COMPLETE OCCLUSION OF BOWEL
DWIGHT E. CONE
Journal of the American Medical Association (JAMA)
rotin's cases of ovarian abscess following abortion, and I have found in such cases, as the cause of the septic process, staphylococci, streptococci, diplococci, and the colon bacillus. Tetanus has also been observed following criminal instrumental abortion with severe traumatism. Sudden death in consequence of embolism has been recorded following intrauterine manipulations with instruments and intrauterine air, water, or glycerin injections. If now we attempt to outline the general principles
... f the pathology of the criminal abortion, we may perhaps characterize them as follows : 1. Premature expulsion of the ovum, if it occurs as the result of the internal administration of abortifacients, is an integral part of the general toxic symptoms, changes and processes due to those drugs or chemicals, acting in their deleterious influence on both mother and child. 2. Premature expulsion of the ovum if it occurs after detachment of the membranes, perforation of the amniotie cavity, etc., is brought about, because after such manipulations which may or may not bring about the speedy death of the embryo, the ovum acts as a foreign body and stimulates the uterine muscularis to contractions, or because intervillous or interdecidual hemorrhages occur. 3. Septic infection in its broadest sense, following criminal abortion is-ceteris paribus-not fundamentally different in its general and special pathology, its sequelae and complications from other septic infections. I have almost entirely neglected a pathologic consideration of criminal abortion brought about by copious hot douches, irritating applications to the cervix, etc. I have not been able to find a firm physiologic basis for even a modest attempt at explanation of the causal nexus between these means and the desired or accomplished result. I have to repeat in this respect, in conclusion, what was said above in the beginning: The trouble in trying to clear up the intrinsic pathology of certain types of criminal abortion lies in the fact that we practically know nothing definite about the primary factors which initiate normal labor at full term. in consultation with Dr. Williams of that town, who gave the following history: An American, aged 63, her family history was good. She had been married for forty-five years and had one child forty-two years ago. She had been troubled with what she called "bilious" attacks ever since she could remember. About thi rty\x=req-\ five years ago she had a very severe illness which was described as inflammation of the bowels and, though "given up" to die, she gradually recovered. Since that time her troubles with her stomach, or "bilious attacks," have been more or less constant. On September 4, last, she was attacked with vomiting and free purging, and after a week felt some better. In a few days there was another and one week later a third attack lasting about one week, after which there was no more purging, but the stomach sooner or later rejected everything taken, nothing having been retained for more than ten hours. She was attended by a homeopath for four weeks and, for the week previous to my seeing her, by a clairvoyant. Dr. Williams saw her for the first time about six hours before my arrival. There had been rapid emaciation, due to inability to retain any nourishment except rectal enemas, while these had not been able to keep up the vital forces. Temperature was 99 ; pulse 84 and feeble. There was no headache, and but slight soreness over the abdomen, though no point of marked tenderness. The bowels were much distended with gas so that their outline could be easily discerned through the abdominal wall. There was no dulness on percussion, but tympanitis everywhere. The urine was practically normal. Everything given by mouth distressed her, with the exception of 1/10-gr. doses of calomel and a small quantity of peroxid of hydrogen and "alkalol" in water. There had been no movement of bowels for four weeks, except as enemata were given, and the question that confronted us was whether the obstipation was due to some obstruction or paralysis of the muscular coat. The vomitus consisted of whatever might be taken, together with a tasteless and odorless frothy mucus. On November 5 there was no change in conditions, except that the patient was weaker and more easily exhausted. A saturated solution of sulphate of magnesia to the extent of twenty-four teaspoonfuls-a teaspoonful every ten minutes-was given with no result. Gentle massage over the bowels seemed to give relief. A large enema brought some fecal matter and gas. On November 9, when I saw her for the third time, the pulse was very rapid and the vital forces nearly exhausted, the temperature being 97, the pulse 132. There was no fecal vomiting, although the stomach refused to retain even water. There was no pain, except distress produced by distension of the bowels with gas and pressure against the diaphragm. Deeming the case in extremis, I advised against any operative measures. The patient died November 10. Autopsy was held November 11, with Drs. Williams of Greene, Hitchcock of South Oxford and myself present. The body was very much emaciated and the abdomen tympanitic from the distended bowel. An incision extending from the ensiform cartilage to the symphysis disclosed no subperitoneal fat. The cecum and colon, ascending and transverse, were enormously distended with gas, the small intestine but slightly distended. At the junction of the transverse and descending colon there was a constriction five-eighths of an inch in length and three-quarters in diameter, which completely occluded the lumen of the bowel. On the gastric sidfe of the obstruction there were five old cicatrices, probably from ulcers which had existed at some time, but were now only in evidence by their scars. There was about one quart of liquid feces in the large intestine, and probably much more in the small, but there were no enteroliths larger than a pea and very few of these. On the mesenterie side of the constriction there was a firm band of adhesion, fan-shaped, with its broad extremity attached to the parietal peritoneum. Attempts to loosen this attachment caused the bowel to rupture on the gastric side of the obstruction. The bowels were emptied of gas and feces and the diseased portion excised. The liver was displaced to the left so that the left lobe lay entirely to the left of the stomach, and the right lobe lay directly on the stomach, as did the distended colon. The stomach was empty. All the organs in the body were healthy and normal with the exception of the point described in the colon. This constricted part consisted of cicatricial tissue only, indicating that it was caused by ulcération and destruction of mucous and muscular coats of the bowel, and subsequent contraction.