Colorectal Surgery:Footprints in the sands of time.

Welch has rather facetiously stated that the motto of the proctologist is onward and upward and this is true in another sense as well.The advance from the days of John of Arderne to the present-day status of the colorectal surgeon being a well-trained abdominal surgeon, as well as a specialist in anal problems, has been long upward climb. In 1936, Rankin stated:

"This huge progress over a period of years in rectal surgery is a monument to these pioneers whose untiring efforts,sturdy courage and maintenance of the highest tradition of the profession, forced progress in a field not too favorably looked upon by general surgeons as a whole because of an unwarrantably high mortality, unpleasant,disease and prolonged and complicated convalescence."

Colorectal surgery, as a specialty, parallels the development of surgery in general. Homans stated that man appears to differ from the four-footed animals in suffering from a great number of painful and disabling anorectal diseases. Whether these diseases were more prevalent in other times is unknown, but there are numerous records of treatment of anal and rectal diseases handed down to us by the ancients.


The Egyptians

The Ebers medical papyrus, c. 1700 B.C., gives 33 prescriptions or recipes for the treatment of anorectal diseases. 'These include ointments, suppositories, enema'; and liniments, most of which had a fatty base, plus prescriptions for cathartics and vermifuges. The Beatty medical papyrus of the 12th and 13th century B.C. consists almost entirely of methods and remedies for treating colon and anorectal disease. The prescriptions contain such ingredients as honey, myrrh, flour, ibex fat, and rectal injections containing honey and sweet beer. Banov, in his review, mentions 41 prescriptions found in the Beatty papyrus which were used to treat such conditions as pruritus ani, painful swelling (probably in thrombosed hemorrhoids), and prolapse of the rectum. Study of this papyrus leads one to agree with Herodotus that there were specialists for colorectal diseases as well as for many other diseases.

The Indians

In the Susruta Samhita(represents arguably the zenith of ancient India’s medical and surgical system. It provides a historical window into a school of professionalized surgical practice over 2000 years ago, during when it almost certainly represented the most advanced school of surgery in the world) recorded between 800 - 600 BC., the treatment of penetrating intestinal wounds was clearly described. In the case of disembowelment, the protruded bowel is carefully examined for injury, anointed with ghee and honey and returned into the peritoneal cavity in its natural position. Lacerations of the intestine were ingeniously repaired with living Bengal black ants that were used to approximate the bowel edges; these ants were then decapitated so that the bowel approximation was maintained. Following anointment with ghee, milk and honey, the bowel was returned to the peritoneal cavity.


The Greeks
Hippocrates (460-377 B.C.) wrote extensively on the diseases of the anus and rectum, as shown by his dissertations "On Fistula" and "On Hemorrhoids."The treatment of these diseases by means of suppositories, ointments, and enemas was much the same as that of the Egyptians. The Greeks seemed to do more in the way of surgery. Hippocrates writes in some depth on the treatment of hemorrhoids by cutting, excising, sewing, binding, and cautery. His directions for the use of the cautery include: "Force out the anus as much as possible with the fingers, make the irons red-hot, and burn the pile until it be dried up, and so as that no part may be left behind .... You will recognize the hemorrhoids without difficulty, for they project on the inside of the gut like dark-colored grapes, and when the anus is forced out they spurt blood. When the cautery is applied the patient's head and hands should be held so that he may not stir, but he himself should cry out, for this will make the rectum project the more.. .. '" Up until the 19th century, hemorrhoids were some• times called "condylomata" and this is a point to be noted in reading the d escriptions of the old authors.
Hippocrates recognized the relationship between the anorectal abscess and the resulting fistula. His treatment of fistula was by a stent or by a ligature technique. In his treatise "On Fistula" he gives the following description of treatment:
"Another method of cure:-Taking a very slender thread of raw lint, and uniting it into five folds of the length of a span, and wrapping them round with a ho rse hair; then having made a director (specillum) of tin, with an eye at its extremity, and passed through it th e end of raw lint wrapped round as above described, introduce the director into the fistula, and, at the same time, introduce the index finger of the left hand per anum; and when the director touches the finger, bring it out with the finger, bending the extremity of the director and the ends of the threads in it, and the director is to be withdrawn, but the ends of the threads are to be knotted twice or thrice, and the res! of the raw threads is to be twisted round and fastened into a knot." , Hippocrates also realized the relationship of the urinary tract to anorectal diseases. Prescriptions for both were often given at the same time. Cutting, a I well as cautery, was often used for hemorrhoids and astringent dressings applied to control the bleeding.
Hemorrhoids were also treated with suppository and they were advised to be opened when they may become ripe. In regard to wounds of the intestine, Hippocrates was of the opinion that all such wounds were fatal, although the ancient Hindu writings, Susruta (6th century B.C.), advised the closing of the wounds of the intestines with the pincers of black ants, washing it off with emoluments and reintroducing it into the abdomen. The first description of an intestinal wound, as frequently quoted, is from the Bible, Judges 2: 3:22, when Eglon was stabbed by Ehud "he could not draw, the dagger out of his belly and the dirt came out."

The Romans

The Romans did not contribute much to the practice of proctology, following for the most part the Egyptian and Greek methods of treatment. However, Cclsus (25 B.c.-50 A.D.) stated that wounds of the intestine should be sutured in all layers and, in "De Re Medica," advocated the use of the knife for anal fistula; for multiple fistulous openings, he recommended that the ligature be used along with the surgery.Galen (129-199 A.D.), despite his great fame and authority, contributed little to the treatment of anorectal diseases.

The Byzantines

Skipping a few centuries, we come to Paul Aegina, 7th century surgeon of the Byzantine period. Paul gives excellent descriptions for the procedures for
hemorrhoidectomy and anal fistula.
"Tile existence of hemorrhoids is rendered manifest to us by the discharge from them. Before proceeding to the operation we must use sequent clysters with the view of evacuating at the same time the contents of the intestine, and by irritating the anus, of rendering it more disposed to eversion and protrusion of the gut. Having, therefore, laid the patient on his back in a clear light, if we are to use the ligature we pass a very thick thread round the lips and ,secure each of the hemorrhoids with this ligature, leaving one as an outlet to the superfluous blood (for so Hippocrates directs). After the application of the ligature, using a compress that has been dipped in oil and the bandage adapted for the anus, we order the patient to remain quiet, ... Leonides has not recourse to the ligature, but having seized the hemorrhoids and held them for some time with the forceps used for operations on the uvula, he cuts them off with a scalpel. ... Others by filling the cavity of the instrument called staphylocaustes, with caustic medicines, have burnt hemorrhoids like a scirrhous uvula.""

The Arabs

Under the Arabs, there was not much improvement in treatment of these diseases, although Maimonides (1135-1204 A.D.) wrote a treatise "On Hemorrhoids" in which he recommended light diet and Sitz baths. He did not believe that this would cure many cases as the cause of the disease would not be attacked directly and he felt that recurrence would be frequent.

School of Salerno

The next step takes us to the School of Salerno where Roger Frugardi ( 1170) or Roger of Salerno, as he was known, is said to have recommended the suture of wounds of the intestine over a stent using the trachea of a large bird or large or large hollow elder twig, according to some authorities. The School of Salerno was noted for its rules of hygiene as set forth in one of the most popular medical books of all time, The Regimen Sanitatis Salerni. The English translation of one of their dictums by Sir John Harrington, a godson of Queen Elizabeth I and inventor of the
modern water closet, is of interest in this regard:
"Great Harmes have grown, and Maladies exceeding, By keeping in a little blast of wind; So cramps and dropsy, colics have their breeding and mazed brains for want of vent behind; Besides we find the stories worth the reading, A certain Roman Emperor was so kind, Claudius by name, he made a proclamation, Escape of wind to be no longer loss of reputation. Great suppers to the stomach much offend, Sup light to sleep intend.'"
During the Middle Ages, sufferers from most diseases had a patron saint whom they could invoke. Saint Fiacre, a 7th century acolyte, was the patron saint of gardeners and eventually became the patron saint of hemorrhoid sufferers. He must have been a popular saint, for in Paris an inn was named after him and featured a statue of the saint. The carriages that stood outside the inn thus eventually assumed the name of fiacres.

Fourteenth Century

If Saint Fiacre was the patron saint of hemorrhoid and fistula sufferers, those who treated these diseases would probably have chosen John of Arderne, born in the year 1307 A.D. His works were studied extensively and translated by Sir D'Arcy Power. Arderne served in the Hundred Years' War under the Duke of Lancaster (John of Gaunt). He began his surgery in Newark upon discharge from the military.
He was particularly interested in diseases of the rectum and anus and described an operation for anal fistula which differs very little from the modern treatment of this condition. He had a very prominent clientele and charged correspondingly large fees which were sometimes paid in the form of annuities. He laid down rules of conduct and urged his followers to cultivate charity and a chaste mode of life,avoiding all harlotry , and to be particularly careful in their conduct with the wives, daughters and other women in the household of their patients. He believed in careful following of his cases and the importance of aftercare; and he reported his failures as well as his successes. He recognized ischiorectal abscesses as a cause of fistulas and urged that they be opened before they ruptured into the rectum. His description of cancer of the rectum is classic and follows:

"Bubo is an apostem breeding within the anus in the rectum with great hardness but little aching. This I say, before it ulcerates, is nothing else than a hidden cancer, that may not in the beginning of it be known by the sight of the eye, for it is all hidden within the rectum; and therefore it is called bubo, for as bubo, i.e. , an owl, is always dwelling in hiding so that this sickness lurks within the rectum in the beginning, but after passage of time it ulcerates and, eroding the anus, comes out. And often it erodes and wastes all of the circumference of it so that ... it may never be cured with man's cure. But if it pleases God, that made man out of nothing, to help with his unspeakable virtue; which , forsooth, is known thus: the leech put his finger into the anus of the patient, and if he finds within the anus a thing hard as a stone, sometimes on one side only, sometimes on both, so that it permits the patient to have egestibn, it is bubo [cancer 1 for certain. Signs, forsooth, of ulceration are these: the patient cannot abstain from going to the privy because of aching and pricking and that twice or thrice within one hour; and he passes a stinking discharge mixed with watery blood. Ignorant leeches will assure the patient, that he has dysentery, that is, the bloody flux, when truly it is not. I never saw nor heard of any man that was cured of cancer of the rectum, but I have known manv that died'of the foresaid sickness."

Sixteenth Century

The 16th century gave us two of the greatest names in surgery. Andreas Vesalius (1514-1564 A.D.), called the Father of Anatomy, and Ambroise Pare (1510-1590 A.D.), military surgeon and surgeon to several Kings of France. However great their contributions to surgery and anatomy, they left very little of interest to the history of colorectal surgery. There are two items of interest in Pare's works, one paper on wounds of the intestine appears under the title "The Guts" in his
essay "How to Make Reports": "When the guts are wounded, the whole body is griped and pained, the excrements come out at the wound, whereat often times the guts breake forth with great violence." The other appears in his "An Apology and Treatise," in which he differs from the authority of Hippocrates:
"Moreover, I should be sorry to follow the saying of the sayd Hippocrates, in the third book, De Morbis, who commands in the disease called Volvulus to cause the belly to be blown with a pair of Bellowes, putting the nosell of them into the
intestinum rectum:, and then blow there till the belly be much stretch, afterwards to give an emollient glister, and to stop the fundament with a sponge. Such practise as this is not made now a day therefore wonder not if I have not spoken of it." •

Seventeenth Century

Concerning the 17th century, Mettler 3 states "Proctologic operations, notably those for hemorrhoids and fistulae, were much the same as we have previously found. ... "

The 17th century, however, produced a notable event. in the form of Louis XIV's operation for fistula.Bettman describes it as follows:

"In 1685, Louis developed a small lump in the rectum. The court doctors and apothecaries failed to remove it, so a surgeon, Charles Francois Felix, was summoned. First he explained to Louis how surgery would bring relief. Then he set the date of operation six months ahead. This gave him time to practice on more lowly patients, the greater part of who died under his knife. They were buried at night, to keep the news from reaching the public ear. Finally, on November 18, 1686, Felix performed the operation at Versailles, in the presence of Madame de
Maintenon and the court medical staff. It proved a complete success. As Louis recovered, his sycophants walked around the court with their bottoms bandaged, to show their sympathy with the King's posterior discomfort. "Felix received 300,000 livres for the job, three times the annual salary of the chief physician. He was made a nobleman, and the year 1686 became known as 'I'anee dela fistule.”
The event was considered of such importance that Michelet considered this "more important than the work of Pare," and Garrison states that this brought about the rehabilitation of French surgery.

The 17-century physician Morgani receives special praise from Charles Elton Blanchard's 1938 classic, The Romance of Proctology.says of him on our behalf: "We are thankful to Morgani that, in the midst of all his many researches, he, of all the great names at Padua, looked into the human rectum, and discovered and named its crypts and pillars.
"It is strange," Blanchard reminds us, "how immortality in medicine is often gained by some very minor contribution.
"Morgani is remembered by the crypts and columns of the rectal outlet; Hilton by his 'white line', which is seldom white in the living subject.

Eighteenth Century

In Paris, in 1701, Jean Mery (1645-1722) performed in a patient, suffering from large bowel gangrene after a strangulated hernia, the first artificial anus, followed by Françoi s-Gigot de la Peyronie (1678-1747) who carried out the same intervention in 1723 and 1743, and Jean-Louis Petit (1674-1750), are announcing in 1718 with success the same procedure. Simultaneously, surgeons tried to create a colostomy not only in cases of intestinal obstruction due to hernias but also due to tumors. Two methods will appear having the same objective, but a different realization: the method of Callisen and the method of Littre.
One year after the death of François Broussais (1772-1838) from rectal cancer, the French surgeon Jean-Zuléma Amussat (1796-1856; who treated Broussais but didn’t dare to realize on his master the technique which he proposed, in 1839, in the Gazette Médicale de Paris entitled “Mémoire sur la possibilité d’établir un anus artifi ciel dans la région lombaire, sans pénétrer dans le péritoine”, had the idea to perform an orifice for the fecal discharge by a section in the descending colon, in the left lumbar region . The part of the bowel to an exterior abdominal orifice that we will never close and which will function as an anus”
The rifle-barrel colostomy and Hartmann’s operation are based on this idea. The first recorded suggestion for enterostomy or colostomy was made by Littre; (1658-1726 A.D.) as reported by Fontanelle in 1710. In part, the incident is described as follows:

'M. Littre'," saw in the dead body of an infant of six days a mal development of the rectum. The rectum was divided into two portions both closed and connected by only a few threads of tissue of about an inch long. The upper portion or the closed bowel was filled with meconium. The lower portion was entirely empty. M. Littre, wishing to render his observations useful, imagined and proposed a very delicate operation in the case where one would recognize a similar conformation. It would be necessary to make an incision in the belly, open the two ends of the closed bowel and stitch them together, or at least to bring the upper part of the bowel to the surface of the belly wall, where',' it would never close, but perform the function of anus. Upon this slight suggestion a clever surgeon could imagine for himself details which we suppress. It often suffices to know in general that a thing may be possible and not to despair of it at first sight.” However the operation was not to be performed for another sixty-six years when it was performed by another French surgeon, Pillore. The extensive, interesting history and case report is quoted by Dinnick in some detail. The surgeon, Pillore, had several of his colleagues see the patient but no one thought he should be operated on. However, the patient, when he knew there was no other release for his obstruction, urged the surgeon to operate. He made a transverse incision of the abdomen and a transverse incision of the cecum and sutured them to the edges of the wound. The patient died 20 days after the operation from erosion of the intestine by several pounds of quicksilver which he had taken, but had been unable to pass either per anum or through the cecostomy.
Pierre Duret (1745-1825), surgeon Major in Brest’s navy, was the first surgeon to perform colostomy in a child. In 1793, thanks to an iliac colostomy, he saved the life of a child affected by anal imperforation. The first colostomy to treat a cancer was a caecostomy and was performed by Pillore of Rouen in 1770. The patient was a wine merchant suffering by large bowel obstruction due a scirrhous carcinoma located at the colorectal junction. The distended caecum was exposed through a transverse section, opened and fixed to the margins of the wound with a couple of sutures. The operation produced great relief of the obstruction but the patient died on the 28th post-operative day because of necrosis of a loop of jejunum produced by the large amounts of mercury amounting to 2 lbs in weight that had been given in the original conservative attempts to overcome the obstruction. This case went unnoticed, although the technique became well-known; an excellent technique and a good post-operative care thanks to a sponge maintained in the caecostomy allowing the faeces deposition. Charles Louis Dumas (1765-1813) Professor of Anatomy and Physiology in Montpelier, then Dean of the Faculty and vice-chancellor of the University, ignoring the operation of Pillore, proposed the left colostomy in a case of rectal cancer (1797) , followed by Pierre Fine (1760-1814), chief surgeon of the General Hospital of Geneva, who carried out the first successful transverse colostomy in 1797. The patient, a woman aged 63 with a recto-sigmoid obstructing growth, lived for 3.5 months before dying of ascites . These two case reports published in Annales de la Société de Médecine de Montpellier remained ignored.
However, the real birth of colostomy as a successful operation occurred in 1793 when Duret performed a left iliac colostomy in a case of imperforate anus in a child three days old. Again, a complete operative note was made and is recorded in Dinnick's paper. The patient survived and lived to the age of 45 years. Desault (1744-1795 A.D.) surgeon-in-chief at L'Hotel Dieu performed the same operation on a two-clay-old infant with an imperforate anus, in 1774. However, he did not suture the edges and the patient died four days postoperatively.



In the 18th century, Morgagni (1689-1771 A.D.) described the crypts and columns which still bear his name and he was the first to propose an operation for cancer of the rectum. According to Meade a posterior resection of the rectum was performed in 1739 by Fajet which resulted in an uncontrollable sacral anus. More important, however, was the study and development of the operation of colostomy which was of great importance in giving experience with surgeon of the bowels which would prove valuable when more extensive operations would be performed later in the Century. Throughout the centuries, physicians acquired considerable knowledge of colostomies from observation of the fistulas caused by trauma or disease.
Lorenz Heister (1683-1758 A.D.) gives this account of state of that knowledge entitled "On the Spontaneous Colitis or Operative Creation of an External Intestinal Fistula in Injuries or Gangrene of Bowel."Or Loss of Substance in the Intestines”

Where any Part of the Intestine is carried away, the case seems to be plainly desperate. It was therefore wonderful that Persons thus wounded did not all die upon the Spot. ' in the Operation of making the Sutures: till various surgeons observed, that the Lips of Intestines so wounded, would sometimes quite unexpectedly adhere to the Wound in the Abdomen: and therefore there seemed to be no Reason why we should not take this Hint from Nature. Whenever therefore a Surgeon is called to a Case of this Kind, after he has diligently examined the State of the Copper Pan of the Intestine, which has suffered a Loss of Substance, he should stitch it to the external Wound, either by the continued or interrupted Suture. For by this means the Patient may not only be saved from instant Death. but there have been Instances where the wounded intestine has been so far healed, that the Faeces which used to be voided per Anum, have been voided by the Wound in the Abdomen: Which, from the Necessity of wearing a Tine or Silver Pipe, or keeping Cloths constantly upon the Part to receive the Excrement, may seem to be very troublesome: But it is surely far better to part with one of the Conveniences of Life, than to part with Life itself. Besides, the Excrements that are voided by this Passage are not altogether so offensive, as those that are voided per Anum.

The same Method of Cure may conveniently enough to be put in practice, where any Part of the Intestine is identified by being forced out of the Abdomen. For in this Case, if you tie up the mesenteric Arteries, the corrupted or mortified Part of the Intestine may be cut off, and the remaining sound Part made to adhere to the Wound of the Abdomen. For it is better to try this Method, though few should be saved by it, than to suffer all to perish, as Celsus observes; It is wiser to attempt a doubtful remedy than absolutely to despair. ronce published a Cure of this Kind in a Dissertation containing various Observations, printed at Heimstadt." ,.

Nineteenth Century

During the first half of the 19th century, interest in colostomy continued and the operation was performed more frequently. In 1810, Callisen, professor of surgery at Copenhagen, wrote concerning Colostomy, and conceived the lumbar colostomy in order to prevent the peritoneal penetration (extraperitoneal colostomy) but didn’t realize it . A French surgeon,Amussat began by studying meticulously the anatomical
region on which the operation was based. He reviewed the literature and found that in a period of 63 years since the time of Pillore's first case in 1776 to his own first case in 1839 there had been 29 cases. Nine of these patients survived: 21 of the operations had been for imperforate anus, of these only 4 survived. All of these 4 had been operated on in Brest, the town where Duret had first performed the operation. Of the remaining 8 adults, 5 had survived and all of these had been operated on by the abdominal route. Amussat attributed the fatalities to peritonitis He realized that the left colon lacks peritoneum. Having tried on cadavers all the surgical procedures for colostomy proposed or executed until then and after numerous experiments on animals, Amussat decided to make a transverse section in the region. The first opportunity to apply his procedure in a patient appeared in 1839. It was the case of a woman presented with intestinal obstruction caused by a rectal growth and on June 2, 1839 Amussat carried out the first successfully extraperitoneal colostomy in the lumbar region. One month later, the patient left for the countryside after a rigorous evaluation by the council of the Academy of Science, François Magendie (1783-1855) and Gilbert Breschet (1783-1845), who were able to notice that the colostomy functioned perfectly and the feces appeared regularly. Amussat practised a second operation on a 62-year-old man with cancer obstructing the upper half of the rectum, resistant to dilatation and cauterization. This operation was performed with the same technique and had the same success as the previous one.

Amussat performed a lumbar colostomy through a transverse incision and laid down some rules for the performance of the operation. He determined the site of obstruction by first, rectal examination; second, the amount of f1uid it was possible to inject into the rectum; and third, when the exact site of the tumor could not be determined he punctured the distended bowel with a small trocar. He advised the operation on the right side (1) when the tumor was too near the site of operation on the left side, (2) when the obstruction was far from the anus, and (3) when the site of the obstruction could not be determined. The importance of colostomy is that it was well suited for the pre-anesthetic and pre-antiseptic days and it gave a certain impetus and moderate amount of experience in surgery of the bowel. Amussat's writings are important to the colorectal surgeon; they are complete, precise and show excel lent study of the cases. Amussat defends his operation in the following statement, "An artificial anus , it is true, it is a grave infirmity, but it is not insupportable. To be able to practise it a surgeon ought to fear to be surprised by a pressing occasion, and he should prepare himself by many repetitions of the operation upon the cadaver."
John Ericson, surgeon of the University College Hospital in London, was a pupil of Amussat and was present at his first operation. 14 In 1841, he published a report giving the following indications for colostomy:

1. Imperforate anus
2. Simple retention of feces which could not
otherwise be relieved
3. Obstruction of the big bowel
4. In cancer of the rectum, as soon as pain becomes severe.



Freer, a surgeon of Birmingham, England, performed the first colostomy in that country in 1815. 13 He was followed by Daniel Pring, of Bath, who performed a left iliac colostomy for obstruction due to cancer of the rectum in 1820. An American, Philip Syng Physick (1768-1837), known as the Father of American Surgery, wrote "An Operation for Artificial Anus" in 1826. Dupuyo'en (1777-1835) in France developed a clamp for treating the spur in artificial anus and wrote of this in 1828. "Before using the instrument on man, I made some experiments on living animals; its effects surpassed my hopes. The parts were always divided in six or eight days, and whenever serous membranes were included between the branches of the enterotome, they were found to adhere on the second or third day, consequently. long before the division which happened only on the seventh or eighth. "This highly important adhesive inflammation extends on each side, along the whole length of the branches often cnterotomc, as well as around its point which it exactly circumscribes. It is accompanied by the signs of moderate inf1ammation, at first weak and easily destroyed; at the end of five or six days, this adhesion is pretty strong. It afterwards becomes cellular, and is as solid as a natural union.
"The action of the enterotome and the division of the parts are never attended by acute pain; the inf1ammation is always limited to the vicinity of the parts, around which it forms a small areola, but never extends to the tissue of the organs. It operates by causing mortification of the included parts, and the solution of continuity resulting proceeds from the fall of a slough which is always in between the blades of the instrument. ... "The cure has not been equally perfect in all these cases. In nine there have remained fistulas of various extents, obliging the patient to wear constantly a bandage in order to prevent the escape of flatus, mucous, bilious or fecal matter. The other twenty nine were radically cured in from two to six months. The fatality has therefore been one in fourteen; and taking away the one who perished accidentally from indigestion, it is reduced to one twentieth of the cases operated upon; a result much more favorable than generally obtained in great surgical operations. Lastly, it is to be remarked, that the last fourth of the patients, although less fortunate and obliged to wear a bandage with a pad, were in a situation incomparably preferable to that in which they had previously existed.'"Dieffenbach (1792-1847) in Germany wrote on the treatment of praeternatural anus in 1834.

Fajet attempted a resection of the rectum posteriorly in 1793, but the first successful operation was performed by Jacques Lisfranc (1790-1847), a surgeon of La Pitie Hospital in Paris.' His first successful perineal or posterior resection of the rectum was carried out in 1826 and, in 1833; he reported nine cases on which he had operated. He recommended treating only lesions that were palpable on digital examination and which were not relieved by other forms of treatment. This operation was carried out below the level of the peritoneal retrof1xion by pulling down and amputating a couple of inches of the rectum. According to Mettler, "although these operations were spoken of as rectal removals, they were really only anal excisions with more or less of the lower end of the rectum taken out and were still only palliative and not curative procedures." Most of the patients died with generalized carcinomatosis within two years. Further interest in disease of the colon, rectum and anus was shown by the publication of several volumes•In England and the United States. British books on anorectal diseases in the first 40 years of the nineteenth century were produced by George Calvert, Thomas Copeland, William White, Fredertck. Salmon, John Hawship, and John Kirby in the United States the first standard book on diseases of the rectum was written in 1836 by Bushe, a man of somewhat mysterious origins, who died very young of tuberculosis, Copeland, whose book was pubiished in 1810 described stenosing cancer of the rectum as much as Joan of Arderne. Frederick Salmon (1796-1868) was an important person in the history of proctology. In 1835, he founded seven bed infirmary known as "The Infirmary for the relief of the Poor Afflicted with Fistula and Other Diseases of the Rectum." In 1854 this became St.Marks Hospital, with twenty-five beds, and St. Marks, in turn, became a fountainhead for the education of colorectal surgeons in England and in this country. The early years of the nineteenth century produced a great interest in the treatment of intestinal wounds and suturing of the intestines. Benjamin Travers (1783-1858), in 1812, made a study of intestinal wounds called "An Inquiry into the Process of nature in Repairing Injuries of the Intestines," citing many experiments on dogs and concluding that it was better to attempt to suture these wounds than merely to perform an ileostomy or colostomy. South, in his English translation of Chelius' "Surgery ," gives a summary of the types of suture in vogue in the first half of the nineteenth century. Another interesting item in the above-mentioned book (Chelius) is an early prototype of the Murphy button. In 1826, Denans was said to introduce "into the upper and lower end of the gut a silver or zinc ring, thrusting it inwards about two lines from each end; he then brings out the two ends together over a third ring, of which the two springs retain the external rings. T he included ends of the intestine mortify, and the rings thereby becoming unfastened are discharged by stool, after they have united the serous
till faces in contact. This experiment in the dog has most successful results."
Perhaps, however, the most important of all methods of suturing was introduced in the same year, 1826, by A. Lembert and the description given in Chelius deserves repetition because of the imporlance and continued popularity of the Lembert
suture: "Lembert holds one lip of the wound, whilst he introduces the fore finger into the cavity of the gut, and with the thumb on the external surface presses and pierces it within two lines and a half from the bleeding edge, allowing the needle to pass about a line between the membranes or the intestine, and again passes it out a line and a half from the edge. After he has thus fastened on the external surface of the intestine a small piece of the serous and muscular coats, or even of the mucous coat, if the two former be not sufficiently resistant, he takes hold of the opposite edges of the wound, finds the point which corresponds to the part already pierced, and pushes in the same needle about a line and a half from the edge, allowing it to pass for a line's space between the coats, and about two lines and a half from the bleeding edge. The other threads are applied in the same manner at a distance from three or four lines. The edges of the wound are then turned inwards by means of a probe, and a simple knot is made upon the probe, after which it is withdrawn. In consequence of stitching, a ridge formed by the edges of the wound, projects into the intestine; externally a groove is seen, where the serous surfaces of the intestines lie close together. If the intestines be cut completely through , the edges of the wound produce an internal circular valve."The freedom given by anesthesia and antisepsis led to the development of more and different operations than had been possible in the past, and, in the case of colorectal surgery, this took two different courses because of the anatomic differences encountered in excising the rectum and in operations on the rest of the colon. Acting on the pioneer work of Lisfranc in 1826 and Pinault in 1824, the perineal excision of the rectum continued to be carried out. Theodore Billroth, the father of visceral surgery, is said to have excised the rectum 12 times between 1860 and 1867, and 33 times between 1868 and 1872.'2 Volkmann reported on excision of the rectum in 1878. Verneuil in 1873 began removing the coccyx routinely to improve exposure and revived interest in the resection of the rectum for carcinoma. He modified the original Lisfranc operation by greatly extending the field of operation. Kocher in 1875 and 1876 began closing the anus with a purse string suture and excising a portion of the sacrum as well as the coccyx. This allowed for more radical excision. In this operation, the colon was brought down and sutured to the anus. In 1878, Harrison Cripps excised the rectum, but did not bring the colon down, merely packing the wound. His patients survived at least fourteen months. One of the greatest contributors to the posterior proctectomy was Kraske who, in 1885, presented his operation to the Fourteenth Congress of German Surgeons. His operation, briefly stated, was to make an incision in the median line from the center of the sacrum to the anus, detach the ligaments and fibrous tissue from the left side of the coccyx and sacrum as high as the third sacral foramen, disarticulate and remove the coccyx and, with a gouge, remove the lower part of the left side of the sacrum in a curved outline to the level of the lower border of the third sacral foramen. The posterior wall of the gut was then freed from connective tissue and muscle and the anterior connections likewise severed. The parts to be removed were carefully walled off with gauze to prevent infection and the diseased segment was removed by transverse division of the gut at least half an inch on either side of the growth. The bowel was drawn down from above and joined in the usual manner to the perianal skin and external sphincter with the division of the peritoneum close to the bowel, as was favored by Kocher. This operation and minor modifications by Hochenegg, Badenhauer, Levy and Rydygier was popular into the twentieth century. In the early 1890's, Maunseli added a great deal to the preoperative preparation of patients by washing out the stomach and rectum, dilating the rectum, cleansing the abdomen, using a water mattress, and wrapping the limbs and chest with wadding. His operation was otherwise little different from previous ones. Vincent Czerny in 1883, finding that he could not complete a resection of the rectum by the sacral route, turned the patient over and completed the operation abdominally, thus introducing the abdominal perineal operation which was to be developed and perfected by W. E. Miles in the early part of the twentieth century.

Three years later, in 1900, R. Kronlein reported to the Berlin Surgical Congress a review of 881 cases of rectal cancer in which the three year survival rate had been 14.8 per cent and the operative mortality had been 19.4 per cent. The deaths of 52 patients were attributed to sepsis. This was the status of the surgical treatment for cancer of the rectum at the beginning of the twentieth century. The operations for resection of the colon followed a quite different course from that of excision of the rectum. Suture methods, as we mentioned before, had been developed as well as colostomy, but a planned, formal resection of the bowel with immediate anastomosis was a rarity as peritonitis was still a major problem. Reybard, in 1823, is said to have resected a portion of the sigmoid flexure in a patient for cancer and performed an end to end anastomosis. The patient lived one year, dying of recurrence. Tiersch's case, in 1843, is the next recorded resection of the colon for acute intestinal obstruction and, as late as 1880, only ten resections of the large bowel were recorded, with seven failures. However, from 1880 to 1890, there were 48 resections with the mortality of 45 per cent. Billroth did a resection with closure of the distal end of the bowel, performing a colostomy with the proximal end, much as in the Hartman procedure. C. Gussenbauer, of Liege, reported a partial resection of the descending colon in 1878 and, in 1879, he and Martin of Hamburg each removed a tumor of the sigmoid colon with glands and mesentery and left a double barrel colostomy. They were followed with the same procedure by Schede and Czerny, thus establishing one of the fundamentals of surgery of the large bowel. W. H. Heineke performed a multiple stage operation of resection of the colon in 1884, placing lb. proximal and distal loop side by side. Then he removed the tumor and sutured the bowel to the abdominal wall and crushed the spur with intestinal forceps later, thus closing the colostomy. This sounds very much like the Miculicz procedure. Robert Weir performed an operation similar to that of Billroth in 1885, bringing out the proximal end a, a colostomy and he found that, of 35 excisions of the colon since 1843, eight had completely recovered. He was the first American surgeon to perform a Successful colon resection. Activity in colon surgery was vigorous between 1880 and 1900. Marshall, in 1882, performed an operation similar to Billroth's, with an additional stab wound incision for the colostomy. Kraussold performed the first successful resection of the right colon in two stages. Other operations were also devised, such as the exclusion of a segment of bowel by colostomy and ileo-sigmoidostomy which were done by Maisonneuvean and Trendelenburg. There were many attempts to find safe methods of anastomosis, plus excisions of the bowel, among which were Magaw's elastic ligature 1891 and Murphy's button in 1892. The Murphy budton, a device which stimulated intestinal anastomosis and simplified the procedure, was used for many years. Other methods, such as the use of vegetable plated as Magill used in 56 cases, and the bone plates devised by Micholas Senn, were also used. Halstead attempted anastomosis over an inflated balloon, at the turn of the century, a great deal of experience had been accumulated on large bowel surgery. Perhaps the most important development was the so-called Miculicz procedure. Bloch, of Copenhagcn in 1890 brought the tumor out of the wound and opened the proximal end of the intestine for decompression and later resected the exteriorized loop, later joining together the end of the resected bowel.This was essentially the Miculicz operation. Although Bloch was the first to perform it, Miculicz performed it in 16 cases, reporting on them in 1902. He had lost only 1 patient , and he has received the credit for this development..The accumulated experience in Europe was considerable, but it was much less in this country if we were to judge from the statistics quoted by Welch at the Massachusetts General Hospital for the year 1908 of 347 operations on the colon, 311 were done for appendicitis, with a death rate of 12 per cent; of 36 other operations, there were 3 for cancer of the colon. There were 108 operations on the rectum, 71 of these were hemorrhoids and only 7 for cancer.
There were 60 operations on the anus, 54 for fistula and 5 for fissures. As can be seen, the incidence of rectal and colon resections in this active hospital was rather slight.

During the nineteenth century, there was an increase in knowledge of the anatomy of the colon and rectum. Contributions were made by John Hilton (1804-1878), President of the Royal College of Surgeons and author of the classical "Rest and Pain," who described the line which bears his name. The muscular tube and coats of the rectum were described by the American anatomist, William E. Horner (1773- J8S3), and Professor D. Gerota in 1855 described the perirectal lymph nodes and lym phatic channels of the rectum and perirectum. Two contributions were made in the way of intestinal suturing late in the nineteenth century. M. E. Connell, in 1892, described the popular and important suture that is still extensively used, and H. W. Cushing, in 1899, delineated his right angle continuous suture. Another phenomenon of the nineteenth century which was very important was the influence of St. Mark's Hospital. It was dominant in the development of proctology and the education of proctologists, both in England and in the United States. Frederick Salmon (1796-1868)founded the hospital. Salmon retired in 1859 and is said to have performed 3500 operations in St. Mark's Hospital without any mortality. Following his tenure, short terms as chief surgeon were served by Robert J. Lane and Peter Y. Gounlin, and, in 1864, William Ailingham took over as chief surgeon of the hospital and retained this position for 24 years. Allingham and his son, who developed the crushing clamp for hemorrhoids, were prominent English proctologists and contributed Allingham's textbook, "Diseases of the Rectum," published in 1873, was the standard textbook for many years. In 1877, Joseph M. Mathews (1847-1928) went to St. Mark's Hospital to study under Allingham, and later became known as the "Father of American Proctology." In 1893, he published an extensive treatise on "Diseases of the Rectum, Anus and Sigmoid" which was the first really credible textbook on the Subject, although numerous small pamphlets and handbooks had been published on the subject. Mathews, together with Pennington, Gant, and Tuttle, formed the American Proctologic Society in 1899 and Mathews was elected as its first president. The avowed purpose of the society was to accumulate and disseminate knowledge and encourage teaching and research pertaining to the colon and rectum. The society continues this activity today as the American Society of Colon and Rectal Surgeon.

Twentieth Century

The first decade of the twentieth century brought forth two of the standardized operations for resection of the colon and rectum for carcinoma. Miculicz, in 1902, reported the mortality of 12.5 per cent, having lost only one patient in his operation. This was essentially the operation performed by Bloch, with the added dimension of excision of regional mesentery and lymph nodes. In 1903, Miculicz reported that an operation for cancer of the colon, which involved resection and immediate anastomosis, carried a mortality of 30 to 50 per cent due to peritonitis. He recommended doing the colon procedure in two stages, and described it as follows: "If now the tumor has been freed and completely enucleated, it is drawn out of the wound, the loop of gut is stitched to the parietal peritoneum with sutures including only the serosal coat and the abdominal wound is closed, leaving only room enought for the loop of the gut. Now, only after the abdominal cavity is completely closed, the tumor is excised, and an artificial anus is established which is closed in two to four weeks according to the usual methods." Of note is that Allingham had done a single case in two procedures in 1895. He added the variation of leaving a clamp on the bowel for 36 hours, a maneuver which was to be refined and popularized by Rankin in the next century.
It is interesting to note that Catell, as late as 1941, in a report from the Lahey Clinic 19 makes the following statement: "As a result of this experience certain deductions have also been drawn relating to technical procedures. All colon resections in the clinic are performed with a modified Miculicz plan of procedure. No resections with primary anastomosis are now being, or have for many years, been undertaken. " In regard to the operation of excision of the rectum for carcinoma, the modern type of operation was introduced in 1907 by W. E. Miles, of London. Miles had been a house surgeon in St. Mark's Hospital at the turn of the century and had originally started with the Cripps operation, but gradually developed his operation so that, finally, the description of what he considered an adequate cancer operation should include was :
1. An abdominal anus (colostomy)
2. Removal of all the pelvic colon
3. Excision of the pelvic mesocolon below the crossing of the common iliac artery and a strip of peritoneum
4. Removal of a group of lymph nodes over the bifurcation
of the common iliac arteries
5. Carrying out the perineal portion of the operation as widely as possible
The Miles operation was originally envisioned as a one-stage operation, but, because of infection and hemorrhage, there were many men who preferred to
do a resection of the rectum in two stages. Two-stage operations were described by W. J. Mayo in 1912, by Robert Coffey and Dan Jones in 1915, and by Mummery,
Paul, Gordon-Taylor in England, and, in addition, by Stone and Lahey in this country.An important modification of the Miculicz procedure was developed in 1930 by Rankin. He stated that his operation removed not only all the mesentery desirable, but the tissues in the immediate juxtaposition to the growth, peritonealized the raw surface, insured the blood supply to the two ends of the bowel, and have the bowel obstructed for 48 to 72 hours. He had a three-bladed clamp, which produced the obstruction and held the bowel in position during the 48 to 72 hour period. An important preliminary to this was the decompression of any obstructed bowel and mechanical cleansing of the bowel. The operation, as
stated by Rankin, was similar to Miculicz's with the additional removal of wide piece of mesentery and the lymph nodes in proximity to the growth. The
steps in the procedure were:
1. Incision over the tumor and exploration of the abdomen
2. Mobilization of the colon bearing the tumor
3. Ligation of the blood supply and dissection of the lymph nodes
4. Resection of the growth between two-bladed clamps with the cautery
5. Peritonealization and closure of the rent in the mesentery
6. Wound closed around the clamp, the growth having previously been excised.

The Miculicz and Rankin operations are seldom performed nowadays. In most cases, the tumor is removed widely with mesenteric lymph nodes and an immediate anastomosis performed. Several of the contributions that have made this possible are better preoperative preparation and postoperative care, particularly the easy availability of transfusions and the introduction of antibiotics. Of special importance is preoperative mechanical cleansing and sterilization of the bowel. Improvements in anesthesia also played an important role.Operations involving the colon and rectum evolved, principally, because of two specific problems, namely trauma and tumor. As these procedures were developed with decreasing morbidity and mortality they were applied to other, more benign, conditions ;among these were Hirschsprung's Disease, idiopathic inflammatory bowel disease, diverticular disease, prolapse of the rectum. Rectal prolapse received a great deal of attention in the earlier medical literature. A comment by Hippocrates states, "eversion of the gut takes place in middle aged persons having piles, of children affected with stone and in protracted and intense discharges of the bowel, and in old persons having mucous concrctions (scybale)."The first treatment to be tried is application of fomentations and reductions, then gradually through the ages curative treatments were attempted by hemorrhoidectomy, incision, cauterization and excision. In Ehelius' "Surgery" 17 in 1843, a bibliography of some of the famous names who have written this subject is given. They include Heister in 1745, Copeland in 1814, Howship in 1820, George Bushe in 1827, Syme in 1828, Salmon and Dupuytren in 1831, May in 1833, Brodis in 1835, and Velpeau in 1841. The operations of Copeland, Syme, and Dupuytren were somewhat similar. Dupuytren describes his operation as follows: " ... the patient is put upon his belly, his head and shoulders low, but his pelvis on the contrary much raised by one or several pillows, for the purpose of rendering the aperture of the anus more distinct. Two, three, four, five, or six, of the radiating folds surrounding the anus, which arc either level or less prominent, arc to be seized with a pair of pincers, with somewhat flattened points, one after another, right and left, and even before and behind, and each fold, as raised, is to be taken off with scissors curved towards the surface, and the cut is then to be continued to the (111 us, or even higher into it; but it is ordinarily necessary only to continue the cut some lines upwards. In less relaxation, two cuts, in greater relaxation, several cuts are to be made on each side. Bleeding and other symptoms do not come on; but usually during the operation there is violent contraction of the sphincter. The wound is to be simply treated, and after scarring, the opening of the anus has proper firmness, and the prolapse docs not recur." The development of many more procedures during the early and middle part of the twentieth century attest to the complexity of the problem. In his review of colon rectal operations at Massachusetts General Hospital in the year 1900, Welch" was struck by the relative absence of operations for colonic polyps, ulcerative colitis, granulomatous illitis and diverticulitis. The incidence of these disease has become noted with increased frequency. The development of the sigmoidoscope, barium enema, all now the flexible fiberoptic colonoscope, has helped increase the frequency of the diagnosis of these diseases.

How useful the experience with early operations for tumors was can be seen in the types of operations used for benign diseases today. Diverticulitis is treated mainly for its com plications, usually by drainage and resection. Ulcerative colitis and its complications are treated, in most part, by total proctocolectomy and permanent ileostomy. Congenital idiopathic dilatation of the colon or Hirschsprung's Disease is usually treated by resection of the aganglionic area and preservation of anal sphincter by some type of pull-through procedure. Crohn's disease is usually treated by segmental resection or Lower proctoco!cctomy. Familial polyposis of the colon and its relative, Gardner's Syndrome, are usually treated by resection and ileoproctostomy. With modern methods, the treatment of colorectal diseases by surgery now meets two of the three ancient admonitions for the performance of surgery; that it should be done tuto (safely), cito (quickly) and
iutlllide (pleasantly). We have mentioned the factors that contributed to tile safety (tuto) of operations: decompression of the bowel, preoperative preparation, use of blood and fluids, better anesthesia, and better postoperativecare.
The jllcunde: these operations are now done with less frequent colostomies and, where colostomies and ileostomies are necessary, there has been much improvemcnt in the training of the patient in the care of Ileostomies which has increased their acceptance.
The third admonition, cito, works somewhat in reverse because of the improved condition of the patient and better anesthesia and the operation can be done more slowly and carefully, which in the end leads to a safer and more agreeable result.

In 1966, Morson establishes the degeneration in familial diffuse polyposis. Gilberstein in 1974, by monitoring for 25 years 18,000 persons by rectoscopy,
and by excising the rectal polyps, obtained a decreased number of rectal cancers. The essential preventive treatment of colon cancer, the polyp’s excision started.
From then on, the discovery of early-stage cancer or better the recognition by colonoscopy and excision of polyps (polypectomy) became the gold standard for the
prevention or cure of this malignancy.


In 1952, A. E. Whipple 20 stated that many surgeons dreaded and shunned colon surgery because of the morbidity and mortality due to of leakage and peritonitis. Today, the colorectal surgeon is a board-certified specialist and possesses all the training to combat these complications. Improved results in therapy of diseases of the colon and rectum will rest on the continued development of fully trained surgeons who have a continuing interest in these problems.

Surgical advances in Ancient India

Surgical advances in Ancient India

“A physician who fails to enter the body of a patient with the lamp of knowledge and understanding can never treat diseases. He should first study all the factors, including environment, which influence a patient’s disease, and then prescribe treatment. It is more important to prevent the occurrence of disease than to seek a cure.” – Charaka

Diseases and ailments have affected humanity since time immemorial. The response of
humanity to treat disease and, on occasions to find its cause has been synonymous with the evolution of an organizing society, however ancient and culturally primitive. Thus medicine, as we know today, is as old as man and must have therefore evolved with the first awakening of human consciousness. It is not surprising that the antiquity and the rich tapestry of the ancient Indian society has been associated with seminal contributions to the history of medicine in general and specifically with the development of surgical theory, practice and ethics.

From the ruins of Harappa and Mohenjodaro, the evidence of a medical system practice
can be traced. The Harappa people used plant drugs, animal products and minerals. It is also apparent that water supply and sanitary drainage was well established.

The difficulties in establishing chronology and authorship Many factors contribute to the incertitude regarding details of the historicity of surgical
practice, its origin and authorship. For centuries it was the custom for teaching to be carried out by word of mouth; the texts, in this process would be greatly modified and altered, being committed much later on to writing upon leaves and barks, which being perishable, were readily destroyed not only by the climate but also by frequent foreign invasions.
The philosophy that it was immodest to ascribe a treatise to one individual would explain why most of the older texts have never been ascribed to a definitely historically recognizable individual. Thus statements and authorships have often been ascribed to mythical personages or Gods, probably in an attempt to resonate the underlying message.

Hindu mythology and medicine: Dhanvantari - the mythical god of Surgery
The venerable state of the art of healing was enhanced by myths and legends; Brahma,
the Creator of the universe, evolved Ayurveda by meditation and imparted it to Daksha Prajapati, who in turn taught the Ashwini Kumars (twin sons of the Sun Gods). Lord Indra, the celestial ruler, learnt it from Ashwini Kumars and in turn passed on the knowledge to many rishis such as Sage Bharadwaja (Guru of Atreya) and King Divodasa.

Dhanvantari of Kasi

The God Dhanvantari - the “Patron Saint of Surgery - is nowhere mentioned in the
Vedas; he is a later creation of the epic and puranic mythology. According to the epic legends, at the time of the churning of the ocean of milk by devas and asuras,
Dhanvantari emerged out of the waves carrying amrita or the elixir of life. Medical
knowledge was passed down to, amongst others, Divodasa Dhanvantari who in years to
come, became a renowned teacher in the art of surgery and imparts this subject to his disciples (Anpadhenava, Vaitarana, Aurabhra, Panskalavata. Karavirya, Gopuranksita and Susruta) at Kasi (Varanasi). Divodasa Dhanvantari was later elevated to divinity of classical medical wisdom. Susruta, one of the disciples, attainted great proficiency in surgery and in time came to be known as the “Father of Indian Surgery”

The Vedic Period

Before the advent of writing, the ancient wisdom of healing was a part of the spiritual tradition of the Sanatana Dharma or Vedic religion. We find the roots of modern medicine in the earliest known texts of ancient India, the Vedas, which are at least 6000 years old. In the Rig Veda (prior to 3100 BC), there are hymms which record 86 achievements of Ashwini Kumar, the forerunner of the art of healing. Thus we note in the Rig Veda that legs were amputated with the application of prostheses [note the copper prosthesis applied to the amputated thigh of King Visala (Rv.1.163. 9 and Rv.1.116.15)], that injured eyes were removed and arrow shafts extracted from limbs and torso. There is also evidence of tracheostomy being undertaken in ancient India; the Rig Veda mentions:

“the bountiful one, who, without ligature, can cause the windpipe to reunite
when the cervical cartilages are cut across, provided they are not entirely
severed”

In the next Vedic era of Yajurveda, there is a mention of ligating bleeder (mutraveda), the passing of a catheter (bran chikitsa), treatment of an ulcer and the interference with a gravid uterus (garbhaveda).
In the Atharvaveda, there is reference to the technique of surgery and a description of surgical instruments.
The primacy of the science and practice of medicine was considered of such importance that they were termed the Ayurveda and were considered to be the 5th and last of the Vedas. Ayurveda is said to have its origin in the Atharvaveda compiled sometime during 1000BC. Surgery formed one of the eight specialities of Ayurveda and was known as Salya-tantra.

The Samhita Period

The Vedic period was followed by the Samhita (compendium) period; at this period
(about the 7th – 8th century BC), Indian civilization showed signs of a new evolution of ethics, rational thinking and conscience that threatened the prevailing religions of custom and magic. Profound intellectual turmoil and thinkers ushered the era of scientific method that prompted the transformation from magico-religious medicine to rationalist medicine.

The legacy of this transformation is evident in the scope and practice of surgery that is encapsulated in Sushruta Samhita (compendium) recorded between 800 - 600 BC. Given the incertitude of the surgical historicity and authorship in ancient India, it is presently unclear what the Samhita as originally written by Susruta was like; the present form is considered to be a recession or rather a recession of recessions made by Nagarjuna around 200 BC.
Notwithstanding these hiatuses in chronology and authorship, it is acknowledged that the Susruta Samhita generally reflects the surgical practice during the Samhita period. It also represents a centuries old practice presented in the context of rationalist medicine; of the available ancient Indian medical text, it is one of the oldest.
The Susruta Samhita represents arguably the zenith of ancient India’s medical and
surgical system. It provides a historical window into a school of professionalized surgical practice over 2000 years ago, during when it almost certainly represented the most advanced school of surgery in the world. The Susruta Samhita was followed by other medical treatises that served as the foundation for the practice of rational medicine that followed in ancient India.

“……and it was doubtless one of the best developed medical systems of antiquity”
and “…… the surgical art of India is doubtless sui generis and does not bear any traceable resemblance to the contemporary surgical practice of any other country”
Ilza Veith

Susruta
The historicity of Susruta is unclear; it is mentioned that he taught surgery at the eastern University of Benaras on the banks of the river Ganges. A disciple of the Dhanvantari school, the Mahabharata mentions Susruta as the son of the great saint Viswamitra. It is apparent that Susruta had no desire of abandoning the Vedas and pushing an independent science. An accomplished surgeon, philosopher and above all a great teacher, his compilation of the Susruta Samhita, a monumental treatise of seminal value, established him as arguably the brightest jewel in the history of surgery in the ancient and medieval period.
“All in all, Susruta, must be considered the greatest surgeon of the medieval period”
Whipple AO, 1963

The highly respected authority on the life and practice of Susruta, KK Bhishagratna,
writes;

“to Sushruta may be attributed the glory of elevating the art of handling a lancet
or forceps to the status of a practical science….”

Susruta Samhita

The Susruta Samhita has been divided into 6 volumes (stanas), including the so-called appendix, dealing with the different aspects of surgery. The Susruta Samhita states that surgery is the most ancient and honored branch of Ayurveda that is capable to effect immediate cure. A magnum opus, its comprehensiveness possibly rivals current day medical books; it includes the fundamental concepts of surgery, knowledge about herbs and drugs, diagnosis, physiological and embryological aspects, therapeutics, poisons and science of nutrition. Treatment of subjects such as paediatrics, ophthalmology, geriatrics, reproduction and virility and comment on social hygiene are outlined. A whole volume is devoted to the study and treatment of ailments through psychotherapy. By going through this Samhita, every subject is classified and explained in a scientific manner. A classification in the form of groups, sub-groups, divisions and sub-divisions was outlined.
Such classification was possible only because of the practical experience, close
observation and logical interpretation of disease.

The 6 divisions of the Suhruta Samhita are the following:
i sutrasthana - comprises 46 chapters; deals with basic doctrines, surgical instruments, procedures of surgery training methods, duties of army surgeon
evolution of disease, Classification of disease, properties of different foods and
characteristics of drugs.

ii nidanasthana - comprises 16 chapters; deals with pathology of surgical disease
fistula,chronic skin disease,urinary tract disease,abdominal swellings,genital disease,diseases of oral tract and dental disease

iii sarirasthana - comprises 10 chapters; describes the cosmic origin of life
embryology and anatomy with emphasis on organs of surgical importance,vascular system and bodily fluids,care of the pregnant and new born

iv cikitsasthana - comprises 40 chapters; deals with treatment of surgical disease
rejuvenation therapies like emesis, purgation, enema, inhalation, nasal
medication, mouth gargles

v kalpasthana - comprises 8 chapters; deals with toxicology
poisoning of foods and drink
vegetable and mineral poisoning
animal poisoning
snake venom and bites
rabies
insect poisons and their treatment

vi uttaratantra - comprises 66 chapters; the largest section of the Susruta Samhita, it is believed to have been added to the original text by Nagarjuna. Deals
with the following:
diseases of the eye, ear and of the nasal passages
diseases of the head and diseases of the female organs
various kinds of fever
malignant tumours
heart diseases
jaundice
haemorrhages
epileptic fits, asthma, insanity, hygiene rules, etc
Being fundamentally a surgical treatise, the Susruta Samhita lays more emphasis on
practical training. Susruta insists that the enormous amount of oral training should be
balanced by practical efficiency.

“He who knows theory only but is not so good in practical work, gets bewildered on
being confronted with a patient, in the same way as a coward feels on the battlefield”
Susruta Samhita

The scope and nature of Susruta’s Surgery
Susruta devoted his whole life to the pursuit of surgery and excelled in his surgical
teaching.; he classified all surgical operations into eight different kinds, as follows:
Aharya - extraction of solid bodies
Bhodya - excising
Chedya - incising
Esya - probing
Lakhya - scarification
Sivya - suturing
Vedya - puncturing
Visravya – evacuating fluids
A total of 13 types of alcoholic decoctions and soporific agents such as henbane
(Hyoscyamus niger) and Indian hemp (Cannabis indica), opium were used as anaesthetic
agents (in addition to tying down the patient!).
Surgical instruments
Susruta provided painstaking details of the manufacture, maintenance and the indications
for usage of at least 125 surgical instruments. Surgical instruments were made from iron
or substituted for by substance where iron would be unavailable. The range of
instruments included various shapes of scalpels, bistouries, lancets, scarifiers, swas,
bone-nippers, scissors, trocars and needles. There were also blunt hooks, loops and
forceps as well as catheters, syringes, rectal speculums and bougies.
the range of instruments as described by Susruta. Significantly it is emphasized that the surgeon’s hands are the most important instrument of all!
The surgical instruments described were either blunt (yantra) or sharp (asatra). The bluntvinstruments numbered 101 and, according to shape and size, were divided into 6 groups:
i svastika (forceps) - 24 varietes
- measure 18 fingers in length
- ‘mouths’ made to resemble those of lions, tigers, wolves,
hyenas etc
ii sandamsa (tongs) - 2 varietes
- measure 16 fingers in length
iii tala (picklock like) - 2 varietes
- measure 12 fingers in length
iv nadi (tubular or syringe like) - 20 varietes
- for enemas, injections into urethra, the bowels,
vagina, uterus
- inspection and aspiration of secretions in bodily
passages
v salaka (bougies or rods) - 28 varietes
- serve as probes or directors
vi upa (accessory) - 25 varietes
- include substances such as rope, braided hair, silk thread, bark
and inner skin of trees, linen, oval shaped pebbles, a hammer, a
magnet etc
The cutting or sharp instruments numbered 24. The mandalagram and karapatram were
used for incising and scraping; the vrddhipatram, nakhasatram, mudrika and
utpalapatram for incising and excising.
The kusapatram, suci, timukhan, sararimukhan, trikurcakam and antarmukham were
used for exudation or expression of secretions; the kutharika, ara, vrihimukham and
vetasapatram were used for puncturing.
The badisa and danta-sanku was used for extracting solid foreign bodies.
The esani served as a probe that searched the course of pus.
Suturing was undertaken by the suci (needle)

Needles and sutures
Three types of needles were use
i round needle to the length of 2 fingers width
ii triangular body (trihedral) needle to the length of 3 fingers width
iii semi-circular or bow-shaped
The suture material used included thin cotton thread, fibers of Indian hemp, plaited horse
hair, strips of leather, animal sinew and goat gut.
The care of instruments was emphasized; caustics, alkali, oil, heat and water were
advocated to temper and clean instruments. Instruments were stored in special boxes. The commendable features in an instrument are underscored by the emphasis on its sharpness, the ease of grip, shape and edges that are not jagged.

“ An instrument, well-shaped, fitted with a convenient handle and capable of (literally)
cutting a hair in two and made according to measures laid in the Sastras, should be
alone used in a surgical operation”

The scope and nature of surgery
The surgery practiced in ancient India has been universally lauded for its scope of
practice, innovation, meticulousness of technique. Whilst the practice of surgery in those days can by no means compare to the exciting developments in current practice, the remarkable contributions made by our surgical ancestry were of seminal value.
The timing of surgical intervention and the need to individualize surgical judgment was stressed by Caraka, the medical counterpart of Susruta:
“ Circumstances arise sometimes, depending upon the part affected, age and general
condition.....and the severity of the disease, when a recommended procedure become
contraindicated and a prohibited method of treatment becomes indicated”
Charaka Samhita VII
The spectrum of surgery included the following:

Orthopaedic trauma
In the absence of radiology a useful and logical method of determining the types of
fractures by clinical evaluation evolved. Skeletal injuries were classified into 2 broad
categories, dislocation of joints and fractures. Treatment was by traction and countertraction,
circumduction and other manipulations; acceptable reduction was confirmed by
comparison to adjacent side
A variety of bandages and splints were available for immobilization. Management of
compound fractures outlined as well as the role of physiotherapy

General trauma
Wounds were classified as incised, punctured, lacerated and contused. Lacerations were
sutured; an insight to the potential of wound sepsis and contamination is demonstrated in
the following excerpt:

“ Dust, hair, nails, loose bone pieces and other (foreign) matter, when found in the
wound (before closure), should be removed, because if they are not removed, they
produce extensive suppuration and different types of pain”
Susruta Samhita
Skill in extracting foreign bodies was carried to a great height with the magnet being used under specified circumstances.
The importance of blood and of timeous flud replacement (by an identical substance to that which has been lost) was mentioned.

“ in a case of quick loss of fluid, immediate replacement restores the balance
and stabizes the patient ”
Charaka Samhita 1. 23. 31 16
“ Best treatment of any lost substance is replacement by an ideal expander”
Susruta Samhita 1 .15 .10 17
Haemostasis was stressed and methods of stopping bleeding outlined; cautery was
mentioned, as was the ligation of blood vessels using hemp fibers

The surgical incision
Emphasis was placed on the qualities of an incision:
“…..it should be of adequate length. Extensible, having regular and uniformly cut
edges, having all the layers cleanly incised and should be independent”
Susruta Samhita 1. 5. 8
The correct technique of incising was outlined (swiftly in one stroke!) as well as the
direction of the incision:
“ The incision should be made in the direction of the hairs”
Susruta Samhita 1. 5. 7
“…….oblique in the following regions – eyebrow, cheek, temple, forehead, eyelid,
lip, gum, axilla, belly and groin”
Susruta Samhita 1. 5. 13

Laparotomy
The abdomen was entered by a short incision below the umbilicus slightly to the left of the midline. Laparotomy was undertaken for the removal of intestinal concretions or other obstructions and perforations, an injunction well ahead of contemporary surgical practice. Hippocrates (460 – 370 BC) and Galen some six centuries later considered intestinal perforations invariably fatal. It is also a matter of interest to note that from the time of the Susruta Samhita until the last century, the only cause of intestinal obstruction known in Western practice was a strangulated hernia.
In the Susruta Samhita, the treatment of penetrating intestinal wounds was clearly
described. In the case of disembowelment, the protruded bowel is carefully examined for injury, anointed with ghee and honey and returned into the peritoneal cavity in its natural position. Lacerations of the intestine were ingeniously repaired with living Bengal black ants that were used to approximate the bowel edges; these ants were then decapitated so that the bowel approximation was maintained. Following anointment with ghee, milk and honey, the bowel was returned to the peritoneal cavity.

Urological surgery
The management of urethral strictures was effected by repeated dilatation using “a tube open at both ends made of iron, wood or shellac … lubricated with clarified butter and gently introduced into the urethra……thicker and thicker tubes should be duly introduced into the urethra every third day…. As an alternative, an incision should be made into the lower part of the penis, avoiding the Sevani (raphe of the perineum) and it should be treated as an incidental ulcer”
The pathogenesis and management of urinary calculous disease was outlined. The several varieties of urinary calculi were detailed as were the dietary indiscretions that prompted their development.The initial management prescribed included diet modifications, fluids, alkalis and instillations.The technique of the then pioneering surgery of perineal vesicolithotomy was outlined:
“A physician should have recourse to surgical operations in cases where………the
aforesaid drugs prove ineffective….. the umbilical region should pressed down with a
closed fist so that the stone comes within the reach of the operator. The surgeon should then introduce into the rectum the second and third fingers of left hand duly anointed and with the nails well pared. The fingers should be carried upwards towards the raphe of the perineum so as bring the stone between the rectum and the penis where it should be so firmly pressed as to look like an elevated tumour …… an incision should be made on the left side of the raphe of the perineum and of sufficient width to allow the free egress of the stone. Special care should be taken in extracting the stone so that it will not break into pieces or leave any broken particles behind, however small, as they would in such a case be sure to grow large again’
The value of the Sitz bath as we know today, was well appreciated. Thus following “the extraction of a stone, the patient should be made to sit in a cauldron full of warm water and be fomented thereby. In doing so the possibility of an accumulation of blood in the bladder will be prevented; however if blood should be accumulated therein, a decoction of the Kshira-tree should be injected into the bladder with the help of urethral syringe”

Plastic surgery
The spectrum of plastic surgery operations undertaken during ancient India included the reconstruction of the cut nose by cheek flap, repair of cut ear lobes, repair of cut lip and skin grafting. In addition there were guidelines on wound care, wound healing and a classification of burns.
Accidental burns were classified into 4 categories depending upon the tissues burnt:
i 1st degree - partial epidermal
ii 2nd degree - dermo-epidermal
iii 3rd degree - whole skin thickness
iv 4th, 5th and 6th degree - fatty and muscle layer
It was recognized that special kinds of burns (asphyxiation by flames, sun stroke, frost bite and chilblain, burns by extremely hot objects, burns by lightning) required specialized treatment.
The rhinoplasty procedure represents arguably the acme of ancient India’s contribution to surgery. The amputation of the nose was not uncommonly undertaken during ancient India as a form of judicial punishment. Thus, reconstruction of the nose, must have been widely undertaken during that era. The use of the pedicle flap in the rhinoplasty technique forms a fascinating chapter of surgical history. The credit for being the first to conceive and execute operations involving the use of pedicle flaps goes to the surgeons of ancient India. The Susruta Samhita contains the first record of the use of pedicle flaps in the world literature. The technique described was revived much later by the Italian surgeon Tagliacozzi. It is acknowledged that technique spread from India to Arabia and Persia and from there to Egypt and Italy by the 15th Century. The first description in the English literature appeared in The Gentleman’s Magazine and the Historical Chronicle in 1794.
In the Sustruta Samhita, the rhinoplasty technique is described as follows:
“The leaf of a creeper, long and broad enough to fully cover the whole of the severed or clipped off part, should be gathered. A patch of living flesh, equal in dimension to the preceding leaf should be sliced off from the region of the cheek. After scarifying the severed nose with a knife, the flesh is swiftly adhered to it. Insert two small pipes in the nostrils to facilitate respiration and to prevent flesh from hanging down. The adhesioned part is dusted with the powders of pattanga, yashtimadhukam and rasanjana pulverized together. The nose should be enveloped in karpasa cotton and several times sprinkled over with the refined oil of pure sesamum. When the healing is complete and parts have united, remove the excess skin.”
It is remarkable that even then the accurate cutting and suturing of the flap, haemostasis and maintenance of airway was emphasized. The following description of Susruta is considered appropriate:

“……there shines the unmistakable picture of a great surgeon. Undaunted by his
failures, unimpressed by his successes, he sought the truth unceasingly and passed it on to those who followed. He attacked disease and deformity definitely, with reasoned and logical methods. When the path did not exist, he made one.”
Frank McDowell, 1977
Ear lobes, due to the use of heavy ornaments, often get considerably expanded and
ultimately sunder. Fifteen methods of joining these cut-up ear-lobes were described. For these plastic operations, skin was harvested from the cheek, turned back, and appropriately sutured on the affected ear-lobe.

Ophthalmic surgery
Seventy six different diseases of the eye were outlined, 51 of which required surgical treatment.
Conditions such as dacryocystitis, lacrimal fistula, hordeolum, trachoma, glaucoma and conjunctivitis were described with their treatment; 5 types of ptreygium were described.
Different varieties of cataracts were described. Susruta is credited to having pioneered the technique of removing cataracts by a method of couching.
Clearly the undertaking of ophthalmic surgery required a comprehensive understanding
of the eye anatomy; it was appreciated that the angle of reflection is equal to the angle of incidence, and that the same ray which impinges upon the retina serves the double purpose of illuminating the eye and the external world, and is in itself converted into the sensation of light!

Neurosurgery
The neurosurgical interventions during ancient India include trepihnation and the removal of intracranial mass by Jivaka (physician to the Lord Buddha) and the accomplishments documented in the Susruta Samhita, It is mentioned that:
“In 927 AD two surgeons trephined the skull of a Hindu king, and made him
insensitive to the operation by administering a drug called samohini”
Dr Will Durant, 1937
Treatment of neuralgia by the section of the supraorbital nerve was undertaken when
medical treatment proved unhelpful.
“The ancient Indian surgeons also mentioned a cure for neuralgia, analogous to the
modern cutting of the fifth nerve above the eyebrow…”
Sir Willian Hunter (British Surgeon 1718-1783)
Other surgical procedures
The other procedures undertaken during this period included:
- excision of tumours and lymph nodes, the raw surfaces being applied with arsenic to prevent recurrence
- limb amputations; precise directions were outlined. The use of prosthesis has been
alluded to
- hernia repair
- hydrocoeles were treated by aspiration
- ano-rectal conditions such as fistulo-in-ano and haemorrhoids were excised; rectal
prolapse was recognized and treated
- dental extractions and tonsillectomy
- drainage of abscess with precise directions for incising in various parts of the body

The surgical process
Each surgical procedure was a phased process of three periods namely, the pre-operative, operative and the post-operative period. Each period had well described measures.
In the pre-operative period, the emphasis was to be forewarned of any problems that may be encountered during surgery. To this end emphasis was placed to bring the patient to as ideal a state of health as possible to prevent post-operative complications. Some of the measures undertaken included restriction of diet, softening by anointing, fomentation, internal administration of medicated oils and emesis and purgation.
For the surgeon it is stressed that:
“First of all one should consider his own merits as to whether he is capable
of performing that particular work or not”
Charaka Samhita 111. 8. 86 33
and, furthermore that:
“All forms of treatment should be done only after full consideration of the
intensity of the disease, the general condition of the patient and his
digestive and metabolic powers”
Susruta Samhita
The operating theatre was a separate room, free from contamination, direct sunlight and air currents. The theatre is fumigated with the vapours of white mustard, bdellium nimba leaves and resinous gums of Sala trees, etc, which foreshadows the antiseptic theory of modern times. Surgical instruments necessary for the operation should be available in the theatre, thoroughly cleaned, heated and sterilized, ready for use.
Theatre etiquette included the emphasis on asepsis and antisepsis, care in the use of instruments and adherence to surgical principles such as the quality of incision, suturing technique, haemostasis and fluid replacement.
The post-operative care was undertaken in a facility well equipped, well arranged and “attended upon by sympathetic and affectionate friends and relatives, who should also be good conversationalists”. Detailed follow up regarding post-operative sedation administration, appropriate bandaging, antiseptic fumigation, dietetics and rest was advocated.

Surgical training and ethics
The training of doctors, the code of ethics and practice in ancient India hold a salutary position in the history of medicine. These high ideals are emphasized in the following excerpts of the Caraka Samitha:
“Those who trade their medical skills for personal livelihood can be considered as
collecting a pile of dust, leaving aside the heap of real gold”
Charaka Samita and, “ He, who regards kindness to humanity as his supreme religion and treats his patients accordingly, succeeds best in achieving his aims of life
and obtains the greatest pleasures”

Charaka Samiha
Prospective medical students were careful selected, in the light of the noble expectations of the profession. Students were expected to study for six years before being allowed to practice the art of healing. At the onset of training, a solemn injunction was delivered to the student. Chronologically preceding the Hippocratic oath, the student had to


“ ……renounce lust, anger, greed, ignorance, vanity, selfishness, envy, rudeness, miserliness, falsehood, sloth and all other acts that bring a man to disrepute. At the proper time, you must clip your nails and trim your hair, and put on the saffron robe of the student. You must live the truthful, disciplined life of a student and obey and respect your teacher. At rest, asleep or awake,
at meals, at study and in all your acts, at all times you must be guided by my instructions. All actions should be pleasant and beneficial to me, otherwise your knowledge and study will be ineffective and you will never achieve fame. If I act unjustly towards you even when you obey me totally and faithfully carry out my instructions, may I incur sin, and may my knowledge, rendered futile, never be displayed or come to fruition” .


The initiation of a surgical student and his training in the various techniques was
emphasized. In a manner that is analogous of the current workshops on surgical
techniques, students were expected to hone surgical skills as follows:

“ ….the art of making specific forms of incisions should be taught by cuts in the body of a pushpaphala (a kind of gourd), watermelon, cucumber… the art of making cuts in an upward or downward direction should be similarly taught. The art of making excisions should be practically demonstrated by making openings in the body of a full water-bag, or in the bladder of a dead animal……the art of scraping should be instructed on a piece of skin on which the hair has been allowed to remain. The art of venesection should be taught on the vein of a dead animal, or with the help of a lotus stem. The art of probing….on worm eaten wood, or a bamboo……..the art of extracting by withdrawing seeds from the kernel of a vimbi or jack fruit, as well as by extracting teeth from the jaws of a dead animal. The act of secreting or evacuating ….on the surface of a shalmali plank covered with a coat of bee’s wax, and suturing on pieces of cloth, skin or hide.
Similarly the art of bandaging or ligaturing should be practically learnt by tying bandages round the specific limbs and members of a full-sized doll of stuff linen. The art of tying up a karnasandhi (severed ear lobe) should be practically demonstrated on a soft severed muscle or on flesh, or with the stem of a lotus lily. The art of cauterizing, or applying alkaline preparations
should be demonstrated on a piece of soft flesh; and lastly the art of inserting syringes and injecting enemas into the regions of the bladder or into an ulcerated channel, should be taught by asking the pupil to insert a tube into a lateral fissure of a pitcher, full of water, or into the mouth of a gourd” .

The anatomy and pathology as the basis of surgery was emphasized. In the Susruta
Samhita it is stated that “ only he can be considered an expert (surgeon) who is well versed in the practical and descriptive anatomy. Therefore, one should start the procedures (of surgery) after clearing away the doubts by actually seeing (the surgical anatomy concerned) and consulting (the appropriate literature)” . ___ The surgeon was counselled to value the role of other branches of science. The importance of anatomical knowledge has been mentioned. To this end :
“ …one should listen to the lectures given by specialists of that branch, as it is
not possible to include all branches of science in one subject”
Susruta Samhita furthermore, “ In order to broaden your knowledge and outlook, you should study the subject regularly, take part in scientific debates and discussions, observe the allied sciences and take training from specialists of those branches” .
Susruta Samhita

The influence of ancient India on surgical practice
It is generally acknowledged that ancient India developed a medical system that was
independent of parallel civilizations, particularly the Hellenic civilization. There is ample evidence that Indian medicine, especially its surgery, had a development independent of the Greeks. Thorwald comments:
“Greek medicine, including that variety of it called Hippocratian, had produced nothing in the field of surgery that could remotely compare with the striking ideas of Shushruta” .
There is further comment that there was nothing in Greek medicine from which Susruta’s ideas were borrowed and that, “ in many instances there was nothing that corresponded to them before the Middle Ages of Europe”. Indeed, Royle opines that Hippocrates borrowed much of his materia medica from the Hindus! . Neuburger comments “…that Greek medicine adopted Indian medicaments and methods, which is evident from the literature” .
Indian medicine had a great influence on Arabic medicine; up to the 7th century AD
Indian surgeons and physicians were respectfully appointed in Baghdad. Translations of the Samhita in Arabic were undertaken. Indian medical textbooks were popular in China;
a Chinese text composed in 455 century AD is derived from Indian texts.
Sir William Hunter, British surgeon, comments that Arab medicine was foundered on
translations from Sanskrit treatises and that European medicine up to the 7th century was based on the Latin version of the Arabian translations.
With respect to the contemporary Egyptian medicine it has been suggested that Indian
surgery was far superior in practice; in terms of therapeutics and hygiene, it is suggested that both ancient civilizations were equally ranked.

The fundamental principle of surgery laid by ancient Indian surgeons holds good even in the present era, even though technical advances have made current surgery highly sophisticated. With all its refinements and sophistication, modern surgery could yet benefit from the simplicity of inferences drawn and the procedures employed in ancient India. In the light of the profanation of the medical science and its commercialization today, we can draw great inspiration from the code of practice, nobility of profession and service to humanity exhibited by the ancient Indian surgeons.

Serendipity in Modern Medical Breakthroughs

Serendip is the old Arabic name for Ceylon, now known as Sri Lanka.The origin of the word “serendipity” is in a Persian fairy tale,The Three Princes of Serendip, whose traveling heroes were “always making discoveries, by accidents and sagacity, of things they were not in quest of.” In the 16th century, the tale was translated from Persian to Italian, and from Italian to French. Horace Walpole (1717-1797), an English man of letters, encountered it in a collection of oriental tales in French, and coined the English term “serendipity” in a letter to his friend, Horace Mann, dated June 28, 1754.

Today, the word “serendipity” is a word that is used in everyday language.The Oxford English Dictionary defines it as “the faculty of making happy and unexpected discoveries by accident,” and Webster’s New Collegiate Dictionary as “the faculty of finding valuable or agreeable things not sought for.”

According to the Doctor Out of Zebulon column in the Archives of Internal Medicine, “serendipity signifies a mental state in which serenity and stupidity are blended,” as for example, “the serendipity of a cow chewing its cud under a shady tree,” or “the sort of thing that happens to you when on a dull day collecting fossils you find instead a beautiful woman who proves to be neither geologist nor archeologist.” However, this definition is erroneous, at least insofar as scientific discoveries are concerned.No scientific discovery has ever been made by pure luck.All happy accidents in science have one point in common:
“each was recognized, evaluated and acted upon in the light of the discoverer’s total intellectual experience.”
“Chance favors the prepared mind,” as Pasteur (1822- 1896) said, or more precisely: “Dans les champs de l’observation, le hasard ne favorise que les esprits préparés.”Indeed, it is hard to think of a better expression of “serendipity” as one reviews the incredible concatenation of intentional and chance events in medicine’s happy accidents.Salvador Luria, a Nobel
laureate in medicine, deemed it “the chance observation falling on the receptive eye.” I have the answer. What is the question? Turning an observation inside out, seeking the problem that fits the answer, is the essence of creative discovery. Such circumstances lead the astute investigator to solutions in search of problems and beyond established points of view

Many scientists, including the Harvard physiologist Walter Cannon and, later, the British immunologist Peter Medawar, liked to emphasize how much of scientific discovery was unplanned and even accidental. One of Cannon's favorite examples of such serendipity is Luigi Galvani's observation of the twitching of dissected frogs' legs, hanging from a copper wire, when they accidentally touched an iron railing, leading to the discovery of "galvanism"; another is Hans Christian Ørsted's discovery of electromagnetism when he unintentionally brought a current-carrying wire parallel to a magnetic needle. Rhetoric about the sufficiency of rational method was so much hot air. Indeed, as Medawar insisted in The Art of the Soluble, "There is no such thing as The Scientific Method," no way at all of systematizing the process of discovery. Really important discoveries had a way of showing up when they had a mind to do so and not when you were looking for them. Maybe some scientists, like some book collectors, had a happy knack; maybe serendipity described the situation rather than a personal skill or capacity.
As Robert Root‐Bernstein, physiology professor and author of Discovering, observed,“We invent by intention; we discover by surprise.” In other words, accidents will happen, and it’s a blessing for us that they do.
Serendipity is the way to make discoveries, by accident but also by sagacity, of things one is not in quest of. Based on experience, knowledge, it is the creative exploitation of the unforeseen.

Quinine
The story behind the chance discovery of the anti-malarial drug quinine may be more legend than fact, but it is nevertheless a story worthy of note. The account that has gained the most currency credits a South American Indian with being the first to find a medical application for quinine. According to legend, the man unwittingly ingested quinine while suffering a malarial fever in a jungle high in the Andes. Needing desperately to quench his thirst, he drank his fill from a small, bitter-tasting pool of water. Nearby stood one or more varieties of cinchona, which grows from Colombia to Bolivia on humid slopes above 5,000 feet. The bark of the cinchona, which the indigenous people knew as quina-quina, was thought to be poisonous. But when this man's fever miraculously abated, he brought news of the medicinal tree back to his tribe, which began to use its bark to treat malaria.

Since the first officially noted use of quinine to fight malaria occurred in a community of Jesuit missionaries in Lima, Peru in 1630, historians have surmised that Indian tribes taught the missionaries how to extract the chemical quinine from cinchona bark. In any case, the Jesuits' use of quinine as a malaria medication was the first documented use of a chemical compound to successfully treat an infectious disease. To this day, quinine-based anti-malarials are widely used as effective treatments against the growth and reproduction of malarial parasites in humans.

Smallpox vaccination
In 1796, Edward Jenner, a British scientist and surgeon, had a brainstorm that ultimately led to the development of the first vaccine. A young milkmaid had told him how people who contracted cowpox, a harmless disease easily picked up during contact with cows, never got smallpox, a deadly scourge.

With this in mind, Jenner took samples from the open cowpox sores on the hands of a young dairymaid named Sarah Nelmes and inoculated eight-year-old James Phipps with pus he extracted from Nelmes' sores. (Experimenting on a child would be anathema today, but this was the 18th century.) The boy developed a slight fever and a few lesions but remained for the most part unscathed. A few months later, Jenner gave the boy another injection, this one containing smallpox. James failed to develop the disease, and the idea behind the modern vaccine was born.

Though doctors and scientists would not begin to understand the biological basis of immunity for at least 50 years after Jenner's first inoculation, the technique of vaccinating against smallpox using the human strain of cowpox soon became a common and effective practice worldwide.

Allergy
Charles Robert Richet, a French physiologist, made several experiments testing the reaction of dogs exposed to poison from the tentacles of sea anemones. Some of the dogs died from allergic shock, but others survived their reactions and made full recoveries.

Weeks later, because the recovered dogs seemed completely normal, Richet wasted no time in reusing them for more experiments. They were given another dose of anemone poison, this time much smaller than before. The first time the dogs' allergic symptoms, including vomiting, shock, loss of consciousness, and in some cases death, had taken several days to fully develop. But this time the dogs suffered such serious symptoms just minutes after Richet administered the poison.

Though Richet was puzzled by what had happened, he realized he could not disregard the unexpected result of his experiment. Later, he noted that his eventual conclusions about the dogs' affliction were "not at all the result of deep thinking, but of a simple observation, almost accidental; so that I have had no other merit than that of not refusing to see the facts which presented themselves before me, completely evident."

Richet's conclusions from his findings came to form the theoretical basis of the medical study and treatment of allergies. He eventually proved that there was a physiological state called anaphylaxis that was the antithesis of prophylaxis: When an allergic subject is exposed to an allergen a second time, he or she is even more sensitive to its effects than the first time. Instead of building immunity to the substance through exposure (prophylaxis), the allergic subject's immunity becomes greatly reduced.

In 1913 Richet received a Nobel Prize for his discovery and articulation of diseases of allergy

Viagra

The telephone call from a doctor in Merthyr Tydfil was one of the first clues. He had been running a small clinical trial on a new drug that had been designed for treating patients with angina. With other trials showing little efficacy for treating the disease, the future for the compound known as UK-92,480 was looking bleak.

When the doctor gave Pfizer the results, he mentioned that there had been some side effects among the healthy volunteers on the trial at Merthyr Tydfil, including indigestion and back pain. And, he added, some of the men had involuntary erections when they took the drug.

Scientists quickly discovered the scientific reason for the erections, and five years later and after much research, Pfizer applied for marketing approval for the drug – not for angina, this time, but for male impotence. Ten years on, Viagra has been used by more than 30 million men worldwide for impotence, and researchers are still finding new uses. The drug that nearly didn't make it is currently being used or investigated for treating more than a dozen diseases and health problems.


Botulinum Toxin

In 1895, three members of a music club in Ellezelles, Belgium died and 34 fell ill, after eating a meal of raw salted ham. The culprit was eventually found to be Clostridium botulinum, which produces botulinum toxin, the most deadly poison of all. Work started in 1920, with researchers trying to isolate the toxin, but it wasn't until the 1950s that they discovered that the toxin could be used in tiny doses to treat "crossed eyes", spasms of the eyelids and excessive underarm sweating.

The cosmetically desirable effects of Botox were first discovered by Canadian surgeons Alastair and Jean Carruthers, a husband and wife team who noticed the softening of patients' frown lines following treatment for eye-muscle disorders.

"Its present cosmetic and non-cosmetic applications could certainly be considered a journey of serendipity,'' says Dr Arnold Klein of the University of California.

Later, Dr Richard Glogau, a dermatologist at the University of California, noticed a curious side effect when he injected Botox into the head and facial muscles of patients. The bacteria was being injected for cosmetic reasons, to temporarily get rid of wrinkles, but Glogau and his team noticed that patients who also had regular migraines were no longer getting them. Further research showed that botulinum toxin A injected into the muscles of the brow, eyes, forehead, side of the head and back of the head near the neck could induce immediate headache relief that may last for up to six months.

Penicillin
The identification of penicillium mold by Dr. Alexander Fleming in 1928 is one of the best-known stories of medical discovery, not only because of its accidental nature, but also because penicillin has remained one of the most important and useful drugs in our arsenal, and its discovery triggered invaluable research into a range of other invaluable antibiotic drugs.

Alexander Fleming, who was notorious for having the messiest laboratory at London's St.Mary's Hospital. But the chaotic state of his surroundings did not bother Fleming in the least and in 1928 he took off on holiday leaving his lab in a particularly squalid state. On his return he noticed that some mold had contaminated a flu culture in one of his petri dishes. Instead of throwing out the ruined dish, he decided to examine the moldy sample more closely.

Fleming had reaped the benefits of taking time to scrutinize contaminated samples before. In 1922, Fleming had accidentally shed one of his own tears into a bacteria sample and noticed that the spot where the tear had fallen was free of the bacteria that grew all around it. This discovery peaked his curiosity. After conducting some tests, he concluded that tears contain an antibiotic-like enzyme that could stave off minor bacterial growth.

Six years later, the mold Fleming observed in his petri dish reminded him of this first experience with a contaminated sample. The area surrounding the mold growing in the dish was clear, which told Fleming that the mold was lethal to the potent staphylococcus bacteria in the dish. Later he noted, "But for the previous experience, I would have thrown the plate away, as many bacteriologists have done before."

Instead, Fleming took the time to isolate the mold, eventually categorizing it as belonging to the genus penicillium. After many tests, Fleming realized that he had discovered a non-toxic antibiotic substance capable of killing many of the bacteria that cause minor and severe infections in humans and other animals. His work, which has saved countless lives, won him a Nobel Prize in 1945.



X-Rays
X-rays have become an important tool for medical diagnoses, but their discovery in 1895 by the German physicist Wilhelm Conrad Röntgen had little to do with medical experimentation. Röntgen was studying cathode rays, the phosphorescent stream of electrons used today in everything from televisions to fluorescent light bulbs. One earlier scientist had found that cathode rays can penetrate thin pieces of metal, while another showed that these rays could light up a fluorescent screen placed an inch or two away from a thin aluminum "window" in the glass tube.

Röntgen wanted to determine if he could see cathode rays escaping from a glass tube completely covered with black cardboard. While performing this experiment, Röntgen noticed that a glow appeared in his darkened laboratory several feet away from his cardboard-covered glass tube. At first he thought a tear in the paper sheathing was allowing light from the high-voltage coil inside the cathode-ray tube to escape. But he soon realized he had happened upon something entirely different. Rays of light were passing right through the thick paper and appearing on a fluorescent screen over a yard away.

Röntgen found that this new ray, which had many characteristics different from the cathode ray he had been studying, could penetrate solids and even record the image of a human skeleton on a photographic negative. In 1901, the first year of the Nobel Prize, Röntgen won for his accidental discovery of what he called the "X-ray," which physicians worldwide soon adopted as a standard medical tool.

Insulin
Frederick G. Banting, a young Canadian doctor, and Professor John J.R. MacLeod of the University of Toronto shared a Nobel Prize in 1923 for their isolation and clinical use of insulin against diabetes. Their work with insulin followed from the chance discovery of the link between the pancreas and blood-sugar levels by two other doctors on the other side of the Atlantic decades earlier.

In 1889, German physicians Joseph von Mering and Oscar Minkowski removed the pancreas from a healthy dog in order to study the role of the pancreas in digestion. Several days after the dog's pancreas was removed, the doctors happened to notice a swarm of flies feeding on a puddle of the dog's urine. On testing the urine to determine the cause of the flies' attraction, the doctors realized that the dog was secreting sugar in its urine, a sign of diabetes. Because the dog had been healthy prior to the surgery, the doctors knew that they had created its diabetic condition by removing its pancreas and thus understood for the first time the relationship between the pancreas and diabetes.

With more tests, von Mering and Minkowski concluded that a healthy pancreas must secrete a substance that controls the metabolism of sugar in the body. Though many scientists tried in vain to isolate the particular substance released by the pancreas after the Germans' accidental discovery, it was Banting and MacLeod who established that the mysterious substance was insulin and began to put it to use as the first truly valuable means of controlling diabetes.

Isaac Newton, who came up with his theory of gravitation while walking in his garden under an apple tree. We would not have Velcro if it was not for engineer Georges de Mestral taking his dog for a walk and becoming intrigued by the Burdock (Arctium lappa)) seeds that stuck to his dog's coat. Examining the seeds more closely, he saw the possibility of using hooks and loops to bind two surfaces reversibly in a simple fashion. He subsequently developed the hook and loop fastener and patented Velcro in 1951.The baldness drug Minoxidil (marketed as Rogaine) was first developed to treat high blood pressure. But when balding male subjects in a clinical trial starting sprouting new hair, the researchers changed tack and produced a topical treatment for baldness and hair loss. And tretinoin (marketed as Retin A), an acne treatment with a long list of side-effects, is now primarily known for its smoothing effect on wrinkles.

Despite all the examples given, mainstream medical research stubbornly continues to assume that new discoveries will follow exclusively from a predetermined research path.Many in fact,will.Others ,if history is an indication,will not.They will not come from a committee or a research team but from an individual,a maverick who views a problem with fresh perspective.Serendipity will strike and be seized upon by a well trained scientist or clinician who also dares to rely upon intuition,imagination, and creativity.Unbound by traditional theory, willing to suspend the usual set of beliefs,unconstrained by the requirement to obtain approval or funding for his or her pursuits,this outsider will persevere and lead the way to a fascinating breakthrough.Eventually, once the breakthrough becomes part of accepted medical wisdom,the insiders will pretend that the outsider was one of them all along.

As John Barth wrote in the Last Voyage of Somebody the Sailor,”You don’t reach Serendip by plotting a course for it.You have to set out in good faith for elsewhere and lose your bearings serendipitously”.The challenge for educational institutions, government policy,research centers,funding agencies will be how to recognize scientists to lose their bearings creatively.What they discover may just save our lives!