Croupous pneumonia may occur early in the disease, when Ebcrth's bacillus is probably the direct agent. It may also occur in the second and third week, when it is clue to the presence of the pneumo coccus.
The renal form of typhoid has already been described. Inflammation of the kidney is not a common sequel. It may, however, occur in the stage of convales cence.
Acute yellow atrophy has been de scribed by Murchison as a sequel of typhoid fever. There are occasionally abscesses of the liver, either single or multiple.
The principal symptoms of this form of suppuration are prolonged and re peated chills, great variations of tem perature, profuse sweating, and pains in the hepatic region. Fluctuation, when present, is a valuable sign. The usual causes of abscess are metastasis, pyle phlebitis, and typhoid ulceration in the biliary passages, with secondary sup puration.
Much attention has recently been given to the relationship between typhoid fever and gall-stones.
The fact that gall-stones have been produced experimentally by injecting a culture of typhoid bacilli into the gall bladder of rabbits, as well as the fact that pure cultures of these organisms have been made from the nuclei of gall-stones found in the human subject, leads to the conclusion that an attack of typhoid fever may, in some cases, be the direct cause of gall-stones and in others predispose to their formation.
Post-typhoid insanity, such as is usu ally caused by exhaustion, is noticed in a limited number of cases. It disappears within six months or a year.
Cases in which typhoid spine as a com plication occurred have been recently reported by Gibney and Osler. Gibney ascribes the condition to an acute inflam mation of the periostenin and the fibrous structures which hold the spinal column together. Osler is of the opinion that in many cases the condition is similar to that of hysterical or railway spine, and that it is really a post-typhoid neurosis.
Paraplegia and hemiplegia have al ready been referred to.
RELAPSE.—In a certain proportion of cases—from 3 to 15 per cent.—usually one and sometimes as many as three or four relapses take place.
They occur after an interval of three or four days of normal or subnormal tem perature. They do not seem to be in fluenced by any form of treatment, and they frequently take place after a change of diet. It has recently been suggested that the digestion of solid food brings about an emptying of the gall-bladder of bile, which latter may be loaded with bacilli, and a second infection then takes place through the intestinal glands. West is of the opinion that any change of diet, even from one liquid to another, —from milk, for instance, to broths,— may cause a relapse.
There is a gradual, but more rapid rise of temperature than in the first attack. The pulse is increased in frequency and the rose-colored spots reappear, together with the characteristic abdominal symp toms. The intestinal glands become again swelled and ulcerated, but the lesions are found higher up the ileum than in the first attack. The spleen re mains enlarged throughout the interval and the relapse. Death may occur from the same causes as in the first attack. Relapses do not usually last more than ten or twelve days. They sometimes occur without any interval, and are then called intercurrent relapses. As Wilson states, this may account for some of the prolonged cases of fever.
Elevations of temperature lasting two or three days and caused by excitement or errors of diet must be distinguished from a relapse. In the latter there is a reinfection because the patient has not become sufficiently immune during the first attack.
A second attack of typhoid fever is not common, but cases have been reported in which two or three distinct attacks have occurred.