HISTOIRE DE LA MÉDECINE/HISTORY OF MEDICINE SUTURING...
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Lebanese Medical Journal 2010 • Volume 58 (1) 53 HISTOIRE DE LA MÉDECINE / HISTORY OF MEDICINE SUTURING METHODS AND MATERIALS WITH SPECIAL EMPHASIS ON THE JAWS OF GIANT ANTS (an old-new surgical instrument) http://www.lebanesemedicaljournal.org/articles/58-1/history4.pdf Farid S. HADDAD* INTRODUCTION Man and especially physicians and surgeons have been genuinely very inventive when it comes to ways and means of preventing, diagnosing, and healing disease. In this occurrence, the number of the various kinds of instru- ments which have been devised by surgeons for the diag- nosis and the operative treatment of disease, is legion. From the earliest metal instruments, to bees wax, to metal clips, optico-scopic devices used in endoscopic work, and most recently in laparoscopic surgery, passing by the elec- tric cautery, the ultrasonic knife, and the lithotriptor, the variety of surgical modalities remains the trellis on which grows and thrives the ever advancing surgical instrumen- tation. One of the several dimensions of the history of surgery relates to the development of suturing and ligaturing tech- niques. These include simple suture, the development of catgut, the use of silk, cotton thread, hair, cautery, and boiling oil, and more recently metallic suturing with sil- ver, gold, tantalum, steel and other alloys, electric cautery, and finally the techniques of stapling. The most interest- ing chapter, however, is that in which the jaws of the giant ant are used in a protostapling technique. HISTORICAL BACKGROUND The use of fine gold wire in dentistry was probably invented and first practiced in Phoenicia. The first archeo- logical evidence of the use of gold wire in dentistry was an example of gold-wired teeth in a mandible found in a Tyrean necropolis by Mr Ford ; and it has been referred to in the literature as the “Ford mandible”. The jaw with its beautiful gold wiring of the teeth has been dated back to the 14 th or 15 th century BC [1], the jaw is now exhibited at the Museum of the American University of Beirut. The all-important use of animal gut, as a ligature in sur- gical operations, seems to have been introduced by åbw bakr zakariyyA ålrAzÿ (d c 932) [2-4]. åbw ålqAsim ålzahrAwÿ (d c 1013 AD) confirmed the use of animal gut for the ligation of arteries and emphasized the necessity of being careful not to ligate an adjacent nerve. He also intro- duced the use of gut in intestinal surgery [5]. Albucasis, as he was later known in Latin Europe, described the use of wire suture for fractured jaw and for loose teeth [6] ; he also developed the art of cauterization to a superlative degree and described and illustrated a large variety of cau- teries, many of which he devised himself [6]. In the choice of suture material, Albucasis is also very versatile. He rec- ommended the use of wool for surgical procedures on the eyelid, such as entropion, the use of silk in the ligature of the temporal artery, horse or ox hair for the operation of pterygium, and wire, silver or gold, for the wiring of loose teeth or artificial teeth [7]. When I was practicing surgery in riyAD, Saudi Arabia (1977-81) [8], I saw an elderly black patient on 1977 05 24 ; he wanted something removed from his leg. But no- thing could be seen on his leg until it was thoroughly washed, and a 1/4 inch layer of dirt was washed and scraped off ; only then a 12 cm long sutured incision was seen and the man ordered me to remove the sutures. The suture material was thick hemp thread or flax twines (khayT maSSÿS) that he had used himself on a mattress needle (msallé) about 22 days earlier. It is amazing how dexterous our patient, and his like, are and how stoic to have stitched his own leg wound himself with thick thread and a huge needle, without any anesthesia or sedation ! There was absolutely no reaction to the suture and no infection whatsoever. The wound had amazingly healed very nicely. I guess that the patients who were seen in Saudi Arabia must have been selected by nature and have a great immunity to the common germs that become path- ogenic in the less selected people living in modern cities ! Perhaps the dry climate was also a factor ! ANTS Whether man learned the technique of suturing wounds with the jaws of ants from ants themselves or devised it independently, will probably never be known. For it had been recorded that a species of ants Œcophylla smarag- dina use their jaws to suture green leaves for their nests [Baroni-Urbani, 9 : pp 14, 307-8] ; they use their own larva as shuttles to weave their own fine silk performing a Haddad FS. Suturing methods and materials with special em- phasis on the jaws of giant ants (an old-new surgical instrument). J Med Liban 2010 ; 58 (1) : 53-56. *Curator of The Sami I Haddad Memorial Library, Rancho Palos Verdes, California. Correspondance : Farid S. Haddad, MD. 6409 Vista Pacifica. Rancho Palos Verdes. CA 90275 USA. e-mail : [email protected] Tel/Fax : +1 310 541 0435 ABSTRACT : The historical development of surgical sutures, ligatures, and staples is discussed. The use of the jaws of giant ants, especially in the suturing of bowel injuries, is documented.
Transcript of HISTOIRE DE LA MÉDECINE/HISTORY OF MEDICINE SUTURING...
Lebanese Medical Journal 2010 • Volume 58 (1) 53
HHIISSTTOOIIRREE DDEE LLAA MMÉÉDDEECCIINNEE//HHIISSTTOORRYY OOFF MMEEDDIICCIINNEESUTURING METHODS AND MATERIALS WITH SPECIAL EMPHASIS ON THE JAWSOF GIANT ANTS (an old-new surgical instrument)http://www.lebanesemedicaljournal.org/articles/58-1/history4.pdf
Farid S. HADDAD*
INTRODUCTION
Man and especially physicians and surgeons have beengenuinely very inventive when it comes to ways andmeans of preventing, diagnosing, and healing disease. Inthis occurrence, the number of the various kinds of instru-ments which have been devised by surgeons for the diag-nosis and the operative treatment of disease, is legion.From the earliest metal instruments, to bees wax, to metalclips, optico-scopic devices used in endoscopic work, andmost recently in laparoscopic surgery, passing by the elec-tric cautery, the ultrasonic knife, and the lithotriptor, thevariety of surgical modalities remains the trellis on whichgrows and thrives the ever advancing surgical instrumen-tation.
One of the several dimensions of the history of surgeryrelates to the development of suturing and ligaturing tech-niques. These include simple suture, the development ofcatgut, the use of silk, cotton thread, hair, cautery, andboiling oil, and more recently metallic suturing with sil-ver, gold, tantalum, steel and other alloys, electric cautery,and finally the techniques of stapling. The most interest-ing chapter, however, is that in which the jaws of the giantant are used in a protostapling technique.
HISTORICAL BACKGROUND
The use of fine gold wire in dentistry was probablyinvented and first practiced in Phoenicia. The first archeo-logical evidence of the use of gold wire in dentistry wasan example of gold-wired teeth in a mandible found in aTyrean necropolis by Mr Ford ; and it has been referred toin the literature as the “Ford mandible”. The jaw with itsbeautiful gold wiring of the teeth has been dated back to
the 14th or 15th century BC [1], the jaw is now exhibited at the Museum of the American University of Beirut.
The all-important use of animal gut, as a ligature in sur-gical operations, seems to have been introduced by åbwbakr zakariyyA ålrAzÿ (d c 932) [2-4]. åbw ålqAsimålzahrAwÿ (d c 1013 AD) confirmed the use of animal gutfor the ligation of arteries and emphasized the necessity ofbeing careful not to ligate an adjacent nerve. He also intro-duced the use of gut in intestinal surgery [5]. Albucasis, ashe was later known in Latin Europe, described the use ofwire suture for fractured jaw and for loose teeth [6] ; healso developed the art of cauterization to a superlativedegree and described and illustrated a large variety of cau-teries, many of which he devised himself [6]. In the choiceof suture material, Albucasis is also very versatile. He rec-ommended the use of wool for surgical procedures on theeyelid, such as entropion, the use of silk in the ligature ofthe temporal artery, horse or ox hair for the operation ofpterygium, and wire, silver or gold, for the wiring of looseteeth or artificial teeth [7].
When I was practicing surgery in riyAD, Saudi Arabia(1977-81) [8], I saw an elderly black patient on 1977 0524 ; he wanted something removed from his leg. But no-thing could be seen on his leg until it was thoroughlywashed, and a 1/4 inch layer of dirt was washed andscraped off ; only then a 12 cm long sutured incision wasseen and the man ordered me to remove the sutures. Thesuture material was thick hemp thread or flax twines(khayT maSSÿS) that he had used himself on a mattressneedle (msallé) about 22 days earlier. It is amazing howdexterous our patient, and his like, are and how stoic tohave stitched his own leg wound himself with thick threadand a huge needle, without any anesthesia or sedation !There was absolutely no reaction to the suture and noinfection whatsoever. The wound had amazingly healedvery nicely. I guess that the patients who were seen inSaudi Arabia must have been selected by nature and havea great immunity to the common germs that become path-ogenic in the less selected people living in modern cities !Perhaps the dry climate was also a factor !
ANTS
Whether man learned the technique of suturing woundswith the jaws of ants from ants themselves or devised itindependently, will probably never be known. For it hadbeen recorded that a species of ants Œcophylla smarag-dina use their jaws to suture green leaves for their nests[Baroni-Urbani, 9 : pp 14, 307-8] ; they use their ownlarva as shuttles to weave their own fine silk performing a
Haddad FS. Suturing methods and materials with special em-phasis on the jaws of giant ants (an old-new surgical instrument).J Med Liban 2010 ; 58 (1) : 53-56.
*Curator of The Sami I Haddad Memorial Library, RanchoPalos Verdes, California.
Correspondance : Farid S. Haddad, MD. 6409 VistaPacifica. Rancho Palos Verdes. CA 90275 USA.
e-mail : [email protected] Tel/Fax : +1 310 541 0435
ABSTRACT : The historical development of surgicalsutures, ligatures, and staples is discussed. The use ofthe jaws of giant ants, especially in the suturing ofbowel injuries, is documented.
54 Lebanese Medical Journal 2010 • Volume 58 (1) F. S. HADDAD. – Ant jaws as surgical sutures
marvelous stitch, which is reinforced by gluing [10].The use of the jaws of ants to suture wounds has been
sporadically reported from several countries, as early asthe 10th century BC [11-13, 19] and as late as 1984, arange of nearly 3000 years.
The earliest mention of ants used in surgery occurs inthe Samhita : “Black ants should be applied to the perfo-rated intestines … and their bodies should be separatedfrom their heads after they had firmly bitten the perforat-ed parts with their jaws. After that the intestines with theheads of the ants attached to them should be gentlypushed back into the cavity” [12, 9 p 304].
Arabic medical literature contains a description of thistechnique in åltaSrÿf liman `ajiza `an ålta'lÿf written in the 11th century AD by the famous Arab surgeon,ålzahrAwÿ [Abulcasis or Albucasis, 5-6, 14] (Fig 1). Hewrote : “It has been said by people of experience thatwhen the intestine is wounded and the wound is small, oneought to use the following suture technique : ants withlarge heads are used ; the lips of the wound are approxi-mated ; one of the ants, with its jaws open, is applied overthe lips of the wound ; when it grasps and firmly closes itsjaws, its head is cut off ; it will then hold and will notloosen its grip ; another ant is then applied next to the firstone ; this process is continued with one ant after the otherover the whole extent of the wound ... the jaws will remain
holding the intestines until they stick and heal. The patientsuffers no complication.”
Between 1352 and 1569 the use of ants was mentioned,at least, four times in Latin medical texts [14], but onecannot tell whether the authors really tried them or justrepeated what they had read in Albucasis [9, p 519].
Fallopio [14] (of Fallopian tubes fame) himself was the author of one of these reports (1569 AD). This verycurious technique was found so neat and so interestingthat it was reported, in 1844, to the “Société entomolo-gique de la France” and, in 1845, it was communicated toMalgaigne, editor of the Journal de Chirurgie [14].
In 1845, Furnari [15] reported that he had seen inAlgeria, wounds clamped with the jaws of the beetle Sca-rites pyracmon [9, p 308]. Beebe reported in 1921 [16]that Guiana Indians suture wounds with the jaws of giantAtta cephalotes. He found the jaws of two Attas clampedonto his own boots, “with a mechanical vise-like grip,wholly independent of life or death [9, p 304].
In November 2004, my polymath brother Ibrahimalerted me to the reference from Bernard’s book [17] thatsaid : “Henry de Monfreid … trafiquant et écrivain ; con-nut la Somalie mieux que personne … Or, dans un de seslivres … les sorciers … savent coudre une plaie à l’aide,non d’instruments, mais d’insectes … ils emploient unevariété particulière de fourmi, les prennent en main une à
FIGURE 1. The suture of intestinal wounds with the jaws of ants : the original Arabic text of ålzahrAwÿ. The calligraphy is by Dr Ahmad Younis (Ahmad ywnis ålTarTwsÿ) presently from N Bethesda MD.
F. S. HADDAD. – Ant jaws as surgical sutures Lebanese Medical Journal 2010 • Volume 58 (1) 55
une, de façon que les pinces de l’insecte saisissent cha-cune des lèvres de la plaie, puis, à l’aide du doigt, ilsdécapitent la fourmi.”
The report of the use of the jaws of giant ants for sutur-ing surgical wounds (Fig. 2) has emanated from many dif-ferent parts of the world (Asia, Europe, Africa, SouthAmerica) including : India, Spain, Italy, Brazil, Turkey,Algeria, Guiana, Congo, and Somalia, and by many dif-ferent historians and surgeons (Table I).
For obvious reasons, the use of ants in surgery does notseem to have spread much, nor has it become general.
Whitaker [23] identified the giant ant used as a suture asthe army ant of the subfamily Aenictinae ; it can be identi-fied by the lack “of compound eyes, the 10-segmentedantennae, the mesosoma being attached to the gaster bytwo distinct segments, the petiole and postpetiole and thelack of frontal lobes which makes the antennal socketscompletely visible when viewed from the front … they
range from 4 to 25 mm … their strength lies in their power-ful jaws … once the jaws are clamped they are practicallyimpossible to pry open.”
Writing about the subject of the use of ants in surgery,Majno, in his wonderful book [9, p 306], consulted manyentomologists including TC Scheirla* and NA Weber**,then experimented with several species of ants to find outif they could be used in surgery. Several were found to beuseless : the jaws of Atta ants, for example, were found tobe too small to have any practical value [9, p 306].
However, he obtained beautiful and excellent resultswith other ant species, namely : • Eciton burchelli andEciton hamatu [9, pp 306-9 and Pt 7.2 between p 286 andp 287] from South America, and • Dorylus [9, pp 306-8]from Africa and Asia.
STAPLING
Professor Humer Hueltl first devised metallic stapling inHungary in 1908, using steel wire staples [24]. In 1928,another Hungarian, Alader von Petz, developed a sim-pler and lighter instrument using silver wire staples [24].In 1938, Dr H. Friedrich of Ulm, Germany, introducedthe first stapling instrument with a replaceable staplecartridge. In 1951, the Russians introduced several sta-pling instruments ; each devised for a specific applica-tion (vascular surgery, bronchus, GI, etc.). In the USA,the first modern stapling device was demonstrated in1954 in New York by Nakayama from Chiba, Japan [25-26] ; this is one of those historical facts that has notreceived the recognition it deserves [27].
REFERENCES
1. Haddad FS. ålTibb alfÿnÿqÿ ålqadÿm [Old PhoenicianMedicine]. ålmÿcAq 1968 ; 5 : 418-21.
2. Haddad FS. Pioneers of Arabian medicine. Leb Med J1968 ; 21 : 67-80.
3. Haddad FS. Arab contributions to Medicine. Leb Med J1973 ; 26 : 331-46.
4. Haddad FS. Surgical firsts in Arabic medical literature.Studies in Hist Medicine and Science 1986-1987 ; 10/11 :95-103.
5. Haddad FS. Albucassis. Abbottempo 1968 ; 3 : 22-5.6. Albucasis : On Surgery and Instruments, Spink MS and
Lewis GL, editors, Berkeley and Los Angeles : Universityof California, 1973 : ix, 292, 538, 540, 550 and 716.
7. Haddad FS. Reimplantation of teeth. The J Kuweit MedAss 1967 ; 1 : 243.
8. Haddad FS : Down under the veil - A surgeon in SaudiArabia, Phoenix : Shad Board, 1997, p 84.
9. Majno G : The healing hand, Cambridge : The Common-wealth Fund, 1975.
10. Wheeler WM : Ants. Their Structure and Behavior, New
FIGURE 2. The jaws of a giant ant used to suture a wound,drawn by Linda Stone [18].
TABLE ISTAPLING WITH THE JAWS OF GIANT ANTS [9]
COUNTRY Date Author
INDIA 1000 BC Atharva-Veda Samhita [19]Sushruta Samhita [12]Charaka Samhita [13]
SPAIN 1000 AD abw alqAsim alzahrAwy [5, 6, 14]PADUA 1352 Brunus of CalabriaBOLOGNA 1493 Mondino da LuzziPADUA 1499 Leonardo BertapagliaPADUA 1569 Gabriel Fallopio
1839 A. Vidal [20]BRAZIL 1844 Emile Mocquerys of RouenALGERIA 1845 S. Furnari [15]SMYRNA 1896 R. M. Middleton [21]ALGERIA 1898 Marcel BaudoinGUIANA 1921 Beebe [16, 9 p 519]CONGO 1975 Raignier [22, 9 pp 456, 519]SOMALIA 1984 Bernard [17]
*who wrote : “It is a real problem to get the jaws of these in-sects out of your skin once they have been firmly implanted”[9, p 306].
**was personally bitten by an ant so effectively that his clotheshad become sutured to his skin.
56 Lebanese Medical Journal 2010 • Volume 58 (1) F. S. HADDAD. – Ant jaws as surgical sutures
York : Columbia University Press, 1910 (repr 1960).11. Ackerknecht EH. Primitive surgery. In : Brothwell D and
Sandison AT, eds. Diseases in Antiquity. Springfield : CC Thomas, 1967, Ch 51, pp 635-50.
12. Samhita S. Trans by KL Bhishagratna Chowkhamba,Sanskrit Series Office, Varanasi, India (1907-1911 ; repr1963, 3 vols) [Cf. ref 17 pp 304, 456, 519].
13. Samhita C. Trans ACh Kaviratna. Calcutta [pub by thetrans ; in 51 fascicles between 1897 and 1912] [Cf. ref 17pp 454, 519].
14. Gudger EW. Stitching wounds with the mandibles of antsand beetles. JAMA 1925 ; 84 : 1861-4.
15. Furnari S. Notes sur un mode particulier de réunion desplaies, usité chez les Arabes. J de Chir 1845 ; 3 : 118-19.
16. Beebe W : The Edge of the Jungle, New York : Holt,1921, p 178.
17. Bernard JL : Le retour d’Isis, Bayonne : Harriet, 1984.18. Haddad FS. Sutures, ligatures, ants and staples. JIMA 1994
Apr ; 26 (2) : 83-4 and Spicilegia II Paradise Valley : ShadBoard, 2005, pp 87-91.
19. Samhita AV. Transl by WD Whitney. Delhi : MotilalBanarsidas, 1962 (Reprint of the American ed. ; 2 vols).
20. Benedum J. Aus der Geschichte der Wundbehandlung.Zbl Chir 2000 ; 125 (Suppl 1) : S84-S86.
21. Burr M : The Insect Legion, London : Nisbet, 1939 [Cf ref 17 p 453].
22. Raignier A. Les Doryles africains. In : Parcs nationaux(Belgium). Bull trimestr de l’ASBI Ardenne et Gaume 15 : 3-19 [Cf. ref 17 pp 456, 519].
23. Whitaker IS, Chahal CA, Foot IT. Historical case :Aenictinae : the arthropodic suture. Br J Oral MaxillofacSurg 2005 Aug ; 43 (4) : 362.
24. Hardy KJ. Non-suture anastomosis : the historical devel-opment. Aust N Z J Surg 1990 ; 60 : 625-33.
25. Haddad FS. News of medical meetings and congresses.Ann Rep Orient Hosp 1954 ; 7 : 53-65.
26. Nakayama K. Simplification of the Billroth I gastricresection. Surgery 1954 ; 35 : 837-43.
27. Ravitch MM. Development of intestinal anastomoticdevices. South Med J 1982 ; 75 : 1520-30.
