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 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 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.
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).