CONTRIBUTION TO THE PEACTICE OF MIDWIFERY.
By
P. S. cal t
Mootoosamy, G.M.S., F.L S., Felloio of the ObstetriSociety of London, Native Surgeon, Mannargoody, / / Tanjore District.
REMARKS
ON
PUERPERAL TETANUS BY A CASE.
:
ILLUSTRATED
At 10 p. m., on the 10th July 1876, I was summoned to a poor native woman residing in the town, who was said to have been in labour of her tenth child for some days. I was taken to a
small, badly
ventilated hut, where I fouud the patient, a woman of about 35 years of age, lying on an old mat on the floor, with a block of wood under her head for a pillow. I learnt on inquiry that labour pains had set in four days
previously,
that
they
were
vigorous
and
frequent
at the
com-
mencement, but that subsequently they became weak, and the intervals between each prolonged. The membranes had ruptured at 3 a.m. of the day on which I was called in. The woman complained of urgent thirst; the tongue was rough and dry; pulse 126, small and frequent ; the bowels were said to be no action of the bladder for three days. examination, the abdomen was found hot ; the uterus large and firmly contracted on the body of the foetus; the external parts were a good deal swollen, and the passages hot and tender. All uterine action had ceased, and there was no indication of foetal life. The head was found presenting, but firmly impacted in the hollow of the sacrum. There was much rigidity of the perinseum. Having made an unsuccessful attempt to relieve the bladder, I proceeded to extract the child by craniotomy. The foetus was The placenta was found adherent, and a male, and of large size. its separation was followed by flooding to some extent. With the exception that the lochia were unusually scanty, no untoward symptom presented itself until the sixth day, when it free purulent discharge from the was found that there was a next day tetanic symptoms appeared and rapidvagina. On ly increased in severity?the opisthotonic form of convulsion being frequent and severe. For two days the convulsions continued, and the woman expired exhausted on the tenth day.
free, but there had been On
The intellect remained clear to the last. She was treated by chloral hydrate in conjunction with morphia, turpenture and nutrient eneinata, and embrocations of aconite, &c.
Observations.?Though puerperal tetanus is so rare an affecEurope that no mention of it is made in any of our works on midwifery, yet it is unfortunately sufficiently common in India to come under the observation of most practitioners, and to add to the causes of mortality to which puerperal women are here so liable. It has been pointed out tiiat the darkskinned races are peculiarly prone to the complication; and tion in
November 1,
A MIRROR OF HOSPITAL PRACTICE.
1877.]
proclivity is, no doubt, in Southern India at least due, in not altogether, to the strange and injurious treatment
this
part if
which women in labour receive at the hands of their friends and attendants. In the first place the confinement usually takes place on the floor, between which and the poor woman's body nothing intervenes but a thin mat, on which, saturated as it must bccome, she must be undisturbed perhaps for days, and with nothing for a covering but a light cotton cloth. The room dark and damp, and as if these conor hut is ill-ventilated,
enough in themselves to light up tetanus or disease, the unfortunate woman is literally starved for the first three days after delivery. It is not difficult, under these circumstances, to find a cause for the tetanic symptoms when they do occur. In that peculiar state of exhaustion, induced by the shock of labour, the parturient woman must be considered especially liable to disease, but when in this condition she is deprived of food, pure air and light, and exposed moreover to damp and cold, we need not wonder that tetanus should ditions other
were
severe
not
form of
result. I am certainly disposed to believe that the case I have recorded had its origin in this manner, and I have no doubt that my medical brethren, who practise amongst the Natives? the poorer classes especially,?will bear me out in my assertion that tetanus springs from the causes mentioned. Most of us continually witness cases in which the patients are, as it were, on the very verge of tetanus, and in which, if I may be allowed tetanoid symptoms present use the expression in this sense, themselves. The patients complain of pain and stiffness in the back of the neck and jaw, and sometimes of spasm of the muscles of these regions. Often there are general bodily pains to
with
feelings
receives from or or
convulsion,
and I have
is tetanus in
expression a
of weariness and exhaustion. This condition the natives the name Junnee, equivalent to spasm a
no
doubt that it is allied to tetanus, or undeveloped form. I take the
modified
tetanoid from Dr. Barnes, who however applies it to He says, " the tetanic state consists in
different condition.
exhalted irritability of the spinal cord, a condition which may be regarded as a morbid exaggeration of the normally increased irritability of pregnancy. I have often seen in labour evidence of stich extreme reflex and emotional irritability that I have expressed it to myself as tetanoid.'"
intensely
That the causes mentioned predispose the patient to tetanus if they do not directly induce the disease is, I think, also borne out by the fact that comparatively few females, who are delivered in I have our public hospitals, become the subjects of tetanus. examined the Eeports of the Madras Lying-in Hospital for five in my possession years and a half, as published in a few volumes Madras Quarterly Journal of Medical Science," of the late and I find that not a single case of tetanus occurred in 5,794 deliveries which took place during the period referred to?a fact which may perhaps be accounted for by the totally different circumstances attending an accouchement in a public institution "
and one in a poor woman's own home. If the symptoms, which have been referred to as tetanoid, be really allied to tetanus, and, in fact, only the manifestations of a minor or milder form of the affection itself, it is difficult to explain why the disease should at
times be thus arrested, as it were, in its course instead of
becoming fully developed. It occurs to me that a solution of the difficulty might be found in the suggestion as to the true nature His view of tetanus lately thrown out by Dr. Sydney Ringer. is. that so far from tetanus being due to excitement or stimulation of the spinal cord, it has its origin in diminished or destroyed resistive power in the reflex portion of the cord which permits of nervous force being set free from every part of it, and in the same way that besides tetanus, other explosive neuroses like migraine, epilepsy, neuralgia, asthma, &c., are best explained by the supposition that a loss of resistance occurs in certain portions of the central nervous system, whereby impressions conducting to these parts spread beyond their normal "
291
the various symptoms of these diseases." May of the tetanoid symptoms be explained on the supposition that in these cases in which they appear, the diminution of the resistive power takes place in a very slight degree only, and is confined to a limited area ? area
not
and
the
produce
occurrence
By
P. S. cal t
Mootoosamy, G.M.S., F.L S., Felloio of the ObstetriSociety of London, Native Surgeon, Mannargoody, / / Tanjore District.
REMARKS
ON
PUERPERAL TETANUS BY A CASE.
:
ILLUSTRATED
At 10 p. m., on the 10th July 1876, I was summoned to a poor native woman residing in the town, who was said to have been in labour of her tenth child for some days. I was taken to a
small, badly
ventilated hut, where I fouud the patient, a woman of about 35 years of age, lying on an old mat on the floor, with a block of wood under her head for a pillow. I learnt on inquiry that labour pains had set in four days
previously,
that
they
were
vigorous
and
frequent
at the
com-
mencement, but that subsequently they became weak, and the intervals between each prolonged. The membranes had ruptured at 3 a.m. of the day on which I was called in. The woman complained of urgent thirst; the tongue was rough and dry; pulse 126, small and frequent ; the bowels were said to be no action of the bladder for three days. examination, the abdomen was found hot ; the uterus large and firmly contracted on the body of the foetus; the external parts were a good deal swollen, and the passages hot and tender. All uterine action had ceased, and there was no indication of foetal life. The head was found presenting, but firmly impacted in the hollow of the sacrum. There was much rigidity of the perinseum. Having made an unsuccessful attempt to relieve the bladder, I proceeded to extract the child by craniotomy. The foetus was The placenta was found adherent, and a male, and of large size. its separation was followed by flooding to some extent. With the exception that the lochia were unusually scanty, no untoward symptom presented itself until the sixth day, when it free purulent discharge from the was found that there was a next day tetanic symptoms appeared and rapidvagina. On ly increased in severity?the opisthotonic form of convulsion being frequent and severe. For two days the convulsions continued, and the woman expired exhausted on the tenth day.
free, but there had been On
The intellect remained clear to the last. She was treated by chloral hydrate in conjunction with morphia, turpenture and nutrient eneinata, and embrocations of aconite, &c.
Observations.?Though puerperal tetanus is so rare an affecEurope that no mention of it is made in any of our works on midwifery, yet it is unfortunately sufficiently common in India to come under the observation of most practitioners, and to add to the causes of mortality to which puerperal women are here so liable. It has been pointed out tiiat the darkskinned races are peculiarly prone to the complication; and tion in
November 1,
A MIRROR OF HOSPITAL PRACTICE.
1877.]
proclivity is, no doubt, in Southern India at least due, in not altogether, to the strange and injurious treatment
this
part if
which women in labour receive at the hands of their friends and attendants. In the first place the confinement usually takes place on the floor, between which and the poor woman's body nothing intervenes but a thin mat, on which, saturated as it must bccome, she must be undisturbed perhaps for days, and with nothing for a covering but a light cotton cloth. The room dark and damp, and as if these conor hut is ill-ventilated,
enough in themselves to light up tetanus or disease, the unfortunate woman is literally starved for the first three days after delivery. It is not difficult, under these circumstances, to find a cause for the tetanic symptoms when they do occur. In that peculiar state of exhaustion, induced by the shock of labour, the parturient woman must be considered especially liable to disease, but when in this condition she is deprived of food, pure air and light, and exposed moreover to damp and cold, we need not wonder that tetanus should ditions other
were
severe
not
form of
result. I am certainly disposed to believe that the case I have recorded had its origin in this manner, and I have no doubt that my medical brethren, who practise amongst the Natives? the poorer classes especially,?will bear me out in my assertion that tetanus springs from the causes mentioned. Most of us continually witness cases in which the patients are, as it were, on the very verge of tetanus, and in which, if I may be allowed tetanoid symptoms present use the expression in this sense, themselves. The patients complain of pain and stiffness in the back of the neck and jaw, and sometimes of spasm of the muscles of these regions. Often there are general bodily pains to
with
feelings
receives from or or
convulsion,
and I have
is tetanus in
expression a
of weariness and exhaustion. This condition the natives the name Junnee, equivalent to spasm a
no
doubt that it is allied to tetanus, or undeveloped form. I take the
modified
tetanoid from Dr. Barnes, who however applies it to He says, " the tetanic state consists in
different condition.
exhalted irritability of the spinal cord, a condition which may be regarded as a morbid exaggeration of the normally increased irritability of pregnancy. I have often seen in labour evidence of stich extreme reflex and emotional irritability that I have expressed it to myself as tetanoid.'"
intensely
That the causes mentioned predispose the patient to tetanus if they do not directly induce the disease is, I think, also borne out by the fact that comparatively few females, who are delivered in I have our public hospitals, become the subjects of tetanus. examined the Eeports of the Madras Lying-in Hospital for five in my possession years and a half, as published in a few volumes Madras Quarterly Journal of Medical Science," of the late and I find that not a single case of tetanus occurred in 5,794 deliveries which took place during the period referred to?a fact which may perhaps be accounted for by the totally different circumstances attending an accouchement in a public institution "
and one in a poor woman's own home. If the symptoms, which have been referred to as tetanoid, be really allied to tetanus, and, in fact, only the manifestations of a minor or milder form of the affection itself, it is difficult to explain why the disease should at
times be thus arrested, as it were, in its course instead of
becoming fully developed. It occurs to me that a solution of the difficulty might be found in the suggestion as to the true nature His view of tetanus lately thrown out by Dr. Sydney Ringer. is. that so far from tetanus being due to excitement or stimulation of the spinal cord, it has its origin in diminished or destroyed resistive power in the reflex portion of the cord which permits of nervous force being set free from every part of it, and in the same way that besides tetanus, other explosive neuroses like migraine, epilepsy, neuralgia, asthma, &c., are best explained by the supposition that a loss of resistance occurs in certain portions of the central nervous system, whereby impressions conducting to these parts spread beyond their normal "
291
the various symptoms of these diseases." May of the tetanoid symptoms be explained on the supposition that in these cases in which they appear, the diminution of the resistive power takes place in a very slight degree only, and is confined to a limited area ? area
not
and
the
produce
occurrence
