ACUTE INTESTINAL INDIGESTION WITH IMPACTION OF THE LARGE INTESTINES IN THE HORSE.
Definition. Causes: dessication of ingesta in colon, sacculation, constriction at pelvic flexure, debility, ill health, local peristalsis, diseased teeth, jaws or salivary apparatus, excess of food, heating grain, hard fibrous indigestible fodder, green leguminosæ, privation of water, inactivity, verminous aneurisms, tumors, strictures, obstructions. Symptoms: colics after meals, becoming more severe, tension and firmness of right side, sitting on haunches, stretching, small, hard, dry coated stools, obstruction felt on rectal exploration, frequent attempts to urinate, tympany. Course: six hours to six days or more, signs of aggravation and improvement. Lesions: large intestines tympanitic, impaction often at pelvic flexure, or other constriction, adherent mucosa has thick mucus or blood, is discolored, friable, necrosis, perforation, liquid contents of distended bowel in front, rupture, invagination, volvulus. Treatment: laxative diet, injections, aloes, pilocarpin, eserine, barium chloride, chloral hydrate, morphia, henbane, belladonna, puncture, cold or oleaginous enemata, empty or knead rectum and colon, cold compress, electricity, friction, laparotomy.
Definition. This is an impaction and obstruction of the colon, and usually of the pelvic flexure with dried and badly digested alimentary matters.
Causes. Certain anatomical and physiological conditions contribute to this disease in the horse. The ingesta as it leaves the stomach is liquid or pultaceous and throughout the small intestines it remains so, so that they are little liable to impaction. But by the time the cæcum is reached much of the liquid has been absorbed, and as the contents pass into the double colon they are usually a soft solid, which gradually becomes dried as it advances through the double and floating colon. The sacculation of cæcum and colon tends to delay the masses and favors absorption. The pelvic flexure, the narrowest part of the double colon, is formed by an acute bend of the viscus on itself so that the dried masses advancing from in front are especially liable to become arrested and impacted at this point. Impaction may, however, occur at any part of the large intestine.
Any debility or atony of the intestines predisposes to the condition. The ingesta accumulates in the portion which does not contract sufficiently to pass it onward, and this soon becomes distended to a state of absolute paresis. All conditions of debility, and all prolonged ill health tend to operate in this way by lessening vermicular movement.
Again in cases of nausea or intestinal disorder the supervention of antiperistaltic movements, will tend to accumulate the ingesta at one point and favor impaction (Ernst).
As in the case of other indigestions the imperfect preparation of the food is an active factor. Diseased teeth, jaws or salivary glands, act in this way and a functionally weak stomach contributes to this as to other intestinal disorders.
An excess of food and especially indigestible food will contribute to impaction. Heating grain, like corn, wheat, buckwheat, passed rapidly through the stomach in an imperfectly digested condition, tends to accumulate in the larger intestines. Hard, fibrous fodders like hay and straw that have run to seed, or which have been washed out by rains, bleached or heated, rye-straw, the stalks of beans, peas, vetches, which have been similarly spoiled, and clover hay affected with cryptogams or other ferments act in the same way. Even clover eaten green, produces in foals impactions to which the hairs of the leaves and chalices materially contribute (Verrier). The allied plants alfalfa and sainfoin when passed rapidly through the stomach tend to impaction of the large intestines. But any fibrous, indigestible and innutritious fodder, taken in excess to make up the deficiency of nutriment is liable to act in this way.
Other conditions that contribute to impaction are lack of water, especially at night when much hay is consumed, and lack of exercise which tends to torpor of both liver and bowels.
Finally verminous aneurisms and embolism of the intestinal arteries induce congestion, paresis, spasms, and other disorders which tend to aggregation and impaction. Also tumors, strictures and obstructions of all kinds tend to impaction.
Symptoms. A certain amount of impaction is not incompatible with ordinary health, but as this increases all grades of colic may be met with from the most simple and transient to the most persistent and severe.
In the milder forms slight and transient colics come on after meals, for days in succession, before any serious attack is sustained. These are especially marked under dry bulky fodder (hay), less so on grain, and less on green food or roots. The animal paws, moves the hind limbs uneasily, looks at the flanks, he may even kick at the abdomen, lie down and roll, rise, pass a little manure or flatus, and seeming relieved may resume feeding, until the next attack. The intermissions may last a few minutes, a quarter of an hour or longer, and they gradually become more prolonged until they disappear for the time. Sooner or later, however, the obstruction becomes more complete and the colic more severe and persistent. To the ordinary symptoms of violent abdominal pain there are added symptoms which point to bowel impaction or obstruction. There is a special tension of the right side of the abdomen, with flatness on percussion. When down there is a tendency to sit on the haunches to relieve pressure on the diaphragm and lungs. When standing there is a disposition to stretch the fore limbs out forward and the hind ones backward. Fæces may be passed at first in a few small round balls at a time, but this soon ceases, and very little or none can be obtained even by the use of enemas. The straining is usually so violent as to expel the enemata as soon as introduced. The hand introduced into the rectum can easily detect the solid impacted pelvic flexure of the colon pressing backward into the pelvis or impinging on the right pubis. Another common symptom is the frequent passage of urine in dribblets, due to the irritation of the bladder by the pressure upon it of the impacted colon during straining. In cases of this kind the colon and cæcum become tympanitic as first shown by a resonant distension of the right flank obliterating the hollow in front of the ilium, and later by a similar condition of the left flank.
The abdominal pain is usually less acute than in simple spasmodic colic or intestinal congestion. The face is less pinched and anxious, the eye less frightened, the kicking at the belly less violent, and the lying down more deliberate and careful. Very commonly the patient merely rests on his belly or side without attempting to roll.
Course. The disease may last six to twelve hours, or even as many days before it ends in recovery or death. The colicy symptoms usually increase, with the complication of dyspnœa when tympany becomes well marked, hyperthermia in case of the supervention of enteritis, and signs of general peritonitis and collapse in case of rupture of the bowel. A sudden increase of the pain may otherwise indicate the occurrence of invagination.
As indicating a favorable termination there may be restoration of the rumbling, the passage of fæces at first perhaps in the form of solid cylindroid masses, and later as a mixture of broken up ingesta, liquid and gas, the tension of the abdomen disappears, the pains lessen and cease, and there is a gradual restoration to health.
Lesions. The abdominal walls are tense and more or less drumlike, and when these are cut through the large intestines protrude strongly. When punctured there is a free discharge of gas. The most common seat of obstruction is the pelvic flexure, but it may occur in the floating colon, or rectum, in the double colon even at other parts than its pelvic flexure, in the cæcum or in the ilio-cæcal opening. The impacted mass is firm, rather dry, covered with mucus and sometimes blood, and manifestly only partially digested. Its size and form vary greatly as it is moulded into the affected viscus. The mucosa in contact with the impacted mass is covered with a thick layer of viscid mucus sometimes streaked with blood. The mucosa itself is congested, thickened, friable, and marked with spots or patches of various colors (white, gray, green,) indicating commencing necrosis. In old standing cases this may extend to the other coats of the bowel determining perforation or laceration.
The portion of the bowel immediately in front of the obstruction is filled with liquid which has been forced down upon the barrier by the active peristaltic movements, and the distension by liquid and gas may have increased until rupture has ensued with the escape of the contents into the peritoneal cavity. Invagination, volvulus and peritonitis are common.
Treatment. This will vary according to the stage and degree of the illness. In slight cases with transient colics only after meals, a more laxative diet may suffice. Boiled flaxseed, roots, potatoes, apples, green cornstalks, silage, or even sloppy bran mashes, with an abundance of good water and active exercise may prove efficient. Copious injections of warm water, soapsuds, or linseed oil emulsion may be added.
In the more violent cases we must resort to more active measures and yet drastic purgatives are full of danger. The free secretion from the vascular small intestines and the active vermicular movements, lead to the speedy overdistension of the bowel just in front of the obstruction, the current being strong and active all around the contracting gut in contact with the mucosa, while a weaker return current sets in in the centre, but is effectually checked and arrested at no great distance in front of the impaction by the strong backward peripheral stream. If therefore the impaction is not broken up, it is inevitable that the gut above must be more and more distended until a rupture ensues.
Yet in a certain number of cases a moderate dose of aloes or castor oil supplemented by frequent enemata and other measures, succeeds in safely overcoming the obstruction. The solid impacted mass is gradually softened and removed, and finally after perhaps three or four days of complete obstruction the fæces begin to pass and recovery ensues.
With or without the aloes, the hypodermic use of pilocarpin or eserine or both will often succeed in obtaining successful peristalsis. Barium chloride while inducing more active peristalsis is, on that account, somewhat more dangerous.
Pain may be moderated and fermentation checked by chloral hydrate (½ oz.), or, an anodyne, morphia (2–4 grs.), may be given hypodermically. In the absence of these, extract of hyoscyamus or belladonna (2 drs.) may be given by the mouth, and repeated as may be necessary. If tympany is dangerous use the trochar and cannula. Enemata and other accessory measures must not be neglected.
W. Williams has resorted to rectal injections of 2 oz. aloes forced into the rectum by a syringe furnished with a long elastic tube, and repeated when expelled. Brusasco has used copious liquid injections poured into a rectal tube the end of which is raised at least ten feet above the croup, so as to gain the requisite force. Schadrin uses injections of cold water to stimulate the bowels to contractions. Injections of oils or mucilaginous matters when they can be carried far enough lubricate the walls and favor the passage of solid matters. Castor oil which acts to a large extent locally is especially applicable.
Mechanical applications are often valuable. If the obstruction is lodged in the rectum or floating colon it can usually be reached by the oiled hand and carefully extracted. If this is not successful, impactions in the floating colon or pelvic flexure may still be to a large extent broken up and loosened by the knuckles of the oiled hand in the rectum. I have often resorted to this with excellent effect. Impactions in the cæcum or elsewhere in the double colon are however inaccessible for such treatment. For these, external measures are available. Wilhelm wraps the abdomen in cold compresses. Causse and Lafosse recommend the electric current. Friction to the skin of the abdomen is a common resort. Rudofsky turns the animal on his side or his back, to remove the weight of the small intestines from the impacted cæcum or colon, and favor the exit by gravitation of the contents from the cæcum into the colon. Kneading of the abdomen with the fists or knee when in this recumbent position may also be resorted to.
As a dernier resort, Gaullet performed laparotomy but with no success as the animal died the following day. The horse was, however, in extremis at the time of the operation and a portion of the intestinal wall was blackish and gangrenous. To be successful such an operation should be practiced before there is any probability of gangrene, and while the patient is still in good condition for recuperation. But these are just the cases in which success is to be hoped for from less dangerous measures. Again the conditions for its success are best in case of obstruction of the pelvic flexure, as that could easily be drawn out through a spacious abdominal wound, incised, emptied and sutured with careful antiseptic precautions, and with little risk of infection of the peritoneum. But this is just the point where an obstruction can be efficiently dealt with in a less dangerous way, by kneading through the rectum for example. The operation, however, is not one to be utterly condemned, but in any case in which it is certain that the obstruction is otherwise irremediable, it should be adopted at as early a stage as possible, under anæsthesia, and with antiseptic precautions. The after treatment would consist in a restricted diet of milk or gruel with antiseptics to prevent fermentation and bloating.