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.