Sutureless Skin Closure To the Editor.\p=m-\Thearticle, "A New
An
in
appropriate commentary exists that is perhaps as ancient
a source
the Smith
Papyrus (Ecclesiastes
Sutureless Technique For Skin Closure" (Arch Surg 111:83-84, 1976) by Hasson and colleagues presents an ingenious method for approximating the skin edges without the necessity of perforating the dermis. The method differs from the use of "butterfly" closure in that the tension on the individual closure devices is
as
without necessitating removal and/or reapplication of material, and in the ability to avoid actual contact of adhesive-coated surfaces to the wound edge itself. It strikes me that a great debt is owed some unknown physician\p=n-\ perhaps Imhotep\p=n-\wholived and died some time prior to 2500 bc. It was he who first described the sutureless closure\p=n-\ofwhich the present communication details only a nicety in evolution. At the time of the writing of The Edwin Smith Surgical Papyrus\p=n-\ translated and retranscribed some time during 1600 bc\p=n-\the"butterfly" dressing for wound closure was already in use.
Papyrus. Chicago, University
adjustable
Case 10. Instructions concerning a wound in the top of his eyebrow. If thou examinest a man having a wound in the top of his eyebrow, penetrating to the bone, thou shouldst palpate his wound, [and] draw together for him his gash with stitching. Thou shouldst say concerning him: [he has] a wound in his eyebrow. An ailment which I will treat. Now after thou hast stitched it [thou shouldst bind] fresh meat upon [it] the first day. If thou findst that the stitching of this wound is loose thou shouldst draw [it] together for him with two strips of [adhesive plaster], and thou shouldst treat it with grease and honey everyday until he recovers. As for: "two strips of linen" it means two bands of linen which one applies upon the two lips of the gaping wound in order to cause that one [lip] join to the other.'
The dressing was used for wound closure throughout recorded medical history,- and even into the present.
1:9-10, Masoretic text): "And there is
thing under the sun. Is there a thing whereof it is said, 'See, this is
no new
new?'... It has already been in the ages which were before us." CARL JELENKO III, MD Augusta, Ga 1. Breasted JH: The Edwin Smith Surgical of Chicago Press, 1930. 2. Jelenko C, Jelenko JM, Buxton RW, et al: The evolution of adhesive tape. Surg Gynecol Obstet 126:1083-1088, 1968.
In Reply.\p=m-\Ihave reviewed with great interest The Edwin Smith Surgical
as transcribed by Breasted. The ancient Egyptians did use adhesive plaster made of strips of linen. These were applied, in pairs, "to the two lips of the gaping wound in order to cause that one join to the other."1 Wound closure therefore was effected by a sutureless technique. Dr Jelenko is to be commended on his astute observations and keen knowledge of the surgical literature. We are indebted to the unknown surgeon who described a sutureless closure some 4,500 years ago, and we recognize his contribution. Although his achievement has been largely forgotten, he might take solace from the words of Longfellow, who wrote Let us, then, be up and doing, With a heart for any fate;
Papyrus
achieving, still pursuing, Learn to labour and to wait.2
Still
HARRITH M. HASSON, MD
Chicago 1. Breasted JH:
The Edwin Smith Surgical
Papyrus. Chicago, University 1930, vol 1, p 54. 2.
Longfellow
HW: A Psalm
of
Chicago Press,
of Life,
stanza 9.
Primary Repair of Colonic Injuries To the Editor.\p=m-\Iam writing concerning the article by Matolo et al, "Exper-
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/19/2015
imental Evaluation of Primary Repair of Colonic Injuries" (Arch Surg 111:78-80, 1976). I think the authors offer an important contribution in showing that clean, incised wounds of the colon will heal in the presence of infection. However, in a clinical setting, this finding applies only to low-velocity penetrating injuries, such as stab wounds. It does not apply to the high-energy penetrating wounds
produced by high-velocity gunshot or a close-range shotgun wound, nor does it apply to perforations induced by blunt trauma. Both blunt
injuries and
high-velocity penetrating injuries are surrounded by a margin of contusion injury that extends beyond the obvious open edges. Since this area develops subsequent to the "blast" effect of these injuries, it needs time to appear. It does become manifest at
the time of an early laparotomy. Therefore, due to the inability to define exactly where the uninjured borders are, these wounds should be resected with a margin of apparently normal tissue. Again, since one cannot always be sure the resection will remove all devitalized tissue, espe¬ cially in the left part of the colon, these anastomoses should be protected either by exteriorization or colostomy. In the event of gross contamination of the peritoneal cavity with left-sided colon wounds, exteriorization or colos¬ tomy appeals, because either of these seem to afford greater safety. At the Maryland Institute for Emergency Medicine, in two quite recent cases of very close-range shotgun wounds of the left side of the abdomen, involving massive hemorrhage and multiple organ injuries including both the intestines and urinary tract, we have found it more expeditious to do primary left colectomies and doublebarreled colostomies. Both patients have done well and escaped intraabdominal septic complications. J. STANLEY SMITH, MD Baltimore
An
in
appropriate commentary exists that is perhaps as ancient
a source
the Smith
Papyrus (Ecclesiastes
Sutureless Technique For Skin Closure" (Arch Surg 111:83-84, 1976) by Hasson and colleagues presents an ingenious method for approximating the skin edges without the necessity of perforating the dermis. The method differs from the use of "butterfly" closure in that the tension on the individual closure devices is
as
without necessitating removal and/or reapplication of material, and in the ability to avoid actual contact of adhesive-coated surfaces to the wound edge itself. It strikes me that a great debt is owed some unknown physician\p=n-\ perhaps Imhotep\p=n-\wholived and died some time prior to 2500 bc. It was he who first described the sutureless closure\p=n-\ofwhich the present communication details only a nicety in evolution. At the time of the writing of The Edwin Smith Surgical Papyrus\p=n-\ translated and retranscribed some time during 1600 bc\p=n-\the"butterfly" dressing for wound closure was already in use.
Papyrus. Chicago, University
adjustable
Case 10. Instructions concerning a wound in the top of his eyebrow. If thou examinest a man having a wound in the top of his eyebrow, penetrating to the bone, thou shouldst palpate his wound, [and] draw together for him his gash with stitching. Thou shouldst say concerning him: [he has] a wound in his eyebrow. An ailment which I will treat. Now after thou hast stitched it [thou shouldst bind] fresh meat upon [it] the first day. If thou findst that the stitching of this wound is loose thou shouldst draw [it] together for him with two strips of [adhesive plaster], and thou shouldst treat it with grease and honey everyday until he recovers. As for: "two strips of linen" it means two bands of linen which one applies upon the two lips of the gaping wound in order to cause that one [lip] join to the other.'
The dressing was used for wound closure throughout recorded medical history,- and even into the present.
1:9-10, Masoretic text): "And there is
thing under the sun. Is there a thing whereof it is said, 'See, this is
no new
new?'... It has already been in the ages which were before us." CARL JELENKO III, MD Augusta, Ga 1. Breasted JH: The Edwin Smith Surgical of Chicago Press, 1930. 2. Jelenko C, Jelenko JM, Buxton RW, et al: The evolution of adhesive tape. Surg Gynecol Obstet 126:1083-1088, 1968.
In Reply.\p=m-\Ihave reviewed with great interest The Edwin Smith Surgical
as transcribed by Breasted. The ancient Egyptians did use adhesive plaster made of strips of linen. These were applied, in pairs, "to the two lips of the gaping wound in order to cause that one join to the other."1 Wound closure therefore was effected by a sutureless technique. Dr Jelenko is to be commended on his astute observations and keen knowledge of the surgical literature. We are indebted to the unknown surgeon who described a sutureless closure some 4,500 years ago, and we recognize his contribution. Although his achievement has been largely forgotten, he might take solace from the words of Longfellow, who wrote Let us, then, be up and doing, With a heart for any fate;
Papyrus
achieving, still pursuing, Learn to labour and to wait.2
Still
HARRITH M. HASSON, MD
Chicago 1. Breasted JH:
The Edwin Smith Surgical
Papyrus. Chicago, University 1930, vol 1, p 54. 2.
Longfellow
HW: A Psalm
of
Chicago Press,
of Life,
stanza 9.
Primary Repair of Colonic Injuries To the Editor.\p=m-\Iam writing concerning the article by Matolo et al, "Exper-
Downloaded From: http://archsurg.jamanetwork.com/ by a UQ Library User on 06/19/2015
imental Evaluation of Primary Repair of Colonic Injuries" (Arch Surg 111:78-80, 1976). I think the authors offer an important contribution in showing that clean, incised wounds of the colon will heal in the presence of infection. However, in a clinical setting, this finding applies only to low-velocity penetrating injuries, such as stab wounds. It does not apply to the high-energy penetrating wounds
produced by high-velocity gunshot or a close-range shotgun wound, nor does it apply to perforations induced by blunt trauma. Both blunt
injuries and
high-velocity penetrating injuries are surrounded by a margin of contusion injury that extends beyond the obvious open edges. Since this area develops subsequent to the "blast" effect of these injuries, it needs time to appear. It does become manifest at
the time of an early laparotomy. Therefore, due to the inability to define exactly where the uninjured borders are, these wounds should be resected with a margin of apparently normal tissue. Again, since one cannot always be sure the resection will remove all devitalized tissue, espe¬ cially in the left part of the colon, these anastomoses should be protected either by exteriorization or colostomy. In the event of gross contamination of the peritoneal cavity with left-sided colon wounds, exteriorization or colos¬ tomy appeals, because either of these seem to afford greater safety. At the Maryland Institute for Emergency Medicine, in two quite recent cases of very close-range shotgun wounds of the left side of the abdomen, involving massive hemorrhage and multiple organ injuries including both the intestines and urinary tract, we have found it more expeditious to do primary left colectomies and doublebarreled colostomies. Both patients have done well and escaped intraabdominal septic complications. J. STANLEY SMITH, MD Baltimore
