History of CRC

Int J Colorectal Dis
DOI 10.1007/s00384-015-2152-7
REVIEW
History of colorectal surgery

A comprehensive historical review from the ancient Egyptians to the surgical robot
Giovanni Domenico Tebala
Accepted: 2 February 2015

# Springer-Verlag Berlin Heidelberg 2015
Abstract BThe Lord God caused the man to fall into a deep sleep.
Background Colorectal surgery has its roots in the early civ- As the man slept, he took one of his ribs, and closed up
ilisations and its development followed a complex pathway the flesh in its place. (Genesis 2:21)^ [1]
never disjoined from the social and cultural environment
Clearly, according to the same source, the second special-
where it took place.
isation was chest surgery.
Method The most relevant historical sources have been
But also colorectal surgery has its origins in the midst of
evaluated.
Results A comprehensive review of the history of colorectal time and evolution. As a matter of fact, man and other pri-
surgery is presented, from the ancient Egyptian culture to the mates appear to differ from the four-footed animals in suffer-
modern achievements. The development of surgery of colon, ing from some painful anorectal diseases, due to the effect of
rectum and anus is reported with particular reference to the gravity [2]. The passage from the four legs to the two legs lead
social environment and history; as the development of colo- to the development of the falciform and triangular ligaments
rectal surgery parallels the occurrence of human historical of the liver, to keep it in place and avoiding straining on the
events, the study of the former cannot be disjoined from the inferior vena cava, the uterosacral ligaments to keep the uterus
latter. in place fixing it to the sacrum and the ligaments of the rectum
Conclusion Study and knowledge of the history of medicine — to avoid its prolapse.
and, in particular, of colorectal surgery for those interested in this In this review, we will try to summarise the history of
particular subject — is a privileged way to understand who we colorectal surgery, from its very beginning in the Nile Valley
are nowadays and where we come from. to the surgical robot. We will demonstrate that some of the
most actual pathophysiologic theories and most of the surgical
techniques have their bases in history.
Keywords Colorectal surgery . Colorectal cancer .
Only studying history we can understand what and where
Proctology . Haemorrhoids . History of surgery
we are now. This is true for every human activity and is
significantly true for colorectal surgery. Moreover, as the
development of colorectal surgery parallels the occurrence of
human historical events, the study of the former cannot be
Introduction disjoined from the latter.
Colorectal surgery cannot boast of noble birth as other spe-

cialties. In fact, the first medical specialisation was anaes-
Egypt
thesia, even if it was acknowledged as autonomous in the last
40–50 years.
The Egyptian empire is to be considered the first of the ancient
empires. It is extended for more than 2,000 miles, from trop-
ical Africa to the Mediterranean and from Libya to the Sinai
G. D. Tebala (*)
Noble’s Hospital, Strang, Douglas IM4 4RJ, Isle of Man Peninsula, even if its influence area was much larger. Also
e-mail: [email protected] unique was its continuity; for a period of 40 centuries,
Egyptians enjoyed a long period of prosperity in a well- Diodorus from Sicily stated that the practitioner who did
organised state. The fourth millennium saw the development not cure a patient’s condition must show the patient the
of towns and their unification in two reigns, the Upper Egypt, Bbook^ to convince him/her that all the guidelines had been
with capital Thebes, and the Lower Egypt, centred on the Nile followed. The lack of adherence to the guidelines — and not
Delta. In 3150 BC, King Menes united the two states in a single the death of the patient — could affect the practitioner’s career
big kingdom that flourished around its capital Memphis, near and reputation [4].
the present-day Cairo, where even today we can see the archi- Medical papyruses are often copies made by scribes, not
tectural and artistic wonders of the Great Pyramids and the necessarily expert in medicine, so they have several errors,
Sphinx. amended by late scholars with addendums and comments.
The key of the Egyptian history is the Nile. Its periodic There are 14 medical papyruses and various fragments, deal-
floods allowed the inhabitants of an almost deserted large zone ing with (a) anatomy and physiology and the theoretical bases,
of northern Africa to develop a prosperous agriculture with (b) pathology, usually divided in title, examination, diagnosis,
unmatched productivity, and the Nile itself was a trading way prognosis, treatment and notes, and (c) recipes [4].
between the Mediterranean, Rome, Greece, Near East, As regards surgery, there are three major papyruses. The
Anatolia, Asia and the Tropical Africa and the Indian Ocean. first is the surgical Papyrus Edwin Smith, dated back to the
Agriculture and trade attracted people and cultures from Africa middle kingdom or the second intermediate period, around
and Near East as well as from the whole Mediterranean [3]. 1600 BC, but is likely a copy of an older papyrus of the old
Egypt acted as the first world power. Of course, ruling such kingdom written by Imhotep himself. It must be regarded as
an extensive region required a perfectly organised central ad- the first textbook of surgery. It reports 48 surgical cases. It was
ministration, with able managers and skilled technicians. bought in 1862 in Luxor by Edwin Smith, an American anti-
Furthermore, the great number of citizens and workers needed quarian, but now the 4.67-m-long papyrus is in the New York
medical assistance. Academy of Medicine [4].
Egyptian medicine was considered the most advance of its The Chester Beatty Papyrus VI — meaning the sixth pa-
age. Foreign kings used to go to Egypt to see local doctors or, pyrus bought by Chester Beatty, another American antiquari-
simply, they asked the Pharaoh to send them a physician to be an — was written during the New Kingdom, around 1200 BC,
enrolled in their own healthcare team. Even Hippocrates and and deals only with anal diseases. There are 41 prescriptions
Galen studied on Egyptian textbooks. to treat pruritus ani, painful perianal swelling (thrombosed
There were general practitioners and specialised physicians haemorrhoids, perianal abscess) and rectal prolapse [4].
and surgeons. Each practitioner was a civil servant who The Georg Ebers Papyrus can be dated at the beginning of
trained in a temple called Bthe House of Life^, where he the New Kingdom (1555 BC) and was sold in 1873 by Edwin
worshipped the lioness goddess Sachmet who controlled dis- Smith to Georg Ebers, a German archaeologist. Now it is in
eases and health. The practitioner himself was called Bthe the Library of the Leipzig University. It is the longest of all
Sachmet’s priest^, thus demonstrating a close relationship be- papyruses, more than 20 m, and reports 876 recipes and 500
tween magic and medicine. drugs.
Many of the practitioners were also scribes and had rele- For the Egyptians, the abdomen was a very important an-
vant posts in the public administration. Maybe the most fa- atomical entity, demonstrated by the existence of a Bphysician
mous Egyptian physician — and the father of Egyptian med- of the tummy^. This deep interest in the abdominal diseases
icine — was Imhotep, who was also the architect and advisor was maybe due to the high incidence of intestinal parasitosis.
of King Zoser; for him, he built the first pyramid. From the A devil was responsible of intestinal worms and could be
available sources, we know the names of about 150 practi- expelled with sneeze, vomit, sweat, bowel motions but mostly,
tioners, and at least two of them were women [4]. roots of pomegranate containing pyridine, an alkaloid, that
Despite their very good medicine, the Egyptians had a very acts on the worm nervous system and detaches it from the
poor knowledge of human anatomy, even if they almost bowel walls [4].
reached the concept of blood circulation. Unfortunately, the The pelvis was the place where all mucous and negative
practitioner could not take advantage of the science and prac- substances go before coming out as urine or faeces. The pip-
tise of embalming, as embalmers were a separate caste not ing system should be kept working with snake grass, beans
linked to physicians [4]. flour, natron, myrrh, juniper fruits, incense, cumin, colocynth
Regarding available resources about ancient Egyptian flour, honey, etc. [4].
medicine, there are the body of papyruses and the work of To the rectum and the treatment of rectal diseases is dedi-
indirect witnesses. Unfortunately, the fall of the Ancient cated the Beatty VI medical papyrus. Rectum was considered
Kingdom, 2300–2650 BC, closed the Egyptian golden age a very important part, and in the Ancient Kingdom, there was
and led to the destruction of archives and libraries including a specialist in enemas, the BShepherd of the Anus^. According
many specialty textbooks. to Herodotus and Pliny, the Egyptians learnt the technique of
the enema from their Holy Ibis Thot, who used to clean its that evolved into Greek. The Achaeans, as they have been
own bowel using its long beak to introduce water into the back called lately, built several city states, the most important of
passage [4]. them were Mycenae and Crete, the latter ruled by the
Painful defecation, haemorrhoids and rectal prolapse were Minoans. While the first were dedicated to war, the second
considered the same disease — this concept was quite clear in were mostly traders and lovers of high-quality lifestyle. After
those papyruses, but has been demonstrated by Antonio the war of Troy, the power of Mycenae and Crete disappeared,
Longo only about 15 years ago. substituted by the incursions of the BSea People^, who should
Perianal abscess was treated with local application of two be regarded as the true founders of classical Greece. They
types of salt, myrrh, human milk, honey, incense and fat [4]. settled in mainland Greece and in Cyprus, and from them,
The Smith surgical papyrus reports 48 cases or diagnoses, the cultural light of Athens arose in the 5th century BC.
with a topographical classification, starting with the head to Greece was never able to build up an Empire or to set up a
end at the chest. They are almost exclusively trauma cases sort of nation. The many city states continued to fight against
occurring in a working place, in particular, where lots of each other, even after the wonderful victories against the
men were involved in building some great item. We cannot Persian army, until Philip II of Macedon, a northern Greek
avoid thinking that the writer refers to the construction of the leader, started to build up his personal Empire whose grand-
pyramids, whose inventor was Imhotep, who wrote the papy- ness was finally established by his son Alexander the Great
rus. No surgical instrument or technique is detailed in the [3].
papyrus; it was only generically reported [4]. Unfortunately, Science and medicine flourished during the classical peri-
this papyrus is incomplete, as the scribe who wrote it — and od, and for the most part, they were strictly linked with reli-
was not a surgeon as many terms are wrong or mistyped — gion. Whereas Sachmet was the Egyptian goddess related to
stopped at midsentence and nobody knows why [5]. medicine, Asclepius was the Greek god of medicine.
The surgical knowledge should be learnt on the field and According to mythology, Asclepius was son of Apollo and
never put in writing to preserve the caste. Cutting instruments, the nymph Coronis and was raised by the centaur Chiron,
forceps and drills were used, and the operation ended with who taught him the basics of medicine. He became such a
dressing the wound. In half cases, a dressing with fresh meat proficient practitioner that Hades, god of the underworld,
was put on the wound to control bleeding, therefore a cream complained with Zeus who killed him with a thunderbolt.
made by fat, honey and vegetables [4]. After his death, Asclepius was raised into the Olympus and
Two surgical operations have never been reported in the became god of medicine and surgery [5]. Asclepius’ temples
texts. Circumcision was quite diffuse, as demonstrated by were attended by people anxious to be healed who found their
drawings and incisions, but we do not know the exact reason relaxation and maybe a placebo effect, probably mixed with
for that. Hebrews probably learnt the practise of circumcision some basic natural remedies. The only surgical operation per-
during their Egyptian captivity. Was it a religious or a hygienic formed there were incision of abscesses and blisters [5].
procedure? Herodotus claimed it was to reduce the incidence But a scientifically oriented medicine started to flourish
of balanitis and urethritis due to the desert sand, and the sub- even in the classical age, with scientists and philosophers like
sequent sterility. Or it could be a sort of initiation ceremony Anaximander and Anaximenes of Miletus [5].
[5]. Skull burr holes were described first by Hippocrates, but The best known exponent of ancient Greek medicine was
never reported in the Egyptian official medical papyruses. Hippocrates.
Some researchers agree that it was to get free a Bdemon^ Hippocrates was born in Kos in 460 BC. He was a physician
responsible for chronic headache. But they had other drug of the Age of Pericles, which is deemed to be the Golden Age
remedies to treat headache such as salicylic acid, so maybe for ancient Greece. Very little is known about what
they did not need such an invasive treatment. At least some of Hippocrates actually thought, did and wrote, as the collection
the patients survived the operation, as demonstrated by the of writing known as BCorpus Hippocraticum^ has been writ-
edges of the hole, with natural postoperative changes [5]. ten by his followers and his Aphorisms are sentences and
ideas reported by others. Even if he was son of a practitioner
(Heraclides), he was a great opposer of the Bclassical^ Greek
Greece medicine, mixed with magic and theology, and for this reason,
he spent 20 years in a prison, where he wrote BThe
The ancient Greece was central to all later history, culture, Complicated Body^, which contains many of the medical con-
science, politics, laws and social behaviour. Greece was the cepts we consider true today. The Corpus Hippocraticum con-
birthplace of philosophy, democracy, tragedies and comedies, tains also the famous Hippocraticum Oath, which was an oath
geography and historical research. The history of ancient historically taken by physicians and other healthcare profes-
Greece starts in about 2000 BC, when the original inhabitants sionals swearing to practise medicine honestly and with pro-
were succeeded by Indo-Europeans who brought a language fessionalism. He died in Larissa at age 85 (even if someone
says he lived well over 100 years) [5]. For the purpose of the to deal with other surgical conditions as we will see later on,
present article, his statements about colorectal surgery are in was not only due to the sealing of the vessels but mostly to the
some of his aphorisms and in his two dissertations BOn formation of scar fibrous tissue that fixed the prolapse higher
Fistula^ and BOn Haemorrhoids^. Let us analyse some of on the rectum.
his aphorisms [6]. In the treatise on fistulae, Hippocrates recognises the rela-
tionship between perianal abscess and fistula and proposes a
BAll diseases begin in the gut^ treatment that is very similar to the Bloose seton^ in use today,
more than 2300 years before Sir Alan Parks and the St. Mark’s
Once again, as in the ancient Egyptian medicine, the abdo-
Hospital. The technique entails the cannulation of the fistula
men was the source of all the diseases, maybe because this is
with a speculum or director, followed by a long thread of raw
the place where all the food collects and is processed. So, a
lint, wrapped within a horse hair [7].
disease is a consequence of what we eat. This is quite consis-
tent with the likely high incidence of food poisoning and toxic
BTaking a very slender thread of raw lint and uniting it
gastroenteritis in a period with no proper food storing and
into five folds of length of a span and wrapping them
conservation and no perfect cooking.
round with a horse hair, then having made a director
(specillum) of tin, with an eye at its extremity, and
BA lesion of the bladder, brain, heart, diaphragm, stom-
passed through it the end of raw lint wrapped round
ach, liver or any of the small intestines, proves fatal^
as above described, introduce the director into the fis-
and BA lesion of the small intestines is never followed by
tula and, at the same time, introduce the index finger of
a reunion of parts^
the left hand per anum, and when the director touches
With respect to penetrating wounds and, in particular, bow- the finger, bring it out with the finger, bending the ex-
el injuries, Hippocrates states they have a very poor prognosis. tremity of the director and the ends of the threads in it,
The cause of death in penetrating bowel injuries was peritoni- and the director is to be withdrawn, but the ends of the
tis, and later on, we will see that the only way those unfortu- thread are to be knotted twice or thrice and the rest of
nate had to save their life was to develop an enterocutaneous the raw threads is to be twisted round and fastened into
fistula. a knot^ [7]
In case of intestinal injuries, bearing in mind the extreme
BIn long continued haemorrhoids, a total cure is fre-
gravity of those lesions, Hippocrates — or more likely his
quently followed by dropsy and phtisis^.
followers — used to suture the bowel with a running suture
This probably refers to the few cases — if any — of without knots at the beginning and at the end, bringing the two
haemorrhoids as a consequence of portal hypertension. long extremities out of the abdominal wound, where they were
Cutting away a possible drainage of the portal system into secured. This was aimed to prevent the leakage of intestinal
the caval system would increase the risk of ascites. content into the peritoneum and to fix the wound to the ab-
In his treatise on haemorrhoids, Hippocrates gives a won- dominal wall, in the hope to create a spontaneous fistula [8].
derful description of the surgical treatment by cauterisation,
preceded by a method to force the prolapse out of the rectum
and identify the cushions [7].
Hebrews
BForce out the anus as much as possible with the fin-
According to the Bible and Jewish tradition, Jewish ancestry
gers… He himself should cry out, for this will make the
is traced back to the Biblical patriarchs Abraham, Isaac and
rectum project the more… You will recognize the
Jacob, who lived in Canaan about 1800 years BC. Jacob’s son
haemorrhoids without difficulty for they project on the
Joseph went to Egypt where he was appointed as high official
inside of the gut like dark-coloured grapes and when the
of the Pharaoh and called his father and brothers to join him.
anus is forced out they sprit blood… Burn the pile until it
Their descendants were enslaved in Egypt until the Exodus
is dried up and so as that no part may be left behind…
led by Moses, around the 13th century BC. The Jews then
When the cautery is applied the patient’s head and
settled in Canaan and, according to the Bible, they were in
hands should be held so that he may not stir^.
constant war with neighbouring tribes and kingdoms. King
It is quite interesting that the patient should Bcry out^ to David was the first of a dynasty and King Solomon, David’s
increase the abdominal pressure and cause the prolapse to son, built the first Temple in Jerusalem, a symbol of Jewish
slide down. If we do not consider the systemic response to religion, tradition and culture. In 586 BC, the Babylonian king
such a painful treatment done without anaesthesia, the real Nebuchadnezzar II conquered Israel, destroyed the Solomon
efficacy of cautery, used for the treatment of piles and also temple and exiled the Jews to Babylon. In 538, Cyrus, the
Great of Persia, conquered Babylon and the Jews returned to Eglon of Moab and stabs him in his belly. Eglon is eviscerated
Israel and rebuilt the temple. In 64 BC, the Romans conquered by the blow, and excrements leak out; he was so overweight
Syria, and Israel became a Roman protectorate under the that the sword disappeared into the wound and Ehud left it
Herod dynasty and then a Roman province in AD 6. In AD there.
390, at the split of the Roman Empire, Israel became part of
the East Roman Empire under the Byzantines. In 634, Arabs B…And the haft also went in after the blade; and the fat
took over the rule of Israel until the first Crusade in 1099. The closed upon the blade, so that he could not draw the
Middle Ages saw frequent changes of rulers and the alternat- dagger out of his belly; and the dirt came out.^ (Judges
ing destiny of the crusades. In 1517, the Turkish rule started 3:22) [1]
and lasted up to the end of World War I, when Israel became a
British Protectorate until the birth of the State of Israel in This demonstrated that Hebrews had knowledge, maybe
1948 at the end of World War II. What we know about derived from their war experience, of penetrating abdominal
Jewish medicine and surgery can be found in the Bible and wounds. They had also a direct knowledge of human anatomy
in the Talmud (commentaries and notes on the Bible) [3]. learned by the dissections of corpses that, although not en-
From the Talmud, God is the healer. This idea is common couraged, was not prohibited and by the dissection of animals,
to all theocratic societies. God was the origin of all good and very diffused and frequent due to ritual slaughtering to get
all evil, so health and disease. In this social context, being able Bkosher^ food. Even if the Jewish world opposed the spread
to Bcure^ meant be similar to God, take from God His divine of Hellenism and therefore also of its scientific culture, the
knowledge. Elijah the Prophet could resuscitate a boy, with a Talmud reports of autopsy studies performed by Rabbi doc-
manoeuvre very similar to our cardiopulmonary resuscitation, tors. Another factor to consider is the excellent communica-
with the help of God. tion between the social classes that existed in Jewish society.
In fact, while in the Egyptian and Greek-Roman society, the
BAnd he stretched himself upon the child three times, anatomical knowledge of embalmers and butchers was rarely
and cried unto the Lord, and said, O Lord my God, I sent to the medical profession, in the Jewish world, knowl-
pray thee, let this child’s soul come into him again. And edge was available to everyone [9]. Unfortunately, the de-
the Lord heard the voice of Elijah; and the soul of the scription of human body reported in the Talmud is mostly a
child came into him again, and he revived.^ (1 Kings functional anatomy of the living, to check the ability for cer-
17:21–22) [1]. tain functions, related to religion and social life. The Mishnah
— part of the Talmud –refers that there are B248 limbs in the
In the second book of Chronicles, the prophet Elijah re-
human body…and 5 orifices^. In the Hebrew Bible, there are
proaches Joram, King of Judah, of not following the path
613 commandments; 248 are positive and are equivalent to the
indicated by his father Jehoshaphat and predicts a disease of
number of the active limbs and to the number of organs, 365
the intestine, which is described in great detail and looks just
are negative and correspond to the number of blood vessels in
like the rapid course of a bowel cancer, which is manifested by
the human body. The five orifices are considered essential for
malaise, pain and rectal prolapse.
life, since some of them allow the vital substances to enter and
others the waste substances to leave. In the Talmud, in fact,
BThou shalt have great sickness by disease of thy
one of the blessings to God was for creating man with orifices
bowels, until thy bowels fall out by reason of the sick-
and cavities that must function properly to allow life. The
ness day by day… And after all this the LORD smote
regular bowel activity was considered vital [9].
him in his bowels with an incurable disease… And it
Mosheh ben Maimon, called Moses Maimonides (or
came to pass, that in process of time, after the end of
Rambem — Hebrew acronym for Rabbeinu Mosheh Ben
two [2] years, his bowels fell out by reason of his sick-
Maimon, Our Rabbi Moses Son of Maimon) was a promi-
ness: so he died of sore diseases…^ (2 Chronicles
nent medieval Spanish Sephardic Jewish philosopher, astron-
21:12–19) [1]
omer, physician and one of the most important Torah
From this description is quite evident that the Hebrews scholars. He was born in Cordoba in 1135 and died in
knew very well the clinical presentation of an obstructive co- Egypt in 1204. He lived during the Moorish rule of Spain
lonic cancer, but the writer of this book of the Bible empha- and his family was forced into exile, so he had the possibility
sises that this is a punishment coming from God and serves as to study medicine in Morocco and Egypt and was appointed
a warning to people. Court Physician to the Grand Vizier Al Qadi al Fadil, then to
The Book of Judges is the seventh book of the Hebrew and Sultan Saladin ( alā ad-Dīn Yūsuf ibn Ayyūb). He wrote a
Christian Bible. It contains the history of biblical judges, lot of philosophical and theological books and some medical
leaders of the Israelites in their continuous wars against for- books as well. In particular, for our purpose, he wrote a
eign rulers. In the third chapter, the Judges Ehud fights against treatise Bon Heamorrhoids^, where he recommends healthy
diet and BSitz baths^, but admitted that this treatment is not overthrown and the first Roman Republic started. During the
to cure the very deep cause of haemorrhoids, and so they can republican period, Rome invaded the neighbouring Italian
recur [10]. states and then conquered the trade pathway of the
Sitz baths are suggested even nowadays also for the cure of Mediterranean Sea destroying Carthage in 146 BC. Within
fissures and irritable bowel syndrome. In the introduction of 50 years, the bases of Roman Empire were built up. In the
his book, Maimonides explains why he is interested in this 2nd century BC, Rome ruled over Italy, Spain, southern
subject. He visited a young Egyptian man, related to the France, Northern Western Africa, Macedonia, Greece and part
Sultan, being troubled by haemorrhoids; in this case, the of Turkey. The important historical figure of Julius Caesar
choice was not easy, but at the end, he did not suggest any links the Roman republic to the so-called Age of Augustus
kind of surgical treatment, as he was not sure if those of the Roman Empire. He himself was never a king or an
haemorrhoids were of the type to be excised or to be left as emperor, but just a consul, self-proclaimed dictator. After his
very likely to recur. He thought surgery should be the last assassination in March 44 BC, his great nephew Augustus took
choice. In his dissertation, Maimonides explains his theory, over and self-proclaimed himself as Emperor. During the
derived from Hippocrates, where haemorrhoids are due to an Empire Age, Rome gradually expanded his boundaries up to
excess of black bile, which accumulates in the lower parts of the Hadrian Wall in England, the Rhine in Germany, the Near
the body. Interestingly, he describes haemorrhoids as follows: East, Turkey. The Emperors Diocletian, and Constantine
started the decline of Roman power first changing its state
B…the vessels of the mouth of the anus (rectum) become religion to Christianity, second building up a new capital in
engorged therewith and stretch and widen. Warmth de- the east, Constantinople, and leading to two separate Empires,
velops at these sites as well as moistness, and these the West Roman Empire and the East Roman Empire. The last
prolapses develop… sometimes become acute…swell- West Emperor, Romulus Augustulus, abdicated in AD 476 and
ing develops, pain increases and the stool is with- marked in this way the fall of the Western Roman Empire.
held…occasionally, something egresses from them and Roman success was due largely to its military and social or-
swells externally and the pain becomes stronger and ganisation. All volunteers were entitled to Roman citizenship
fever and suffering ensue…^ [10] and were given a land at the end of their service in the army.
Many conquered territories were divided amongst Roman sol-
This is clearly the description of an acute episode of
diers and generals. The society was divided in four classes:
haemorrhoidal prolapse with thrombosis. Even if they are
slaves, plebeians, knights and patricians. The latter classes had
due to a derangement of the body humours, haemorrhoids
a central role in public life and culture. Wherever the Romans
are associated with prolapse. At the end of his writing, he
went, they brought their own way of living and their own
discusses the role of surgery, indicated just for strangulated
culture. Apart from the codes of law that represent the bases
(thrombosed) haemorrhoids, saying that this operation should
of most of the European modern codes of right and duties, the
be performed by experienced surgeons — patients’ safety is
Romans did not give any great new contribution to culture.
paramount even in Maimonides works — who take into ac-
The same should be said about coloproctology, where they
count the general condition of the patient and eventual comor-
followed for the most the Egyptian and Greek knowledge
bidities [10].
and guidelines. But two Roman practitioners must have a
place in the history of colorectal surgery, Celsus and Galenus.
Aulus Cornelius Celsus was born in 25 BC and died in AD
Romans 50. His work BDe Medicina^ is one of the best sources
concerning surgical practise in the Roman world. He is
If we do not consider the myth — reported in the Aeneid by deemed to be the Author of the cardinal signs of inflamma-
the Latin poet Virgil — that links the birth of Rome to the War tion: rubor (redness), tumor (swelling), calor (warmth) and
of Troy and the escape of the Troyan hero Aeneas, the actual dolor (pain). In Book 4 of BDe Medicina^, he demonstrates
ancestors of the Romans were some Indo-European tribes that a good knowledge of anatomy and gives an outstanding de-
moved to Italy in about 1000 BC and overlapped with the pre- scription of the colon.
existing Etruscan, ancient population of the west coast of Italy.
As a matter of fact, three of the first seven kings of Rome were BBeyond is the thinner intestine, infolded into many
Etruscan. The established date of the birth of Rome is 21st loops, its several coils being connected with the more
April 753 BC, when, according to the legend, Romulus began internal parts by fine membranes; these coils are direct-
building the city. During the first phase of Roman history, the ed rather to the right side, to end in the region of the
rule of the Seven Kings, the Roman Senatus, a popular assem- right hip; however, they occupy mostly the upper parts.
bly nominated by the King himself, had just an advisory role. After that spot this intestine makes a junction crosswise
In 509, the Senatus took over, the last Roman King was with another, the thicker intestine; which, beginning on
the right side, is long and pervious towards the left, but despair; for occasionally it heals up. Then if either in-
not towards the right, which is therefore called the blind testine is livid or pallid or black, in which case there is
intestine. But that one which is pervious being wide- necessarily no sensation, all medical aid is vain.^ [12]
spread and winding, and less sinewy than the upper
In case of perianal fistula, he proposes the technique
intestines, has a flexure on both sides, right and left,
of the Bcutting seton^, in use up to few years ago. The
especially on the left side and in the lower parts and
principle is to pass a long thread into the fistula, fol-
touches the liver and stomach, next it is joined to some
lowing a probe, then the two ends of the thread must be
fine membranes coming from the left kidney, and hence
tightly ligated to allow a slow and progressive cut of
bending backwards and to the right, it is directed
the tissues whilst fibrous scar tissue forms, where the
straight downwards to the place where it excretes; and
tissues have been just cut, thus preventing the complete
so it is there named the straight intestine^ [11]
breakdown of the sphincters.
Book 7 of the same writing is a surgical book, dealing with
Bthe third art of medicine^, that is surgery, the art that cures by BWhere a probe has been passed up to its end, the
the hands. In the same book, he gives a definition of the skin should be cut through, next through this new
surgeon, as youthful, strong and steady-handed, with sharp orifice the probe is to be drawn out, followed by a
and clear vision and not moved by the cries of pain of the linen thread which has been passed through the eye
patient. made for the purpose in the other end of the probe.
Then the two ends of the linen thread are taken and
BThe third part of the Art of Medicine is that which cures knotted together so as to grip loosely the skin over-
by the hand…in cases where we depend chiefly upon lying the fistula. The linen thread should be made
medicaments, although an improvement is clear up of two or three strands of raw flax, twisted up so
enough, yet it is often clear that recovery is sought in as to make one. Meanwhile, the patient can do his
vain with them and gained without them… But in that business, walk, bathe, and take food as if in the best
part of medicine which cures by hand, it is obvious that of health. Only this thread is to be moved twice a
all improvement comes chiefly from this, even if it be day, but without undoing the knot, the part of the
assisted somewhat in other ways. This branch, although thread outside being drawn within the fistula, and
very ancient, was more practised by Hippocrates, the the thread must not be left until it becomes foul,
father of all medical art, than by his forerunners… but every third day the knot is to be undone, and
Now a surgeon should be youthful or at any rate nearer to one end that of another fresh thread is tied, and
youth than age; with a strong and steady hand which the old thread being withdrawn the new one is to be
never trembles, and ready to use the left hand as well as left in the fistula after being similarly knotted. For
the right; with vision sharp and clear, and spirit un- thus the thread cuts through the skin overlying the
daunted; filled with pity, so that he wishes to cure his fistula slowly, and whilst the skin released from the
patient, yet is not moved by his cries, to go too fast, or thread undergoes healing, that which is still gripped
cut less than is necessary; but he does everything just as is being cut through.^ [12]
if the cries of pain cause him no emotion^ [12]
In case of anal fissure and haemorrhoids, every surgical
In case of penetrating abdominal wounds, he recommends treatment must be preceded by enemas to clean the bowel.
inspection of the wound. If there is no bowel injury, all the The haemorrhoids must be excised after seizing them with
prolapsed content should be repositioned inside the abdomen forceps, but attention must be paid to not perform a complete
and the wound sutured (double layer). If there is an intestinal haemorrhoidectomy for the risk of a stricture of the anus. This
injury, the prognosis is poor for small bowel injuries, whereas is a principle at the basis of the modern treatment of
large bowel injuries can be sutured, only if the bowel is not haemorrhoids.
ischemic or in poor conditions.
BThe mouths of veins which discharge blood are re-
BSometimes the abdomen is penetrated by a stab of moved as follows. When any patient is losing blood,
some sort, and it follows that intestines roll out. When fasting is indicated, and a rather severe clystering of
this happens we must first examine whether they are the bowel, to make the openings more prominent, and
uninjured, and then whether their proper colour per- thus what may be called the little heads of the veins all
sists. If the smaller intestine has been penetrated, no come into view…. If there are two or three, the lowest
good can be done, as I have already said. The larger must be dealt with first; if more, they are not all treated
intestine can be sutured, not with any certain assurance, at once, to avoid having tender scars in several places at
but because a doubtful hope is preferable to certain once.^ [12]
The treatment of the fissure is simply the excision of the capital existed, that is from 330 to 1453. Byzantium, later
lesion to create a fresh wound that should heal by itself, after known as Constantinople and Istanbul, was the cultural and
local dressing with honey. political centre of the Empire. Byzantine art spread all over the
Mediterranean up to Ravenna and Venice, but even in the
B…If, therefore, any fissure has persisted so long that it south of Italy, as well as in Greece and in Turkey.
has become hard and callous, it is best to move the In this period, surgery had few developments and was just
bowels by a clyster, then apply a hot sponge to soften about applying the ancient Greek and Arab teachings. The
the fissures and cause them to protrude. When brought translations of the manuscript were done in the Christian mon-
into view each is excised and made into a fresh wound; asteries and abbeys, which were the real centres of knowledge
then soft lint is put on and over this a pad smeared with and culture [5].
honey, and all is covered with soft wool, fixed by a Paul of Aegina (Paul Aegineta) was a Greek byzantine
bandage.^ [12] physician known for writing a huge medical textbook De Re
Medica Libri Septem (i.e., the BMedical Compendium in
Claudius Aelius Galenus was the second important Roman
Seven Books^). This was translated into English by the sur-
physician, surgeon and philosopher. He was born in
geon Mr. Francis Adams and published in 1834. Paul was
September AD 129 in Pergamon. His father was a wealthy
born in Aegina probably in AD 625 and his precise date of
patrician, architect, builder and philosopher, with interests in
death is not known, probably around AD 690. He was greatly
mathematics, astronomy, literature…, and planned for his son
appreciated in the Arabic world, where all his works were
a Bnormal career^ as a philosopher. But, according to the same
extensively translated and studied. His experience in the treat-
Galenus, when he was 16, his father had a dream in which
ment of pelvic floor diseases has earned him the Arabic nick-
Asclepius himself suggested for Galenus a medical career. So
name of Al-kawabeli, the obstetrician. In his third book, head
he was sent to spend four years at the local Asclepius temple
59, he gives an accurate description of haemorrhoids and their
as an attendant. At that time, Asclepius sanctuaries were used
treatment. The first approach should be a local treatment with
as houses of cure for both body and soul and as schools of
herbs, decoctions and suppositories [13], but surgery was still
medicine. After being abroad for a period, he came back to
indicated in selected cases. In the same Book 3, piles were no
Pergamon aged 28 to become physician to the gladiators.
more considered an effect of a rectal prolapse, but as enlarged
Obviously, this was an outstanding experience for him, as he
blood vessels that should be treated with ligation. It is inter-
could study living anatomy on wounded gladiators and master
esting to note the two other different techniques he reports,
the treatment of trauma and fractures. In particular, he had a
from Leonides — a Greek surgeon — and from Bothers^. The
great commitment in the treatment of abdominal penetrating
first of them uses compression to close the vessels before
trauma and in intestinal sutures. As a matter of fact, during his
cutting them off, and the second uses hot temperature to cause
employment as gladiators’ surgeon, mortality rate fell signifi-
a coagulative necrosis of them by cauterisation [14].
cantly. When his fame spread all over the Roman empire, in
AD 162, Galenus was summoned to Rome, to be appointed as
BBefore proceeding to the operation we must use
a physician to the emperors Marcus Aurelius, Commodus,
frequent clysters with the view of evacuating at the
Septimius Severus and Caracalla and where he died aged 87.
same time the content of the intestine and, by ir-
During his period, in Rome, he produced his extensive med-
ritating the anus, of rendering it more disposed to
ical literature spanning from anatomy — he performed dissec-
eversion and protrusion of the gut. Having there-
tions of alive and dead animals as Roman law prohibited dis-
fore laid the patient on his back in a clear light, if
section of human bodies — to surgery — famous is his inter-
we are to use the ligature we pass a very thick
est in brain and eye surgery. Unfortunately, he added nothing
thread round the lips and secure each of the
to colorectal and proctologic surgery, but just applied
haemorrhoids with this ligature, leaving one as
Hippocrates’ teaching on bowel suturing.
an outlet to the superfluous blood. After the appli-
cation of the ligature, using a compress that has
been dipped in oil and the bandage adapted for
Byzantines the anus, we order the patient to remain quiet…
Leonides has not recourse to the ligature, but hav-
The Byzantine Empire was the continuation of the Eastern ing seized the haemorrhoids and held them for
Roman Empire, which survived the fall of the Western some time with the forceps used for operation on
Roman Empire and existed up to the Ottomans’ takeover. the uvula, he cuts them off with a scalpel… Others
Diocletian divided the Roman Empire in AD 285 to get a better by filling the cavity of the instrument called
organisation of the central power, but officially, the Eastern staphylocaustes with caustic medicines, have burnt
Roman Empire, or Byzantine Empire, existed as long as its haemorrhoids like a scirrhous uvula…^ [14]
Arabs back to Bagdad to become the head of a new hospital. He is

regarded as one of the first freethinkers in the history of Islam,
Arab surgeons and physicians lead surgery and medicine a big but probably this earned him a total blindness, as a conse-
step forward, even if they added nothing new in colorectal quence of being beaten by a mullah or his killers. He stated
surgery. More often, they just systematised and popularised that every good doctor should base his cure on the deep
the ideas of Galen. knowledge of human anatomy. It seems that a local physician
It is interesting to note that the history of Arab medicine offered to treat his blindness, but when he failed to answer Al-
and surgery arises from a Christian heretic, Nestorius, patri- Razi’s question on how many layers the eye contains, Al Razi
arch of Constantinople, who around 435, after the Council of declined his offer saying, Bmy eyes will not be treated by one
Ephesus, was forced into exile. To survive, his followers were who does not know the basics of its anatomy^. He was a very
forced to study medicine and instituted a medical school in prolific writer not only in medicine but also in chemistry,
Edessa, Syria, based on Greek ideas. Unfortunately, the alchemy, philosophy and religion. His fame is linked to his
Nestorians also clashed with the bishop of Cyprus and were description of various diseases. His Al-Hawi is a huge text-
expelled once again. In 489, they came to Gundeshapur, book of medicine where he was the first to describe measles
where they founded a new school of medicine. This city saw and smallpox. He was also interested in the diseases of chil-
the flourishing of culture in the Arabic language and the be- dren and is regarded as one of the fathers of paediatrics.
ginning of its spread throughout the Mediterranean basin. The Surgery is the subject of his seventh book. In surgery, he
history of Islam officially starts in AD 622, the first year of the was one of the first to use animal gut derived suture to
Islamic calendar, when Muhammad fled from Mecca to close bowel wounds, but described also several orthopedic
Medina. Mecca had been always a centre of cult, where the operations [5].
nomadic tribes came to venerate the Ka’aba, a huge granite Ali ibn al-Abbas al Majusi was born in Ahwaz in 930.
cube that contains the black stone traditionally placed there by After his studies, he worked in Shiraz and Bagdad. He is best
Abraham and Ishmael (his first son according to the Bible and known for his textbook Kitāb Kāmil as-Sinā’a at-Tibbiyya,
the Quran). In 612, Muhammad ibn-Abdullah, a merchant, the BComplete Art of Medicine^, known in the Western world
began to reveal the words he received from God through the as Al-Maleki, from the name of the Emir it was dedicated to.
angel Jibril, but this upset the local religious establishment and This was one of the most known treatises of medicine for more
he was forced to move to the town of Yathrib, later renamed than one century, replaced only by Avicenna’s Canon, and was
Medina (Bcity of the prophet^). In Medina, he reorganised his used as a textbook in the Medical School of Salerno. Hali-
people and threw the conquest of neighbouring countries such Abbas 19th volume contains 110 chapters on surgery. His
as Persia, Syria, Palestine and Egypt, then across the treatment for imperforated anus was the incision of the anal
Mediterranean to the south and west to invade Spain and membrane followed by the insertion of a sponge or a lead
Sicily. They were about to enter France, but the French army probe to avoid early closure. But he was also the first to de-
stopped them in Poitiers in 732. scribe the treatment of arterial bleeding with proximal and
Through their military conquests, the Arab civilisation and distal ligation of the artery, six centuries before Ambroise
culture spread throughout the Mediterranean and beyond, up Paré [5].
to India and South-East of Asia. We can consider the Arab The importance of Avicenna is equal to that of Hippocrates
civilisation as the point of union between the Greek-Roman and Galen, not only for the Arab world but also throughout the
world and the Renaissance. Most important was the contribu- culture of medieval, modern and contemporary world.
tion of the Jewish translators, who made the Greek and Latin Avicenna is said to have been a child prodigy and studied
classics available to Arab physicians and, therefore, helped the medicine in Baghdad with the Nestorians. His real name
Arabic medical texts to spread throughout Europe. was Abū ‘Alī al-Husayn ibn ‘Abd Allāh ibn Al-Hasan ibn
In 755, a big schism split the Arabic empire in a western Ali ibn Sīnā, but is known as Ibn-Sina or Avicenna. He was
caliphate, based in Cordoba, and an eastern caliphate, based in born in 980 in Afsana, a little village near Bukhara, today
Bagdad [3]. Each of them had its own traditions and culture Uzbekistan. According to his autobiography, he had learnt
and its own approach to science. the entire Quran by the age of 10, and then he studied arith-
The most important surgeons in the Eastern Caliphate were metic and even Islamic laws. As a teenager, he studied philos-
Al-Razi, Haly Abbas and, mostly, Avicenna. In the Western ophy and turned to medicine aged 16 and graduated at 18. His
Caliphate, worth of notes are Albucasis, Avenzoar and fame spread and he was appointed as the Emir’s physician and
Averroes. gained access to the library of the Samanids. When he was 24,
Muhammad ibn Zakariyā Rāzī was born in Rey, on the the end of the Samanids dynasty meant the start of his nomad
Great Silk Road, in 854, but moved to Bagdad to study med- life. During this period, he continued working, writing and
icine. Later, he came back to Rey to work as the head of the teaching. His greater treatise Canon of Medicine has been
local hospital but due to his growing popularity he was called composed in his period. He died in 1037 in Hamadan, today
Iran, where he was buried. Avicenna’s Canon was largely pillow under him; let another assistant sit on his legs
influential in the Middle Ages and was used as a university and another on his chest, holding his hands. Then apply
textbook up to the 17th century. It explains the causes of the cautery to the mark, keeping the cautery upright and
diseases. Most important, in his Canon Avicenna anticipates hold it till he reaches the bone… You must take the
the WHO definition of medicine as Bthe art whereby health is greatest care that the intestine does not come out while
concerned and the art by which it is restored after being lost^, you are cauterizing, lest you burn it and it result in death
meaning that the central interest of medicine is health, not or grave injury to the patient.^ [15]
disease. Generally speaking, there is nothing new in the
As regards our particular interest, his use of cat or sheep gut
Canon as it should be regarded as a huge exposition of the
for internal stitching was the basis of modern bowel sutures.
Galenic theories. From the surgical point of view, he intro-
Abū-Marwān ‘Abd al-Malik ibn Zuhr, better known as
duced the theory that surgery is somewhat inferior to medicine
Avenzoar, was born in Seville in 1094, the son of a Hebrew
that dominated the Western world for many centuries, but
physician who taught him the basic of medicine. His main
described the tracheostomy and a treatment of the cancer of
treatise was Kitab al-taysir (BBook of Simplification^), where
the breast. As regards bowel surgery, he suggested to use
he presented the first descriptions of oesophageal and gastric
twisted human or pig hair to suture intestinal wounds [14].
cancers. One of his greatest contributions to medicine was
The western caliphate had its centre in the town of
experimental surgery on animals before applying the same
Cordoba, where a university was founded in the 8th century,
technique on humans. He was a great admirer of Galen, and
alongside with at least 50 hospitals. The main medical author-
in his writings, he protests emphatically against quackery and
ities in the western caliphate were Albucasis, Avenzoar and
the superstitious remedies of the astrologers. Unfortunately, he
Averroé. Modern surgery has several fathers… one of them is,
did not add anything to colorectal surgery [5].
for sure, Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi,
Abū l-Walīd Muhammad bin Ahmad bin Rušd, known as
known as Albucasis. He was an Arab Muslim, born in El-
Averroes, was a philosopher, theologian, physician and as-
Zahra, near Cordoba, in 936 and lived and practised surgery
tronomer. He was born in Seville in 1126 and was a master
in Cordoba until his death in 1013. We have few details of his
of Aristotelian philosophy. He is famous for his commentaries
life, but we know he was Court Surgeon to the caliph Al-
of Aristotle, but he gave a great contribution also to medicine.
Hakam III. He described several surgical instruments, such
He was trained in Cordoba under Avenzoar and spent his
as surgical hooks, cannulas, forceps and specula, and
working life between Cordoba, Seville and Marrakesh, where
specialised in curing surgical diseases by cauterisation. It is
he died in 1198. Averroes wrote a medical encyclopaedia
known also for describing the first ectopic pregnancy in 963.
called Kulliyat (BGeneralities^), translated in Latin, which is
Albucasis’ most important writing is Kitab el-Tasrif (BThe
inspired by Avenzoar’s work Al-Tavsir. He is known more for
Collection^), a 30-book treatise reporting the up-to-date med-
his philosophical interests and for commenting Aristotle than
ical knowledge alongside the basic principles of medical de-
for his medical writings, and for this reason, he earned an
ontology. He emphasised the need to treat patient
honour place in Raffaello’s BThe School of Athens^ [5].
irrespectively of their social status and was one of the first to
Unfortunately, little is known about the real practise of
write on the importance of a positive doctor–patient relation-
advanced surgery in ancient Islamic lands. In particular, there
ship. In the Middle Ages, El-Tasrif was the main surgical
is uncertainty about what kind of operation has been actually
textbook. Here, he describes the use of cautery to treat many
performed and what has just been described, citing previous
conditions. Very interesting is his description of the use of
sources (as Hippocrates and Paul Aegineta), but it is
cautery in the treatment of groin hernia.
recognised that many of the Arabian writers modified ancient
surgical instruments and proposed new items and techniques.
BWhen a rupture occurs in the groin, and part of the
For sure, they dealt with haemorrhoids and performed tonsil-
intestine and omentum comes down into the scrotum,
lectomies, as well as eye operations and dental extraction and
being the onset of the disease, forbid the patient to take
replacement [16].
food for one day and have him to use laxatives to empty
the bowel. Then let him lie on his back in front of you
and bid him hold his breath till the intestine or omentum
comes out, then put it back with your finger. Then below Ancient India
the hernia over the pubic bone, mark a semicircle whose
extremities point upward. Then heat a cautery… When it Even if there is evidence of the presence of Homo Erectus in
is white hot and emits sparks then return the intestine or the Indian subcontinent about 500,000 years ago, the history
omentum into his abdominal cavity and have an assis- of India begins with the Indus valley civilisation, which
tant put his hand over the place to prevent the exit of the started in 3300 BC around the Indu river. An Indo-Aryan cul-
intestine. You should first have parted his legs and put a ture began in the second millennium BC and is associated with
the first texts of Vedas, sacred books composed in Sanskrit. In stronghold in the church. Church and faith were the leading
this period, there was no proper Indian state, but small city themes of this period, which saw the beginning of Western
states sharing the same language and religion. In 530 BC, Monasticism with Saint Benedict of Norcia. For centuries,
Cyrus the Great started the invasion of the southern part of abbeys and monasteries were the only centre custodians of
Asia and brought India under the Persian Empire. The first culture. The Middle Ages saw also that big disaster represent-
Indian empire was established in the 4th century BC by the ed by the Crusades. These were a series of political and eco-
Maurya Dynasty, but it was under the Guptas that India had a nomical wars, started and fought within the flag of religion,
big development in art and literature between 320AD and with long-lasting consequences such as the mutual hostility
460AD. Sumudra Gupta was a great empire builder and ex- between Europe and Islam and also the destruction of the
tended Indian rule all over the Indian subcontinent up to the Byzantine culture and the ancient Muslim culture. The real
Himalaya. During this period, not only art but also technology reasons for the Crusades have been debated for decades, but
and mathematics flourished, alongside with medicine and sur- definitely they were supposed to regain the papal power by
gery. This was called the BGolden Age^ of India. compacting the Christendom and to open the trade ways from
Between the 8th and the 6th century BC, India hosted one of Asia to Europe. The Crusades have been also the occasion for
the most advanced medical and surgical schools in the ancient the foundation of the Order of the Templar Knights in 1118, to
world. The Hindu Sushruta was a milestone in Indian surgery; protect Jerusalem and European pilgrims, whose power in
maybe he was the first proper surgeon in India. He lived some Europe lasted until the 1307, when Philip the Fair, King of
600 years BC, which means he lived almost two centuries France, confiscated their possessions and executed the
before Hippocrates. The Sushruta Samhita is the first Indian knights. The greatest medieval empire was established by
textbook of surgery. It is part of the Ayurveda, the collection of Charles the Great (Charlemagne) starting from the land previ-
knowledge of ancient Indian medicine, and was translated into ously owned by the Merovingian kings of France, descen-
English in 1883. In its 184 chapters, he reports every kind of dants from Clovis, the first Frank King. Charlemagne was
surgical operations, from cataract surgery to tooth extraction, crowned by Pope Leo III in Rome on the Christmas Day of
from urological operations, such as prostatectomy to laparot- AD800. In the 7th–9th centuries, the BMen of the North^, the
omies, and bowel surgery in election and emergency. Sushruta Vikings and the Norseman — Normans, started their invasion
can be also considered the first anaesthetist as he suggested the of Europe bringing a new age of culture and political organi-
use of wine and cannabis for the anaesthesia. He described the sation. In 1066, their descendants from Normandy invaded
use of different knives and incisions to cut fistulous tracts. Britain [3].
According to his writings, in case of abdominal wound with During the Bdark ages^, Medicine had a slow but radical
exposition of the bowel, the bowel itself should be carefully transformation, from an almost magic and God-related prac-
inspected, wetted with honey and butter and pushed back. tise to a more scientific discipline that was taught in universi-
Wounds of the bowel were repaired using alive Bengala black ties and medical schools, the first of whom was the Medical
ants, whose pincers were used to approximate the two edges. School of Salerno. The popular culture always linked — and
Afterwards, the ants were decapitated and the following rigor still does nowadays in many parts of the world — specific
mortis kept the claws closed and the wound closed. After parts of the body and specific diseases to specific Saints, de-
washing it off with honey and butter, the bowel was pushed pending on their hagiography and often their — usually vio-
back in the abdominal cavity and the wall stitched [13, 17]. lent — death.
Saint Benedict believed that only prayers could cure, so he
forbade the practise of medicine and surgery in his monaster-
Middle Ages ies [5], endorsing in this way the common opinion of the
Catholic Church that Ecclesia abhorret a sanguine (Church
The Middle Ages is considered that long period of time going abhors blood). For many centuries, surgery was excluded
from the Fall of the Western Roman Empire, AD476, to the from the cultural environments, necessarily limited to the
discovery of America — better, the first voyage of monasteries and was therefore practised by quackers and bar-
Christopher Columbus — in 1492, even if other dates could bers, the usual guests of the monasteries where it was forbid-
be considered, such as the Protestant Reformation starting in den to wear beards [5].
1517 in Wittemburg by Martin Luther or the invention of the St. Fiacre is regarded as the patron saint of haemorrhoids
printing press by Johannes Gutenberg in 1439 or even the fall and gardeners. He was born in Ireland at the end of the 6th
of Constantinople in 1453. At the collapse of the Western century and became a hermit in County Kilkenny. But his
Roman Empire, Europe was divided between the new settlers, reputation as a healer and miracle gardener spread in the re-
the only unifying entity being the Christian church. The early gion, and many people went to see him, so he was forced to
Middle Age was a period of social insecurity and instability, leave Ireland to seek refuge in France, at Meaux. Bishop of
so it is quite understandable that people found their only that town was St. Faro, who assigned him a spot in Brodoluim.
The agreement was that he could use as much land as he could first printed edition was edited in Venice in 1480 and the first
plow in a day’s work with a furrow. So he worked all day in English translation was done by Sir John Harington in 1608.
the hot sun and developed a severe haemorrhoidal prolapse. Sir Harington was a godson of Queen Elizabeth I and was the
At the end of that day, exhausted and sore he sat down on a inventor of the modern water closet [5].
stone that was hot for being in the sun all day and started to One of the most influential members of the School was
pray. Either for divine intercession or for the warmth of the Ruggero Frugardi. He wrote an important treatise of surgery,
stone, his prolapse was cured and the mark of his prolapsing Practica Chirurgiae, where he proposed to suture the intesti-
haemorrhoids was forever engraved on that stone. He died on nal wounds using as a stent the trachea of a large bird or a
18th August 670 and his relics are in the Meaux Cathedral piece of hollow wood. In the same treatise he speaks about a
where he is worshipped. His feast day is in 18th of August or Bspongia somnifera^, sleep-inducing sponge, soaked with
1st of September (in Ireland). Three miles from Meaux, he various substances including opium and precursor of modern
founded a town called Saint Fiacre en Brie. The cult of Saint inhalation anaesthesia.
Fiacre, initially limited to S. Fiacre en Brie, extended to all Another important surgeon of the Middle Ages was Bruno
France and Belgium, where haemorrhoids are sometimes of Longobucco. Bruno got trained in Salerno but added inno-
called Bfigs of S. Fiacre^ or BS. Fiacre disease^. vative ideas to his basic knowledge. He wrote two books
Passing from the popular faith to the cultural settings, the Chirurgia Magna and Chirurgia Parva (BGreat Surgery^
Medical School of Salerno, in the south of Italy, achieved its and BSmall Surgery^), where he first proposed the use of
maximum splendour between the 10th and the 13th centuries, animal gut, silk or cotton to suture bowel wounds and close
even if it was founded in the dispensarium of a monastery of vessels and suggested to remove Bgreen or black^ tissues be-
the 9th century. Historically, the true beginning of the School fore suturing. He stated that the Btask of the surgeon is to
is considered the arrival of Constantinus Africanus in Salerno operate in three cases: to join separate things, to separate
in 1077. He was an Arabic doctor who spent part of his life in the joint against nature, to eliminate the superfluous^ [5].
North Africa where he studied medicine with the Arab doc- The figures of Ruggero Frugardi and Bruno of
tors, and then he came to Italy where he became a Professor of Longobucco are quite atypical in the European landscape.
Medicine at the Salerno Medical School and later a Strictly speaking, they were physicians, as they graduated in
Benedictine monk in Monte Cassino Abbey. His fame is due a proper medical school, but were also surgeons, as they wrote
to his translations in Latin of several books of Arabic authors, of surgery and practised surgery. This can be explained by the
which were used as textbooks up to the 17th century. With his fact that in most Italian medieval towns — unlike the rest of
guide, Salerno became BTown of Hippocrates^ and attracted Europe — there was no separation between the barber sur-
sick people looking for a cure and students anxious to learn geons and the academic physician.
medicine. The great point of strength of the school was its On the contrary, in Britain, France and Germany and in the
multiculturalism. As a matter of fact, they followed the Latin rest of the continental Europe, surgeons were trained through
and Greek traditions, merging it to the Arabic and Jewish apprenticeship under experienced barber surgeons and not in
medical traditions, which were the most scientifically ad- universities. Barber surgeons had their gold moment in 1540
vanced at that time. It is said that the Salerno Medical when they established their Company of Barber Surgeons in
School had been founded by the Jewish Helinus, the Greek London for training and examination of the junior apprentices.
Pontus, the Arab Adela and the Latin Salernus. Moreover, In 1745, the company split in a Company of Barbers and a
very much in advance with respect to its time, the Salerno Company of Surgeons. The former gradually disappeared,
School admitted also women both as students and teachers. whereas the latter flourished and, in 1800, was granted the
It was closed in 1812 by Joachim Murat, French General and status of Royal College of Surgeons in London, which later
King of Neaples under the Emperor Napoleon, his brother-in- on became the Royal College of Surgeons of England (http://
law, mostly to favour the newborn School of Montpellier in www.rcseng.ac.uk/about/history-of-the-college).
France. John of Arderne was an eminent barber surgeon of the 13th
The Salerno School was famous for its rules of hygiene and century, born in 1307; he served in the Hundred Years War
healthy diet and for its books, translated and diffused all over under the Duke of Lancaster, then he worked as a surgeon in
Europe. In particular, the book Regimen Sanitatis Newark, Nottingham and London. He is often described as the
Salernitanum is one of the most popular poems in the history Father of English Surgery. What is known and certain about
of both medicine and literature. Written sometime during the him is that he wrote a number of medical and surgical text-
12th or 13th centuries, there have been over 100 manuscript books, translated in English by Sir D’Arcy Power. He was
versions and approximately 300 printed editions. Its author is particularly interested in rectal surgery and wrote a treatise
entirely unknown, but probably it was written for Robert, son on the treatment of anal fistulae, a condition affecting mainly
of William the Conqueror, who stopped in Salerno on his way the knights as they spent a big part of their time on a horse-
home from the Crusades in order to have a fistula cured. The back. John described the process of anal abscess becoming
fistula and suggested that the abscess should be opened before ages^. The invention of the press and availability of paper
it finds its way into the rectum (http://www.rcseng.ac.uk/ allowed the dissemination of ideas, the reformation of the
about/history-of-the-college) [18]. For this purpose he Christendom favoured on both sides a more conscious ap-
designed specific instruments and prescribed ointments and proach to religion and life — on 31st October 1517, Martin
oils to be put on the wound after opening. In his BTreatise of Luther, a German monk, posted his 95 Btheses^ on the door of
Fistula in Ano, Haemorrhoids and Clysters^ and BPractica his church in Wittenburg - helped by the translations of the
Chirurgiae^, his most famous textbooks, he gives also Bible into national languages, the spreading of knowledge and
indication on the ethics of the medical profession. In culture outside the religious environment allowed arts and
particular, he suggested to cultivate charity and to cure rich literature to flourish, alongside with science and technology.
and poor in the same way. His wealthy patients paid him with Possible contributing factor to the Renaissance was the bu-
monthly or annual salary, whereas his poor patients were bonic plague that hit Europe in the 14th century, almost halv-
usually cured free of charge. He claimed to have a mortality ing the population but granting the survivors a new view of the
of less than 50 %, which is an outstanding result for that time. world and of human life, more space to live in and more
He also urged his followers and colleagues to dress as clerks available natural resources. Politically, Europe in the first de-
and not as minstrels and to speak polite, calm and without cades of the 16th century saw the emergence of the first nation
swearing, trying to have always a moral story or a saying for states and the creation of a highly competitive state system. In
patients in pain or discomforted by the treatment. One of the Spain, Ferdinand and Isabella had united the country, had
reasons for writing his textbooks was to Belevate^ his social rejected the Moors out of the Peninsula and had sent
status, and that of his colleagues, to the rank of an academic Christopher Columbus out to find a new trade way to the
doctor. At that time, in fact, there was a clear hierarchy in Eastern India. In France, the Valois kings had gathered under
medicine, where the upper steps were reserved to academic their control most of what is now that country. In England, the
doctors, those who adjusted the Bhumours^ of the body with Tudors had ended the divisive War of the Roses and
fluid, diet, blood lettings and were educated in the universities, established their dynasty with Queen Elizabeth I. From
and the lower levels were for surgeons and barber surgeons. Germany, the Hapsburgs expanded their territories to half
The surgeons are dressed usually with above-the-knee gowns Europe, and Charles V became Emperor of the Holy Roman
and short-sleeved shirts, whereas doctors used long dresses [5, Empire with the protection of the Pope [3].
18, 19]. The 16th and 17th centuries saw the work and words of two
His description of a cancer of the rectum is outstanding, as VIPs of surgery, Andrea Vesalius and Ambroise Paré.
an ulcerated growth in the anus, not particularly tender, but Vesalius was born in 1514 in Brussels, and as soon as he
causing tenesmus . Even more interesting is the play on the graduated in Medicine, he was offered the post of Professor of
Latin word Bbubo^ that means Btumour^ as well as Bowl^. Surgery and Anatomy at the University of Padua. He was also
lecturer in Bologna and Pisa. Before Vesalius, anatomy was
BBubo is an apostem breeding within the anus in the taught by a lecturer who was reading texts by Galen whilst a
rectum with great hardness but little aching. This I say, barber was performing a dissection usually on animals. Galen
before it ulcerates, is nothing else than a hidden can- and Hippocrates statements could not be challenged. On the
cer…but after passage of time it ulcerates and, eroding contrary, Vesalius considered human dissection as the primary
the anus, comes out. And often it erodes and wastes all way to learn and teach anatomy. He did himself his dissections
the circumference of it so that… it may never be cured and suggested the students to do the same. Furthermore, he
with man’s cure… Signs of ulceration are these: the publicly criticised Galen’s work, proving that those studies
patient cannot abstain from going to the privy because were conducted on animals, so that anatomical knowledge
of aching and pricking and that twice or thrice within for 1400 years had been based on wrong concepts, on the
one hour; and he passes a stinking discharge mixed with wrong idea that mammals and humans shared the same anat-
watery blood… I never saw or heard of any man that omy. His criticism towards Galen’s work attracted many at-
was cured of cancer of the rectum, but I have known tacks, and he had to face a public enquiry on the religious
many that died of the foresaid sickness^ [18] implications of his methods. When he was 28, he published
the first edition of De Humani Corporis Fabrica, a huge trea-
tise on human anatomy equipped with 273 artistic illustrations
Renaissance drawn by various skilled artists that were present during the
actual dissections. This was an editorial success and represent-
The Renaissance was a cultural movement beginning in Italy ed the basis of medicine studies for several centuries. In 1564,
in the late Middle Ages and spreading to the rest of Europe, when he was 50, he went for a pilgrimage in the Holy Land,
but it identifies all the historical changes and evolution that where his ship was wrecked in the Isle of Zakynthos, and died
characterised the centuries immediately following the Bdark and was buried in Korfu [5].
The Humani Corporis Fabrica reports the results of 5. He began to rule France personally in 1661, when he was
Vesalius’ dissections, with organs and structures seen in the 23, at the death of Cardinal Mazzarino. He was diabetic and
complex mechanism of the body. The classical Greek and vasculopathic and, probably, suffered of all the diseases relat-
Latin descriptions, mainly derived by religious and magic ed to poor hygiene (infectious diseases, skin diseases…). In
ideas, were lost forever. To better appreciate the function of fact, his personal diary from 1647 to 1711 reported just one
every single muscle or bone, he did not limit to the formal bath in 64 years, but more than 2000 enemas. As regards the
dissection with the corpse lying on a table. subject of this paper, what is interesting about Louis XIV is his
operation for fistula in ano which was performed on 18th
BWhen I undertake the dissection of a human pelvis I November 1686.
pass a stout rope tied like a noose beneath the lower jaw The King started noticing a perianal swelling on the 15th
and through the zygomas up to the top of the head… The January 1685, an abscess formed 1 month later, on the 18th
lower end of the noose I run through a pulley fixed to a February 1685, and on the 2nd May, a fistula appeared, prob-
beam in the room so that I may raise or lower the ca- ably linked to his excessive daily horseback riding, to his poor
daver as it hangs there or turn around in any direction hygiene or to his frequent use of enemas. Many laxatives had
to suit my purpose.^ [20] been useless to treat the fistula, as were all other remedies
suggested by different physicians and tested on patients with
In De fabrica, he described the omentum and his relation-
similar condition. The only possibility was a surgical opera-
ship with stomach, spleen and colon and observed the appen-
tion. The court surgeon, Charles-Francois Felix, was sum-
dix. Vesalius’ work is the basis for surgical practise, and even
moned. He visited the King and proposed surgery. Louis
colorectal surgery took advantage from his studies.
agreed, but Felix asked 6 months to prepare for the operation,
Ambroise Paré was born in Bourg Hersent, France, in
as he had never cut a fistula before. He was allowed to practise
1510. He is one of the fathers of surgery, anatomy and forensic
on peasants of the poor’s hospital of Paris. None of them
pathology and one of the milestones of trauma surgery. As a
actually needed an operation, but many did not survive
child, he followed his older brother who was a barber surgeon
Felix’s treatment. A silver knife and a special anal retractor
and trained at the Hotel Dieu, the oldest hospital in France.
were constructed for the occasion. At 7 a.m. on the 18th
During the battles in France and in the north of Italy, he was
November 1686, the operation was secretly performed in the
battlefield surgeon and experimented new methods to treat
King’s bedroom at Versailles. Present were the court physi-
gunfire wounds and to perform amputations. In particular, he
cians Daquin, Fagon and Besnier, Madame De Maintenon, the
observed how soldiers treated in the usual way with oil
King’s second wife, Monsieur Louvois, the Minister of War,
cauterisation were likely to die whereas those treated with
and the priest La Chaise. History tells us that Felix cut twice
the ancient Roman method using eggs, oil of roses and tur-
with the knife and eight times with scissors. The operation was
pentine survived. Moreover, he introduced ligation of the ves-
performed without anaesthesia, but the King never did a sound
sels during amputation, instead of cauterisation, avoiding ma-
or a cry and his respiratory rate stayed unchanged. One hour
jor blood losses. He died in Paris in 1590, aged 80.
after the operation, the King underwent bloodletting, quite a
In 1564, he wrote his famous BTreatise on Surgery^ where
common procedure at that time. Despite this last manoeuvre,
he reported his experience in the battlefield and his techniques
he recovered well and the following day he received some
for haemostasis and amputations. He also described the
ambassadors. Felix did not want the wounds to heal too
Bphantom limb syndrome^ and a treatment for intestinal
quickly, so the King was operated again on the 6th, 8th
wounds. In BAn Apology and Treatise^, he describes the cur-
and 10th of December to have his wound reopened. The
rent method to treat a sigmoid volvulus conservatively with a
King was able to sit in bed after 1 month and came back
rectal tube.
on a horseback in 3 months. It is claimed that during the
convalescence, Louis visited the nuns of the cloister of
B…cause the belly to bee blowne with a pair of
Saint Cyr, where a song composed for the occasion by
Bellowes, putting the nosell of them into the rectum
Jean-Baptiste Lully and titled Dieu Savez Le Roi (BGod
and then blow there until the belly be much stretch,
Save the King^) was played. An Englishman present at
afterwards to give an emollient glister…^ [5]
the ceremony liked the song and brought it back to
Generally speaking, the proctologic operations were quite England, where it became the English national anthem.
similar to those performed in the previous centuries. Worth to This tale, reported by several sources, has never been
mention is just one particular mundane and cultural event in officially confirmed. The operation was a success and
these centuries, related to the person of Louis XIV of France Felix received 40,000 crowns, a castle at Moulineaux
and to the English national anthem BGod Save the Queen^. and a title, one of the higher fees in the history of private
Louis XIV was born on 5th September 1638 in the Château practise. Felix was shaken by the experience and never
de Saint-Germain-en-Laye in France and became King aged touched a knife again in his life [21, 22].
As regards bowel sutures, in the 16th century Roger, with bowel injury to an elective resective or derivative sur-
Jamerius and Theodorich of Servia used to suture the two gery. Many high level figures arose in this period.
stumps with normal full-thickness stitches over a cylinder of Giovanni Battista Morgagni was the first to describe the
elder put into the bowel as a stent. Wilhelmus of Saliceto used crypts and columns of the anus, and proposed an operation
a dried segment of animal bowel, but later on, he agreed with for the cancer of the rectum. He was born in Forli, Italy on
the other colleagues to use a goose trachea, originating the so- 25th February 1682, went to Bologna to study medicine and
called BSuture of the four Masters^. The bowel was sutured graduated in 1701. His first job was as prosector with Antonio
with four stitches whose long threads were brought out of the Maria Valsalva, another important anatomist and physiologist.
abdominal surface to put the bowel in contact with the abdom- When Valsalva was transferred to Parma, he took over as
inal wall. Others modified this original suture but maintained Anatomical Demonstrator. In 1712, he moved to Padua where
the original idea of a stent to keep the bowel patent and the he got the Chair of Human Anatomy. His great legacy was not
suture waterproof [8]. There is a quick tale, told by only the knowledge of human anatomy but also the study and
Hyeronimus Braunschweig in 1497, referring to Saliceto. In comprehension of the causes of the diseases by the observa-
an attempt to suicide, a Knight of Pavia stabbed himself in his tion of the diseased organs. With him, pathologic anatomy —
abdomen with a knife, causing the bowel to come out. The surgical pathology — became a science. He is also known for
great master Ottebanus of the Pavia University failed to push his description of aortic sinus where the coronary artery depart
the bowel into the abdomen due to its oedema and gave up from the ascending aorta, the foramen between the diaphragm
considering that wound fatal. Saliceto, asked for a second and the sternocostal deep wall where the superior epigastric
opinion, cleaned and sutured the bowel, enlarged the abdom- vessels reach the abdomen and site of the congenital
inal wound, reduced the bowel into the abdomen and treated Morgagni anterior diaphragmatic hernia, and the Bappendix
the perforating wound, saving the knight [5, 8]. of the testis^ (hydatid of Morgagni). He reached an interna-
tional reputation and was member of several scientific acade-
mies. He died in Padua on 6th December 1771, aged 89. Even
18th and 19th centuries if Morgagni proposed an operation for the cancer of the rec-
tum, there is no record of him performing such operation in a
The 18th century was the century of American and French patient.
revolutions. Liberal ideas spread all over the world, and the Maybe for the increasing bellicosity of European states and
Enlightenment favoured the flourishing of philosophy and empires or for the extensive use of gunpowder and more pow-
science. With the French defeat in North America and the erful weapons, the battlefield surgeons had to deal with mul-
Industrial Revolution, Britain became a power worldwide tiple injuries, many of them penetrating into the abdomen and
even if it lost its North American colonies with the threatening the bowel. The bad results of bowel wound suture
American Revolutionary War 1775–1783 and the US decla- in penetrating bowel wounds, together with the observation
ration of Independence in 1776. The French Revolution and that sometimes patients recovered with the formation of an
the Terror period 1789–1799 led to Napoleon Bonaparte be- enterocutaneous fistula lead to an initial conservative ap-
coming first consul in 1799 and then emperor of France in proach bringing the wounded bowel in proximity to the ab-
1804, but he was finally defeated in Waterloo in 1815. The dominal wall. Palfyn, Bell and Reybard proposed different
subsequent Congress of Vienna redrew the map of Europe. methods to approximate the injured bowel to the abdominal
The 19th century saw also the collapse of the Spanish wall [7].
Empire, the French Empire and the Holy Roman Empire and Many modification of the original Hippocrates’ technique
the expansion of the British Empire, after the battle of were described but the very most of them had their rationale in
Trafalgar 1805, and the Russian one. The Industrial closing the bowel and fixing it to the abdominal wall [7].
Revolution spread from Britain to involve the entire world Unfortunately, the resulting fistula was quite difficult to man-
and prepared the way for the modern technologic evolution age. The first methods of direct suture were done by the in-
of the 20th century (in particular, thanks to the railroads and vagination of the proximal stump into the distal one, with or
the improvement of healthcare). In Britain, the Victorian peri- without a stent [7].
od 1837–1901 meant rediscovery of strict social roles, respon- The Lembert’s works in 1826 on intestinal suture brought
sibilities and values. Slavery was gradually abolished and new light on the knowledge of the healing process, which can
sports have been coded and developed. The first official inter- be obtained only if two serosal surfaces are faced each other.
national soccer match England vs. Scotland was 0–0. It was a Lembert should be considered one of the founders of modern
period of great development in all fields, including arts and bowel surgery. He used interrupted sutures of silk to approx-
science [3]. imate the serosa of the two inverted edges of the bowel wound
In the 18th century, we could see the big transformation of and cut the thread just above the knot, not fastening the bowel
bowel surgery, from the mere treatment of abdominal trauma to the abdominal wall. The stitches were passed into the bowel
wall not penetrating the mucosa. Even if in use also nowadays, Hospital, but spent 2 years in Europe, mainly in Wien with
Lembert’s suture has been widely modified with time. Jobert Theodor Billroth. Back to the US, he started his career in
passed whole thickness stitches, Breidenbech tied the knot Chicago as a lecturer at the Rush Medical College and then
inside the lumen of the bowel, Dupuytren used the was appointed as Professor of Surgery at the University of
Lembert’s method with a running suture [7]. Illinois and subsequently at the Northwestern University and
As we will see later on, at the end of the 19th century, the at the Medical School of Chicago. He was the Lead Surgeon at
theories of Lister about asepsis were spreading worldwide, the Mercy Hospital in Chicago, where he did open clinics and
thus drastically reducing the mortality rate of surgical opera- operations that could be attended by physicians from all
tions. As regards bowel sutures, he suggested to use aseptic around the world. His teaching during his clinics was pub-
material to prevent as much as possible the leak of bowel lished as BThe Surgical Clinics of John Murphy at the
content during and after the operation. To perform a more Mercy Hospital of Chicago^, which later became BThe
hermetic suture, Czerny added a second row of stitches on Surgical Clinics of North America^ [7].
the mucosal layer. For many years, this technique has been It is not fair to speak about intestinal suturing without a
considered the safer method to suture the bowel. Even if now- tribute to the surgeon, actually a gynaecologist, unknown to
adays it is well demonstrated that the extramucosal suture, the most, who performed the first laparotomy. Mr. Ephraim
according to Lembert, is the best method as it permits a more McDowell was born in Virginia in 1771, but moved to
physiological healing with no ischemia of the bowel edges, Danville, KY when he was 13. He was first trained locally
most surgeon are still using the two-layer Czerny–Lembert then went back to Europe to attend the medical school in
suture. Halsted’s suture was based on the evidence that the Edinburgh and to receive private lessons by John Bell, one
most important layer in the healing of bowel sutures is the of the fathers of vascular surgery alongside with John Hunter.
submucosa, so at least some fibres of the submucosa should In 1795, he went back to Denville where he practiced surgery.
be taken in the suture. The suture is passed in a different way This was a very difficult frontier country and Mr. McDowell
than in the normal Lembert’s suture and has the advantage of had to cover miles on his horseback to see patients all around
not narrowing the lumen of the bowel. All these techniques that land. On 13th December 1809, he was called to see Mrs.
are still in use nowadays [7]. Jane Crawford, a 44-year-old woman with a progressive ab-
Various attempts have been made to replace sutures with dominal swelling, labelled as a beyond-term pregnancy, but
other devices. In 1826, Denans, of Marseille, proposed a rath- vaginal examination revealed that the uterus was empty and
er clever method to perform an end-to-end anastomosis. He that the pelvic mass was adnexal in nature, so Mr. McDowell
introduced a silver or zinc ring in each stump and inverted its proposed surgery. The operation was performed on Christmas
margin on that ring, then connected the two rings with a third Day 1809, Sunday morning, and took 25 min. Of course, it
ring, longer but smaller in diameter. Within a couple of weeks, was carried out without any anaesthesia whilst the patient was
the inverted margins subject to pressure became ischemic and reciting psalms. The mass turned out to be a massive
fell down, releasing the system into the bowel lumen, to be hydrosalpinx. The breakthrough operation performed by
eliminated with the stools. Henroz clamped together the two Mr. McDowell did not elicit much enthusiasm in the med-
stumps between two rings, each equipped with some pins to ical community at that time, and only in 1826 (17 years
perforate the bowel wall and fixing in correspondent perfora- after the first operation), he received the true scientific and
tions on the other ring, but in this case, the bowel stumps were cultural approbation by the London Medical and Surgical
everted and there was no serosa-to-serosa contact [7]. Review. By that time, McDowell had received an honor-
These ideas lead to the later development of a well- ary MD by the University of Maryland in 1825 and had
established suture device, the Murphy button. It was made performed many more laparotomies. He died in 1830 for
by two subunits. Each intestinal stump was placed onto one an acute appendicitis that could have been treated with an
of these, then the system was assembled and the two parts of easy laparotomy [23].
the bowel put together with perfect apposition of the serosal The real surgical step forward in the 18th century was the
layers. The inverted part was crushed by compression and increasing experience with intestinal stomas. In 1710, the
eliminated in a couple of weeks, when the system was released French surgeon Alexis Littré, speaking at the Royal
free and was eliminated through the anus. John Benjamin Academy of Science in Paris, described the case of a 6-day-
Murphy was born in Appleton, WI in 1857 and died of heart old newborn dead for imperforate anus and proposed the cre-
disease, maybe aortitis, in 1916. He is known for his button — ation of a stoma to deal with this severe condition, adding that
which was actually developed not for bowel suture but for a lumbar colostomy could be helpful also in acute colonic
cholecysto-enteric anastomoses, Murphy’s preferred treat- obstruction. He was born in 1654 and died in 1726, studied
ment of acute cholecystitis — and for the physical sign used medicine in Montpellier and taught anatomy. Famous is his
in the clinical diagnosis of acute cholecystitis. He was trained description of the herniation of a Meckel’s diverticulum
at the Rush Medical College and then at the Cook County through the inguinal canal (Littré hernia).
Lorenz Heister was a German anatomist and surgeon born at the same time care to leave a few of the smallest veins
in Frankfurt am Main in 1683 and died in 1758. He studied open.^ [25]
Medicine at the University of Giessen and Wetzlar, then
Amsterdam and was Assistant Physician in Brussels, and a Actually, the natural formation of a fistula after a penetrat-
Battlefield Surgeon during the Siege of Tournai and the ing bowel wound was a condition well known in the antiquity.
Battle of Malplaquet (War of Spanish Succession). In 1711, Famous physicians as Hippocrates, Celsus, Galenus knew
he was appointed Professor of Surgery at the University of very well that sometimes the only possibility to survive after
Altdorf and then at the University of Halmstadt. He described a penetrating bowel injury was the spontaneous formation of a
the spiral valves of the cystic duct and proposed the creation of natural stoma. In the history, there are several examples of
enterostomies in perforating bowel wounds and in bowel is- intestinal fistula formation. Soldier Praxagoras of Kos had a
chemia. He suggested to not suture the bowel wounds smaller permanent post-traumatic fistula. In the 18th century, soldier
than a goosequill, but in case of larger bowel wounds, he George Deppe had a wound in his back on 23rd May 1706,
suggested performing a suture with the glover’s technique of during the battle of Ramillies (duke of Marlborough vs.
Hippocrates. French army), and developed a fistula with large bowel; even
with the difficulties of dealing with such a debilitating condi-
B…where any part of the intestine is carried away, tion, he lived 14 years with that sort of colostomy. In 1750, the
the case seems to be plainly desperate. It was there- English surgeon William Cheselden operated on Mrs.
fore wonderful that Persons thus wounded did not all Margaret White, 73 years old, and removed 55 cm of ischemic
die upon the spot or in the operation of making the bowel due to volvulus or strangulated hernia; a piece of bowel
sutures, til various surgeons observed that the lips of was left hanging out the abdominal wall to drain the bowel,
intestines so wounded would sometimes quite unex- and she survived many years after that operation. The first true
pectedly adhere to the wound in the abdomen; and stoma was performed in 1776, when the French Surgeon
therefore there seemed to be no reason why we Henri Pillore from Rouen performed a caecostomy on a Mr.
should not take this hint from Nature. Whenever Morel, suffering for an obstructing rectal cancer. He had been
therefore a Surgeon is called to a case of this kind, referred to Mr. Pillore for worsening constipation after being
after he has diligently examined the state of the upper seen by other physicians in Rouen, where he was treated with
part of the intestine…he should stitch it to external laxatives without any effect. Thereafter he was prescribed to
wound either by the continued or interrupted suture… swallow 2 lb of quicksilver, but even this method was useless.
The same method of cure may conveniently enough Mr. Pillore performed a digital rectal examination and found
be put in practise where any part of the intestine is an obstructing tumour of the rectum. Pillore suggested a
mortified by being forced out of the abdomen… For it caecostomy but to be safe he requested a second opinion from
is better to try this method, though but few should be five of his colleagues. They all rejected Pillore’s option, but
saved by it, than to suffer all to perish… It is wiser to when the patient asked them if they had a different option,
attempt a doubtful remedy than absolutely to they said they did not. So the patient asked them if his condi-
despair…^ [24, 25] tion was life-threatening and they confirmed it was, and Mr.
Morel agreed to Mr. Pillore proposal. A stoma on the caecum
As regards the treatment of haemorrhoids, Heister did not
was created by performing a transverse incision of the abdo-
believe we should operate every case of haemorrhoids. He
men and the caecal wall and then suturing the edges of the
agrees with Hippocrates.
caecal incision to the abdominal wound. The patient died
20 days after the operation for bowel perforation due to the
BHaemorrhoidal flux, if moderate, is healthy and ought
large amount of quicksilver taken beforehand [14].
not to be suppressed since the redundant and noxious
In 1781, Mr. Henri Le Dran, a French battlefield surgeon,
parts of the Blood are hereby discharged from the
noticed that some patients, in a desperate attempt to relieve
Body…^ [25]
their pain, tried to lance what they thought were boils over
Anyway, where surgery was indicated, he favoured an their abdomen and were, on the contrary, colocutaneous fistu-
eighteenth century version of the method of Celsus which lae. The resulting wound could heal forming a permanent
strongly resembled present-day Milligan–Morgan stoma. He inferred that it was safer to stitch the injured bowel
haemorrhoidectomy. outside the abdomen to prevent peritoneal contamination.
In 1793, a French surgeon Mr. Duret performed a stoma in
BThe legs are to be held by two strong assistants; the a newborn with imperforated anus. He recovered well and
surgeon is then to tie up the bleeding tubercles with a lived 43 years with the stoma. Pillore and Fine were the first
needle and thread, cutting off those parts which are to describe also a method to irrigate the stoma, but their words
preternaturally distended beyond the ligature, taking were forgotten for more than one century, until the English
surgeon Lockart-Mummery published his experience with ir- cancers, so he reviewed the literature and discovered that in
rigation of colostomy in 1917 [14, 19, 26]. a 63-year period, from the first case of Pillore in 1776 to his
In 1797, Professor Fine, of Geneva, performed a double- case in 1839, 29 colostomies had been reported, with only
ended transverse colostomy on a 63-year-old lady with an nine survivors (mortality 69 %). 21 operation had been done
obstructing rectosigmoid tumour, who lived 5 months with for imperforated anus, and only four survived, all operated in
the colostomy. Actually, he planned an ileostomy, but did a Brest, where Duret performed his first case. Of the remaining
mistake that was evident only at post-mortem [14, 19, 26]. eight adults, five survived the operation. All of these were
In the first half of the 19th century, colostomies became operated by the abdominal route. He thought the deaths were
very established operations. Nonetheless, surgeons were not due to peritonitis, so he proposed a lumbar colostomy through
keen to perform stomas for the risk of peritonitis. a transverse incision. First of all, he advised, one should de-
They were well aware that a patient’s death due to a stoma termine the correct site of obstruction by rectal examination
operation would have destroyed their reputation. As a matter and by the quantity of fluid it was possible to inject in the
of fact, in 1798, the Danish surgeon Hendrik Callisen de- rectum. When the exact site of obstruction was impossible to
scribed in his textbook the technique to create a colostomy be worked out, he probed the distended bowel with a trocar. In
by a retroperitoneal approach to avoid the risk of peritonitis case of left side or indeterminate obstructions, far from the
[14, 19, 26]. anus, he suggested a right colostomy. He believed that:
Going back to the battlefields, the French surgeon
Dominique Larrey, following the Napoleonic Army, devel- BAn artificial anus, it is true, is a grave infirmity but it is
oped a system of emergency trauma care on the battlefield, not insupportable. To be able to practise it, a surgeon
either treating the injured patient on the site or putting in place ought to fear to be surprised by a pressing occasion,
standardised procedures for his transfer. During the battle of and he should prepare himself by many repetitions of
Cairo in 1799, he reported the case of a soldier with a gunshot the operation upon the cadaver^ [26]
to the abdomen and bowel, he stitched the injured bowel to the
The British surgeon Mr. John Ericson, from the University
edge of the abdominal wound and kept it open until the suture
College Hospital in London, was present at Amussat’s first
healed and the patient recovered [14, 19, 26].
operation. In 1841, he gave the following indications for a
The first colostomy in the UK was performed by Mr. Freer,
colostomy: (1) imperforate anus, (2) intractable constipation,
a surgeon at Birmingham, in 1815, on a newborn with
(3) large bowel obstruction and (4) cancer of the rectum when
imperforated anus. The second was Mr. Daniel Pring, of
the pain is severe [26].
Bath, who in 1820 performed a stoma on a Mrs. White suf-
The first ileostomy was created in 1879 by Mr. Baum, a
fering of obstructing rectal cancer. He was the first one to
German surgeon from Danzig, on a patient with bowel ob-
describe complications and side effects of a stoma and to
struction due to an inflammatory bowel disease or a colon
emphasise the need for specialised stoma care [14, 26].
cancer, as first stage of the treatment. The patient recovered
The most prolific writer on colostomy in the 19th century
well and underwent an ileocolic resection 8 weeks later.
was the French surgeon Jean Zùlema Amussat. He was born
Unfortunately, he died 1 week later of peritonitis due to a leak
in Saint Maixent in 1796 and died in Paris in 1856. He is
from the anastomosis [27].
considered one of the fathers of modern urology, but he had
In 1883, Mr. Maydl from Wien performed the first successful
a great interest also in abdominal surgery. He was first trained
loop ileostomy with a rod placed below the loop stoma, follow-
by his father, a physician, then went to attend the medical
ed by William Allingham who, in 1887, described his technique
school in Paris, where he had the possibility to practise ana-
of loop colostomy held in place with a glass rod [19, 28].
tomical dissections at the Salpetriere and at the Charité. So he
Quite interestingly, a great surgeon of the mid-19th century,
became an assistant in the Institute of Anatomy and began to
Professor Gross from Philadelphia, was astonished:
give private lectures on anatomy for artists, but got an infec-
tion and his health was seriously impaired. There is no record
B…that anyone possessed of the proper feeling of hu-
on the exact nature of this infection. It was impossible for him
manity should seriously advocate a procedure so
to apply for the post of Professor of Anatomy, as he preferred,
fraught with danger and followed, if successful, by such
or even for a post as a hospital doctor, so he set up a private
disgusting consequences… I cannot, I must confess, ap-
practise in Paris to treat his patients and to continue his inves-
preciate the benevolence which prompts a surgeon to
tigations and scientific activity. He wrote several books and
form an artificial outlet for the discharge of faeces, in
his name is linked to a method of torsion of the arteries to stop
case of imperforate anus.^ [29]
bleeding, to lithotripsy and to lumbar colostomy. One of his
friends was the French physician Broussais, who died of Resective colorectal surgery was on its way, and well
obstructing rectal cancer. This was the stimulus he needed to before the advent of modern anaesthesia, the first attempts
continue his studies on the possible treatment of colorectal took place.
We can fix between the end of the 18th and the beginning Jane Carstairs, who gave birth to a girl named Wilhelmina,
of the 19th centuries the birth of resective colonic surgery. nicknamed Anaesthesia by the same Simpson. As expected,
Fajet attempted a rectal resection by the posterior approach the use of chloroform was fiercely opposed by both the scien-
in 1793 [30], but the first successful operation was performed tific world and the religious establishment. Every resistance
in 1826 by Jacques Lisfranc, a Surgeon of LaPitié Hospital in was broken when John Snow administered chloroform to
Paris. In 1833, he reported nine cases of rectal resection by the Queen Victoria in 1853 during her labour for Prince
posterior approach [31]. Lisfranc was born in 2nd April Leopold. Simpson died in Edinburgh in 1870 [32, 33].
1790 at St. Paul, Loire and died in 13th May 1847. He started Actually, inhalation anaesthesia was born some years ear-
his training in Lyon then moved to Paris where he was an lier, at the Massachusetts General Hospital (MGH) in Boston
assistant to Guillaume Dupuytren, then he got his medical where William Morton, a 27-year-old dentist administered
degree in 1813. He was Battlefield Surgeon in Napoleon’s ether to the 20-year-old Gilbert Abbott, who had a benign
Army, but in 1814, left the army and devoted himself only vascular tumour of the neck and was being operated by
to surgery. In 1826, he became Chief of the Surgical Professor John Collins Warren. Morton had been
Department at LaPitié Hospital in Paris [14]. His grave is at experimenting with ether for dental extraction and his first
the Montparnasse Cemetery in Paris with the following epi- patient was an Eben Frost, who was put asleep after breathing
taph: BSurgery is bright when operating but it is still brighter from a handkerchief saturated with ether. A common friend
when there is no blood and mutilation and yet leads to the introduced Morton to Professor John Warren who immediate-
patient’s recovery^. Lisfranc’s resection was a limited resec- ly invited him for a demonstration at the hospital. The opera-
tion of the rectum and anus performed well below the perito- tion was scheduled at 10 o’clock of 16th October 1846. The
neal reflection, after mobilisation of a short rectal segment. operation was a success and Abbott had his tumour removed
This was not a radical operation, and all his patients died without any pain. William Morton was born in Charlton, MA
within 2 years from the operation [30, 31]. in 1819. In 1840, he entered the Baltimore College of Dental
Resective colorectal surgery could not develop completely Surgery, but left the college 2 years later to become Horace
before the advent of chloroform anaesthesia in 1847 by Mr. Wells’ partner in Hertford. Wells was the one who first used
James Young Simpson. A plaque in the St. Giles cathedral of the nitrous oxide to reduce pain from an operation. Both ether
Edinburgh is a proof of the enormous benefit anaesthesia gave and nitrous oxide were known recreational drugs already in
to patients and surgeons. It is worth describing this discovery. use in the 1840s. As his partner did, with scarce fortune, with
Sir James Young Simpson was born in Bathgate, near nitrous oxide he tried to do with ether, obtaining the outstand-
Edinburg, in 1811. During the summer in which Simpson ing results just mentioned. After his first demonstration at the
was born, his family was in very poor conditions due to finan- MGH, the use of ether spread worldwide. Morton died in New
cial crisis. He was the eighth, after six other sons and one York in 1868, probably for a heart attack [19].
daughter. Fortunately, right after James’ birth the fortune The widespread diffusion of chloroform anaesthesia
wheel began to turn, family business improved, his father, a boosted the resective colorectal surgery. Actually, the clinical
baker, became an accountant in the local branch of the Royal interest was equally divided between colonic surgery and rec-
Bank of Scotland, and James could attend the Edinburgh tal surgery. Theodor Billroth, the real father of gastrointestinal
University, where he graduated in 1832. When he was 28, surgery, did 12 resections of the rectum between 1860 and
he became Professor of Obstetrics, and physician to Queen 1867 and 33 between 1868 and 1872. He was born in
Victoria, and married Jessie Grindlay. Actually, he was so Bergen auf Rugen (Kingdom of Prussia) in 1829, graduated
young when he got this post that he added the midname at the University of Greifswald, then went to the University of
BYoung^ to his birth name BJames Simpson^. His most im- Gottinghen and got his PhD at the University of Berlin, where
portant achievement, after improving the technique of natural he had his first post, then he moved to Zurich where he was
delivery and designing new obstetrical instruments, was the appointed Professor and Director of the surgical hospital and
introduction of chloroform anaesthesia, originally to reduce clinic. Afterwards, he moved to Wien where he was Director
the pain in difficult labours, but afterwards extended to all of the second surgical clinic at the Allgemeine Krankenhaus.
kind of surgery. In 1847, he introduced in his hospital the He performed the first oesophagectomy, the first laryngecto-
use of ether, already in use in America, but he was always my and the first gastrectomy for cancer and left an important
looking for new agents. With two colleagues, Drs. Keith and footprint in the history of surgery mostly for introducing the
Duncan, he used to sit in his dining room every evening to try concept of clinical audit. He was also a very good musician,
the effect of different vaporised chemicals. On 4th November playing piano and violin, and Brahms was used to send him
1847, they tried chloroform and suddenly they fainted and his manuscript in order to get his approval before publication.
slept all night long. They recovered well after a long sleep He died in 1894.
and chloroform was introduced in Simpson’s clinical practise. Verneuil, in 1873, proposed a technique of rectal resection
The first woman who had chloroform during her labour was a beginning with the excision of the coccix to gain better
exposure. For the same reason, Kocher, in 1875, began the in 1878 and, 1 year later, a formal sigmoidectomy with lymph-
operation by closing the anus with a purse string and excising adenectomy. This operation was performed also by Martin of
the coccix and a portion of the sacrum. After the excision, the Hamburg, Schede and Czerny. In 1884, Heineke mobilised a
colon was brought down and sutured to the anus, creating in segment of bowel, placed the two loops aside, then removed
this way no more than a perineal colostomy. Considering the the tumour and sutured the bowel to the abdominal wall. Later
poor results of this operation in terms of continence, in 1878. on, he crushed the spur with bowel forceps and closed the
Harrison Cripps proposed to pack the perineal wound and colostomy. The most important and perhaps revolutionary
create a colostomy. In 1885, at the 14th Congress of German method to remove a bowel tumour was the so-called
Surgeons, Kraske proposed his posterior proctectomy that was Mikulicz operation. Following the first experience by
popular into the 20th century. This entails the excision of the Heineke, Bloch of Copenhagen, in 1890, did a staged proce-
coccix and the lower segment of the left part of the sacrum, the dure, bringing the tumour out of the abdomen and opening the
mobilisation and resection of the rectum and the anastomosis proximal stump as a colostomy in the first stage. Later, he
of the colon with the external sphincter and the anal skin [30]. resected the exteriorised loop and then reconnected the two
In 1883, Vincenz Czerny (1842–1916) did the first bowel stumps. Mikulicz, in 1902, published 16 cases treated
sacroabdominal resection of the rectum. In the impossibility with this method, with only one death, so the operation was
to complete a rectal resection with the Kraske technique, he named after him.
turned the patient over and completed the operation through Jan Von Mikulics Radecki was born in Czernowitz in 1850
his abdomen. He graduated in Wien in 1866, worked with and grew up in a multicultural environment. As a boy, he was
Theodor Billroth and Johann Ritter von Oppolzer and was able to speak different languages and play piano. His father
director of surgery at the Universities of Freiburg and, later, planned for him a political career, but he chose to attend the
Heidelberg. With his sacral-abdominal resection, he opened medical school in Wien and graduated in 1875. He became
the way to Miles, who developed his abdominoperineal resec- one of Billroth’s favourite pupils. Both were able musician
tion in the 20th century. and used to play together Brahms’ music. In 1880, he became
A different method was proposed by Henry Widenham Professor of Surgery at the university of Cracow, then
Maunsell (1845–1895), who was an Irish surgeon, born in Konigsberg and Breslaw. In his career, he developed intestinal
Dublin where he graduated and got his MRCS then moved surgery and endoscopy, proposing new operations, such as the
to Melbourne, Australia, and, lately, to Hokitika, New staged procedure for sigmoidectomy, and in particular, he was
Zealand, then again to Dublin and then back to New a pioneer of antisepsis. He died in 1905 in Breslaw of a gastric
Zealand, to work at the Dunedin Hospital, where he developed cancer that he diagnosed by himself [13, 34].
several new operations. His method for stitching the bowel At the end of the 19th century, the mortality rate for colo-
was based on the way he saw his wife sew the lining in a rectal surgery was still quite high, but rapidly reducing. The
sleeve by first turning it inside out. He developed an leading cause of death was still sepsis.
abdominoanal pull-through operation, where he sutured the The history of antisepsis is long and has his roots in the
mobilised colon to the rectum by a perineal approach, after Middle Ages. Between the 10th and 13th centuries, the
invaginating the colon into the rectum and reverting the rec- Salernitan School considered the pus Bbonum et laudabile^
tum inside–out from the anus. He was deeply interested in (good and laudable) as part of the normal wound healing pro-
surgical teaching and so visited many European university cess, and despite the words of the Dominican friar Theodoric
centres. Whilst in London, he decided to resign from the of Bologna that Bit is not necessary that pus should be gener-
Dunedin Hospital and got established in South Kensington, ated in wounds… such a practise is indeed to hinder nature, to
where he worked as a Consultant Surgeon until his death. prolong the disease and to prevent the consolidation of the
Colon surgery had a different development. As already wound^, for many years surgeons considered suppuration a
seen, colostomy and bowel suture had been already imple- normal phase of tissue healing. The idea that pus formation
mented, but formal colonic resection and anastomosis were and infection could be carried from an individual to another
quite rare as postoperative peritonitis was still a major cause and that they could be caused by microorganisms followed a
of death. Reybard, in 1823, did the first segmental colonic long and difficult path starting in the 18th century with the
resection for a tumour of the sigmoid. The patient died 1 year observations of Alexander Gordon and Ignaz Semmelweiss.
later for tumour recurrence. The second resection was per- Unfortunately, this interesting branch of the history of medi-
formed by Tiersch in 1843, and until 1880, only ten colonic cine is beyond the aims of this writing, so we are obliged to
resection had been recorded, with seven deaths. Between jump at least one century and arrive at the works of Louis
1880 and 1890, 48 resections had been recorded, with a mor- Pasteur, whose studies on the fermentation of wine and putre-
tality rate of 45 %. Theodor Billroth did a segmental colonic faction of milk demonstrated that this process is caused by
resection with a terminal stoma, just like a Hartmann opera- Bferments^, microorganisms he could see with the micro-
tion. Gussembauer of Liege reported a partial left colectomy scope. Pasteur’s works inspired the interest of Joseph Lister
on the prevention of surgical infections. Before Pasteur and In the UK, Frederick Salmon left a huge footprint in the
Lister, surgeons were not used to wear gloves or even wash history of proctology and rectal surgery. He was born in 1796
their hand before examining or operating on a patient. Even in Bath, where he did his first medical training, then he went
the operating gowns were hardly washed. Joseph Lister was to London as a medical student, got his MRCS in April 1818
born in Upton, Essex, in 1828 and attended the University and was appointed as House Surgeon at Barts’. Subsequently
College of London, where he got his Bachelor of Medicine he began to specialise in surgery and was particularly inter-
in 1854. Short after graduation, he was accepted as Fellow of ested in rectal disease. In 1828, he published a book on stric-
the Royal College of Surgeons and was appointed as Assistant tures of the rectum, which was an immediate editorial success
Surgeon at the Royal Infirmary of Edinburgh. After 4 years, and had several editions. In his first book, he stated that stric-
he was Professor of Surgery at the University of Glasgow. He ture of the rectum is quite a common disease which can be
was aware of the studies of Pasteur on bacteria and those of treated by surgery. According to his description, at least some
Friedlieb Runge on carbolic acid — this latter was used to of his cases were stricturing cancers of the rectum and anus.
prevent wood from decomposition and to fight parasites — He was well aware that very few could be done at that time to
and started spraying carbolic acid on surgical instruments, treat rectoanal malignancies, and Bthe utmost effect we may
wounds and dressings and washing his hands with the same hope for from our labours is to soothe the passage of the
substance. He reported his first experience on antiseptic afflicted sufferer to the grave^. He also wrote a pamphlet on
surgery in a series of six articles on Lancet in 1867. BPractical Observations on Prolapsus of the Rectum^ and
After discovering that the risk of infection was more from several articles on Lancet. In 1835, he bought a property at
hands, instruments and dressings than by air transmission, 11 Aldersgate Street in London, where he set up the seven
he stopped spraying the carbolic acid all over the place and beds BInfirmary for the Relief of the Poor afflicted with
started using heat and steam sterilisation of instruments and Fistula and other Diseases of the Rectum^. In 1836, the
dressing and using clean gloves and gowns during the sur- Infirmary moved to 38 Charterhouse Square, and in 1851, a
gical operations. The new concept of antiseptic surgery new site for the hospital was bought in City Road, to set up a
took a whilst to be accepted and universally spread, 25-bed infirmary. The new hospital was opened officially on
Lister’s many opponents being in Britain. Eventually, St. Mark’s Day, 25th April 1854, and for this reason, it was
Lister moved to London, at the King’s College where he named BSt. Mark’s Hospital for Fistula and other diseases of
ended his career. In 1883, he was created a Baronet, and in the Rectum^. In his career, Salmon did more than 3500 oper-
1897, he was raised to the peerage as Baron Lister of Lyme ation with mortality zero. The St. Mark’s hospital’s staff was a
Regis, Dorset. He died in 1912 in Walmer, Kent in his surgeon, a matron, a dispenser, nurses and servants. No phy-
country home. He is one of the two surgeons who have a sician was appointed up to 1948. In 1859, Salmon retired from
public monument in London (in Portland Place, the active work and died in 1868 aged 72. In 1896, the hos-
Marylebone) [19, 23]. pital was completely renewed and enlarged after purchasing
The apex of Lister’s career is related to the unfortunate an adjacent site. In 1909, the name of the hospital was
experience of Edward VII, who got an acute appendicitis on changed again, to reflect the work and interest of Sir John
the 14th June 1902, less than 2 weeks before his coronation, Percy Lockhart-Mummery BSt. Mark’s Hospital for Cancer,
scheduled for the 26th June. Edward was determined to go Fistula, etc^.
ahead with his coronation, despite his physicians’ advices, but The St. Mark’s hospital was very influential to the surgical
he was progressively unwell and developed an appendiceal culture on all the 19th century, in particular, for the develop-
abscess, so he agreed to be seen by a surgeon, sir Frederick ment and training of proctology. In 1864, William Allingham
Treves, who had implemented the surgical excision of the was appointed as Chief Surgeon and kept this post for
appendix at the London Hospital and, until 1901, had per- 24 years. Allingham’s textbook was the BHoly Bible^ of proc-
formed more than 100 appendectomies. After a consultation tologist for many years. In 1871, David Henry Goodsall was
between Treves, the royal physicians and Lister himself, the appointed as Consultant Surgeon at the St. Marks, where he
king was told that his operation was urgent and the coronation studied the topographical relations of perianal fistulae and was
was postponed. The operation was performed in Buckingham famous for his Brule^. In 1948, with the creation of the
Palace, Frederick Hewitt was to administer the anaesthesia National Health System, St. Mark’s was taken over by the
and Treves drained the abscess, put two tube drains and NHS as a teaching hospital. At that time, it had 93 beds and
packed the wound with gauzes. The whole operation was treated 1,800 inpatients per year. In 1959, Sir Alan Parks was
performed following Lister’s advices and suggestions. As a appointed as Surgeon, and he gave a boost to pelvic floor
reward, Mr. Treves was created Baronet, alongside with the surgery. In 1994, St. Marks (http://www.stmarkshospital.org.
anaesthetist Dr. Hewitt. Lister was already a peer, but this uk/about-st-marks) was transferred to a big and newer
event represented in definitive coronation as one of the kings building in Harrow and became part of the North West
of surgery [23]. London NHS Trust [35].
The real anatomical bases of modern colorectal surgery Guy’s Hospital in London, then he was appointed Professor
have been established just between the 19th and the 20th cen- of Anatomy at the RCSE. He was Surgeon to Queen Victoria.
turies by three anatomists, Dimitrie Gerota from Bucharest, He is known for his outstanding knowledge of anatomy. The
Carl Toldt from Wien and Pierre Fredet from France, and an anal Hilton white line is a whitish line, right below the dentate
English surgeon, John Hilton. They are the lights that guided line, which marks the interval between the lower border of the
the anatomical surgery of the colon and the rectum. Of course, internal sphincter and the subcutaneous part of the external
many other anatomists and surgeons contributed to expand sphincter. This is a landmark for the lymphatic drain of the
our knowledge of the colorectal anatomy, and their works anus, the inferior part draining to the inguinal lymphnodes and
would be worthy of note in a more extensive review. the superior part to the mesenteric lymphnodes.
Dimitrie Gerota was born in Craiova in 1867 and graduated
in Bucharest in 1892. He taught anatomy and practised sur-
gery and radiology. Actually he is considered the first 20th and 21st centuries
Romanian radiologist but, at the beginning of the 20th centu-
ry, had to retire due to a radiodermatitis and an epithelioma at With the 20th century, history gives way to chronicle. It is
his hand, which was amputated. In 1895, he published his impossible to summarise the development of colorectal sur-
historical article on the fixation of kidneys and the anterior gery in the 20th and 21st centuries, as it is impossible to
renal fascia, named after him Gerota’s fascia. He was the as- summarise the history of the world from 1900 to nowadays
sistant of Professor Waldayer with whom he studied anatomy in a scientific paper.
of the rectum. From 1913, he was a Professor of Anatomy at As regards history, the 20th century is the century of the
the University of Bucharest and was the owner and Chief two World Wars, of the Iron Curtain and its fall, of the fall of
Surgeon of the leading private hospital in Bucharest, the the Soviet Empire, of the rise and fall of the ideologies… The
Gerota’s Sanatorium. He died in Bucharest in 1939 after 21th century saw the 9/11, War against Terror, Al-Qaeda, the
spending a period in jail due to a press article that criticised wars in the Near East.
King Carol II. These are the centuries of the Internet, of communication,
Carl Toldt was born in Bruneck/Tyrol, now Italy, in 1840 of space voyages. It is our everyday life. In colorectal surgery,
and became qualified in 1864 in Wien. He was Professor at the the most radical changes with respect to the previous times
University of Wien and his main works were on the structure have been laparoscopic and robotic surgery, total mesorectal
of mesentery, the anatomy of the chest and the structure of the excision and the unitary theory of prolapse, all of them pre-
bone. In the last years of his career, he devoted himself to ceded by the invention and widespread diffusion of stapling
anthropology and studied the occipital bone in a population devices.
of the south of Germany. He died in 1920 in Wien. Toldt was The British contribution to the development of colorectal
the first one who really understood the surgical importance of surgery in the last one hundred years is outstanding.
the embriological development of the mesocolon. He pointed The basics of modern techniques of rectal surgery have
out how the primary mesocolon of the ascending and descend- been drawn by John Percy Lockhart-Mummery, of the St.
ing colon attaches posteriorly, whilst the lateral aspect of the Marks Hospital, who developed and proposed in 1907 a tech-
meso merges with the posterior parietal peritoneum just in nique for a two-stage perineal rectal resection. A loop colos-
front of the Gerota fascia, to form the Toldt plane. This is a tomy was fashioned 10 days before the perineal rectal resec-
fundamental landmark in left and right colonic resections as tion, where the rectum was mobilised and the proximal divi-
an early step of mobilisation of the colon is the dissection sion was done at the level of the sigmoid. Lockhart-Mummery
along this avascular plane. suggested that the total operative time should not exceed
Worth of mention is also the work of Pierre Fredet, a 45 min and the patient should be discharged within 3 weeks.
French surgeon who was born in 1870 in Clermond Ferrant Lockhart-Mummery was born in 1875 in Northolt and died in
and died in Paris in 1946. He proposed, with Ramsted, the 1957 at Hove. He was educated and trained in Cambridge
extramucosal pyloromiotomy in the newborn and studied the where he got his first job as Anatomical Demonstrator. In
preduodenopancreatic fascia, named after him, that corre- 1900, he became a Fellow of the Royal College of
sponds to the Toldt’s fascia in left and right colon. The Surgeons, and in 1903, he was appointed at the St. Mark’s
Fredet’s fascia is the cohalescence fascia between the inferior Hospital as Assistant Surgeon. During his career at St.
leaflet of the transverse mesocolon and the submesocolic Mark’s, he developed new techniques, as the perineal rectal
prepancreatic fascia. resection already mentioned. In 1926, he published 200 cases
John Hilton, an English surgeon and the President of the operated with this technique, with a mortality of just three
Royal College of Surgeons of England (RCSE), was born in cases (1.5 %) and an overall cure rate of 50 %, which is
Sible Hedingham, Essex, in 1805. He was Anatomical absolutely remarkable for those times. He was an energetic
Demonstrator, Assistant Surgeon and then Surgeon at the man, golfer and fishermen, which is quite surprising as he
underwent a leg amputation for a sarcoma, performed by Lord and WWII stopped every progress in this field, even if a lot
Lister himself, when he was a student in Cambridge [19, 36]. of medical innovation, including the use of antibiotics, were
In the same period, another Bv.i.p.^ of colorectal surgery done during the war. A boosting of the studies on surgical
was working in London, at the Royal Cancer Hospital (later innovation took place after WWII. In 1951, in Moscow, the
called Royal Marsden). This man was William Ernest Miles, All Union Scientific Research and Trial Institute of Medical
who proposed his operation of abdominoperineal resection of Engineering was founded. They produced several prototypes
the rectum in 1908. Miles was born in 1869 and died in 1947. of surgical staplers, for vessels, bronchi, lung parenchyma and
He was a House Surgeon at St. Mark’s Hospital in London, bowel. They were all reusable devices that put a single row of
then he was appointed to the Gordon’s Hospital for the everting steel stitches that required to be further buried with a
Diseases of the Rectum and finally ended up at the Royal manual suture. It is quite understandable that the staplers were
Cancer Hospital. Most of his training was with David born in the Soviet Union, as the spirit behind this innovation is
Goodsall to whose memory he dedicated his first book on finding a way to standardise the anastomosis and surgical
rectal surgery. His fame is linked to the surgical operation that sutures regardless of the personal skills of the surgeon.
bears his name and entails the excision of the pelvic colon, an Surgical staplers were imported in the US in 1958, and from
extended lymphadenectomy of the pelvic and iliac there, they spread all around the world also driven by financial
lymphnodes within the pelvic mesocolon (later defined as interests and business strategies. In this way the Bdifficult^
mesorectum), a wider excision of the rectum via the perineal anastomoses came within the reach of every single surgeon.
approach and the fashioning of a terminal colostomy [25]. After the Bcommunist^ period, the first private company ap-
But the real turning point in rectal cancer surgery is repre- peared in 1965, the United States Surgical Corporation —
sented by the demonstration that the total excision of the Autosuture, followed by Johnson & Johnson’s Ethicon in
mesorectum reduces significantly the risk of tumour relapse. 1971. In 1966, United States Surgical Corporation (USSC)
This demonstration, alongside with the anatomical definition produced the first reusable TA with a changeable cartridge.
of the so-called Bholy plane^ between the mesorectum and the In 1973, they developed the circular staplers, and in 1981,
sacral plane, was done by Richard Heald, from Basingstoke in Ethicon launched the disposable ones. Their use increased
the 1980s. To perform an effective total mesorectal excision, and, nowadays, they are applied in almost all surgical fields,
the rectum should be prepared and excised up to the levator from colorectal surgery to upper GI, hepato-pancreato-biliary
ani plane and the whole mesorectum with an intact mesorectal and urology. In 1985, T.G. Hardy proposed a modern version
fascia should be removed. The total mesorectal excision en- of the Murphy’s button for compression anastomoses, the so-
tails the use of sharp dissection to develop a plane between the called Biofragmentable Anastomotic Ring (BAR), a
mesorectal fascia and the presacral fascia. The fat tissue sur- reabsorbable anastomotic button that keeps the two anasto-
rounding the rectum posteriorly and laterally should be motic stumps compressed for 5–7 days, then it dissolves leav-
completely excised up to the levator ani plane. In Heald’s first ing a perfectly healed anastomosis. The last improvement in
series of 112 patients, the rate of local recurrence was around surgical staplers is the powered stapler introduced separately
2 %, whereas with the conventional rectal resection, it was by Covidien and Ethicon.
around 20 % [37–40]. In 1993, Antonio Longo, an Italian surgeon from Palermo,
The principles of the total mesorectal excision apply to the and moved to Wien, proved a new theory for the aetiology of
abdominoperineal dissection as well as to the anterior resec- haemorrhoids, demonstrating with cadaveric studies and
tion of the rectum, where, maintaining a right distance be- videodefecographies that haemorrhoids are always a conse-
tween the tumour and the division margin, the colonic stump quence of a prolapse which originates from the rectal mucosa.
is sutured to the rectal stump. This anastomosis, first per- Following this revolutionary theory, he proposed a new surgical
formed with hand suture, was greatly simplified by the use treatment for this disease, the stapled haemorrhoidopexy. This
of surgical staplers. Actually, the birthplace of the mechanical is an anatomical reconstruction of the anal canal with the cir-
staplers was the heart of Europe, the Austro-Hungarian cumferential excision of the rectal prolapse and a lifting of the
Empire. In 1908, at the second Congress of the Hungarian haemorrhoidal tissue, which is repositioned in the correct
Society of Surgery, Humer Hültl of Budapest presented his intrarectal place. Since 1998, when Longo presented his tech-
device to close the proximal gastric stump after distal gastrec- nique at the World Congress of Endoscopic Surgery in Rome
tomy with a mechanical everting suture. This device, designed [41], the technique has developed and had a wide acceptance
by Humer Hultl surgeon with his brother engineer, had a and a huge success, due mainly to its benefits in reducing post-
weight of 4 kg and required a long assembling time. In operative pain, shortening hospital stay and achieving an earlier
1921, Aladar von Petz presented at the 7th Congress of the return to normal activities with respect to the Btraditional^
Hungarian Society of Surgery, a lighter stapler that weighed methods. At the beginning, it represented a source of contro-
only 1.5 kg that, like the Hultl stapler, was able to apply a versy, but then he was critically appraised by a number of
single row of B-shaped steel stitches. Unfortunately, WWI randomised clinical trials and meta-analyses and obtained a
favourable review and acceptance by the National Institute Further evolution of laparoscopic surgery has been robotic
for Health and Care Excellence (NICE) in 2007 [42]. surgery. The word Brobot^ comes from the Czech Brobota^,
Further to his first studies, Antonio Longo proposed a forced labour, and was first used in 1921 by the Czech play-
unitary theory of the pelvic prolapse, where prolapse of wright Karel Capek in his play BRossom’s Universal Robots^.
the anterior, median and posterior compartments are differ- Today, robots are used to perform highly specific and highly
ent expressions of a single disease, causing rectoanal in- precise tasks, in industry and research. This attracted the in-
vagination, rectocele, obstructed defecation syndrome and/ terest of the surgeons, for the increasing request of skill and
or urinary and faecal incontinence. This new and widely dexterity. The history of robotic surgery starts in 1985 with the
accepted theory led to the introduction of two other new robot Puma 560, used to perform neurosurgical biopsies. In
techniques, the Stapled TransAnal Rectal Resection, a full 1988, the Imperial College of London developed a new pro-
thickness resection of rectal prolapse to treat rectocele, totype, PROBOT, used to perform transurethral resection of
rectoanal invagination and obstructed defecation syndrome, the prostate. In the same year, ROBODOC was developed by
and the Pelvic Organs Prolapse Suspension, a laparoscopic the Integrated Surgical Supplies, Sacramento, CA for hip re-
technique to reduce and fix pelvic organs prolapse and placement. ROBODOC was approved by the FDA. In the late
treat its consequences. 1980s, the National Air and Space Agency and the US Army
Antonio Longo has also the historical merit to recall the were interested in the development of telesurgery, to bring the
ancient theories dating back to the Egypt of the Pharaohs that surgeon on the battlefield, with the hope to decrease mortality
haemorrhoids are a consequence of rectal prolapse. from war trauma. A system was produced whereby a wounded
The greatest innovation in surgery in the 20th and 21th soldier could be brought into a vehicle with robotic surgery
centuries has been the advent of laparoscopic or Bkeyhole^ equipment and operated on remotely by a surgeon who was in
surgery. As every modern technique, also laparoscopic sur- the Mobile Advanced Surgical Hospital. This system was test-
gery has its roots in the ancient times, when physicians and ed on animals but was never applied on the battlefield.
surgeons always tried to explore the internal organs and cav- Computer Motion (Santa Barbara, CA) developed a robotic
ities of the human body, initially for divination, then to evac- system to move the videolaparoscopic camera by voice-
uate ill humours or to understand the causes of the diseases. activated control, the Automatic Endoscopic System for
But only in the 20th centuries the technologic progress Optimal Positioning (AESOP). Shortly after AESOP,
allowed us to develop laparoscopic surgery. This was initially Integrated Surgical Supply (now Intuitive Surgical) of
used mostly by physicians, in particular, for the investigation Mountain View, CA developed the DaVinci Robot whose first
of the liver, and by gynaecologists, for the investigation and clinical use was during a coronary artery bypass in 1998 in
treatment of pelvic diseases. But in 1985, the surgeons took Germany. In the same year, Computer Motion developed
over and laparoscopy had widespread acceptance due to its Zeus, first used for a tube reconnection. The aim of the surgi-
well-known advantages. cal robots gradually shifted from remote surgery to onsite
The application of laparoscopy to the colorectal surgery surgery. In this last case, the real advantages of surgical robot
was quite slow to establish as surgeons were very reluctant are more precise movements without tremors, more complex
to abandon knowledge and manual skills acquired in years to tasks with complete freedom of movements of the robotic
learn new skills and get new anatomical landmarks. Actually, hand with respect to the laparoscopic instruments and more
there was another important cause for this delay. Major colo- intuitive surgical skills, resembling the surgeon’s hand natural
rectal surgery has always been the prerogative of consultants movements. Downsides of surgical robots are the excessive
and senior members of the team, whereas laparoscopy was cost and mostly the increased difficulty if the surgical
considered a business of the juniors. Furthermore, advanced operation requires frequent changes of surgical field. For
laparoscopic colorectal surgery required new instruments for this reason, their applications in colorectal surgery are
dissection and stapling. As a consequence of this, the first quite limited, mostly during the rectal preparation, using
laparoscopic colectomies were actually Blaparoscopically normal laparoscopic techniques in the other surgical steps,
assisted^, where laparoscopy was used just to mobilise the or for rectal rectopexy. Whilst robotic surgery has clearly
colon at the operation itself performed outside the abdomen demonstrated its superiority with respect to laparoscopic or
through limited laparotomies. The first laparoscopic colonic open surgery in radical prostatectomy, in liver resection
resection using this technique was a right colectomy per- and in pancreatic surgery, this is not yet the case with
formed by Moises Jacobs in Miami, FL in June 1990. The colorectal surgery [44].
first true laparoscopic sigmoid resection was performed by Scuola Superiore Sant’Anna’s CRIM Lab in Italy has de-
Dennis Fowler in October 1990. He used the brand new veloped a robot called the Assembling Reconfigurable
Endo-GIA and Premium CEEA by USSC. The following Endoluminal Surgical System (ARESS). This will be some-
month Patrick Leahy performed a laparoscopic anterior resec- how introduced into the human body where it will assemble
tion of the rectum with a low rectal anastomosis [43]. and do the operation from inside [45]. At my knowledge, this
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Int J Colorectal Dis

History of colorectal surgery

Giovanni Domenico Tebala

Accepted: 2 February 2015

Colorectal surgery cannot boast of noble birth as other spe-

Arabs back to Bagdad to become the head of a new hospital. He is

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