Chapter XVI: Part 16

The advance of bacteriology has greatly simplified our views of the disease, as microbes are found to be at work in practically all cases. If we could exclude microbes from this membrane, peritonitis would be practically abolished, portions of aseptic powdered glass, sponge or gauze can be left in the abdominal cavity with comparative impunity, the tendency being, as shown in the dog, to coat themselves with a fibrinous exudate, and to make their way into the intestines through which they escape (Sternberg, Jalaguier and Manclaire). Hence it is that peritonitis is to a very large extent the result of a traumatism (castration, penetrating wound of the abdomen, contused wound of the abdomen), or of a rupture or ulceration of the stomach or intestine, through which the microbes make their way into the peritoneal cavity. In enteritis, congestions, strangulations, intussusceptions and obstructions of the bowels, the cause is the same, the microbes making their way with greater ease through the coats of the bowels in which the circulation and nutrition are impaired and the power of resistance diminished. Finally the occurrence of the disease as a consequence of exposure to cold or wet, of exposure in a cold rain or snow storm, of standing in a draught when perspiring, or plunging into cold water when heated and fatigued, or drinking ice cold water when in a similar condition, may in most cases be explained on the same grounds. The germs in this case had already gained access to the blood, but were helpless to accomplish much harm, until by chilling, the resisting power of the system was lowered and an occasion furnished for their successfully colonizing the peritoneum. Parallel cases are found in the frog which is immune from anthrax until it is heated, and in the chicken which is immune from anthrax until chilled. Reduce the vitality of the system and the germ which was already present, and up till now harmless, takes occasion to colonize more or less destructively.

This view also furnishes an explanation of the tendency of local peritonitis to become generalized. In the scanty liquid which bedews the surface of the abdominal organs, the microbes grow, multiply and spread; by the constant peristaltic movements of the bowels and their rolling upon each other this extension is largely favored; and the tendency to generalization will be in ratio with the potency of the invading germ, and the general or local weakening of the invaded tissues. With a limited infection wound in an otherwise healthy peritoneum and system, and invasion by a pus coccus only, the infection may not succeed in extending from its primary centre, but with a debilitated system, an extended enteritis, or when the invasion is made by septic germs it is likely to become speedily and fatally generalized.

Pernice has shown, however, that peritonitis may occur independently of infection. The injection into the cavity of concentrated mineral acids, acetic acid, phenol, nitrate of silver and other powerful antiseptics determine inflammation by their purely irritant action. By weakening the tissues of the bowels these in their turn pave the way for the escape of the microbes from the contents, and to the occurrence of a secondary infective inflammation.

Cases occur as a manifestation of rheumatism, tuberculosis, actinomycosis and other affections which will be treated at greater length under these respective heads.

The microbes would seem to vary greatly. Soula attributes infection of castration wounds mainly to the bacillus of malignant œdema which is 3 to 3.5 μ long and 1 to 1.1 μ broad often bearing a refrangent spore at one end (is sporeless in the peritoneal cultures), and growing out into chains in artificial cultures. They are anærobic, liquefying, motile, easily stained by aniline colors, but bleached by iodine.

In other forms of peritonitis the bacillus coli commune is found and probably comes from the intestinal contents where it is present in all our domestic animals.

In man Fränkel found the bacillus coli communis 9 times, streptococcus pyogenes 7 times, bacillus lactis aerogenes 2 times, micrococcus pneumoniæ crouposæ 1 time, staphylococcus pyogenes aureus 1 time. Flexner found the proteus vulgaris.

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.

CHRONIC PERITONITIS IN SOLIPEDS.

Secondary: after acute, or with disease of liver, spleen, kidney,
rheumatism, melanosis, lymphadenoma, epithelioma, carcinoma, or
sarcoma. Gastric ulcer, infected punctures. Symptoms: poor health,
tender abdomen, irregular bowels, slight colic, tense, fluctuating
belly, pallid mucosæ, dropsy of sheath, limbs, etc., slight fever.
Treatment: remove primary disease: saline laxatives, diuretics,
drainage, antiseptic irrigation (boric acid, etc.), abdominal bandage,
tonics, derivatives.

_Causes._ Chronic peritonitis is always a secondary disease, succeeding the acute, or dependent on some other affection of the abdominal organs, as chronic congestion of the liver, or spleen, Bright’s disease, rheumatism, melanosis, lymphadenoma, epithelioma, carcinoma, or sarcoma. Tuberculosis and actinomycosis, so common in cattle, are rare in solipeds. Chronic ulcers of stomach or bowels and injuries and infections from punctures are exceptional causes.

_Symptoms._ The manifestations of the disease are indefinite, the acute form may have subsided so that the patient is supposed to have completely recovered, a moderate appetite and a certain capacity for work may be present, yet he is easily fatigued, there is some tenderness of the abdomen to pressure, some irregularity of the bowels—constipation and diarrhœa alternating—and occasional slight colics. Some weeks later may be noticed abdominal tension and tympany, with perhaps fluctuation in the lower parts, increasing pallor of the mucosæ, and œdematous swelling of the sheath, mammæ, abdominal walls or hind limbs. To detect fluctuation it is sometimes necessary to introduce one hand into the rectum. When present hyperthermia is slight, but assists in diagnosis from ascites.

_Treatment_ should be directed to the primary disease. As that is too often irremediable the peritonitis will resist all other treatment.

In cases that supervene on the acute form, paracentesis, saline laxatives and diuretics with antiseptics, tonics, and counter-irritants will sometimes succeed. As in the acute form of the disease the removal of the effusion is the removal of the culture fluid, and may be followed by irrigation of the peritoneum with a normal salt solution, or with an antiseptic solution (boric acid or potassium permanganate), 1:20 warm water; Aluminum acetate, 1:2000. Sulphate of soda given to keep up a moderately laxative action, tends to counteract the contraction of the intestine by false membranes, and operates with diuretics in reducing the tendency to exudation or in causing its reabsorption. After removal of the liquid, support by a close (or elastic) abdominal bandage is often of value in preventing further effusion. As tonics, gentian, nux vomica and the iron salts may be profitably employed, and as antiseptics salicylate of soda and iodide of potassium. As counter-irritants mustard and cantharides may be named.

PERITONITIS IN RUMINANTS.

Causes: infection, chill, blows, wounds, debility, ill health,
Chauveau’s experiment with castration, dystokia, abdominal congestion
and inflammation, bile or urine in absence of sepsis, gastric or
intestinal ulcer or perforation, foreign bodies, abscesses, surgical
wounds. Spoilt marc of beet sugar factories. Symptoms: fever,
stiffness, dragging hind limbs, knuckling, arched back, shifting feet,
moving tail, tense belly, pendent, fluctuating below, friction sounds,
diarrhœa, later constipation, weakness, emaciation, death fourth to
twentieth day. Recovery, often partial. After dystokia putrid vaginal
discharge, and nervous depression, resembling parturition fever.
Infection in ewes through shepherd’s hands, œdematous swellings of
vulva, perineum and abdomen. Lesions: as in solipeds, with abundant
false membranes, fœtid pus metritis, with putrid contents of womb.
Treatment: saline laxatives, diuretics, demulcents, enemata, morphia,
antiseptics, cold to abdomen. After dystokia, antiseptic irrigation of
womb, elevation of head, with ice, strychnia, acetanilid. Tubercular
peritonitis.

_Causes._ As in solipeds infection of the peritoneum and the increase of susceptibility by exposure to cold, blows, wounds, poor feeding or stabling, disease and other causes of ill health, operate together in inducing peritonitis.

The effect of debility or predisposition of the tissues is well shown in Chauveau’s experiments with _bistournage_ in rams. Healthy rams subjected to bistournage showed no infection, and rams subjected to intravenous injection of pus microbes without _bistournage_ showed no infection, whereas if the rams were first subjected to injection of pus microbes, and then to _bistournage_, peritonitis set in. In the same way chills occurring after dystokia, when the womb is charged with microbes and more or less congested, may determine peritonitis, and congestions, impactions, tympanies, and other injuries of the gastro-intestinal viscera coöperate with cold to the same end. Rupture of the gall or urinary bladder does not usually cause prompt peritonitis, yet it irritates the serosa and lays it open to infection if the germs should reach it through the circulation. Otherwise the animal suffers only from uræmia or biliary poisoning and may survive one or two weeks. Ruptures of stomach or intestine, or ulceration or the perforation of their walls by hard, pointed or other metallic bodies are causes of peritonitis. The rupture of abscesses into the peritoneum and the escape of germs from the womb in case of rupture of the womb in difficult parturition, or in metritis, are additional causes. Surgical wounds as in castration of the male or female, and punctures and incisions of the rumen are occasional causes, but there is by no means the tendency to extension of such peritonitis that we see in solipeds. The self-protective power of the tissues is incomparably greater in the ruminant.

Nocard, Butel and others have recorded a gastro-entero-peritonitis of septic nature, occurring in cattle and above all in sheep, fed on the fermented refuse of beet sugar factories, which had been kept in silos through the winter. On the third and fourth days of this feeding many were attacked.

_Symptoms._ Beside the general systemic disorder and a very variable amount of hyperthermia (102° to 107°), there are the special indications of abdominal inflammation, stiff movement and dragging of the hind limbs, or if standing the back is arched, the head drooping and the legs drawn together and slightly bent, with uneasy shifting of the hind feet, and lateral movements of the tail. The walls of the abdomen are usually tense, often bulging laterally below, though fallen in beneath the lumbar transverse processes (pot-bellied); they are tender to pressure, and may be drum like to percussion above, while flat, dull, and fluctuating below. The tenderness is slightest below, where liquid effusion has settled, but is quite marked in the upper and resonant parts, where pressure will cause wincing and trembling. In this upper part on the left side may be heard friction sounds after the fourth or sixth day. This is especially observable in tuberculous peritonitis over the parts covered by tubercular growths. There may be at first diarrhœa which usually soon gives place to constipation, and weakness and emaciation advances rapidly, and death may take place from the fourth to eighth day, or may be deferred for some weeks.

In favorable cases the acute symptoms subside, the liquid effusion is absorbed, appetite and rumination are in great part restored, and a partial recovery is made. It is, however, very liable to merge into the chronic form, and inevitably so in tuberculous cases.

In cases following on difficult parturition there are redness of the vaginal mucosa, with mucopurulent or putrid discharges, and swelling of the lower part of the abdomen, with liquid effusion and fluctuation, and tenderness of the right flank. The further symptoms are largely nervous, approximating somewhat to those of parturition fever. Temperature may rise to 104° or 106°, blindness, stupor, incoördination of muscular movement, staggering gait, if down she may lie on the side or sternum unable to rise, has frequent afterpains, tympany, sour eructations, and grinding of the teeth. The case may culminate in loss of vision, in stupor and coma, or improvement may set in and go on to a rapid recovery. This is a more common affection in ewes than in cows and is very destructive, the infection being carried by the hands of the shepherd. The most fatal cases are those in which the infection becomes generalized, and œdematous swellings appear round the vulva, between the thighs and beneath the abdomen.

In traumatic cases the external wounds can usually be found with active inflammation and surrounding tumefaction.

_Lesions._ The peritoneum, as in solipeds, shows the symptoms of congestion, exudation of a fine fibrinous network or shreds, of thicker and more extended false membranes in patches, of effusions more or less sanguineous, of formation of pus, usually fœtid, or the presence of decomposing ingesta which has escaped through a lesion of stomach or bowels. The peritoneal and subserous tissue are infiltrated with liquid, and the other gastric and intestinal organs are more or less tympanitic, and the mucosa of the latter is thickened, ecchymosed, or eroded, with black, fœtid bloodstained contents. In parturient cases, the uterine mucosa is congested, reddened and softened, the cotyledons swollen, perhaps gangrenous, and the membranes, if still present, float in a dark, putrid offensive liquid.

_Treatment._ As in the horse, morphia has been used to relieve pain and check peristalsis. The addition of saline laxatives, and diuretics, will assist in elimination and depletion, and in the removal of intestinal bacteria which become a source of danger. A laxative dose should be followed by frequent drinks of pure water or mucilaginous liquids, and sulphate of soda may also be given freely in enema. As diuretics, saltpeter or digitalis may be resorted to. Antiferments (salicylate of soda, bisulphite of soda) should not be forgotten nor cold applications to the abdomen. When effusion or suppuration has taken place evacuation by puncture may be followed by antiseptic irrigation.

If with septic metritis, antiseptic injections of the vagina and womb are the first consideration. With boiled water at a tepid heat the womb should be thoroughly washed out, followed by a solution of mercuric chloride (1:2000), or permanganate of potash (1:1000), or boric acid (1:25) until the liquid returns clear and odorless. This may be repeated several times a day. The symptoms of brain congestion, may be met by tying, or packing up the patient with straw so that the head will be somewhat elevated, and bags of ice or snow, or simple cold water may be kept applied to the upper part of the head and neck. When there is no great nervous excitement the nervous functions may be roused by nux vomica in enema, or strychnia subcutem. If on the other hand the temperature runs very high acetanilid may be tried with caution, or resort may be had to wet compresses.

In case of perforation or rupture, if the animal cannot be at once sacrificed for beef or mutton before inflammation has set in, the only hope lies in laparotomy, followed by the cleansing, disinfection and suturing of the wound.

In tubercular peritonitis which constitutes a very large proportion of bovine cases, treatment is undesirable, and the animal is unfit for consumption.

PERITONITIS IN CARNIVORA.

Causes: gastro-intestinal inflammations, metritis, trauma to walls of
abdomen, pyæmia, septicæmia, tuberculosis, cancer, tumors, parasites.
Symptoms: dullness, hiding away, movements tardy, painful, arched
back, retracted abdomen, tense and tender, drags hind limbs, vomits,
yawns, bloats, hopeless look, snappish, death in 2 to 8 days.
Treatment: anodynes, saline laxatives by mouth and rectum, damp
compress, warm bath, antiseptics, diuretics, in effusion, puncture,
antiseptic irrigation, laparotomy.

_Causes._ All inflammatory and other serious affections of the stomach and bowels may be associated with peritonitis. Metritis and injuries to the womb, and all injuries to the walls of the abdomen (kicks, blows, penetrating and castration wounds), may have a similar complication. Pyæmia and septicæmia may also have localization in the peritoneum. It must be borne in mind, however, that purulent and septic infection are less likely to occur in the dog than in cattle, the leucocytes of the dog having much more resisting power. On the other hand the dog, and, still more so, the cat has a fair measure of susceptibility to tuberculosis, cancer and various forms of tumors, which show a strong tendency to localization in the abdomen. Parasites also penetrate and irritate the peritoneum.

_Symptoms._ The animal becomes dull, retiring, and inclined to lie in a quiet place, though his suffering may lead to frequent change of bed, he moves slowly, painfully, with arched back, retracted abdomen, and drooping head, and dragging his hind limbs stiffly. The abdomen is tense and firm, hot and very tender, drawing forth whines and yelps when it is handled. There are hyperthermia (104°), small, weak, accelerated pulse, hurried, catching breathing, vomiting, yawning, tympany and constipation. The face has a hopeless, stupid look and the eyes are sunken and at times glazed. Some patients become ill natured and snappish. The animal gradually sinks into a condition of prostration and finally of collapse and dies in two to eight days.

_Treatment_ does not differ materially from that given for larger animals. Pain may be moderated by belladonna, hyoscyamus, chloral, or even opium, while the sulphate of soda is employed by both mouth and rectum. The abdomen may be enveloped in a damp compress, or a warm bath may be given. Diuretics will be in order and above all antiferments, the latter by enema as well. Distension of the abdomen with fluid may be relieved by puncture, followed by antiseptic irrigation. If there is good ground to suspect a gastric or intestinal lesion or tumors, laparotomy is a much more hopeful resort than in the larger animals.

PERITONITIS IN BIRDS.

From caponizing, accidental traumas, ruptured oviduct, perforations of
bowels by foreign bodies or worms, pyogenic susceptibility slight.
Symptoms: inappetence, drooping head, wings, tail, erect plumage,
stiffness, straining, tense, tender, pendent belly. Treatment: unload
cloaca, puncture and irrigate abdomen, laxatives. Prophylaxis, by
laxative food, expulsion of worms, antisepsis in operations, unloading
cloaca, etc.

_Causes._ Male birds contract peritonitis from caponizing, and other penetrating wounds of the abdomen, from rupture of the oviduct impacted with egg matter, from perforations of the intestines by foreign bodies, and from perforations by worms.

The danger from ordinary pyogenic germs is, however, at its minimum, since birds stand at the opposite extreme from the horse, and their wounds rarely suppurate.

_Symptoms._ The bird loses appetite, droops head, wings and tail, ruffles its feathers, walks stiffly and heavily, and expels fæces with much effort and even with cries. When caught the abdomen is found to be full, tense and pendent and very tender to the touch. There is more or less hyperthermia (108° and upward), and the subject becomes more and more dull, stupid and feeble until death.

_Treatment._ In certain cases relief may be had by the unloading of the cloaca, or the evacuation of peritoneal fluid, followed by antiseptic, irrigation of the cavity. Laxatives may also be resorted to. The most important measures are however prophylactic, and run in the direction of careful manipulation and antisepsis in caponizing, the unloading of impacted cloaca, before it has developed serious disease, the maintenance of a suitably laxative diet, and the prevention and treatment of worms. In case of tumors causing chronic peritonitis, laparotomy can be resorted to with great confidence.

ASCITES IN SOLIPEDS.

Causes: follows peritonitis, obstruction of portal vein, tumors,
hepatic diseases, pressure on posterior cava, dilated right heart,
heaves, ovarian disease, nephritis or kidney degeneration, hydroæmia.
Symptoms: slow advance, pot-bellied, with fluctuation, hollow above,
dropsy in limbs, sheath and under belly, percussion sound flat below,
weakness, debility, no fever. Diagnosis: Absence of fever, and of
fibrine, cells and granules in effusion. Lesions: those of primary
disease, amount and composition of effusion. Treatment: treat primary
disease glandular swelling or actinomycosis, iodide of potassium,
remove diseased ovary or tumor, draw off fluid, compress abdomen,
saline laxatives, diuretics, iodides, pilocarpin, electricity,
bitters.

_Causes._ Ascites may be a remnant of a pre-existing chronic peritonitis, or it may occur from any obstruction of the portal vein, such as compression by organized false membranes, thrombus, in the vessel, or pressure by lympadenoma in the portal fissure, melanosis, sarcoma and other tumors. It results from cirrhosis and other diseases of the liver which retard its circulation, from pressure on the posterior vena cava, from insufficiency of the right auriculo-ventricular valves, from dilatation of the right heart, and from heaves or other obstruction in the pulmonic circulation. Other causes are cystic or other disease of the ovary, diseases of the kidney and hydroæmia, the latter two tending to general œdema as well as ascites.

_Symptoms._ The disease comes on slowly and insidiously and at first it usually passes unnoticed. When more fully developed the abdomen is distended but somewhat pendent (pot-bellied), fluctuating below, with falling in beneath the lumbar transverse processes. Later the whole abdomen may be full, rounded, smooth and tense, and the hind limbs œdematous to above the fetlocks or hocks. There may be œdema of the sheath or lower wall of the abdomen. Fluctuation can still be felt as a shock when an assistant makes sudden concussion with the fist on the opposite side from that on which the hand is pressed. This may be felt even more distinctly by the hand introduced into the rectum. Percussion gives a flat sound below and more or less resonant above. The pulse is small, weak, and accelerated, heart beats irritable (sometimes palpitating), and respiration labored and with lifting of the flank. From first to last there is no hyperthermia.

If the cause is irremediable the issue is necessarily fatal sooner or later.

_Diagnosis_ from peritonitis depends largely on the absence of hyperthermia, and of abdominal tenderness, and on the nature of the ascitic fluid which is incoagulable, and comparatively destitute of leucocytes cells and granules.

_Lesions._ The quantity of effused liquid is often enormous (50 qts. Reynal, 80 qts. Woodger, 150 qts. Friedberger and Fröhner). It is very watery and poor in salts and albuminoids, of a density near 1012, neutral or slightly alkaline, does not coagulate spontaneously, and is not associated with false membranes. The peritoneum shows no congestion, but is pale, and, like the abdominal walls, infiltrated. Tumors, cysts and venous obstructions referred to under causes may be found.

_Treatment._ When ascites depends on actinomycosis or glandular enlargement a course of iodide of potassium may remove the cause. In other cases an operation may remove the offending tumor or ovary. Too often, however, the cause is beyond remedy and palliative treatment only is available. The most urgent indication is the removal of the accumulated fluid, and paracentesis under proper antiseptic precautions is the readiest means to this end. Compression by a tight bandage is necessary to prevent the sensation of vacuity and tendency to fainting which come from the removal of the fluid and to counteract the disposition to the instant effusion of more. Even with the compress it is judicious not to draw off all of the fluid at once in bad cases, but to make two or three operations and allow the patient to become accustomed to the change in the intervals. These may be repeated as circumstances demand. Saline purgatives, or diuretics (saltpetre 1 oz., digitalis 25 grs., squill 3 ozs., iodide of potassium 2 drs.), are useful, and pilocarpin is the most efficient agent of this kind, but also dangerous by reason of the extreme depletion which it causes. Electricity has been employed with alleged advantage, also poultices of digitalis applied over the loins.

Cholagogues are also recommended especially in cases of liver disease. Bitters may prove useful.

ASCITES IN RUMINANTS.

Causes: as in horse, tuberculosis, in sheep distomatosis, chills when
heated and fatigued. Symptoms: pot-belly, fluctuating on percussion,
gives flat sound, debility, pallid mucosæ, sunken eyes, superficial
dropsies on belly, in limbs, and under jaw, in distomatosis, great
emaciation, weakness, paperskin, ova of distoma in fæces. Diagnosis:
from ruptured bladder by passage of urine, and perhaps by sex, and
absence of urinous odor in liquid, from hydrometra by fluctuation over
whole belly. Lesions: those of solipeds, also tubercles or enlarged
gall ducts with distomata. Treatment: as for solipeds. Tuberculosis
demands separation or destruction, distomatosis, prevention.

_Causes._ These are in the main those which operate in the horse and need not be repeated. In cattle, however, the affection is to a large extent the result of abdominal tuberculosis, while in sheep it is a constant result of advanced distomatosis. Gellé says it is common in working oxen, which are turned out, hot and perspiring, to pass the night in cold and wet.

_Symptoms._ The belly is enlarged and pendent, bulging out back of the ribs, with fluctuation and dullness on percussion. The animal is in very low condition, the mucosæ pale or yellowish white, the eyes dull and sunken, panting and palpitations may be roused on the least exertion, and swellings often appear along the lower aspect of the body and between the branches of the lower jaw. In distomatosis it is common to find dropsy of the chest, pallor and attenuation of the skin, complete absence of the subcutaneous fat (paperskin), and great emaciation and weakness. Ova of the distoma can be found in the fæces. (See distomatosis). By turning the sheep on its back or setting it up on its croup the percussion dullness will be made to shift, always to the dependent part of the abdomen.

_Diagnosis._ From rupture of the bladder it is distinguished, by its occurrence in females as well as males, by the absence of fever, and of the complete suppression of urine and emptiness and tenderness of the bladder which characterize the latter. Liquid drawn from the abdomen has no urinous odor. From hydrometra, pyometra, and hydramnios it is distinguished by the fact that the water accumulates in the lower part of the abdomen, and is not confined to the womb. On rectal exploration the outline of the empty womb is made out.

_Lesions._ Besides the lesions described for solipeds, one finds in cattle, tuberculosis of the liver, spleen, and lymph glands, and extensive clusters of tubercles on the peritoneum. In sheep the white branching lines on the back of the liver may indicate the distension of gall ducts infested by distomata.

_Treatment_ does not differ from that recommended for solipeds. In tuberculous cases, sanitary considerations demand the destruction of the animal and disinfection of the carcass. In distomatosis treatment must be preventive, as the distomata are difficult to reach with vermifuges.

ASCITES IN CARNIVORA.

Causes: obstructed flow of blood in hepatic, portal or renal veins, or
in vena cava, renal, heart, liver or splenic diseases, pulmonary
congestion, asthma, tuberculosis. Symptoms: pot-belly, hollow above,
drooping back and loins, flat percussion sound and fluctuation, change
of position changes area of flatness, anæmia, debility, scanty urine,
diarrhœa, no fever. Diagnosis: absence of fever, general fluctuation
changing its seat by turning the patient, not confined to a given
organ like the bladder or womb. Lesions: quantity and composition of
liquid, lesions of primary diseases. Treatment: Correct if possible
the primary disease, evacuate the liquid, compress on abdomen, iodine
solution for irrigation, saline purgatives, diuretics, pilocarpine,
bitters, iron, sunshine.

_Causes._ Ascites is generally the result of some obstruction to the return of blood from some abdominal organ, but may also come from renal disease, or hydroæmia in which general dropsy is likely to occur. The dog is specially subject to heart disease, and disease of the right heart (tricuspid insufficiency, dilatation, hydro-pericarditis, fatty degeneration, etc.) throws the blood back on the whole venous system and the extensive and dilatable portal veins are especially liable to suffer. Diseases of the liver, so common in pampered house dogs, still more directly block the portal circulation and induce ascites. Tumors in the liver or spleen or in the lymph glands of the porta act in this way, also cirrhosis, tuberculosis, cancer, hepatic congestion, and degeneration. Constrictions of the vena portæ by false membranes the result of former peritonitis must also be recognized. As more distant causes, must be named obstruction to the pulmonary circulation, as in congestion, asthma, tuberculosis and diseases of the left heart. Seventy-eight cases were traced as follows: to diseases of the heart and pericardium, 10; to tuberculosis, 8; to pleurisy, 4; to malignant tumors of the liver and lung, 2; to hepatic disease without heart lesion, 3; to cancer of the liver, 1; (Cadiot).

_Symptoms._ Enlargement of the belly is marked and peculiar, the liquid accumulating below, pushing outward the lower ends of the ribs, and making the lower part of the abdomen baggy while the upper part, under the lumbar transverse processes, is flattened or hollow. The back and loins droop forming a concavity superiorly, so that the belly may almost drag on the ground. On palpation this pendent abdominal sac gives the sensation of a mobile fluid without the usual firm outlines of the intestinal masses, and when percussed it gives out a flat, dull sound and produces a fluctuation or shock at the opposite side of the abdomen. In the upper part of the abdomen over the hollow flank more or less resonance is found. If the animal is made to stand on his hind limbs the saccular dilatation and flatness on percussion are in the region adjoining the pelvis; if held up by its hind limbs they are transferred to the epigastric and hypochondriac regions and the respiration is seriously interfered with; if turned upon his back, the resonance is obtained on the linea alba and at each side, while the percussion dullness is next to the vertebræ. The clearness of the fluctuation is in ratio with the amount of liquid present.

As in other animals, there are anæmia, pale mucosæ, poor condition, thin, dry, unhealthy skin, weak pulse, irritable heart and interference with respiration proportionate to the amount of liquid. The urine is scanty, and there may be diarrhœa.

_Diagnosis._ From advanced or chronic peritonitis it is distinguished by the history or evidence of diseased liver, heart, or kidney, the absence of hyperthermia or abdominal tenderness, and the absence in the ascitic fluid, extracted with a hypodermic needle, of blood globules, or leucocytes in numbers, of false membranes, of excess of salts, or of a tendency to coagulate firmly.

From overdistended bladder it is diagnosed by its slow, and gradual development, and the change of fluctuation to the most dependent part no matter what position is given to the patient, whereas the tense bladder can be felt through the abdominal walls, extending forward from the pelvis under all circumstances.

From ruptured bladder there is the same distinguishing feature of slow development, the absence of symptoms of uræmic poisoning, of tenderness of the bladder, and of suppression of urine, and also of the urinous odor in the ascitic liquid obtained with the hypodermic needle.

From advanced gestation the differentiation is found in the general diffusion of the swelling and fluctuation, which is not confined as in gestation to the mobile uterine horns, with a series of enlargements each containing a solid nodular fœtus.

From hydrometra and pyometra there are the same pathognomonic differential features of the general diffusion of the swelling among the intestines, and its accumulation in one fluctuating mass at the most dependent part of the abdomen.

Tympany of the bowels causes uniform drumlike resonance, and the swelling does not sag and fluctuate in the lower part of the abdomen.

Abdominal obesity in old dogs gives the rounded swollen abdomen, but there is an entire absence of the pendulous and fluctuating features, and when punctured with the hypodermic needle it furnishes no fluid.

From tuberculosis it is distinguished by the absence of nasal discharge, or of tubercle bacilli in such discharge, or in the ascitic fluid, and the latter inoculated on guinea pigs or rabbits does not cause tuberculosis. The tuberculin test may also be resorted to.