FOCAL NECROSIS OF THE LIVER IN TYPHOID FEVER 
lymph sinuses; certain of these were large and phagocytic, containing leucocytes in 
various stages of disintegration — a condition described by Mallory. A few plasma 
cells were seen ; multinuclear leucocytes and fibrin were practically absent. 
No ulceration had occurred on the surface of the glands, but in the deeper parts 
there were a few patches of necrosis dotted with fragments of nuclei. The submucous 
coat contained several endothelial cells and lymphocytes, the latter mostly grouped 
around the engorged blood vessels. The muscular and peritoneal coats were normal. 
The most striking feature in the mesenteric gland, apart from the general 
congestion, was extensive necrosis. The normal lymphatic nodules had almost com- 
pletely disappeared, and were replaced by darkly staining granular masses filled with 
fragmented nuclei, in appearance not unlike early tubercular caseation. The lymph 
sinuses adjoining these masses were blocked with fibrin and endothelial cells in an 
early stage of necrosis. 
The clinical history, the results of the autopsy, the microscopic appearances of the 
intestinal lesions, and the bacteriological examination, prove that the patient was suffer- 
ing from chronic heart disease, and died from a virulent attack of typhoid fever. 
The duration of the attack was probably six days, beginning with the pyrexia on 
November 14 ; the slight temperature on November 1 1 is of no significance, for patients 
are often feverish during the first night in the hospital. 
The absence of intestinal ulceration is additional evidence of the brevity of the 
attack, while the presence of some necrosis within the lymphoid tissue, a condition 
usually obtaining about the tenth day of the disease or later, does not prove that the 
disease was in the second or third week ; but it must be regarded as a natural result 
of the virulent infection indicated by the temperature and cerebral symptoms. 
The microscopical appearances of the liver were most interesting. Apart from 
early and uniform parenchymatous changes the organ was studded with areas of focal 
necrosis, which were so numerous that three or more often appeared in the field of a 
half-inch objective. The areas were usually slightly larger, sometimes much larger, than 
a human kidney glomerulus (Plate IV, Fig. 1). They were situated mainly at the peri- 
phery or in the centre of the liver lobule. Their shape was roughly round or oval, the 
margins being rather irregular. They consisted essentially of necrosing or necrosed 
cells — probably liver cells — detritus, and occasionally persisting strands of stroma 
mingled with numerous irregular nuclei, sometimes club shape, triangular, or fusiform ; 
and often a few lymphocytes. These irregular nuclei were as a rule more conspicuous 
than the necrosing cells, giving the lesions a most characteristic appearance, and 
especially when a few lymphocytes were present, suggested the original misnomer 
' lymphoid nodules.' This term is less incorrectly applied to certain areas of the 
periportal connective tissue densely infiltrated with lymphocytes, but in which there 
was neither necrosis nor irregular nuclei — a lesion met with in typhoid and other toxic 
diseases. 
