Complications.-G. P. Yule1 reports 10 cases of perforation in typhoid fever. In his experience the onset is likely to be gradual in many cases. Only one of those reported showed violent onset. There was no immediate primary shock in any of the 10 cases. The distention that commonly follows may be postponed for hours. There may be but little change in the pulse and no severe pain, and the patient may take nourishment freely. Under such circumstances there may be an entire lack of the usual anxious expression, the position may not be typical, and in general it may be extremely difficult to determine that such a grave complication has arisen. Two patients were operated on; 1 recovered and 1 died. [We must agree that our experience has been that the onset of the complication is insidious in some cases; but we believe that this is much more infrequent than the author intimates. On the other hand, it is undoubtedly true that textbooks and teachers give an equally erroneous impression in describing the symptoms as sudden and vehement in most cases.]

D. J. M. Miller reports a case of typhoid fever which occurred in a girl of 11, in which there occurred a sudden fall of temperature and increase of tympany, these symptoms having been preceded by tenderness and rigidity of the recti muscles. The seeming perforation was followed by convalescence. This was interrupted by a relapse, and again there were symptoms of perforation, this time with fatal issue. Autopsy showed two perforations, one of which had been closed by an adherent tag of omentum; the other was quite recent. [The case is of very great interest in showing the possibility of spontaneous cure of perforation. Of course, this must be very unusual.]

R. H. Fitz and H. H. A. Beach describe a case of typhoid fever which presented symptoms of peritonitis in the right iliac region during the third week. A perforation was believed to exist, and the abdominal cavity was opened. The ileum was found perforated near the ileocecal valve. The perforation was closed by Lembert sutures, the abdomen flushed with hot water and closed. The further history of the case is not given.

J. M. DaCosta' reports 5 cases of jaundice complicating typhoid fever. From a study of these cases and from those which he has collected from the literature, he decides that when it appears this complication commonly does so after the middle period of the fever is past, though sometimes it may occur before the fever begins. It is usually an accompaniment of a severe case, chills often occur, and vomiting is frequent. The stools are not commonly clay-colored, but are more like dark typhoid stools; epistaxis is frequent. Of 52 cases which DaCosta has collected, 32 ended in death. In 28 of these there were evidences of degeneration of the hepatic parenchyma. The method of treatment seems to have no influence upon the production of the condition, nor does the age of the patient; it has occurred in every period of life excepting early childhood. The author discusses other diseases of the liver complicating typhoid fever, and reports 22 cases of abscess which he has discovered in the literature and upon which he has based the following points in diagnosis: There are usually severe and repeated

1 Edinb. Med. Jour., Apr., 1899. Ibid., Oct. 20, 1898.

2 Boston M. and S. Jour., May 25, 1899. Am. Jour. Med. Sci., July, 1898.

chills, marked variability of temperature, much sweating, and pain in the region of the liver. Jaundice is usually absent. Pylephlebitis gives a very similar picture, but is distinguished by the presence of enlargement of the subcutaneous veins of the abdomen and ascites. DaCosta thinks that there may be a biliary typhoid without intestinal lesions, resulting from the direct action of the bacilli or of their toxins upon the liver. Gallbladder complications are frequent in typhoid, cholecystitis being the gravest, having caused 39 deaths in the 58 cases of this condition which DaCosta has found reported. Pain, tumor, and jaundice are the important symptoms, the first being the most constant. Chills are nearly always absent, though nausea and vomiting are frequent. The condition is most likely to be confounded with appendicitis.

R. T. Morris' describes a case which he believes was one of primary typhoid infection of the gallbladder. It occurred in a man of 26, and began with severe pain in the region of the gallbladder, soon followed by symptoms of general peritonitis. A tumor was found at the side of the gallbladder, and operation showed that this was an empyema of this viscus, the contents being thick pus. The temperature decreased somewhat then, but the patient shortly afterward showed the typical symptoms of typhoid fever, which ran the usual course, ending in recovery. No bacteriologic examination of the contents of the gallbladder is reported.

2

J. Anderson reports a case of typhoid fever which terminated by perforation of an ulcer of the gallbladder. There had been some pain and tenderness in this region before death, but no marked symptoms. The postmortem disclosed numerous small ulcers of the gallbladder; localized peritonitis with abscess-formation was found about it.

C. N. B. Camac3 describes a case of typhoid fever in which cholecystitis came on during the fourth week of the disease. The gallbladder was tapped, and bacilli having the morphologic characteristics of typhoid bacilli were found in the fluid. Another tapping was undertaken, but as it was unsuccessful cholecystotomy was done, and 120 cc. of fluid were removed from the gallbladder. Death, however, followed. The literature on this subject is reviewed, and of 28 cases Camac finds that 21 resulted in perforation, so that energetic treatment is necessary; cholecystotomy or aspiration should be done, preferably cholecystotomy.

A. Fränkel discusses the affections of the respiratory apparatus associated with typhoid fever. He first directs attention to the confusion that has accompanied the use of the term pneumotyphoid, some of the cases being real pneumonia, merely presenting a typhoid course; others, a combination of pneumococcus-pneumonia with typhoid fever; and, third, there are the real cases, which are typhoid fever with marked pulmonary symptoms, the lung-symptoms probably being due to the direct action of the typhoid bacillus in association with other microorganisms. He reports an interesting case as an example of the difficulty in being positive after clinical examination that the case is one of pneumotyphoid. This occurred in a girl of 21, who died after having presented a typical typhoid appearance with enlargement of the spleen and eruption of rose-spots upon the abdomen, together with consolidation of the lungs.

IN. Y. Med. Jour., Jan. 28, 1899.

3 Am. Jour. Med. Sci., Mar., 1889.

Lancet, Apr. 22, 1899.
Deutsch. med. Woch., Apr. 13, 1899.

After death, however, the intestines were found free from any lesions, while there was a typical fibrinous pneumonia of the right upper lobe and, to some extent, of the left upper and lower lobes. The spleen was enlarged. [Bacteriologic examination does not seem to have been made; it is therefore possible that the case was pneumotyphoid.] In the atypical forms of pneumonia Fränkel finds from his investigations that the pneumococcus is usually the only microorganism present. He has investigated a large number of cases and has never found any other microorganism active in the disease, and he believes that the reason streptococci have been frequently found is that the pneumococcus is often discovered in streptococcus-form in the sputum, and that the secretions from the mouth and pharynx are constantly infected with the streptococcus. If the streptococcus-form of pneumococcus be injected into mice, subsequent cultures will give typical lancet-shaped cocci.

C. Achard' reports 2 cases of pleurisy following typhoid fever. One of them became purulent. In both repeated paracentesis was undertaken, and in the suppurating case operation was finally carried out. Both recovered. It was found that the fluid removed from the pleura gave a typical reaction with the typhoid bacillus in both cases.

Subse

J. C. Wilson discusses a renal form of enteric fever, reporting the case of a boy of 19, whose symptoms were for some time purely those of acute nephritis; but the Widal test was positive and there were slight hemorrhages from the bowels. The temperature after a few days declined somewhat, but subsequently rose again, and the patient became delirious, and albumin, casts, and blood-cells reappeared in the urine. quently, however, the usual symptoms of typhoid fever developed, and the common course of that disease was passed through and the patient recovered. Wilson insists upon the importance of these cases because of the danger of administering improper diet to them, the likelihood of using purgatives improperly, and, most important of all, the danger of infection of others through overlooking the disease. Very similar cases are described by Rostoski, who found that renal involvement had been noted in 59.2% of 346 cases treated during the past 12 years in the Würzburg clinic. Albuminuria is more common in the early stage of the disease. In 37 of the cases there were evidences of severe nephritis; 7 of these were fatal, while of the remaining 309 but 20 were fatal. He then discusses those cases in which typhoid fever begins with renal symptoms, and describes 2 such cases. In the first case the illness came on with the usual signs of acute violent nephritis, the typical typhoid symptoms appearing later. In the second case the patient, who was convalescent, received enemas for constipation, when peritonitis came on and the hemorrhagic nephritis returned ; she recovered, however.

T. Houston reports the discovery of the typhoid bacillus in the urine from a case of cystitis which had lasted for 3 years. The study was begun in the belief that the colon-bacillus would probably be found; but a bacillus identical with that of typhoid fever was discovered; it reacted with the patient's blood, and the blood also reacted with other cultures of the typhoid bacillus, and not with the colon-bacillus. It seemed to be a case of typhoid infection without the usual symptoms or lesions 1 Sem. méd., Oct. 19, 1898. 2 Am. Jour. Med. Sci., Dec., 1898. 4 Brit. Med. Jour., Jan. 14, 1899.

3 Münch. med. Woch., Feb. 14, 1899.

any

of typhoid. The history showed that there had been at no time any severe symptoms, and at no time in the course of the cystitis was there evidence of a new or more severe infection; therefore Houston believes that the original infection was with the bacillus of Eberth. The fact that this unusual local result ensued from the infection and that the general system escaped might be due to a lack of general susceptibility to the typhoid bacillus; to the fact that the bacillus discovered was of different virulence from the one which commonly causes typhoid; or possibly typhoid fever may be the result of other factors than the bacillus of Eberth alone. [A number of cases might be collected from the literature in which the typhoid bacillus has been found in actively vegetative form in lesions of many months' or even of several years' duration. This is especially noted in the case of bone-lesions.]

G. Blumer reports a case which occurred in a woman of 45, in which in the fourth week after the onset of typical typhoid fever swelling and pain appeared at the junction of the fourth rib with the sternum. The introduction of a needle revealed no pus. Five months later, however, she was seen because of a nodule in the left breast, and this was removed; but a sinus remained, and a later operation showed necrosis of the fourth rib at its junction with the cartilage. Bacteriologic examination showed the presence of the colon-bacillus. Removal of the necrotic portion of the rib and packing of the wound caused it to heal perfectly by granulation.

2

Takali and Werner record a case of posttyphoidal suppuration which was unusual because of its situation in the glands of Bartholin. The pus contained a pure culture of typhoid bacilli.

3

A. Loeb discusses the question of meningotyphoid. He reports the case of a boy of 18, who was admitted probably at the end of the first week of his illness. He was very stupid, but presented somewhat the appearance of typhoid, with fever, and enlargement of the spleen and liver. He showed marked right-sided papillitis, however, and the veins were distended; the temperature ran a very irregular course, with only slight elevation. The patient developed rigidity of the neck and the papillitis continued, the edges of the papilla being blurred, but the physiologic cup was present. The Widal reaction was negative. Gradually, however, the symptoms became more like those of typhoid; the stiffness of the neck and blurring of the papilla disappeared, and toward the end of his illness the Widal reaction was positive. It seemed, therefore, undoubtedly typhoid; but Loeb, after reviewing the literature, decides that it was probably an infection which first attacked the meninges and produced a serous meningitis. Lumbar puncture in this case had been negative; but Jemma has reported an instance in which lumbar puncture in typhoid with meningeal symptoms yielded fluid which contained typhoid bacilli; and although in many cases thought to be meningitis with typhoid the postmortem examination has shown normal microscopic appearances of the meninges, Loeb believes with others. that this cannot be taken as final evidence of the absence of serous meningitis. He considers the papillitis a positive sign of increased intracranial pressure, and since any sign of tumor or abscess was absent in 'Pacific Rec. of M. and S., Nov. 15, 1898. 2 Zeit. f. Hyg., p. 31, 1898. 3 Deutsch. Arch. f. klin. Med., Band Ixii., Hefte 3 u. 4.

this case, he believes that it positively indicated meningitis. The reflexes were much increased in this case, and they have been noted to be increased in many other cases of typhoid. It is uncertain whether this should be considered a sign of involvement of the nervous system or not.

W. W. Kerr and H. Moffitt' reported a case of typhoid fever which ran a course suggesting tuberculous meningitis, though there were no eye-symptoms and no hyperesthesia. The Widal reaction was positive toward the end of the disease, which was fatal. The autopsy showed enlargement of the spleen with ulceration in the ileum, and there was a purulent meningitis from which cultures of the typhoid bacillus were obtained. The meningitis was due to general infection, and not to any local disease, such as mastoiditis.

2

Hugot describes a case of meningitis complicating typhoid fever. At the autopsy the usual intestinal lesions of typhoid were found as well as a purulent meningitis, in the exudate of which the typhoid bacillus was present.

3

N. Ritscher discusses the literature concerning paralysis with typhoid fever, and reports 3 cases, in the first of which there occurred a right-sided hemiplegia which appeared on the thirty-fifth day of the disease, while the other cases both involved the left facial nerve and both appeared on the ninth day. In most cases posttyphoidal paralysis appears in the earlier period of convalescence. It usually disappears ultimately; though at times it remains and may cause death. Among the causes of the paralysis he mentions inflammation of the muscles and nerves, myelitis, and encephalitis, as well as embolism and thrombosis. Embolism and thrombosis may be due to the general circulatory failure, while in other instances paralysis usually results from the action of the. typhoid toxins.

F. W. Sutler reports the case of a man of 24, who had continued fever (probably typhoid), and who suddenly during convalescence became completely paralyzed on the right side. The report is very imperfect.

Lopriori reports the case of a girl of 5, who had typhoid fever, and who on the seventeenth day of the disease developed a sudden aphasia without signs of paralysis. The difficulty in speech persisted for a month and a half. It was thought to be due probably to embolism.

M. Dide has made a study of 120 cases of epilepsy in order to learn whether typhoid fever is of importance in causing this disease. Among these 120 cases were 7 patients who had had typhoid fever. In 1 of these there was hereditary predisposition to epilepsy. In 2 others infantile convulsions had occurred, and this made it probable that typhoid fever was but an accidental cause of the outbreak of epilepsy. In 4 cases, however, there was no evident predisposition, the typhoid fever had run a severe course and had been accompanied by violent delirium, which in several cases was protracted, and the epilepsy had appeared soon after and had continued. From these cases, Dide is led to believe that typhoid fever may be an exciting cause of epilepsy. In none of the

1 Jour. Am. Med. Assoc., Mar. 18, 1899.

2 Gaz. hebdom, de Méd. et de Chir., No. 20, 1899.

3 Bolnitschnaya Gazeta Botkina, Nos. 45 and 46, 1899.

4 Georgia Jour. M. and S., Nov., 1898.

* Gaz. degli Ospedali, Jan. 5, 1899.

Rev de Méd., Feb. 10, 1899.