58 REVIEW — TROPICAL MEDICINE, ETC. 



Enteric 5. The objective sign of return of the reflex is often associated with the return of the subjective feeling of 



Pever ticklishness normal to the individual. 



continual *^- -^'^ reappearance of pyrexia in convalescence, the condition of the abdominal reflex is a valuable index 



of the nature of the pyrexia. (That is to say, its disiippearauce or its becoming sluggish would point to a relapse.) 



7. No constant relation exists between the condition of the abdominal reflex and that of the tendon 

 reflexes. 



8. The frequency, degree and duration of impairment of the abdominal reflex are, aa a rule, in direct 

 proportion to the age of the patient. 



Another clinical aid is the recognition of leucopaenia. Horderi records a case in which 

 the bacilli were demonstrated in the blood in the absence of the Widal test and where there 

 was a marked leucopaenia, the white cells numbering 1400 only. Here the leucopajnia 

 suggested enteric fever and the further examination which led to the diagnosis being 

 established. Gennari'-* has specially investigated this subject. He concludes that in the 

 early stage of typhoid, leucopaenia, if present, is a valuable aid to diagnosis, and all the more 

 so because at the beginning the Widal reaction is often negative. Leucop<Bnia may be met 

 witli in miliary tuberculosis, but it is rarer in these cases. If any complications occur in 

 the course of the typhoid a comparative leucocytosis may ensue, but apart from this, 

 leucopaenia or a normal leucocyte count is the rule. Leucopaenia seems more often present 

 in bad cases. In 55 of Gennari's 106 cases the differential leucocyte count showed no 

 departure from the normal in 19, while in 36 there was diminution of the polynucleated 

 cells, increase of the lymphocytes, absence of eosinophils cells and increase in the 

 mononuclears. 



Passing now to bacteriological methods, we find the value of Ficker's modification of 

 Widal's test mentioned^ in an article taken from a Berlin medical paper. While it is quite 

 reliable and very convenient, it has the disadvantage that the reaction is useless in the early 

 stages of the fever and is not obtained much before the end of the second week of the disease. 



Numerous papers testify to the value and usefulness of the Widal test, although the 

 discovery of the paratyphoid fevers has, to some extent, interfered with it. Eogers'' devotes 

 a page to this subject. He regards complete reactions up to 1 in 100 by the microscopical 

 method, with a time limit of one hour as almost absolute evidence of an actual attack of 

 typhoid or immediate convalescence from one. Such reactions are exceptional in the first 

 week of the disease, and only found by a single examination at later dates in three-fifths to 

 two-thirds of the cases. Reactions in lower dilutions are highly suggestive and should lead 

 to further testing after a few days have elapsed, while any case at all resembling typhoid in 

 which a negative reaction is got should also be re-tested in five to seven days' time. It 

 must also be borne in mind that repeated negative reactions throughout may he obtained iii 

 luidouhted and often very severe typhoid, so that when clinically there are any good reasons for 

 looking on a case as one of typhoid, a negative Widal should be allowed little or no weight 

 against the clinical diagnosis. Where it is most valuable is in enabling very mild and 

 abortive cases to be recognised and properly treated, and preventive measures against the 

 spread of the disease being taken, but it still remains only an additional aid in forming a 

 diagnosis, which in the majority of cases can be usually made from a study of the 

 temj)erature curve, pulse rate and other clinical characters before a reliable Widal reaction 

 can be obtained. This is an excellent precis of the case, and in the Sudan one has met 

 with the exceptional cases mentioned. Eogers' technique for the Widal test can also be 

 recommended, and one has adopted it in preference to Eostoski's method previously 

 employed. The latter author'' discusses the conditions other than enteric which are apt to 

 give the Widal reaction. Chief amongst these is jaundice, and hence it may be found 

 present in Weil's disease. A case of puerperal fever has also been known to give a 

 positive Widal, while proteus and staphylococci can give rise to an agglutinin acting on 

 typhoid bacilli. Direct culture from the blood has come to the fore of late. 



Castellani" describes his so-called " dilution method," which consists in adding small 

 quantities (a few c.c.) of blood to comparatively large quantities (300 c.c.) of faintly 



» Horder, T. J. (January 19th, 1907), "A Case of Typhoid Fever Diagnosed by Blood Culture in the 

 Absence of the Agglutination Reaction." Lancet, p. 168, Vol. I. 



« Gennari, C, Ref. Med. (March 16th, 1907). Quoted in Epit., British Medical Journal of June 15th, 1907. 

 = November, 1906, "The Diagnosis of Typhoid by Ficker's Test." British Medical Journal, p. 451, Vol. II. 

 ■• Rogers, L., "Fevers in the Tropics." London, 1908. 

 ' Rostoski, " Manual of Serum Diagnosis," Translated by Bolduan, 1904. 



" Castellani, A. (May 5th, 1906), " Early Diagnosis of Typhoid Fever." British Medical Journal, p. 1071, 

 Vol. I. 



* Article not consulted in the original. 



