Among the surgical artifacts in the Bjoring History Center is No. 2013.0040, a leather pouch that unfolds to reveal an array of snugly fastened glass tubes. It looks like a portable variety pack, each delicate tube containing a loop of fibers. Ordinary though it may be, this small satchel--stamped “Johnson & Johnson ligatures”—is a vestige of time before the advent of synthetic sutures, representing millennia of experimentation and scientific debate.
Preparing catgut for surgical use was difficult, tedious, and time-consuming—and a burden that fell to the operating nurse. Sterilization required "both experience and skill for its satisfactory culmination without ruining the entire lot of gut."1947 edition of Surgical Nursing
Throughout history, the search for a superior material to close up wounds has taken some exotic twists and turns. Wounds have been stitched with gold thread, silver, copper, kangaroo tendon, black horse hair, linen, wire, animal intestines, cotton, silk, tantalum (a rare metal), even whalebone. (A ligature is a free piece of suture material; once threaded on a needle, it becomes a suture.)
In ancient times, giant ants were employed. Held close to a wound, their powerful jaws would bite the edges, bringing them together. The insect would then be decapitated, its scissor-like jaws left in the flesh. Such a procedure is described in medieval Arabic medical literature.
Animal viscera, prepared and treated to attain a thread-like consistency, was first mentioned by the Greek physician Galen (129 – 216 AD) to heal gladiators’ cut tendons. Known as catgut, this absorbable material was made from the twisted intestines of sheep. Similar materials were used for sutures well into the 20th century.
But the ideal material for suturing proved elusive. Considering the lengthy list of desirable attributes, perhaps this isn’t surprising: the material needed to be flexible, easy to sterilize, easy to handle, and provoking little or no tissue reaction. It also had to provide strong tension throughout the healing process, make good knots, and keep uniform characteristics without shrinking. And it had to be cheap.
In the 1800s, violin strings became one option. A catgut derivative, it was both cheap and readily available. (The term ‘catgut’ likely derived from a small pocket fiddle called a “kit” that used lamb intestines as its strings, though this is debated.) Guidelines for transforming a violin string into an antiseptic ligature called for submerging it in a glass bottle of pure oil of juniper berries and tightly corking it for 24 hours. The ‘E’ and ‘A’ strings were best for smaller vessels, while the ‘D’ strings did well for large vessels. Harp strings, twice as large as the ‘D’ string, was best suited for common carotid and femoral sutures.
By the middle of the 19th century, silk sutures were the norm, even as they frequently caused suppuration and putrefaction. The British surgeon Joseph Lister believed it was the germs embedded in the silk that caused the problems, since surgeons and their assistants would hold the threads in their mouths during an operation for ready access. But the problem wasn’t just germs; the material itself “fretted” the living tissue. Lister re-introduced catgut to the practice of surgery and it became standard by the 1870s.
Preparing catgut for surgical use was difficult, tedious, and time-consuming—and a burden that fell to the operating nurse. Catgut has to be cleaned, dried, and twisted into threads of various sizes. Sterilization required “both experience and skill for its satisfactory culmination without ruining the entire lot of gut,” according to the 1947 edition of Surgical Nursing.
In time, catgut became commercially prepared and sterilized and was hermetically sealed in glass tubes. This brings us back to the History Center’s artifact; we don’t know its age, but Johnson & Johnson began mass-producing its sterile sutures in 1887, ushering in modern antiseptic surgery.
By the early 20th century, silk was in (again) and catgut was out because it dissolved unevenly, leading to knot slippage and other problems. Eventually, even silk had its day, when synthetic sutures arrived on the market in the 1970s.
This #FlashbackFriday brought to you by the @BjoringCenter for Nursing Historical Inquiry.