The Aseptic Animal Suture:Its Place in Surgery.

BY HENRY O. MARCY, A.M., M.D., LL.D.BOSTON, U. S. A.

Surgeon to the Cambridge Hospital for Women; late President of theAmerican Medical Association; President of the Section on Gynae-

cology, Ninth International Medical Congress; late President ofthe Americon Academy of Medicine; Member of the British

Medical Association; Member of the Massachusetts Medi-cal Society; Member of the Boston Gynaecological

Society; CorrespondingMember of the Medico-Chirurgical Society of Bologna, Italy;

late Surgeon U. S. A., etc.

REPRINTED FROMTHE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION ,

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CHICiGO:__

American Medical Association Press.1898.

THE ASEPTIC ANIMAL SUTURE: ITS PLACEIN SURGERY.

BY HENRY O. MARCY, M.D., A,M., LL.D.BOSTON, MASS.

Modern surgical technic differs in such a markeddegree from the methods of even a recent period, thatit is not a wonder that great differences of opinionstill exist in regard to many questions pertaining tothe treatment of wounds. For the present, at least,certain conditions of fundamental type may be ac-cepted as settled, so far as the theory, or ideal, aimedat is concerned; for example, a wound made in aseptic,well-vitalized tissues, and maintained aseptic will befollowed by primary union. It is not my present pur-pose to discuss the methods for maintaining a woundaseptic only so far as pertains to its closure and sub-sequent protection.

In any considerable wound it is necessary to occludeblood vessels and rejoin the separated structures.This must be done by the use of ligatures and sutures.The material best adapted for this purpose is the sub-ject of thepresent inquiry. The materials in use are,thread made from hemp, linen or silk, almost exclu-sively the latter; metallic sutures, iron, gold and silver;silkworm gut, catgut, and the tendon of animals,especially that from the tail of the kangaroo.

The silk fiber, spun, twisted or braided in varioussizes, is so manifestly superior to the vegetable fibersof cotton, hemp and linen, that only silk merits dis-cussion. Silk has continued in more general use asa ligature for the following reasons: It is strong, ismanufactured into a thread that is very smooth andeven, can be readily sterilized by wet and dry heat,is comparatively cheap and easily obtained in anydesired size. Until it was found possible to close andseal wounds without drainage, silk seemed the idealmaterial for ligatures and sutures. Then it was sup-posed necessary to remove both ligatures and sutures,

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no matter how applied. When it was shown to beunnecessary and even harmful to drain aseptic wounds,the inquiry naturally arose, can not some material befound for sutures which will remain in the tissuessufficiently long to serve the purpose of constrictionor coaptation, and ultimately disappear under theinfluences of the vital processes of the surroundingstructures?

So far as the ligation of the larger arteries is con-cerned the problem thus presented is by no meansnew. The most important of the original studies inthis direction of an early type were conducted byDr, H. Gr. Jameson of Baltimore, and his prize essaypublished in 1829, upon the closure of arteries in con-tinuity by the use of the animal ligature is worthy ofcommendation as a contribution of the highest scien-tific importance. It is singular to note that many ofthe leading surgeons of this period accepted his teach-ings as of great value, and ligated arteries as Dr.Jameson directed, using for material, more commonly,carefully prepared strips of buckskin. These wereexperimented with, somewhat, by English surgeonsand met the approval of even Sir Astley Cooper. Thedirections were explicit, to ligate so as to occlude, butnot to devitalize the artery, cut short and leave theligature in the deep part of the wound.

The list of experimental studies published by Dr.Jameson demonstrated that the result of such ligationin the calf, dog and sheep caused a permanent occlu-sion of theartery, that the foreign material was encap-sulated by living cells, and that ultimately the ligatureentirely disappeared, leaving in its place a permanentreinforcement of connective tissue.

However, all this valuable experience was lost andforgotten in the heated controversy over the so-calledinflammatory processes in wounds, which promised afruitless and endless discussion, until the masterlystudies of Lord Lister demonstrated the cause of thesame to be vital and extraneous. He naturally arrivedat the theoretic conclusion that, in a non-infected

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wound, the vital processes would be ample to permitof the safe application of an absorbable ligature forthe constriction of an artery. So far as I know, Mr.Lister was utterly ignorant of the demonstrations ofDr. Jameson referred to above, and as the laws ofEngland at that time were so framed that studies uponthe lower animals, even of such an important charac-ter, were not permitted, this great master was obligedto resort to France for the privilege of pursuing hisinvestigations. His conclusions are almost identicalwith those of Dr. Jameson. He used for ligaturematerial, however, catgut as furnished for musicalinstruments, steeping it in a strong carbolic solutionin order to render it antiseptic.

So far as I am aware it had not occurred to any tomake use of sutures deeply implanted in wounds,buried, until in 1870, when it became very evident tome that it was necessary for the purpose of curinghernia to close separately the different structures ofthe abdominal wall and to restore the inguinal canalto its normal oblique direction.

Based upon the knowledge of the animal ligatureleft in situ about an artery, it seemed a logical deduc-tion that this could be safely effected. I instituted atonce a series of comparative studies in order to ascer-tain if such suturing was safe and trustworthy. Myinvestigations proved conclusively that aseptic ani-mal structures buried in well-vitalized tissues weresurrounded by leucocytes, which, little by little, in-vaded the material used and pari-passu were them-selves transformed into connective tissue-cells, takingin a considerable degree the shape and direction ofthe suture material. So noteworthy was this, that atfirst I was constrained to believe that the materialitself became revitalized as a sort of graft, but morecareful observations demonstrated that the foreignmaterial disappeared by a process of absorption, leav-ing in its place a vitalized band of connective tissue,the resulting product of which, in certain conditions,proves to be of the greatest value, to-wit, where the

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integrity of the parts are liable to damage because oftension, e. g,, as in hernia and all wounded structuressubject to special mobility. It gradually becameevident that a careful coaptation of wounded tissuescould be safely made, thus avoiding pockets of bloodor serum, and, as a consequence, do away with the useof drainage-tubes, then supposed absolutely essential.

The drainage-tube in aseptic wounds can be only adamage and used as the least of two evils, since somuch of the wound as is occupied by the tube mustnecessarily be left open, and closed by processes of amuch slower character, so-called secondary union.Again, too, it was soon demonstrated that, notwith-standing the extraordinary precautions taken in theuse of antiseptic dressings, a considerable percentageof wounds in which the drainage-tube wT as used,although aseptic so far as operative measures wereconcerned, became septic from the introduction ofinfection along the canal of the drainage-tube, morecommonly due to the ever-present bacteria pertainingto the skin.

One of the most interesting and profitable originalstudies made in the Johns Hopkins Hospital was thedemonstration of the micrococcus pyogenes albus asthe normal habitant of the dying epithelium of theskin and their causation of so-called stitch abscesses,when the suture included the skin. Now the deduc-tion seemed clear that an aseptic wound to remainaseptic must be ooaptated so that pockets can notdevelop for the undueaccumulation of fluids; that thedrainage-tube should be abandoned, and that even theskin itself should be closed by a sub-cuticular suturein order to avoid skin infection. Then it was appar-ent that in the devising of the sub-cuticular suture inorder to avoid stitch abscesses I had acted wiser thanI then knew, and that the ideal dressing should con-sist of an hermetic seal so absolute as to prevent thepossibility of extraneous infection. This is found incollodion, the contractile preferred, to which is addeda small percentage of iodoform, reinforced by a few

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fibers of absorbent cotton, which admirably accom-plishes the purpose while it still further fixes and holdsat rest the evenly ooapted edges of the skin and min-imizes the cicatricial line of repair. Oftentimes a cica-trix is traced with difficulty some weeks after the unionof such a wmund, a result, which upon certain parts ofthe body, for esthetic purposes is of the highest im-portance. Having worked out, by slow process ofdetail, the above conclusions and published 1 theresults from time to time, I now thought it was of thefirst importance to demonstrate the kind of suturematerial best adapted for this purpose, viz., buriedsutures.

Material.—Silk is manifestly unfitted, since, to saythe least, when aseptically implanted in the tissues, itrarely, if ever, disappears by a process of absorption,and not seldom after a long period of discomfort, thestructures rid themselves of it, attended with a con-siderable amount of suffering, with injury to the sur-rounding parts.

When silk sutures are buried, it is unquestionablybetter that the thread should be as fine as can be usedwith advantage. The sutures should be interruptedand few in number. Even thus carefully applied, itoften happens that weeks or months afterward thesesutures are thrown off by a process of proliferation,although the wound has been made and maintainedaseptic.

Silk buried in portions of the body called into spe-cial activity is most likely to give trouble. So wellestablished are the foregoing objections to buried silksutures that a general inquiry has arisen, is it not pos-sible to substitute something better in its place?Although metallic sutures were at one time in very1 A New Use of Carbolized Catgut Ligatures, Applied for the Cure of

Hernia. Henry O. Marcy, M.D., Boston Med. Surg. Journal, Novem-ber. 1871, p, 315.

The Radical Cure of Hernia by the Use of Carbolized Catgut Ligatures.Trans. Amer. Med. Association, Vol. 29, pp. 295-305, 1878.

Animal Ligatures, Annals of Anatomy and Surgery, 1881, p. 282.The Animal Suture, New England Medical Monthly, June 15,1883.The Surgical Advantages of the Buried Animal Suture, Journal of the

American MedicalAssociation, July 2,1885. Reprint.

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general use, for manifest reasons they have been dis-carded, until now they are limited to a very narrowrange of possibilities. (Where it is necessary to makea permanent fixation of the osseous structures, thewire suture has an advantage, and here it is intendedto be permanently left. Even under these conditions,when cut short and buried beneath the soft tissues,wire is very likely to be a source of subsequent irrita-tion.) Silk-worm gut is absorbable in such a slowdegree that it can be classed as belonging to the non-absorbable material used for ligatures and sutures, andfor this reason is almost as objectionable as wire.The use of wire and silk-worm gut as a buried suturehas its advocates for the most part among those whodo not feel that animal sutures have a durability suf-ficient to be trustworthy.

I am indebted to Dr. Charles P. Noble of Phila-delphia for a recent reprint of an article entitled,“Remarks upon the Use of the Buried PermanentSuture in Abdominal Surgery,” published December,1896. In it he states, “the original and simple methodof a through-and-through suture for the closure ofthe wound in celiotomy has been tried and foundwanting, because of suppuration and subsequent her-nia. That he has had no experience with the use ofcatgut or other absorbable material in the closure ofthe celiotomy wound, because of the unfortunateresults reported from Germany.” He quotes Winter,who reports 8 per cent, of hernias following the use ofthe buried catgut suture. He also refers to the expe-rience of Dr. Schede of Hamburg, who has employedsilver wire as a buried permanent suture in the clo-sure of celiotomy wounds since May, 1887. Hethinks the favorable opinion of Schede is borne outby the experience in the Johns Hopkins Hospitalwhere silver wire has been in general use for a num-ber of years, with a low percentage of suppurationand few subsequent removals of the buried sutures.He also refers to the experience of Dr. Edebohls ofNew York, who for a considerable period used silk-

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worm gut as a buried suture in the closure of the ab-dominal wall. Dr. Edebohls reports that from sto 10per cent, of all his sutures thus employed caused sup-puration and were either discharged spontaneously orrequired removal in order to secure closure of thewound or suppurating sinuses. In his aseptic woundswhere primary union had taken place, suppurationfollowed in some cases in a few weeks, in others aftersome months, and in one after two years and a half.On this account Dr. Edebohls now uses chromicisedcatgut instead of silk-worm gut.

Dr. Nobe’s object in writing his article is to showthat in his experience silk-worm gut has proved a safeand reliable means of closing celiotomy wounds. Hestates, “that he has closed two hundred and ninety-seven celiotomy wounds by the use of buried silk-w'orm gut sutures with only seven cases of suppura-tion and with satisfactory results in preventinghernia.” He emphasizes- the selection of fine gutwhich is boiled for half an hour before each opera-tion. The sutures arenot tied too tightly and the endsare cut as short as possible. He used catgut for theclosure of the peritoneum, the fatty structures and theskin as a continuous suture.

Dr. William B. Coley of New York reports2 indetail sixteen cases where silk, silk-worm gut andsilver wire were used as buried sutures for the cure ofhernia. In these not alone was the hernia not cured,but suppuration supervened, and the sutures had tobe removed. Of the number, five were closed withsilk-worm gut sutures. He reports from the recentwork of Schimmellbusch, page 121: “It has more thanonce been observed that in primary closure of woundsby silk or silver wire, the ligature, at the beginningwell imbedded in the tissues, after a long period oftime becomes repelled and suppurates out. Theimbedded silk or silver wire simply remains as a for-eign body in the tissues, of which the organismendeavors to free itself as soon as a favorable oppor-2 New York Medical Journal,Feb. 29, 1891.

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tnnity presents.” He also reports: “In two hundredand fifty cases of hernia operations in which I haveused kangaroo tendon for buried sutures I have nothad a single instance of sinus formation, and the per-centage of primary union has been ninety-six percent.” . . . “The ideal suture, then, would be onethat would hold the parts in apposition for eight orten weeks and then disappear by absorption. Inkangaroo tendon we have these conditions perfectlyfulfilled. There has never been observed at the Hos-pital for Ruptured and Crippled a single case of delayedhealing sinus when tendon or absorbable suture wasused. Unless those who use and advocate silk, silk-worm gut or silver wire in hernia operations are ableto present some advantages to offset the serious dis-advantages that have been demonstrated, I believethese non-absorbable sutures should be entirely aban-doned.”

Chance furnished me the opportunity of being LordLister’s first American pupil, and so great was myenthusiasm for the master that I accepted unques-tionably his teachings of the value of catgut as a lig-ature. I prepared my own catgut ligatures for someyears, according to his directions, and they wereundoubtedly aseptic. It was not long, however, be-fore infection followed the use of commercial catgutsuture material which was obtained from the mostreliable sources. This led me to investigate anewwith painstaking care the animal structures whichmight be better suited for this purpose. I soonascertained that catgut is necessarily faulty for tworeasons, first, as the connective tissue sheath of thesmall intestine of the sheep, it must necessarily beseparated from the other coats of intestine by macera-tion. This is in reality a process of bacterial putre-faction. The connective tissue sheath being moreresistant to the putrefactive bacteria, remains lessinjured by it, and as a consequence can be removedentire, but it is necessarily damaged by the processesinvolved. When thus separated and cleaned, although

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appearing as a white sheath of uninjured connectivetissue, it is everywhere teeming with bacteria, andthe cement substance which holds the connective tis-sue cells in fixation has been damaged by their action,and by the necessarily long-continued maceration. Sofar as I am able to learn, at this stage of the processin the manufacture of catgut no thought of the valueof sterilization has been entertained and no effortmade for its accomplishment. The second objectionto catgut as a suture material is the disposition of theconnective tissue fibers themselves. For the physio-logic necessity of dilatation and contraction of theintestine these fibers cross each other in a directionoblique to its long axis. The intestinal sheath isdivided into strips more or less narrow in order toproduce the desired sizes. When wet, it is an elastic,flat band with irregular edges. This is twisted uponitself into a cord and dried and thus is manufacturedthe catgut of commerce (strings originally designedfor musical instruments).

Such is the extraordinary strength of the connectivetissue that even thus disposed, when dry, catgut isvery strong, but every musician knows the great carehe must exercise in keeping it dry and keyed to theproper tension point. When damp it soon becomessoft, elastic and unreliable. When catgut is com-pared with the connective tissue found in the tendonsof animals, the illustration is not overdrawn to saythat the differences are as great as would result fromweaving silk into the finest fabric, cutting it diago-nally into strips and twisting it for use as a fishingline. When dry, it is comparatively strong, but whenwet, a soft, elastic, flat band takes the place of thewell-made fishing line. The surgeon must rememberthat his buried suture is ever wet since it is immersedin the fluids of the body. This is the reason that cat-gut swells so extraordinarily upon being soaked, thatknots in catgut are unreliable, and the yielding of theligature may be sufficient to prevent the closure of theenclosed artery. In the tendons of animals the con-

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nective tissue cells are disposed parallel to each otherand held firmly in contact by the cement substance,which in the preparation of sutures should be injuredas little as possible. Tendons should be taken fromfreshly killed animus and prepared so that infectivedecomposition never ensues. Their use as ligaturesis not new. Paul Eve, the great surgeon of Tennes-see, employed them in the ligation of vessels manyyears before Mr. Lister’s study of the subject. Heused the tendons of the deer, taken directly from thefreshly killed animal.

However, the knowledge of the use of tendons forligatures was unknown to me until after my first pub-lications upon the subject. As the result of my inves-tigation and research for good suture materials, I wasso convinced of their superiority that I contributed apaper upon the subject at the International Congressheld in London in 1881. Tendons from the whale,the broad fascia of the back of the buffalo and moose(Indian thread) proved of about the same value as thelong tendons from the leg of the moose, deer and cari-bou. Although less fatty they were little to be pre-ferred to the tendons from the domestic animals.Good ligatures are comparatively easy to obtain fromthese sources, but suture material must be smooth,even, strong, fine and for a continuous suture, of con-siderable length to be of service.

After a prolonged research, I found that the ten-dons from the tail of a medium-sized kangaroo fur-nished a material which possessed all these requisites.The entire family of marsupials have the psoas mus-cle divided into fasciculi, each of which has its inde-pendent tendon, extending to the very extremity ofthe tail. These lie parallel to each other and areeasily separated. In the larger kangaroo these ten-dons are not infrequently thirty inches long, but en-tirely too large for sutures. Many of them will splitreadily, but are never as strong or satisfactory as thewhole tendon from a smaller animal. Much thelarger amount of kangaroo tendon shipped for com-

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mercial purposes is naturally obtainedfrom the largerspecies, since it is sold by the pound, and by far thegreater portion of tendon in the market is conse-quently less valuable.

Good tendon is smooth, even, and of a tensilestrength greater than silver wire of the same weight.It should be taken from freshly killed animals, quicklysun-dried, and kept dry during theperiod of shipment,and as a consequence, its sterilizationis effected withmuch greater certainty and with less damage to theintercellular cement substance. The tendon fromthe variety called theWallaby furnishes thebest suturematerial, but so difficult is it to obtain first-class ten-dons, that out of a lot of one hundred and fortypounds recently sent me, scarcely twenty were of firstquality.

Preparation and sterilization of catgut—The rec-ognition of the advantages attendant upon the useof absorbable suture material has been so universalthat a very great many different methods have beenexperimentally tried in order to furnish from catgutthe so-called ideal suture. The very fact that somany different methods of preparation have beenemployed is an evidence that none of them haveproved entirely satisfactory. Only recently Dr. Nich-olas Senn 3 of Chicago, has given his experience inthe preparation of catgut. He approves Hofmeister’smethod of preparing catgut by the use of formalin.With this the profession is already familiar. Thecatgut is rendered tense by winding it upon a glassplate and immersed from twelve to forty-eight hoursin a 2 to 4 per cent, aqueous solution of formalin;then immersed in flowing water for twelve hours tofree the gut of the formalin, boiled in water fromfifteen to twenty minutes, hardened and preserved inabsolute alcohol containing 5 per cent, of glycerinand 1/10 of 1 per cent, of biohlorid of mercury.

Dr. Senn modifies the foregoing method by pre-serving the formalin gut, after boiling it, in absolute3 Journalof the American Medical Association, Dec. 12,1896.

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alcohol 950 parts, glycerin 50, finely pulverized iodo-form 100parts. He considers the iodoform of value as amild antiseptic, and that it diminishes the amount ofprimary wound secretion. He speaks of it only as aligature, but I infer that he also uses it as a buriedsuture. He quotes from Nusbaum approvingly.“ Catgut is without doubtLister’s greatest discovery,”and states that he considers “ the aseptic absorbableligature as one of the greatest achievements of mod-ern surgery.” Dr. Ralph C. Larrabee of Boston ina recent article 4 gives an interesting review of thesterilization of catgut by boiling in alcohol. Hequotes Lauenstein’s investigations, 5 where, in a largeseries of cultures made for the purpose, he demon-strated quite a variety of micro-organisms as com-monly present in catgut. Dr, Larrabee shows fromhis own experimental studies that boiling in 95 percent, alcohol for one hour did not render the catgutsterile, and in each case he obtained cultures of abacillus. Chemically, catgut contains water (23 percent.) and fat (7.5 per cent.). By most of the recentprocesses of sterilization these substances must beremoved. The remainder consists chiefly of collagen,which under the continued action of hot water istransformed into gelatin. Dr. Larrabee quotes theexperiments of Saul, who found that if catgut wasboiled in a 5 per cent, solution of carbolic acid inabsolute alcohol, three hours were not enough to killanthrax bacilli dried upon it. The addition of a smallquantity of water gave much better results, since byusing a 90 per cent, solution, instead of absolute alco-hol, the bacilli were killed in ten minutes. Hofmeisterhas, however, found gut, after such boiling, containedstaphylococci, which developed in proper culturemedia. As a result of Dr. Larrabee’s investigations,he found that boiling the gut after Saul’s method forfifteen minutes was sufficient to sterilize the smallersizes, but, in forty experiments from the larger sizes,* Boston Medical and Surgical Journal, Jan. 28,1897.5 Archiv. f. klin. Cliirurg., 50, 323, 1895.

boiled from fifteen to thirty minutes, he obtained sixcultures. He therefore concludes that it is necessary,in order to be absolutely sure of sterility, to boil thesmaller sizes thirty minutes, the medium forty-fiveminutes; the largest sizes are safer boiled one hour,“Catgut thus prepared deteriorates by age, andwhether preserved wet or dry, a certain per cent, ofthe actual strength is certainly lost.”

Dr. R. M. Pearce reports6 a series of careful studies ofsterilization of catgut with formaldehyde. This he ap-plied by vaporizing small amounts of the 40 per cent,solution (formalin) into a glass chamber in which thecatgut was exposed. In every experiment steriliza-tion was satisfactory, but the gut became so brittlethat it was ruined. He shows that the injury occurredlargely from the moisture necessarily contained inthe vaporized formalin. He found that the gas in adry condition gave a much better result and this herecommends as a practical method of sterilization:“Nothing is required but a wide-mouthed jar, someparaforrn pastilles, a piece of wire gauze or open-meshed cloth and a wide-mouthed bottle. A dozenpastilles are put in the bottom of the jar and coveredwith a piece of wire gauze to prevent actual contactwith the gut. The pastilles yield a sufficient amountof gas for complete sterilization.”

Dr. A. Goldspohn' of Chicago has contributed aninteresting article upon the preparation of catgut byformalin and boiling. From a careful review of theexperimental studies of a number of reliable investi-gators and a series of his own he deduces the follow-ing : “These facts being known we must not dependon formalin to sterilize catgut but simply to hardenit so that it may be boiled ad maximum. That thismaximum boiling of twenty minutes may be possibleit is necessary to remove all excess of formalin fromthe gut by prolonged washing in running water pre-viously. But the vexatious question is now settled6 Boston Medical and Surgical Journal, April 19, 1898.7 Reprint, Chicago Medical Recorder, Vol. xiii.

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that catgut can be certainly sterilized, for we can nowboil it in water, the ideal menstruum, as long as theadherents of silk need or usually care to boil that, andthe advantages of absorbable ligatures are too obviousto require further comment. However, there is oneslight objection to catgut remaining, which arisesfrom the ptomains which it may sometimes contain.On this subject Dr. Bdmondo Orlandi in Turin pub-lished researches in 1895, and Professor Papfert ofGiessen likewise toward theclose of 1896. Both affirmthe occurrence of slight or non-virulent suppurationlimited to theimmediate vicinity of the gut, not produc-ing any systemic disturbance, and usually subsidingwithout any marked detriment locally. However, toavoid this objection partly, I am now having all cat-gut soaked in ether previously for forty-eight hours ormore, to extract the fat, hoping also to get rid of someof the ptomains that may be present.”

“ My reasons for preferring catgut so prepared are,first and chiefly, because it stands the crucial culturetests that have been applied to it by its founders,which is not true of any former method, that of vonBergman not excepted, for Braatz cultivated anthraxspores of only moderate resistance in abundance fromcatgut prepared by that method. Secondly, becauseof the immense satisfaction to a surgeon derived froma knowledge of the supreme germicidal capacity ofwater boiling for twenty minutes, Thirdly, becausethis catgut is hardened enough to answer the pur-poses of chromicized catgut reasonably well withoutbeing too hard. From clinical observations my im-pression is that the smaller sizes hold from seven toten days, while the larger sizes, as No. 6, used on ped-icles, etc., hold for about fourteen days.”

Formalin acts upon connective tissue in a way tochange its ultimate cells and cement substance intoa homogeneous mass of gelatinous character. Defor-malized in running water for twenty-four hours andboiled loosely coiled in water, the gut or tendon swellsimmensely and shortens to about one-third its former

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length. It is fibular, elastic, a homogeneous translu-cent mass. If wound tightly on a small test tube andboiled shrinkage does not take place, but the otherchanges ensue and the tensile strength is much les-sened. If catgut thus heated remains in the tissuesonly as long as Dr. Goldspohn has determined, itsdurability is much too little to be trustworthy formany operative purposes.

In the present status of the question, the views ofthose who have, for a time at least, discarded the useof catgut as an unreliable suture material must beheld to be justifiable.

In the New York Medical Journal, Feb. 18, 1897,is an interesting article upon slowly absorbable anti-septic catgut, prepared by a modification of Boeck-mann’s method, by 0. W. Borden, M.D., U. S. Army,He believes that the chief merit of the method is inrendering the suture material much more slowlyabsorbable by boiling it for an hour and a half in a1/500 solution of mercuric biohlorid in alcohol. Thisantiseptic catgut has given, in his experience, mostexcellent results. He does not think the small amountof bichlorid of importance in producing irritation orwound secretion, and that it is readily disposed of inthe tissues without injury. He believes there is aslittle danger of bichlorid irritation as of iodoformpoisoning from using the formalized catgut soakedin an alcoholic solution of iodoform, recommended bySenn.

Dr. Borden thinks that it is of manifest advantageto add his method of making an antiseptic suture tothat of Boeckmann, which consists in sterilization bydry heat. He considers that the formalin method ofHofmeister produces a catgut not in any way equal tothat which he recommends. He thinks kangarootendon has been greatly overrated and attempts toshow by an experimental study of a wound that it isfar less resistant to the tissues than has been usuallyconsidered, and singularly believes it conclusive bygiving a photograph of a frayed end of a kangaroo

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tendon suture emerging from the skin, “where it hadbeen completely eaten through by leucocytes.” Suchexamination teaches only the extraordinary rapidity■with which the active proliferating processes super-vene in the superficial layer of the skin, and thisphenomenon has often been remarked upon in con-tradistinction to the processes which take place whenthe suture is buried in the tissues. The same processis observed uniformly, when the sutures are deeplytaken through the mucous surfaces, as for example,the continuous over-and-over suture taken throughthe cervix of the uterus. Dr. Borden has taken thetrouble to reproduce by micro-photographs the differ-ence which followed the implantation of “unbichlo-rided kangaroo tendon and bichlorided catgut” in aseptic wound, and shows that the tendon is less irritantthan the catgut to disintegration changes. This shouldfollow", if the bichlorid is of any value in preventingdecomposition. He reports no attempt to showresults where the catgut and kangaroo tendon, both ofgood quality and sterilized by the same method, havebeen aseptically buried in the same animal. Here, asI long since demonstrated, the contrast is most marked,and the results show that the tendon remains com-paratively unchanged for a much longer period.

In the coaptation of the skin the subcuticularsuture should be completely buried. The first end isfastened by a half knot, after the skin is penetrated.The stitch is taken parallel to the long axis of thewound, each succeeding stitch entering exactly oppo-site to the emergence of the previous one, and securedwhere the needle finally emerges through the skinby a half knot as at the beginning. This holds theedges in even, close coaptation. The ends of thesuture are cut even with the skin, and slight tensionin the long axis of the wound causes the ends todisappear below the surface (buried). It is thensealed with iodoform contractile collodion withoutdrainage. The skin suture should be a fine one, andit is important to implant it only in the deeper layer

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of the skin, subcuticular; otherwise the skin mayproliferate before absorption ensues and superficialabscesses follow.

Sterilization of tendon.—-A small portion of thedried tendon is soaked for a considerable period ina warm solution of biohlorid of mercury (1-1000).When well softened the tendons are easily separable.Each individual tendon is laid straight upon a vretsublimated towel and allowed to dry. When drythey are assorted. In this state they may be usedwith comparative safety. I have never been able tocultivate bacteria where culture tests have been madeof tendons thus prepared. By reason of its histo-logic structure, as before explained, the tendon, whenburied in the tissues, is much more slowly pene-trated by the proliferative leucocytes than catgut.The effect of chromic acid upon the intercellularcement substance is extraordinary. It fixes it by aprocess of tanning and does not in any way inter-fere with its pliability, increases somewhat its tensilestrength; causes it to absorb moisture more slowly andrenders it much more resistant to the disintegratinginfluences, when buried in vitalized structures.

The tanning of certain grades of leather has beenmuch improved by a somewhat similar use of chromicacid. The process is not only much shortened andcheapened, but the resultant product is very muchmore valuable. Recently, a large manufacturershowed me a goat skin thus tanned. It was not fineleather, but he said it would make a durable shoe,whereas under the old processes of tanning it wouldhardly be worth manufacturing. These methods areprotected by patents and have already earned theowners over two millions of dollars. Chromic acidmay be applied to the suture material in a strengthwhich renders it unfit for use and makes it almost asslowly absorbable as silkworm gut. When properlychromicized, the suture should be of a light goldencolor and slightly translucent. It may be well pre-served for an indefinite period in the dry state, but, as

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Lord Lister long ago pointed out, preserved in light-colored boiled linseed oil, to which 5 per cent, ofcarbolic acid has been added, it seems to keep indefi-nitely, and for a certain period, I think, is improvedby age. When only partially immersed, as in a bottlehalf full of oil, the tendon becomes sticky and isgreatly damaged. If replaced, after being removed,in a wet state, in the carbolized oil, the water in thetendon forms a sort of emulsion which speedily ruinsit. It may be preserved in many of the differentways which have been recommended for catgut, andso far as lam aware I have tried them all. By none,however, has the product remained permanently asreliable as by the method just given. Kangaroo ten-don prepared as above is objected to because of thetrouble in preparation and its cost; trouble in thatthe oily product is difficult to seal after having beenbottled, and the oil must be removed from the tendonbefore using. However, the latter is easily effectedby immersing the sutures, just previous to use, in awarm sublimate solution for half an hour. I considerthe antiseptic quality resulting from the remainingbiohlorid beneficial rather than otherwise.

Is such tendon trustworthy and assuredly aseptic?Infective wounds, from a variety of causes, will followin a small percentage of cases in the practice of everysurgeon, but it is his imperative duty to exercise everypossible care to prevent it. The sterilization by heatis considered absolute, hence instruments, towels,gauze, etc., may be assumed non-infective. The cer-tainty of such knowledge, so far as suture materialgoes, is of equal importance, and hence the oft-repeated injunction, “trust no sutures that you havenot personally prepared.” By culture tests I haveassured myself that the tendon is sterile and each ofthe various processes in its preparation is always con-ducted under my personal supervision. The querymost often made is “What shall I do with the unusedtendon that has been soaked in the bichlorid solu-tion?” Wrapped in a sterilized towel, it should be

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sun-dried, and when thoroughly dry, replaced it in thecarbolic oil for future use. Repeated treatment inthis way leaves the tendon undamaged. For the lasttwo years I have soaked the tendon for a consider-able period in a solution of formalin, prior to itschromicization. This is a still further guarantee ofdisinfection.

Boiling in alcohol has been a favorite method withmany surgeons for the disinfection of catgut. Ster-ilization of tendon may be effected by this method,but it renders it brittle, hard, and is much less satis-factory in its application. Dry heat is less damagingthan by any other, except theabove-mentioned chem-ical processes, and leaves a product more satisfactorythan when boiled in alcohol. It is also perfectly easyof application by the simplest of all methods. Thereare two requisites, however, which are essential, thetendon must be entirely freed of the oil and moisture.A simple means of drying is to retain it for somehours in the sunshine, or in a warm oven. A coil ofthe dry tendon is placed in a large test-tube, with adry cotton plug; over the end of the tube a rubbercap is securely tied. This is put in the sterilizeras long as it may be deemed desirable and thereby isknown to be trustworthy. If only a very slightdegree of moisture remains in the tendon, the result-ant will be a compact mass of ruined material.

Tendon will bear repeated heating in this way withcomparatively little damage, and it may be recom-mended as a safe means of assurance to the surgeonthat any possible subsequent infection of the woundis not caused by his suture material. Kangaroo ten-don sutures should be obtained at a cost of ten dollarsper hundred, and so great has been the demand for itthat I have had it prepared in quantity, under mypersonal supervision, for general use, which I fullybelieve is absolutely trustworthy and reliable. Thesesutures are coming into general use. lam constantlyin receipt of letters reporting the great satisfactionfollowing their employment; I have already quoted

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Dr. Coley. Dr. F. W. Longyear of Detroit says;“My experience has been entirely with this material,and has extended over a period of more than four andone-half years, during which time I have used it forboth ligature and suture in fifty-seven cases of celi-otomy, with and without drainage, and I have yet tosee my first case of post-operative hernia where thismaterial was employed.”

Kangaroo tendon ligatures, ten or twelve inches inlength, should cost less, since in the preparation ofsutures which are long, fine, smooth and even, thelarger part of the gross material is rejected.

It is quite difficult to obtain really fine sutures, andmuch placed upon the market is not of first quality.I have written the above description in careful detail,since there can be no question but that the use of theburied animal suture marks the greatest advance inthe development of aseptic surgery. When appliedin closing the abdominal wound by suturing the dif-ferent layers independently, the skin also closed by asubcuticular continuous suture and the wound sealedwith iodoform collodion, hernia is practically avoided,In over eight hundredaseptic laparotomies thus closedI have had but once subsequent hernia, and that inan extremely thin abdominal wall after the removalof a large uterine myoma. The cure of hernia byany of the so-called modern methods is dependentabsolutely upon the use of buried sutures in closingthe neck of the sac, reinforcing the weakened struc-tures and the reconstruction of the obliquity of theinguinal canal, and it was for this very purpose I firstemployed animal sutures in 1870. With all the emphasisof an earnest conviction, I commend to every asepticsurgeon familiarization with the methods of woundclosure by means of buried absorbable sutures, prefer-ably tendon, and not alone predict their general adop-tion, but believe that in importance they hold thefirst place in the technic of modern aseptic woundtreatment.

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