Man’s ingenuity in attempting to use all sorts of available materials has never waned in an effort to close wounds. The Edwin Smith Surgical Papyrus, formulated by the Egyptians around 3,500 BC,1 was one of the first references to allude to the use of sutures, although there still remains uncertainty as to the precise timing of the introduction of the suture. Initially simple wound bandaging and even insect mandibles were employed,2 followed by materials such as silk, silver wire, twine and horsehair,3 through to modern sutures used today. It was the technical difficulty in manufacturing the needles that delayed the development of suture materials.4 In the early nineteenth century catgut and silk gradually became widely used in surgical fields. However these materials did not provide all the qualities that were required for the expanding scope of surgery.
In the mid?nineteenth century, the name of Joseph Lister is synonymous with the introduction of surgical antisepsis. However his work on the absorbable suture is less well known, but arguably just as significant to the field of surgery. At this time the usual practice was to ligate the blood vessel and leave the ends of the silk or twine to hang out of the wound in order that they could be pulled free when they had ulcerated through the artery. This usually took?seven to ten days.3 While this conveyed some benefit by providing a form of wound drainage, these threads invariably gave rise to infection deep within the wound, often resulting in secondary haemorrhage. Lister realised that the ligatures were the source of the irritation and were acting as a nidus for the growth of bacteria deep within the wound. He believed there was a need for a strong, flexible material that could easily be knotted, would remain intact in the tissues until its purpose has been fulfilled and then be completely absorbed or at least made inactive. This material had to be capable of being buried subcutaneously with no knots ends trailing to the surface.5 He initially thought that silk might fulfil these criteria. In 1867, he began to test his theory on the absorbable ligature with an experiment on a horse. The experiment involved ligating a major blood vessel with silk. Several months later the animal died and the site of the initial operation re?investigated. Lister was not surprised to find that a small abscess had replaced the silk ligature, and to him this was an ‘illustration of the mischief which a ligature of ordinary material may do’.5
Since silk had been demonstrated to be unsuitable, Lister turned his mind to alternative materials in use at that time. Catgut was widely used at the time to string musical instruments, such as violins and guitars, for which the qualities of strength and smoothness were paramount. The method used to prepare catgut was a rather protracted, but guaranteed the quality.
Lister describes:
‘Catgut, as you are all doubtless aware, is prepared from the small intestine of the sheep. The gut is treated in what seems an exceedingly rude manner for so a delicate a structure. It is scraped with a blunt instrument, such as the back of a knife over a board; and by this means, as the people express it, the dirt is scraped out; the result comes to be that the intestine is converted into a comparatively insubstantial material’.3
In 1881, Lister gave the Presidential Address to the Clinical Society of London entitled ‘On the catgut ligature’.5 He described an interesting case of a young woman who presented with a simple goitre in her neck. He carried out a thyroidectomy using his antiseptic technique; he wanted to use catgut to ligate the blood vessels. None was available, so he used hempen instead. Post?operatively she made a good recovery from surgery, although on discharge home she was noted to still have a small sinus at the site of surgery that continued to drain a small amount of pus. After a period of eight months of continued discharge the ligatures were eventually extruded from the sinus and the wound healed. This left Lister in no doubt that this protracted convalescence would not have occurred if he had used a material which would have dissolved within two to three weeks. Although unfortunate for the young lady involved, he used this case to illustrate to the members of the gathered medical fraternity the great disadvantage that may arise, even under antiseptic conditions, from the use of the ordinary forms of ligature.
However, two problems existed with catgut. First, the material quickly absorbed fluid becoming soft, swollen and pulpy in?situ, and was then useless to a surgeon, as even the most basic of knots would simply not hold. Second, was the protracted period of preparation before catgut was fit for use. Lister questioned whether this protracted method of preparation was essential, and whether during this process some antiseptic properties could be installed into the catgut during the preparation process.
A fortuitous meeting outside the Royal Infirmary in Edinburgh one wet Christmas, with a fiddler who was going in to entertain the patients, led Lister to re?evaluate the problem. The fiddler said that his fiddle would not play properly that day since the wet strings had not been properly seasoned. The problem was to shorten the seasoning period. After a series of experiments using a variety of substances, Lister eventually found the desired result could be achieved with chromic acid. By itself, chromic acid did not work very well, but when mixed with other substances, particularly carbolic acid, the results improved. It was at the address to the Clinical Society of London that Lister finally publicised his work, and detailed the method by which he could now achieve an absorbable ligature in a relative short period of time: ‘I dissolve one part of the chromic acid in 4000 parts of distilled water and add to the solution 200 parts carbolic acid; minute is the quantity of the chromic acid, it exerts, when in conjunction with carbolic acid, a most powerful effect upon the gut’.
From Lister’s subsequent trials using this catgut, he found that two to three weeks would pass before ‘erosion and absorption of the ligature would occur’.5 At the same time a fellow surgeon called William MacEwen, twenty?one years Lister’s junior, had begun to achieve promising results using similar techniques to modify the properties of catgut. By an extraordinary coincidence in the issue of the British Medical Journal the week of the 29th January 1881, the week prior to Lister’s publication, MacEwen had published a paper entitled ‘Clinical Lectures on some points connected with the treatment of wounds’.6 In retrospect it seems remarkable that the two surgeons who were responsible for the successful development of the catgut ligatures should have their observations published within two weeks in the same journal. In the end they both came to similar conclusions, however Lister’s product was regarded at the time as being superior to that of MacEwen’s, with respect to the speed of absorption of the catgut.
After this initial discovery Lister went on to improve catgut ligatures for many years. Subsequently, manufacturers have developed other techniques that have superseded this initial discovery, but the method that Lister published in the British Medical Journal, 1881, was the end of the beginning. The impetus created in the field of surgery by the work of Joseph Lister in developing the antiseptic era over?shadows his work in developing the absorbable suture. It could be argued that the two in fact go hand?in?hand. From original papers written by Lister, it appears that he considered the development of the absorbable suture as a natural progression to the antiseptic theory, and without the latter then the success he had with the absorbable suture may not have occurred so readily. In applying his research he was undoubtedly aided by contemporaneous writings, but it is a tribute to Lister that his experiments with silk and catgut demonstrated a passion for continuing research when acclaim had previously been achieved with antisepsis.7 Joseph Lister has guaranteed his place in surgical history, and what better title than ‘The man who made surgery safe’. His work throughout his career encompassed a range of surgical spheres, but these fundamental discoveries help set the foundations of modern surgical practice used across the world today.