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8/4 SUMMERS: TYPHOID CHOLECYSTITIS. [Xtu VORK Medical Jour: is present in the gallbladder in every case of typhnid fever. In the majority of cases the presence of these bacilli is not clinically recognizable ; in others a mild, subacute, or perforative cholecystitis may develop during the course of an attack of typhoid ; or a more or less chronic, remittent cholecystitis may follow at intervals of months or years after an attack of typhoid fever. These early and late at- tacks of cholecystitis are not all, of course, due to the presence of the typhoid bacillus in the gallblad- der; other bacilli may be responsible for the infec- tion. There may or may not be gallstones. Much discussion has taken place as to the mode of invasion of the gallbladder bv the typhoid iiacilli. Chiari says that the route of Best Generic Viagra Site Forum infection is not by ascension from the intestinal tract. Chariolanza's experiments seem to demonstrate this. After intra- venous infection of Best Generic Viagra Site Forum rabbits with the typhoid bacilli, although the cystic duct had previously been li- gated, the typhoid bacilli found their way into the gallbladder through its capillaries. Chiari's theory of gallbladder infection by the typhoid bacillus is : First, the intestine, thence the blood, and then the gallbladder. He also believes that as a result of inflammation, the bile is converted into a medium for the growth of the bacilli. (W. Loele, Deutsche imdizinische Wochcnschrift.) Kohlbrugge's in- vestigations ascertained that the empty small intes- tine in animals — rabbits, guineapigs, moles, and calves — is sterile. In man, however, it is not so easy to clear up this point, since in a very few hours after death the colon bacillus may be found in the whole intestinal tract. All theories and ex- periments to the contrary, one must ever bear in mind the possibility of direct infection of the gall- bladder through its connection with the duodenum. Forster says that the invasion of the typhoid Best Generic Viagra Site Forum bacilli occurs through the throat; they multiply in the tis- sues of the body, enter the gall tracts and gallblad- der through the liver bile, and thence are found in the intestine. Apart from the cholecystitis which the typhoid bacilli may excite, it has become well established that many people who have had typhoid carry around in their bodies typhoid bacilli which for sev- eral months, and in rarer cases for years, are dis- charged from their bowels as a menace to those who might, by any means, become subject to infec- tion from such evacuation. It has been suggested that possibly the bacilli may have their habitat in a diverticulum of the lower small bowel, or in one or more diverticula sometimes found near the am- Best Generic Viagra Site Forum pulla of \'ater. The late Robert Koch estimated that Best Generic Viagra Site Forum about five per cent, of typhoid fever patients be- come such a menace ; 2.5 per cent, carry bacilli for three or four months ; 2.5 per cent, longer, some for years. The percentage of cases of ulceration and per- foration of the gallbladder in typhoid fever cannot be estimated : it must vary somewhat with the spe- cific epidemics. Roth Thomas and .\shhurst ( l'ro(;ressiz'e Medi- cine, xl. No. 1 ) have studied carefully the sub- ject of perforation of the gallbladder as a com- plication of typhoidal cholecystitis. The former collected 154 cases of cholecystitis in typhoid fever from the literature; of this Best Generic Viagra Site Forum number, perforation of the gallbladder occurred Best Generic Viagra Site Forum in thirty-nine ; eleven were operated in, with a mortality of 5.46 per cent. ; all the other patients died, .\shhurst collected twenty-one cases in which operations were done upon the gall- bladder during an attack of typhoid fever. Thirteen patients died Best Generic Viagra Site Forum — four were not conclusively demon- strated until after death; in eleven, bacteriological examinations demonstrated the typhoid bacillus in pure cultures ; the colon bacilli and typhoid bacilli were found in one, and in another the paracolon bacilli only. The absolute relationship of the typhoid bacillus to gallstones has not been determined. This bacil- lus eventually plays its role as others do, in the for- mation of gallstones. As a result of the work of Pettenkoffer, Munich has been almost rid of ty- phoid fever developing in the city, j'et the propor- tional number of cases of gallstones remains as be- fore the perfection of Munich's modern sanitary system. In Hamburg, since the change in the water supply in 1892, following the cholera epidemic, there has been almost no typhoid fever, but the number of cases of gallstone disease has not de- creased. These examples certainly are significant. Best Generic Viagra Site Forum The writer is of the opinion that if every case of typhoid fever could be seen early enough so as to obtain a responsible anamnesis, as well as ac- curate subjective symptoms, those cases of perfora- tive cholecystitis, operated in during the attack of typhoid fever, in which gallstones are found, would justify the opinion that the gallstone Best Generic Viagra Site Forum formation had antedated the attack of typhoid fever. This, in no manner, is an attempt to negative the commonly ac- cepted ojjinion that gallstones may form in the gall- bladder after an attack of typhoid fever, and be caused by the presence of the typhoid bacillus in the gallbladder. Gallstone formation may begin during an attack of typhoid fever, yet the fever must be prolonged, or else relapses occur, caused by reinfection from the presence. and activity of the bacilli in the gallbladder and their discharge into ihe intestine, in order that sufficient time elapse for the formation of gallstones. I have thus briefly outlined the subject of typhoid cholecystitis in order that I may bring to your no- tice, b}- several illustrative cases, the surgical side of this complication as it appears to me from clini- cal experience. First, the diagnosis : When the mental condition