DIAGNOSIS OF ENTERIC IN INOCULATED PERSONS 1393 



Bacteriological Examination of Urine. — The urine should be collected 

 aseptically. In women a catheter should be used. In males this is not neces- 

 sary. It is sufficient, after purifying the glans and meatus first with a'( dis- 

 infecting lotion, and then with boiled water, to make the patient pass his urine. 

 Any germs of the anterior portion of the urethra will probably pass with the 

 first portion of urine, which is thrown away, while the last portion is collected 

 into a sterile vessel, and immediately sown in tubes containing Coleman and 

 Buxton's bile-glycerine medium. These are incubated at 35° to 37° C. for 

 twenty-four to thirty-six hours, and then the further bacteriological investiga- 

 tion is carried out in the usual manner by making plates, etc. 



Diazo-Reaction. — A chemical laboratory test often used is EhrUch's diazo- 

 reaction, which, however, is positive in several other febrile conditions. 



Harris's Atropine Test. — Harris found out that the injection of ^ grain 

 of atropine sulphate in fevers of the enteric group hardly accelerated the pulse- 

 rate, while in patients sufiering from other diseases such an injection will 

 increase the rate of the heart by some twenty to forty beats per minute in 

 the same manner as in normal individuals. 



Harris's technique is as follows: — The patient should lie horizontally, 

 perfectly quiet, and the test should be carried out at least one hour after meals. 

 The pulse-rate is taken and recorded minute by minute until found to be 

 steady. This usually takes ten minutes. An injection of -^^ grain of atropine 

 sulphate is then given in the deltoid region. The patient remains absolutely 

 quiet, and after twenty-five minutes the pulse-rate is taken and recorded 

 minute by minute. An increase of the pulse-rate by about twenty or more 

 per minute indicates that the patient is not suffering from enteric. If the 

 increase in the pulse-rate is only ten beats or less, the reaction is suggestive 

 of enteric. 



Diagnosis of Enteric in Inoculated Persons. — ^The diag- 

 nosis of enteric in inoculated persons may be very difficult, the 

 symptoms being often most atypical. Moreover, the commonest 

 laboratory test — agglutination — is of little use unless carried out 

 according to certain methods. 



It is well known that in individuals inoculated with the triple 

 vaccine typhoid and para A and para B, specific agglutinins develop 

 for the three germs, as was shown by one of us long ago. The maxi- 

 mum agglutination titre is reached two to three weeks after the 

 first inoculation, then the titre falls at first — for a few weeks^ — 

 rapidly, but later on in an extremely slow, gradual manner, so slow 

 as to remain practically constant for months and years. After two 

 months from inoculation only very exceptionally one finds an agglu- 

 tination limit greater, than i in 320 for B. typhosus and B. para- 

 typhosusB, and for 5. paratyphosus A greater than i in 180. There- 

 fore, in a person inoculated longer than two months, if the agglu- 

 tination limit is higher than i in 300 for B. typhosus or para B, or 

 more than i in 180 for B. para A, and there is fever, a provisional 

 diagnosis of enteric may be made. It is always advisable, however, 

 as emphasized especially by Dreyer, Walker, and Gibbon, to take 

 the agglutination titre at intervals of three to five days several times 

 during the course of the suspected fever and make an agglutination 

 curve iovB. typhosus, B. paratyphosus B, andB. paratyphosus A. 



If the agglutination for B. typhosus exhibits a regular rise, with 

 a maximum of even 100 per cent, in the third or fourth week from 

 onset of fever, and then a subsequent regular fall, as seen in non- 

 inoculated subjects, but starting from and returning towards the 



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