the fifth week. A pure
growth of M. Melitensis was got on all the tubes inseminated (Multan III).
Case IV.—Sahib Singh; aged 29, Sepoy, 27th Punjabis, Multan. Patient.
was admitted into hospital on 31st March 1905 suffering from fever. The tem
- p e r a t u r e
( v i d e
chart IV) was of a markedly remittent type. After nearly nine
7
weeks' illness patient was sent on sick leave, the temperature not yet having
come to normal. There were no other prominent symptoms.
The serum was examined as regards its agglutination reaction with M.
Melitensis at the beginning of the third week. The following was the result:-
Dilution of serum.
Stock.
Multan I.
1 — 4 0 .
.
. Complete sedimenta-
tion.
Complete sedimenta-
tion,
1—80.
.
. Complete ,,
Complete ,,
1—120 .
.
,
•
. Complete ,,
Complet ,,
1—240 .
.
..
•
. Trace of ,,
Well marked ,,
1—480
.
.
No ,,
Trace of ,,
1—960
.it
.
. No ,,
No ,,
Blood was with drawn from the spleen at the beginning of the fourth week.
Agar tubes sown with this blood gave a pure growth of M. Melitensis (Multan IV).
Case V.—Secunder Khan; aged 27, Sepoy, 27th Punjabis, Multan.
Patient was admitted into hospital on 20th March 1905 suffering from fever
and bronchitis. The bronchitis soon passed off, but the fever, which was mark
- e d l y i n t e r m i t t e n t
( v i d e
c h a r t V ) c o n t i n u e d . T h e t e m p e r a t u r e c a m e t o n o r m a
about the beginning of the fourth week and the patient was shortly afterwards
sent on sick leave.
The agglutination reaction of the serum with M. Melitensis, tested at the
end of the third week, was as follows:—
Dilution of serum.
Stock.
Multan I.
•
1—80.
.
. Complete sedimenta-
tion.
Complete sedimenta
-tion.
1—160
.
. Complete ,,
Complete ,,
1 — 3 2 0
. . . .
Complete ,,
Complete ,,
1 — 6 4 0
. .
. Complete ,,
Complete ,,
1—
1 2 8 0
.
.
•
.
Well marked ,,
Complete ,,
1
—
2 5 6 0
.
.
•
•
e
•
Trace of ,,
Trace of ,,
1— 5120.
. No ,,
No
, ,
8
Blood was taken from the spleen on the second day of the fourth week,
namely, the first day on which the temperature was normal. A pure culture of
M. Melitensis was obtained (Multan V).
Case VI.—Bishan Singh (1); aged 20 , Sepoy, 27th Punjabis, Multan.
Patient was admitted into hospital on 3oth March 1905 suffering from
fever of an intermittent type. During the second week the temperature was
markedly remittent, but came to normal about the end of this week. There was
now an apyretic interval of exactly seven days. This was followed by a severe
relapse of over three weeks' duration. The temperature ultimately came to
normal about the beginning of the seventh week,
T6he agglutination reaction of the serum was tested with M. Melitensis at
the end of the third week, that is to say, at the very beginning of the relapse.
The following was the result:—
Dilution of serum.
Stock.
Multan I.
1—40
•
•
°
.
Complete sedimenta
-tion.
Complete sedimenta-
tion.
1 — 8 0
.
.
Complete ,,
Complete ,,
1—160
.
.
. Complete ,,
Complete ,,
1 — 3 2 0
. . .
Trace of ,,
Well marked ,,
1 — 6 4 0
. .
No ,,
No ,,
Blood was taken from the spleen at the beginning of the sixth week. M.
Melitensis was isolated in pure culture from the tubes inseminated (Multan VI).
Case VII.—Bishan Singh (2); aged 34, Sepoy, 27th Punjabis, Multan.
Patient was in hospital in Ferozepore under treatment for " remittent fever"
from 5th September till 2nd November 1904. He was then sent back to duty.
No chart or detailed record of this illness is available. On the 1st May 1905,
six months after his discharge, he was again admitted into hospital suffering
from fever. The temperature (vide chart VII) came to normal in seven days,
and five days afterwards he was discharged to duty. For fourteen days after
his discharge from hospital patient was under observation and doing ordinary
duty. He had no relapse during this period. He was then sent on furlough.
The agglutination reaction of the serum with M. Melitensis was tested on
two occasions: first, on the fourth day after his admission to hospital and again
9
eight days after the temperature had come to normal. The result, the same
on both occasions, was as follows:—
Dilution of serum.
Stock.
Multan I.
1 — 4 0
Complete sedimenta
-tion.
Complete sedimenta
-tion.
1—80
.
.
.
.
.
.
Complete ,,
Complete ,,
1 — 1 6 0
. . ,
Well marked ,,
Well marked ,,
1—320
.
.
.
. No ,,
No ,,
Blood was taken from the spleen eight days after the temperature fell to nor-
mal. In one tube a pure culture of M. Melitensis was obtained (Multan VII).
Case VIII.—Labh Singh; aged 23, Sepoy, 27th Punjabis, Multan.
Patient was admitted into hospital on the 5th May 1905 suffering from fever
which was of a remittent type (vide chart VIII) and persisted for seven
weeks in spite of the exhibition of large doses of quinine. He complained at one
time of slight pains in the knee-joints. Just before the temperature came to
normal, patient suffered from such severe pain in the right hip-joint that he
was almost unable to move. This pain lasted on and off for a month,
The serum agglutination reaction with M. Melitensis was tested on two
occasions.
In the middle of the third week the result was as follows:—
Dilution of serum.
Stock.
Multan I.
1 — 4 0
•
•
Complete sedimenta-
tion.
Complete sedimenta-
tion.
1—80
.
. Well marked ,,
Well marked ,,
1 — 1 6 0
. .
No ,,
Trace of ,,
1 — 3 2 0
. .
. .
No ,,
No ,,
Again tested at the beginning of the sixth week the following result was
obtained:—
Dilution of serum.
Stock.
Multan I.
1 — 4 0
Complete sedimenta
-tion.
Complete sedimenta-
tion,
1 — 8 0
Complete ,,
Complete ,,
1—160
.
•
.
Trace of ,,
Trace of ,,
1— 320
,•
.
.
No ,,
No ,,
10
Blood was withdrawn from the spleen at the beginning of the sixth week.
The tubes were all contaminated with a white staplylococcus, but M. Melitensis
was easily isolated. (Multan VIII).
Case IX.—Gulab Khan; aged 19, Sepoy, 27th Punjabis, Multan. Patient
was admitted into hospital on 28th May 1905 suffering from continued fever
which resisted large doses of quinine, (chart IX.) There was slight delirium at
first, but this soon passed off. During the fifth week patient complained of severe
pain in the right hip-joint: this pain lasted only for a few days. There were no
other marked symptoms.
The serum agglutination reaction with M. Melitensis was tested about the
end of the second week. The following was the result:—
Dilution of serum.
Stock.
Multan I.
1—40.
.
Complete sedimenta-
tion.
Complete sedimenta-
tion.
.
.1—80
Complete ,,
Complete ,,
1—160. .
.
Complete ,,
Complete ,,
1—320
.. .
Trace of ,,
Trace of ,,
1—640
.
.
.
.
.
.
No ,,
No ,,
.
At the end of the second week blood was removed from the spleen and sown
in agar. A pure culture of M. Melitensis was obtained (Multan IX).
Case X.—Dalhara Singh; aged 22 , Sepoy, 15th, Sikhs, Ferozepore. Patient
was admitted into hospital on 26th April 1905 suffering from fever of a remittent
type. For temperature vide chart X. There were no other marked symptoms.
The serum agglutination reaction with M. Melitensis was estimated on two
occasions. First, at the end of the second week. The following result was ob
- t a i n e d : —
Dilution of serum.
Stock.
Multan I / .
.1—80
.
. Complete sedimenta-
tion.
Complete sedimenta-
tion.
1 — 1 6 0 .
.
,
.
Complete ,,
Complete ,,
1 — 3 2 0
,
.
.
Complete ,,
Complete ,,
1 — 6 4 0 ,
Well marked ,,
Complete ,,
1—1280 ..
.
.
. No ,,
Trace of ,,
1— 2560
.
.
.
.
.
. No ,,
No ,,
Again, at the end of the sixth week and a fortnight after the temperature had
come to normal the serum tested with the same two emulsions gave the follow
-ing reaction;—
Dilution of serum.
Stock.
Multan I.
1—80.
.
.
.
.
Complete sedimenta-
tion.
Complete sedimenta-
tion.
1—160
..
.
.
.
.
Complete ,,
Complete ,,
.
.
1—320
..
,
.
Trace of ,,
Well marked ,,
1 — 6 4 0 .
.
.
.
.
No ,,
Trace of ,,
1 — 1 , 2 8 0
.
.
.
.
.
No ,,
No ,,
Blood was withdrawn from the spleen at the end of the second week.
M. Melitensis was isolated in pure culture (Ferozepore I).
Case XI.—Mr. M.; aged 32, Ferozepore. Patient had been ten years
resident in India before the present illness. He came under observation for
the first time on 18th May 1905. Before this date he had suffered from fever
for a week. For temperature vide chart XI. During the short time of which
there is no temperature record the patient was removed from Ferozepore to
the Murree Hills. He states, however, that during this period his temperature
was above normal. The fever continued for several weeks after his arrival in
the hills and at the time of writing is still present. Constipation was trouble
-some throughout. Further, he complained a good deal of joint pains, first in the
left shoulder, next in the right shoulder and then more generally in several
of the other joints. Latterly severe pain was complained of in the right hip
and back, There was no orchitis.
The serum reaction with M. Melitensis, first examined towards the begin
-ning of the illness, namely on the tenth day, was as follows;—
Dilution of serum.
Stock.
Multan I.
1—8o . . .
Complete sedimenta-
tion.
Complete sedimenta-
tion.
1 — 1 6 0
.
.
.
.
.
Complete ,,
Complete ,,
.
.
1—320
.
..
Complete ,,
Complete ,,
1—640
.
•
.
Well marked ,,
Complete ,,
1—1,280.
.
.
. No ,,
No ,,
I2
The serum reaction was tested with the same emulsions twice afterwards,
namely, in the middle of the fifth week and towards the end of the sixth week.
The result, the same on both occasions, was as follows:—
Dilution of serum.
Stock.
Multan I.
1—80
.
..
.
.
.
Complete sedimenta-
tion.
Complete sedimenta-
tion.
1—160
.
.
.
.
.
. Complete ,,
Complete ,,
1—320
.
.
.
.
.
. Complete „
Complete ,,
1—640
.
.
.
.
.
.
1—1280 .
.
_
.
.. .
Complete ,,
Well marked „
Complete ,,
Complete ,,
1—2560 .
.
.
.
. „
„
Trace of ,,
Well marked ,,
Blood was taken from the spleen towards the end of the sixth week.
M. Melitensis was isolated in pure culture (Ferozepore II).
Before passing on to record those cases in which no splenic puncture was
made and in which the diagnosis rested mainly on the serum agglutination reac
- t i o n , w e h a v e t o d r a w a t t e n t i o n t o t w o o f t h e t e s t s , t o w h i c h t h e m i c r o b e s
isolated from the cases described above were subjected.
We have already pointed out in passing that one of the tests, to which all
the strains confirmed, was the serum agglutination test. This test was carried
out in the following manner
: —
Two rabbits were treated with intra-peritoneal injections of sterile emulsions
of M. Melitensis, one with the race known as stock and the other with the
organism isolated from Sher Hussain (Multan I). The former strain was
procured about two years ago from the Royal Army Medical College, London,
and probably had its origin from a case at Netley Hospital. After several
injections the sera of these rabbits were tested against all the races which had
been isolated by us. The following tables show the results obtained:—
Table I with the serum of the rabbit immunised with stock M. Melitensis.
Table II with the serum of the rabbit immunised with M. Melitensis,
Multan I.
13
TABLE L.
Rabbit I. Immunised with emulsions of stock M. Melitensis.
RACES OF M. MELITENSIS.
Dilution of
serum.
Stock.
MULTAN.
Ferozepore.
i
ii
i i i
iv
v
vi
vii
viii
ix
i
ii
200
*
*
*
*
*
*
*
*
*
*
*
*
400
*
*
*
*
*
*
*
*
*
*
*
*
6 0 0
*
*
*
*
*
*
*
*
*
*
*
*
8 0 0
*
*
*
*
*
† *
†
*
*
*
†
1 0 0 0
*
*
*
†
*
†
*
†
†
†
†
†
1500
†
‡
†
‡
‡
‡
‡
‡
‡
‡
‡
‡
2000
‡
§
‡
‡
‡
§
§
§
§
§
§
§
2500
§
§
§
§
§
§
§
§
§
§
§
TABLE II.
Rabbit II. Immunised with emulsions of M. Melitensis Multan I.
RACES OF M. MELITENSIS.
Dilution of
serum.
Stock.
MULTAN.
Ferozepore.
i
ii
iii iv
v
vi
vii
viii
ix
i
ii
200
*
*
*
*
*
*
*
*
*
*
* *
400
*
*
*
*
*
*
*
*
*
*
*
*
6 0 0
†
*
*
*
*
*
*
*
*
*
*
*
8 0 0
†
*
*
*
*
†
*
‡
*
*
*
* 4
1 0 0 0
?
* *
†
*
†
†
‡
?
?
*
†
1500
§
‡ †
‡
‡
‡
‡
‡
‡
‡
‡
‡
2000
§
§
†
§
‡
§
§
§
§
§
§
§
2500
§
§
‡
§.
§
§
§
§
§
§
§
§
NOTE.—In these tables—
* Denotes complete sedimentation.
† D e n o t e s
w e l l m a r k e d b u t n o t c o m p l e t e s e d i m e n t a t i o n .
‡ D e n o t e s s l i g h t
o r t r a c e o f s e d i m e n t a t i o n .
§ D e n o t e s n o s e d i m e n t a t i o n .
It will be seen from these tables that all the races isolated by us gave good
agglutination reactions with both sera.
We have also mentioned that in two instances a monkey was infected with a
strain of M. Melitensis isolated by us. The following are the details of these
two experiments.
Monkey I .—Received subcutaneously one agar tube of M. Melitensis,
Multan I.
For temperature see chart. During the third week the animal was very ill;
it would eat nothing and became very thin; it lay at the bottom of its cage
and at one time appeared moribund. However, it gradually recovered and was
quite well at the end of the ninth week; then it was killed with chloroform.
The serum agglutination reaction with two races of M. Melitensis was
determined on three occasions.
First, before inoculation no reaction even in dilution of 1—4 was got with
either stock or Multan I.
Secondly, on the sixth day after infection a complete reaction in dilution of
1—10 and a nearly complete sedimentation in dilution of 1-20 with both these
strains were observed.
Thirdly, in the middle of the third week the following result was ob
-tained:—
Dilution of serum.
Stock.
Multan I.
I 1—40
..
.
.
.
•
Complete sedimenta-
tion.
Complete sedimenta-
Hon.
1—80
.
. Complete ,,
Complete
1—160
.
.
.
.
Complete ,,
Complete ,,
.
. 1 — 3 2 0
- 3 2 o
. . .
.
Trace of ,,
Complete ,,
1—640.
.
. No ,,
Complete ,,
.
.
1—1280
.
a
a
No ,,
Trace of ,,
In the middle of the fourth week 1c.c. of blood was withdrawn from a super
- f i c i a l v e i n a n d p l a n t e d i n b r o t h a n d o n a g a r . A p u r e c u l t u r e o f M . M e l i t e n s i s ,
which answered to all the tests mentioned above, was obtained. The animal
was killed by chloroform at the end of the ninth week. Cultures made from the
heart's blood, the liver and the spleen all remained sterile.
Monkey II.—Received subcutaneously one agar tube of M. Melitensis,
Multan II.
15
There was a well marked local reaction at the site of inoculation ; this
resolved without abscess formation. The animal was never at any time as ill
as the first monkey had been ; it never refused food and, in fact, appeared
always to be in fair health. For temperature see chart.
The serum agglutination reaction with three races of M. Melitensis was
estimated on three occasions.
First, before inoculation no reaction was obtained in dilution of I in 4 with
stock, Multan I or Multan II.
Secondly, at the beginning of the third week complete sedimentation in
dilution of 1 in 40 was observed with all three strains.
Thirdly, at the beginning of the fourth week the following result was
obtained:—
Dilution of serum.
Stock.
Multan I.
Multan II.
1 - 8 0
.
.
.
.
Complete sedi-
mentation.
Complete sedi-
mentation.
Complete sedi-
mentation.
1-160
. . .
Complete sedi-
mentation.
Complete sedi-
mentation.
Complete sedi-
mentation.
1-320
. . . .
Complete sedi-
mentation.
Complete sedi-
mentation.
Complete sedi-
mentation.
1—640
. . . . Trace of sedi-
mentation.
Well marked sedi-
mentation.
Complete sedi-
mentation.
1—1280
.
.
.
.
No sedimentation No sedimentation Trace of sedi-
mentation.
These estimations show a great increase in the agglutinin content of the
blood in the course of one week.
At the beginning of the fifth week 2 c.c. of blood were removed from a peri-
pheral vein and planted in broth and on agar. A pure growth of M. Melitensis
was got from one of the broth tubes. The other tubes remained sterile.
At the end of the ninth week the animal was killed with chloroform. Cultures
were made from the heart's blood, from the liver and from the spleen. The
tubes inoculated with heart's blood remained sterile. A pure culture of M.
Melitensis was obtained from both the liver and spleen. This organism responded
to all the tests mentioned above.
Group b.—We have now briefly to refer to a few cases of continued fever,
in which for various reasons no attempt was made to isolate the causal agent of
the disease, but the sera of which gave a good agglutination reaction with
M. Melitensis. These cases in the light of our recent researches we must regard
as undoubted cases of Mediterranean fever.
Case XII .—Sohun, aged 32 ; Sepoy, 27th Punjabis, Multan. Patient
was admitted into hospital on 6th March 1905 complaining of cough and fever.