A CASE OF OBSTRUCTED LABOUR BY FIB-

ROUS POLYPUS; CRANIOTOMY; SUBSEQUENT CARBOLIC ACID POISONING AND RECOVERY; FOLLOWED BY TETANUS AND DEATH. By W. J.

Wanless,

m.d.

Missionary Physician in charge Presbyterian Hospital Miraj, S. M. G.

Mission

On November 27th, 1897, I was called in consultation with a native practitioner Dr. Chutri to see Radhabai G., age 30, of Haripore, 9 miles from Miraj. Patient married in childhood ; first pregnancy 7 years ago, terminated normally, child male, still living. Up to 9 months ago, when she became pregnant for the second time, suffered from irregular menstruation, two or three months frequently elapsing between the period. Menstruation, when it took place, was usually profuse and painful. For several years patient had been conscious of a tumour mass (/'a ball"; in the lower abdomen which seemed to disappear with advancing pregnancy. Present pregnancy apparently normal. The patient was first seen by Dr. Chutri about 20 hours after labour began. He diagnosed living foetus, cross position, which lie said he corrected and left the case to nature. T1 le following day, about 55 hours after labour began, Dr. Chutri was again called, diagnosed placenta previa and death of the foetus, the membranes having ruptured the day before. Temperature was then 102? and accompanied by 1 was at length sent for a foul vaginal discharge. and arrived after the patient had been in labour for some 65 hours. 1 found a well nourished woman considerably exhausted,temperature 102?. Pulse 115, of good volume. Vaginal examination revealed a free and foul,-smelling, dark discharge and a large hard mass filling the lower part of the pelvis and extending within the cervical canal which was fully dilated; with difficulty the examining fingers could be passed above the tumour to the presenting head The child, of course, was at the pelvic brim. dead. The

patient

was

given

a

hip bath, genitals,

scrubbed with soap and water, pubis and very free vaginal douche of carbolic acid The vagina having previously been 1 in 80. washed with soap and water applied with the hand. Complete asepsis was of course impossible but antisepsis was carried out as thoroughly The patient was as circumstances permitted. placed in the lithotomy position across a low table and opposite an open door. and

thighs

May

OBSTRUCTED LABOUR: WANLESS.

1898.]

native residence and

179

and at the end of four hours she was in better condition as regards pulse and respiration pooi lig roomy but, as than she was at the close of delivery. Her pulse means Chloroform was administered by was She suffered lve Na stronger and slower (110). a of Junker inhaler in the hands little distress in the mouth and stomach in very was a. s I tal Assistant. In the operation consequence of the acid. by Dr. Chutri and a trained nurse. The mucous membrane of the mouth and ansest The patient was incompletely were covered with throat the usual white coatvagina, Passing the whole hand into the which follows the application of carbolic ea e ing enuc to able after about 10 minutes acid. No urine was voided for 16 hours, when fibrous P? V growth which proved to be a she passed about 18oz. of dark-coloured greenishsize of a small cocoanut, with a pro:tty The urine soon after became tinted urine. antos pedicle attached within the internal normal. left lower segment of the uterus. The patient was brought to the hospital in a to be in The capsule of the tumour was found 16 hours after delivery in order to 15 1 palanquin ie to a sloughing condition, giving rise secure suitable vaginal antisepsis. All went odour of putrefaction. the patient's temperature ranging between well; The tumour removed the vagina was again 99 and 1015 and pulse of 85 to 110 until the wa fifth day when she began to develop stiffness in irrigated with carbolic lotion. Theonuteius oe us. the now found to be her throat muscles, and this was followed in two tightly contracted ie o The cranium was perforated, a hook put in days by general tetanus. Three days after adi foramen magnum and a female child was spee mission to the hospital the patient developed an i no ly delivered weighing about 7'bs. wit oi abscess on each arm and one on the chest below laceration evidence of putrefaction, without the clavicle all at the site of the hypodermic a apparent injury to the mother, lhe placen These were opened, drained and punctures. in was slowly treated with wet bichloride gauze dressings expressed and was normal appeal ance. The uterus was now irrigated wi changed twice daily. The patient was treated bichloride lotion 1 in 8000, and the vagina with with quinine and alcoholic stimulants for the the same lotion 1 in 2000. first few days after admission. On the appearThe vagina was packed loosely with iodofoim ance of the tetanus symptoms, full doses of gauze, an?l the patient put to bed with a pulse morphia were given to secure relaxation. These ot 120 rather weak. Recovery from the anaes- were followed by large doses of chloral, bromide thesia was speedy (3vi of chloroform having of potassium, and stimulants administered per The chloral and bromide was given been given). rectum. The patient was put to bed. I directed the every 4 to 6 hours and the stimulants every 2 watei to 4 hours; nourishment nurse to give zii of brandy in a little consisting of eggs, instrubroths was and of milk administered while I looked after the cleaning my by mouth until development of trismus, subsequently ments. Inadvertently the nurse picked up carbolic acid bottle, the colour of whose con ten s by the rectum. Treatment proved unavailing, o and the patient died on the fifth day after the resembled brandy, and, adding half an ounce water, administered practically the whole quan- onset of the tetanus and ten days after delitity, a few drops only remaining in the glass. very. The chief points of interest in the case The patient immediately complained of burning are?(1) conception after an interval of seven in her throat which caused the nurse to hastily 37ears, and three }^ears after tumour was known examine the label on the bottle when she by patient to exist; (2) normal pregnancy with discovered her mistake, and at once notified me tumour present; (3) mistaken diagnosis of polyin the adjoining room. Mustard seeds, the pus for placenta prsevia ; (4) prolonged labour (65 emetic to be found at hand, were ground hours) resulting in pressure necrosis of tumour only but followed up and administered in a pint of hot water,^ by general sepsis without special injury with negative result. Cocoanut oil was previous- to birth; and (5) carbolic acid poisoning after ly administered to neutralize the cauterizing administration of chloroform; speedily alarming action of the carbolic acid. symptoms and prompt reaction to stimulants and In half an hour our (6) tetanus. This is not at all remarkpatient became uncon- recovery; scious, delirium followed, respirations became able under the circumstances, but the question shallow, pulse rose to 100, barely perceptible may naturally be raised was the tetanus the at the wrist. Brandy was now administered result of the septic infection introduced per hypodermically. At least 20 syringefuls (20 mi- vaginam, or was it due to the hypodermic puncnims each, a larger syringe was not available) tures? I think to the latter. There was no were injected into the and time either to sterilize the needle or the skin, and arms, chest, back abdomen one after the other. Tincture digitalis, the injections caused a good deal of localized strychnine, and atropine were also administered induration and at points abscesses developed. hypodermically at short intervals. At the end After deliveiy there was no unusual pain in the of three hours the patient's condition began to uterus and the lochia were not at all offensive, The house

was

a

good

usual, with

a

improve, a

1

?

,

?

^P

-

|e

ISO

INDIAN MEDICAL GAZETTE.

the

putrefaction before delivery being confined largely to the tumour. The patient had been freely handled and examined by unclean hands before m}' arrival, and with the almost constant presence of tetanus bacillus in the cow-dung washed floors of the native houses, it is not

impossible

entered

the

patient

was

that that

1

1

bacillus could have

while the the floor or during vaginal examinations. 1 recall a case which I attended some years ago where the vulva were covered by a layer of cow-dung dust which had adhered from the floor. In this patient after cleansing I performed podalic version, the patient lying on the floor. My back was crippled for a week subsequently. The patient, however, recovered.

system

per

squatting

011

vaginam,

[May

1898.

A Case of Obstructed Labour by Fibrous Polypus; Craniotomy; Subsequent Carbolic Acid Poisoning and Recovery; Followed by Tetanus and Death.

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