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The Lay Use of Potassium Permanganate as an Abortifacient*
THE LAY USE OF POTASSIUM PERMANGANATE AS AN ABORTIFACIENT* F. D.
WANAMAKER,
M.D.,
F.A.C.S., SAIKT JoHN,
NEw
BRUNSWICK
(From the Department of Obstetrics and Gynecology, Saint John General Hospital)
RECENT years attention has been focused in various parts of North I NAmerica on the increasing use of potassium permanganate by the public
in an attempt, usually :futile, to produce abortion. It is apparent from a study of the literature that this practice has been relatively common in Europe and in South America for a considerable period of time, in spite of the fact that the first North American article on the subject appeared in 1941. In that year ShulF presented 17 cases in which potassium permanganate was used as an abortifacient, and dated the first ease at the Boston City Hospital in March, 1936. McDonough, 2 in 1945, extended the Boston City Hospital series to 6~) cases, and reported that 6 had been successful in producing abortion. He pointed out that in most cases vaginal bleeding took place within two hours of inserting the tablet in the vagina, and in one case which continued to term delivery by section was necessary because of the severe scarring of the cervix from the previously attempted abortion. Jetter and Hunter, 3 in 1949, reported the first fatality from the use of a douche containing a saturated solution of potassium permanganate in which about 7 Gm. of the chemical were dissolved. Carney, in 1953, reviewed the literature and added 20 cases without a fatality or a successful abortion. Our attention was first directed to this problem by a fatality on our service in November, 1947. Between 1947 and 1953 we have been able to find 10 cases in our hospital, 8 on our own service and 2 from private sources, in which potassium permanganate tablets, either singly or several, had been inserted by the patient in order to produce abortion. In this series there were 2 deaths, 3 abortions, 2 patients continued to term, and 2 were shown not to have been pregnant. In one case the follow-up was lacking and it is not known whether or not the pregnancy continued. The tablets were of 5 grain strength, easily procurable at the drugstore without prescription. The question of sale of this drug owr the counter was brought to the attention of the Saint John Medical Society several years ago, and at that time a resolution was passed asking the druggists of the city to refrain from selling potassium permanganate tablets to the public without a prescription.
Summary of Case Reports CASE 1.--No. 7480/47. Mrs. M. H., a 25-year-old gravida vi, para ii, was admitted to our service with a history of low back pains for seven days, and vaginal bleeding for four days. She was five months pregnant, but denied interference. The obstetrical history *Presented at the Tenth Annual Meeting- of the Society of Obstetricians and Gynaecologists of Canada, Harrison Hot Spring-s, B. C., June 11 to 13, 1954.
259
260
\VAN A1v!AKF.m
\ill
f
included three abortions, one stillbirth at eight months, allil OUt) full-terru living dild •~<' livered in 1947. The present pregnancy had been uneventful until seven day~ 1"''"' (ou,l.•. On admission the patient was in good dP~pite emPrg<'ttey l!JP:t'u n·,;. 'l'he total urinary output during her stay in ho~pital wa,s :2 otlllet•s, obtainr•d :storeLl and her gPneral condition was then considered to be satisfactory. 'l'he terminal episode of sluwk was the resuit ot fnrthn blood loss to the point of exsanguination. CASE 2.-No. 13423/.J-8. ::\frs. R. M., a :.!5-year-old white woman, was admitted to th<' hospital with a history of vaginal bleeding for an undetPrmined period of time. '!'he gpneral physical eonditiou of the patient was gooH and topical ami :;y;;temic penieillin t hnapy. (~uestioning elicited the information that potassium permanganat.e had l>Pen inserte
Mrs .. r. G., a 27-year-old white woman, was admitted to the CASE 3.-No. 32511/50. hospital with a history of bleeding per Ya!{inam for four hours. 'l'he products of ermeeption were believe(] to have been passe
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POTASSIUM PERMANGANATE AS ABORTIFACIENT
261
each about 2 em. in diameter. These ulcers had a punched-out appearance and their bases were very red. In the base of one ulcer, on the postero-lateral vaginal wall, about five em. from the cervix, there was a medium sized artery with a large section of its wall missing. Fluid blood flowed freely from this Yessel. '' 'l'he uterus ''contained a perfectly formed fe· male fetus of about six months' gestation.'' All other systems were negative. The pathological findings are in keeping with the history of profuse bleeding and severe shock as the result of erosion of an artery in the genital tract. It is apparent in retrospect that the initial shock should have been treated with more than 500 c.c. of blood, and that the patient should have been watched more closely for hemorrhage. CASE 5.-No. 39765/51. ::\Iiss .M. R., a 27-year-old white woman, was admitted to the hot
WANA~fAKER
262
Arn. ]. Ob"t.. & Gynec. Fchnury, {')<::')
fascia approximated with sutures. The patient stated she had inserted potas~ium perrnanganate tablets in the vagina after going two weeks past her period. 'rhe first tahlpt was inserted at that time, and when no result was obtained a second tablet was inserted a week later. The following day she began to bleed and was admitted. She was di>'charged on the ninth day. We have no evidence that she was pregnant. Since this patient inserted two tablets a week apart before producing any hleeding it is Inore than likely that the first tablet did not remain in the Yag·ina very long. CASE 9.-No. 15449/53. A 2,6-year-olu graviua v, para iv, was admitted to the hospital five months pregnant, with a history of irregular vaginal bleeding. She admitteu inserting potassium permanganate tablets some three months previously, and had ble
Comment Jetter and Hunter, in an exhaustive study on the effects of potassium permanganate both locally and systemically, point out that the actiDn of the substance on the vaginal mucosa can he explained by the following formula: 4 KMnO,
+ 2 H,O 2 Mn,O,
~ ~
4 KOH 4 MnO,
+ +
:2 Mn,O, 3 0,
Potassium permanganate is a strong oxidizing agent, reacting promptly with the protoplasm to produce necrosis, and at the same time undergoing reduction to the brown, almost completely insoluble, oxides of manganese. This brown staining of the tissues is pathognomonic of the potassium permanganate reaction. The prompt interreaction of the chemical and the tissue results in the superficial necrosis nDted initially, with the later effe-ct due to the caustic potassium hydroxide penetrating into the deeper tissues. There is evidence also that potassium permanganate acts as a sy~ten1.ic poison. When ingested in doses of 10 to 20 Gm., which is considered lethal, it acts as an acute hemolytic agent, and has been shown to cause lower nephron nephrosis. It has also been suggested that late collapse and death may be due to hyperpotassemia. The manganese dioxide, though almost insoluble, will cause convulsions and coma in animals. In the case quoted by ,Jetter and Hunter in which the patient died after using a saturated solution of the chemical as a vaginal douche, autopsy revealed typical mahogany brown staining of the uterine musculature, and to a lesser extent of the other organs as well. The renal tubules contained brown casts. We may say, therefore, that death from potassium permanganate may be due to one or more of three causes: (l) circulatory collapse due to the local
Volume 69 ~umber 2
POTASSIUM PERMANGANATE AS ABORTIFACIENT
263
injury and resultant blood loss; (2) intravascular hemolysis; (3) hyperpotassemia, which is considered more likely to be caused by liberation of intracellular potassium by the hemolytic action of the chemical than by the absorption of potassium from the chemical itself. It is obvious that the damage by potassium permanganate will depend on the amount of the chemical used, the concentration, the length of tin1e that it is permitted to act, and the site of injury. ·when used locally the initial necrotizing effect is usually attended by severe pain, and the patient as a rule seeks medical aid quickly. By the same token the diagnosis can easily be missed, as the patient presents herself with vaginal bleeding, abdominal pain, and a history of having missed one or more periods. lf shock is present, one is even rnore likely to treat the case as an incomplete abortion, although in so doing the lesion in the vaginal traet will usually be found and the true nature of the condition will then appear. Questioning revealed that in 3 of the nonfatal cases the tablets were placed in absorbent cotton and inserted into the vagina. By this method the interaction of the vaginal secretions and the chemical was delayed by the absorbent cotton, and the concentration of potassium permanganate in eontact with the mucosa was much decreased from what would be expected had the pills been placed in direct contact with the mucosa. In each case the patient stated that the onset of severe pain necessitated the removal of the absorbent cotton plug. We have no information on the method of insertion in the 2 fatal cases, nor in the other 5 cases in which the patient recovered.
Diagnosis Careful attention to the history in these cases will reveal that the pain, unlike the intermittent crampy pains of abortion, is steady in character, and is located immediately over the suprapubic area. In addition to this, the bleeding is usually more severe than would he expected of an abortion in the early stage in which most of these patients are seen; and the amount of shock is sometimes disproportionate to the amount of blood loss, although it is recognized that this latter is difficult of assessment. Digital examination will occasionally indicate the presence of deep ulcers. The finding of dark granules of manganese dioxide or the presence of bits of the tablet are pathognomonic. Careful speculum examination v1ill alv::a) S make the diagnosis clear, provided that care is taken to visualize all parts of the vaginal vault. The burns are generally found on the posterior fornix, the posterior surface of the cervix, and the posterior wall of the vagina. 7
Treatment There is little to he said in this regard. The superficial ulcers may require no treatment, or at the most firm packing for forty-eight hours. It is felt advisable to use low pressure douches to remove the excess chemical from the vagina in an effort to negate the later penetration of the tissues by potassium hydroxide. The deep ulcers will require suturing; otherwise, firm paeking of the vagina for forty-eight to ninety-six hours is indicated. We have
264
\VAN ;\~L\KEH
\II
J
~\ : "11\ J
! ._,, -~
used systemic penicillin to reduce the possibility of secondary inf<·etion of th(• ulcers. As previously mentionetd with uncomplient<'
Summary 1. Ten cases of chemical hurns to the vagina from the use of potassium permanganate as an abortifacient have heen presented. 2. Four patients were successful in pro
References 1. 2. 3. 4. 5. 6.
Shull, J. C.: AM. J. OBST. & GYNEC. 41: 161, 1941. McDonough, J. F.: New England .T. Med. 232: 189, 1945. Jetter, W. W., and Hunter, F. T.: New England J. Med. 240: 794, 1949. Duekman, S., and Tortora, .T. M.: New York J·. Med. 51: 2260, 1951. Lubin, S., and Waltman, R.: Am. J. Surg. 82: 227, 1951. Carney, B. H.: AM. J. 0BST. & GYNEC. 65: 127, 1953.
WANAMAKER,
M.D.,
F.A.C.S., SAIKT JoHN,
NEw
BRUNSWICK
(From the Department of Obstetrics and Gynecology, Saint John General Hospital)
RECENT years attention has been focused in various parts of North I NAmerica on the increasing use of potassium permanganate by the public
in an attempt, usually :futile, to produce abortion. It is apparent from a study of the literature that this practice has been relatively common in Europe and in South America for a considerable period of time, in spite of the fact that the first North American article on the subject appeared in 1941. In that year ShulF presented 17 cases in which potassium permanganate was used as an abortifacient, and dated the first ease at the Boston City Hospital in March, 1936. McDonough, 2 in 1945, extended the Boston City Hospital series to 6~) cases, and reported that 6 had been successful in producing abortion. He pointed out that in most cases vaginal bleeding took place within two hours of inserting the tablet in the vagina, and in one case which continued to term delivery by section was necessary because of the severe scarring of the cervix from the previously attempted abortion. Jetter and Hunter, 3 in 1949, reported the first fatality from the use of a douche containing a saturated solution of potassium permanganate in which about 7 Gm. of the chemical were dissolved. Carney, in 1953, reviewed the literature and added 20 cases without a fatality or a successful abortion. Our attention was first directed to this problem by a fatality on our service in November, 1947. Between 1947 and 1953 we have been able to find 10 cases in our hospital, 8 on our own service and 2 from private sources, in which potassium permanganate tablets, either singly or several, had been inserted by the patient in order to produce abortion. In this series there were 2 deaths, 3 abortions, 2 patients continued to term, and 2 were shown not to have been pregnant. In one case the follow-up was lacking and it is not known whether or not the pregnancy continued. The tablets were of 5 grain strength, easily procurable at the drugstore without prescription. The question of sale of this drug owr the counter was brought to the attention of the Saint John Medical Society several years ago, and at that time a resolution was passed asking the druggists of the city to refrain from selling potassium permanganate tablets to the public without a prescription.
Summary of Case Reports CASE 1.--No. 7480/47. Mrs. M. H., a 25-year-old gravida vi, para ii, was admitted to our service with a history of low back pains for seven days, and vaginal bleeding for four days. She was five months pregnant, but denied interference. The obstetrical history *Presented at the Tenth Annual Meeting- of the Society of Obstetricians and Gynaecologists of Canada, Harrison Hot Spring-s, B. C., June 11 to 13, 1954.
259
260
\VAN A1v!AKF.m
\ill
f
included three abortions, one stillbirth at eight months, allil OUt) full-terru living dild •~<' livered in 1947. The present pregnancy had been uneventful until seven day~ 1"''"' (ou,l.•. On admission the patient was in goo
Mrs .. r. G., a 27-year-old white woman, was admitted to the CASE 3.-No. 32511/50. hospital with a history of bleeding per Ya!{inam for four hours. 'l'he products of ermeeption were believe(] to have been passe
Volume 6\l Number 2
POTASSIUM PERMANGANATE AS ABORTIFACIENT
261
each about 2 em. in diameter. These ulcers had a punched-out appearance and their bases were very red. In the base of one ulcer, on the postero-lateral vaginal wall, about five em. from the cervix, there was a medium sized artery with a large section of its wall missing. Fluid blood flowed freely from this Yessel. '' 'l'he uterus ''contained a perfectly formed fe· male fetus of about six months' gestation.'' All other systems were negative. The pathological findings are in keeping with the history of profuse bleeding and severe shock as the result of erosion of an artery in the genital tract. It is apparent in retrospect that the initial shock should have been treated with more than 500 c.c. of blood, and that the patient should have been watched more closely for hemorrhage. CASE 5.-No. 39765/51. ::\Iiss .M. R., a 27-year-old white woman, was admitted to the hot
WANA~fAKER
262
Arn. ]. Ob"t.. & Gynec. Fchnury, {')<::')
fascia approximated with sutures. The patient stated she had inserted potas~ium perrnanganate tablets in the vagina after going two weeks past her period. 'rhe first tahlpt was inserted at that time, and when no result was obtained a second tablet was inserted a week later. The following day she began to bleed and was admitted. She was di>'charged on the ninth day. We have no evidence that she was pregnant. Since this patient inserted two tablets a week apart before producing any hleeding it is Inore than likely that the first tablet did not remain in the Yag·ina very long. CASE 9.-No. 15449/53. A 2,6-year-olu graviua v, para iv, was admitted to the hospital five months pregnant, with a history of irregular vaginal bleeding. She admitteu inserting potassium permanganate tablets some three months previously, and had ble
Comment Jetter and Hunter, in an exhaustive study on the effects of potassium permanganate both locally and systemically, point out that the actiDn of the substance on the vaginal mucosa can he explained by the following formula: 4 KMnO,
+ 2 H,O 2 Mn,O,
~ ~
4 KOH 4 MnO,
+ +
:2 Mn,O, 3 0,
Potassium permanganate is a strong oxidizing agent, reacting promptly with the protoplasm to produce necrosis, and at the same time undergoing reduction to the brown, almost completely insoluble, oxides of manganese. This brown staining of the tissues is pathognomonic of the potassium permanganate reaction. The prompt interreaction of the chemical and the tissue results in the superficial necrosis nDted initially, with the later effe-ct due to the caustic potassium hydroxide penetrating into the deeper tissues. There is evidence also that potassium permanganate acts as a sy~ten1.ic poison. When ingested in doses of 10 to 20 Gm., which is considered lethal, it acts as an acute hemolytic agent, and has been shown to cause lower nephron nephrosis. It has also been suggested that late collapse and death may be due to hyperpotassemia. The manganese dioxide, though almost insoluble, will cause convulsions and coma in animals. In the case quoted by ,Jetter and Hunter in which the patient died after using a saturated solution of the chemical as a vaginal douche, autopsy revealed typical mahogany brown staining of the uterine musculature, and to a lesser extent of the other organs as well. The renal tubules contained brown casts. We may say, therefore, that death from potassium permanganate may be due to one or more of three causes: (l) circulatory collapse due to the local
Volume 69 ~umber 2
POTASSIUM PERMANGANATE AS ABORTIFACIENT
263
injury and resultant blood loss; (2) intravascular hemolysis; (3) hyperpotassemia, which is considered more likely to be caused by liberation of intracellular potassium by the hemolytic action of the chemical than by the absorption of potassium from the chemical itself. It is obvious that the damage by potassium permanganate will depend on the amount of the chemical used, the concentration, the length of tin1e that it is permitted to act, and the site of injury. ·when used locally the initial necrotizing effect is usually attended by severe pain, and the patient as a rule seeks medical aid quickly. By the same token the diagnosis can easily be missed, as the patient presents herself with vaginal bleeding, abdominal pain, and a history of having missed one or more periods. lf shock is present, one is even rnore likely to treat the case as an incomplete abortion, although in so doing the lesion in the vaginal traet will usually be found and the true nature of the condition will then appear. Questioning revealed that in 3 of the nonfatal cases the tablets were placed in absorbent cotton and inserted into the vagina. By this method the interaction of the vaginal secretions and the chemical was delayed by the absorbent cotton, and the concentration of potassium permanganate in eontact with the mucosa was much decreased from what would be expected had the pills been placed in direct contact with the mucosa. In each case the patient stated that the onset of severe pain necessitated the removal of the absorbent cotton plug. We have no information on the method of insertion in the 2 fatal cases, nor in the other 5 cases in which the patient recovered.
Diagnosis Careful attention to the history in these cases will reveal that the pain, unlike the intermittent crampy pains of abortion, is steady in character, and is located immediately over the suprapubic area. In addition to this, the bleeding is usually more severe than would he expected of an abortion in the early stage in which most of these patients are seen; and the amount of shock is sometimes disproportionate to the amount of blood loss, although it is recognized that this latter is difficult of assessment. Digital examination will occasionally indicate the presence of deep ulcers. The finding of dark granules of manganese dioxide or the presence of bits of the tablet are pathognomonic. Careful speculum examination v1ill alv::a) S make the diagnosis clear, provided that care is taken to visualize all parts of the vaginal vault. The burns are generally found on the posterior fornix, the posterior surface of the cervix, and the posterior wall of the vagina. 7
Treatment There is little to he said in this regard. The superficial ulcers may require no treatment, or at the most firm packing for forty-eight hours. It is felt advisable to use low pressure douches to remove the excess chemical from the vagina in an effort to negate the later penetration of the tissues by potassium hydroxide. The deep ulcers will require suturing; otherwise, firm paeking of the vagina for forty-eight to ninety-six hours is indicated. We have
264
\VAN ;\~L\KEH
\II
J
~\ : "11\ J
! ._,, -~
used systemic penicillin to reduce the possibility of secondary inf<·etion of th(• ulcers. As previously mentione
Summary 1. Ten cases of chemical hurns to the vagina from the use of potassium permanganate as an abortifacient have heen presented. 2. Four patients were successful in pro
References 1. 2. 3. 4. 5. 6.
Shull, J. C.: AM. J. OBST. & GYNEC. 41: 161, 1941. McDonough, J. F.: New England .T. Med. 232: 189, 1945. Jetter, W. W., and Hunter, F. T.: New England J. Med. 240: 794, 1949. Duekman, S., and Tortora, .T. M.: New York J·. Med. 51: 2260, 1951. Lubin, S., and Waltman, R.: Am. J. Surg. 82: 227, 1951. Carney, B. H.: AM. J. 0BST. & GYNEC. 65: 127, 1953.