ACUTE PERITONITIS IN SOLIPEDS.
Susceptibility to pyogenic bacteria, infection simple or complex. Traumatic injuries: accidental, omphalitis, operations, strangulation, wounds in rectum or vagina, coition, hernia, castration of mare, or horse, infected from 2d to 6th day, later granulation protects, ruptured stomach, perforating ulcer, perforation of parturient womb, ruptured abscess, microbes in circulation, debility. Symptoms: trauma with spreading swelling, œdema, tenderness, stiffness, arched back, tucked up abdomen, fever, prostration, colics, careful decubitus and rising, tense tender belly, ridge along flank, breathing short, inspirations catching, straddles, steps short, costive or later diarrhœa, enuresis, abdomen fluctuates, death in 1 to 8 days. With ruptured stomach or intestine prostration extreme, collapse, vomiting. Resolution. Ascites. Diagnosis: trauma, gastric or intestinal lesion, followed by specific symptoms. Lesions: trauma, rupture and escape of ingesta, congestion, ecchymoses, false membranes, adhesions, liquid effusion, bloody, pink, or straw colored, albuminous, fibrinous, granules, cells, salts, bacteria, pus, fœtor, bowels tympanitic, later fibrous bands, strangulations, degenerations. Prevention: fatal in solipeds, avoid abdominal congestions, inflammations, traumas, infections, accumulation of serum, blood, etc., also debility, ill health, chill. Treatment: old methods, by anodynes and checking peristalsis. Modern method: antisepsis, iodoform, carbolic acid, mercuric chloride, irrigation with boiled water, drainage; internally, saline laxatives, eliminates from bowels, blood, peritoneum, favoring phagocytosis, and innervation, antiseptics, sodium salicylate, chloral hydrate, morphia, enemata, hot fomentations, or ice, in suppuration drainage and washing with normal salt solution at body temperature, derivatives, laparotomy, puncture in tympany.
Causes. Solipeds are especially subject to peritonitis in its acute and dangerous forms largely because this class of animals is preëminently obnoxious to the attacks of pyogenic bacteria. The disease may however be dependent on a great variety of different organisms, and these may cause different forms through invasion by one specific microbe or by a complex invasion. It is convenient to note the different channels of invasion.
a. Traumatic injuries. Wounds are not uncommon from pricks with forks, pickets, broken rails, prongs of stump fences, poles or shafts of wagons, nails, barbed wire, horns of cattle, tusks of boar, and other sharp or pointed objects, which carry infecting germs, or in any case make an entrance for those found in the dust of the stable, on the horses skin, comb, brush, rubber or clothing. Inflammation of the umbilicus and resulting abscess may prove an entrance way for the germs either by rupture into the peritoneum or by causing adhesions between two loops of intestines from which the microbes escape through the weakened tissues. Wounds made in operations on hernias may have a similar ending and as Dieckerhoff has pointed out the onset of the peritonitis may be delayed for one or two weeks while the abscess is maturing or the walls of the bowels are being traversed by the microbes. Strangulated hernias and those in which the intestine is congested are especially subject to such peritonitis, as the germs may enter by the external wound and through the intestinal wall as well. The author has seen artificial anus formed through inclusion in the clamps of an adherent loop of small intestine, and at such a point peritonitis is liable to start.
Wounds of the rectum or vagina are sometimes the starting point of the inflammation. The penis of a stallion entering and lacerating the rectum of a mare, or the large penis of an ardent male rupturing the roof of the vagina are occasional causes. The latter may occur without fatal consequences, yet the author has seen a generalized and rapidly fatal attack follow such an injury when the mare had at once thereafter made a journey of nine miles in a cold rainstorm. The horse was a Percheron with very large penis and the mare would weigh about 900 lbs. The castration of mares, even through the vagina may be followed by peritonitis from sepsis of the instruments, hands or arms.
The castration of the horse is more liable to be followed by this infection. Too often no attempt at asepsis is made, implicit trust being placed in the defensive power of the tissues. In other cases even a very careful local antisepsis fails, the germ being already present in the circulation and the extensive wound and resulting local congestion and debility are seized upon as an opportunity for colonization and growth. This infection usually takes place from the second to the sixth day while the inguinal canal and vaginal sheath are still open to the cavity of the abdomen. Later when these have closed by adhesion, and when protective granulation has formed the implication of the peritoneum is rare.
b. Rupture of the Stomach or Intestine. This comes as already shown from gaseous distension, overloading, sudden shock or concussion, obstruction by dried ingesta, calculi, foreign bodies, parasites, etc., and by abuse of too powerful purgatives in cases of obstruction. The resulting infection is very abundant and varied, and the microbes accustomed to an anærobic existence in the intestines, multiply with extreme rapidity in the peritoneum and prove rapidly fatal. Beside the bacillus coli commune, there are usually staphylococcus and streptococcus pyogenes and not unfrequently the bacillus of malignant œdema.
c. Perforating ulcer. Though having a separate point of origin the effect of this is precisely the same as in rupture, the same bacteria escaping and the nature of the infection being identical. Inasmuch, however, as the perforation is usually small at first and the escape of contents very limited the symptoms advance more slowly and reach their acme later.
d. Perforation of the Parturient Womb. This usually depends on a case of dystokia in which the organ is torn by a foot of the fœtus or by some ill-directed instrument. The infection has usually been carried in on the hands or instruments, or introduced as dust by an aspiratory movement in the intervals of labor pains. The healthy womb is usually sterile as regards microbes, yet Lignieres claims that he has found staphylococcus pyogenes albus and aureus and in contagious abortion the specific bacillus of this affection can always be found. In woman peritonitis following rupture of the womb usually shows streptococcus pyogenes.
e. Rupture of Abscess into the Peritoneum. As an abscess is nearly always the product of pus microbes it follows that its rupture into the abdominal cavity will determine infection. If the abscess contains some special infective germ like that of strangles or glanders the resulting inflammation partakes of their nature.
f. Penetration of Microbes through the Circulation. Healthy blood is free from germs, yet it is not uncommon to find a few circulating in the blood in given conditions. Debility, toxin and ptomaine poisoning and other conditions render it possible for bacteria to successfully invade the circulating blood, hence, many infective diseases are at first local, and later on become generalized. Under these circumstances any cause of debility operating especially on the peritoneum opens the door to their infection. Under such debilitating causes all those already referred to as chills must be recognized, together with kicks, blows, local congestions and other injuries.
Symptoms. The existence of a penetrating wound or sore of the abdomen, a kick, an open abscess, or a recent exposure to severe cold when heated and fatigued, or finally some serious affection of the abdominal organs will give definiteness to some of the symptoms which follow. There may have been noticed a rigor, or trembling of the muscles may still continue. There is swelling around the external wound, which in case of castration is usually œdematous and more or less tense, affecting the entire sheath and extending forward on the abdomen. In any such case there is tenderness to pressure around the margin of the wound, for a distance that constantly increases. The animal moves stiffly and the back is more or less arched. The temperature is raised two or three degrees and may go on till it has reached 107. The patient becomes dull and listless, with drooping head and ears, sunken, lustreless, pale eye, more or less fixed, lips drawn up firmly and muscles of the face contracted and prominent. He stands with back arched, loins insensible to pinching, and legs drawn somewhat toward each other under the belly. There are indications of colic, pawing, looking toward the flanks, and shifting of the hind feet without the violent kicking motion of spasmodic colic or intestinal congestion. When he lies down it is comparatively slowly and carefully and he is more inclined to lie on the side with hind legs, or at least the one on the affected side extended backward. The rolling on the back and the sudden jerking movement of the hind limbs, seen in spasmodic colic are rarely noticed. There are exceptions to this rule when violent spasms or acute congestion is present as well as in some cases following castration and with strangulated cord.
The abdominal walls are always tense from muscular contraction, and often also from tympany, in which case there is marked drumlike resonance, on percussion. An elevated ridge like that seen in pleurisy extends from the outer angle of the ilium to the lower end of the last rib. The breathing is hurried and carried on mainly by the ribs, the diaphragm being kept as fixed as possible. The inspirations are short and catching as in pleurisy, the expirations a little more prolonged. In standing the hind legs are held apart, and in moving the animal straddles and moves them stiffly avoiding advancing them far forward. Constipation is the rule the rectum containing a number of small, round, dry balls, yet after a day or two diarrhœa may set in. Urine is usually suppressed, or passed in small amount and of a high color. The pulse is usually small, hard, and at times thready, the skin perspires more or less generally, prostration and dullness set in and death may occur within 24 hours or more commonly in 4 to 8 days. After the 1st day there may be fluctuation of the abdomen from liquid effusion.
In case of infection from perforated or ruptured stomach or intestine the symptoms are more severe from the first, and the issue is more rapidly fatal. With marked trembling, there occur extreme weakness and prostration, dull, sunken eyes, flaccid facial muscles, cold perspiration, chilly ears and limbs, entire cessation of defecation, small, weak accelerated pulse, breathing rapid, broken in inspiration or expiration, and more or less tympany. Yet the tenderness of the abdomen is less marked, and the animal may move with somewhat less stiffness, and gets up and down with less apparent suffering. The temperature is less elevated than in the external traumatism, and the whole aspect is that of collapse and sinking. These cases may die from shock or tympany in a few hours, or they may survive 24 or even as long as 48 hours but rarely longer. In case of rupture of the stomach there may be the usual feature of eructation or vomiting. Resolution may occur but non-fatal cases are liable to become chronic with ascites.
Diagnosis. Apart from traumatism, the evidence of some previous intestinal or gastric lesion, or abscess, succeeded by continuous dull colicy pains, the arching of the back and drawing together of the limbs, the tender abdomen, the careful decubitus and lying on the side, the tympany, obstinate constipation, and pale conjunctiva, the pleuritic ridge and breathing without the friction sounds or intercostal tenderness of pleurisy, the high temperature, the weak rapid pulse and rapidly advancing weakness, prostration and collapse furnish a combination which is very characteristic.
Lesions. In rapidly fatal cases there may appear to be little more than general peritoneal congestion and ecchymosis. In such cases, however, there is usually a mixture of the ingesta with the intestinal convolutions and omentum.
In cases that have survived twelve hours, false membranes are found, in the form of fine filamentous shreds on the surface of the congested serosa, which has become dull, opaque, and thickened. In twenty-four to thirty hours these have increased in thickness and solidity, binding together the convolutions of the intestines or floating free as shreds or membranous layers in the exuded liquid. At first yellowish white, these become gray, red, and finally white as they become organized into fibrous tissue. They may cover any of the abdominal organs and bind these together more or less firmly.
The liquid effusion collecting at the lower part of the abdomen, may be blood red, serosanguinolent, or straw colored, and contains a considerable amount of albumen, fibrine, granules and cells as well as the bacteria. It may attain to as much as 25 or 30 quarts. When purulent or septic the liquid is comparatively limited in amount and is usually connected with a ruptured abscess or external wound or intestinal perforation. The presence of alimentary matters, the fœtid odor, and gaseous emanations are marked features in this last condition.
The intestines are usually distended with gas, and have thin walls infiltrated, pale and thickened, and often bound to other convolutions or to adjacent organs by false membranes. The liver and spleen are pallid, and their capsules swollen, thick and opaque, with more or less membranous exudate.
In case the patient survives, the effusion and neoplasm are slowly absorbed, but the false membranes only imperfectly, and they may be found later as organized bands attaching the intestines or other organs to adjacent parts, and limiting their motions or constricting and strangling them. Hence there is left a predisposition to relapse or to other disease of the abdomen. Röll has noticed degeneration and softening of the false membranes, which extended to the wall of the bowel beneath and led to perforation.
Prevention. In solipeds especially this affection is so fatal that every precaution should be adopted to prevent its occurrence. In this class of animal the tendency to suppuration in wounds and inflammations of all kinds greatly exceeds what we see in other animals. A wound that in man will heal kindly by first intention will almost certainly suppurate in the horse, and an abdominal wound which in man, ruminant, or pachyderm might be viewed with confidence, must be treated as a very serious matter in the horse. But though thus differing in degree, all abdominal wounds must be considered as serious lesions. The peritoneal sac is, like other serous sacs, a dependency of the great lymphatic system of vessels, and the liquid present in it in health is, like the lymph, the most favorable culture medium of the body for microbian life, the greater the amount of such peritoneal fluid (as in inflammatory or other exudate) the more favorable it becomes to its growth and diffusion, and finally the enclosed intestine is teeming with micro-organisms, which, though held in check by the healthy mucosa, are ready when any congestion, inflammation or other morbid process gives occasion, to traverse these thin walls and start their deadly career in the peritoneum.
In every animal, therefore, but in solipeds above all, every precaution should be taken against the infliction of accidental wounds of the abdominal walls, and to remedy any serious derangement of the digestive organs. Above all, operations that involve the peritoneal cavity should be made only under careful surgical precautions. The introduction of pyogenic, septic or potentially septic material from hands, head, beard, floating dust, unboiled water, or surgical appliance of any kind, is a direct bid for a fatal peritonitis. Next to this the greatest care must be exercised to prevent unnecessary injury to the peritoneum or any abdominal organ, which would in any way impair its vital properties and resisting power. Again, to leave blood or exudate of any kind in the wounded peritoneum is a direct bid for the propagation of micro-organisms. These should be removed by means of aseptic agents. Finally, in case of enteric disease and abdominal wounds the patient should be guarded against chill, which would lower the vital and resisting powers and lay the system open to microbian invasion.
Treatment. The therapeutics of peritonitis furnishes a striking example of the transforming influence of bacteriological discovery. Systematic medical and veterinary works enjoin the time-honored method of treatment by opium to check intestinal peristalsis and the painful friction of inflamed surfaces on each other, and to keep the organs quiescent until nature shall have time to subdue the inflammation. The still older treatment by calomel and opium has essentially the same foundation. To the bacteriologist the latter has the recommendation of being to some extent antiseptic and of tending to secure depletion from the intestinal mucosa. Another cardinal principle of the old practitioner was to hail the liquid exudate as tending to separate the inflamed and painful surfaces, and as allowing them to move past each other without aggravating the suffering and inflammation. In short, the practitioner of the past had an especial dread of mechanical injury, and treated all other measures as secondary to this though by no means unessential.
Bacteriological considerations direct attention rather to the vital properties of the causative bacteria and seek to check the disease by checking this its most effective cause.
In simple local peritonitis, as in the infection following castration, the washing out of the infected wound with boiled water and application of an antiseptic (iodoform, iodoform or carbolic acid guaze), and the free use of carbolic acid solution (1:50) to the skin is of great value. If the sheath or inguinal region is swollen to any extent, puncturing it at intervals with a lancet to the depth of half an inch so as to drain it speedily and thus reduce the swelling and culture fluid, and to restore the vitality of the parts, and the frequent bathing with the carbolic acid lotion, will usually succeed in bringing about a healthy action.
The question of medical treatment comes forward mainly in cases that have invaded the abdominal peritoneum, and which are not already completely generalized, nor the result of extensive escape of gastric nor intestinal contents. In such forms and above all in the early stages of surgical cases sulphate of soda given to the extent of causing free purgation has been found to be incomparably more effective than the opium treatment. The explanation of its action may rest in part (1) on the expulsion from the bowel of a large proportion of the dangerous microbes which are simply waiting for that opportunity to pass into the peritoneum, which will be furnished by the inflammation of the intestinal walls; (2). On the elimination from the blood and system of much of the deleterious ptomaines and toxins which have already been absorbed from the inflamed surface and the presence of which robs the tissues of their vitality and resisting power; (3). On the active depletion from the intestinal mucosa and (through the common capillary plexus) from the congested peritoneal coat, counteracting alike the effusion into the peritoneum which forms the culture fluid for the invading bacteria, and the infiltration of the serous and subserous tissues which beside tearing apart the tissue-elements, and robbing their leucocytes of their power of phagocytosis, furnishes within the invaded tissue itself the most favorable of culture media; and (4) on preserving a better tone of the nervous system and, locally, of the tissues the cells of which, can struggle more successfully against the small body of invading bacteria advancing slowly along the surface of the peritoneum, than with the countless myriads produced in and washed everywhere by the abundant liquid exudate.
Along with the soda sulphate may be given antiseptics, like sodium salicylate, or chloral hydrate. The latter serves to mitigate the pain without checking the secretion or peristalsis.
When the suffering is very acute, opium may still be resorted to, but preferably subcutem, in the form of morphia sulphate so as to lock up the poisons as little as possible.
Enemata are in order to facilitate the operation of the bowels, and may be made laxative and antiseptic. The danger of tympanitis speaks forcibly for a judicious use of antiferments, both by the mouth and anus.
Hot fomentations have long been in use but require persistent application and this is often difficult to secure. Recently cold applications to the abdomen in the form of ice or snow, or in the absence of these of cold water applied on a light rug, kept against the abdominal walls by elastic circingles, have been found of great service. This can be persistently applied, as all that is requisite is to keep the rug constantly wet.
When pus forms in the peritoneum or when extensive effusion has taken place, it should certainly be evacuated, as it is but a centre for the development of the deadly bacteria. It can be drawn off through the already existing traumatic orifice, or, if necessary, a new opening can be made by cannula and trochar, or by direct incision under suitable antiseptic precautions. The opening having been made, and the liquid having escaped, the peritoneum may be profitably washed out with a normal salt solution which has been recently boiled and which is used at near the body temperature (80° to 90°).
Blisters are sometimes of use in the advanced stages of the disease, in stimulating resolution and reabsorption, but hot or cold applications are preferable in the early acute stages.
Laparotomy in cases due to rupture of stomach or bowel, or of extensive perforation, has not been attempted in solipeds, and it could hardly be expected to succeed, yet in such cases, which are otherwise inevitably fatal, any measure giving even a remote hope of success is allowable.
When tympany sets in it may be met by using a fine cannula and trochar, and as soon as the gas has escaped, antiseptics like chloral hydrate, salicylate of soda, salicylic acid, or glycerine, can be injected into the fermenting mass by attaching a caouchouc tube and funnel to the cannula.