History of colorectal surgery: A comprehensive historical review from the ancient Egyptians to the surgical robot.

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 civilisations 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 colorectal 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 specialties. In fact, the first medical specialisation was anaesthesia, 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: [email protected]

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 specialisation 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 primates appear to differ from the four-footed animals in suffering 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 tropical 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,

Int J Colorectal Dis

Egyptians enjoyed a long period of prosperity in a wellorganised 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 architectural 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 administration, 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 diseases and health. The practitioner himself was called Bthe Sachmet’s priest^, thus demonstrating a close relationship between magic and medicine. Many of the practitioners were also scribes and had relevant posts in the public administration. Maybe the most famous Egyptian physician — and the father of Egyptian medicine — 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 practitioners, 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 practise 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.

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, dealing 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 antiquarian, 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 papyrus bought by Chester Beatty, another American antiquarian — 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 anatomical 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 piping 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 dedicated 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


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 papyrus. 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 subsequent 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 grandness was finally established by his son Alexander the Great [3]. Science and medicine flourished during the classical period, and for the most part, they were strictly linked with religion. 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 performed 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 written 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 concepts we consider true today. The Corpus Hippocraticum contains also the famous Hippocraticum Oath, which was an oath historically taken by physicians and other healthcare professionals swearing to practise medicine honestly and with professionalism. 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 abdomen 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 consistent 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, stomach, 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, bowel injuries, Hippocrates states they have a very poor prognosis. The cause of death in penetrating bowel injuries was peritonitis, and later on, we will see that the only way those unfortunate had to save their life was to develop an enterocutaneous fistula. BIn long continued haemorrhoids, a total cure is frequently 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 wonderful 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 fingers… 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

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 relationship 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 fistula and, at the same time, introduce the index finger of the left hand per anum, and when the director touches the finger, bring it out with the finger, bending the extremity of the director and the ends of the threads in it, and the director is to be withdrawn, but the ends of the 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 abdominal 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


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 alternating 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 reproaches 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 sickness 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 sickness: 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 colonic cancer, but the writer of this book of the Bible emphasises 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 foreign 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 encouraged, 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 doctors. Another factor to consider is the excellent communication 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, knowledge was available to everyone [9]. Unfortunately, the description of human body reported in the Talmud is mostly a functional anatomy of the living, to check the ability for certain 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 prominent medieval Spanish Sephardic Jewish philosopher, astronomer, 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 develops at these sites as well as moistness, and these prolapses develop… sometimes become acute…swelling develops, pain increases and the stool is withheld…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 account the general condition of the patient and eventual comorbidities [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 preexisting 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 assembly nominated by the King himself, had just an advisory role. In 509, the Senatus took over, the last Roman King was

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 organisation. 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 soldiers 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 inflammation: 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 description 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 directed 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


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 widespread 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 undaunted; 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 persists. 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 intestine 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, following 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 overlying 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 removed 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 significantly. 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 medical literature spanning from anatomy — he performed dissections of alive and dead animals as Roman law prohibited dissection of human bodies — to surgery — famous is his interest 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

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 monasteries 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 surgeon 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 treatment of pelvic floor diseases has earned him the Arabic nickname 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 interesting 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 irritating the anus, of rendering it more disposed to eversion and protrusion of the gut. Having therefore laid the patient on his back in a clear light, if we are to use the ligature we pass a very thick thread round the lips and secure each of the haemorrhoids with this ligature, leaving one as an outlet to the superfluous blood. After the application of the ligature, using a compress that has been dipped in oil and the bandage adapted for the anus, we order the patient to remain quiet… Leonides has not recourse to the ligature, but having seized the 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]


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, patriarch 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 beginning 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 contribution 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 medicine. 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 consequence 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 AlRazi’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 textbook of medicine where he was the first to describe measles and smallpox. He was also interested in the diseases of children 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. HaliAbbas 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 describe 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 arithmetic and even Islamic laws. As a teenager, he studied philosophy 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


Iran, where he was buried. Avicenna’s Canon was largely influential in the Middle Ages and was used as a university textbook up to the 17th century. It explains the causes of diseases. Most important, in his Canon Avicenna anticipates the WHO definition of medicine as Bthe art whereby health is concerned and the art by which it is restored after being lost^, meaning that the central interest of medicine is health, not disease. Generally speaking, there is nothing new in the Canon as it should be regarded as a huge exposition of the Galenic theories. From the surgical point of view, he introduced the theory that surgery is somewhat inferior to medicine that dominated the Western world for many centuries, but described the tracheostomy and a treatment of the cancer of the breast. As regards bowel surgery, he suggested to use twisted human or pig hair to suture intestinal wounds [14]. The western caliphate had its centre in the town of Cordoba, where a university was founded in the 8th century, alongside with at least 50 hospitals. The main medical authorities in the western caliphate were Albucasis, Avenzoar and Averroé. Modern surgery has several fathers… one of them is, for sure, Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi, known as Albucasis. He was an Arab Muslim, born in ElZahra, near Cordoba, in 936 and lived and practised surgery in Cordoba until his death in 1013. We have few details of his life, but we know he was Court Surgeon to the caliph AlHakam III. He described several surgical instruments, such as surgical hooks, cannulas, forceps and specula, and specialised in curing surgical diseases by cauterisation. It is known also for describing the first ectopic pregnancy in 963. Albucasis’ most important writing is Kitab el-Tasrif (BThe Collection^), a 30-book treatise reporting the up-to-date medical knowledge alongside the basic principles of medical deontology. He emphasised the need to treat patient irrespectively of their social status and was one of the first to write on the importance of a positive doctor–patient relationship. In the Middle Ages, El-Tasrif was the main surgical textbook. Here, he describes the use of cautery to treat many conditions. Very interesting is his description of the use of cautery in the treatment of groin hernia. BWhen a rupture occurs in the groin, and part of the intestine and omentum comes down into the scrotum, being the onset of the disease, forbid the patient to take 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 the hernia over the pubic bone, mark a semicircle whose extremities point upward. Then heat a cautery… When it is white hot and emits sparks then return the intestine or omentum into his abdominal cavity and have an assistant put his hand over the place to prevent the exit of the intestine. You should first have parted his legs and put a

pillow under him; let another assistant sit on his legs and another on his chest, holding his hands. Then apply the cautery to the mark, keeping the cautery upright and hold it till he reaches the bone… You must take the greatest care that the intestine does not come out while you are cauterizing, lest you burn it and it result in death or grave injury to the patient.^ [15] As regards our particular interest, his use of cat or sheep gut for internal stitching was the basis of modern bowel sutures. Abū-Marwān ‘Abd al-Malik ibn Zuhr, better known as Avenzoar, was born in Seville in 1094, the son of a Hebrew physician who taught him the basic of medicine. His main treatise was Kitab al-taysir (BBook of Simplification^), where he presented the first descriptions of oesophageal and gastric cancers. One of his greatest contributions to medicine was experimental surgery on animals before applying the same technique on humans. He was a great admirer of Galen, and in his writings, he protests emphatically against quackery and the superstitious remedies of the astrologers. Unfortunately, he did not add anything to colorectal surgery [5]. Abū l-Walīd Muhammad bin Ahmad bin Rušd, known as Averroes, was a philosopher, theologian, physician and astronomer. He was born in Seville in 1126 and was a master of Aristotelian philosophy. He is famous for his commentaries of Aristotle, but he gave a great contribution also to medicine. He was trained in Cordoba under Avenzoar and spent his working life between Cordoba, Seville and Marrakesh, where he died in 1198. Averroes wrote a medical encyclopaedia called Kulliyat (BGeneralities^), translated in Latin, which is inspired by Avenzoar’s work Al-Tavsir. He is known more for his philosophical interests and for commenting Aristotle than for his medical writings, and for this reason, he earned an honour place in Raffaello’s BThe School of Athens^ [5]. Unfortunately, little is known about the real practise of advanced surgery in ancient Islamic lands. In particular, there is uncertainty about what kind of operation has been actually performed and what has just been described, citing previous sources (as Hippocrates and Paul Aegineta), but it is recognised that many of the Arabian writers modified ancient surgical instruments and proposed new items and techniques. For sure, they dealt with haemorrhoids and performed tonsillectomies, as well as eye operations and dental extraction and replacement [16].

Ancient India Even if there is evidence of the presence of Homo Erectus in the Indian subcontinent about 500,000 years ago, the history of India begins with the Indus valley civilisation, which started in 3300 BC around the Indu river. An Indo-Aryan culture began in the second millennium BC and is associated with


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 extended 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 surgery. 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 laparotomies, 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 represented by the Crusades. These were a series of political and economical 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 previously owned by the Merovingian kings of France, descendants 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 organisation. 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 practise to a more scientific discipline that was taught in universities 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, depending on their hagiography and often their — usually violent — death. Saint Benedict believed that only prayers could cure, so he forbade the practise of medicine and surgery in his monasteries [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 barbers, the usual guests of the monasteries where it was forbidden 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 region, 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 doctors, 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 advanced 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-inlaw, 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

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 intestinal 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 innovative 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 before 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 surgeons 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 textbooks, 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 horseback. John described the process of anal abscess becoming


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 cancer…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 approach 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 bubonic plague that hit Europe in the 14th century, almost halving 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 decades 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 anatomy. His criticism towards Galen’s work attracted many attacks, 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 treatise 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 represented 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 cadaver as it hangs there or turn around in any direction to suit my purpose.^ [20] In De fabrica, he described the omentum and his relationship with stomach, spleen and colon and observed the appendix. 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 turpentine survived. Moreover, he introduced ligation of the vessels during amputation, instead of cauterisation, avoiding major 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 current 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

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 related 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, probably 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 operation. The court surgeon, Charles-Francois Felix, was summoned. 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 physicians 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].


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 socalled 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 abdominal 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 abdominal 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 declaration of Independence in 1776. The French Revolution and the Terror period 1789–1799 led to Napoleon Bonaparte becoming 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 period 1837–1901 meant rediscovery of strict social roles, responsibilities and values. Slavery was gradually abolished and sports have been coded and developed. The first official international 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 surgery. 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 observation 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 international reputation and was member of several scientific academies. He died in Padua on 6th December 1771, aged 89. Even if Morgagni proposed an operation for the cancer of the rectum, 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 powerful weapons, the battlefield surgeons had to deal with multiple 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 approach bringing the wounded bowel in proximity to the abdominal 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 manage. The first methods of direct suture were done by the invagination 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 approximate 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 operations. 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 nowadays 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 rather 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 perforations 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 wellestablished 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 treatment 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

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 published 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 abdominal 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 medical 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 honorary 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-dayold newborn dead for imperforate anus and proposed the creation 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).


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 ischemia. 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 therefore 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 unexpectedly adhere to the wound in the abdomen; and therefore there seemed to be no reason why we should not take this hint from Nature. Whenever therefore a Surgeon is called to a case of this kind, after he has diligently examined the state of the 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 penetrating 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 condition, 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 condition 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 abdomen 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 fistulae. 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 irrigation of colostomy in 1917 [14, 19, 26]. In 1797, Professor Fine, of Geneva, performed a doubleended 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 described 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, developed 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 suffering 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 anatomical 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 infection 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 investigations 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

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 determine 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 obstruction 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, followed 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 humanity should seriously advocate a procedure so fraught with danger and followed, if successful, by such disgusting consequences… I cannot, I must confess, appreciate 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.


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 epitaph: 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 resection of the rectum and anus performed well below the peritoneal 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 financial 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 important 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 scientific 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 earlier, 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 immediately invited him for a demonstration at the hospital. The operation 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 outstanding 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 rectal 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 laryngectomy 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 resection 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 rectum 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 implemented, 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 performed 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 mortality rate of 45 %. Theodor Billroth did a segmental colonic resection with a terminal stoma, just like a Hartmann operation. Gussembauer of Liege reported a partial left colectomy

in 1878 and, 1 year later, a formal sigmoidectomy with lymphadenectomy. 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 procedure, 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 colorectal 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 process, and despite the words of the Dominican friar Theodoric of Bologna that Bit is not necessary that pus should be generated 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 medicine 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 putrefaction of milk demonstrated that this process is caused by Bferments^, microorganisms he could see with the microscope. Pasteur’s works inspired the interest of Joseph Lister


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 surgical 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 performed 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 interested in rectal disease. In 1828, he published a book on strictures of the rectum, which was an immediate editorial success and had several editions. In his first book, he stated that stricture 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 operation with mortality zero. The St. Mark’s hospital’s staff was a surgeon, a matron, a dispenser, nurses and servants. No physician was appointed up to 1948. In 1859, Salmon retired from the active work and died in 1868 aged 72. In 1896, the hospital 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 development 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 proctologist 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 centuries 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 surgery and radiology. Actually he is considered the first Romanian radiologist but, at the beginning of the 20th century, 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 assistant 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 descending 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 corresponds 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

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 surgery 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 preceded 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 technique for a two-stage perineal rectal resection. A loop colostomy was fashioned 10 days before the perineal rectal resection, where the rectum was mobilised and the proximal division 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


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 represented 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 entails the use of sharp dissection to develop a plane between the mesorectal fascia and the presacral fascia. The fat tissue surrounding 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 resection of the rectum, where, maintaining a right distance between the tumour and the division margin, the colonic stump is sutured to the rectal stump. This anastomosis, first performed 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 gastrectomy 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 appeared 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 socalled Biofragmentable Anastomotic Ring (BAR), a reabsorbable anastomotic button that keeps the two anastomotic stumps compressed for 5–7 days, then it dissolves leaving 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 consequence 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 circumferential 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 technique 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 postoperative 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 controversy, 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 different expressions of a single disease, causing rectoanal invagination, 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 surgery has its roots in the ancient times, when physicians and surgeons always tried to explore the internal organs and cavities of the human body, initially for divination, then to evacuate 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 colorectal 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 performed 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 resection of the rectum with a low rectal anastomosis [43].

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 playwright 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 interest 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 prototype, 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 replacement. 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 tested on animals but was never applied on the battlefield. Computer Motion (Santa Barbara, CA) developed a robotic system to move the videolaparoscopic camera by voiceactivated 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 surgical 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 developed a robot called the Assembling Reconfigurable Endoluminal Surgical System (ARESS). This will be somehow introduced into the human body where it will assemble and do the operation from inside [45]. At my knowledge, this


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 surgical 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 patients with cancer, traditionally a disease of the advanced age. In response to this new public health emergency, elective oncologic 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 physician 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 colorectal 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.

References 1. The Holy Bible, King James version. http://www.o-bible.com/kjv. html 2. Homans J (1931) A textbook of surgery. Baltimore 3. Welsh (2011) The history of the world. Quercus, London 4. Imperiali G (1995) L’antica medicina Egizia, Xenia edn. Milan 5. Rutkov IM (1993) Surgery: an illustrated history. Mosby Year Book, St. Louis 6. Marks E. The aphorisms of Hippocrates. Collins, New York, 1817. https://ia700503.us.archive.org/23/items/aphorismsofhippo00hipp/ aphorismsofhippo00hipp.pdf 7. Mettler CC (1947) History of medicine: a correlative text, arranged according to subjects. Blakiston 8. Senn N (1893) Enterorraphy; its history, technique and present status. JAMA 21:275–283 9. Cosmacini G (2001) Medicina e mondo ebraico. Editori Laterza, Roma 10. Magrill D, Sekaran P (2007) Maimonides: an early but accurate view on the treatment of haemorrhoids. Postgrad Med J 83:352–354 11. Celsus. De Medicina. http://penelope.uchicago.edu/Thayer/E/ Roman/Texts/Celsus/4*.html 12. Celsus. De Medicina. http://penelope.uchicago.edu/Thayer/E/ Roman/Texts/Celsus/7*.html 13. Adams F (1834) The medical works of Paulus Aegineta translated into English. London 14. Graney MJ, Graney CM (1980) Colorectal surgery from the antiquity to the modern era. Dis Colon Rect 23:432–441 15. Patiño J (2002) A history of the treatment of hernia. In: Fitzgibbons RJ, Gerson Greenburg A (eds) Nyhus and Condon’s hernia. Lippincott Williams and Wikins 16. Savage-Smith E. The practice of surgery in Islamic lands: myth and reality. The Society for the Social History of Medicine, 2000. http:// shm.oxfordjournals.org 17. An English translation of the Sushruta Samhita (1911) Kaviraj Kunja Lal Bhishagratna (ed). Calcutta 18. Arderne J (1910) Treatise of fistula in ano, haemorrhoids and clysters. Oxford University Press, London 19. Ellis H (2011) The Cambridge illustrated history of surgery, 3rd edn. Cambridge University Press 20. Vesalius Andrea. De Humani Corporis Fabrica. http://archive.nlm. nih.gov/proj/ttp/flash/vesalius/vesalius.html and http:// digitalcommons.library.tmc.edu/anatomicaltexts/1/ 21. Diller T (1926) Louis XIV, and his operation for fistula in ano. JAMA 87:2018–2019 22. Haeger K (1988) The illustrated history of surgery. AB Nordbok, Gothenburg 23. Ellis H (1996) Operations that made history. Cambridge University Press 24. Heister LA (1739) A general system of surgery. Innys, London 25. Perrin WS (1931) Some landmarks in the history of rectal surgery. Proceedings of the Royal Society of Medicine, London 26. Wagener DJ (2009) The history of oncology. Bohn Stafleu van Loghum 27. Wilson E (1973) A place for colostomy in the treatment of ulcerative colitis. Dis Colon Rectum 16:98–102 28. Baum W (1879) Resection eines carcinomatoses Dickdarmstuckes. Centralblatt fur Chir 6:169 29. Gross SD (1866) A system of surgery. Blanchard and Lea, Philadelphia 30. Meade RH (1968) An introduction to the history of general surgery. WB Saunders, Philadelphia, pp 277–314 31. Lisfranc J (1833) Sur l’excision de la partie inferieure de rectum devenue carcinomateuse. Mem Acad R Med Belg 11(1–8)

Int J Colorectal Dis 32. Defalque RJ (2009) The myth of baby Banaesthesia^. Anesthesiology 111:682 33. Laing Gordon H (2002) Sir James Young Simpson and chloroform. The Minerva Group 34. Kielan W, Lazarkiewicz B, Grzebieniak Z, Skalki A, Zukrowski P (2005) Jan Mikulicz Radecki: one of the creators of world surgery. Keio J Med 54:1–7 35. Dukes CE (1959) Frederick Salmon. Founder of the St Mark’s Hospital, London. Med Hist 3:312–316 36. Corman ML (1984) John Percy Lockhart-Mummery. Dis Colon Rectum 27:208–214 37. Heald RJ, Husband EM, Ryall RDH (1982) The mesorectum in rectal cancer surgery — the clue to pelvic recurrence. Br J Surg 69:613–616 38. Heald RJ, Ryall RDH (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 327:1479–1482 39. Heald RJ (1988) The ‘holy plane’ of rectal surgery. J Royal Soc Med 81:503

40. Heald RJ, Moran BJ, Ryall RDH, Sexton R, MacFarlane JK (1998) Rectal cancer. The Basingstoke experience of total mesorectal excision 1978–1997. Arch Surg 133:894–899 41. Longo A (1998) Treatment of haemorrhoidal disease by reduction of mucosal and haemorrhoidal prolapse with a circular stapling device: a new procedure. Proceedings of the 6thWorld Congress of Endoscopic Surgery, Rome, pp 777–784 42. National Institute for Health and Clinical Excellence. Stapled haemorrhoidopexy for the treatment of haemorrhoids. NICE Technology appraisal guidance n.128. http://www.nice.org.uk/ TA128 43. Fowler DC, White SA (1991) Brief clinical report: laparoscopic assisted sigmoid resection. Surg Laparosc Endosc 1:183–188 44. Lanfranco AR, Castellanos AE, Desai JP, Meyers WC (2004) Robotic surgery. A current perspective. Ann Surg 239:14–21 45. Harada K, Susilo E, Watanabe T, Kawamura K, Fujie MG, Menciassi A, Dario P (2012) Modular robotic approach in surgical applications. In: Dutta A (ed) Robotic systems — applications, control and programming. InTech Europe

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[Surgery in the Ancient Egypt].

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