HOLDER PHD BPHARM PHCEdin Historical The dictionary definition of catgut is a tough cord made from the intestines of animals es pecially sheep There may or may not follow an indication of its uses Mention catgut to surgeon and he th ID: 65873
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427THESTORYOFCATGUTByELDREDJ.HOLDER,PH.D.,B.PHARM.,PH.C.(Edin.)HistoricalThedictionarydefinitionofcatgutis'atoughcordmadefromtheintestinesofanimals,es-peciallysheep.'Theremayormaynotfollowanindicationofitsuses.Mentioncatguttoasurgeonandhethinksofasuturematerial;toamusician,herecallsthemellowtonesoftheviolinorcello;toasportsmanandhewondersifherememberedtoreplacethethepressonhistennisracquet.Catgut,toEvery-man,promptsspeculationastoitsfelineorigin.Thereis,however,infactnoevidencethattheintestineofthecathaseverbeenusedtoproducecatgutstrings.ThenamecanbetracedbacktotheArabiccither,anearlystringedinstrument.Thesamerootisseenintheoldnameforthedancingmaster'sfiddle,akit.Fromkitguttocatgutisaneasyetymologicalstep.Noaidtosurgeryhashadsuchachequeredcareerascatgut.Ithasbeeninandoutoffavour,swornbyandswornat,overaperiodofsome75years.Catgutforsuturinghasbeen'goingoutoffashion'sincethewriterfirsttookinterestinitsomeI7yearsago.Nevertheless,moreisbeingmanufacturedandusedtodaythaneverbefore.Whyshouldthisbeso?Theanswerliesinonespecialfeature-itsabsorbabilityinlivinganimaltissues.Althoughthisabsorbabilitywasnotrealizeduntilcomparativelyrecently,theuseofanimalintestineasa'string'datesbackasfarastherearerecordsofmankind.Indeed,itisreasonabletoassumethatitsutilitywouldhavebeenrecognizedlongbeforetherewasevolvedtheartoftwistingvegetablefibresorhairsintothread.TheuseofdriedintestineasasutureisundoubtedevensofarbackinhistoryasthePapyrusofEbers,circa3750B.C.Egyptiansurgeonsatthattimeappeartohaveacquiredconsiderableskillinwoundrepair.Susruta,aHinduwriterwholivedabout1500B.C.,referstotheuseofcotton,drawncopper,horsehairandanimalintestinesasligatures.Ferrara,anItalian,attheendofthei6thcenturyusedintestinesoftortoisesamongstothersuturematerials;heseemstohavehadsomeprecognitionoftheneedforsterilizingbecauseheissaidtohavestoredhissuturesinwinebeforeuse.InFrancetheimportanceofcatgutmakerswasrecognizedinI656byLouisXIV,whograntedletterspatenttotheGuildwhosememberssuppliedracquetmakers,clockmakers,musicians,cross-bowmakersandsurgeons.Ashortdigressionmaybepermissibletomakereferencetoanaturalmeansofwoundclosurewhichhasbeenknownforhundredsofyears,namelytheuseofthemandiblesofcertainspeciesofbitingants.Theedgesofawoundarebroughttogethermanually,theantisheldbyitsbodyandallowedtobiteacrossthewoundedges;themomentithasdonesothebodyistwistedawayfromtheheadwhich,withthejaws,isleftactinglikeamodernmetalclip.ThisprocedureisstillusedbytheaboriginalnativesofcentralAustraliaandtherearerecordsofitsuseuptorecenttimesinGreece,SerbiaandAlgeria.Toreturntocatgut,itwasini868,theyearbeforehecametoEdinburghUniversityasProfessorofClinicalSurgery,thatJosephListerexperimentallytiedcatgutroundtherightcarotidarteryofa1l.ThirtydayslatertheanimalwaskilledandListerexaminedtheligature.Atfirsthethoughtthatitwasunchanged,butcloserin-vestigationrevealedthefactthatthecatgutwasnolongerpresentbuthadbeenreplacedbyaringoflivingtissue.ThoughListerismainlyrememberedforhisintroductionofantisepsisintosurgery,hisrecognitionoftheabsorbabilityofcatguthasbeenoffundamentalimportanceinthesuccessfulmodernuseofthismaterial.Hequicklyrealizedalsotheriskofintroducinginfectionintowoundsbytheuseof'raw'catgut.TherearerecordsthatinI869hewasusinganaqueoussolutionofphenolasasterilizingagentforcatgut.Thiswouldbefairlyefficientasasterilizingagent(exceptforresistantspores)butwouldleavethesuturesinawaterloggedandweakenedcondition.Apparentlywiththeideaofovercomingthesedefects,Listerthenusedasolutionofphenolinoliveoil.Thiswouldun-doubtedlyobviatelossoftensilestrengthbutwouldbeevenlessefficientinsterilization,thoughthecatgutwouldbe'antiseptic'andfarlessdangerousthanuntreatedmaterial.Hefurtheranticipatedthemodernprocessfor'hardening'catgut,thatisfordelayingitsrateofabsorptioninthetissues,bychromicizingbytheuseofmixturesofphenolandchromicacidsolutioninC 428POSTGRADUATEMEDICALJOURNALSeptemberI949whichthecatgutwassteepedforvaryingperiods.Surgicalcatgutisnoteasytomake.Therawmaterial,sheep'sintestine,variesfromanimaltoanimalinquality,widthandtoughness;itvariesaccordingtoage,tofeedingandsoon,andcannotbebulkedinordertoobtainuniformity.Initsnaturalstateitisloadedwithbacteria,bothpathogenicandnon-pathogenic.Theproblemliesinitscompletesterilizationwithoutthedestructionofthenaturalpropertiesofthegut.ItismanufacturedinthiscountryonlyunderGovernmentlicence,andtheconditionsandin-spectionsrequiredleavenodoubtastothebacteriologicalsafetyofthefinalproduct.Itsrateofabsorptioninthehumanbodyishardtocontrol;thesamestranddividedintotwopiecesandimplantedinsimilarlocationsintwoin-dividualsmayhavedifferentabsorptionperiodsduetoidiosyncrasy,sensitivity,vitamindeficiencyorcachexia.Manyargumentshavebeenusedforandagainstnon-absorbablesuturematerials.Theyareoftenlessexpensiveandmoreeasilysterilizedthancat-gut,theycanbeofabsolutelystandardsizeandtensilestrength.Ifburied,however,theyremainpermanentlyinthetissuesandmayatanytimesubsequentlybecomeafocusforinfection.Twofurtherpointsregardingnon-absorbablesuturesareworthnoting.First,theharshnessofmonofilamentssuchassilk-wormgut.Harshness,thatis,tothepatient,forifthestitchesareonthesurfacethecutendstendtohardenandmaycatchinthedressings;ifsuchmaterialsareusedforburiedsuturesthereisagraveriskofthesharppointsofthecutendsdoingdamagetoadjacenttissues,particularlytobloodvessels.Theotherpointconcernsthesofterandgenerallypreferablebraidedmaterialssuchasbraidedsilk.Evenininterruptedsuturesofsuchmaterialsthereisthepossibilityofbacteriafindingrefugeintheirinter-stices,whilstincontinuoussuturesthemovementofserumalongthesuturematerialbycapillaryactionfavoursthespreadofanyincidentalin-fection.If,toeliminatethiswick-likeaction,thebraidedmaterialhasbeenrenderednon-capillary,thedisadvantagedisappearsandgivesprobablytheidealformofnon-absorbablesuture.Theidealsuturematerialisonewhichwillretainitsholdingpoweruntilhealingiscompleteandwillthendisappearwithaminimumofdis-turbancetothetissues.Untilasubstituteisfound,eithernaturalorsynthetic,whichhassuperiorphysicalqualitiesaswellasabsorbability,catgutislikelytoremainthemostpopularandvaluableofallsutureandligaturematerials.Foradetailedandcomprehensivehistoryofsutures,andespeciallyofcatgut,throughtheages,thereaderisconfidentlyreferredto'LeCatgut'byDr.A.Fandre(I944).ManufactureTherearetwomainstagesintheproductionofasterilesuture;firstthemanufactureofthestrand,thenitssterilizationandpreparationforuseatoperation.Acrosssectionofsheep'sintestinerevealsthreemainlayers;theoutermesentericcoatwherebytheintestineis'slung'withintheabdominalcavity;themiddle(sub-mucousandmuscular)layerwhichisthin,elasticandmuscular;andtheinner,absorptivemucouslayer.Inpreparationthegutissplitlongitudinallyintoribbonsandbycarefullycontrolledscrapingopera-tionstheoutermesentericandinnermucouscoatsareremoved.Thesub-mucous,muscularrib-bonsaretwisted,sometimessingly,moreoftenintwos,threesorfours,thenstretchedanddriedtoformanalmostsolidfilament.Thereafterthestringsmustbepolishedtogiveuniformityofdiameteralongthestrandandasmoothsurface,butnottoosmoothortheknotmayslipaftersuturingwiththeriskofadisastersuchasa'burstabdomen.'FinallythestrandsaresortedintogaugestoagreewiththesizestandardsintheBritishPharmaceuticalCodexandtheUnitedStatesPharmacopoeia.UntilI944Britishmanufacturerseachhadtheirowncatgutsizestandardswiththeresultthatonemaker'sNo.Imightbeequivalenttoanothermaker'sNo.3,andsoon.Duringtherecentwar,standardsforgaugeandtensilestrengthweredrawnupandincludedintheSixthSupplement,I944,totheBritishPharmaceuticalCodex,1934edition.TheB.P.C.sizestandardsarenearlyidenticalwiththoseoftheUnitedStatesPharma-copoeiawhich,inadditiontoreducingconfusionamongstBritishmakes,wasausefulcontributiontowardsinternationalco-operation.Deliberatehardeningtodelaytherateofabsorptioninthetissuesisreferredtolaterandisusuallydoneduringmanufactureoftherawcatgutstrings.SterilizationAphraseoftenusedbymakersandusersofsurgicalcatgutis'thecatgutproblem.'Thisex-expressionsummarizesthedifficultyofdevisingasterilizingprocesswhichisrigorousenoughtokillthemostresistantsporingorganismswithoutalsodamagingthetensilestrengthofthestrand.Whatisthebacteriologicalfloraofunsterilizedcatgut?Primarilyitisthatofthecontentsoftheintestineinthelivinganimal.Thenon-sporingorganisms,staphylococci,streptococci,B.coli,etc.,maybedisregarded.Whatevertheirpathological SeptemberI949HOLDER:TheStoryofCatgut429;It:·::·;·'''':'':·riidi..a.lil.aP8l.dg.::liBi?'·::;i·:i·ri·Li."....i....t1a···i·d:'InvivodigestiontestChromiccatgutstitchesindorso-lumbarmuscleofrabbittendaysafterimplanting.Notefreedomfromlocalreaction..IS...L;l.·"#1InvivodigestiontestThick,plaincatgutstitchessevendaysafteroperationshowingaccumula-tionofdetritus. 430POSTGRADUATEMEDICALJOURNAI.SeptembetI949I-..ik'IAnd-,6eIge.J.NManufactureofcatgutstringsSplittingthesheepintestineintoribbons.:.:BacteriolokicaltestineofcatoutTheillustrationshowsamuscle-brothmediumwithparaffinsealforaerobic/anaerobictest.I'·*t"'1:.:;f"i,.i1··,:iiM¥1anufactureofcatgutstringsMachineforcleaningintestinalribbons. SeptemberI949HOLDER:TheStoryofCatgut431significanceinhumanailments,theyarecom-parativelyeasytokillincatgut.Eveniftheysur-vivedotherprocessesofmanufacture,thealcoholicfluidnormallypresentinthesealedtubecontain-ingthefinishedsuturewouldkillallbutsporingorganisms.Sporesarenormallynotkilledbyalcohol(Williams,I936)whichtothemismerelyanotherkindofanhydrousstate,anditispreciselyforsuchaconditionthatthedormantsporestageisdesigned.Thispointmaystillnotbefullyappreciatedasisapparentfromthecontinuedpopularityofrinsingwithalcoholoretherasameansof'sterilizing'hypodermicsyringes.Theoretically,ifthefaecalandpre-faecalcon-tentsoftheintestinecouldbeentirelyremovedatthemomentofdeath,thegutshouldbesterile.Inpracticalslaughterhouseconditionsthisisim-possibleasisshownbyculturesobtainedfromrawcatgutstrings.Bothanaerobicandaerobicsporesmaybepresent,themostspectacularandalarmingbeingClostridiumtetani.Thepresenceoftetanusbacilliinbowelcon-tentshasbeendemonstratedoftenenough.Yetthousandsofsamplesofrawcatgutstringscanbetestedwithoutfindingit.Moreover,inmanyyearsofexperiencethewriterhasyettofindacaseoftetanusinwhichimperfectlysterilizedcatgutcouldreasonablybeblamedasthesourceoftheinfection.Nevertheless,thewisemanufacturertreatseverystrandasthoughitwereloadedwiththemostresistantsporesknown.OtherpathogenicanaerobessuchasCl.welchii,CI.sporogenesandC1.oedematismaligniarecom-monlypresentinunsterilizedcatgut.Thesporingaerobes,whicharemostlynon-pathogenic,includeinadditiontovarietiesofB.subtilis,B.mesentericusruberwhichissometimescalledthe'catgutbacillus,'beingverycommonandgiving,inbrothculture,adistinctiveoff-whitepelliclewitharedlinerunningthroughit.Fromexperimentalworkithasbeenfoundthataerobicsporesaremoreresistantthanthoseofanaerobes.Incontrolbacteriologicaltestsonsterilecatgutitis,however,necessarytotestbothaerobicallyandanaerobically.FromtheendofthelastcenturywhenLister,whofirstdemonstratedtheabsorbabilityofcatgut,sterilizedhissuturesbyimmersioninastrongphenolsolution,untilcatgutofferedforsaleassterilecamewithinthepurviewoftheTherapeuticSubstancesAct,manymethodsof'sterilization'usedwereasunreliableastheywerenumerous.Theyincludedtheuseofphenol,mercurycom-pounds,essentialoils,peroxideofhydrogen,iodine,silversalts,formaldehydeandheatinginoiloralcohol(Holder,I939).Themainfaultsincludedfailuretokillspores(phenol,mercurycompounds,essentialoils);causticity(phenol);inhibition,givinganapparentbutfalsesterility(mercurycompounds);damagetothecatgut(silversalts;iodine:acidityandwater-logging;hotoiloralcohol:'cooking'ofthegut);unintentionalincreaseinresistancetoabsorption(iodineandformaldehyde).UndertheTherapeuticSubstancesAct,I93I,andsubsequentregulations,manufacturersoffer-ingsterilesurgicalcatgutforsalemustbelicensedbytheMinistryofHealthorbytheDepartmentofHealthforScotland.Bythetermsofthelicence,theauthoritiesmustapprovethepremisesinwhichsterilizationisperformed,thequalificationsofthetechnicalpersonnelandtheprocessesused,whilstsamplesfromeverybatchsterilizedmustbesubmittedtoapprovedbacteriologicaltestbeforetheremaindermaybesold.Afundamentaldifficultyinsterilizingcatgutisthatthecontaminatingsporesarenotallonthesurfaceofthestrand.Itwillberememberedthatinmanufacturingrawcatgutstrings,ribbonsofgutaretwistedtoformthestrand.Sporespresentonthesurfaceoftheribbonsaretherebysealedintotheinteriorofthestring.Thesterilizingagent,whetherchemicalorheat,mustthereforereachanddestroytheresistantsporeenvelopeswithoutdamagingthesensitivecollagenofthecatgutthroughwhichitmustfirstpass.Chemicalsterilizationispracticableundercare-fullycontrolledconditions,iodinesterilizationhavingbeenemployedformanyyearstogivesterilecatgutofexcellenttensilestrengthandpliability.Aseriousobjectiontothismethodisthatitisuneconomical,takingmanyweeksfromstarttofinishandrequiringmuchspaceandcon-stantsupervisiontoobtainoptimumresults.Anotherobjectionisthatalthoughnouncombinediodineneedbeleftinthecatgut,achangetakesplaceinitschemicalconstitutionwhichgreatlyprolongstheperiodrequiredforabsorptionbythetissues(Holder,I946).Althoughthiswaslessseriousthanhavingthesuturesabsorbedtooquickly,itwasnotuncommontofindfragmentsofcatgutstitchesexpelledtothesurfaceofawoundweeksafterhealinghadtakenplace.Heatsterilizationhasnowlargelyreplacedthechemicalmethod.Ithasthegreatadvantageofbeingaquickprocesswhichhaslittleeffectupontheabsorptionrateoftheproductandithasbeenimprovedtoastagewhichgivessterilecatgutofexcellenttensilestrengthandpliability.Normallyholding15to20percent.ofmoisture,thecatgutmustbedriedbeforeahightemperatureisappliedotherwisethewaterpresentinitwouldcause'cooking'orpartialhydrolysiswithalmostcompletelossoftensilestrength.Thesterilizingtemperatureiscritical,lessthan1500C.beingin-Dl 432POSTGRADUATEMEDICALJOURNALSeptember1949sufficientforconsistentsterilityandmorethanI55°C.tendingtocausebrittleness.Theheatmustbeappliedevenlythroughoutthestrandandforthisreasonhotair,whichhasalowheatcon-ductivityfactor,cannotbeusedforsterilizing.Thecustomaryprocedureisforthecatguttobecoiled,placedintubesopenatoneend,driedinovensatamoderatetemperatureandthenim-mersedforsterilizationinaheatedinertanhydrousfluidwhereintherequiredtemperatureandtimeofexposurecanbecloselycontrolled.Thetubesofcatgutareusuallyprocessedinsuitablebasketcontainersfromwhichtheoilcanbedrainedaftersterilizationand,maintainingstrictlyasepticconditions,asterilizedalcoholicre-conditioningfluid,containingapredeterminedproportionofwater,isintroducedandtheopenendofeachtubeisatoncehermeticallysealed.Samplesaretakenfromeachbatch.ofsealedtubes,someforbacteriologicalandsomeforphysicaltests,whichmustbepassedbeforetheremainderofthebatchisreleasedforsale.'Multiple'"packingsforsterilesutures,fromwhichsuccessiveportionsmaybewithdrawnforuseondifferentoccasions,arebeingdiscardedonsafetygrounds.Withthesealedglasstubepack-ing,anyportionofthesuturematerialnotrequiredontheoccasionforwhichthetubewasopenedshouldbethrownaway,notkeptforuselaterwiththeconsequentriskofcontamination.Inordertocleantheoutsidesofthesealedtubesbeforeopeninginthetheatre,theymaybewashedinsoapywaterandstoredinjarsofantisepticsolution.Tubeswhichcanbeboiledorplacedininthesterilizerwiththeinstrumentsbeforeoperationareobtainable,butmostmakersdonotrecommendthis'boilable'pack.Inordertoavoiddamagetothecatgutduringboilingorsteamsterilizingthestoragefluidinthetubesmustbecompletelyanhydrous;catguttakenfromsuchtubesisthereforebrittleandwiryanditscorrectreconditioninginweakalcoholorphysiologicalsalineisadifficultproceduretocontrolintheoperatingtheatre.AbsorptionTherateofabsorptionofcatgutinthebodyisusuallydeterminedinnormalmusclesuchastherectusabdominis.Catgutwhichhasnotbeenspeciallytreatedtoprolongitsresistancetodigestionlastsfrom7to15daysinnormalmuscle;suchcatgutisknownas'plain.'Inpracticethe,processofmanufactureofrawcatgutstringstendstohardenthemalittleandmostcommercial'plain'catgutlastsfrom14to2zdaysinnormalmuscle.Whenusedtosuturethebowel,catgutusuallylastsonlyone-thirdtoone-quarterofitsdurationinmuscle.Samplesofhardenedcatgut,insertedthroughthegastricwallinrabbitsandbeingincontactwiththestomachcontents,wereabsorbedinlessthanfourdays(Holder,'946).Althoughwoundsofthestomachwallhealwithgreatrapidity,theseexperimentssuggestthatanabsorbablesuturemaybecontra-indicatedwherethestitchescomeintocontactwiththegastricjuice.Itiscustomaryformuchofthecatgutusedinsuturingtobehardenedtoprolongitsabsorptionperiod.Thisiscommonlyachievedbytheactionofchromesalts,preferablyintheribbonstageofmanufacture.Catgutcontainingtheequivalentofapproximatelyone-halfpercent.Cr2O,lastsfor20to30daysinnormalmuscleandforfivetotendaysinintestinaltissue.MoreresistantcatgutmaybeobtainedcontaininguptoIpercent.Cr203.Manufacturersusuallycontroltheabsorptionrateoftheircatgutbyroutineinvitrotests.Thesemaytaketheformofhydrolysistime-checksinhotaqueoussolutionsorofenzymedigestion-periodsofcatgutstrandsundertension,usingpepsinorbetteranalkaline-actingenzymesuchaspapainortrypsin.Theidealcontrolistheimplantingofcatgutintolivinganimaltissue(Holder,1946).Thismaybeperformedbyclosinganincisioninthedorso-lumbarmuscleofrabbitswithin-terruptedstitchesandobserving,atre-operationatalaterdate,thebreakingstrainofthestitcheswiththeaidofanaccuratespringbalance.Thelossofstrengthofcatgutstitchesbydigestion,whenplottedagainsttime,givesastraight-linegraphsothatthedateafterwhicheffectiveholdingpower(whichmayberegardedas450gm.orIlb.)wouldbelostcanbecalculated.Generallyspeaking,itissafertohavecatgutresistabsorptionfortoolongratherthanfortooshortatime.Itisoftenrecommendedthatonlyplaincatgutshouldbeusedinsubcutaneousorfattytissue.This,however,leadstoanotherinterestingpoint,namelythereactionofthetissuestotheintro-ductionofcatgutstitches.Thesignificantfactorsare:-themoretruly'plain'thecatgutandthethickerthestrand,thegreateristhelocalreaction(Jenkins,I942).Thefirstreactioninthetissuesafterimplantingcatgutisaconcentrationofpolymorphonuclearleucocytes.Ifthecatgutisquiteunhardened,digestionproceedsatsuchapacethatthereissoonamarkedcollectionofdetritus,formedlargelyofdisintegratedleucocytes.Ifthecatgutismoreresistantthantheplainvariety,littleornodetritusisobservableanddigestionproceedsmainlybytheingrowthofgiant-cells.Suchreactionastakesplaceisgreaterwithathicksuturethanwithafineone,particularlywithplaincatgut. September1949LEQUESNE:Hind-QuarterAmputation433Atendencytousethickcatgutatoperationisduetoanunfoundedfearthatfinestitchesmaybeinsufficientlystrongtoholdthewoundedgesinapposition,Greatforceisnotnormallynecessarytokeepawoundclosedandevenifconsiderablestrainisexpected,asinretchingorcoughingafterlaparotomy,itismorelikelythatthesutureswouldcutoutofthetissuesthanthatthestitchesthem-selveswouldbreak.,Theshearingstrainoftissues,whichisanalogoustotheirresistancetothecuttingoutofstitches,isnotsohighasappearstobegenerallybelieved,varyingfromlessthanIlb.insofttissue,asforinstancebowel,tonomorethan24lb.inrectusmusclesheath.TheminimumstandardbreakingstrainforNo.2/0catgut,evenwhenknotted,is3lb.Thisbearsouttheex-perimentsofvariousworkerswhoadvocatetheuseoffihercatgutsuturesthanthosecommonlyused,withNo.oforfasciaasthethickestrecommended,downtoNo.3/0orNo.4/0formuscle,peritoneumandsubcutaneoustissue(Howes,I929,I941).Suspectedinfectioninawoundneednotbeareasonforusingthickcatgut;besidestheadditionof'thickcatgutreaction'tothebacterialdis-turbance,itisbynomeanscertainthatamoderateinfectionspeedsuptheabsorptionofcatgutex-cessively.Inasummaryofalargenumberofabdominalwounddisruptions,itwasfoundthatthecasesinwhichinfectionwaspresentdisruptedconsiderablylaterthanthecleancases.Furthermore,withtheconsiderableimprove-mentsinthemanufactureofsurgicalcatgutoverrecentyearsresultingingreatertensilestrength,thereisnojustificationonthisscoreforusingthethickersizes.ConclusionTosummarizethepointscoveredinthisgeneralsurveyofcatgutasasuturematerial:I.Thefundamentaladvantageofcatgutisitsabsorbability.2.Ithasexcellenttensilestrength.3.Sterility,astakenfromthesealedtubes,isassured.4.Ahardenedor'chromed,'catgutispre-ferabletothe'plain'variety.5.Thefinestpossiblesizesshouldbeusedinpreferencetothickersizes.Inconclusion,thefollowingquotationfromMikuliczisofferedwithrespectandsincerity:-'Jereconnaislebonchirurgien,nonpasalafafondontilcoupe,maisalafaFondontilsaitrecoudre.'BIBLIOGRAPHYFANDRE,A.(i944),'LeCatgut,'MassonetCie,Paris.WILLIAMS,F.E.(1936),'AlcoholandSporingOrganisms,'Med.Jour.Australia.HOLDER,E.J.(I939),'SurgicalSuturesandLigatures,'E.&S.Livingstone,Edinburgh.HOLDER,E.J.(1946),'DesirableFactorsinSurgicalSutures,'Wm.Blackwood&Sons,Ltd.,Edinburgh.JENKINS,H.P.,etal.(1942),Arch.Surg.,44,88I,984.JENKINS,H.P.,etal.(1942),Ibid.,45,74.JENKINS,H.P.,etal.(1942),Ibid.,45,323.HOWES,E.L.,andHARVEY,S.C.(I929),NewEng.J.Med.,200,I285.HOWES,E.L.(4x),Surg.Gyn.andObst.,73,319.HIND-QUARTERAMPUTATIONByL.P.LEQUESNE,M.A.,F.R.C.S.SecondAssistant,SurgicalProfessorialUnit,MiddlesexHospitalHind-quarteramputationwasfirstperformedini891byBillroth(1902),butitwasnotuntili895thatasuccessfulresultwasobtainedbyGirard(I895).Sincethattimetheoperationhasbeenperformedbymanysurgeonswithincreasingsuccess.PackandEhrlich(1946)reportthat132casesarerecordedinsurgicalliteratureoverthelast50years.SirGordonGordon-Taylor,inI946,reportedapersonalseriesof2Icases,andsincethattimehasperformedafurtheriisuchopera-tions;itislargelyasaresultofhisworkthatthisformidableablationhasbeenestablishedinthiscountryasastandardprocedureinthesurgicalmanagementofmalignantdisease.Inmostcasestheoperationisperformedforprimarymalignanttumoursofthebonesorcon-nectivetissuesofthepelvis,orforsimilartumoursintheupperthirdofthethighwhichhaveex-'tendedtoofarproximallytoallowofdisarticula-tionthroughthehip-joint;typicalofthetumoursnecessitatingthisprocedurearethoseillustratedinFigs.Iand2.Onoccasiontheoperationhasbeenperformedforextensivetuberculousorchronicinflammatorydisease.ofthehipandpelvicbones.Byvirtueoftheirlesssinisterpathologicalpotentialities,thebestresultsareobtainedincaseswherethetumouris.essentiallyonlyoflocalmalignancy,suchasinfiltratingchondromasofthe