POST-OPERATIVE TETANUS.-While the occurrence of tetanus as a post-operative complication is fortunately not common, nevertheless, the occasional cases that do occur are of great importance, not only on account of the intrinsic nature of the disease, but also because of the possibility of infection of others by the same technic. Peterson, of Ann Arbor, has recently published in the "Journal of the American Medical Association" a quite extensive article upon this trouble, parts of which may be abstracted with benefit.

"While tetanus cannot be said to be a very frequent post-operative complication, a study of the reported cases shows it does occasionally follow all kinds of gynecologic operations.

"It most frequently is a complication of operations involving the opening of the peritoneal cavity, although in quite a percentage of cases it complicates plastic and other non-peritoneal operations.

tion.

"The infection in all probability is introduced at the time of opera

"It has been proved that the tetanus bacillus and its spores are most difficult to kill, and that under certain circumstances they survive boiling for sixty minutes; hence when this organism is present, more than ordinary heat, applied over a longer time, is necessary.

"Absorbable ligatures, like catgut, may be carriers of the infection unless the most approved methods of sterilization be employed.

"The process of manufacture of the catgut renders it peculiarly liable to infection by the tetanus bacillus, which may not be destroyed by the ordinary methods of chemical sterilization.

"The initial symptoms of post-operative tetanus appear within ten days in from two-thirds to four-fifths of the cases. The onset of symptoms in the remaining cases varies from the eleventh to the twentysecond day after the operation.

"In the 150 cases tabulated no case showed symptoms of tetanus the first two days after the operations.

"From a study of these cases it would seem that the average period of incubation for post-operative tetanus was about eight days.

"The shorter the incubation period the more virulent and active the disease, and, conversely, the longer the incubation the milder the disease or the longer is it possible for the patient to survive before a fatal issue.

"Whenever possible the point of entrance of tetanus bacilli should be ascertained and the proper disinfection and drainage be instituted. This is often difficult in cases of post-operative tetanus."

Soon after the discovery of antitoxin for diphtheria it was supposed that many other diseases might be similarly treated. With the exception of tetanus, however, this has proven to be a hope founded on but little substance. In the post-operative tetanus Peterson has obtained some results and has been able to somewhat decrease the mortality. He says: "Antitetanic serum acts on the free toxins in the blood, but has no effect on the toxins after they have become fixed in the nerve cells.

"A study of the tables shows that the mortality of tetanus has been reduced nearly 10 per cent. through the use of the antitetanic serum.

"The best effects of the serum will be seen when its administration is begun on the first appearance of the symptoms of the disease.

"Chloretone is able to control the muscular spasms of tetanus and to do away with the muscular rigidity. It is harmless and does not prevent elimination.

"In tetanus, elimination through free catharsis and the administration of salt solution is of the utmost importance."

The following is a report of the clinic held at the Emerson Hospital on June 4, 1910, as the closing exercises of Clinical Week of that year, conducted by Boston University School of Medicine. These cases proved so interesting to the operator and his assistants that it was suggested a report of them might be equally interesting, not only to those who were present and saw what was done, but also to others who are inclined to postgraduate work. This clinic was arranged with the definite idea of offering a group of typical cases of such character that they would not only prove interesting to those in active general practice but would show typical examples of certain classes of cases, the practical deductions from which would be so plain that they would carry their own teachings. In this we were more fortunate than we expected because of a mistaken diagnosis in the first case, as will be explained later.

The morning of the clinic the following list of cases was posted upon the bulletin board at the Medical School. As will be seen, a definite diagnosis was made in advance in each case, and the mistake in diagnosis in the first case only added to its value for teaching purposes:

The first patient was a woman, 30 years old, the mother of three children, the youngest being three years old. I saw her first on June 1, when she told me that two months previous (having gone two months over her regular period) she offere

Showing head and shaft of humerus of the sound arm. Note the definition of the epiphysis. This is exhibited for comparison with Plate II.

herself for an induced abortion, and the attempt to procure this was made. Since then, that is, for two months, she had been flowing almost all the time, passing a considerable number of clots. For the last few days she was some better, although prostrated and weak as the result of the flowing. There was no odor to the discharge. There was much indigestion with alternating constipation and diarrhoea. She was very tender through the whole lower abdomen, especially worse on the right side, pain extending into the right leg. There was a well-defined movable tumor in the left lower quadrant of the abdomen. She was exquisitely tender through the whole abdomen below the level of the umbilicus, and the pelvis was filled with a fluctuating tumor, which rose into the abdomen, above which and attached to it could be felt two somewhat movable growths, both of which fluctuated and both of which were very tender, the left one being roted above. She was so thin and emaciated that both of these growths could be seen by their irregularities upon an inspection of the abdomen, the one to the left being more prominent and

more easily palpated. In both of these growths fluctuation could be demonstrated, and this condition, with their mobility and the easily elicited fluctuation through the pelvis, led to the preoperative diagnosis of ovarian cysts. Even after examination. under ether, no reasons were found for questioning the diagnosis.

Showing shaft of left humerus fractured at the surgical neck. A B C emphasizes the broken end. D F and F G emphasize the outer and inner margins of the upper fragment. The latter is tilted outward, while the shaft is tilted inward so that the angle between the two fragments is well defined. The broken end of the shaft lies in front of the head of the bone and firm union had taken place in this position. The epiphysis is well shown, although the line of demarcation is obscured by the callus. The broken end of the shaft shows clearly, but the broken end of the upper fragment is ill-defined, nor could repeated attempts show it any clearer. The bones had become firmly united in this position and callus had filled in so completely that the apparent line of fracture of upper fragment was markedly oblique and on the outer side appeared to terminate at D and on the inner side at G. This was apparent only, due to the callus.

Upon opening the abdomen sufficiently to admit an examining finger, everything in the lower abdomen was found adherent, with the pelvis full. Above the masses of adhesion were the two before-mentioned tumor-like growths, the one on the right side being the ovary, much enlarged by a multiple cystic growth and comparatively free from the underlying adhesions which embraced the right tube. In an attempt to break up these adhesions a hematoma was opened, from which exuded a dark fluid with a quantity of shredded tissue, which was easily demonstrated as broken-down blood clots. This led to an immediate revision of diagnosis, and the operator then said the case would probably prove one of extra-uterine pregnancy. Investigation of the left side showed a very unusual and remarkable, and in some ways strikingly typical state of affairs. The superficial tumor, which had been seen and palpated through the abdominal wall, proved to be the right tube in which impregnation had occurred. and which had never ruptured. The implantation of the impregnated ovary had taken place so near the free end of the tube that when the tube had become distended almost to the limit of bursting, it had relieved itself by a hemorrhage from the open end of the tube. This had occurred rapidly, but with so little