TYPHOID FEVER. 171 



the feces they are not found before the second week 

 of the disease, usually after the tenth day, but, as a rule, 

 not in large number. In most cases they disappear from 

 the stools as early as the fourth week of the disease, and 

 in rare cases they are demonstrable until after defervescence. 

 The blood of typhoid patients is generally sterile, although 

 typhoid-bacilli have been found in the blood of the rose- 

 spots and from the veins. It is necessary to employ con- 

 siderable amounts of blood (i cu. cm.) for the purpose of 

 examination. The urine during life and the kidneys after 

 death frequently contain the bacilli, especially in cases 

 complicated by albuminuria. Rarely the bacilli have been 

 found, besides, in the Inngs in some cases of typhoid pneu- 

 monia or bronchopneumonia, in the meninges in cases of 

 typhoid meningitis, in the myocardium in cases of typhoid 

 myocarditis, and in the testicles in cases of typhoid orchitis. 



Typhoid-bacilli have been found repeatedly in the pus of 

 suppurative processes that develop in the course, or as a 

 sequel, of an attack of typhoid fever : as, for instance, 

 osteoperiostitic processes, encapsulated peritonitis, abscesses 

 of the spleen and the liver, inflammation of joints, thyroiditis, 

 empyema, etc. These observations show that the typhoid- 

 bacillus is also capable of manifesting pyogenic activity. 

 Typhoid-bacilli have been found in such posttyphoid sup- 

 purative processes fifteen months after the termination of 

 the disease, and in one case of old bone-disease as long as 

 seven years afterward.* 



Mixed Infection and Secondary Infection. The course 

 of typhoid fever is frequently modified by complicating in- 

 fections due to other microorganisms, usually those exciting 

 inflammation. At times these complications appear at the 

 commencement of the disease as the expression of a mixed 

 infection ; at other times they occur later as secondary in- 

 fections. The bacterium coli commune plays the most im- 

 portant part in the development of these conditions. It is 

 found to be the cause of peritonitis, cholangitis, etc. Next 

 in importance is the streptococcus pyogenes, which has 

 been frequently demonstrated in cases presenting secondary 

 empyema, otitis, and bronchopneumonia. Mixed infection 



*Hunner, "Bulletin of the Johns Hopkins Hospital," Aug.-Sept., 1899, 

 p. 163, has reported a case of acute suppurative cholecystitis in which typhoid- 

 bacilli were isolated from the contents of the gall-bladder eighteen years after 

 an attack of typhoid fever. A. A. E. 



