(Reprinted from The American Journal of Obstetrics and Diseases of 
Women and Children, Vol. XXXVI., No. 2, 1897.] 
SILKWORM GUT AS A SUBCUTANEOUS SUTURE IN CLOSURE 
OF ABDOMINAL INCISIONS.1 
BY 
THOMAS S. CULLEN, M.B. Tor., 
Resident Gynecologist, Johns Hopkins Hospital; Instructor in Gynecology, 
Johns Hopkins University. 
In March of this year Dr. Harvey, of Troy, when visiting- 
us, suggested the use of silkworm gut as a subcutaneous suture 
instead of silver wire or catgut. He told us that Dr. David 
W. Houston, of Troy, had employed it for some time and was 
highly pleased with it. 
Since March this suture has given such satisfaction that we 
employ it almost entirely. Heretofore we closed the peritone- 
um with catgut, the fascia and muscle with mattress sutures 
of silver wire or silkworm gut, and the skin with subcutaneous 
catgut. If the walls contained much fat it was deemed advis- 
able to use several catgut sutures to secure accurate approxi- 
mation, as there was danger of the catgut absorbing before 
satisfactory union had taken place. Occasionally we employed 
subcutaneous silver wire, which answered very well. 
Our method of closure now is: (a) For the peritoneum, con- 
tinuous catgut. 
(b) For the fascia and muscle, mattress sutures of silver wire 
or silkworm gut; where the walls are thick and much tension 
required, usually silver wire; and where the walls are thin, 
silkworm gut. 
(c) Subcutaneous silkworm gut, even though the walls are 
thick, no fat suture is employed, the adipose surfaces lying 
loosely one against the other. It may be mentioned that Dr. 
Halsted has for a long period paid no attention to the fat, 
merely using the subcutaneous silver wire. 
It is advisable to pick out good, strong strands of silkworm 
1 Read before the Clinical Society of Baltimore, May, 1897, when nine 
patients closed by this method were exhibited. 2 
CULLEN: SILKWORM GUT AS A SUBCUTANEOUS 
Name. 
Date. 
Nature of operation. 
Thickness 
of abdomi- 
nal wall. 
Layers of sutures. 
When 
removed. 
Difficulty. 
Result. 
Remarks. 
S. McC... 
A. H. .. 
E. W. ... 
March 31st, 
1897. 
April 24th, 
1897. 
April 12th, 
1897. 
April 19th, 
1897. 
April 23d, 
1897. 
May 19th, 
1897. 
April 19th, 
1897. 
May 15th, 
1897. 
May 12th, 
1897. 
May 10th, 
1897. 
May 28th, 
Thick 
Twenty-fifth 
day. 
Twenty-first 
day. 
Twenty-first 
day. 
None 
Perfect. 
Hystero-myomectomy.. 
u 
Breaking up pelvic ad- 
hesions; suspension of 
uterus. 
(a) Catgut, (b) silver wire, (c) sub- 
cutaneous silkworm gut. 
(a) Catgut, (b) silkworm gut, (c) 
subcutaneous silkworm gut. 
Stitch broke off 
B. P 
S. P .... 
Eighteenth 
day. 
and could not he 
removed. 
Appendectomy. 
XT F 
About twen- 
None 
J. w. w.. 
G. H 
S. B. T... 
R. A 
Myomectomy and sus- 
pension of uterus. 
Myomectomy; suspen- 
sion of uterus. 
Hystero-myomectomy.. 
Nephrorrhaphy and sus- 
gut, (c) subcutaneous silkworm 
gut. 
(a) Catgut, (b) silver wire, (c) sub- 
cutaneous silkworm gut. 
(a) Catgut, (b) catgut, (c) silkworm 
gut. 
(a) Catgut, (b) silver wire, (c) sub- 
cutaneous silkworm gut. 
(a) Catgut, (b) silver wire, (c) sub- 
ty-fifth day. 
About twen- 
ty-fifth day. 
u 
ty-fifth day. 
About twen- 
ty fifth day. 
About nine- 
u 
Thin 
» 
“ 
B. S 
F. R 
K. D. . 
A. D. .. 
A. W .... 
1897. 
May 24 th, 
1897. 
May 17th, 
1897. 
May 14th, 
1897. 
April 21st, 
1897. 
May 14th, 
1897. 
pension of uterus. 
Hystero-myomectomy.. 
Suspension of uterus.... 
Removal of parovarian 
cyst. 
Repair of perineum; 
suspension of uterus. 
Removal of left tuho- 
ovarian mass. 
u 
cutaneous silkworm gut. 
Jiiy. 
An attempt was 
made to remove 
on twenty-fifth 
day, but unsuc- 
cessful, as su- 
ture broke off. 
None 
» 
Moderate.. 
worm gut. 
(a) Catgut, (6) silver wire, (c) silk- 
worm gut. 
(a) Catgut, (b) silver wire, (c) silk- 
worm gut. 
(a) Catgut, (b) silver wire, (c) sub- 
cutaneous silkworm gut. 
(a) catgut, (b) silver wire, (c) sub- 
cutaneous silkworm gut. 
Twenty-fifth 
day. 
“ 
There was a 
kink, evident- 
ly due to one 
loop of liga- 
ture being 
caught by the 
next. 
Twenty-third 
day. 
Perfect. 
cision broke 
down and a 
large quan- 
tity of pus es- 
caped; evi- 
dently some 
infection 
down near the 
muscle. SUTURE IN CLOSURE OF ABDOMINAL INCISIONS. 
3 
A. P 
S. E. C... 
M FT 
May 14tli, 
i 1897. 
iJune 6th, 
1897. 
May 29th, 
1897. 
May 22d, 
1897. 
May 17th, 
1897. 
N ephr orrhaphy 
Cure of umbilical her- 
nia. 
Hystero.myomectomy.. 
Moderate.. 
Thick . ... 
Moderate.. 
Thin 
(a) Catgut, (b) silkworm gut, 
(c) subcutaneous silkworm gut. 
(a) Catgut, (b) catgut, (c) subcu- 
taneous silkworm gut. 
Twenty-third 
day. 
None 
Perfect. 
day. 
Twenty-third 
day. 
Attempted 
removal at 
twenty-fifth 
day. 
U 
C. L. ... 
M. E. . 
(a) Catgut, (6) silver wire, (c) sub- 
cutaneous silkworm gut. 
(a) Catgut, (6) silkworm gut, (c) sub- 
cutaneous silkworm gut. 
Ends broke off left 
in situ. 
None 
“ 
Long incision; 
should have 
been two 
sutures. 
ty-fifth day. 
E W. ... 
M K 
May 22d, 
1897. 
May 24th, 
1897. 
May 21st, 
1897. 
June 7th, 
1897. 
June 16th, 
1897'. 
May 31st, 
1897. 
May 31st, 
1897. 
May 29th, 
1897. 
Release of general pel- 
vic adhesions. 
Double hydrosalpinx; 
both tubes opened and 
washed out. 
Hystero-myomectomy.. 
u 
Peritoneum, catgut; fascia and 
muscle, silver wire; subcutaneous 
silkworm gut. 
(a) Catgut, (b) silkworm gut, (c) sub 
cutaneous silkworm gut. 
(a) Catgut, (b) silver wire, (c) sub- 
cutaneous silkworm gut. 
(a) Catgut, (6) silver wire, (c) subcu- 
taneous silkworm gut. 
(a) Catgut, (6) silkworm gut, (c) sub- 
cutaneous silkworm gut. 
(a) Catgut, (b) , (c) subcutaneous 
silkworm gut. 
a 
u 
ty-third 
day. 
Twenty-sec- 
ond day. 
Twenty- 
seventh 
day. 
J s 
Silver stitch 
L N . 
Moderate.. 
came almost 
to surface, 
and caused 
slight irrita- 
tion for five 
days. 
W. H. H. 
L M. 
Suspension of uterus.... 
day. 
Nineteenth 
tt 
L. K. .. 
F. McL.. 
H 
day. 
it 
Amputation of cervix; 
repair of outlet; sus- 
pension of uterus. 
Repair of perineum; 
myomectomy; sus- 
pension of uterus. 
Nephrectomy 
Removal of small cyst 
of right ovary. 
Thin 
(a) Catgut, (6) silkworm gut, (c) sub- 
cutaneous silkworm gut. 
(a) Catgut, (6) silver wire, (c) sub- 
cutaneous silkworm gut. 
(a) Catgut, (b) silver wire, (c) sub- 
cutaneous silkworm gut. 
(a) Catgut, (6) silkworm gut, (c) sub- 
cutaneous silkworm gut. 
ty-third 
day. 
Twenty-third 
day. 
t 
it 
it 
E. E 
1897. 
May 22d, 
1897. 
June 9th, 
1897. 
June 7th, 
1897. 
Twenty-sec- 
ond day 
A. M 
tt 
E. T 
day. 
Thirteenth 
tt 
E. G 
Thin 
(a) Catgut, (6) silkworm gut, 
(c) subcutaneous silkworm gut. 
day. 
Twenty-first 
day. 
tt 
M S 
1897. 
June 7th, 
1897. 
June 16th, 
1897. 
Removal of a fibroma of 
left ovary; suspension 
of uterus. 
Appendectomy; sus- 
pension of uterus. 
Hystero-myomectomy.. 
tt 
M T 
silkworm gut. 
(a) Catgut, (6) silver wire, (c) sub- 
cutaneous silkworm gut. 
(a) Catgut, (b) silver wire, (c) subcu- 
taneous silkworm gut. 
(a) Catgut, (b) silver wire, (c) sub- 
cutaneous silkworm gut. 
day. 
Tenth day .. 
Tenth day.... 
Twenty-third 
day. 
tt 
J. C . 
Very thick. 
Moderate.. 
Long incision. 
R. McC.. 
1897. 
May 26th, 
1897. 4 
CULLEN: SILKWORM GUT AS SUBCUTANEOUS SUTURE. 
gut, and where the incision is long a new strand should be in- 
serted every six or seven centimetres; the ends are then tied 
together. 
Advantages.—This suture is very pliable, does not kink, and 
if good will not break. It may be left in place one month, or 
more if desired, and causes little or no irritation. 
Disadvantage.—It is occasionally so firmly embedded in the 
tissues that it will break off. 
The Removal of the Continuous Sutur'e.—It may be looked 
at about the tenth day, and, if union be satisfactory, removed; 
if desirable it may be left much longer. Where the suture is 
short it can often be removed by the slightest traction; if the 
incision be a long one the knots where the sutures join are cut 
and firm and steady traction is made with a pair of artery for- 
ceps Should the silkworm gut break off beneath the skin the 
remaining piece is left behind, as is the case when silver wire 
breaks. 
The accompanying is a synopsis of thirty-eight cases, operated 
upon by Dr. Kelly and myself since March, where subcutane- 
ous silkworm gut was employed. 
From a perusal of these cases it will be seen that in two 
a knot had been formed which prevented the removal of the 
suture. Here the needle had retraced its steps, catching in 
the loop that had just been formed. Such a mistake is easily 
avoided after one has once been put on his guard. In four cases 
the sutures broke; this fault we have overcome by making 
the sutures shorter where the incision is long, employing two 
or even three sutures instead of one long one. 
Dr. Houston has employed this method of closure since May, 
1895, using it not only in abdominal surgery, but also in all 
kinds of operative work. He finds it especially suited to 
wounds on the face, where very fine strands are employed, and 
can be removed at the end of forty-eight hours or longer. 
At the meeting of the Society Dr. J. W. Williams said that 
he had used this method in closing the abdomen for one and 
a half years and was thoroughly satisfied with it. Whether 
this suture has been adopted or not by others we cannot say, 
but it is one that may well be utilized by the profession at large.