HORSE-HAIR IN MINOR SURGERY BY C. 0. THOMPSON, PH.G., M.D. Reprinted from the Boston Medical and Surgical Journal, of October 1893. W. 8. BBST & OO., 93 Federal Street, Boston. 1893. Compliments of DIRECTIONS.-Place the hair at once in a bottle containing a solution of Bichloride of Mercury (1 - 1 OOO) and allow it to remain until needed for use. STERILIZED Horse-Hair. C. O. THOMPSON, M. D., BOSTON, MASS. HORSE-HAIR IN MINOR SURGERY.1 BY C. O. THOMPSON, PH.G., M.D. In calling attention to this subject it is not assumed that anything entirely new is to be presented, for horse- hair was probably used by surgeons in early times; but that its real usefulness is practically unknown to many is evident from the fact, that little has been written re- garding its use, and it is found in the hands of very few at the present time. The principal materials now in general use in sutur- ing wounds, are catgut, silk and silver-wire. Catgut for stitching, has many disadvantages. When it is removed from the various liquids in which it is usually kept, it is harsh and kinky. When moistened with water or fluids from the tissues, it becomes slippery; and in either con- dition it is not easily bandied, and is particularly diffi- cult to tie. It is quite uncertain as to its retaining pow- ers; and the line gut cannot be used as it is too quickly absorbed. It is, therefore, often necessary to use a much larger needle than is desirable, as the eye of a smaller needle will not admit it, and its want of pliability causes it to form a shoulder at the eye, which is certainly objec- tionable. Silk, although probably used more than any other ma- terial, is also open to several objections. It must be sterilized by immersion in antiseptic solution or moist i Bead before the Surgical Section ofthe Suffolk District Medical Society, April 5, 1893. 2 heat; and when this is done it becomes swelled, so that it is difficult to get it through the eye of the needle. If threaded before it is sterilized, the needle will rust. When placed in the wound it imbibes the secretions of the tissue, and there forms a media for the invasion of bacteria, which have been proven to be present in the epidermis even after the most thorough disinfection. In this softened and soggy condition it becomes yielding and allows the opposed surfaces to move easily, which is unfavorable to union. If drawn sufficiently tight to hold the tissues in place, tension is apt to occur in the wound. Silver-wire as a suture, offers fewer objections than any in common use, this being due largely to its non-absorbing property, but wire is not suited to all parts of the body. In its application to the lax and del- icate integuments, it disposes the edges of the wound to twist and coil up fai more readily than the wire itself. It is too stiff and unyielding, and therefore, its adjust- ment to these parts is difficult. After it has remained in the tissues for some time, it becomes so rigid that its removal is not only painful, but the parts are often torn, and the freshly united edges of the wound separated. It was not until I had used horse-hair for three years, and had become thoroughly impressed with its practica- bility, that I had occasion to review the literature on the subject. The first mention of horse-hair found was in an article by Mr. T. Smith, of St. Bartholomew's Hos- pital, in the London Lancet, in 1862; in which he gives the results of a series of experiments with this material. In 1870, Dr. J. T. Darby published a monograph on 3 " Hair as a Suture and Ligature;" a report of twenty cases was given in which hair was used in suturing with excellent results. In a paper entitled " Horse-hair Sut- ure and Drainage," read before the New York Medical Society in 1884, Dr. Daniel Lewis relates his experience with horse-hair, and speaks highly of its utility. Horse-hair is readily obtained by all surgeons, whether in city or country practice, and its preparation for use is perfectly simple. The objection has been made that horse-hair, being cellular in structure, cannot be sterilized. This objec- tion, however, is not well founded, as horse-hair is not materially injured by any of the methods used in the sterilization of dressings. Boiling in water is acceded to be one of the most practical methods; and accord- ing to the experiments of Drs. Stone, Dowd and others, all pyogenic bacteria are quickly destroyed, even the spores of these organisms cannot long resist this treat- ment. It is, therefore, an easy matter should sutures not be at hand, for one to always readily prepare a prac- tically sterilized suture, by removing a few hairs from the tail of a horse, placing them in boiling water for from three to five minutes, when they will be ready for use. Although pus-producing micro-organisms are unques- tionably destroyed by boiling, there are, however, cer- tain forms of germ life whose spores are very resistant, as those of anthrax and tetanus; and as there is always a possibility of these being found in horse-hair, a series of experiments were performed with various disinfect- 4 ing solutions. Dr. A. K. Stone kindly made the bacte- riological tests for me. I will not here detail the vari- ous experiments; but it is enough to say that the simple immersion in ether, alcohol, solutions of carbolic acid and corrosive sublimate, for several hours or days, and even repeated boiling in water was found not to render the hair absolutely sterile. I have used the following method in preparing the hair for use : a bundle of carefully selected hair weigh- ing from one to four drachms (the very fine and coarse hairs being discarded), is freed from dust as much as possible by shaking and combing. It is then washed in strong soap or soda solution, and when dry placed in a jar or bottle of the capacity of about one pint (a Mason fruit-jar answers the purpose admirably) which is then filled with benzine, the jar being agitated frequently. The treatment with benzine may be repeated several times; thus all fatty material is removed from the hair. It is next treated with a strong solution of bichloride of mercury, and finally immersed in bichloride of mercury solution, i-iooo. After this treatment the hair was found to be absolutely free from germ life. If removed from the antiseptic solution it becomes stiff and wiry, and is not easily tied. It should, there- fore, be kept in the solution until needed for use. A small bundle of hair can be folded and placed in antisep- tic solution in a small vial, such as is carried in the or- dinary medicine case, and is then ready for immediate use. Unlike catgut or silk it does not swell when placed in aqueous solution, but, on the other hand is rendered 5 more suitable for use by its becoming more pliable, and its flexibility is retained so long as it is kept in a moist condition. It can be easily tied and holds a knot per- fectly well. Its smoothness and uniformity of calibre is such that it can be very easily passed through the eye of the needle, which is certainly a marked advantage over catgut or silk. When a single hair only is required, a small needle or one with a small eye can be used. This is of decided advantage, notably in stitching about the eye and face, where one is particular not to leave stitch scars. How frequently we see in recently healed wounds, that have been closed with either catgut or silk sutures, stitch scars that are even more unsightly than the line of union it- self. These scars after the use of the hair stitch, prop- erly applied with a fine needle, are almost impercepti- ble. The sole disadvantage of horse-hair is its want of tensile strength, which makes it less useful than wire where several tissues are to be included and there is much tension in the wound; but by using two or more hairs together the strength is quite sufficient to readily overcome the tension of even large wounds. As a rule a single hair is sufficient for closing a wound, unless it be large and much gaping is present. The large, black tail-hairs are preferred for sutures, as they are more easily seen when you desire to remove them, which is done by seizing the knot with forceps and snipping the hair to one side, when its smoothness and elasticity greatly facilitates its removal. Horse-hair has all the advantages of the metallic sut- 6 ure, save that of strength, and is much more desirable to use where the tissues are lax and delicate, as of the eyelids, scrotum, penis and mucous membranes. It is equally unirritating, and so flexible as to readily accom- modate itself to the folds of the integuments. Its plia- bility permits it to be easily passed through the tissues, and by its expansion it almost relieves itself from the tis- sues in which it is placed. Its removal is accompanied with no pain or liability of injuring the part. The hair suture produces so little irritation in the tissues that it can be allowed to remain for some time. I have removed these stitches that had been in the scalp from fifteen to eighteen days, and had apparently produced no disturbance. The fact of their being tolerated by the tissues for so long a period, makes it specially applicable to plastic surgery. I have used this material for drainage, a small bundle being passed through the eye of a probe, and then the probe passed through the closed linear wound, drawing in the hair; or, if the wound be deep with narrow out- let, a bundle folded upon itself can be forced into the wound, and it certainly answers the purpose well. As the wound heals, the drainage can be gradually removed a few hairs at a time. It is not, of course, suited for draining large wounds. My experience with horse-hair has been considerable, having employed it in the treatment of 296 incised and lacerated wounds during the past year. These have in- cluded nearly every part of the external body and its ori- fices, but principally of the face and scalp. The results 7 in these cases have been so gratifying that I am con- vinced that the value of horse-hair renders it deserving of more general use. I venture to call attention to the following cases: Case I, January ir, 1892. Mr. C. D., age thirty-one years. He came to the office with incised wounds caused by broken glass. First wound on right eyelid three-fourths of an inch in length. Second, beginning at right eye- brow, extending upward and to the left, across the fore- head, about two inches in length. Third, horizontally above left eyebrow, one inch long. The fourth, hori- zontally across the upper part of forehead, two inches long. First was closed with five single horse-hair sut- ures, second with eight, third with three, and fourth with seven, making in all twenty-three stitches in the face. Bichloride dressings were applied, the wounds healing promptly. In three days half of the sutures were removed, and the remainder on the fifth day. Case II, October 2, 1892. Mr. C. L., age twenty- six years. Congenital phymosis; circumcision. Elastic band placed about the penis. Forty minims four-per-cent, solution of cocaine injected. About one inch of prepuce was removed, and frenum (which was short) was snipped. Elastic band removed. Small vessels seized and twisted. Fourteen interrupted sut- ures used to bring together edges of skin and mucous membrane. Dressed with sublimate gauze. Seven stitches removed on the sixth day and remainder on the 8 eighth. Union by first intention. This is the tenth adult circumcision in which I have used horse-hair. Case HI, Mrs. C. R., age twenty-seven, primipara Lacerated perineum. Saw her on September 28, 1892. Had been in labor about six hours. Examination showed breech to be the presenting part. Labor was allowed to proceed with- out interference until breech was delivered. Patient was then anaesthetized, and feet and hands of child brought down. In haste to deliver the head I applied the for- ceps, and head was rapidly delivered. Child was resus- citated, and labor was concluded by expressing placenta. Upon examination perineum was found to be lacerated for about three-fourths of its depth. This I determined to close immediately. Vagina was loosely packed with sublimate cotton, edges of laceration thoroughly cleansed, and wound closed with nine double horse-hair sutures. Packing was removed and no dressing was applied, and owing to circumstances and surroundings of patient, no special care was taken of wound. Patient made a good recovery. On the tenth day stitches were removed, the wound having closed by first intention. bhe above is one of several perineal cases, in all of which I have closed laceration with horse-hair sutures with pleasing results. Case IV, February 2, 1893. Mr. J, G., age twenty- seven years. Applied for treatment of swelling in left groin. Examination and history led to the diagnosis of syphil- 9 itic bubo. There were no signs of fluctuation. Solu- tion of cocaine was injected, and an incision three inches long was made. Four large softened suppurating glands were removed, cavity curretted, and wound closed with five double horse-hair sutures, a drain being placed in lower end of incision. A large bichloride dressing was applied, and patient walked out of office. He returned again on the fourth day, and wound was again dressed. On the tenth day the stitches were removed, the wound having healed by primary union. A SUMMARY OF THE ADVANTAGES OF HORSE-HAIR. (i) Easily obtained and inexpensive. (2) Soft, pliable, elastic and holds a knot well. (3) Aseptic, non-absorbent and non-irritating. (4) Can be used with a very small needle, and makes no shoulder at the eye. (5) More easily removed than any other suture, with- out pain or injury to the tissues. (6) Can be used for drainage.