About 20 years ago, I was offered the opportunity to play Dr. Hunter Holmes McGuire in a History Channel miniseries. I didn’t have a speaking part—just a reenactment. McGuire was the surgeon who happened to amputate the left arm of Gen. Stonewall Jackson.
Jackson died of infection from his wounds. The interesting thing about those Civil War years was that the primary surgery of that time was amputation, and the main cause of death was infection.
The primary suture of the time was either cotton or catgut (twisted sheep or horse intestine). McGuire had a severe shortage of both. Someone came up with the idea to use the skirt of a horse (the long coarse hair of the horse’s tail) as suture material. The problem was that horse skirt hair is very coarse and hard to manipulate and tie. The simple solution was to boil it so that it became softer and more malleable. People noticed a decrease in the infection rate afterward.
It was obvious to all present that there must be a secret property of the horse tail that lowers the infection rate, but no one bothered to think that it may have been the boiling of the hair that killed any bacteria on it. As a side note, after the war, McGuire went on to become the president of the American Medical Association.
It wasn’t until the 1870s that a British surgeon named Sir Joseph Lister realized the benefits of antiseptic surgery. He was mocked for many years and the Lancet (a well-respected medical journal, even today) warned against his ideas. He applied Louis Pasteur’s advances in microbiology. Lister instituted the practices of wearing clean gloves, washing his hands before and after surgery, and washing instruments in a mild carbolic acid solution. Listerine was named in honor of Lister’s discovery.
Suturing has been found in ancient cave paintings as far back as 30,000 B.C. with the use of “eyed needles.” In 1600 B.C., Galen of Pergamon, a Greek surgeon, used catgut for the first time to suture gladiators’ torn or severed tendons. In A.D.150, ancient Egypt mentions suturing a gash in someone’s shoulder.
About 10 years ago, I took an amazing wilderness medicine course in Sante Fe, New Mexico. Besides learning that one can do a great deal with duct tape and a safety pin, I also learned about the giant African ant. This giant ant, Eciton burchelli, has been used for wound closures for as long as time can be remembered. These giant ants are held parallel against the open wound. They bite down with giant claws and bring the wound edges together. The holder then decapitates the ant, leaving the head and claw holding the wound together.
“How does one capture such an ant in the first place?” I asked the lecturer at the time.
I wasn’t given a satisfactory answer.
There also are many reported cases of the use of wires to close wounds starting as far back as the Middle Ages. The first use of staples to do so was in 1908 by a Hungarian surgeon, Dr. Humer Hultl.
That was then and this is now.
Krazy Glue was actually discovered in 1942, when scientists were trying to make clear plastic gun sights during World War II. The problem was that it stuck to everything. It did find its use during the Vietnam War, where emergency medics used it to seal open wounds on the battlefield. It has been credited with saving many lives. The problem with Krazy Glue is that it’s such a strong adhesive that it can be damaging to the skin and even kill cells, especially if it seeps into the deeper tissue. Today, we have much more effective biologic glues for skin closures.
I use different types of sutures on different parts of the body, depending on my goals. I typically use a type of suture that’s quickly absorbed into the skin when operating on muscle and a nonabsorbable suture when tying off larger blood vessels. The skin edges can usually tolerate an absorbable suture just as well as one of the newer biologic glues, which gives a nice cosmetic closure. Patients usually comment on the scar, rarely about what happened underneath.
There’s yet another type of “suturing” that involves the use of lasers. This laser welding uses photothermal energy to connect structural proteins. This also coagulates the flesh (stops the bleeding) and is quick and easy—when it works.
Let me take you into the operating room for a sense of all the suturing tools at a surgeon’s disposal. Modern medicine really has come a long way. Antiseptic is a commonality of every technique. I use “electrocautery,” which is radiofrequency energy to “suture” or coagulate small blood vessels. In the old days, we would have to tie off each bleeding vessel. We still need to tie off larger ones, since the cautery won’t usually work on them.
We have a wide range of suture materials to use, depending on what’s bleeding or what needs to be brought back together. Every suture type has a pro and a con, and knowing what those are makes the difference between a good surgeon and a great one. Knowing how to tie knots also helps.
The next time a friend shows you their scar, you can now ask them what sutures were used and tell them what you would have done if you were the surgeon.
I’ve always taught medical residents to “stitch expeditiously, never waste time: Time is blood loss, and we don’t want any of that.”
