SECONDARY MIXED INFECTION 
IN TYPHOID FEVER. 
BY 
BAYARD D. 
From The Chicago Medical Journal and Examiner. SECONDARY MIXED INFECTION IN 
TYPHOID FEVER. 
cultures from its blood demonstrate the 
presence of the bacillus. Sections from the 
gland show small capillary emboli contain- 
ing the non-vegetating microbe. The same 
conditions are found in the kidneys; and 
when the lesion is sufficient to allow the 
passage of albumen into the urine, the ba- 
cilli may be demonstrated either microscop- 
ically or by cultures. 
An earlier invasion of the blood some- 
times, if not always, takes place through the 
portal circulation. From the infected glands 
in the intestine, the bacilli force themselves 
through the wall of a neighboring vein, and 
are carried into the liver, where they are 
found in masses in the portal capillaries. 
(Liebermeister, pp. 105, 106). 
The typhoid bacillus does not produce 
suppuration, it does not completely destroy 
living tissues, except when in masses suffi- 
cient to produce large infarctions as in the 
spleen and kidneys. It does produce a 
toxaemia or sepraemia, and later, a septicae- 
mia, which has a tendency to self-limitation. 
In the light of bacteriology it seems of itself 
to be far less fatal than the statistics would 
indicate. A careful consideration of the 
various and grave consequences which fol- 
low this disease, leads us to think that most 
of them are due to secondary invasion with 
bacteria which have nothing to do with the 
disease itself, and any of which maybe ab- 
sent in a typical course of typhoid fever. 
Although the typhoid bacillus is found in 
the dead tissues which result from constant 
pressure and consequent arrest of circula- 
tion under the bony prominences of the pa- 
tient, and though they vegetate and multi- 
ply there, there is no evidence that they 
produce any further destruction of 
tissue. 
BY BAYARD 
Typhoid fever is a term applied hereto- 
fore to a complexus of symptoms, well rec- 
ognized and defined, and accompanied by 
a peculiar lesion in the intestinal tract; but 
now to the invasion of a non-pyogenic 
micro-organism, however that invasion take 
place-whether by way of the intestinal or 
of the respiratory* tract, and whether or 
not accompanied by the classical symptoms 
which characterize abdominal typhus. 
In this strict sense, typhoid fever is the 
infection of the typhoid bacillus, and its 
direct consequences. Any symptoms and 
results which are due to other micro-organ- 
isms are not parts of the typhoid disease, 
and must be looked upon as accidental 
complications. The role of the typhoid 
bacillus is now demonstrated beyond the 
possibility of a doubt. The bacilli are found 
in the greatest numbers in the infiltrated 
Peyer's glands, before ulceration begins. 
Thence they are carried to the mesenteric 
glands, which imperfectly act as filters and 
detain them a short time. In a little while 
the pulmonary circulation is invaded through 
the thoracic duct, and a pneumonia follows, 
which is one of the early symptoms observed 
in most cases of typhoid. Examination by 
means of sections of the lung at this time, 
shows capillary emboli containing the ba- 
cillus. Only a part of the microbes are re- 
tained in the capillaries of the lungs. Many, 
if not most of them, escape into the arterial 
circulation, and they are found in every 
organ of the body, giving rise, at times, to 
all the consequences that capillary embol- 
isms entail. The spleen is enlarged, and 
* Klebs, Algemeine Pathologic, June, 1887, I, 165-175. 
It is not, then, the work of the typhoid ORIGINAL COMMUNICATIONS. 
3 
bacillus which we wish at this time to con- 
sider. Wherever the invasion of this ba- 
cillus takes place, whether in the superficial 
lymph-glands of the intestinal or of the re- 
spiratory tract, the inflammation in these 
glands due to the irritation of the bacillus 
and its ptomaine so diminishes their re- 
sistance that a secondary invasion with py- 
ogenic and other bacteria is a very easy 
thing. Many of the pathogenic bacteria 
are only facultative parasites of man, liv- 
ing for the most part as messmates with 
him on the contents of his intestines, or, as 
some think, being necessary even to mam- 
malian digestion. When the intestine or 
any part of it is dead, or the barriers which 
ages of association have thrown up are torn 
down by truamatism,or otherwise, the before 
harmless or even helpful bacteria set up a 
destructive, saprophitic colonization of the 
tissues of their host, and, in the neighboring 
living tissues they may produce suppura- 
tion, coagulation necrosis, haemorrhagic in- 
filtration, lymphatic engorgement, or any of 
the results which are so frequently demon- 
strated in the infectious diseases, depend- 
ent, of course, on the peculiar anatomy and 
physiology of the invading parasite. Of all 
the bacteria capable of becoming pathoge- 
nic, the pus-microbes are the most ubiquit- 
ous, and their influence is most disastrous 
to life. It will be well, then, to consider at 
some length the manner of infection with 
these parasites, alone, and then, afterward, 
some of the other kinds of microbic inva- 
sion separately. 
In addition to the local lesion in the in- 
testine or larynx, the facility of infection 
with the pus-microbe is increased by the 
general condition of the patient brought 
about by the simple typhoid disease. The 
nutrition of the tissues is reduced to a min- 
imum, the circulation is impeded directly 
by numerous capillary emboli, and indirect- 
ly by a diminished nutrition of the heart 
muscles. The poor quality of the blood and 
the retarded circulation invite the forma- 
tion of thrombus. The lymphatic circulation 
is equally impaired. While under ordinary 
circumstances of health, the lymph appara- 
tus has not only a great power of resistance 
to bacterial invasion, but also a remarkable 
power of destroying the invader, a few days 
of typhoid infection is enough to interfere 
with this function materially. 
The infected and engorged Peyer's gland 
is very soon attacked by passing suppura- 
tive bacteria. Ulceration and sloughing 
follow in proportion to the destruction of 
tissue by the second infection. At this 
time, the symptoms begin to show that a 
new factor has begun to operate. The tem- 
perature is less regular in its remissions, and 
takes on a septic character similar to surgi- 
cal-wound diseases. The micrococci are 
carried on into the mesenteric glands, where 
they may, in favorable cases, be arrested 
and destroyed. The glands after being en- 
larged for a long time return to nearly the 
normal size. The fatty degenerated mate- 
rial is removed, and the residue becomes 
calcified. 
Unfortunately, this happy issue is not al- 
ways realized. The filtering power of the 
already over-taxed gland is overcome, and 
the great lymphatic channel is flooded with 
the escaping bacteria. They are poured 
into the venous circulation, and find their 
way directly into the lungs. Here capillary 
embolism results a second time, and with 
the presence of a parasite which is capable 
of producing a destructive inflammation. 
This is the pneumonia which Murchison 
says " rarely appears before the third or 
fourth week," and then "may terminate in 
small abscesses, or, rarely, in gangrene" 
(p. 557). It must not be supposed that the 
presence of the pus-microbe is the only es- 
sential to the formation of destructive in- 
flammation, or that, even in tissues the vi- 
tality of which is so much reduced by dis- 
ease as the lungs in the third week of ty- 
phoid, they would invariably set up the 
suppurative process. The investigations 
of DeBary and Grawitz lead us to think 
that the resistance of the tissues is a 
much more important and powerful factor 
than we had supposed. But not all, if even THE MEDICAL JOURNAL AND EXAMINER. 
4 
a small part, of the bacteria are arrested in 
the capillaries of the lungs. Many of the 
emboli here are, no doubt, taken up by the 
pulmonary lymphatics and carried to the 
mediastinal glands, to be destroyed. En- 
largement of these glands is frequent, and 
their breaking down into abscess is occa- 
sionally noticed. 
Upon the arterial side of the circulation, 
the resistance of the tissues is, upon the 
whole, better preserved; but infection of 
bones, joints, and other serous cavities, and 
of the large organs of the body does take 
place. Then all the severe symptoms of 
osteomyelitis, suppurating synovitis, peri- 
carditis, pleurisy, peritonitis, meningitis, and 
abscess in the large organs are added to 
the typhoid history. It is no wonder that 
the patient, already reduced by weeks of 
disease, is unable to resist this unexpected 
invasion, and very soon succumbs. These 
complications make up a very considerable 
bulk of the fatalities from abdominal ty- 
phus, though each in itself is rarely met 
with. 
There are cases in which it seems that 
the bacteria of suppuration circulate in the 
blood freely until they are arrested by the 
arterial capillaries, and are then removed 
by the lymphatic apparatus. It is only in 
this way that we can account for the dis- 
appearance of bacteria experimentally in- 
jected into the arterial side of the circula- 
tion. For a time they are found in the 
blood, but in a few days no trace of them 
can be found by means of cultures. Some- 
times, however, when there has been noth- 
ing to indicate that the tributary parts have 
been occupied by infection, the centrally 
located lymphatic glands swell up, and 
even undergo a destructive inflammation 
from the arrested pathogenic microbes. In 
the sequelae of typhoid, adenitis is noticed 
by all systematic authors. By some it has 
been considered a favorable symptom 
(Chomel), while others have scarcely ever 
seen a case recover in which it had occurred. 
Of all the packets of glands it seems that 
those of the axilla are most frequently the 
seat of this form of secondary suppuration. 
One case is reported in which suppuration, 
beginning in the axilla, extended to the 
elbow, and into the thorax, and produced 
death by perforating the axillary vein. 
The patient died of uncontrollable venous 
haemorrhage. In a case which came under 
my own observation this secondary infec- 
tion of the axillary glands produced symp- 
toms which resembled a relapse in the 
typhoid. 
" Miss A., age 20, had been ten days 
convalescent from a very severe typhoid. 
Her'temperature had been high, requiring 
the vigorous use of antipyretics. Upon 
the thirty-ninth day of her sickness, and 
the fourth day on which her evening tem- 
perature was normal, she began to eat solid 
food. Two days later the evening tem- 
perature went up to ioo° Fahr, and con- 
tinued to rise about a degree higher every 
night, until on the forty-seventh day of the 
sickness it was 103°. The physician who 
had attended her being taken sick at this 
time, I was called to the case. I found 
the patient very much emaciated. The 
abdomen was not tender or tympanitic. 
The stools were well digested and solid. 
The tongue was not dry and black, but 
lightly coated. There was ravenous hun 
ger, and dreams of food disturbed sleep. 
The patient had been put back on a milk 
diet as soon as the temperature had de- 
clared itself. There was a poultice in the 
right axilla. The glands of the axilla 
were severally enlarged to an inch or more 
in diameter. One of the more superficial 
ones was discharging a small amount of 
pus through a follicle of the skin. 
" Thinking that the condition of the 
axilla was a sufficient cause for the return 
of the temperature, I restored the more 
nutritious diet, removed the poultice and 
had the axilla shaved and covered with a 
wet carbolized dressing. On the following 
day, with the help of Dr. H. H. Frothing- 
ham, I anaesthetized the patient with 
chloroform and extirpated the glands of 
the axilla. The result is shown in the ORIGINAL COMM UNICA TIONS. 
5 
chart which I present. It was kept by the 
nurse. Although I failed to secure a per- 
fectly aseptic wound, the temperature fell 
in four days to the normal, and the patient 
made an uninterrupted recovery." 
Thus far we have considered the infec- 
tion of a typhoid with the pus-microbe, 
the balance of power being, upon the 
whole, all the time on the side of the 
host. This condition of affairs can not 
always be maintained. The tissues of the 
body are all more and more impaired in 
the continuance of the disease, and, at 
last, a time comes when the invasion of the 
coccus is unresisted. Abscess formation 
takes place in all parts of the body. These 
foci may not reach a great size before 
death terminates their progress. This is 
especially the case in the abscesses of the 
brain, which Popoff has shown are al- 
most always miliary and multiples. But 
besides the multiplication of the bacteria in 
definite localities, it may take place in the 
circulating blood itself. A small thrombus 
forms about the microbe, or a phragocite 
fails to devour its prey, and itself becomes 
food for the conqueror. In these ways 
the bacteria vegetate and multiply in the 
blood and lymph. The patient is in a 
state clinically termed septicaemia. This 
is, perhaps, the condition into which all 
cases of pyaemia ultimately verge. 
But the disasters which the pus-microbe 
may precipitate upon the typhoid are not 
yet all rehearsed. At the first point of at- 
tack the destruction may be so great as to 
involve all the coats of the intestine, and 
perforation take place. In this way the 
largest serous cavity of the body is at once 
hopelessly infected, and fatal issue is not 
long delayed. Sometimes adhesions take 
place in advance of the destruction, and 
the perforation may be into a connective- 
tissue space about the caecum, or into one 
of the large organs, or into another intes- 
tine. When the destruction involves a 
large blood-vessel in which an anticipating 
adhesive inflammation has not taken place, 
haemorrhage may result, which, at once, or 
after many repetitions, may lead to dissolu- 
tion. There is reason to think, however, 
that this is not the only cause of intestinal 
haemorrhage in typhoid. When the eroded 
vessel is a vein, the septic bacteria may be 
carried into the portal circulation, and set 
up suppuration in the liver. In this way 
abscess of the liver may arise rather early 
in the disease, and before general pyaemia 
appears. 
When the low state of nutrition of all 
tissues has reduced the resisting power to 
a minimum, infection may take place in 
any part of the body where germs are 
present. It is in this way that old scars 
open, from the germination of lasting 
spores, and old bone-disease lights up 
again. The secreting glands of the body 
may be invaded by way of their ducts. 
Suppuration of the parotid is not infre- 
quent, and some cases of suppuration of 
the gall-apparatus without abscess of the 
liver are explainable only in this way. 
Through the Eustachian tube the middle 
ear is invaded, and extension may go on 
into the brain, resulting in abscess or 
meningitis. In the same manner the sex- 
ual tract may offer a way to invasion, and 
orchitis, ovaritis and peritonitis supervene. 
Slight traumatisms result in defects of the 
skin, which immediately become the seat 
of protracted suppuration or other forms of 
infection. 
It is probable that through the constant 
picking a way is made for infection with 
erysipelas, which so frequently appears 
about the nose and lips of typhoids. Te- 
tanus also may make its way through the 
abraded skin or intestinal mucous mem- 
brane. 
That a specific infection is the cause of 
the disease which Ceci terms haemorrhagic 
infiltration, is now well demonstrated. 
This is the secondary infection which 
causes the uncontrollable epistaxis in diph- 
theria. There can be no doubt that the 
same form of infection is responsible not 
only for the epistaxis of typhoid, but, also, 
for a great many cases of diffuse intestinal 6 
THE MEDICAL JOURNAL AND EXAMINER. 
haemorrhages and haemorrhages from the 
stomach and colon. 
Noma, malignant oedema, and diphtheria 
present no anomalies in their appearance in 
typhoid. 
There is a form of infection to which 
the poor typhoid is exposed which is the 
most pitiable of all. Either from the pres- 
ence of the lasting spores of the bacillus, 
or from infection through the milk and 
other food, or through the inspired air, 
tuberculosis is a very frequent sequela of 
typhoid. All systematic writers notice this 
frequency, and attribute it to the protracted 
depression of the disease. Murchison says 
that it is more common after typhoid than 
after typhus, and that it is to be feared in 
all cases when hectic fever and bronchitis 
persist after the end of the fourth week 
(p. Louis records four cases of 
section in which the lungs were found 
studded with recent tubercle. The fre- 
quency of tuberculosis and typhoid in 
Ireland has led Kennedy to suspect some 
essential relation between them. There 
is no doubt that the low state of vitality 
to which'the patient is usually reduced 
and the slow convalescence give the 
latent spores in old glandular foci or in 
the cicatrices of the lungs an opportunity 
to vegetate again, and at the same time 
offer easy access to more virulent bacilli 
from tubercular nurses, or patients, or 
food. 
It is to be regretted that no extensive 
and systematic study of the complications 
of typhoid have been clinically made in 
the light of modern bacteriological re- 
search. The use of cultures from aspi- 
rated products in the course of typhoid 
has been only just begun. Such researches 
carried on diligently for a few years would 
throw great light on many dark corners of 
symptomatology and pathology. So far we 
can only say that the work done allows us 
to reach theoretically and provisionally the 
following practical conclusions : 
The local effects of an invasion with the 
typhoid bacillus is a non-destructive one, 
and the tendency is toward complete resti- 
tution to a state of health. 
The primary lesion in the bowel or in 
the larynx gives rise to a point of least re- 
sistance; and the general impairment of 
nutrition renders all those causes which or- 
dinarily determine the localization of in- 
fection far more potent. 
Pyogenic and other forms of infection 
do take place through the primary lesion, 
and result in more than ordinarily serious 
consequences on account of the diminished 
resistance of all the tissues of the 
body. 
Therefore all traumatism to the abdo- 
men, either external, through violent, care- 
less, or unnecessary palpation, or internal, 
through the use of food containing solid 
particles which might cause abrasion, should 
be strenuously avoided. 
The imminent danger of typhoids to tu- 
berculosis is conceded by all, and every 
precaution should be taken to prevent in- 
fection through contact with phthisical pa- 
tients or nurses, or through confinement in 
rooms occupied by them, or through uten- 
sils or food which might furnish the infec- 
tion ; and when there is reason to suspect 
latent tuberculosis, the use of all anti-tu- 
bercular measures is recommended. 
The treatment of typhoids and phthis- 
ical patients in the same hospital ward is 
little short of criminal, and the employment 
of tubercular nurses, attendants, or cooks, 
or ward-servants is incompatible with the 
present state of our knowledge of tubercu- 
lar aetiology. 
As typhoids are more than ordinarily 
susceptible to all contagious diseases, they 
should be rigorously excluded from direct 
and indirect contact with diphtheria, erysip- 
elas, and all wound diseases; the most 
thorough cleanliness should be observed 
about their person, and the towels, bedding, 
and utensils should be beyond reproach. 
In the care of the lips, the tongue, and 
the nose, care should be taken that no 
abrasions be made which might open a 
way to secondary invasion. ORIGINAL COMMUNICATIONS. 
7 
So-called relapses are often due to a sec- 
ondary mixed infection. Therefore,* in 
all cases of relapse, careful, diligent, and, 
if necessary, repeated search should be 
made for foci or infection which could give 
rise to the symptoms of relapse or any 
anomaly of temperature. 
When a localization of infection has 
been discovered, the fact that the patient 
is, or has been, suffering from typhoid does 
not interdict the employment of ordinary 
surgical principles, but furnishes an addi- 
tional and imperative indication for speedy 
operative interference, as furnishing the 
only known means of preventing the most 
disastrous issue. 
statement that, under proper treatment, 
ninety-five or more per centum of typhoids 
recover. 
The fact that the typhoid bacillus does not 
produce suppuration or other destructive 
lesion is so well established by numerous 
observers that the anomalous observation 
of an encysted suppurative peritonitis by 
Frankel (Centralb. f. Bact. u. Parask., 1887, 
I., p. 546) must wait further explanation. 
He found only the typhoid bacillus in the 
pus from this peritonitis, which occurred 
long after convalescence from a typhoid had 
been established. Baumgarten thinks the 
pyogenic bacteria had died at the time of 
the observation (p. 524). Seitz (Bacterili- 
gische Studien sur Typhus ZEtiologie, 1886) 
finds that this bacillus is not pyogenic in 
animals, although pathogenic in some. 
Mafucci (Centralb. f. Bact. u. Parastk., 
1887, I., p. 149) concludes from experi- 
ments on animals that the bacteria are elim- 
inated through the excretory and secre- 
tory glands without any destruction to their 
epithelium or the capillaries. 
The most valuable information has been 
obtained from the following works: 
Murchison: A Treatise on the Continued 
Fevers of Great Britain. Third edition. 
London. 1884. 
Liebermeister: In the Cyclopedia of 
the Practice of Medicine, von Ziemsen's. 
American Translation. New York. 1874. 
Vol. I. 
Seitz, Dr. Franz: Der Abdominalty- 
phus nach langjaehriger Beobachtung. 
Stuttgart. 1888. 
Gottstein: Die Verwerthung der Bac- 
terologie in der klinischen Diagnostik. 
Berlin. 1887. 
DeBary and Grawitz: Ref. Centralb. 
f. Bact. u. Parastknd. 1887. 
Dunin: Ueber die Ursache eiteriger 
Entziindungen und Venenthrombosen im 
Verlauf des Abdominaltyphus. Deut. Arch, 
f. klin. Med., XXXIX, pp. 369-392. 
In an epidemic of typhoid in which com- 
plications were numerous, he made many 
examinations and cultures from the suppu- 
NOTES AND LITERATURE. 
It is unnecessary to refer to the literature 
of typhoid from a bacterial standpoint. 
The battle between mysticism and material- 
ism was fought on the field of Anthrax and 
Tuberculosis before the real study of ty- 
phoid began. The difficulties in staining 
and in obtaining pure cultures of this 
microbe retarded its advance into the place 
it now occupies as the prime setiological 
factor of abdominal typhus. Every modern 
text book on medicine or pathology gives 
a sufficient history and bibliography of this 
phase of the disease. The last German 
edition of Ziegler's Pathology, Klebs'Alge- 
meine Pathologic, and Baumgarten's Lehr- 
buch der Pathologischen Mykologie are 
especially recommended. 
Gottstein says that the complications of 
typhoid are not caused by the typhoid ba- 
cillus, but by the various pus-microbes. 
The importance of these complications 
may be inferred from the space devoted to 
their consideration by the systematic 
writers and in the current literature. More 
than ten quarto pages are devoted to the 
articles on this subject alone in the Cata- 
logue of the Library of the Surgeon-Gen- 
eral's Office. No statistics are available to 
show the fatality of the complications as 
compared with the pure disease. Baum- 
garten (1. c., p. 526) makes the remarkable 8 
THE MEDICAL JOURNAL AND EXAMINER. 
rative products, and found, in all cases, the 
pyogenic microbe. While his method 
leaves much to be desired, it is a very 
complete demonstration of the true cause 
of these accidents which had been pre- 
viously only conjectured. 
Metschinkoff: Phragocitic microbes in 
the relapses of Typhoid Fever. Virchow's 
Archive, Vol. 105-109, 1887-88. 
W. H. Thompson : Diphteritic Paraly- 
sis. Medical News, June 9,1888, p. 630. 
Condition of the Mesenteric Glands. 
-Before any secondary infection has taken 
place, they are enlarged and filled with the 
typhoid-bacillus, which is never found with- 
in the cell elements (Klebs, Baumgarten, 
and Liebermeister). In a few cases post- 
mortem examination has discovered the 
suppuration of these glands resulting in 
large abscesses, but there is abundant evi- 
dence that perforation does frequently take 
place in an intestine and recovery follow. 
Such is probably the explanation of the 
case of a late interne at the Cook County 
Hospital, who began to suffer a relapse two 
or three months after typhoid. Besides the 
peculiar renal and cerebral symptoms which 
he suffered, his temperature was not char- 
acteristic of typhoid, and, at last, a consid- 
erable amount of pus was discharged from 
the bowels. This was occasionally repeat- 
ed after exacerbation of the symptoms 
throughout the course of a year or more. 
Jenner (Medical Times, Vol. XX) re- 
cords a case where perforation into the peri- 
toneum followed suppuration of a mesen- 
teric gland. 
Andral (Clinique Medical, Paris, 1834, I, 
p. 599) observed the correspondence be- 
tween the degree of ulceration in the in- 
testinal (Peyer's) lymphatics and the en- 
gorgement of the mesenteric glands, 
and says that MM. Petit and Serres have 
compared this engorgement to that which 
follows in the crural and axillary glands in 
infection in the area tributary to them. 
The Lungs.-Although the infection of 
the typhoid bacillus produces a pneumo- 
nia, it invariably tends to speedy recovery, 
and is observed only early in the disease. 
When, however, the secondary infection ap- 
pears, the symptoms are of a much graver 
character, depending on the destructive 
power of the pyogenic infection. 
Liebermeister (p. 172) calls attention to 
the fact that severe and fatal embolic pneu- 
monia occurred in Basle when the hospital 
was overcrowded and in bad condition. 
This symptom disappeared when these 
defects were corrected. 
This secondary pneumonia is aetiologic- 
ally a unit, whether it appears as abscess, 
or gangrene, or suppurative bronchitis, and 
each may or may not be accompanied by 
suppurative pleuritis. 
As we should expect, this disease ap- 
pears about the third or fourth week. The 
lungs and the pleural cavity may become 
infected with putrid and gas-forming bac- 
teria through the inspired air. (See a case 
by Witkowski, Virch. and Hirsch, Jahres- 
bericht, 1872, II, p. 239, and Delafield, A. 
Y. Medical Record, 18-(?) 
Pleurisy is not infrequent (Liebermeis- 
ter, p. 173). It was observed in sixty-four 
out of 1,743 cases at Basle, of which 
twenty-one came to section. 
Infection of Glands by Way of Their 
Ducts.-All authors mention the frequent 
occurrence of parotitis, often in the course of 
a general pyaemia, but more often as the 
only evidence of infection. Careful study 
of parotitis, as it occurs in other condi- 
tions, leads me to think that the infection 
by way of the duct is not the rule. 
Stephen Paget (Lancet, 1886) attempts to 
establish some relation between the pelvic 
organs and the parotid gland. He remarks 
that parotitis is frequently the only second- 
ary lesion to injury or operation upon the 
pelvis. He has collected sixty cases, in- 
cluding ten of Goodall's, only a few of 
which manifested any symptoms of pyaemia. 
I am inclined to think that the determi- 
nation of infection in the parotid gland 
will be found to depend on some histolog- 
ical or physiological peculiarity of the 
gland, inviting the formation of thrombi. ORIGINAL COMM UNICA TLONS. 
9 
Suppuration of the gall-apparatus is cer- 
tainly occasionally noticed post-mortem, but 
oftener symptoms referable to inflammation 
of the common duct are recognized during 
life. Both of these conditions are depend- 
ent on the invasion of some form of bac- 
teria, either alone or assisted by protozoa, 
during the depression of the typhoid dis- 
ease. 
In a few instances the pancreas has been 
found inflamed. In no case do I find 
that suppuration has been actually ob- 
served. There does not seem to be any 
reason why it should not occur (Andral). 
Other small glands may become infected 
in the same manner. The middle ear 
thus becomes the seat of suppuration 
through the invasion, by way of the Eu- 
stachian tube (Seitz, 85). 
This inflammation may invade the tem- 
poral bone, and suppurative meningitis or 
abscess of the brain result (Murchison, p. 
561)- 
Joints and Other Serous Cavities.- 
A concise statement of the aetiology and 
clinical appearances of joint diseases in the 
course of convalescence of the acute infec- 
tious diseases, is given by Max Schueller 
(Die Pathologic und Therapie der Gelenk- 
entziindungen, Wein u. Leipzig, 1887), 
with a full account of the literature. The 
large joints are most affected. Usually the 
invasion takes place late (19th to 60th day) 
in the disease. It is certainly rare, as in 
3,130 cases in Vienna, Guttenbock found 
only two complicated by joint disease 
(Arch. f. klin. Chir., XVI, p. 61). Bar- 
well (Diseases of the Joints, N. ¥., 1881, p. 
79) says that he has observed a large 
number of cases of this rare disease. He 
notices a painless mono-articular variety, 
and a painful poly-articular variety. If 
this is really the case, it does not seem 
difficult to account for the difference. The 
former is probably a tubercular or atten- 
uated pyogenic infection, while the latter 
is a more destructive and virulent form. 
Murchison considers joint affection a sign 
of a fatal termination of the typhoid dis- 
ease. Langenbeck (Akiurgie, p. 155) says 
that suppuration of the knee-joint as a 
complication of typhoid is an indication 
for resection, and Hager (Dent. Zeitschr. 
f. Chir., XXVII, p. 155) mentions two 
cases treated by antiseptic irrigation of the 
joint. 
The bursse in various parts of the body 
are only rarely mentioned as the seat of 
secondary invasion. I can find no case 
where it was not a part of a general pyaemia. 
There is no doubt that it does occasionally 
occur separately, but is then not considered 
of enough account to require mention. 
Pleurisy, pericarditis, and peritonitis are 
more frequently mentioned than meningitis, 
but no one of them is often found as the 
only locus of infection. 
Bones and the Large Organs of the 
body.-Cases of bone disease originating in 
the course of typhoid are mentioned by all 
authors. Murchison (p. 584) has observed 
in his own practice two cases of disease 
of the tibia, one of the femur, one of the 
temporal bone, and two of the lower jaw. 
Old bone diseases frequently break out 
during typhoid, and scars that have been 
long healed open spontaneously and sup- 
purate (Liebermeister, p. 146). These 
phenomena may be due to the germination 
of lasting spores, or to the localization of 
infection in the non-resisting scar. The 
same thing occurs in the pelvic cellular 
tissue (Zeigler, 1. c., II, p. 894). 
Abscess of the liver is a very common 
and fatal complication of typhoid (all 
authors). Two forms are to be considered : 
One, the result of infection through the 
portal circulation, appears early (7th to 
11 th day) in the disease, and is followed by 
pyaemia, or, especially, embolic pneumonia, 
and the other, due to arterial capillary 
thrombosis or embolism, appears as late as 
the third or fourth week, or long after con- 
valescence has been established. Bender 
(Lancet, Oct., 1874) and Burger (Arch. f. 
klin. Med., XII, p. 623) have recorded 
cases of the former, and many authors of 
the latter (Murchison, Liebermeister etc.) 10 
THE MEDICAL JOURNAL AND EXAMINER. 
Abcesses of the brain are not very rare, 
though they do not often attain any great 
size (Gowers, Diseases of the Nervous Sys- 
tem, 1888. p. 1215). They are mostly mil- 
iary and very numerous (Popoff, Virch., 
Arch., Bd. 87). One of the first operations for 
abscess of the brain is reoorted by Heineke 
(Die chirurgisch. Krankheit des Kopfes, 
p. 99). It occurred after a typhoid, and 
is supposed to have ended in recovery. 
Suppuration of the thyroid is of unusual 
frequency. It occurred six times in 1,700 
cases of typhoid (Liebermeister, p. 174). 
This frequency can hardly be accounted 
for by the size of the gland, and must de- 
pend on some anatomical peculiarity. 
Infection of the bronchial and mediasti- 
nal glands by way of the larynx is of 
rather rare occurrence, but of a very fatal 
character. It is accompanied by oedema 
of the glottis, and often extensive destruc- 
tion of cartilage (Seitz, pp. 85, 86). Mur- 
chison (p. 558) says that it appears to be 
very common in Germany. 
All authors agree that bubo is more fre- 
quent after typhoid in the axilla than in 
the groin or in other packets of glands. 
This can, perhaps, be accounted for by 
supposing infection of the fingers and hands 
to take place from the mouth by biting the 
nails and picking the lips and teeth. In 
the Library of the Surgeon-General's Of- 
fice, are three monographs on Axillary 
Phlegmons. 
Haemorrhagic Infection (Ceci).-In 
diphtheria the unfavorable significance of 
repeated haemorrhages from the nose has 
long been recognized by all clinicians. It 
has been shown by Klebs (p. 199) to be 
due to a secondary specific infection which 
he asserts is often the cause of epistaxis in 
typhoid. The same form of infection has 
been noticed in other localities. Frequently 
an intercellular haemorrhage has been ob- 
served in the new-born which has been 
attributed heretofore to the " haemorrhagic 
diathesis. " Ritter has demonstrated it to 
be due to haemhorrhagic infection through 
the umbilical wound. That the intestinal 
haemorrhages of typhoid are due to the 
same specific microbe has not, so far as I 
know, been proved by cultures. Seitz 
(Case 5i,p. 185) gives an account of a case 
in which severe pain in the stomach in the 
third week was followed by repeated gastric 
haemhorrhages. Murchison (p. 530) men- 
tions a case in which intestinal haemor- 
rhage took place from diffuse spongy patches 
of excrescences firmly attached to the in- 
testinal wall. The mesenteric glands and 
the spleen were enlarged. When haem- 
orrhage occurs in many places besides the 
bowel, the typhoid has been clinically 
termed "haemorrhagic putrid fever" (M., 
p. 527). Out of 107 cases of epistaxis 
mentioned by Liebermeister (p. 175), four- 
teen cases were accompanied by haemor- 
rhage from other parts of the body, es- 
pecially from the bowels. It usually occurs 
in young people, who are known to suffer 
most frequently from haemorrhagic infec- 
tion in other diseases: The appearance of the 
haemorrhagic infection is sometimes alarm- 
ingly rapid. Ruggein (Virch. & Hirsch's 
Jahresberischt, 1872, II, p. 237), records 
such a case. An eighteen-year-old man was 
suffering a rather mild course of typhoid, 
when in the second week he was prostrated 
by an intestinal haemorrhage accompanied 
by haemhorrhages from every observable 
surface of the body. All the secretions 
and excretions were bloody. Nevertheless 
convalescense began in the fifth week. 
Gas-Forming Bacilli (Malignant 
(Edema).-Although emphysema is fre- 
quently the result of an ulceration and per- 
foration in those parts of the respiratory 
apparatus from which the atmospheric pres- 
sure is removed in inspiration (Murchison, 
p. 557) there are cases In which a second- 
ary infection with a gas-producing bacil- 
lus is perfectly demonstrated. 
Such an infection was observed by Meigs 
{Philadelphia Medical Times, Oct. 5, 1872), 
in which the liver was emphysematous 
throughout before death, and the case came 
to post mortem on the fourteenth day. 
Diphtheria.-Murchison (pp. 558-588) ORIGINA L COMMi UNICA TIONS. 
11 
mentions three cases by Louis, two by For- 
get, and six by Rilliet and Barthey, and one 
of his own observation. In this case diph- 
theria appeared on the thirtieth day, and 
a local infection of the pus-microbe pro- 
duced a post-coracoid abscess. Other il- 
lustrations are not wanting in the literature. 
Noma.-This has been observed by most 
systematic writers as an extremely rare 
complication. Murchison has met with it 
once. Greissinger noticed only one in 600 
cases of typhoid. Out of eighty-nine 
cases of noma observed by Tourdes seven 
followed typhoid fever. West observed 
two similar cases. (See Murchison and 
Liebermeister.) 
Erysipelas.-This usually appears in an 
advanced stage of the disease (Murchison, 
p. 582). It appears in about 1 per centum 
of all cases. Seitz has rarely seen erysip- 
elas in the early weeks of typhoid, but often 
in the later weeks or in convalescence 
(page 104). 
Tetanus.-One of the most frequent 
and fatal of mixed infections in wound dis- 
eases is tetanus, which is also occasionally 
a complication of typhoid. Seitz (Cases 
ii and 12, pages 80-83) gives the history of 
two cases, the result of which indicates 
that it is not always fatal. 
Tuberculosis.-Murchison observes that 
tuberculosis of the lungs is more common 
after typhoid than after typhus, and that 
tubercle ought always to be feared when 
hectic fever and bronchitis persist after the 
fourth week. Louis records four cases of 
fatal typhoid in which the lungs were 
studded with recent tubercles, and Bartlett 
observed long ago that consumption is a 
frequent sequela of this disease. Trouseau 
(Union Medicale, 1859) records cases of 
tubercular meningitis after typhoid. Har- 
ley and Kennedy (Murchison, p. 462) have 
even considered typhoid and tuberculosis 
dependent upon the same setiological factor. 
125 State Street.