TETANUS AND TECHNIQUE.

By A. HOOTON,

LT.-COL., I.M.S.,

Gokuldas Tejpal Hospital, Bombay.

From time to time?fortunately at very long intervals, as a rule?the British medical journals

May, 1918.] CAT-GUT AND TETANUS. '175

publish sporadic cases of operative tetanus, or

tetanus which is apparently due to operation, and the fashionable (and no doubt, in a consider- able proportion, correct) explanation is the use of catgut for ligatures and sutures. I think it was Mr. Rutherford Morison who remarked

years ago that men who employed catgut regularly might go on for many years pooh-poohing the danger, but sooner or later most of them would find that they would lose a patient or two from this cause, and although catgut still seems to be the favourite material we probably all have our moments of uneasiness with regard to it. One distinguished London surgeon, for instance, told me that he always used a particular brand, for the reason that it was stated to be made in

Xorway, where tetanus was supposed to be non-

existent, and there is a considerable proportion of the most careful men who, on account of the fear of tetanus or for other reasons, refuse to

use it at all. The evidence in some cases cer-

tainly appears to have been conclusive. A surgeon practising in this country, for instance, informs

me that he lost three abdominal operations, all

performed in one morning, from acute tetanus, and on discussing the disaster later with a New

York surgeon found that the latter had also

lost an operation case from the same disease,

using catgut from the same firm, of the same

date. Evidence like this cannot be disregarded, and it may be taken as proved that catgut is at all events one cause of the appearance of tetanus

after operation. In temperate climates, in fact, under ordinary conditions, it may very well be

the main cause. But in the tropics, where the

disease is so prevalent not only after but in the

absence of any definite sign of injury, it is even

more necessary to be extremely critical as to its

origin, especially in operation cases. My own recent experience emphasises this, and may

perhaps be of sufficient interest to place on record, in view of the undoubted disadvantages in some respects of the universal adoption of silk. Some

time ago, when working in another hospital, I had had occasion to be dissatisfied with the

results of the operative work as regards asepsis. In spite of a theatre technique, as careful and

thorough as one knew how to make it, the wounds were not healing as well as they should have done. " Stitch abscesses

" were too frequent, and

every now and then a more extensive failure

of asepsis occurred. The ultimate results, fortu-

nately, were usually satisfactory enough, but

one felt uneasy and dissatisfied with this condition of things. Over and over again our methods

Were reconsidered and the details checked and

modified, but with no apparent effect. Catgut and tendon were both in use, and samples were sent for bacteriological examination, but with

negative results. Gloves, caps, and respirators Were all employed, and it was difficult to see

what more could be done. The fluid which collected in the wounds affected was for the most

part of a clear serous or sero-sanious description, not to be described as pus, and even where a small quantity of true pus formed there was

usually no constitutional disturbance. A routine

bacteriological examination of the discharges was not undertaken, but in one clean appendix case,

where perhaps an ounce of clear serous fluid

was evacuated from the wound after about a

fortnight, the discharge was reported as sterile

after culture. I took it, however, that in most

cases a low form of sepsis must have been the

cause of the trouble. Things went on in this

fashion, much to our disgust, but without any grave results, when suddenly the question assumed a more serious aspect. A case of severe

pyosalpinx, in which both tubes had been removed and a glass drain inserted in Douglas' pouch (the peritoneal cavity having been soiled), developed tetanus, and another case, in, which laparotomy had been performed for tubercular peritonitis, followed suit after a few days. In both operations catgut had been used, but the gut was from different sources, and prepared separately. The

operations were, not performed on the same day. but, curiously enough, the cases were not only in the same ward but in opposite beds. Both

these cases died, and every one was naturally very much disturbed, but the tension was some- what relieved when a patient admitted for opera- tion fdr an old sinus a few days later developed tetanus?fortunately before any operative measures were undertaken. Eventually I was led to attribute the worst of our troubles, as regards ordinary failures of asepsis, to the use of a too

small steriliser, which had been packed progressively tighter with every attempt to

stiffen up the theatre technique, and the same

cause, with the consequently imperfect sterilisa-

tion of towels, perhaps previously exposed on the

ground by the dhobi, may account for the

tetanus. It certainly would not be fair to

attribute these cases to catgut. As regards the

general operation results, they improved with the advent of a larger steriliser and strict

injunctions against tight packing, and no further cases of tetanus after operation occurred.

Bombay is notorious for tetanus, and I find

that the Orokuldas Tejpal Hospital has admitted 43 cases during the years 1915, 1916, and 1917. Of these, three patients contracted the disease in

hospital?one during treatment for burns, one for lacerated wound of the leg, the third for a

Pott's fracture associated with abrasions. During the present year my attention has again been

drawn to the subject by the occurrence of three

cases in the wards?originally admitted for

scrotal abscess, lacerated wound of the foot, and

burns, respectively. The only one in which any operation was performed was the first. In this

176 THK INDIAN MEDICAL GAZKITJi. [Mat, iai8

case the swelling had been in existence some

time before admission on the 20th February, and the part was incised on the 21st. On the

6th of March, symptoms of tetanus set in. No

catgut was used at the operation. The prepuce and scrotum were sloughing extensively on

admission, and there is no reason to suppose that infection actually occurred in the hospital.

It is the custom in the GrokuldasTejpal Hospital, as I believe in most hospitals now, to inoculate all cases of serious lacerated wounds with anti-

tetanic serum, as far as it is available, and

during these three years 82 prophylactic doses have been given in this way. So far as is known

only one of these (a lacerated leg wound) has

developed tetanus, and in him the injection was made on the second day, amputation through the thigh performed on the seventh, and tetanus developed on the tenth. This case,

which ended fatally, is one of those previously quoted. Catgut was used, but infection was

presumably previous to the operation. In this connection, and in view of the difficulty

in obtaining the serum at the present time, it

may be worth while to draw attention to the fact

that the army medical authorities have recently advised and extensively employed in France doses of 500 units, as contrasted with the 1,500 issued as a matter of routine by the Lister Insti- tute. If 500 units is enough in France, it is

presumably enough here, and a curtailment by two-thirds would result in a very considerable

economy of the serum. The general question of aseptic technique is

a very difficult one in India, and I think we

are all agreed that conditions are more adverse here than in Europe. Dust is more prevalent, the temperature favourable to most microbes, Indian servants are not always too reliable, and tetanus is ubiquitous. Here, even more perhaps than elsewhere, it is necessary to remember the fundamental essentials of aseptic and antiseptic surgery, and to look beyond the latest theatre fashions which are sometimes insisted on at their

expense. I am personally of opinion that a good many failures may be attributed (as probably in the above quoted instance of the small steriliser, too tightly packed) to imperfect sterilisation. An inadequate high pressure steriliser, like a bad filter, so far from being a safeguard, is merely a trap, and one still occasionally comes across the so-called low pressure Schmmelbusch contrivance, a thing which has always struck me as worse

than useless. Rather than use an inefficient

apparatus of this description, it is better to rely on the old Listerian methods. Whether ligatures are often concerned?apart from the very rare cases of tetanus due to catgut?it is hard to say, but it is a noteworthy fact that the two theatres which I believe to have obtained the best aseptic results of all those with which I am

acquainted in India have been working with

carefully boiled silk and silkworm gut ligatures and sutures, and attribute their success in part to the exclusion of catgut and tendon. As

regards special Indian conditions, the officer in

charge of a large military laboratory tells me that he finds much greater difficulty in keeping his media sterile here than at home, and no doubt we are entitled to bear such factors as excessive heat and dust in mind in comparing our results with those of European surgeons, but it is not sound to press that excuse too far. More good is likely to result from remembering the limita- tions of high pressure sterilisers than multiplying the already sufficiently numerous complications of a modern theatre. What is the use, for

example, of projecting steam on to the outside of a mass of towels packed together as tight as the pagies of a family Bible, or expecting it to

find its way into the interior of compressed bandages ?

Catgut, for the present, I continue to use to a certain extent, having had unfortunate experience of the trouble caused by silk, sometimes after prolonged periods, both in my own and other

people's practice. I do not think that any of the tetanus cases which have come my way were

fairly to be attributed to catgut. But the fact remains that this material has been definitely saddled with the responsibility for the disease in certain cases, and the question arises as to

whether tendon should not take its place in those tissues, chiefly muscle and fascia, where silk is most prone to give rise to trouble. With tendon for these, fine silk for ligatures for vessels, and coarser silk and silkworm gut for most other work, one would be rid of the catgut-tetanus bugbear a bugbear which, if it only materialises once in 50 years, is too serious to be entirely disregarded.