which the disease appears to have been caused by the use of the flesh
of diseased animals or of meat in a condition of putrefaction. In some
of these the symptoms were rather those of irritant poisoning than of
typhoid fever, and consisted principally in violent vomiting and
purging coming on very shortly after the ingestion of the unwholesome
food. There yet remains a certain number in which the symptoms cannot
be thus explained.[39] One of the most remarkable of these occurred in
1878 at a festival which was held at Kloten, a place about seven miles
north of Zurich, of which the following is a condensed description:
Out of 690 persons who sat down to the collation, 290 were taken ill;
378 other persons, who did not attend the festival, but who partook of
the meat provided for it, were also affected. In addition these, 49
secondary cases occurred--_i.e._ of persons who subsequently became
affected without having eaten of the meat. All other sources of
infection could be certainly excluded, as Kloten was quite free from
typhoid fever at the time, and as it was clearly shown that the water
was not the cause of the outbreak. All the visitors at the festival
who ate no meat escaped, as did also several persons who drank wine to
excess and subsequently vomited. The period of incubation was short,
as in other epidemics arising from the same cause. Some of the people
were ill on the second day, with loss of appetite, nausea, headache,
pain and swelling of the belly, and slight fever. These cases were
slight, and generally ended in recovery. The greater number were
affected between the fifth and ninth days. The symptoms in these
cases, which usually ran a rapid course, and generally ended in
recovery, were chills, fever, diarrhoea, great prostration, frequently
violent delirium, and also profuse intestinal hemorrhage. The
rose-colored eruption was present in almost all of them, and in a few
the tâches bleuâtres were detected. On post-mortem {258} examination
the characteristic appearances of typhoid fever were found. With
regard to the meat supplied, the following facts were ascertained:
Forty-two pounds of veal were furnished by a butcher at Seebach, taken
from a calf which appears to have been at the point of death when it
received the coup de grace from the hands of the butcher. All the
flesh of the animal was sent to supply the festival at Kloten, but the
liver was eaten by an inhabitant of Seebach, and he was attacked by
typhoid fever. The brain was sent to the parsonage at Seebach, and all
the household became affected by the same disease. It was also
ascertained that another of the calves was diseased. The veal from
this calf had been kept fourteen days, and was in a decomposed state.
All the meat was placed together in the meat-receptacle of the inn at
which the festival was held. This receptacle was in a horribly filthy
state, and Cayley thinks there can be no doubt that the putrefying
flesh of this last calf, together with the state of the receptacle,
would rapidly excite decomposition in the whole supply.
[Footnote 39: _On Some Points in the Pathology and Treatment of
Typhoid Fever_, by William Cayley, London, 1880; also Prof. Huguenin,
_Schmidt's Jahrbuch_, from _Schweiz. Corr. Bl._, viii. 15, 1878; Carl
Walder, _Schmidt's Jahrbuch_, from _Berl. klin. Wochenschr._, xv. 39,
40, 1878; George R. Shattuck, M.D., Supplement to _Ziemssen's
Cyclopædia_, New York, 1881.]
Geissler, it is true, doubts whether the epidemic above described was
really typhoid fever, and points out that the symptoms occurred too
soon after the ingestion of the diseased meat, and reached their full
development too rapidly. The cases were also accompanied by more pain
in the abdomen than is generally met with in typhoid fever. The
proportion of recoveries also appears to have been unusually large.
Unquestionably, the patients in the Kloten epidemic were in a large
number of instances simply suffering from the action of an irritant
poison; but the presence of the characteristic lesions of typhoid
fever in some of the fatal cases renders it certain that this disease
also existed in the village at the same time.
In the report of this epidemic it is not stated that either of the
calves which furnished a part of the meat for the entertainment were
suffering from typhoid fever at the time they were slaughtered. It is
now known positively that this animal is liable to be attacked by this
disease, and a certain number of cases are on record in which the
eating of the flesh of such animals has been followed by typhoid
fever.[40] That it does not oftener occur from this cause is probably
due to the fact that a certain time must elapse before the flesh of
such an animal acquires infective properties, and that it is usually
used as food before this has been allowed to pass.
[Footnote 40: _Medical Times and Gazette_, Feb. 8, 1879, p. 149, from
_Berl. klin. Wochenschrift_, No. 39, 1878.]
Ludwig Letzench[41] asserts that he has produced some of the
intestinal appearances of typhoid fever, as well as a high degree of
pyrexia, in rabbits by the subcutaneous injection of the sputa and
stools of typhoid fever patients.
[Footnote 41: _Arch. f. exper. Pathol. u. Pharmak._, 1878 and 1881.]
THE BACILLUS TYPHOSUS.--From what has preceded, it will be seen that
the writer is disposed to range himself with those who hold that the
exciting cause of typhoid fever is an organized germ, or, in other
words, a contagium vivum. Although this view cannot be regarded as
positively proven as yet, it has recently received some support
through the investigations of Klebs, Eberth of Zurich, and others,[42]
who believe that they {259} have found in the bodies of those who have
died of typhoid fever a micro-organism peculiar to that disease.
[Footnote 42: Klebs (_Philadelphia Medical Times_, Dec. 3, 1881, from
_Archiv für experimentelle Pathologie und Pharmakologie_, Bd. xiii. H.
5 and 6) claims that he has proved "that there exists in typhoid fever
a separate and distinct bacillus--the _Bacillus typhosus_; that it
undergoes certain transformations, consisting at first of little rods
and small fine threads, containing a spore in the centre and often at
the end, which spores divide off and form new bacilli. It later
assumes a larger thread-like form, twisted at the end, and frequently
taking a beautiful spiral shape; that the bacilli are observed first
in the masses of epithelial cells which accumulate in the alimentary
tract or in the air-passages; that they later penetrate the tissues,
and are carried along by the blood-vessels and the lymphatics, and
form a large network among the tissues they invade; that under a
certain procedure, which never causes this same staining in any other
living organism or tissue, they appear of a blue color; that they are
found only in enteric fever, in which disease every part of the human
body is the seat of masses of these bacilli, their quantity
corresponding exactly with the severity of the symptoms; and that they
produce, when carried into the system of animals, exactly the same
disease with the same morbid alterations as in men." He says, further,
that "the Bacillus typhosus enters the system by the respiratory
passages and by the alimentary canal. This is the cause that in some
cases of typhoid fever almost no abdominal symptoms are present, but a
low form of pneumonia, developing from the very beginning, so that the
lung seems alone to bear the brunt of the disease." He has found these
bacilli in greatest numbers in Peyer's patches.
Eberth (_British Medical Journal_, Nov. 26, 1881, from _Virchow's
Archiv_, Bd. lxxxi. and lxxxiii.) has shown that in typhoid fever the
intestinal mucous membrane, the mesenteric glands, and the spleen
contain rod bacteria, differing, as he believes, from organisms found
in the body in other conditions (among others in phthisis with
extensive ulceration of the intestinal mucous membrane). In seventeen
cases of typhoid these bacilli were found in six and wanting in
eleven. In the six cases the number of bacilli were in inverse
proportion to the duration of the disease. They were not found in the
spleen in the cases of the longest duration, and only scantily in the
mesenteric glands. These bacilli appear not to differ in shape and
size from the ordinary rod bacteria, but Eberth believes that they
differ from them in their small capacity for taking on the staining of
hæmatoxylon, methyl-violet, and Bismarck brown.
Wernich's views (_Vjhrschr. f. Off. Geshpfl._, xiii. 4, p. 513, 1881)
in regard to the nature of the Bacillus typhosus differ from those
held by the two authors just quoted. He regards the specific Bacillus
typhosus as nothing but the ordinary Bacillus subtilis of the large
intestines, which under certain circumstances acquires the power to
accommodate itself to the small intestines, to undergo a higher
development and to become the exciting cause of disease.]
PERIOD OF INCUBATION.--The conditions under which typhoid fever occurs
in large cities render it difficult, if not impossible, to arrive at a
definite conclusion as to its period of incubation. Occasionally,
however, the time which has intervened between the exposure to the
cause and the invasion of the disease may be ascertained with
precision in the outbreaks which occur in small towns or in isolated
country-houses. Under these circumstances it has been found to vary
within very wide limits. In the three cases related by Griesinger the
attack began the day after exposure to the infection, and in the
outbreak at the school at Clapham, referred to by Murchison, twenty
out of twenty-two boys were seized with the disease within four days
of exposure to the causes. Other instances of a similar character are
on record. In cases like the above the rapidity with which the attack
follows upon exposure to the cause is no doubt due to the intensity of
the poison--a view which is to a certain extent at least supported by
the fact that the invasion of the disease under these circumstances is
very apt to be abrupt; the attack being often ushered in with vomiting
and purging or with grave cerebral symptoms. Sometimes, indeed, the
gastro-intestinal symptoms have been so violent as to have given rise
to suspicions of criminal or accidental poisoning. In the majority of
cases, however, the period of incubation is probably very much longer
than in those above referred to. In the outbreak which recently
occurred in a farm-house about seven miles distant from {260}
Philadelphia, the history of which has already been given in detail,
the second case began three weeks after the first, the other six
following in rapid succession. In the celebrated epidemic which
occurred at Lausen in Switzerland in 1872, and which is referred to by
Cayley,[43] the first ten patients were attacked within three weeks of
the time when the contamination of the spring which supplied the
village must have taken place, and these ten cases were followed in
the course of nine days by fifty-seven others. In the town of Over
Darwen 1500 persons were seized with typhoid fever within three weeks
after a patient suffering from this disease was brought to a
particular house, the sewage of which was allowed to soak into the
ground through which the water-supply pipes of the town passed, and at
a point at which they were leaky. Lothholz observed in an epidemic
which occurred in the neighborhood of Jena that the average period of
incubation was three weeks, the shortest period eighteen days, the
longest twenty-eight days. Haegler found in three cases produced by
contaminated water a period of at least three weeks.[44] There are,
however, epidemics on record in which the period of incubation was
under two weeks, as, for instance, that of Basle, referred to by
Liebermeister, in which a few persons were attacked who had only been
in the city from seven to fourteen days. Cayley also refers to
localized outbreaks of the disease, as those of Calne and Nunney, in
which persons were attacked within fourteen days of their exposure to
the cause. C. J. C. Muller of Posen[45] says that the average period
of incubation of the disease is fourteen days; that it may be not more
than ten days, or, on the other hand, as long as from three to four
weeks; and that he has known a case in which it was thirty-four days.
Murchison believed that it was most commonly about two weeks, and
William Budd arrived at the conclusion, from the observation of a
large number of cases, that it varied from ten to fourteen days.
[Footnote 43: _Brit. Med. Jour._, Mar. 15, 1880.]
[Footnote 44: _Ziemssen's Cyclopædia_, vol. i.]
[Footnote 45: _Neue Beiträge zur Aetologie des Unterleibs-Typhus_,
Posen, 1878.]
From this review of the opinions of various authors the conclusion
would seem to be justifiable that the period of incubation in typhoid
fever is usually between two and three weeks, but that in many cases
it does not exceed ten days, and in rare instances has unquestionably
been very much less. On the other hand, there are authentic cases on
record in which it is said to have reached, or even exceeded,
twenty-eight days. Unfortunately, we do not possess any reliable data
with which to decide the question whether it is shorter or longer when
the poison is imbibed with the ingesta than when it is inhaled. It
would seem, however, that there is a difference in the susceptibility
of different individuals to the poison of this disease, in many
persons a single exposure to the cause being sufficient to induce an
attack, while in others the disease is contracted only after repeated
exposure.
MORBID ANATOMY.--As a thorough knowledge of the morbid anatomy of
typhoid fever is absolutely necessary to a correct understanding of
its pathology, it seems to me better to deviate from the order usually
observed in systematic treatises and to proceed at once to a
description of the former, rather than to defer it, as it is usual to
do, until after the symptomatology of the disease has been discussed.
Rigor mortis is generally more marked and more prolonged than after
{261} typhus. Emaciation is often extreme in cases in which death has
taken place after the third week, especially if they have been
attended by much diarrhoea and fever. No traces of the characteristic
rose-colored eruption are found after death, no matter how profuse it
may have been during life. Sudamina, on the other hand, persist, and
discolorations of the dependent portions from settling of blood are
always present in the dead body.
The lesions of typhoid fever may be divided into two classes. The
first class includes certain changes in the glands of Peyer, the
solitary glands of the intestines, the spleen, and other lymphatic
structures of the body. These changes, which consist essentially in a
medullary infiltration of these glands, will be minutely described
presently. They are peculiar to the disease, and are just as
characteristic of it as the condition of the lungs and their membranes
found in pneumonia and pleurisy are characteristic of those diseases.
They are usually most developed in grave cases, but occasionally they
are slight and but little marked in cases in which the general
symptoms were severe. They therefore cannot be regarded as the sole
cause of the latter. It is more probable that they are themselves the
results of the local action of the typhoid poison, and bear somewhat
of the same relation to typhoid fever that the eruption in small-pox
does to that disease. The second class is made up of lesions which are
met with not only in this disease, but in other diseases accompanied
by high fever, and are therefore unquestionably the result of the
general process. They consist essentially of parenchymatous
degenerations of various organs and tissues, and are generally more
marked in typhoid fever because the pyrexia is not only of high grade,
but also of longer duration than in other diseases.
We shall first consider the lesions peculiar to typhoid fever. Among
the most important of these are the changes which occur in the
agminated and solitary glands of the intestines. These have been
usually described as passing through four stages, as follows: (1) the
stage of medullary infiltration; (2) the stage of softening or
sloughing; (3) the stage of ulceration; (4) the stage of
cicatrization. These stages are said to last almost a week, and
correspond to certain definite periods of the disease, but it is not
uncommon to find in the same intestine glands in two or more of these
stages. Indeed, the same gland may sometimes be found ulcerating at
one side while cicatrization is going on at the other.
In the first stage the agminated glands are enlarged, each patch
preserving its oblong shape, and being flattened on the surface and
elevated from half a line to two lines above the surrounding mucous
membrane, from which it is separated by an abrupt border, and which it
may in a few cases overhang like a fungous growth. The solitary
follicles are also swollen, and may vary in size from a hempseed to a
split pea. In very severe cases all the glands may be more or less
involved, but in mild cases the changes may be limited to three or
four of the patches of Peyer, although the solitary glands rarely
wholly escape. It is uncommon also for the latter to be alone
affected, but a few such cases have been reported. In these the mucous
membrane appears to be studded with pustules, and hence Cruveilhier
designated this variety as the forme pustuleuse. The mucous membrane
covering the affected glands is reddish-green in color, and that in
their immediate vicinity is {262} often injected. The changes above
described occur early in the disease--Murchison has seen them in two
cases in which death took place at the end of the first day--and they
are often well marked at the end of the third or fourth day. They are
usually limited to the glands in the lower part of the ileum, the
agminated glands being often found perfectly healthy four feet above
the ileo-cæcal valve. In mild cases, indeed, the lesions may be
confined to those nearest to this valve. So, too, the changes in the
solitary glands may be confined to the last twelve inches of the
smaller intestine, but this is by no means universally the case, for
these glands are not only often found enlarged higher up in the small
intestine, but also occasionally in the cæcum. The agminated glands
are sometimes found enlarged in the bodies of those who have died of
measles and of some other diseases, but the degree of enlargement is
rarely as great as in typhoid fever, and the further changes presently
to be described are never found except in the latter disease.
Under the microscope the medullary infiltration upon which the
enlargement of the glands depends is found to be due to proliferation
of the cellular elements. In the case of the agminated glands this
proliferation may be limited to the follicles or it may extend to the
intercellular tissue, and even to the adjacent mucous membrane. In the
former case the patches have a reticulated aspect; they are soft and
but little elevated. These are the plaques molles of Louis and the
plaques reticulées of Chomel. In the latter they are harder, smoother,
and more elevated. To this variety Louis has given the name of plaques
dures, Chomel that of plaques gauffrées. The morbid process is also
very apt to extend from the solitary follicles to the surrounding
mucous membrane.
In a large number of the glands in many cases, and probably in all of
them in the abortive form of the disease, the changes never advance
beyond the first stage, a restoration to their normal condition taking
place by colliquative softening.[46] The morbid material upon which
their enlargement depends breaks down into an oily débris which is
gradually absorbed. This retrograde process takes place faster in the
follicles than in the interfollicular tissue, and, as pigment is very
apt to be deposited in the depressions thus formed, the patches
acquire an appearance which has been compared to that of a recently
shaven beard. This appearance is met with, however, in other diseases,
and is therefore not peculiar to typhoid fever.
[Footnote 46: Rindfleisch, _Pathological Histology_, Sydenham Society
Translation, vol. i. p. 441.]
The description of the changes in these glands in the subsequent
stages of the disease which follows is taken mainly from Rindfleisch's
work on _Pathological Histology_.
In the stage of necrosis small portions of single Peyerian patches,
varying in size from that of a lentil to from three-quarters of an
inch to an inch and a quarter in diameter, assume a yellowish-white,
opaque tint instead of their former reddish and translucent aspect,
gradually become separated from the surrounding tissue by a sharp line
of demarcation, and then pass into a state of cheesy necrosis. Here
and there the same changes are observed to have taken place in the
solitary glands. When once this has occurred, recovery can only take
place by expulsion of the necrosed parts and consequent ulceration.
Necrosis of the glands {263} probably rarely occurs before the
beginning of the second week, but it has occasionally been observed
much earlier. Murchison reports cases in which he saw it as early as
the first and second days. The process usually involves the mucous
membrane only, but it may extend to the muscular and even to the
peritoneal coats.
In the third stage the dead parts are gradually thrown off, the
process of separation usually occupying several days. At first an
increased degree of congestion, followed by suppuration, is observed
at the edges of the sloughs, which before their complete detachment
may often acquire a yellow, green, or brown color from the imbibition
of bile. The ulcers which result correspond in size and form with the
sloughs. They are, therefore, in the case of the agminated glands
elliptical in shape, with their long diameter corresponding to the
axis of the intestine. Their edges are swollen and overhanging, and
their floor is generally formed by the deepest layer of the submucous
connective tissue. They sometimes penetrate much more deeply, and may
even extend to the peritoneal coat, and thus give rise to perforation
of the bowel. The ulcers which result from sloughing of the solitary
glands are, as a rule, small and round. Murchison says that ulceration
may also be produced in the following way: The mucous membrane becomes
softened, and one or more superficial abrasions appear on the surface
of the diseased patch, which extend and unite into one large ulcer,
and this ulcer proceeds to various depths through the coats of the
bowel, and even to completed perforation, but Rindfleisch and other
recent German writers do not allude to this process.
The fourth stage, or that of cicatrization, usually commences with the
beginning of the fourth week. The swelling of the edges of the ulcers
gradually diminishes, and they become adherent to the tissues beneath.
The floor of the ulcers covers itself with delicate granulations,
which in course of time are converted into connective tissue. This is
ultimately coated with epithelium, but neither the villi nor the
glands of the mucous membrane are ever reproduced. The resulting
cicatrices may be recognized by the affected parts of the bowel being
thin and more translucent than in health, and may retain these
characters after the lapse of several years. They never give rise to
contraction of the bowel. The time occupied in the cicatrization of
each ulcer is said to be about two weeks. It occasionally happens that
while cicatrization is taking place at one end of the ulcer the
process of necrosis and ulceration is still going on at the other, so
that two or more ulcers may occasionally run together. This form of
ulcer may often retard recovery, and may sometimes end in perforation
of the bowel, even after convalescence seems to have been established.