BACILLUS OF TYPHOID FEVEE 413 



either late in the disease or months after convalescence, and are char- 

 acterized by very severe pain. Osteomyelitis may also occur, but is 

 comparatively rare. Subcutaneous abscesses and deep abscesses in the 

 muscles, due to this bacillus, have been described by Pratt. 1 Synovitis 

 may also occur. 



Meningitis, due to the typhoid bacillus, occurs not infrequently, 

 usually during convalescence from typhoid fever. A case of primary 

 typhoid meningitis has been reported by Farnet. 2 



Peritoneal abscesses, due to the typhoid bacillus, have been re- 

 ported. The writer 3 has reported a case in which typhoid bacilli were 

 found free in the peritoneal cavity during typhoid fever without per- 

 foration of the gut. 



Isolated instances of typhoid bacilli in abscesses of the thyroid and 

 parotid glands and in brain abscesses have been observed. 



Typhoid Fever without Intestinal Lesions. A considerable number 

 of cases have been reported in which typhoid bacilli have been isolated 

 from the organs after death or from the secretions during life of pa- 

 tients in whom the characteristic lesions of typhoid fever have been 

 lacking. M&st of these cases must be regarded as true typhoid septi- 

 cemias. In some cases the bacilli were isolated from the spleen, liver, 

 or kidneys; in others, from the urine or the gall-bladder. In a case 

 observed by Zinsser the bacilli were isolated from an infarct of the 

 kidney removed by operation. . In this case the clinical course of the 

 disease had pointed only s toward the existence of an indefinite fever ac- 

 companied by symptoms referable to the kidneys. The Widal test, 

 however, was positive. An excellent summary of such cases, together 

 with several personally observed, has been given by Flexner. 4 



Hygienic Considerations. Although typhoid fever is frequently 

 spoken of as an epidemic disease, it is, more truly, endemic in character 

 in almost all parts of the world, but subject to occasional epidemic ex- 

 acerbations. In the larger communities of the temperate zones these 

 epidemics take place chiefly in the autumn, are circumscribed and 

 limited usually by the distribution of a water or milk supply. 



Since the disease never occurs except by transmission, directly or 

 indirectly, from a previous case, it is amenable more than most other 

 maladies to sanitary regulation, and it may be said without exaggera- 

 tion, in the light of our present knowledge, that any extensive prevalence 



1 Pratt, Jour. Boston Soc. Med. Sci., 3, 1899. 



2 Farnet, Bull, de la soc. med. des hop..de P., 3, 1891. 



3 Zinsser, Proc. N. Y. Path. Soc., 1907. 4 Flexner, Johns Hopk., Rep., 5, 1896. 



