672 PATHOGENIC MICROORGANISMS 



who, during typhoid convalescence, manifested gall-bladder symptoms. 

 Direct culture of the bile by means of the duodenal tube method showed 

 typhoid bacilli in " A," but not in "B." In both, the gall bladder was 

 removed and a pure culture of typhoid bacilli obtained from both gall 

 bladders. At the time of operation, the negative culture in "B" was 

 explained by the fact that a large stone was fixed in the cystic duct which 

 completely occluded the passage. The bile from "B," before operation 

 had come directly from the liver, and had not entered the gall bladder 

 which was in this case, the only site of infection. After operation 

 however, typhoid bacilli completely disappeared from "B," where the 

 bile that had come from the liver had been found sterile by the original 

 duodenal culture, but in "A," in spite of the complete removal of the 

 gall bladder and cystic duct, repeated duodenal cultures remained posi- 

 tive. Similar cases have been reported in the literature, but none which 

 seem quite as convincing as a proof for the existence of the true liver 

 carrier as these instances reported by Garbat. 



The manner in which typhoid bacilli get into the gall bladder has 

 occupied the attention of a number of investigators. According to 

 Kiister 84 and a more recent report by Garbat ascending infection of the 

 gall bladder from the duodenal is a possibility, though it is probably 

 not the most common method of infection. Nichols 85 too has admitted 

 the possibility of such a process, although no one believes that this is 

 very common. The fact also that, according to Blumenthal 86 Lauben- 

 heimer 87 and others, colon bacilli are very commonly found in the gall 

 bladder, gives support to the possibility of ascending infection. The 

 opinion, however, that the bile is hematogeneously infected by way of 

 the hepatic circulation in most cases is generally accepted. 



The existence of pure intestinal carriers has been suggested by Kraus 

 and others, and in addition to the cases cited by Kraus, there is one by 

 Garbat in which duodenal cultures were repeatedly negative, whereas 

 the feces remained positive. Cholecystectomy on this case did not 

 relieve the carrier condition. The intestinal carrier type, according 

 to Kraus 88 may be associated with chronic intestinal ulcerations, 

 chronic appendicitis, etc., but is unquestionably extremely rare, a large 

 majority of carriers being due to actual gall-bladder infection. 



Chronic urinary carriers are less common than chronic feces carriers. 



M Ku ter, Beitr. f. Klin. d. Infkrankh, etc., 7, 1918, 98. 



85 Nichols, Jour, of the A. M. A., 68, 1917. 



86 Blumenthal, Arch, f . klin. Med., 88, 1907, 509. 



87 Laubenheimer, Zeit. f . Hyg., 58, 1909. 



88 Kraus, Wien. klin. Woch., 27, 1914, 1443. 



