Morbidity and Mortality Of The Malta Garrison 1816 — 1909
Morbidity and Mortality Malta Garrison
The garrison of Malta annually lost about eighteen of its soldiers for every thousand troops stationed on the island. Between 1817 and 1836, the annual mortality rate was 18.7 per 1000 of mean strength. It remained virtually unchanged over the following twenty years at 18.2 per 1000 mean strength (Image I). From 1817 to 1836, there were 1,142 hospital admissions per 1000 of the force annually (Image VI). The proportion constantly sick over this period was 45 per 1000, so that each soldier in Malta was off sick for an average of sixteen and a half days a year. In Gibraltar and the Ionian Islands, the proportion constantly sick was 41 and 47 per 1000 respectively. The average time off sick of each soldier serving on the Rock was fifteen and a half days each year; it was slightly lower in the Ionian Islands at fourteen and a half days.1
Soldiers serving in Malta had a similar mortality rate to troops in England (Image II). However, the mortality among the Foot Guards, the Dragoon Guards and Dragoons, and the Household Cavalry was almost double that of the civilian British population, even though these troops did next to no foreign tours (Image III). Their mortality rate was even higher than the City of Manchester, considered at the time one of the unhealthiest towns in England, with a mortality rate of 12.4 per thousand. British troops in Malta had a lower mortality rate than the civilian population, which in 1838 was given by Major Alexander Tulloch as 25 per 1000 of all ages.2 This concurred with that given by the Chief Physician of Police, Dr Antonio Ghio. In 1867 he gave an average mortality rate for the Maltese Islands under ordinary circumstances, as 24 per 1000 annually on the entire population. The annual mortality from fevers in the inhabitants was about 9 per 1000 of the population.3
Three main groups of diseases disabled the garrison: (i) continued fevers (ii) pulmonic and bowel affections and (iii) venereal complaints. Two infections in particular, pulmonary tuberculosis or phthisis, and enteric or typhoid fever were mainly to blame for the marked mortality. Chart I depicts the mortality and morbidity among British troops in Malta from 1817 to 1846.4 The marked admission rate in relation to the strength of the garrison, is partly explained by the regulation which compelled Medical officers to hospitalize every patient they encountered, irrespective of the severity of their symptoms. No distinction was made between new admissions and re-admissions following relapses. Inaccuracies also arose from the practice followed in military hospitals, of making a diagnosis of the patient immediately on his admission. If the surgeon later discovered that his initial diagnosis was incorrect, his only means of rectifying the mistake was to discharge the patient, and readmit him under the new diagnosis. Alternatively, he could continue treating him for one disease, while his name was entered as suffering from another. The sick soldier, thus appeared in the statistics as two patients rather than one. Sending invalids home spuriously decreased deaths in the station. No adjustment was made in the statistics to include those who died on their passage to England or after reaching British soil, from diseases picked up in Malta.
Images IV and V tabulate the admissions into hospital and deaths among troops serving at various stations from 1817 to 1836, and from 1837 to 1856. These show that over the first twenty years, the main afflictions sending soldiers into hospital were venereal affections with 7,336 admissions, followed closely by fevers with 7,078 admissions. In third place we have diseases of the stomach and bowels with 6,317 admissions. Diseases of the lungs, despite registering fourth with 4,883 admissions, gave the highest number of deaths with 245, against 118 deaths for fevers, and 147 deaths for stomach and bowel diseases. Over the period 1837 to 1856, admissions for fevers shot right up the table with 10,772 admissions (107 deaths); diseases of the stomach and bowel 9,534 admissions (125 deaths); venereal affections 5,630 admissions (1 death); diseases of the lungs 5,400 admissions (226 deaths).
Image VI is an abstract of the ratio of admissions into hospital and deaths per thousand strength by each class of disease for the period 1817 to 1836, and 1837 to 1856. It shows that although fevers in the garrison of Malta, prior to 1837, were responsible for 173 admissions per 1000 strength, the death rate was only 2.9 deaths per 1000 strength. Lung diseases on the other hand, provided 120 admissions per 1000 strength, but a relatively high death rate at 6 deaths per 1000 strength. The data for 1837 to 1856 shows little improvement; the mortality rate for fevers and lung diseases was 2.2 and 4.7 per 1000 strength respectively.
In civil life in England, at the soldiers' age groups, deaths through pulmonary diseases were 6.3 per 1000, but in the infantry they amounted to 10.2 per 1000. In the army as a whole, diseases of the lungs constituted 57.27 per cent of the entire number of deaths from all causes. In Malta, from 1837 to 1846, phthisis was the cause of 129 admissions (6.1 per 1000 aggregate strength or 1 admission per 164 troops), and 91 deaths (4.3 per 1000 aggregate strength, or 1 death per 232 troops); pneumonia gave 287 admissions and 6 deaths; acute catarrh engendered 2,009 admissions (94.9 per 1000 aggregate strength) and 11 deaths (0.5 per 1000 aggregate strength). Haemoptysis, a symptom of tuberculosis, gave 79 admissions with one recorded death. During these ten years the aggregate strength of the garrison was 21,172 troops.5
Lung diseases were blamed on a vitiated atmosphere generated by overcrowding and deficient ventilation, and the absence of proper sewerage. Staff Surgeon James Barry attributed it to dampness in the barracks. Boards take a long time to dry after washing to remove bugs, said Barry, and, as "headboards lie against porous stone, and the men's heads come in close contact with the wall, which being porous retains damp, and when acted upon by the atmosphere, the moisture is inhaled by the men, thus rendering it extremely deleterious, generating pulmonic and rheumatic affections, both of which prevail to a great extent in Malta among the military and civil population, often proving fatal".6
Why soldiers fell ill, rather than what made them ill, became the subject of a Royal Commission assembled in 1857 under the chairmanship of the Secretary of State for War Sidney Herbert (Image VII). Nine commissioners examined every aspect of the soldier's life, and singled out four evils, which in their opinion, contributed significantly to the soldiers' poor health:
Night duty. In his annual report on the sick of the Malta garrison for 1835, Assistant Inspector of Hospitals John Davy reported that the guard posts used by the 5th Northumberland Regiment >were all exposed to cold and winds and to every vicissitude of atmospheric change. The guard rooms were without fireplaces, and many of them swamped in rainy weather. Anything but comfort is found by the soldier returning from his post.7
Want of exercise and suitable employment. The soldier's daily life was monotonous. No individual suffered more than he did from boredom. He had no employment, save drill and guard duty. His residence in towns proved a great temptation for excessive drinking, and greater opportunity for sexual debauchery.
Intemperate habits. Soldiers who drank to excess, had relatively higher deaths from diseases of the nervous system and the digestive organs. In England and Wales, these two groups of diseases in non drinking men, aged 20 years and upwards, constituted 15.95 per cent of the deaths from all causes, but amongst intemperate persons, they formed 50.4 per cent of all deaths, more than three times the general average. In 1867, Inspector General Joshua Paynter singled out drinking to excess as "a fertile cause of disease". Intoxication led to fatal accidents. The Blue Book of the Army Medical Department for 1866 reported four deaths from fracture of the skull, all occasioned by falls from the fortifications when the men were in a state of intoxication.8
Poor ventilation of casemated barracks, and nuisances arising from latrines and defective sewerage. With the exception of St Francis' Barracks Floriana, and Pembroke Camp St George's Bay, all the barracks in Malta were ill constructed, dark, gloomy, damp, and ill ventilated places. Much of the excess of mortality from fever was attributed to the state of the latrines, cesspools, and drains.
In Malta, successive Principal Medical Officers attributed the causes of ill health among the troops to the following deficiencies:9
Insufficient water supply.
Badly constructed and ill ventilated barrack rooms.
Ill constructed latrines and urinals, with faulty sewerage and drainage.
Dampness of rooms in winter, without means of warming and drying them.
Unsatisfactory lavatory and bath accommodation.
Inadequate means for cooking food in a satisfactory manner.
Barracks located in insanitary neighbourhoods.
Insufficient light and ventilation of guard rooms and very small, dimly lit detention cells.
Medical officers tenaciously held on to the notion that miasma generated disease. Miasma arose from putrefying organic matter. It acted on those whose debauchery, moral weakness, or intemperate habits, made them fertile ground for the breeding of disease. The view that a local poison made soldiers ill, became spuriously credible, as soldiers were observed to improve once they were removed from their overcrowded barracks, and encamped on the glacis exposed to invigorating breezes. Such was the fear of miasma, that in 1883, the more serious patients at the Valletta Hospital were transferred to Citta Vecchia and the Forrest Hospital, so as to prevent them inhaling noxious emanations when the main drains in the vicinity were exposed. Physicians affirmed that Mediterranean fever was caused by an emission from the soil. Dr Antonio Ghio stated emphatically that the fever was due to the horrible pollution of the subsoil of Sliema and the inland towns, and to the lack of flushing water in the drains of Valletta and the three cities.10 Similarly, typhoid fever was believed to arise from the introduction of the miasm of decomposing animal matter, either in the form of aerial emanations such as sewer gas, or of local pollution of the drinking water by infiltration of such matter.
Malta was the seat of the Mediterranean Fleet. As more and more seaman went down with the mysterious illness known as Malta fever, the sanitation and health of the island came repeatedly under scrutiny. In spite of improvements, whereby most of the sewage was pumped out to sea, large sewer outlets still emptied their contents into the Quarantine Harbour. The excreta of some 5,000 to 8,000 sailors employed on ships of war and mercantile vessels, was continually poured into the enclosed and tideless harbours of Malta, converting their basins into one large cesspool. The offensive state of the water was apparent at the sewer outlets at all times, and in the enclosed creeks on rough days. Yet in summer, soldiers and sailors were seen to bath daily around these very places. In June 1899, Dr Robert Farquharson tabled a question in the House of Commons, addressed to the First Lord of the Admiralty, asking whether his attention had been drawn to an article in the Br Med J (18) of 18 May 1899, in which the Grand Harbour was described as being little better than a cess pool, and that the seamen of the fleet exposed to the emanations from the harbour suffered from fever almost as much as if stationed on the Gold Coast.11 Lord George Hamilton agreed that the harbour in Malta, surrounded by a dense population and frequented by much shipping, was comparatively unhealthy as an anchorage, but explained that the commanders-in-chief kept the fleet out of Malta during the summer months, the most unhealthy part of the year. In addition, every effort was being made to render the harbour as healthy as possible, and recent sanitary improvements in the town and suburbs of Malta had been carried out, including a pure water-supply and a well-arranged system of sewers discharging into the sea at a considerable distance from the harbour.12
The Maltese Islands are an archipelago with a total surface area of 316 square kilometres. In 1871, the population of Malta reached 123,373. This was equivalent to a density of 1,309 persons per 2.59 square kilometer.14 The majority lived around the Grand Harbour, and in the Three Cities of Cottonera, Senglea and Vittoriosa. The towns were overcrowded; drinking water came from the aqueduct or from roof water stored in underground cisterns; sewage was stored in cesspools which leaked and contaminated the drinking water. That cholera, a water borne disease, was enabled to repeatedly grip the islands in successive epidemics, (1837, 1847, 1848, 1850, 1854, 1856, 1865, 1867, 1885, 1887), was indicative of the insanitary state of the towns. Malta was hit by smallpox between 1870 to 1873, while diphtheria was more or less prevalent from 1867 to 1873. In 1895, the infant mortality rate, a crucial index of the sanitation of the country, reached 267 per 1000 – nearly three times what would have been expected under more favourable conditions.
The notion that germs, and not contagion or miasma, caused disease was first proposed by Jakob Henle (1809–1885) in the 1840s, and expounded by his pupil, Robert Koch (1843–1910). In 1882, Koch unravelled the mystery of tuberculosis when he isolated the Mycobacterium tuberculosis; in January 1884 he discovered the comma bacillus, the agent responsible for cholera. Koch's work on bacteria heralded a new dawn, where diseases became attributed to specific organisms. In 1880, Karl Joseph Eberth discovered Salmonella typhi, the germ of typhoid, but it was Georg Theodor Gaffky (1850–1918), an assistant to Koch, who succeeded in growing the bacillus in 1884.
On 26 December 1866, Surgeon Captain David Bruce (1855–1931), while at the Military Hospital Valletta, observed a large number of micrococci in stained sections of splenic tissue. The specimens were taken from a twenty one year old soldier of the King's Own Yorkshire Light Infantry, who had died of Malta fever. On 6 July 1887, Bruce with the support of the Maltese bacteriologist Giuseppe Caruana Scicluna, succeeded in culturing the micrococcus from the spleen of a twenty four year old Highlander of the 1st/42nd Royal Highland Regiment (The Black Watch). In 1893, the micrococcus of Bruce was named Micrococcus melitensis; in 1920 it became Brucella melitensis in his honour.
This chapter analyses how the fevers of the Maltese Islands affected the garrison over the period 1816 to 1909. Medical statistics on the health of troops commence from 1816, when the Director General Army Medical Department, Sir James McGregor, instituted a system of annual returns from regimental surgeons serving on overseas stations. The first annual report for the Malta garrison was produced by Inspector of Hospitals John Hennen.15 This covered the period 21 December 1821 to 20 December 1822, although a half-yearly return had been compiled by Inspector of Hospitals John Warren in December 1819. In 1859, Deputy Inspector General Thomas Graham Balfour, Head of the Statistical Branch of the Medical Department 1859 to 1873, prepared the first Report on the Health of the Army.16 In June 1906, the substitution of goats' milk by tinned milk in military hospitals and barracks, led to such a dramatic fall in admissions for fever that the Long Ward in the Valletta Station Hospital became redundant; it was closed down in March 1909. In addition, improvement in hygiene at the turn of the century, coupled with the gradual introduction of inoculation against typhoid fever, led to a fall in the mortality rate from infectious diseases.
Core body temperature is kept at a set point of around 37.5°C. by a thermoregulatory centre, located in a part of the brain known as the hypothalamus.
Ludwig Traube (1818–1876) was the first to recognise that a rise in body temperature is the essence of a febrile state. This challenged the prevalent theory set forth by Herman Boerhaave (1668–1738), that an increased frequency of the pulse was the great characteristic of the febrile state. In 1854, Rudolf Virchow (1821–1902) defined fever as "essentially an elevation of temperature, which must arise in increased tissue change, and have its immediate cause in alterations of the nervous system".17 The iatro-mechanical physicians, professed that fever was due to friction of the blood; the physiological school of Francois Joseph Victor Broussais (1772-1838), or the pathologico-anatomical school of his period, rejected all fever that was not demonstrably dependent upon a local inflammation. Thus, enteric fever was to them a dothinenteritis, while intermittent fever was a periodical gastro-enteritis or an inflammation of the spleen.18
The introduction of the thermometer placed the study of fever on a scientific footing. Assistant Surgeon John Peter Hamilton Boileau recognised the value of thermometry in the investigation and diagnosis of fevers. "To the military practitioner", wrote Boileau, "it is of especial importance, adding much to the certainty of prognosis as well as of diagnosis, and enabling him, in many instances, to foretell the approach of evident and formidable symptoms. In masked forms of febrile disease, he may thus too be enabled to say that disease is really present with a certainty hitherto unattained, and dispose of his morning sick with a justice to them and credit to himself which he cannot always secure without the assistance of the thermometer".19
In the 19th century fever was regarded as a disease in its own right. Its classification conformed to a Linnaean binomial nomenclature of genus and species. In 1823, Inspector of Hospitals John Hennen said of the fevers of Malta: "I agree in the theory that there is one order of Idiopathic Continued Fever and that all its different species and varieties depend on adventitious circumstances such as situation, season, climate, power and quantity of the exciting causes etc". Febris was the genus; its species were: Febris quotidian intermittent, F. tertian, F. continua, F. synochus, and F. typhosus. The Army Medical Blue Book included febricula, simple continued fever, and enteric or typhoid fever under the generic term of common continued fever. Eruptive fevers such as small pox, and typhus, and the eruptive exanthemas such as measles and scarlet fever were excluded.
Until the rise of bacteriology in the 1880s, fevers took their names either from the locality they were first described (Dum Dum fever for Kala-azar), or according to the pattern of their temperature chart (undulant fever for Brucellosis), or to their prominent presenting symptom. Thus, Brucellosis went by such synonyms as: gastric remittent and bilious remittent fever (Marston 1861), Mediterranean gastric remittent fever (Chartres 1865 and Boileau 1866), faecomalarial fever (Donaldson 1876), intermittent typhoid fever (Borrelli 1877), febris complicata (Veale, 1879), febris sudorais (Tomaselli 1880), Neapolitan Fever, Malta Fever, and in Gibraltar, Rock Fever. The isolation of bacteria, and the linking of one micro organism to one disease, brought clarity to the aetiology of different fevers, which had hitherto been all consigned to the broad category of Common Continued Fevers.
In 1896, Georges Fernand Widal discovered that the serum of typhoid patients contained antibodies which immobilised the typhoid bacillus. The following year, Professor Almroth Wright and Surgeon-Major David Semple at the Army Medical School Netley developed a simple technique which enabled medical officers to differentiate between Malta fever and enteric fever through the use of an agglutination test.20 It seems, however, that some doctors needed convincing. In 1900, the Malta Government Analytical Chemist, Temi Zammit, reminded his colleagues "that if bacteriology is to aid us in diagnosis, it is imperative that we should find out a method by which the specific micro organism can be demonstrated as soon as the patient is attacked by the fever. Everyone knows how difficult it is to give an opinion as to the nature of a fever when the patient is in the first week of his illness, and every practitioner understands the importance of a rapid diagnosis with a view of establishing a proper treatment. A practical method of diagnosis has been suggested based upon the well-known agglutination of specific micro organisms in a solution of the blood serum from the corresponding disease. In the annual report of the Public Health Department for 1898, I have endeavoured to give a summary of our attempts to use the serum reaction as a help to practitioners to come to an early diagnosis in doubtful cases of enteric and Mediterranean fever. Our technique was quite successful, for we were able to obtain the reaction in a very short time after the sample of blood had reached us, but I am sorry to say that our enthusiasm was by no means shared by our medical colleagues, and very few of them responded to our appeal. Although this first attempt was discouraging, still the question is of such importance that I venture to repeat the appeal".21
Common Continued Fever
Continued Fevers were intractable fevers of unknown origin. The term embraced simple continued fevers, remittent fevers, and enteric fevers. The continued fevers were a mixed bag of infections which included: brucellosis, typhoid and paratyphoid fevers, Kala-azar, and sand-fly fevers. Malta fever was often, not only grouped with simple continued fevers, but also with remittent and enteric fevers, as its symptoms suggested a typhoid origin. In 1896, the Royal College of Physicians of London adopted a separate heading of Mediterranean Fever in the nomenclature of diseases. One would have expected the incidence of simple continued fevers to have declined once the separate category of Malta Fever came into use, but this does not appear to have been the case (Chart III).
In 1869, Febricula was used in the returns of the Army Medical Department for the first time; the name was dropped from the nomenclature in 1886. Febricula was predominantly due to sand-fly fever.
The Report of the Barrack and Hospital Commission, Mediterranean Stations 1863, states that: "During the entire period which has elapsed since the first hospital records were kept in Malta, the prevailing type of fever has been Common Continued. Out of 22,969 cases, 21,122 have been registered thus; many of the cases have been very slight and mild, passing off in a day or two. Chart II plots the seasonal prevalence of continued fevers from 1822 to 1888, against the strength of the garrison (blue).23 Interpreting the statistics of the time is fraught with pitfalls, but what is apparent is that fever predominated during the summer months of June to September. It was held that these warmer months of Malta generated a malarious poison, of so powerful a character, so as to prove highly detrimental to the efficiency of any troops quartered there.
Regimental surgeons observed that spring was the worst season for troops to arrive in the station, as soldiers were unseasoned to the heat, and under the combined influence of sun and intemperance, fell victim to summer fevers in large numbers. In 1891, the Principal Medical Officer commented that the increased sickness from simple continued fever was "attributed to the prolonged and trying summer, and to the presence in the ranks of several of the regiments of a large number of weakly and immature youths who were unable to withstand the trying effects of climate". The history of the 2nd Battalion Essex Regiment is instructive. The Regiment landed in Malta on 28 April 1904, with a strength of 698. In June, 9.6 per cent of their strength were admitted to hospital with simple continued fever; in July, 35 per cent; in August, 5 per cent; in September, 6.3 per cent; in October, 6 per cent. That is, no less than 55 per cent of this regiment were attacked with simple continued fever during the first summer of their residence in Malta. In the following year only 19 per cent of their number contracted the ailment.23
Chart III plots the incidence of total continued fevers against simple continued fevers over the period 1859 to 1909. The graph was assembled from data collected by Lieutenant Colonel Cecil Birt RAMC from the annual returns of the Medical Blue Books.23 The blue line represents all the fever admissions irrespective of their cause. This proceeds in a series of fluctuations, whose peaks seem to correspond with the arrival of troops in Malta. The curve drops precipitously after 1906, coinciding with the practical disappearance of Malta Fever from the garrison. The bar coloured red is the total admissions for simple continued fevers. When all the fevers were included under this heading, the top of the red bar virtually coincided with the blue line of total continued fevers. However, as more and more fevers came to be recognised as separate diseases, and were removed from this category, the gap between the two widened. This is obvious for the years 1869 to 1886, when the heading febricula came into use and took away those fevers that would otherwise have been included with the simple continued fevers. In 1885, there was a sudden upheaval in the total continued fever curve, when some cases of Malta fever were returned under the heading of remittent fever, while others as simple continued fever, of which 345 were recorded. In 1885, Febricula admissions stood at 495, the majority of which were mild. It will be seen from Chart VI, that from 1885 Malta fever was becoming recognised as distinct from enteric fever. This is reflected in the widening of the gap between the mortality curve for total continued fevers (blue) and enteric (grey).
From 1817 to 1836, the aggregate annual strength of the garrison was 40,826 troops. During this period there were 7,078 admissions and 118 deaths from continued fevers. This equates to a ratio per 1,000 of mean strength of 173 admissions and 2.9 deaths. The case mortality was 1.66 per cent. The aggregate annual strength from 1837 to 1856 was 47,961 troops. During this period there were 10,772 admissions and 107 deaths for continued fevers. This equates to 224 admissions per 1,000 of mean strength and 2.2 deaths per 1,000 of mean strength. The case mortality was 1 per cent. Thus, on the whole, continued fevers were characterised by high morbidity but low mortality.
Simple Continued Fever — Febricula
The terms Simple Continued Fever and Febricula were often interchangeable. Captain James Crawford Kennedy in his minute to the Mediterranean Fever Commission, dated 16 December 1905, defined Simple Continued Fever as "a fever of the nature of influenza, coming on with severe pains in the head and limbs, pyrexia 101°F (38.3°C) to 104°F (40°C), and lasting one to four days. It attacked newcomers, was epidemic during June, July and August, and occurred irrespectively of exposure to the sun".22 This description is similar to that given by Surgeon Captain Matthew Louis Hughes for Febricula. Hughes described it as a fever of "short attack which appears to be of a specific nature. It is common in hot countries, and attacks almost everyone there, often year after year, and in a large number of cases at the same time of each year. It is a filth disease, and not the result of exposure to the sun. The pyrexia lasts some three or four days, with pain in the back and head, foul tongue, and but little else." In 1904, Fleet Surgeon Bassett Smith RN remarked that "in the Station Hospital, Valletta, there was a fever which occurred in summer, and in one summer in great numbers, which attacked almost every patient in hospital, whatever his complaint. But this fever only lasted four to seven days, and although it was acute while it lasted, left no ill-effects. It was never properly diagnosed, but passed under the name of Febricula or Simple Continued Fever".23
Febricula was known by a variety of names such as Ephemeral fever (from its shortness), Ardent fever (from its sharpness), and in the West Indies, Broken Bone Fever (from the frequent severity of the neuralgic symptoms). Febricula was the so called summer influenza or seasoning fever, as it struck during the summer months those soldiers who had arrived in the command the previous spring.24 In 1867, John P H Boileau, referred to it as the Maltese Fever, and declared it to be the commonest type of fever at the station. He attributed febricula to intemperance and indolence, the heat of the sun, and insanitary barracks.
Chart IV plots the admissions for simple continued fever (green) vs febricula (red) over the period 1859-1909. The admission rate per 1,000 strength for simple continued fever regularly rose and fell in seven year cycles between the maximum of 269.5 per 1,000 of strength in 1859, and the minimum of 71.2 per 1000 strength in 1888. Febricula appears in the returns for the first time in 1869, with 151 recorded admissions. In the same year there were 734 admissions for simple continued fever and 19 for enteric fever. In 1871, 202 pyrexial cases were shown as febricula, 357 admissions as simple continued fevers, and 16 for enteric fever. In 1874, there were no entries under febricula; consequently the number of admissions of simple continued fever rose to 864. In 1877, there occurred 209 cases of simple continued fever with two deaths, and 635 cases of febricula. The febricula admissions in 1878 amounted to 920, but in this year there were no recorded admissions under remittent fevers; simple continued fever totalled 150, and enteric 94. In 1886 febricula was dropped out of the nomenclature of diseases. If febricula was entirely due to sand-fly fever, then the difference between the recorded admissions for febricula and simple continued fever should, in theory, give the number of cases of Malta fever, which were often included under this heading. Enteric fever, however, was also sometimes recorded under simple continued fever.
The admission rate for simple continued fevers in 1859 was remarkably high with 1,431 cases, and a mortality rate of 8.3 per 1,000 strength. The mortality rate from all causes for 1859 was 19.02 per 1000 strength. Inspector General John Forrest attributed this to the arrival of the 2nd/22nd (Cheshire) Regiment on 20 May 1859. The Cheshires had 289 cases of fever (400 per 1,000 strength) with 3 deaths out of a battalion strength of 722 men. In 1861, there was a reduction in the prevalence of fevers, but the 1st/22nd (Cheshire) Regiment arrived on 22 June 1860, to replace its linked battalion in Floriana Barracks, and their troops suffered much, with 279 admissions and three deaths. In 1873 many of these recent arrivals had become immune, indicated by the fall in the fever curve. There were, nevertheless, 346 cases of simple continued fevers with four deaths, and 429 cases of febricula in the garrison.
Over the period 1859 to 1909, when the aggregate annual strength of the garrison was 311,566 troops, the total admissions for all continued fevers was 50,947; deaths 985. This gives a ratio of admissions of all continued fevers per 1,000 mean annual strength as 164, and a ratio of deaths per 1,000 strength as 3.16, with a case mortality of 1.93 per cent. The expected mortality for enteric fever was 12 to 14 per 100; that of Malta Fever 2 to 3 per 100. Lieutenant Colonel Cecil Birt concluded that such a low death rate among the cases of total continued fever supported his view that most of the cases entered under this heading, were the due to annual summer epidemics of sand-fly fever or phlebotomus fever.22
Sandfly — Phlebotomus Fever
On 13 April 1909, Lieutenant Colonel Cecil Birt undertook an extensive study of Common Continued Fever, and concluded that the Maltese Fever alluded to by Boileau, was none other than phlebotomus fever, a sand-fly-borne viral infection or sand-fly fever virus infection (SFV).25 Pappataci fever is caused by a phleboviruses of the Bunyaviridae family. In the Mediterranean, the phleboviruses Toscana Virus (TOSV), Sandfly Fever Naples virus (SFNV), Sandfly Fever Sicilian Virus (SFSV), and Sandfly Fever Cyprus virus (SFCV) are transmitted by phlebotomine sand-flies. Among these, TOSV circulates in countries bordering the Mediterranean Sea. Viruses in the genus Phlebovirus cause a variety of clinical syndromes ranging from a brief, three day self-limiting febrile illness or pappataci fever, to encephalitis, meningoencephalitis and fatal haemorrhagic fever. Patients present with influenza-like symptoms including fever, retro-orbital pain, myalgia and malaise and usually recover fully within a week. However, infections with these viruses, even when mild, have been shown to be highly incapacitating during the time the patients are affected.25
Research on the Phlebotomus sand-fly (Phlebotomus papatasii), was carried out by Captain Philip Jauvrin Marett at Floriana Barracks and Fort Chambray Gozo, with the assistance of Corporal Kerr. Marett served at Malta from February 1907 to March 1912, but returned as a Beit Memorial Research Fellow, on 9 August 1913 to resume his work on the Papatasii flies. His studies were unfortunately interrupted by the outbreak of war. Our current knowledge of the life-history of the phlebotomus is mainly due to the painstaking work of Squadron Leader H E Whittingham and Flight Lieutenant A F Rook who were in Malta between 1921 and 1923, as part of the Royal Air Force Sandfly Fever Commission. In 1921, the Commission consisted of: Squadron Leader H E Whittingham, Corporal G H Noakes, and Aircraft man R Stewart. In 1922 it comprised Squadron Leader H E Whittingham, Flight Lieutenant A F Rook, Corporal R. Stewart, and Aircraft man H A Collett. In 1923 it was made up of: Wing Commander H E Whittingham, Corporal R Stewart, and Leading Aircraft man H A Collett.26
Malta has four species of sand-flies. On 25 June 1910, R Newstead from the Liverpool School of Tropical Medicine spent two months searching for the breeding places of the Phlebotomus. Newstead discovered that two distinct species, Phlebotomus papatasii, and P. pernicious, were found to be almost equally abundant. Later, two other phlebotomi, P. minutus and P. nigerrimus were also identified.27 The common and widely distributed P. papatasii was found from insect biting experiments on volunteers carried out by Birt, to be the transmitter of sand-fly fever. In one experiment Lieutenant Howard Graeme Gibson offered his arm to the "silent feeder", was only bitten once, and the sudden onset of a very unpleasant fever occurred at the predicted time.28
The chief breeding-places of the papataci flies (P. papatasii and P. perniciosus) were the damp crevices between the loose rocks in rubble walls, the interstices between the masonry of the bastions, and in the loose earth at the base of walls and buildings. Sand flies made their appearance in scant numbers at the end of April and beginning of May, and became more numerous as the summer advanced, until they disappeared in November. There was a correlation between the incidence of fever and the abundance of P. papatasii. The female phlebotomus bit after sunset. During their first summer of residence, newcomers were afflicted by a fever which incapacitated them completely for several days. In 1907, the loss to the army in the Mediterranean area was nearly 6,000 days' service. The first attempts to reduce the number of sand-flies, and consequently the incidence of sand-fly fever were adopted by Captain J P Marett, in 1910. These seemed to have been successful. The Army Medical Report for 1912, stated that preventive measures taken against the sand-fly had reduced the incidence of sand-fly fever, among British troops stationed in Malta from more than 300 attacks in 1908, to only 104 in 1912.
In August 1909, Captain Henry Stewart Anderson commented that "now that the scientist has almost eliminated the sun as a cause of short attacks of fever, the island is a true pearl, no longer a disease spot in the Mediterranean oyster. In future, the summer fever of newcomers can easily be avoided by using "Grassi grease". Improvements are noticeable in many directions, although the perambulating goat still swallows street garbage in defiance of ordinances".29
Splenic leucocythaemia — Kala azar
Phlebotomus perniciosus not only spreads sand-fly fever, but also, the protozoa Leishmania donovani, which causes visceral leishmaniasis or Kala-azar in adults, and Leishmania infantum in children. Sick dogs act as reservoirs of the parasite. Before the discovery of the Leishman body by Colonel William Boog Leishman (1865-1926) in 1903, the illness was regarded as another form of Malta Fever or malaria.
Kala-azar causes a febrile illness, which before the availability of pentavalent antimony in the 1920s, was invariably fatal. The clinical picture of visceral leishmaniasis is one of lethargy and listlessness with an intermittent or remittent type of fever. The spleen was always enlarged. The combination of a large spleen and a low white cell count gave the illness its name of splenic leucocythaemia.
In September 1909, Captain Marcus Hill Babington published in the Journal of the Royal Army Medical Corps, a case of "a disease prevalent in Malta and known as splenic leucocythaemia".30 On 28 November 1908, Babington had examined an English female child, aged five and a half years, who had fallen ill in July 1908. The girl was initially misdiagnosed as suffering from Malta Fever, but after seven weeks of bed rest, her spleen was found to be enlarged, and the diagnosis was revised to one of splenic leucocythaemia. The child succumbed to her illness on 30 November 1908. This was the first reported case of infantile Kala-azar in an English family in Malta, although the condition was not unknown among Maltese medical practitioners.
In 1811, two further cases of Kala-azar were reported by Babington and by Captain William Lincoln Baker in the Corps Journal.31 Towards the end of June 1910, Baker had examined a male child aged 19 months, who was listless, had a temperature and an enlarged spleen. The infant died in September 1910. A post mortem examination isolated Leishman bodies from the liver and spleen. Major Babington's case, reported in the same journal, was that of a 21 year old gunner of the Royal Garrison Artillery who had served in Malta for two out of his five years' service. The soldier presented in June 1910 with fever, shortness of breath and an enlarged spleen. He was invalided to England in September, where the isolation of Leishman donovan bodies confirmed Kala-azar.32
Kala-azar in Malta was probably more common in British soldiers than was generally realised. In the summer of 1917, a soldier of No 1 Company RAMC proceeding to Salonica fell ill with Kala-azar and was treated with intravenous antimony (1% tartar emetic).33 Throughout the whole of the Mediterranean, infantile kala-azar had been prevalent, but adults were not spared. In Malta in the year 1907-08, splenic leucocythaemia was responsible for causing 84.1 per 1000 deaths in children aged over 1 year and under 5 years. Between January 1909 and August 1914, seventeen cases of Kala-azar and four deaths were reported from the Families Military Hospital Valletta. From 1946, disinfestation with the pesticide DDT was adopted in an attempt to eradicate the sand-fly.34
Intermittent fever or Marsh Miasma was rare in Malta. All true cases of intermittent fever were relapses in soldiers who had contracted the fever in India or the Ionian Islands. In the first half of the 19th century, mild cases of benign tertian malaria did occur in Malta. Certain localities, such as the valley beyond Naxxar on the way to Saint Paul's Bay, was probably malarious. This area is known as Bur-Marrad, which means literally unhealthy plain. The low lying Marsa at the head of the Grand Harbour was another notorious spot. In the Capuchin Convent at Floriana, which overlooks the Marsa, malaria was said to have been endemic at one time, and the friars were forbidden to go down to church before daylight for fear of contracting the disease.35
In August 1904, farmers toiling their fields in a valley known as Wied il Kligha, about a mile away from Rabat, went down with intermittent fever. In 1887, a portion of the ravine had been dammed to collect rain water for agricultural use. On week days, about fifty labourers slept in huts on the side of the ravine, so as to start work early in the morning; the men returned to their own homes in Rabat on Sundays. On 16 September, Drs Themi Zammit and Giuseppe Caruana Scicluna investigated the epidemic. Blood samples showed the Laveran's parasite, and the vector Anopheles maculipennis was recovered from the dwellings. It was surmised that the mosquitoes became infected through feeding on malarious soldiers barracked in the new camp on Mtarfa Ridge, situated about half a mile from the epicentre of the infection. This hypothesis was, however, never proven. The 1st/Royal Dublin Fusiliers had arrived from Crete in March 1904 and left for Alexandria in November 1905. The battalion occupied St George's Barracks Pembroke. The battalion that occupied Mtarfa in 1904 has as yet not been identified.
Gastric Remittent Fever — Mediterranean Fever
In 1889, Colonel David Bruce defined Malta Fever as "an endemic disease of long duration, characterised by fever, continuous, remittent, and intermittent in type, in most cases an enlarged spleen, profuse perspiration, sudamina, constipation, relapses almost invariably, accompanied by pains of a rheumatic or neuralgic character, sometimes swelling of joints or orchitis, ending almost always in complete recovery; in fatal cases enlargement of the spleen, no swelling or ulceration of intestinal Peyer's glands, and the constant occurrence in various organs of a species of micrococcus".36
What this definition does not convey is that those who contracted the disease were left shattered by its symptoms, never fully recovered, and were often invalided out of the service. William Campbell Maclean, Professor of Clinical and Military Medicine Army Medical School Netley (1861-1885), said of Malta Fever that it was one of the most distressing forms of fever which the British soldier had to face, and the medical officer to treat, in their respective careers; and the latter was often called on not only to treat it, but to suffer from it in his own person.37 Surgeon Major Henry Richard Lobb Veale, Assistant Professor of Military Medicine Netley (1878-1882), called Malta Fever, Febris complicata after its extraordinary range of complications affecting every system in the body. Captain J P H Boileau called it the long fever from its protracted character. The fever was characterised by its dyspeptic symptoms and profuse sweating; night gowns, pillow cases, pillows, sheets, and blankets became saturated in a couple of hours.
In 1863, Assistant Surgeon Jeffery Allen Marston described an illness that had befallen him in Malta in 1861, which he called Gastric Remittent Fever of the Mediterranean. The fever had a peculiarly irregular temperature curve, consisting of intermittent waves of pyrexia of a distinctly remittent type. These waves of pyrexial intensity were separated by periods of apyrexia, giving a peculiar relapsing character to the fever. In some instances the daily remissions became so marked that the temperature became intermittent in character.38 In 1897, Captain Matthew Louis Hughes proposed that the names Malta Fever and Mediterranean Fever be replaced by Undulant Fever. Hughes pointed out that "the temperature constitutes the primary, in many cases, the only clinical manifestation of the illness, and although the curve may not always be of the undulant type yet the phenomenon is sufficiently frequent and typical to justify the adoption of the word undulant as a term which would clearly convey to any person the principal clinical feature of the disease".39
Chart V plots the admissions for Enteric vs Malta vs Remittent Fevers for the years 1859 to 1909. No more admissions for Remittent Fever, (purple), are recorded after 1897 when the heading of Malta Fever was introduced into the nomenclature of diseases. The year 1894 recorded the highest number of admissions for remittent fever (273 with 1 death). This was more than double the admissions for 1893 (121 with no deaths). In 1897 there were 279 admissions for Malta Fever, (blue), with 12 deaths. The highest number of admissions was in 1905 with 634 admissions and 6 deaths. In 1897, Hughes gave the mortality rate for Malta fever as slightly over 2 per cent of the cases attacked; Johnstone gave the case mortality in the Army, from 1897 to 1903, at 3.2 per cent.
Malta Fever was blamed on poor sanitation. In July 1887, Bruce conclusively proved that Malta Fever was an infection with the Micrococcus melitensis, but how the germ entered the body was not known. Dr Temi Zammit, bacteriologist to the Public Health Department, suggested conveyance of the infection by some blood sucking insect. Major Sydney Glenn Allen, officer in charge of the Floriana district January 1902 to September 1903, reported that the prevailing view among the officers of the RAMC in Malta was that the disease was an airborne infection. This theory was accepted and advocated at the time by the Senior Medical Officer in Valletta, and all sanitary recommendations put forward to check the disease in the station, were based upon it. Captain James Crawford Kennedy, officer in charge of the Valletta Laboratory, attributed the extraordinary amount of Mediterranean Fever among the men of the regiments in the summer of 1903 to the disturbance of the soil during the building of new quarters close to the men's barracks. Kennedy was convinced that the disease was air-borne, and that it entered the body through the tonsils.
In October 1902, the 1st/Kings Royal Rifle Corps arrived in Malta from South Africa, and occupied Floriana Barracks. A new block of married quarters had been completed just before their arrival, and was inhabited for the first time by the regimental families. These married quarters overlooked the Quarantine Harbour. During the first six months of 1903, the occupants of the new families quarters at Floriana enjoyed good health. However, about the middle of June, cases of Mediterranean Fever appeared, and the infection passed from quarter to quarter until a large proportion of the families were affected. The infection spread to the families of the Royal Engineers, occupying quarters which had only been completed in autumn 1902, situated on the other side of the road closer to Valletta. In 1903, there were 404 admissions for Mediterranean Fever (9 deaths), 781 admissions for simple continued fevers (zero deaths), and 18 admissions for enteric fever (8 deaths). It was postulated that those infected had contracted their illness through the inhalation of the Micrococcus melitensis in dust that had been disturbed by the digging of new foundations for married quarters.
The role of the goat in the transmission of Malta Fever was fortuitously stumbled upon by Dr Themistocles Zammit. On 12 June 1905, six goats were placed at the lazaretto to ascertain by experimental inoculation, whether the animal was susceptible to infection with the M. melitensis or not. On 14 June, Zammit carried out a preliminary agglutination test on each goat, and to his amazement found that the serum of five of the goats, agglutinated the micrococcus. On 23 June 1905, Major William Heaton Horrocks announced the discovery of the Micrococcus melitensis in the milk of an apparently healthy goat. Further examinations of animals in herds supplying milk to the Valletta Station Hospital, and Forrest Hospital St Julians' Bay found the M. melitensis being exuded with the milk in enormous numbers. Malta had 20,000 goats which supplied milk to the whole island. Half of these animals were affected by Malta Fever, and a tenth were constantly passing the micrococcus in their milk.
Zammit and Horrocks were members of the Mediterranean Fever Commission, which was set up by the Royal Society in February 1904, at the instigation of the Secretary of State for the Colonies, Alfred Lyttelton. David Bruce was appointed Chairman of the commission. He arrived in Malta on 13 June 1904, when work begun in earnest. Bruce returned to England on 14 July 1904. The members of the Malta Fever Commission between 1904 and 1906 were:
Colonel David Bruce – Chairman
Dr Themistocles Zammit, Board of Health, 1904-06
Captain James Crawford Kennedy RAMC, 1904-06
Dr Ralph W Johnstone, Local Government Board, 30 June 1904
Major William Heaton Horrocks RAMC, 1904-05
Fleet Surgeon P W Bassett-Smith RN, 1904-05
Staff Surgeon R T Gilmour RN, Bighi Hospital, 1904-05
Lt Col Arthur Mercer Davies RAMC, 1905
Staff Surgeon E A Shaw RN, 1905-06
Major James Christopher Weir RAMC, 1906
Major James Gibson McNaught RAMC, 1906
Dr J W H Eyre, Bacteriologist Guy's Hospital, 1906
Major Thomas McCulloch RAMC, 1906
Staff Surgeon E M A Clayton RN, 1906
Brucellosis infected medical and nursing staff, and patients admitted to the Royal Naval Hospital Bighi, and the military hospitals. One-third of all cases of the fever occurring in the fleet at Malta, originated in the Royal Naval Hospital, either as patients suffering from other diseases, or among the nursing staff. In 1901, out of 10 naval sick-berth staff who became ill, 7 were hospital acquired; in 1902, out of 28 cases, 22 were hospital acquired; and in 1903, out of 15 cases, 11 were hospital acquired. Thus, out of the 53 attacked among the sick-berth staff, 40 of them contracted the disease while serving in the hospital.40 The army hospitals fared no better as Table I for 1905 illustrates:
Table I. Malta Fever in Military Hospitals 1905
Number of Patients
Strength of RAMC
Hospital Acquired Malta Fever In Patients
Hospital Acquired Malta Fever In RAMC
Hospital Acquired Malta Fever In Attached
In 1905, the total number of cases of Mediterranean Fever acquired in hospital, either as patients admitted for some other illness, or as non-commissioned officers and men of the Royal Army Medical Corps, and other men attached for nursing duties, amounted to 56. Of this number 33 occurred at Valletta Hospital, and 17 at Cottonera Hospital. In total, 23 patients, 30 RAMC, and 3 men attached for nursing duties contracted Brucellosis. From A M Davies, J.RAMC 1906; vii: 319.
In 1905, one out of the four nurses of the Queen Alexandra's Imperial Military Nursing Service employed at the Valletta Hospital, went down with Mediterranean fever. Of the four nurses working at Cottonera Hospital, four cases occurred in June and July 1904, and two in January 1905. On 20 June 1905, the head nurse of the Military Families Hospital situated alongside of the Military Hospital Valletta, was placed on the sick list with Mediterranean Fever. The sisters working at the Valletta Station Hospital were accommodated in rooms overlooking the hospital quadrangle; those at Cottonera Hospital had their own sisters' quarters located in a detached house in the hospital grounds. At Cottonera Hospital, it had been the practice until July 1905, to milk the goats on a plot of land within a few yards of the sister's quarters. This became fouled with goat's urine and faecal droppings, and it was assumed that the sisters became infected through the inhalation of infected air borne droplets, as no further cases occurred among them during the summer, once the goats were removed from this spot. On 21 May 1906, the supply of goat's milk to military hospitals was stopped, and in June 1906, the military banished goat's milk from all barracks and substituted it by tinned milk.41
Table II shows the incidence of Malta Fever in the Valletta Garrison from 1897 to 1904.
Table II. Malta Fever Valletta Garrison 1897-1904
Annual Average Strength
Annual Average constantly sick
Number of cases per 1000 constantly sick
Number of Malta Fever
Number of cases per 1000 of strength
Number of Malta Fever infected in hospital
Annual Average Strength RAMC
Number of Malta Fever in RAMC
Number of RAMC Malta Fever per 1000 of strength
Malta Fever Valletta Garrison 1897-1904 from J C Kennedy J.RAMC 1905; 4 (5): 634 (May 1905)
According to Colonel James Gaussen MacNeece, up to the middle of 1906, the garrison of Malta lost the services of some 650 soldiers and sailors for 120 days each every year, making a total of some 80,000 days of illness. From July 1906, when the new preventive measures were brought into use, Malta Fever had virtually disappeared from the garrison. No cases of Mediterranean Fever were contracted in military hospitals after June 1906. In 1906 there were 163 admissions to hospital from Malta fever (4 deaths), of which 19 were distinct relapses. The total average strength of the garrison during this period was 6,661, giving a percentage of admissions to strength for Malta Fever of 2.44 per cent, and relapses of 0.29 per cent. In 1907, the number of admissions for Malta fever was 11 with 1 death. Of these, two were relapses of cases admitted the previous year. All the 11 cases that occurred in 1907 were traced to the use of unboiled goat's milk. The garrison strength was 5,700. The percentage of admissions to strength among the troops in 1907 was only 0.19 per cent. In 1908, there were 5 admissions for Malta Fever; the following year there was just 1 admission. The number of cases of Malta fever contracted in the Royal Naval Hospital in 1905 was 105, and after goats' milk was discontinued in 1906, and tinned milk substituted, not a single case of that disease had been contracted in the hospital. The threat posed by Malta Fever to the health of the garrison had been virtually eliminated by the simple task of withholding goats' milk from the barracks.
Enteric Fever — Typhoid Fever
Enteric or typhoid fever is caused by Salmonella typhi, the so called Eberth bacillus, discovered by Karl Joseph Eberth in 1880. Enteric fever is spread by sewage contamination of drinking water, or pollution of milk and food by flies, or human carriers of the typhoid bacillus. About 1 to 3 per cent of enteric fever patients became chronic carriers, who continued to excrete the organism in their stools.
In 1878, Surgeon General John Harry Ker Innes remarked that enteric fever was pre-eminently the disease of which soldiers die; it is one, if not the chief, source of sickness and inefficiency in well nigh every corps and battery. Although his remarks referred to the Bengal Presidency, they were equally relevant to the Maltese islands. Innes described enteric fever as a fever of varying degrees of severity and duration, but invariably lasting beyond a week, with an evening temperature of over 100 F ( 37.7 C), and characterised by a tendency to abdominal symptoms, looseness of the bowels, the appearance of rose coloured spots in successive crops, sparsely spread, and pulmonic complication; the disease is invariably connected with splenic enlargement, an infarction of the peyerian and solitary and mesenteric glands, and commonly followed by ulceration in the former. Faecal contamination of the air or water was regarded as the cause.
Chart VI portrays the deaths from fevers in the Malta Garrison for 1859 to 1909. This shows that enteric fever (purple) was the most destructive of all the fevers. The case mortality of total continued fevers over this period was 1.93 per cent; the case mortality for continued fevers less enteric was 0.83 per cent; the case mortality for enteric fever was 19.8 per cent; in marked contrast, the case mortality from Malta Fever (1897-1909) was only 2.93 per cent. The highest number of recorded admissions for enteric fever occurred in 1883 (120 admissions/17 deaths) and 1893 (101 admissions/32 deaths). The highest number of recorded deaths was in 1878 (94 admissions/32 deaths) and 1893. The returns for 1883, 1884 and 1885 show the impact exerted by enteric fever on the health of the station.
In 1883, the average strength of the garrison was 4,611. There were 3,526 hospital admissions, giving a ratio of 764.7 per 1000; and among these were 40 deaths, a mortality of 8.67 per 1000 of the strength. Enteric fever caused 120 admissions, and led to 17 deaths. On one occasion, when 21 cases from the same barracks were admitted in the course of a month, it was discovered that two pipes had been broken, and the water had become contaminated. The medical officer in charge remarked that, on the pipes being mended, the disease ceased almost at once. Foul water was also suspected at Cottonera, where there were 64 admissions and 5 deaths; while at another station, where there were 5 admissions and 1 death, the disease was believed to have been contracted in the low parts of Malta to which the men had resorted".43
In 1884, the average strength of the garrison was 4,637. This force generated 3,897 admissions into hospital, giving a ratio of 840 per 1000; and among these were 43 deaths, a mortality of 9.27 per 1000 of the strength. The average number constantly sick was 272.04, equivalent to a rate of 56 per 1000. Enteric fever caused 94 admissions, with 22 deaths. Of the 94 cases of enteric fever, 46 with 11 deaths, occurred at Cottonera; 36 cases with 9 deaths, at Valletta; 6 cases with 2 deaths at Forrest Hospital St Julian's; and 6 cases at Civita Vecchia, all of which recovered. The medical officer in charge of Cottonera remarked that "The disease was of a severe type, occurring in young soldiers; the average age in the fatal cases was 22 years 5 months, and service 2 years. The greatest number of cases were admitted in May, June, and July, with almost a total cessation of the disease in August, September, and October, the months when it is usually most prevalent. Every barrack in the district contributed to the disease. It is remarkable that only two cases occurred among the women and children, occupying the same quarters, and with the same water-supply". The medical officer was of the opinion that "this disease is seldom contracted in barracks, but in the very unsanitary houses of the natives which the soldiers frequent".44
In 1885, the average strength of the garrison of Malta was 4,602. This force generated 4,249 admissions into hospital, giving a ratio of 923.3 per 1000; and among these were 68 deaths, a mortality of 14.77 per 1000 of the strength. The average number constantly sick was 272.04, equivalent to a rate of 59.11 per 1000. Enteric fever caused 93 admissions and 24 deaths. The deaths from this disease were equal to 35 per cent of the deaths from all causes. Of the 93 cases, 14 with 6 deaths, occurred at Valletta; 74 with 15 deaths, at Cottonera; and the remaining 5 cases broke out at Civita Vecchia. The principal medical officer attributed the disproportion in the number of cases which occurred between Valletta and Cottonera to the improved water-supply of Valletta, while there was no corresponding improvement in the water-supply of Cottonera. The medical officer in charge of Cottonera remarked that the "enteric fever was very fatal during the hot months, and the year 1885 was one of the hottest ever known in Malta".45
Enteric fever was a constant companion in the insanitary barracks occupied by the troops. On 28 November 1893, an epidemic of enteric fever broke out at Pembroke Barracks St George's Bay. The outbreak followed the heavy rains of 13 and 14 November. Pembroke Barracks was a relatively new camp. It was commenced in June 1860, and consisted of six block buildings; four composed of fourteen rooms, and two of seven. Each room had sufficient space for 14 men. In front of each room was a veranda supported on pillars and arches. The men and families were placed partly in stone barracks, and partly in wooden huts. The barrack rooms were built in two lines at a sufficient distance from each other. The huts were constructed on sloping ground in a valley across the natural fall of the drainage. The permanent married quarters also occupied less favourable ground than the barracks, and were situated at the foot of the slope falling from the barracks to St George's Bay. Between the barracks and these quarters were large blocks containing school rooms, day rooms, and offices of various kinds.
Early in 1894, a Joint Civil and Military Committee convened to investigate the typhoid outbreak of the previous year. Their findings revealed grave defects in the sanitary arrangements of the barracks. The chief points requiring attention were the water supply, which was shown to be polluted, and the drainage, which required complete renovation. Suspicion was also cast on the supply of mineral water and milk plied by hawkers to the soldiers. Consequently, the polluted water supply was cut off, and none but aqueduct water was used. The question of renovating the camp drainage proved to be more difficult, as a complete scheme for remodelling the drainage of the whole island had been under consideration, and a thorough reconstruction of the sewers of the camp could only be undertaken in connection with it. Thus, although the drains were in a very foul condition, and dangerous to the health of the troops, no immediate remedial measures were taken. Subsequently, in 1896, the two regiments stationed at the camp, namely 1st/Royal Warwickshire and 1st/King's Own (Royal Lancaster), were obliged to turn out into the parade ground, because of the insanitary condition of the barracks.46
On 21 February 1896, Captain Wilfred Sausmarez Carey and Private James Lucas, 1st/Royal Warwickshire Regiment, died from enteric fever at Pembroke Camp. In March 1896, the Earl of Buckinghamshire, declared in the House of Lords, that Pembroke Camp was in a "shockingly insanitary condition". He asked the Marquis of Lansdowne, Secretary of State for War, whether any inquiry had been instituted into the sanitary arrangements at Pembroke Camp, and what amount of money had been spent there on sanitary arrangements, since the last outbreak of enteric fever. The Marquis of Lansdowne, replied that "much had been done to improve the sanitation of Pembroke Barracks. The remodelling of the drainage of the upper half of the camp had been sanctioned in May 1895, and considerable progress had been made with the work. During 1895, about £300 had been spent on improving the existing drains, and besides this, a very considerable sum had been devoted to the partial remodelling of the drainage. As, however, this had been done in connection with the reconstruction of a part of the barracks, the specific expenditure on drainage had not been earmarked".46
It is interesting to note, that the 1st/King's Own (Royal Lancaster) Regiment, who had arrived in Malta on 4 October 1895, moved from Pembroke Camp to Mtarfa Barracks, where in July 1896, nine cases of enteric fever broke out amongst them – a possible outbreak from a typhoid carrier.
Enteric Fever fell markedly in 1906, when lectures on sanitation were given to all officers, non-commissioned officers, and men by the medical officers in charge of troops. In 1907, there were 14 cases in the command; bacteriological examinations showed that 12 of these were due to infection by an organism of the paratyphoid group. In the country districts of Malta, vegetables were very often watered with liquid sewage from cesspits; such vegetables were often bought by soldiers, and when eaten raw, as is the case with lettuce, were a likely cause of paratyphoid fever. Consequently, a Garrison Order was issued, directing that vegetables eaten uncooked should first be thoroughly washed in water, and then rinsed in a weak solution of vinegar. In 1908, there were only 5 cases of enteric fever; two of these were due to infection by an organism of the paratyphoid group.
Typhoid remained the bane of the army. The memorial to the 2nd/Queens Regiment is a poignant reminder, that in war, diseases take more lives than bullets. Of the regimental men lost, only 19 were killed in action; 21 died subsequently of their wounds, but 99 died of disease. Of the 22,000 lives lost in the South African War, the enemy is debited with only 8,000; preventable febrile diseases for 14,000. Among these, typhoid fever headed the list, 57,684 cases, of whom 19,454 were invalided (33 per cent), and 8,022 died (13.9 per cent). The Bacillus typhosus alone did more damage than the Boers.
The first vaccinations against typhoid were undertaken in July and August of 1896. These were recorded in the Lancet on 19 September 1896 by Sir Almroth Wright, Professor of Pathology at the Army Medical School Netley (1892–1902). On 30 January 1897, Wright and Surgeon Major David Semple, Assistant Professor of Pathology Netley (1894–1899), published their paper on the use of anti-typhoid inoculation of soldiers with dead typhoid bacillus in order to induce immunity.47 During the South African War Wright supplied some 400,000 doses of anti-typhoid vaccine, but only 100,000 men were inoculated as the procedure was not compulsory. A modified vaccine was later developed by Colonel William B Leishman, who succeeded Wright as Professor of Pathology (1903-1910). Leishman's vaccine was administered in two doses, with an interval of ten days between them. The inoculations remained voluntary, but every effort was made to popularize the method by means of lectures to all drafts and regiments proceeding on foreign service. Eight medical officers were attached for a period of three years, to regiments proceeding on foreign service, so as to evaluate the efficacy of vaccination on the troops.
The value of anti-typhoid inoculation was shown in the Great War, where the vaccine significantly reduced the incidence of typhoid fever. During the war, the Vaccine Department of the Royal Army Medical College produced more than thirty-three million doses of vaccines against typhoid, cholera, and dysentery. From August 1914 to the end of 1918, the British Army in France had only 7,423 cases of typhoid and paratyphoid fever, with 266 deaths. In contrast, the French Army, before it was fully protected by anti-typhoid vaccination, had from the beginning of hostilities to the end of October 1915, 95,809 cases, with 11,690 deaths.
The original anti-typhoid vaccine did not protect against paratyphoid fever, a prevalent infection in the East. This omission was rectified by the use of the combined typhoid-paratyphoid vaccine, and after 1916 the incidence of the enteric fevers became practically minimal. A new improved vaccine of Bacterium typhosurn, Bact. paratyphosum A, and Bact. paratyphosum B was brought into general use in the British Army in 1933.
Mortality and Morbidity Military Families
Table III gives the composition of the Malta garrison in 1833. It shows the strength of the station as 2117 non-commissioned officers and men, 235 wives, and 450 children. The mortality rate per 1000 strength was 18.4 for soldiers, 21.2 per 1000 for wives, and 60 per 1000 for children. Mortality was higher in families, as the army initially made very little provision for their welfare. Families lived in insanitary conditions. No married quarters were built in Malta until the 1860s when blocks were built at Pembroke Camp, near Polverista Gate, and on the Ravelin of Floriana. Married families were often just placed in huts or casemates, which they shared with the single soldier; their only degree of privacy being a rug suspended here and there by some constructed contrivance. In 1865, there were no suitable married quarters at Floriana Barracks. Families of the 2nd/4th Regiment consisting of 29 women and 48 children, were placed in wooden huts in the Horn Work of Floriana. The families of the 100th Regiment (21 women and 38 children) occupied the Crown Work of Floriana.
By 1897, the number of families had reached 422 wives and 740 children (Table IV). In August 1879, the British Medical Association was so appalled by the insanitary conditions under which the women and children of soldiers in Malta had to live, that it proposed the drastic solution of prohibiting soldiers to marry, until they transferred to the reserves. "They are living under conditions so insanitary", reported the Journal of the Association, "as to generate and aggravate disease and to render treatment useless. The women suffer from fever, and the children from diarrhoea, to an extent that can only be caused by want of proper sanitary arrangements. In our opinion, soldiers under the six years' term of enlistment may fairly be made to come under an arrangement not to marry until they enter the reserve. In this way, a great saving would result to the State, and much misery, disease, and death be prevented among women and their children. But so long as soldiers are permitted to marry, and to take their families, however limited by regulation in number, to foreign stations, it is clearly the duty of the State to see that they are not exposed to such causes of disease as obtained in Malta".48
Table III. Annual Sick Returns for year ending 31 December 1833
Royal Artillery And Royal Engineers
7th Royal Fusiliers
42nd Royal Highland
There were 72 deaths in the garrison in 1833 equivalent to a mortality rate of 24.7 per 1000 total strength. Of these: two deaths in 7th Fusiliers were suicides; 2 sudden deaths in 42nd Royal Highlanders from a ruptured aneurysm and convulsion; 1 sudden death in 94th from acute disease while detached to Gozo. From Davy J., Annual Sick Returns for year ending 31 December 1833. TNA:WO 334/10.
The number of women and children permitted to reside with their husbands in barracks was dictated by the Royal Warrant for the Regulation of Barracks dated 16 March 1824. Every soldier who intended to marry, had to obtain the consent of his commanding officer. He had to declare "the name and condition of the woman he proposed to marry, and whether she was a spinster or widow". General Order Horse Guards 18 March 1829, directed commanding officers not to allow soldiers who had married without permission, to have their wives in barracks, or to participate in any of the advantages extended by the regulations to married soldiers, and to their wives of good character.
The General Order went on to warn soldiers, "that their comforts as soldiers are in a very small degree increased by their marriage, while the inconvenience and distress naturally occurring to them from such connection are serious and unavoidable, particularly when regiments are ordered to embark on foreign service, when only six women to a 100 men are allowed to proceed with their husbands. On these occasions commanding officers were placed under considerable embarrassment in making selection of the women who are permitted to accompany their husbands abroad, and of those who are to be compelled to return to their friends or their parishes."
Under War Office Circular 849 Section X, and Clause 50 Army Circular 1867 Para 41, women and children who were not entitled to public quarters, were not to be admitted into the military hospitals under any circumstances. Those not on the strength were simply abandoned by their regiments. Charities such as the Soldiers and Sailors Families Association which provided comfort to the wives and families of soldiers off the strength did not exist until after 1885. In May 1866, Mrs Mary Anne Walker was left destitute at Malta. Although she had been on the strength of 2nd/4th Regiment, she separated from her husband as she did not agree with him, and was therefore left behind when the regiment sailed from Malta. Similarly, on 7 June 1866, a woman and her child, were denied embarkation with the 1st/22nd Regiment for New Brunswick, as she had married a soldier by the name of Ellis without the permission of his commanding officer, and was thus not on the strength of the regiment.49
Table IV. Average Strength Women and Children 1898 to 1907
Ave Strength Officers
Ave Strength Soldiers
Ave Strength Wives
Ave Strength Children
From Gilbert Stewart Crawford, Sanitary Work in Malta Br Med J 1909;2:369.
Table V gives a breakdown of the diseases of families admitted to the Military Families Hospital Valletta between January 1909 and August 1914.50 A relatively common infection in Malta was infantile Kala-azar. In the military population this accounted for 17 admissions with 4 deaths. Among the civilian population, the report of the Public Health Department for 1910-11 gives a total of 69 cases of leucocythaemia (Kala-azar) during the year, of which 66 occurred in children below the age of 5 years.
Table V. Mortality in Military Families January 1909 to August 1914
From January 1909 to August 1914 there were 562 general cases with 7 deaths; children 648 cases with 84 deaths. There were 597 parturition cases with 2 deaths. Births 288 boys and 255 girls, and stillbirths 10. From Weld A E., A short note on the work in the Military Families Hospital Malta during the period from January 1909 to August 1914. J R Army Med Corps 1915; 24 (6);579 (June 1915).
The greatest cause of infantile mortality in Malta was enteritis. In 1905, there were 60 admissions and 13 deaths in the garrison from this disease. The highest admission rate was at Mtarfa, which gave 20 admissions and 5 deaths. In 1906, Major Gilbert Stewart Crawford was tasked by the Principal Medical Officer to combat the high incidence of infantile gastroenteritis among the families. In 1906, Mtarfa had the families belonging to the Sussex Regiment stationed in Crete, and in 1907, the married quarters at Mtarfa were kept filled by families sent there by the PMO for change of air. Crawford imposed strict sanitary measures on the families, and instructed the wives on the basic principles of hygiene. Quarters and water closets were cleaned and inspected weekly. Foodstuffs were covered with gauze to keep off flies and dust, and small wire gauze meat safes were provided for each quarter. Mothers were advised as to suitable clothing and food for children, and the necessity of reporting cases of sickness early was impressed upon them. By these measures, Crawford reduced the incidence of gastroenteritis at Mtarfa. In 1906 and 1907 there were only 3 cases of enteritis with no deaths. In 1905, there had been 11 deaths at Mtarfa from all causes; the rest of the garrison had 46 deaths. In 1906 and 1907 there were no deaths among children at Mtarfa; the rest of the garrison had 29 and 25 respectively.51
By 1906, new barracks had been built on Mtarfa Ridge, at St Julian's Bay and St George's Bay. Soldiers were moved away from the urban congestion of Valletta and the Three Cities to the airy and rural camps at Pembroke and Mtarfa. The construction of new sewers for Valletta and the Three Cities played a major role in reducing cholera and enteric fever. By 1913, the average number of soldiers admitted to hospital dropped to 116, from an average strength of 6,336 men. This represented an admission rate of 18.3 per 1000. The death rate was 2.21 per 1000. This favourable state was attributed to the almost complete eradication of Mediterranean Fever, and the gradual fall in the enteric group of diseases due to improved sanitation, and anti-typhoid vaccination. Another factor which had a possible bearing on the reduction in the admission rate, was a change in regulations in 1898, which allowed minor illnesses to be treated in barracks, without the need to be admitted to hospital, and thus appear on the statistics.
The number of sick with tuberculosis also dropped. Between 1837 and 1846 the incidence of tuberculosis was 6.1 per 1000 strength. From 1897 to 1906, it dropped to 2.8 cases per 1000 strength; in 1907 it was slightly lower at 2.4 per 1000 strength. This was favourable when compared with 5.3 per 1000 strength for Crete, and 3.5 per 1000 strength at Gibraltar in 1907. This improvement coincided with the erection of modern barracks and the increased space allowed to each man in the older barracks. The eye infection, known as ophthalmia, also decreased with better ablution facilities and the washing of hands. In the sixties, ophthalmia had been one of the greatest scourges in the Malta garrison. In 1861, for instance, the strength was 6,185, and the number of admissions with this ailment was 598. In 1907, the strength was 5,700 and the number of admissions was 15; in 1908 the strength was 6,030 and the number of admissions was 18.52
In the 19th century, Malta had been regarded as a very undesirable station due to the amount of sickness prevalent in the garrison. This attitude changed post 1906, when suddenly the Maltese Islands became one of the healthiest of the foreign stations. The improvement in the mortality and morbidity of the station was due to a better understanding of hygiene and the implementation of sanitary measures, coupled with new scientific discoveries, in which officers of the RAMC like David Bruce and William Leishman played a leading role.
1Tulloch A. and Marshall H., Report on the sickness and mortality of troops in the Mediterranean (Ionian Islands). The United Service Journal and Naval and Military Magazine Feb 1840;i:227, Henry Colburn London.
2Tulloch A., and Marshall H., Report on the sickness and mortality of troops in the Mediterranean (Malta). The United Service Journal and Naval and Military Mag zine Dec 1839;iii:522, Henry Colburn London.
3Ghio A., The cholera in Malta and Gozo in the year 1865. Malta Government Printing Office 1867.
4Reports of the sickness, mortality and invaliding among troops in the United Kingdom, the Mediterranean and British America from the records of the Army Medical Department in First Annual Report of the Registrar General of Births, Deaths and Marriages in England. pp 21-29 London 1839.
5Ancell H., Facts and opinions relating to tuberculosis with commentaries. Br Med J 1853;1:895 (Published 14 Oct 1853).
6TNA:WO 334/16, Gibraltar, Malta and Ionian Islands Apr 1847–Mar 1848 Annual sick returns and reports of hospitals abroad.
7Davy J., TNA:WO 334/10, Annual sick returns and Reports of Hospital abroad ending 31 December 1833.
8Statistical, Sanitary, and Medical Reports of the Army Medical Department Report for the year 1866; viii.
9Army Medical Department Report for the year 1867; ix:52.
10Malta harbours and Mediterranean fevers. Br Med J 1894; 2:1456.2 (Published 22 Dec 1894).
11Malta Fever and the harbour at Malta Br Med J 1889; 1:1252 (Published 1 June 1889).
12The Sanitary Condition of Malta Harbour. Br Med J 1889; 1:1325.2 (Published 8 June 1889).
13Malta Harbour. Br Med J 1889; 1:1480 (Published 29 June 1889).
14The Health of Malta. Br Med J 1874; 2:747 (Published 12 Dec 1874).
15Wellcome RAMC 374, o/s 18, 1821-22. MS volume of hospital reports and medical summaries from British Army Medical Staff in Malta, Gozo and the Ionian Islands. Hennen J., Observations to accompany the returns of medical diseases from 1816 to 1822 inclusive.
16Health of the Army at Home, Army Medical Department Report for the year 1860. Br Med J 1862; 2:497 (Published 8 Nov 1862).
17Sanderson John Burdon, Address in Physiology Br Med J 1873; 2:152 (Published 9 Aug 1873)
18Goodridge Henry F A., The progress of fever pathology Br Med J 1876; 2:137 (Published 29 July 1876)
19Boileau J P H., Remarks on fever in Malta, with cases, with special reference to the use of the thermometer in diagnosis and prognosis, in Appendix xlvii, Army Medical Department Report for the year 1866; viii: 478-492, (London 1868).
20Wright A E, Semple D., On the employment of dead bacteria in the serum diagnosis of typhoid and Malta fever. Br Med J 1897;1:1214. (Published 15 May 1897).
21Zammit T. The Serum Diagnosis of Mediterranean Fever. Br Med J 1900; 1:315.1 (Published 10 Feb 1900).
Gerrard J J., Notes on Simple Continued Fever. J R Army Med Corps 1907; 9 (5): 487–495 (Nov 1907).
Gerrard J J., Further notes on fevers in Malta. J R Army Med Corps 1909; 13 (3): 390–399 (Sept 1909).
22Birt C., Phlebotomus Fever in Malta and Crete J R Army Med Corps 1910;14 (2): 142-159 (Feb 1910).
Birt C., Phlebotomus Fever in Crete and Malta. J R Army Med Corps 1910;14 (3): 236-258 (Mar 1910).
23Malta Fever Editorial Part II. J R Army Med Corps 1904; 2 (4): 733 (Published Apr 1904).
24Don William G., On the Endemic Continued Fevers of Subtropical Latitudes. Br Med J 1880; 2: 737 (6 Nov 1880).
25Schultze D, Korte W, Rafeiner P, Niedrig M. First report of sand-fly fever virus infection imported from Malta into Switzerland, October 2011. Euro Surveill. 2012;17(27):pii=20209.
Marett P J., An outbreak of simple continued fever assuming epidemic form amongst non commissioned officers and men of C Company 4th Battalion Rifle Brigade. J R Army Med Corps (1909); 13 (3):252 (Sept 1909).
Birt C., Phlebotomus Fever or Sandfly Fever. Br Med J 1915; 2:168 (Published 31 July 1915)
Birt C, Phlebotomus fever and dengue. Br Med J 1913 ; 2:1297 (Published 15 Nov 1913).
Babington M H., Notes on a case of a disease prevalent in Malta and known there as Splenic Leucocythaemia. J R Army Med Corps 1909; 13 (3):291–294 (Sept 1909).
29Corps News - Notes from Malta J R Army Med Corps 1909 vol xiii: 46 (Aug 1909).
30Babington M H., Case of Kala-azar. J R Army Med Corps 1909; 13 (3): 291 (Sept 1909).
31Baker W L., Some notes on a case of Kala-azar in Malta. J R Army Med Corps 1911; 17 (4):380 (Oct 1911).
32Babington M H., Case of Kala-azar. J R Army Med Corps 1911; 17 (4): 380-386 (Oct 1911).
33Kala-azar in an adult contracted in Malta, Br Med J 1944;1:670.2. (Published 13 May 1944).
34Agius Ferrante T J., Infantile Visceral Leishmaniasis in the Maltese Islands. Br Med J 1955; 2:654. (Published 10 Sept 1955).
Weld A E., A clinical note on two cases of Kala-azar treated with Salvarsan at the Military Hospital Valletta. J R Army Med Corps 1911; 17 (3);275 (Sept 1911).
Leishman W B., Infantile Kala-azar J R Army Med Corps 1912; 18 (1): 1-20 (Jan 1912).
Bassett-Smith P W., Discussion on Kala-azar or parasitic splenomegaly and allied infections. Br Med J 1914; 2:1058. (Published 19 Dec 1914).
Brit C., Bateman R., Kala-azar. J R Army Med Corps 1906; 4 (3):341 (Oct 1906).
Newman R E U., Note on three cases of infantile Kala-azar. J R Army Med Corps 1922; 38 (5):379 (May 1922).
Gatt T E H., A case of splenic anaemia in a child due to Leishmania infantum. J R Army Med Corps 1921; 37 (2):142 (Aug 1921).
Bassett Smith, Kala-azar in an adult from Malta. J R Army Med Corps 1913; 21 (5):581 (Nov 1913).
Bentley C A., Kala-azar as an analogous to Malta Fever. Preliminary notes of an investigation and some discoveries regarding the nature of the condition known as Kala-azar, Br Med J 1902; 2:872. (Published 20 Sept 1902).
Localized Leishmaniasis of lymph nodes Kala-azar in Malta. Br Med J 1958; 1:740. (Published 29 Mar 1958).
Davies A M., Report on the prevalence of Mediterranean fever amongst troops in Malta 1905. J R Army Med Corps 1906; 2;94 (Aug 1906).
41Davies A M., Report on the prevalence of Mediterranean fever amongst troops in Malta 1905. J R Army Med Corps 1906; 7 (5);419 (Nov 1906).
42Crawford Kennedy J., Malta fever in the military hospital Valletta Malta during the years 1897 to 1904. J R Army Med Corps 1905; 4 (5): 634 (May 1905).
27Wood O G. What is Malta Fever? Br Med J 1876; 1: 495 (Published 15 April 1876)
Malta Fever. J R Army Med Corps 1904; 2 (4):485, 603. and 731 (Published Apr 1904).
Malta Fever Br Med J 1889; 1:1124 (Published 18 May 1889.
Malta Fever Br Med J 1894; 2:161 (Published 21 July 1894).
Notes from Malta (Mediterranean Fever) J R Army Med Corps 1904; 2; 5: 641. (May 1904).
Reports of the commission appointed by the Admiralty, the War Office and the Civil Government of Malta, for the investigation of Mediterranean fever under the supervision of an advisory committee of the Royal Society.
Godding C C., Malta (Remittent) Fever an analysis of clinical notes of forty two cases in HMS Agamenon, Br Med J 1891; 1:1065 (Published 16 May 1891).
Vassallo D J., The Corps Disease: Brucellosis and its historical association with the Royal Army Medical Corps. J R Army Med Corps 1992; 138:140-150
Bruce D. Notes on Mediterranean or Malta Fever - its Bacteriology. Br Med J 1893; 2:58 (Published 8 July 1893).
Bruce D. Note on Malta Fever, Br Med J 1891; 1:1281 (Published 13 June 1891)
Hughes M L. The geographical distribution of Undulant (Malta) Fever Br Med J 1899; 2:657 (Published 9 Sept 1899).
Glenn Allen S., Some observations on an outbreak of Mediterranean fever in Malta last year, with special reference to the air-borne theory of conveyance of the infection. J R Army Med Corps 1904; 2 (6):699 (Published June 1904).
Crawford Kennedy J., A little humour from the Malta Fever Commission. J R Army Med Corps 1907; 9 (6): 594 (Dec 1907).
Horrocks W H., Preliminary note on goats as a means of propagation of Mediterranean fever. J R Army Med Corps 1905; 5 (3): 343 (Sept 1905).
43Statistical, Sanitary, and Medical Reports of the Army Medical Department Report for the year 1883 concluding part, vol xxv London 1885. Br Med J 1886; 1: 501 (Published 13 Mar 1886).
44Statistical, Sanitary, and Medical Reports of the Army Medical Department Report for the year 1884 part two, vol xxvi London 1886. Br Med J 1886; 2:879 (Published 6 Nov 1886).
Statistical, Sanitary, and Medical Reports of the Army Medical Department Report for the year 1884, vol xxvi London 1886. Br Med J 1886; 2:631 (Published 2 Oct 1886).
45Statistical, Sanitary, and Medical Reports of the Army Medical Department Report for the year 1885, Br Med J 1888; 1:141.2 pp 154-155 (Published 21 Jan 1888).
46Medico-Parliamentary House of Lords, Camp sanitation at Pembroke. Br Med J 1896; 1:824 (Published 28 Mar 1896).
47Wright A E, Semple D., Remarks on vaccination against typhoid fever. Br Med J 1897; 1:256 (Published 30 Jan 1897).
The entity of enteric fever. Br Med J 1898; 2:1829-1830 (Published 17 Dec 1898)
Budd W., Observations on Typhoid or Intestinal Fever: The Pythogenic Theory Br Med J 1861;2:575. (Published 30 Nov 1861).
Hughes M L., Diagnosis between Enteric Fever and the Remittent Fever of the Mediterranean, with a note on Ehrlich's Urine Test. Br Med J 1894;2:219. (Published 28 July 1894).
Statistical, Sanitary, and Medical Reports of the Army Medical Department Report for the year 1867, vol ix.
Statistical, Sanitary, and Medical Reports of the Army Medical Department for the year 1876, vol xviii London Harrison and Sons 1877. Br Med J 1878; 1:373 (Published 16 Mar 1878).
Statistical, Sanitary, and Medical Reports of the Army Medical Department Report for the year 1877, vol xix London HMSO 1879. Br Med J 1879; 1:592 (Published 19 Apr 1879).
Statistical, Sanitary, and Medical Reports of the Army Medical Department Report for the year 1879, vol xxi London 1881. Br Med J 1881; 2:860 (Published 26 Nov 1881).
Statistical, Sanitary, and Medical Reports of the Army Medical Department Report for the year 1883, Volume xxv London 1885. Br Med J (1886); 1:501 (Published 13 March 1886).
Statistical, Sanitary, and Medical Reports of the Army Medical Department Report for the year 1897, vol xxxix Br Med J 1899; 1:704.6, (Published 18 Mar 1899).
Army Medical Department Report for the year 1881, Vol XXIII, London 1883, Br Med J 1883; 2:1196-1198, (Published 15 Dec 1883).
Martin Montgomery R., Hennen's description of diseases in the island of Malta in History of the British possessions in the Mediterranean comprising Gibraltar, Malta, Gozo and the Ionian Islands. London 1837 pp 192-209.
The sanitary condition of the British Army, United Service Magazine and Naval and Military Journal 1858; 353 (Part I): 483-496 (Apr 1858).
Chaplin A. The rate of mortality in the British Army one hundred years ago. J R Army Med Corps 1916; vol xxvii (2): 204-211 (Aug 1916).
Report of the commissioners appointed to inquire into the regulations affecting the sanitary condition of the army, the organisation of military hospitals and the treatment of the sick and wounded. London, George Edward Eyre and William Spottiswoode 1858.
Unhealthy barracks. Br Med J 1867; 2: 255 (Published 21 September 1867).
The Health of Malta. Br Med J 1882; 2:177 (Published 29 July 1882).
Sinclair J., Abstract of presidential address on diseases prevalent in Malta. Br Med J 1889; 1:9 (Published 5 Jan 1889).
Mortality in the army in various stations Br Med J 1863 2:499 (Published 7 Nov 1863).
Report on the health of the army for 1908. Br Med J 1910;1:55.4. (Published 1 January 1910).
Sanitary Condition of Malta. Br Med J 1897; 1:1243 (Published 15 May 1897).
Fever in Malta Br Med J 1893; 1:1075 (Published 20 May 1893).
Fever and invaliding at Malta. Br Med J 1894; 2: 44.4 (7 July 1894).
Henle J., A treatise of General Pathology. Philadelphia 1853.
Murchison Charles, Lectures on the Practice of Medicine Lecture II - Pyrexia Br Med J 1872; 1 :175. (Published 17 Feb 1872)
Wright A E., Note on the Technique of Serum Diagnosis of Acute Specific Fevers. Br Med J 1897;1:139 (Published 16 January 1897)