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
Background Colorectal surgery has its roots in the early civ-
ilisations and its development followed a complex pathway
never disjoined from the social and cultural environment
where it took place.
Method The most relevant historical sources have been
evaluated.
Results A comprehensive review of the history of colorectal
surgery is presented, from the ancient Egyptian culture to the
modern achievements. The development of surgery of colon,
rectum and anus is reported with particular reference to the
social environment and history; as the development of colo-
rectal surgery parallels the occurrence of human historical
events, the study of the former cannot be disjoined from the
latter.
Conclusion Study and knowledge of the history of medicine —
and, in particular, of colorectal surgery for those interested in this
particular subject — is a privileged way to understand who we
are nowadays and where we come from.
Keywords Colorectal surgery . Colorectal cancer .
Proctology . Haemorrhoids . History of surgery
Introduction
Colorectal surgery cannot boast of noble birth as other spe-
cialties. In fact, the first medical specialisation was anaes-
thesia, even if it was acknowledged as autonomous in the last
40–50 years.
G. D. Tebala (*)
Noble’s Hospital, Strang, Douglas IM4 4RJ, Isle of Man
e-mail: Giovanni.Tebala@gov.im
BThe Lord God caused the man to fall into a deep sleep.
As the man slept, he took one of his ribs, and closed up
the flesh in its place. (Genesis 2:21)^ [1]
Clearly, according to the same source, the second special-
isation was chest surgery.
But also colorectal surgery has its origins in the midst of
time and evolution. As a matter of fact, man and other pri-
mates appear to differ from the four-footed animals in suffer-
ing from some painful anorectal diseases, due to the effect of
gravity [2]. The passage from the four legs to the two legs lead
to the development of the falciform and triangular ligaments
of the liver, to keep it in place and avoiding straining on the
inferior vena cava, the uterosacral ligaments to keep the uterus
in place fixing it to the sacrum and the ligaments of the rectum
to avoid its prolapse.
In this review, we will try to summarise the history of
colorectal surgery, from its very beginning in the Nile Valley
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.
Only studying history we can understand what and where
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
disjoined from the latter.
Egypt
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
Peninsula, even if its influence area was much larger. Also
unique was its continuity; for a period of 40 centuries,

Egyptians enjoyed a long period of prosperity in a well-
organised state. The fourth millennium saw the development
of towns and their unification in two reigns, the Upper Egypt,
with capital Thebes, and the Lower Egypt, centred on the Nile
Delta. In 3150 BC, King Menes united the two states in a single
big kingdom that flourished around its capital Memphis, near
the present-day Cairo, where even today we can see the archi-
tectural and artistic wonders of the Great Pyramids and the
Sphinx.
The key of the Egyptian history is the Nile. Its periodic
floods allowed the inhabitants of an almost deserted large zone
of northern Africa to develop a prosperous agriculture with
unmatched productivity, and the Nile itself was a trading way
between the Mediterranean, Rome, Greece, Near East,
Anatolia, Asia and the Tropical Africa and the Indian Ocean.
Agriculture and trade attracted people and cultures from Africa
and Near East as well as from the whole Mediterranean [3].
Egypt acted as the first world power. Of course, ruling such
an extensive region required a perfectly organised central ad-
ministration, with able managers and skilled technicians.
Furthermore, the great number of citizens and workers needed
medical assistance.
Egyptian medicine was considered the most advance of its
age. Foreign kings used to go to Egypt to see local doctors or,
simply, they asked the Pharaoh to send them a physician to be
enrolled in their own healthcare team. Even Hippocrates and
Galen studied on Egyptian textbooks.
There were general practitioners and specialised physicians
and surgeons. Each practitioner was a civil servant who
trained in a temple called Bthe House of Life^, where he
worshipped the lioness goddess Sachmet who controlled dis-
eases and health. The practitioner himself was called Bthe
Sachmet’s priest^, thus demonstrating a close relationship be-
tween magic and medicine.
Many of the practitioners were also scribes and had rele-
vant posts in the public administration. Maybe the most fa-
mous Egyptian physician — and the father of Egyptian med-
icine — was Imhotep, who was also the architect and advisor
of King Zoser; for him, he built the first pyramid. From the
available sources, we know the names of about 150 practi-
tioners, and at least two of them were women [4].
Despite their very good medicine, the Egyptians had a very
poor knowledge of human anatomy, even if they almost
reached the concept of blood circulation. Unfortunately, the
practitioner could not take advantage of the science and prac-
tise of embalming, as embalmers were a separate caste not
linked to physicians [4].
Regarding available resources about ancient Egyptian
medicine, there are the body of papyruses and the work of
indirect witnesses. Unfortunately, the fall of the Ancient
Kingdom, 2300–2650 BC, closed the Egyptian golden age
and led to the destruction of archives and libraries including
many specialty textbooks.
Int J Colorectal Dis
Diodorus from Sicily stated that the practitioner who did
not cure a patient’s condition must show the patient the
Bbook^ to convince him/her that all the guidelines had been
followed. The lack of adherence to the guidelines — and not
the death of the patient — could affect the practitioner’s career
and reputation [4].
Medical papyruses are often copies made by scribes, not
necessarily expert in medicine, so they have several errors,
amended by late scholars with addendums and comments.
There are 14 medical papyruses and various fragments, deal-
ing with (a) anatomy and physiology and the theoretical bases,
(b) pathology, usually divided in title, examination, diagnosis,
prognosis, treatment and notes, and (c) recipes [4].
As regards surgery, there are three major papyruses. The
first is the surgical Papyrus Edwin Smith, dated back to the
middle kingdom or the second intermediate period, around
1600 BC, but is likely a copy of an older papyrus of the old
kingdom written by Imhotep himself. It must be regarded as
the first textbook of surgery. It reports 48 surgical cases. It was
bought in 1862 in Luxor by Edwin Smith, an American anti-
quarian, but now the 4.67-m-long papyrus is in the New York
Academy of Medicine [4].
The Chester Beatty Papyrus VI — meaning the sixth pa-
pyrus bought by Chester Beatty, another American antiquari-
an — was written during the New Kingdom, around 1200 BC,
and deals only with anal diseases. There are 41 prescriptions
to treat pruritus ani, painful perianal swelling (thrombosed
haemorrhoids, perianal abscess) and rectal prolapse [4].
The Georg Ebers Papyrus can be dated at the beginning of
the New Kingdom (1555 BC) and was sold in 1873 by Edwin
Smith to Georg Ebers, a German archaeologist. Now it is in
the Library of the Leipzig University. It is the longest of all
papyruses, more than 20 m, and reports 876 recipes and 500
drugs.
For the Egyptians, the abdomen was a very important an-
atomical entity, demonstrated by the existence of a Bphysician
of the tummy^. This deep interest in the abdominal diseases
was maybe due to the high incidence of intestinal parasitosis.
A devil was responsible of intestinal worms and could be
expelled with sneeze, vomit, sweat, bowel motions but mostly,
roots of pomegranate containing pyridine, an alkaloid, that
acts on the worm nervous system and detaches it from the
bowel walls [4].
The pelvis was the place where all mucous and negative
substances go before coming out as urine or faeces. The pip-
ing system should be kept working with snake grass, beans
flour, natron, myrrh, juniper fruits, incense, cumin, colocynth
flour, honey, etc. [4].
To the rectum and the treatment of rectal diseases is dedi-
cated the Beatty VI medical papyrus. Rectum was considered
a very important part, and in the Ancient Kingdom, there was
a specialist in enemas, the BShepherd of the Anus^. According
to Herodotus and Pliny, the Egyptians learnt the technique of
Int J Colorectal Dis
the enema from their Holy Ibis Thot, who used to clean its
own bowel using its long beak to introduce water into the back
passage [4].
Painful defecation, haemorrhoids and rectal prolapse were
considered the same disease — this concept was quite clear in
those papyruses, but has been demonstrated by Antonio
Longo only about 15 years ago.
Perianal abscess was treated with local application of two
types of salt, myrrh, human milk, honey, incense and fat [4].
The Smith surgical papyrus reports 48 cases or diagnoses,
with a topographical classification, starting with the head to
end at the chest. They are almost exclusively trauma cases
occurring in a working place, in particular, where lots of
men were involved in building some great item. We cannot
avoid thinking that the writer refers to the construction of the
pyramids, whose inventor was Imhotep, who wrote the papy-
rus. No surgical instrument or technique is detailed in the
papyrus; it was only generically reported [4]. Unfortunately,
this papyrus is incomplete, as the scribe who wrote it — and
was not a surgeon as many terms are wrong or mistyped —
stopped at midsentence and nobody knows why [5].
The surgical knowledge should be learnt on the field and
never put in writing to preserve the caste. Cutting instruments,
forceps and drills were used, and the operation ended with
dressing the wound. In half cases, a dressing with fresh meat
was put on the wound to control bleeding, therefore a cream
made by fat, honey and vegetables [4].
Two surgical operations have never been reported in the
texts. Circumcision was quite diffuse, as demonstrated by
drawings and incisions, but we do not know the exact reason
for that. Hebrews probably learnt the practise of circumcision
during their Egyptian captivity. Was it a religious or a hygienic
procedure? Herodotus claimed it was to reduce the incidence
of balanitis and urethritis due to the desert sand, and the sub-
sequent sterility. Or it could be a sort of initiation ceremony
[5]. Skull burr holes were described first by Hippocrates, but
never reported in the Egyptian official medical papyruses.
Some researchers agree that it was to get free a Bdemon^
responsible for chronic headache. But they had other drug
remedies to treat headache such as salicylic acid, so maybe
they did not need such an invasive treatment. At least some of
the patients survived the operation, as demonstrated by the
edges of the hole, with natural postoperative changes [5].
Greece
The ancient Greece was central to all later history, culture,
science, politics, laws and social behaviour. Greece was the
birthplace of philosophy, democracy, tragedies and comedies,
geography and historical research. The history of ancient
Greece starts in about 2000 BC, when the original inhabitants
were succeeded by Indo-Europeans who brought a language
that evolved into Greek. The Achaeans, as they have been
called lately, built several city states, the most important of
them were Mycenae and Crete, the latter ruled by the
Minoans. While the first were dedicated to war, the second
were mostly traders and lovers of high-quality lifestyle. After
the war of Troy, the power of Mycenae and Crete disappeared,
substituted by the incursions of the BSea People^, who should
be regarded as the true founders of classical Greece. They
settled in mainland Greece and in Cyprus, and from them,
the cultural light of Athens arose in the 5th century BC.
Greece was never able to build up an Empire or to set up a
sort of nation. The many city states continued to fight against
each other, even after the wonderful victories against the
Persian army, until Philip II of Macedon, a northern Greek
leader, started to build up his personal Empire whose grand-
ness was finally established by his son Alexander the Great
[3].
Science and medicine flourished during the classical peri-
od, and for the most part, they were strictly linked with reli-
gion. Whereas Sachmet was the Egyptian goddess related to
medicine, Asclepius was the Greek god of medicine.
According to mythology, Asclepius was son of Apollo and
the nymph Coronis and was raised by the centaur Chiron,
who taught him the basics of medicine. He became such a
proficient practitioner that Hades, god of the underworld,
complained with Zeus who killed him with a thunderbolt.
After his death, Asclepius was raised into the Olympus and
became god of medicine and surgery [5]. Asclepius’ temples
were attended by people anxious to be healed who found their
relaxation and maybe a placebo effect, probably mixed with
some basic natural remedies. The only surgical operation per-
formed there were incision of abscesses and blisters [5].
But a scientifically oriented medicine started to flourish
even in the classical age, with scientists and philosophers like
Anaximander and Anaximenes of Miletus [5].
The best known exponent of ancient Greek medicine was
Hippocrates.
Hippocrates was born in Kos in 460 BC. He was a physician
of the Age of Pericles, which is deemed to be the Golden Age
for ancient Greece. Very little is known about what
Hippocrates actually thought, did and wrote, as the collection
of writing known as BCorpus Hippocraticum^ has been writ-
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
medicine, mixed with magic and theology, and for this reason,
he spent 20 years in a prison, where he wrote BThe
Complicated Body^, which contains many of the medical con-
cepts we consider true today. The Corpus Hippocraticum con-
tains also the famous Hippocraticum Oath, which was an oath
historically taken by physicians and other healthcare profes-
sionals swearing to practise medicine honestly and with pro-
fessionalism. He died in Larissa at age 85 (even if someone

says he lived well over 100 years) [5]. For the purpose of the
present article, his statements about colorectal surgery are in
some of his aphorisms and in his two dissertations BOn
Fistula^ and BOn Haemorrhoids^. Let us analyse some of
his aphorisms [6].
BAll diseases begin in the gut^
Once again, as in the ancient Egyptian medicine, the abdo-
men was the source of all the diseases, maybe because this is
the place where all the food collects and is processed. So, a
disease is a consequence of what we eat. This is quite consis-
tent with the likely high incidence of food poisoning and toxic
gastroenteritis in a period with no proper food storing and
conservation and no perfect cooking.
BA lesion of the bladder, brain, heart, diaphragm, stom-
ach, liver or any of the small intestines, proves fatal^
and BA lesion of the small intestines is never followed by
a reunion of parts^
With respect to penetrating wounds and, in particular, bow-
el injuries, Hippocrates states they have a very poor prognosis.
The cause of death in penetrating bowel injuries was peritoni-
tis, and later on, we will see that the only way those unfortu-
nate had to save their life was to develop an enterocutaneous
fistula.
BIn long continued haemorrhoids, a total cure is fre-
quently followed by dropsy and phtisis^.
This probably refers to the few cases — if any — of
haemorrhoids as a consequence of portal hypertension.
Cutting away a possible drainage of the portal system into
the caval system would increase the risk of ascites.
In his treatise on haemorrhoids, Hippocrates gives a won-
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].
BForce out the anus as much as possible with the fin-
gers… He himself should cry out, for this will make the
rectum project the more… You will recognize the
haemorrhoids without difficulty for they project on the
inside of the gut like dark-coloured grapes and when the
anus is forced out they sprit blood… Burn the pile until it
is dried up and so as that no part may be left behind…
When the cautery is applied the patient’s head and
hands should be held so that he may not stir^.
It is quite interesting that the patient should Bcry out^ to
increase the abdominal pressure and cause the prolapse to
slide down. If we do not consider the systemic response to
such a painful treatment done without anaesthesia, the real
efficacy of cautery, used for the treatment of piles and also
Int J Colorectal Dis
to deal with other surgical conditions as we will see later on,
was not only due to the sealing of the vessels but mostly to the
formation of scar fibrous tissue that fixed the prolapse higher
on the rectum.
In the treatise on fistulae, Hippocrates recognises the rela-
tionship between perianal abscess and fistula and proposes a
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
Hospital. The technique entails the cannulation of the fistula
with a speculum or director, followed by a long thread of raw
lint, wrapped within a horse hair [7].
BTaking a very slender thread of raw lint and uniting it
into five folds of length of a span and wrapping them
round with a horse hair, then having made a director
(specillum) of tin, with an eye at its extremity, and
passed through it the end of raw lint wrapped round
as above described, introduce the director into the fis-
tula and, at the same time, introduce the index finger of
the left hand per anum, and when the director touches
the finger, bring it out with the finger, bending the ex-
tremity of the director and the ends of the threads in it,
and the director is to be withdrawn, but the ends of the
thread are to be knotted twice or thrice and the rest of
the raw threads is to be twisted round and fastened into
a knot^ [7]
In case of intestinal injuries, bearing in mind the extreme
gravity of those lesions, Hippocrates — or more likely his
followers — used to suture the bowel with a running suture
without knots at the beginning and at the end, bringing the two
long extremities out of the abdominal wound, where they were
secured. This was aimed to prevent the leakage of intestinal
content into the peritoneum and to fix the wound to the ab-
dominal wall, in the hope to create a spontaneous fistula [8].
Hebrews
According to the Bible and Jewish tradition, Jewish ancestry
is traced back to the Biblical patriarchs Abraham, Isaac and
Jacob, who lived in Canaan about 1800 years BC. Jacob’s son
Joseph went to Egypt where he was appointed as high official
of the Pharaoh and called his father and brothers to join him.
Their descendants were enslaved in Egypt until the Exodus
led by Moses, around the 13th century BC. The Jews then
settled in Canaan and, according to the Bible, they were in
constant war with neighbouring tribes and kingdoms. King
David was the first of a dynasty and King Solomon, David’s
son, built the first Temple in Jerusalem, a symbol of Jewish
religion, tradition and culture. In 586 BC, the Babylonian king
Nebuchadnezzar II conquered Israel, destroyed the Solomon
temple and exiled the Jews to Babylon. In 538, Cyrus, the
Int J Colorectal Dis
Great of Persia, conquered Babylon and the Jews returned to
Israel and rebuilt the temple. In 64 BC, the Romans conquered
Syria, and Israel became a Roman protectorate under the
Herod dynasty and then a Roman province in AD 6. In AD
390, at the split of the Roman Empire, Israel became part of
the East Roman Empire under the Byzantines. In 634, Arabs
took over the rule of Israel until the first Crusade in 1099. The
Middle Ages saw frequent changes of rulers and the alternat-
ing destiny of the crusades. In 1517, the Turkish rule started
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
1948 at the end of World War II. What we know about
Jewish medicine and surgery can be found in the Bible and
in the Talmud (commentaries and notes on the Bible) [3].
From the Talmud, God is the healer. This idea is common
to all theocratic societies. God was the origin of all good and
all evil, so health and disease. In this social context, being able
to Bcure^ meant be similar to God, take from God His divine
knowledge. Elijah the Prophet could resuscitate a boy, with a
manoeuvre very similar to our cardiopulmonary resuscitation,
with the help of God.
BAnd he stretched himself upon the child three times,
and cried unto the Lord, and said, O Lord my God, I
pray thee, let this child’s soul come into him again. And
the Lord heard the voice of Elijah; and the soul of the
child came into him again, and he revived.^ (1 Kings
17:21–22) [1].
In the second book of Chronicles, the prophet Elijah re-
proaches Joram, King of Judah, of not following the path
indicated by his father Jehoshaphat and predicts a disease of
the intestine, which is described in great detail and looks just
like the rapid course of a bowel cancer, which is manifested by
malaise, pain and rectal prolapse.
BThou shalt have great sickness by disease of thy
bowels, until thy bowels fall out by reason of the sick-
ness day by day… And after all this the LORD smote
him in his bowels with an incurable disease… And it
came to pass, that in process of time, after the end of
two [2] years, his bowels fell out by reason of his sick-
ness: so he died of sore diseases…^ (2 Chronicles
21:12–19) [1]
From this description is quite evident that the Hebrews
knew very well the clinical presentation of an obstructive co-
lonic cancer, but the writer of this book of the Bible empha-
sises that this is a punishment coming from God and serves as
a warning to people.
The Book of Judges is the seventh book of the Hebrew and
Christian Bible. It contains the history of biblical judges,
leaders of the Israelites in their continuous wars against for-
eign rulers. In the third chapter, the Judges Ehud fights against
Eglon of Moab and stabs him in his belly. Eglon is eviscerated
by the blow, and excrements leak out; he was so overweight
that the sword disappeared into the wound and Ehud left it
there.
B…And the haft also went in after the blade; and the fat
closed upon the blade, so that he could not draw the
dagger out of his belly; and the dirt came out.^ (Judges
3:22) [1]
This demonstrated that Hebrews had knowledge, maybe
derived from their war experience, of penetrating abdominal
wounds. They had also a direct knowledge of human anatomy
learned by the dissections of corpses that, although not en-
couraged, was not prohibited and by the dissection of animals,
very diffused and frequent due to ritual slaughtering to get
Bkosher^ food. Even if the Jewish world opposed the spread
of Hellenism and therefore also of its scientific culture, the
Talmud reports of autopsy studies performed by Rabbi doc-
tors. Another factor to consider is the excellent communica-
tion between the social classes that existed in Jewish society.
In fact, while in the Egyptian and Greek-Roman society, the
anatomical knowledge of embalmers and butchers was rarely
sent to the medical profession, in the Jewish world, knowl-
edge was available to everyone [9]. Unfortunately, the de-
scription of human body reported in the Talmud is mostly a
functional anatomy of the living, to check the ability for cer-
tain functions, related to religion and social life. The Mishnah
— part of the Talmud –refers that there are B248 limbs in the
human body…and 5 orifices^. In the Hebrew Bible, there are
613 commandments; 248 are positive and are equivalent to the
number of the active limbs and to the number of organs, 365
are negative and correspond to the number of blood vessels in
the human body. The five orifices are considered essential for
life, since some of them allow the vital substances to enter and
others the waste substances to leave. In the Talmud, in fact,
one of the blessings to God was for creating man with orifices
and cavities that must function properly to allow life. The
regular bowel activity was considered vital [9].
Mosheh ben Maimon, called Moses Maimonides (or
Rambem — Hebrew acronym for Rabbeinu Mosheh Ben
Maimon, Our Rabbi Moses Son of Maimon) was a promi-
nent medieval Spanish Sephardic Jewish philosopher, astron-
omer, physician and one of the most important Torah
scholars. He was born in Cordoba in 1135 and died in
Egypt in 1204. He lived during the Moorish rule of Spain
and his family was forced into exile, so he had the possibility
to study medicine in Morocco and Egypt and was appointed
Court Physician to the Grand Vizier Al Qadi al Fadil, then to
Sultan Saladin ( alā ad-Dīn Yūsuf ibn Ayyūb). He wrote a
lot of philosophical and theological books and some medical
books as well. In particular, for our purpose, he wrote a
treatise Bon Heamorrhoids^, where he recommends healthy

diet and BSitz baths^, but admitted that this treatment is not
to cure the very deep cause of haemorrhoids, and so they can
recur [10].
Sitz baths are suggested even nowadays also for the cure of
fissures and irritable bowel syndrome. In the introduction of
his book, Maimonides explains why he is interested in this
subject. He visited a young Egyptian man, related to the
Sultan, being troubled by haemorrhoids; in this case, the
choice was not easy, but at the end, he did not suggest any
kind of surgical treatment, as he was not sure if those
haemorrhoids were of the type to be excised or to be left as
very likely to recur. He thought surgery should be the last
choice. In his dissertation, Maimonides explains his theory,
derived from Hippocrates, where haemorrhoids are due to an
excess of black bile, which accumulates in the lower parts of
the body. Interestingly, he describes haemorrhoids as follows:
B…the vessels of the mouth of the anus (rectum) become
engorged therewith and stretch and widen. Warmth de-
velops at these sites as well as moistness, and these
prolapses develop… sometimes become acute…swell-
ing develops, pain increases and the stool is with-
held…occasionally, something egresses from them and
swells externally and the pain becomes stronger and
fever and suffering ensue…^ [10]
This is clearly the description of an acute episode of
haemorrhoidal prolapse with thrombosis. Even if they are
due to a derangement of the body humours, haemorrhoids
are associated with prolapse. At the end of his writing, he
discusses the role of surgery, indicated just for strangulated
(thrombosed) haemorrhoids, saying that this operation should
be performed by experienced surgeons — patients’ safety is
paramount even in Maimonides works — who take into ac-
count the general condition of the patient and eventual comor-
bidities [10].
Romans
If we do not consider the myth — reported in the Aeneid by
the Latin poet Virgil — that links the birth of Rome to the War
of Troy and the escape of the Troyan hero Aeneas, the actual
ancestors of the Romans were some Indo-European tribes that
moved to Italy in about 1000 BC and overlapped with the pre-
existing Etruscan, ancient population of the west coast of Italy.
As a matter of fact, three of the first seven kings of Rome were
Etruscan. The established date of the birth of Rome is 21st
April 753 BC, when, according to the legend, Romulus began
building the city. During the first phase of Roman history, the
rule of the Seven Kings, the Roman Senatus, a popular assem-
bly nominated by the King himself, had just an advisory role.
In 509, the Senatus took over, the last Roman King was
Int J Colorectal Dis
overthrown and the first Roman Republic started. During the
republican period, Rome invaded the neighbouring Italian
states and then conquered the trade pathway of the
Mediterranean Sea destroying Carthage in 146 BC. Within
50 years, the bases of Roman Empire were built up. In the
2nd century BC, Rome ruled over Italy, Spain, southern
France, Northern Western Africa, Macedonia, Greece and part
of Turkey. The important historical figure of Julius Caesar
links the Roman republic to the so-called Age of Augustus
of the Roman Empire. He himself was never a king or an
emperor, but just a consul, self-proclaimed dictator. After his
assassination in March 44 BC, his great nephew Augustus took
over and self-proclaimed himself as Emperor. During the
Empire Age, Rome gradually expanded his boundaries up to
the Hadrian Wall in England, the Rhine in Germany, the Near
East, Turkey. The Emperors Diocletian, and Constantine
started the decline of Roman power first changing its state
religion to Christianity, second building up a new capital in
the east, Constantinople, and leading to two separate Empires,
the West Roman Empire and the East Roman Empire. The last
West Emperor, Romulus Augustulus, abdicated in AD 476 and
marked in this way the fall of the Western Roman Empire.
Roman success was due largely to its military and social or-
ganisation. All volunteers were entitled to Roman citizenship
and were given a land at the end of their service in the army.
Many conquered territories were divided amongst Roman sol-
diers and generals. The society was divided in four classes:
slaves, plebeians, knights and patricians. The latter classes had
a central role in public life and culture. Wherever the Romans
went, they brought their own way of living and their own
culture. Apart from the codes of law that represent the bases
of most of the European modern codes of right and duties, the
Romans did not give any great new contribution to culture.
The same should be said about coloproctology, where they
followed for the most the Egyptian and Greek knowledge
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
50. His work BDe Medicina^ is one of the best sources
concerning surgical practise in the Roman world. He is
deemed to be the Author of the cardinal signs of inflamma-
tion: rubor (redness), tumor (swelling), calor (warmth) and
dolor (pain). In Book 4 of BDe Medicina^, he demonstrates
a good knowledge of anatomy and gives an outstanding de-
scription of the colon.
BBeyond is the thinner intestine, infolded into many
loops, its several coils being connected with the more
internal parts by fine membranes; these coils are direct-
ed rather to the right side, to end in the region of the
right hip; however, they occupy mostly the upper parts.
After that spot this intestine makes a junction crosswise
with another, the thicker intestine; which, beginning on
Int J Colorectal Dis
the right side, is long and pervious towards the left, but
not towards the right, which is therefore called the blind
intestine. But that one which is pervious being wide-
spread and winding, and less sinewy than the upper
intestines, has a flexure on both sides, right and left,
especially on the left side and in the lower parts and
touches the liver and stomach, next it is joined to some
fine membranes coming from the left kidney, and hence
bending backwards and to the right, it is directed
straight downwards to the place where it excretes; and
so it is there named the straight intestine^ [11]
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
the hands. In the same book, he gives a definition of the
surgeon, as youthful, strong and steady-handed, with sharp
and clear vision and not moved by the cries of pain of the
patient.
BThe third part of the Art of Medicine is that which cures
by the hand…in cases where we depend chiefly upon
medicaments, although an improvement is clear
enough, yet it is often clear that recovery is sought in
vain with them and gained without them… But in that
part of medicine which cures by hand, it is obvious that
all improvement comes chiefly from this, even if it be
assisted somewhat in other ways. This branch, although
very ancient, was more practised by Hippocrates, the
father of all medical art, than by his forerunners…
Now a surgeon should be youthful or at any rate nearer
youth than age; with a strong and steady hand which
never trembles, and ready to use the left hand as well as
the right; with vision sharp and clear, and spirit un-
daunted; filled with pity, so that he wishes to cure his
patient, yet is not moved by his cries, to go too fast, or
cut less than is necessary; but he does everything just as
if the cries of pain cause him no emotion^ [12]
In case of penetrating abdominal wounds, he recommends
inspection of the wound. If there is no bowel injury, all the
prolapsed content should be repositioned inside the abdomen
and the wound sutured (double layer). If there is an intestinal
injury, the prognosis is poor for small bowel injuries, whereas
large bowel injuries can be sutured, only if the bowel is not
ischemic or in poor conditions.
BSometimes the abdomen is penetrated by a stab of
some sort, and it follows that intestines roll out. When
this happens we must first examine whether they are
uninjured, and then whether their proper colour per-
sists. If the smaller intestine has been penetrated, no
good can be done, as I have already said. The larger
intestine can be sutured, not with any certain assurance,
but because a doubtful hope is preferable to certain
despair; for occasionally it heals up. Then if either in-
testine is livid or pallid or black, in which case there is
necessarily no sensation, all medical aid is vain.^ [12]
In case of perianal fistula, he proposes the technique
of the Bcutting seton^, in use up to few years ago. The
principle is to pass a long thread into the fistula, fol-
lowing a probe, then the two ends of the thread must be
tightly ligated to allow a slow and progressive cut of
the tissues whilst fibrous scar tissue forms, where the
tissues have been just cut, thus preventing the complete
breakdown of the sphincters.
BWhere a probe has been passed up to its end, the
skin should be cut through, next through this new
orifice the probe is to be drawn out, followed by a
linen thread which has been passed through the eye
made for the purpose in the other end of the probe.
Then the two ends of the linen thread are taken and
knotted together so as to grip loosely the skin over-
lying the fistula. The linen thread should be made
up of two or three strands of raw flax, twisted up so
as to make one. Meanwhile, the patient can do his
business, walk, bathe, and take food as if in the best
of health. Only this thread is to be moved twice a
day, but without undoing the knot, the part of the
thread outside being drawn within the fistula, and
the thread must not be left until it becomes foul,
but every third day the knot is to be undone, and
to one end that of another fresh thread is tied, and
the old thread being withdrawn the new one is to be
left in the fistula after being similarly knotted. For
thus the thread cuts through the skin overlying the
fistula slowly, and whilst the skin released from the
thread undergoes healing, that which is still gripped
is being cut through.^ [12]
In case of anal fissure and haemorrhoids, every surgical
treatment must be preceded by enemas to clean the bowel.
The haemorrhoids must be excised after seizing them with
forceps, but attention must be paid to not perform a complete
haemorrhoidectomy for the risk of a stricture of the anus. This
is a principle at the basis of the modern treatment of
haemorrhoids.
BThe mouths of veins which discharge blood are re-
moved as follows. When any patient is losing blood,
fasting is indicated, and a rather severe clystering of
the bowel, to make the openings more prominent, and
thus what may be called the little heads of the veins all
come into view…. If there are two or three, the lowest
must be dealt with first; if more, they are not all treated
at once, to avoid having tender scars in several places at
once.^ [12]

The treatment of the fissure is simply the excision of the
lesion to create a fresh wound that should heal by itself, after
local dressing with honey.
B…If, therefore, any fissure has persisted so long that it
has become hard and callous, it is best to move the
bowels by a clyster, then apply a hot sponge to soften
the fissures and cause them to protrude. When brought
into view each is excised and made into a fresh wound;
then soft lint is put on and over this a pad smeared with
honey, and all is covered with soft wool, fixed by a
bandage.^ [12]
Claudius Aelius Galenus was the second important Roman
physician, surgeon and philosopher. He was born in
September AD 129 in Pergamon. His father was a wealthy
patrician, architect, builder and philosopher, with interests in
mathematics, astronomy, literature…, and planned for his son
a Bnormal career^ as a philosopher. But, according to the same
Galenus, when he was 16, his father had a dream in which
Asclepius himself suggested for Galenus a medical career. So
he was sent to spend four years at the local Asclepius temple
as an attendant. At that time, Asclepius sanctuaries were used
as houses of cure for both body and soul and as schools of
medicine. After being abroad for a period, he came back to
Pergamon aged 28 to become physician to the gladiators.
Obviously, this was an outstanding experience for him, as he
could study living anatomy on wounded gladiators and master
the treatment of trauma and fractures. In particular, he had a
great commitment in the treatment of abdominal penetrating
trauma and in intestinal sutures. As a matter of fact, during his
employment as gladiators’ surgeon, mortality rate fell signifi-
cantly. When his fame spread all over the Roman empire, in
AD 162, Galenus was summoned to Rome, to be appointed as
a physician to the emperors Marcus Aurelius, Commodus,
Septimius Severus and Caracalla and where he died aged 87.
During his period, in Rome, he produced his extensive med-
ical literature spanning from anatomy — he performed dissec-
tions of alive and dead animals as Roman law prohibited dis-
section of human bodies — to surgery — famous is his inter-
est in brain and eye surgery. Unfortunately, he added nothing
to colorectal and proctologic surgery, but just applied
Hippocrates’ teaching on bowel suturing.
Byzantines
The Byzantine Empire was the continuation of the Eastern
Roman Empire, which survived the fall of the Western
Roman Empire and existed up to the Ottomans’ takeover.
Diocletian divided the Roman Empire in AD 285 to get a better
organisation of the central power, but officially, the Eastern
Roman Empire, or Byzantine Empire, existed as long as its
Int J Colorectal Dis
capital existed, that is from 330 to 1453. Byzantium, later
known as Constantinople and Istanbul, was the cultural and
political centre of the Empire. Byzantine art spread all over the
Mediterranean up to Ravenna and Venice, but even in the
south of Italy, as well as in Greece and in Turkey.
In this period, surgery had few developments and was just
about applying the ancient Greek and Arab teachings. The
translations of the manuscript were done in the Christian mon-
asteries and abbeys, which were the real centres of knowledge
and culture [5].
Paul of Aegina (Paul Aegineta) was a Greek byzantine
physician known for writing a huge medical textbook De Re
Medica Libri Septem (i.e., the BMedical Compendium in
Seven Books^). This was translated into English by the sur-
geon Mr. Francis Adams and published in 1834. Paul was
born in Aegina probably in AD 625 and his precise date of
death is not known, probably around AD 690. He was greatly
appreciated in the Arabic world, where all his works were
extensively translated and studied. His experience in the treat-
ment of pelvic floor diseases has earned him the Arabic nick-
name of Al-kawabeli, the obstetrician. In his third book, head
59, he gives an accurate description of haemorrhoids and their
treatment. The first approach should be a local treatment with
herbs, decoctions and suppositories [13], but surgery was still
indicated in selected cases. In the same Book 3, piles were no
more considered an effect of a rectal prolapse, but as enlarged
blood vessels that should be treated with ligation. It is inter-
esting to note the two other different techniques he reports,
from Leonides — a Greek surgeon — and from Bothers^. The
first of them uses compression to close the vessels before
cutting them off, and the second uses hot temperature to cause
a coagulative necrosis of them by cauterisation [14].
BBefore proceeding to the operation we must use
frequent clysters with the view of evacuating at the
same time the content of the intestine and, by ir-
ritating the anus, of rendering it more disposed to
eversion and protrusion of the gut. Having there-
fore laid the patient on his back in a clear light, if
we are to use the ligature we pass a very thick
thread round the lips and secure each of the
haemorrhoids with this ligature, leaving one as
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
the anus, we order the patient to remain quiet…
Leonides has not recourse to the ligature, but hav-
ing seized the haemorrhoids and held them for
some time with the forceps used for operation on
the uvula, he cuts them off with a scalpel… Others
by filling the cavity of the instrument called
staphylocaustes with caustic medicines, have burnt
haemorrhoids like a scirrhous uvula…^ [14]
Int J Colorectal Dis
Arabs
Arab surgeons and physicians lead surgery and medicine a big
step forward, even if they added nothing new in colorectal
surgery. More often, they just systematised and popularised
the ideas of Galen.
It is interesting to note that the history of Arab medicine
and surgery arises from a Christian heretic, Nestorius, patri-
arch of Constantinople, who around 435, after the Council of
Ephesus, was forced into exile. To survive, his followers were
forced to study medicine and instituted a medical school in
Edessa, Syria, based on Greek ideas. Unfortunately, the
Nestorians also clashed with the bishop of Cyprus and were
expelled once again. In 489, they came to Gundeshapur,
where they founded a new school of medicine. This city saw
the flourishing of culture in the Arabic language and the be-
ginning of its spread throughout the Mediterranean basin. The
history of Islam officially starts in AD 622, the first year of the
Islamic calendar, when Muhammad fled from Mecca to
Medina. Mecca had been always a centre of cult, where the
nomadic tribes came to venerate the Ka’aba, a huge granite
cube that contains the black stone traditionally placed there by
Abraham and Ishmael (his first son according to the Bible and
the Quran). In 612, Muhammad ibn-Abdullah, a merchant,
began to reveal the words he received from God through the
angel Jibril, but this upset the local religious establishment and
he was forced to move to the town of Yathrib, later renamed
Medina (Bcity of the prophet^). In Medina, he reorganised his
people and threw the conquest of neighbouring countries such
as Persia, Syria, Palestine and Egypt, then across the
Mediterranean to the south and west to invade Spain and
Sicily. They were about to enter France, but the French army
stopped them in Poitiers in 732.
Through their military conquests, the Arab civilisation and
culture spread throughout the Mediterranean and beyond, up
to India and South-East of Asia. We can consider the Arab
civilisation as the point of union between the Greek-Roman
world and the Renaissance. Most important was the contribu-
tion of the Jewish translators, who made the Greek and Latin
classics available to Arab physicians and, therefore, helped the
Arabic medical texts to spread throughout Europe.
In 755, a big schism split the Arabic empire in a western
caliphate, based in Cordoba, and an eastern caliphate, based in
Bagdad [3]. Each of them had its own traditions and culture
and its own approach to science.
The most important surgeons in the Eastern Caliphate were
Al-Razi, Haly Abbas and, mostly, Avicenna. In the Western
Caliphate, worth of notes are Albucasis, Avenzoar and
Averroes.
Muhammad ibn Zakariyā Rāzī was born in Rey, on the
Great Silk Road, in 854, but moved to Bagdad to study med-
icine. Later, he came back to Rey to work as the head of the
local hospital but due to his growing popularity he was called
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,
but probably this earned him a total blindness, as a conse-
quence of being beaten by a mullah or his killers. He stated
that every good doctor should base his cure on the deep
knowledge of human anatomy. It seems that a local physician
offered to treat his blindness, but when he failed to answer Al-
Razi’s question on how many layers the eye contains, Al Razi
declined his offer saying, Bmy eyes will not be treated by one
who does not know the basics of its anatomy^. He was a very
prolific writer not only in medicine but also in chemistry,
alchemy, philosophy and religion. His fame is linked to his
description of various diseases. His Al-Hawi is a huge text-
book of medicine where he was the first to describe measles
and smallpox. He was also interested in the diseases of chil-
dren and is regarded as one of the fathers of paediatrics.
Surgery is the subject of his seventh book. In surgery, he
was one of the first to use animal gut derived suture to
close bowel wounds, but described also several orthopedic
operations [5].
Ali ibn al-Abbas al Majusi was born in Ahwaz in 930.
After his studies, he worked in Shiraz and Bagdad. He is best
known for his textbook Kitāb Kāmil as-Sinā’a at-Tibbiyya,
the BComplete Art of Medicine^, known in the Western world
as Al-Maleki, from the name of the Emir it was dedicated to.
This was one of the most known treatises of medicine for more
than one century, replaced only by Avicenna’s Canon, and was
used as a textbook in the Medical School of Salerno. Hali-
Abbas 19th volume contains 110 chapters on surgery. His
treatment for imperforated anus was the incision of the anal
membrane followed by the insertion of a sponge or a lead
probe to avoid early closure. But he was also the first to de-
scribe the treatment of arterial bleeding with proximal and
distal ligation of the artery, six centuries before Ambroise
Paré [5].
The importance of Avicenna is equal to that of Hippocrates
and Galen, not only for the Arab world but also throughout the
culture of medieval, modern and contemporary world.
Avicenna is said to have been a child prodigy and studied
medicine in Baghdad with the Nestorians. His real name
was Abū ‘Alī al-Husayn ibn ‘Abd Allāh ibn Al-Hasan ibn
Ali ibn Sīnā, but is known as Ibn-Sina or Avicenna. He was
born in 980 in Afsana, a little village near Bukhara, today
Uzbekistan. According to his autobiography, he had learnt
the entire Quran by the age of 10, and then he studied arith-
metic and even Islamic laws. As a teenager, he studied philos-
ophy and turned to medicine aged 16 and graduated at 18. His
fame spread and he was appointed as the Emir’s physician and
gained access to the library of the Samanids. When he was 24,
the end of the Samanids dynasty meant the start of his nomad
life. During this period, he continued working, writing and
teaching. His greater treatise Canon of Medicine has been
composed in his period. He died in 1037 in Hamadan, today
 Int J Colorectal Dis

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