Part 18 (1/2)

STEWART, J. E. F. _Australian Medical Gazette_, 1906, xxv. 446.

WALDO, R. W. _American Journal of Obstetrics_, 1906, liv. 553.

WILSON, H. P. C. _Trans. American Gynecological Society_, 1884, ix. 94.

=Teta.n.u.s.= This dread complication of wounds occasionally occurs after ovariotomy, and during the 'reign of the clamp' it was especially frequent in Germany (Olshausen). Cases have been reported in England, and teta.n.u.s has been noticed to affect patients who have been ovariotomized in rooms recently plastered.

Since Kitasato demonstrated the bacillary origin of teta.n.u.s poison, and showed that the bacillus can be transported by dust, knowing its liability to attack suppurating wounds, we can understand that when the pedicle of an ovarian cyst was secured by a clamp and allowed to slowly slough away, more or less exposed to air and dust, it offered a nidus for the teta.n.u.s bacillus.

Teta.n.u.s, however, has not quite disappeared as a sequel to operations on the pelvic organs, for in 1902 a case was reported by Dorsett in which a patient died of this disease after hysteropexy, and the teta.n.u.s bacillus was detected in some wallaby tendon employed to suspend the uterus.

Teta.n.u.s has also been traced to infected catgut employed in cholecystotomy (1905).

Ed. Martin reported the occurrence of teta.n.u.s after v.a.g.i.n.al fixation of the uterus and colporrhaphia anterior. c.u.mol-catgut was employed.

Menzer has recorded a similar case which occurred in Duhrssen's Klinik (1901). The ligatures were of catgut.

Mallet refers to two post-operative deaths from teta.n.u.s. One patient had undergone an operation for bilateral pyosalpinx and the other had a fibroid of the uterus complicated with an ovarian cyst. There was an interval of eighteen months between the two fatal cases. Catgut was employed as the ligature material.

In practice it is important to remember that teta.n.u.s arises from infection: hence all instruments which have been in contact with this disease must be sterilized, and this should be effected by submitting them to prolonged boiling.

Teta.n.u.s occurs as a rare sequel to miscarriage and normal labour. Kraus and von Rosthorn have reported some carefully investigated cases of this kind.

REFERENCES

DORSETT, W. B. Two fatal cases of Teta.n.u.s following Abdominal Section due to Infected Ligatures, &c. _Am. Journ. of Obstet._, 1902, xlvi.

620.

MALLET, G. H. Some Unusual Causes of Death following Abdominal Operations. Ibid., 1905, li. 515.

MARTIN, ED. Postoperativer Teta.n.u.s (with references). _Zent. f. Gyn._, 1906, x.x.x. 395.

MEINERT. Drei gynakologische Falle von Wundstarrkrampf. _Arch. fur Gyn._, 1893, xliv. 381.

MENZER. Teta.n.u.s Infection after v.a.g.i.n.al Fixation of the Uterus.

_Zeitsch. f. Geb. u. Gyn._, 1901, xliv. 517.

OLSHAUSEN, R. Teta.n.u.s nach Ovariotomie Billroth-Lucke's. _Handb. der Frauenkrankheiten_, 1877-9, ii. 367.

TAYLOR, H. Teta.n.u.s after Hysterectomy. _Am. Journ. of Obstet._, 1908, lvii. 574.

=Injury to intestines.= Intestines great and small are very liable to injury in the performance of intrapelvic operations. Unless care is taken in opening the abdomen, the intestines are apt to be cut, especially when there has been chronic peritonitis, as in tuberculous and gonococcal infections, which cause the small intestine to adhere to the parietal peritoneum investing the anterior abdominal wall. Where cliotomy is being performed a second or third time, through or near the original cicatrix, it is necessary to proceed with extreme caution for fear of cutting an adherent coil of gut.

Intestine is also liable to be torn in separating adhesions from the tumour, and great care is necessary when cysts are firmly adherent to the floor of the pelvis, for in separating them the r.e.c.t.u.m runs a great risk of being damaged.

In removing tumours to which the vermiform appendix adhered it is necessary to be careful and avoid mistaking it for an adhesion, for there is reason to believe that this structure has been divided and its nature overlooked; an accident of this sort leads usually to fatal peritonitis.

It has happened, in the course of removing very adherent ovaries and tubes from the floor of the pelvis, that in transfixing the pedicle a coil of ileum has also been transfixed with the needle and tied to the stump. This accident is not likely to happen now that the Trendelenburg position is almost universally employed.