Ulceration begins at the edge of a slough, gradually separating it from the healthy tissue and leaving an ulcer with excavated edges, oval in form, presenting a smooth base of submucous, muscular, or peritoneal tissue. When death occurs, some glands may be found in the first stage, and often the three conditions— swelling, necrosis, and ulceration—will be found in the same patient. The proc ess becomes more severe toward the meal valve. During and after the separation of the slough healing takes place, leav ing a slight depression and causing lit tle or no contraction of the lumen of the bowel. The mucous membrane gradu ally extends over the site of the pre viously-existing ulcer. This takes place in the third and fourth weeks. In some cases the ulceration extends through the peritoneal coat, allowing the contents of the intestines to pass out into the peri toneal cavity.
During, the process of sloughing and ulceration slight extravasation of blood may take place from distended capil laries, and sometimes an artery is opened, causing severe and fatal haemorrhage.
Secondary ulcerations occasionally occur in the cicatrices, which are said to cause haemorrhage more frequently than in the primary form.
The solitary glands of the small in testines are not always affected, but when involved present roundish eleva tions and ulcerations. The solitary glands of the large intestines undergo r the same changes. The necrosis and ulceration follow in the same way as in Pet'er's patches.
Typhoid without intestinal lesion= studied in 23 cases collected, including 2 personal cases: In 14 of the cases the evidence was decisive in favor of the ex istence of a typhoid infection without intestinal lesion. It is probable that in fection takes place through the intestine, even though there are no manifest lesions 10 be found. In the two personal cases there was bacteriological evidence of ty phoid, but the intestines were normal. Picchi (Lo Sperimentale, anno 53, face. 4, 1900).
The mesenteric glands are enlarged from the presence of leueocytes and con tain numerous colonies of bacilli. Occa sional softening, breaking down, and rupture take place, causing fatal peri tonitis. J-Ttcmorrhage may also arise from this source.
The spleen is enlarged, but never to a great extent. Osier never found it weighing more than 20 ounces. The substance is soft, and infarcts are not _infrequently found. Ruptures may take place from accidents or spontaneously.
This organ may be slightly enlarged and soft in consistency. The lesions most frequently found are lymphoid nodules and small, grayish, opaque areas.
The latter vary in size, sometimes in volving only a few hepatic cells and some times half a nodule. They are foci of necrosis which do not bear any relation to the colonies of bacilli and are prob ably produced by the toxins of the dis ease. As a rule, these do not give rise to any symptoms, but when extensive may afterward terminate in cirrhosis (Osler). Swan (Brit. Med. Jour., July 10, '98) reports a case of hepatic abscess caused by the bacillus typhosus. The abscess resulted from infective pyle phlebitis by direct extension from the intestinal ulcer. Bacteriological exam ination of the abscess-contents revealed the presence of typhoid bacilli, which gave the usual Widal reaction with ty phoid serum. The patient, a female child, 5 years of age, was operated upon and the abscess, which existed about half an inch below the surface of the liver, was evacuated. Recovery followed.
Osler (Edinburgh Med. Jour., Nov., 'S7) speaks of suppurative pylephlebitis as one of the rarest sequelm of typhoid fever. Of solitary abscesses the Munich statistics give 12 out of 2000 cases. Sup purative cholangitis may terminate in abscess of the liver, and abscesses may follow the formation of pus in other parts of the body. Louis has recorded a case which followed suppuration of the parotid. In a case of Chvostek's two large hepatic abscesses followed bone lesions.
Blackstein in 1S91 found typhoid ba cilli in the biliary passages of rabbits some weeks after they were introduced into the gall-bladder.
Chiari found typhoid bacilli in 19 out of 21 cases. They existed in large num bers in most of the cases. He thinks that a reinfection might be caused by the emptying of the gall-bladder after a full meal and the filling of the intes tine with an infected fluid. Murchison states: ,"The lining of the gall-bladder is very liable to become inflamed in enteric fever without producing any marked symptoms during life." In ordinary cases the kidneys are lit tle, if any, affected. In the severe forms cloudy swelling of the epithelial lin ing, with degeneration, may be present. Small areas of round-celled infiltration, in which softening and suppuration may take place, are referred to by Osler. Nephritis occasionally sets in during the post-typhoid period. Catarrh of the bladder is sometimes met with, and may be brought on by the careless use of the catheter for retention. Diphtheritic in flammation of the pelvis of the kidney and bladder has been noted.