TYPHOID FEVER 299 



its result. The pathogenetic action of the bacilli is obscure, but there 

 can be no doubt that the ulcers in the intestine are directly or in- 

 directly the result of the specific bacillus. When the bacilli reach the 

 intestine they multiply, and, penetrating the mucous and submucous 

 coats, set up the changes, which lead, first to hypersemia, then to infil- 

 tration, and finally to ulceration of Peyer's patches. Some of the bacilli 

 pass into the blood, collecting in the spleen and other glands. Whether 

 in the bowels or in the organs of the body, the bacilli produce their 

 toxins, and as a result of their action, inflammation and fever follow. 

 The inflammation in the intestine leads, in conjunction with the 

 irritation produced by the ulcers, to increased peristalsis, and there- 

 fore diarrhoea. Hence the excreta of a typhoid patient have two 

 characteristics. They are usually abundant and frequent : and they 

 are charged with large numbers of the bacilli of typhoid fever. It 

 is, however, necessary to guard against the idea that typhoid fever is 

 a local disease of the intestine, or even chiefly so. In ordinary cases, 

 it is true, the intestinal lesions form the starting-point of the disease, 

 but the bacilli rapidly become generalised, and are found in the most 

 varied parts of the body, and not uncommonly in the blood itself. 

 Such a state of things leads to a condition not remote from septi- 

 caemia, and this may occur with little or no local lesion in the 

 intestinal tract. The reason why the bacilli of typhoid are not found 

 in greater number in the blood, is probably in part due to the fact 

 that in ordinary cases the blood is not a favourable medium for their 

 growth, and in part to the fact that they are rapidly eliminated or 

 excreted. " Any conception of the disease," writes Dr Horton-Smith, 

 " which regards it merely as affecting the alimentary canal, can no 

 longer be maintained. On the contrary, so far from considering it 

 an intestinal disease, pure and simple, we should rather look upon it 

 as a modified form of septicaemia. It is septicaemia in that always, 

 and in all cases, the bacilli pass into the blood, and then into the 

 various organs, and in that the symptoms, excepting so far as they 

 are intestinal, are referable to the poisons there produced. It is a 

 modified form, however, in that in nearly all cases there is a definite 

 local and primary disease, whence the secondary dissemination of 

 the micro-organism, takes place."* 



Whilst it has been held that typhoid infection can pass out of 

 the infected person by means of the sweat, the expectoration, the 

 fasces and the urine, it is only the latter two which need be considered 

 as a rule. Typhoid stools should always be considered infective, 

 both in the early and late stages, and the bacilli have even been found 

 in the stools fifteen clays after the temperature has become normal. 

 Further, it is possible that the typhoid bacillus may be distributed 



* Brit. Med. Jour., 1900, i., pp. 827-34 (Gulstonian Lectures, 1900), P. Horton- 

 Smith. 



