clinical grounds alone, and apart from the agglutination test, it may be almost impossible. It may be that it is only on the post-mortem table that we have the relative assurance, from the absence of ulceration in the ileum, that we have had to deal with a case of undulant fever. Cultures from spleen pulp, with subsequent inoculation into animals, should give reliable evidence if the results are positive. Tuberculosis, abscess, empyema, malaria, relapsing fever, and all the causes of continued high temperature of a septic type have to be carefully excluded in attempting a diagnosis. The possibility of the concurrence of another infection, typhoid for example, must not be overlooked.
Prognosis.— In the present state of our knowledge it is impossible to say how long any given case of this disease may last, what the risk to life may be, or what complications may be encountered. Birt and Lamb, from a series of valuable observations, conclude that important deductions may be derived from the behaviour of the agglutinating substances present in the blood. Their conclusions are, briefly, as follow: (1) Prognosis is unfavourable if the agglutinating reaction is persistently low; (2) also if the agglutinating reaction rapidly falls from a high figure to almost zero. (3) A persistently high and rising agglutinating reaction sustained into convalescence is favourable. (4) A long illness may be anticipated if the agglutination figure, at first high, decreases considerably. These conclusions are borne out by Bassett-Smith's very careful work.
Treatment.— Malta and those Mediterranean ports in which this fever is endemic should be avoided by pleasure- and health-seekers during the summer. Those who are obliged to live there all the year round would do well, at this season, to leave the towns and reside in places of healthy repute in the country. As a matter of precaution, in the endemic area the drinking-water, food, and drains ought at all seasons to receive special attention. All milk should be avoided, or sterilized by boiling, and food dishes should be washed with boiled water. Every care
