J. M. (James Mitchell) Foster.

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of the larfi:e 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 gemination 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



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69



picking a way is made for infection with
erysipelas, which so frequently appears
about the nose and lips ol 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
oiily for the epistaxis of typhoid, but, also,
for a great many cases of diffuse intestinal
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
tjrphoid. 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- 55^)* Louis records four cases of sec-
tion in which the lungs were found studded
with recent tubercle. The frequency of
tuberculosis and t3rphoid in Ireland has led
Kennedy to suspect gome essential relation
between them. There is no doubt that
the low state of vitality to which the pa-
tient is usually reduced and the slow con-
valescence 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 milde in
the light of modem 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, car-
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



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70



THE MEDICAL JOURNAL AND EXAMINER.



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 toague, and
the nose, care should be taken that no
abrasions be made which might open a
way to secondary invasion.

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.

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 aetiological
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 Pathologie, 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
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 -^tiologie, 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-



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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
Entzundungen und Venenthrombosen im
Verlaufdes Abdominal typhus. 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-
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* .*)99) 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 B^sle when the hospital
was overcrowded and in bad condition.
This symptom disappeared when these
defects were corrected.

This secondary pneumonia is setiologic-
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^.
K. Medical Record, 18— (.J^)

Pleurisy is not infrequent (Liebermeis-
ter, p. 173). It was observed in sixty-four
out of 1,743 cases at B^sle, of which
twenty-one came to section.

Infection OF Glands BY Way of Their
Ducts. — All authQrs 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



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THE MEDICAL JOURNAL AND EXAMINER,



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 GoodalPs, 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.

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 And
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 ipflammation 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 Pathologie und Therapie der Gelenk-
entztlndungen, Wein u. Leipzig, 1887),
with a full account of the literature. The
large joints are most afiected. Usually the
invasion takes place late (19th to 6oth 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. Y., ib8i, p.
79) says that he has observed a large
number of cases of this rare disease. Me
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 (Deut. Zeitschr.
f. Chir., XXVII, p. 155) mentions two
cases treated by antiseptic irrigation of the
joint.

The bursae in various parts of the body
are only rarely mentioned as the seat of
secondary invasion. I can And 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



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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
nth day) in the disease, and is followed by
pysemia, 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
{Lancety 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.)

Abcesses of the brain are not very rare,
though they do not often attain any great
size (Gowers, Diseases of the Nervous Sys-
tem, i888j 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, Z6), 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.



HiEMORRHAGIC 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 m
typhoid. The same form of infection has
been noticed in other localities. Frequently
an intercellular haemorrhage has been ob*
served in the new-bom 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. Seitr
(Case 51, 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-
hage 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.



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Gas-Forming Bacili.i (Malignant
<Epema). — 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)
mentions three cases by Louis, two by For-
get, ^nd six by Rilliet and Barthey, and one
of his own observation. In this case diph-
theria appeared on the thirtieth day, and
-a local infectioti 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
oases of typhoid. Out of eighty-nine
oases of noma observed by Tourdes seven
followed typhoid fever. West observed
two similar cases. (See Murchison and
Liebermcister.)

Erysipelas. — This usually appears in an
advanced stage of the disease (Murchison,
p. 582). It appears in about i 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
«. complication of typhoid. Seitz (Cases
J I 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 aetiological factor.

126 Sti^te Stkbbt.



FOUR CASES OF SURGICAL KID-
NEY.



BY I. N. DANPORTH, A. M., M. D.,

Professor of Renal DifleaaeB in The Woman's Medical

College.



Case I. — On the i8th of February, 1879,
I was called to see Mrs. I., an Irish woman,
aged thirty-eight, married, but without
having borne children. She was sitting
upon her bed, propped up by pillows, and
partly supporting the weight of the upper
half of the body upon her clenched fists.



Online LibraryJ. M. (James Mitchell) FosterThe Chicago medical journal and examiner → online text (page 12 of 63)