should be repeated every four to twelve hours until permanent good
effects are secured. A dose of 15 to 30 drops of tincture of opium, or
morphia, one-fourth grain hypodermically, will best protect the patient
from too great exhaustion. The beneficial results are mostly obtained
in the acute cases, though surprising results sometimes follow in cases
of very long standing. Thus, Gayton records a case of severe chronic
dysentery of eighteen months' duration which was entirely cured by
ipecacuanha, and probably most physicians of large practice can recall
cases where the continual relapses of the dysenteric habit have been
completely broken up by {812} one course of active treatment. Should
the remedy fail to be of service in the course of forty-eight hours, it
should be discontinued.
Batiator, the bark of the root of the Ailanthus glandulosa; mudar, the
bark of the root of the Calotropis gigantea; and bael-fruit, more
especially in chronic cases,--have been proposed by Roberts, Duval,
Chuckerbutty, and others as substitutes for ipecacuanha, but are not
likely to soon supplant it.
Materia medica is rich in drugs whose virtues have been vaunted in
dysentery, and cases occur where the judicious physician will make his
selection according to the indications in a given case. Turpentine
internally, as well as externally in the form of a stupe (Copland), has
had advocates from ancient times; astringents, tannic acid or the
substances which contain it, kino, catechu, krameria; the acetate of
lead, nitrate of silver, etc.; antiseptics, carbolic acid, salicylic
acid, boracic acid; anodynes, opium and its preparations; and
quinia,--are among the agents most frequently employed.
Bonjean (1870) had occasion to laud the efficacy of ergotin in checking
hemorrhage and controlling the discharges in a report which
substantiates the claim of Rilliet and Lombard in the epidemic at
Geneva in 1853. Massolez had the same good results in the war of the
Crimea, as had also Andrea in the Spanish hospitals of Ceuta and
Tetuan.
Clysters of nitrate of silver, 4 grains to 5 ounces of water (Duchs),
or with a few drops of tincture of opium (Berger); of ipecacuanha
(Begbie and Duckworth); of laudanum and starch (Sydenham, Abercrombie);
of the various astringents,--may be tried in obstinate, more especially
chronic, cases.
Local inspection of the rectum by means of the speculum may possibly
reveal an ulcer, which is the chief or sole cause of the tenesmus and
bloody discharge. Maury reports such a case in which the ulcer was deep
enough to hide a small sponge. In such cases topical treatment may
effect a cure.
Dilatation may suffice to overcome a stricture in the rectum, the
result of cicatricial contraction, or colotomy may be necessary in
cases more refractory or situated higher in the bowel. Post[10]
reported a successful colotomy, with the formation of an artificial
anus in the left lumbar region, in such a case.
[Footnote 10: _New York Med. Record_, 1879, xvi. 24, p. 260.]
The food should be fluid, but nutritious, and milk best fulfils both
these requisites. Where milk cannot be tolerated it may be substituted
by soups, beef-tea, mutton-broths, chicken-soup, etc. But it should be
known of these substitutes that they contain little or no nutritious
matter on account of the insolubility of the albuminoids, and are
really only stimulants. Soft-boiled egg, thin custards, sweetbreads,
scraped or chopped raw beef--albumen thus in substance--constitute the
best food. But during the intensity of an attack the patient should
almost altogether abstain from food, both from lack of inclination for
it and from lack of ability to digest it. During convalescence the food
should be on the basis of animal diet, though ripe fruits and fresh
succulent vegetables should not be altogether withheld.
In all cases of pronounced prostration stimulants are to be freely
used, and of all stimulants alcohol is the best, as it has also
nutritive and {813} antiseptic properties. Alcohol is thus triply
indicated in the treatment of dysentery, but the choice of the form and
strength will be a matter of judgment in the individual case.
Where life is imperilled by hemorrhage or anæmia from any cause, a
forlorn hope is offered in transfusion, which in the hands of C.
Schmidt (1874) has proved successful in two cases.
Abscess of the liver is best treated by aspiration or hepatotomy;
rheumatism, by the salicylates; and paralysis, by the constant current
of electricity.
Obstinate cases of chronic or continually recurring dysentery are
thoroughly cured only by a sea-voyage, a sojourn at the seashore, a
mountain-excursion, or a permanent change of climate.
{814}
TYPHLITIS, PERITYPHLITIS, PARATYPHLITIS.
BY JAMES T. WHITTAKER, M.D.
HISTORY.--Typhlitis ([Greek: typhlos], blind), inflammation of or about
the head of the colon, more especially the vermiform process, is a
disease of modern recognition. Individual cases had been reported as
curiosities where foreign bodies or fecal accumulations had excited
inflammation in this part of the intestine, but it is undoubtedly to
Dupuytren[1] that the credit is due of having first individualized this
disease as a separate affection. About the same time (1827) Longer
Villermay published his communications in the _Archives gén._, t. v.
246, on the diseases of the vermiform process, to be followed in the
same year by Mêlier[2] and Hussar and Dance with observations on
inflammation of the connective tissue in the region of the cæcum. These
affections, which had been hitherto described as inflammatory tumors in
the right iliac region, now received from Puchelt[3] the distinct name
perityphlitis.
[Footnote 1: _Leçons oral de Cliniq. chirurg._, t. iii. art. xii.]
[Footnote 2: _Arch, gén._, Sept., 1827.]
[Footnote 3: _Heidelberg klin. Annal._, i. 571 and viii. 524.]
Perhaps the most remarkable events in the history of these affections
since this time are the contributions of Stokes and Petrequin (1837) on
the value of opium in the treatment of perforation of the vermiform
appendix, of Albers,[4] who first distinguished the special form of
typhlitis stercoralis, and of Oppolzer (1858-64), who set apart,
perhaps as an unnecessary refinement in differential diagnosis, a
paratyphlitis, an inflammation of the post-cæcal connective tissue.
Matterstock[5] (1880) deserves especial mention for having given such
prominence to anomalies of the vermiform appendix in the etiology of
the affection; and Kraussold[6] (1881) has connected his name with the
therapy of the disease by the boldness with which he expresses his
convictions regarding the necessity of early evacuation, by incision,
of inflammatory products, as first practised by Willard Parker in 1843.
[Footnote 4: _Beobacht. aus dem Gebiete der Pathologie_, ii. 1.]
[Footnote 5: _Handbuch d. Kinderkrank._, Bd. iv. p. 893.]
[Footnote 6: _Volkmann's Sammlung._, No. 191.]
GENERAL REMARKS.--Typhlitis, strictly speaking, is limited to
affections of the cæcum and its appendix vermiformis; perityphlitis is
mostly due to extension of the inflammation to the peritoneal envelope
of these organs; while paratyphlitis signifies an involvement of the
extra-peritoneal and post-cæcal connective tissues. Both perityphlitis
and paratyphlitis are therefore secondary processes, though they may,
in exceptional cases, arise from affections of organs other than the
cæcum, as from {815} perinephritis, psoitis, vertebral caries, or as an
expression of metastatic processes in pyæmia, septicæmia (puerperal
fever), typhoid fever, etc.
ETIOLOGY.--Typhlitis and its allied affections or complications show
especial predilection for the male sex and the period of adolescence.
Nearly three-fourths (733) of the whole number (1030) of cases of
perityphlitis collected from the literature by Matterstock were males,
and this proportion holds good in infancy and early youth as well as in
adolescence. The greatest number of cases, 33 per cent., occurred at
the ages of 21-30; next, 30 per cent., at 11-20; while the ratio
gradually decreases toward both extremes of life. So the opinion is
expressed with singular unanimity by all authors that these diseases
pre-eminently affect the bloom of life.
The observation that typhlitis has so often been found to arise from
disease of the vermiform process has led to a closer study of its
anatomical relations, and developed the fact that this organ is subject
to great variation in size, shape, and situation.
Normally, the appendix vermiformis arises from the posterior interior
aspect of the cæcum as a tube of the diameter of a goosequill and a
length of three to six inches, with a general direction upward and
inward behind the cæcum. It is commonly provided with a small
mesentery, which retains it in its place. Its cavity communicates with
the cavity of the cæcum by a small orifice which is at times guarded by
a valvular fold of mucous membrane, while its free closed end
terminates abruptly in a blunt point. It is commonly found filled with
mucus throughout its entire length. The existence of this superfluous
structure, which is found only in man and certain of the higher apes,
has given rise to much speculation among the anatomists and
physiologists, especially of the teleological school, as to its
possible use. It is now, however, the generally acknowledged opinion
that the appendix vermiformis is a relic or rudiment of a subsidiary
stomach in lower forms of life. The head of the large intestine, which
forms almost an additional stomach in the Gramnivora, and is three
times the length of the whole body in the marsupial koala, is very much
reduced in the Carnivora, whose food contains but little indigestible
matter, and is greatly reduced in the Omnivora, as in man. The
vermiform appendix is the shrivelled remnant of the great cæcal
receptaculum of the lower animals. In the orang it is still a long
convoluted tube, but in man it is reduced, as stated, to the size of a
quill three or four inches in length, and is often entirely absent.
Kraussold, who complains that the vermiform process has hitherto
received only step-motherly treatment at the hands of anatomists and
clinicians, undertook a series of investigations which went to show how
often and what extreme anomalies do occur. In some cases the appendix
was disposed in an exactly opposite to the normal direction, its blind
end being turned upward along the ascending colon. In one case it was
found wound about the ileum; in another, spirally turned at its end and
lightly adherent to a hernial sac. Sometimes it was abnormally long or
short, open or closed with a valve, cylindrical, saccular, or bulbed,
fixed or free, curved or bent upon itself at a sharp angle, provided
with a short mesentery, and sometimes, as stated, it was entirely
absent.
But by far the most interesting point connected with this organ was the
frequency with which it was found the seat of ulceration or stricture
{816} from cicatrization somewhere in its course, the result of
dysentery, typhoid fever, syphilis, and more especially of
tuberculosis. Clinicians who have been struck with the frequency with
which typhlitis has occurred in tuberculous subjects find in this
discovery a satisfactory explanation of this very remarkable
coincidence.
Normally, the vermiform appendix is found filled, as stated, with a
tough vitreous mucus, but not infrequently masses of feces, foreign
bodies, intestinal worms, etc. find their way into it, where they may
remain innocuous or may excite a dangerous inflammation. This fact, in
connection with the general uselessness or superfluousness of this
structure, has led pathologists to characterize the vermiform process
with the significant appellation of a death-trap.
Two anatomical factors deserve especial emphasis in explanation of the
frequent origin of disease in the vermiform appendix. One is the
existence of the valvular fold of mucous membrane, already mentioned,
at or near the orifice of the tube in the cæcum, the clinical
importance of which was first pointed out by Gerlach. This fold is most
marked between the ages of three and twelve, and when pronounced
narrows the orifice to one-half or one-third of the whole calibre of
the tube. As a rule, this fold, and the consequent diminution in the
size of the orifice, are but little marked in the first years of life
and in old age, which accounts for the relative infrequency of
typhlitis at these periods of life.
The second mechanical factor is the deformity caused by the abnormal
anatomical position of the organ, either as a congenital defect or as a
pathological change. Matterstock quotes from Züngel, who observed in 59
cases in the Hamburg hospital whole or partial obliteration 30 times,
catarrh and old fecal concretions 43 times, abnormal adhesions 12
times, and tubercular ulceration (without perforation) 11 times. Toft
claims as the result of 300 personal investigations that every third
person between the ages of twenty and seventy showed the traces of
present or past inflammation, and that actual ulceration existed in 5
per cent. of all bodies examined. Kraussold declares that this
percentage is rather too low than too high, and adds that among his
patients--who were, it should be stated, mostly phthisical--it was
remarkable how extraordinarily often the whole vermiform appendix was
the seat of an encroaching ulcer. In a number of cases cicatrices or
cicatricial alterations were found where typhoid fever or dysentery had
existed in the previous history.
Attention should at least be called to a last anatomical factor in
explanation of the frequency of ulceration and inflammation of this
structure, in that its walls are so sparsely endowed with muscular
tissue as to render it unable to empty itself of the virus or germs of
disease which enter it from the comparatively stagnant reservoir, the
cæcum.
Constipation is usually invoked as a cardinal factor in the genesis of
typhlitis (typhlitis stercoralis). Speck calls attention to the
frequency of the disease in East Siberia, where the food, mostly
vegetable, contains a large amount of indigestible residue. But that
this condition cannot sufficiently account for the disease in most
cases is proved by the fact that constipation is more frequent in
advanced life and among females, in whom typhlitis with its associate
lesions is more infrequent. For the same reason a sedentary mode of
life loses force as an argument in its production. Perhaps the most
efficient cause of the condition is a local {817} paresis of the
muscular tissue of the cæcum produced by the irritation of intestinal
catarrh, of disease virus, of a fecal concretion or a foreign body--an
irritation which may induce first a spasmodic action, and subsequently,
as a result, a partial paralysis or a paresis. The same condition may
be brought about more directly by the presence of a centre of
irritation--viz. by reflex inhibition of innervation. Accumulation and
impaction of feces must then necessarily ensue, and it is highly
probable that this accumulation occurs in this way as a result more
frequently than as a cause of the condition. For the symptoms of a
simple accumulation of feces (coprostasis) are never so severe, at
least at the start, as to mark the onset of a genuine typhlitis. Nor is
there anything in healthy feces to induce the signs of a severe
blood-poisoning which so commonly announces the advent or course of
typhlitis.
Room is here open for the surmise that most cases of typhlitis pur et
simple are due to the presence in the cæcum of the germs or virus of
disease taken with the food or drink, and traversing innocuously the
whole length of the alimentary tract, to finally bring up in this most
stagnant part of the intestinal canal.
The rôle of pure mechanical causes cannot be ignored or underrated in
perityphlitis, understanding by this division processes which commence
in the vermiform appendix. For it is the rule to discover in the
vermiform appendix in these cases either fecal concretions or foreign
bodies. Haeckel and Buhl found concretions of meconium in a new-born
child, and fecal concretions, intestinal stones, are far more
frequently encountered than foreign bodies. In 146 accurately observed
adult cases recorded by Matterstock, fecal concretions were met with 63
times, foreign bodies 9 times, while in the other cases nothing could
be discovered; and in 49 cases among children, fecal concretions were
discovered 27 times, foreign bodies 3 times, and nothing abnormal in
the remaining cases. Not infrequently a small foreign body acts as a
centre of crystallization for feces which become superimposed in
successive layers. Hairs, as of the beard, sometimes officiate in this
way. Among other foreign bodies met with in fatal cases of perforation,
independently of feces, may be mentioned round-worms (Faber),
cherry-stones (Paterson), needles (Payne), fish-bones (Züngel),
gall-stones (Hallete), a mass of ascarides (Klebs), buttons (Gerhardt),
etc., etc. As already intimated, supposed foreign bodies are often
found on examination to be nothing else than intestinal concretions. As
to cherry-stones, which are so often accused of producing typhlitis,
Biermer and Bossard found it difficult or impossible to force them into
the vermiform process.
MORBID ANATOMY.--The lesions revealed upon the post-mortem table show
for the most part the ordinary picture of perforative peritonitis,
which is by far the most frequent cause of death. The peritoneum in the
vicinity of the perforation is found hyperæmic, swollen, necrosed,
covered with flakes of soft fibrin, or partially agglutinated to
contiguous structures. The wall of the bowel is very much thickened by
catarrhal swelling of its mucosa, proliferation of its submucous tissue
in more chronic cases, oedema of all its coats, or suppurative
processes. Not infrequently the mucous tissue is the seat of extensive
ulceration which may involve other structures of the gut or form an
abscess, even as large as a man's head, in its immediate vicinity. The
abscess may remain strictly localized or {818} may wander to discharge
itself into the ileum, cæcum, duodenum, and diaphragm (Bamberger) with
resultant empyema (Duddenhausen), colon (Prudhomme), bladder (Bossard),
in which case the fecal concretion became the nucleus for a vesical
stone; acetabulum (Aubry), inferior vena cava (Demaux), or peritoneal
cavity, the most frequent eventuality. Duddenhausen saw in one case a
pylephlebitis result, Von Buhl a pylephlebitis and metastatic liver
abscess, which condition, Matterstock says, is noted 11 times in 146
autopsies; and older writers speak of discharges into the pleural sac,
into the lungs, pericardium, uterus, vagina, etc. A curious case was
observed by Eichhorst in Frerichs' clinic, where pus found escape
through the umbilicus. So cases of burrowing sinuses with abscesses at
distant seats, as in the groin or lumbar region, fistulæ with
continuous discharge, and other curiosities, may be found among the
records by the curious.
In cases of more acute course the lesions are often found centred about
the vermiform appendix. The most various contortions, adhesions, or
erosions are observed in this structure. Occasionally a constriction
occludes the course of the tube, while the distal end is dilated into a
condition of hydrops. It may be found perforated in one or in several
places. The cicatrices or agglutinations of old attacks may be
encountered; it may be cut in two or three pieces (Matterstock), or
have been entirely absorbed. Kraussold records a case of this kind in a
colleague who died of typhlitis. Upon the post-mortem table no trace of
the vermiform appendix could be encountered except a dimple on the
mucous surface of the cæcum, indicating the site of its former orifice.
SYMPTOMATOLOGY.--Typhlitis announces itself in two ways--suddenly and
insidiously. In adults the disease begins as a rule with violent signs;
in children there is often a prodromatous stage which may last for days
or for months before a positive diagnosis can be established. There are
in these cases anorexia and vomiting, constipation and diarrhoea,
colicky pains, mostly concentrated about the ileo-cæcal region. There
are at this time a disinclination to stand or walk, a stooped posture
or gait, occasionally a light icterus, a feeling of formication or
paresis in the right leg, and lastly an increased resistance or a
palpable tumor in the right ileum.
In the adult the disease is wont to begin with more tempestuous signs.
Not infrequently it is ushered in with a well-marked chill, upon which
immediately supervenes a sharp pain at the affected region. A general
collapse of strength soon follows, with fever, thirst, a husky voice, a
coated tongue, vomiting, singultus, and an expression of anxiety. The
impression of serious illness becomes apparent at once. The case early
bears the aspect of a grave infectious disease. A constant, dull,
boring, gnawing, or lancinating pain in the right iliac region first
excites the suspicion of the physician as to the real nature of the
disease. In children the pain is sometimes felt first in the
epigastrium; in three cases mentioned by Büchner, Herzfelder, and
Traube it was first experienced in the left ileum. There may be at this
time no tumor, but there is increased resistance to pressure and
exquisite tenderness to touch in the neighborhood of the cæcum. The
whole abdomen is more or less tender, and often tumid. If there should
be also gurgling from displacement of gas, doubt is excited as to the
possible existence of typhoid fever.
{819} In the course of a few days the tumor takes shape. A typhlitis
stercoralis shows a distension of the whole ascending colon, a
sausage-shaped tumor, smooth or nodulated, along the entire right side
of the abdomen, with increased resistance also in the transverse colon.
More frequently in typhlitis--and, as a rule, in peri- and
paratyphlitis--the tumor or tumefaction is more localized about the
head of the colon. Frequently the swelling is so great as to be visible
as a protrusion or bulging of the affected region. Percussion shows
dulness, tanquam femoris, in cases of pure typhlitis, whereas in peri-,
and more especially in paratyphlitis, there is tympanites on light and
dulness only on deep percussion. Palpation or palpatory auscultation
occasionally, though very rarely, reveals a peritoneal friction sound
(Gerhardt).
The third cardinal symptom of the disease is the disturbance of
digestion, which, as stated, often precedes or attends the first
manifestation of the pain and the tumor. Anorexia, nausea, and
vomiting--which is in the last stage of the disease often substituted
by singultus--present themselves as occasional or constant signs of the
disease. Constipation remains as a rule throughout the whole course of
the disease with an obstinacy which sometimes excites apprehension of
an intestinal occlusion; or the constipation may alternate with
diarrhoea or dysenteric phenomena, more especially in the earlier
stages. The tongue is, as a rule, heavily coated, or in typhoid states
is dry, glazed, or fissured, and sordes covers the teeth and gums.
Fever is not a necessary factor in typhlitis, but when present
distinguishes itself by its irregular range. The pulse is usually
accelerated, full, and hard; the skin is dry and harsh; the urine is
scanty and high-colored, and contains "almost without exception
unusually large quantities of indican" (Eichhorst).
Perforation, when it occurs, is usually recognized at once by the signs
of more or less immediate collapse, which quickly results in death.
The abdomen becomes suddenly distended, meteoric over its entire
surface, the normal hepatic dulness giving place to a tympanitic
resonance.