It is under just such conditions that the modern bacterial diagnostic methods render valuable aid in enabling us to differentiate between typhoid and tuberculous meningitis. Such differentiation may however be attended with great difficulties at times, cases of abdominal fever occur accompanied by vomiting, scaphoid depression of the abdomen, rigidity of the cervical and dorsal muscles, slow and irregular pulse, "cris cephaliques,"—in short, by all symptoms which point to a tuber culous meningitis, and, on the other hand, a tuberculous meningitis especially in the first years of life, not infrequently exhibits a course like typhoid fever.
In the agglutination test devised by Crunbaum, elaborated by Gruber and Pfeiffer in animal experiments, adapted by \Vida.l for clin ical purposes, and subsequently essentially improved by Ficker, we pos sess a method which in the great majority of cases accomplishes the desired object and into the details of which I need not enter. One of the latest tests of the procedure made by Hopfengartner in children yielded a positive result in all cases examined. The time required for the observation has been materially shortened by Weil, assistant in the Hygiene Institute of the German University in Prague, in the use of a test, heated to 50° C. (122° F.), half an hour being sufficient to obtain the result. A small apparatus for the typhoid test is furnished by some dealers; this enables the physician to institute a diagnosis conveniently at his own residence.
One objection is the occasional late onset of the reaction, which is rather frequent in children. Under such conditions, a diagnostic exam ination of the blood may be required, making cultures either from roseola or—what is best in doubtful cases,—from the blood of the bra chial vein or the finger tip, according to Castellani's procedure. Jo•h mann, Flamini, and Rolly report unqualified success by this method in the great majority of cases of typhoid fever in children examined by them, during the very first days of the disease. Finally cultivation of bacteria from the stools may be necessary. According to observations collected by Koch, the method of Drigalski and Conradi will quickly and surely bring about a satisfactory result during childhood.
The prognosis is, as a whole, favorable during childhood, although during this period of life grave cases and malignant epidemics may oc cur. Filatow, a very experienced observer of great clinical acumen, designates as unfavorable prognostic signs fuliginous coating on tongue and teeth, profuse and obstinate diarrlura, delirium in waking condi tion (with eyes open), rigidity of cervical and especially dorsal muscles, carphology (picking the bed clothes with the fingers) thready pulse and other phenomena of cardiac weakness, as well as complete insensibility.
Intense meteorism, too, is a bad symptom, and constantly retracted abdomen with persistently high fever is yet worse.
The treatment of typhoid fever, in spite of accurate knowledge of its cause and of its life-peculiarities has as yet not reached any specific method and its principal task lies in adequate prophylaxis--in avoid ing the chief sources of infection and as Koch suggests isolating the pa tients, and carefully disinfecting their surroundings, and morbid excre tions. There can be no doubt of the significance of infected water and soil. Sanitation in large cities, consisting on one hand in sewerage and drainage and on the other hand, in supplying wholesome water for drinking, bathing and culinary purposes, has already accomplished remarkable results. Thus, the city of Munich, formerly a notorious haunt of typhoid, has become a salubrious town, and, owing to constant disregard for such sanitary arrangements, Prague has for decades been visited with severe epidemics, against which the individual must pro tect himself. Individual prophylaxis includes boiling and filtration of water for drinking. cooking, and bathing purposes; cleansing of vege tables, fruit, glasses, etc., with boiled water; avoidance of bathing in creeks or rivers flowing through the afflicted locality whose waters may contain typhoid bacilli, careful cleansing of the hands of children after they have played in dirt—a series of disagreeable measures after all and still insufficient for protection. Even a close observance of these precautionary directions may at times prove unsuccessful in preventing typhoid fever, for either the lines of defense were not strong enough or other sources of infection, unsuspected, were left open.
In small towns, where the conditions can be more easily surveyed and the course of the disease more closely pursued than in the labyrin thine paths of a metropolis, strict isolation as recommended by Koch must be insisted upon, bacteriological examination of evacuations to be discontinued only when, after repeated observations, freedom from bacilli has been established, strict disinfection of dwelling, etc. Brilliant results have already been attained by following this pro phylactic advice.