636 Typhoid Fever 



intestinal and mesenteric lymphatics at the time we are able to 

 recognize the disease. 



It is quite certain that the chief operations of the typhoid bacillus 

 are in the tissues and not in the intestine, as seems to be a widely 

 prevalent error. It is contrary to most of our knowledge of the 

 organism that it should easily adapt itself to saprophytic exist- 

 ence among the more vigorous intestinal organisms. Those who 

 look for it in the feces are usually surprised at the difficulty of finding 

 it, or at the small numbers present. It is far more easy to isolate 

 the organism from the blood than from the feces, and much greater 

 numbers occur in the urine than in the feces. It probably es- 

 capes from the blood into the bile, where it grows luxuriantly, 

 and entering the gall-bladder may take up permanent residence 

 there, escaping into the intestine each time the gall-bladder is emptied. 

 Many bacilli thus discharged probably meet with destruction in 

 the intestine, though some convalescents from typhoid fever for 

 years have a periodic appearance of bacilli in the feces. Such in- 

 dividuals have become known as "typhoid carriers" and are a men- 

 ace to the public. 



In a case studied by Miller* bacilli were found in the gall-bladder 

 seven years after recovery from typhoid fever; in a case studied by 

 Drobaf they were found in both the gall-bladder and a gall-stone 

 seventeen years after recovery from the disease; HumerJ found 

 them in the gall-bladder of a patient suffering from cholecystitis, 

 eighteen years after recovery from an attack of t5^hoid fever, and in a 

 case studied by Dean,§ they were present in the stools of a man 

 twenty-nine years after he had had an attack of t}^hoid fever. 



Gushing 1 1 invariably found the baciUi in the bile in clumps re- 

 sembling the agglutinations of the Widal reaction. He thinks it 

 probable that these clumps form nuclei upon which bile salts can 

 be precipitated and calculous formation begun. The presence 

 of gall-stones, together with the long-lived infective agents, may 

 at any subsequent time provoke cholecystitis. Gushing collected 

 6 cases of operation for cholecystitis with calculi in which typhoid 

 bacilli were present, and 5 in which Bacillus -coli was present in 

 the gall-bladder. 



With the most approved methods yet devised, Peabody and 

 Pratt ** were unable to recover the micro-organism from the intestinal 

 contents in more than 21 per cent, of febrile cases, and only in small 

 numbers as a rule. The greatest number was obtained when there 

 was much blood in the stool. 



* "Bull, of the Johns Hopkins Hospital," May, 1898. 

 . t "Wiener klin. Wochenschrift," 1899, xn, p. 1141. 



i "Bull, of the Johns Hopkins Hospital," Aug. and Sept., 1899. 

 § "Brit. Med. Jour.," March 7, 1908, 1, p. 562. 

 Il " Bull, of the Johns Hopkins Hospital," rx, No. 86. 

 ** "Journal of the American Medical Association," Sept. 7, 1907, xldc, p. 

 846. 



