The Development History of Chinese Proctology _ Zhengzhou Anorectal Disease Hospital

The development of anorectal specialty in our country's medicine has made great contributions. When foreign scholars discuss the history of the development of the anorectal discipline, they all quote a large number of ancient documents from our country, unanimously recognizing that in ancient times, the Middle Ages, and modern China, important contributions were made to the development of the anorectal specialty. During the Spring and Autumn-Warring States period (770 BC - 221 BC), medical practitioners in our country proposed the disease names "zhui" (hemorrhoids) and "lou" (fistula), which were later adopted by world medicine and have been used until today. The proposal of these disease names first appeared in the book *Classic of Mountains and Seas*. In the *Classic of Mountains and Seas*, there is: "Southward flows into the sea, where there are tiger eels. Their bodies resemble fish but their tails resemble snakes, and their sounds resemble mandarin ducks. Eating them prevents swelling and can cure hemorrhoids." In the same book, it also mentions: "Cang Wen with red tails, eating them prevents abscesses and can be used for fistulas." In *Zhuangzi · Lie Yuku*, there is: "King Qin was sick and summoned doctors. Those who broke abscesses and drained boils received one carriage, while those who licked hemorrhoids received five carriages." In *Hanfeizi*, there is: "Internally without the harm of carbuncles, ulcers, or hemorrhoids." In *Huainanzi*, there is: "Chicken head has already cured the fistula." From these records, it is evident that during the Warring States period, there was already considerable understanding of some common anal and rectal diseases.

In 1973, the excavation of the Mawangdui Han Tomb unearthed *Fifty-Two Prescriptions* (estimated to have been copied no later than the Qin-Han period), which recorded various anorectal diseases such as "mu zhui" (external hemorrhoids), "pin zhui" (internal hemorrhoids), "mai zhui" (vascular hemorrhoids), "xu yang" (anal itching), "xue zhui" (bloody hemorrhoids), "chao zhe" (anal fistula), "ren zhou chu" (prolapsed anus) and their treatment methods. For example, the ligation and excision method for treating "mu zhui" using small ropes and cutting with a knife. The traction and excision method for treating hemorrhoids and fistulas: "For those with nests blocking the rectum, kill a dog, take its bladder, and insert it into the rectum through a pipe. Blow air into it, pull it out, and slowly cut off the nest with a knife." There are also descriptions of anal exploration techniques and fumigation treatments for "mu zhui," such as guiding with a smooth probe to make blood flow out... sitting and fumigating the lower orifice. The cloth application method and hot ironing method for treating "mu zhui": mixing earthworms with medicinal herbs and applying them, burning small elliptical stones, quenching them in vinegar, and using them for heat therapy, which are the earliest recorded surgical and conservative therapies for anorectal diseases in the world.

The *Inner Canon* provides detailed discussions on anorectal anatomy, physiology, and pathology. For example, the *Lingshu Intestines and Stomach Chapter* describes the length, size, and pathway of the ileum (colon) and wide intestine (rectum). The *Suwen Five Zang Organs Theory* states: "The魄men (anus) is also controlled by the five zang organs; food and drink cannot remain stored for long." This correctly recognizes the main functions of the large intestine and anus. The *Suwen Shengqi Tongtian Lun* states: "When the meridians are transversely obstructed, intestinal polyps become hemorrhoids." This was the first to propose that hemorrhoids are due to vascular relaxation, blood stasis, and accumulation. The *Lingshu Water Zang Chapter* states: "Cold qi invades outside the intestines, colliding with defensive qi. Qi cannot circulate properly, thus causing stagnation and internal accumulation. Evil qi arises, leading to the formation of polyps." This was the earliest to propose the name for intestinal polyps. The *Lingshu Ci Jie Zhen Xie Chapter* states: "Cold and heat collide, lingering internally... forming masses, where qi accumulates and cannot return. Fluids linger for a long time, combining to form intestinal tumors. Over years, they develop into solid masses, feeling soft when pressed. As masses accumulate, qi returns and fluids remain, evil qi invades, gradually becoming more severe, eventually forming cancerous growths, feeling hard when pressed." This was the earliest description of intestinal tumors. The *Inner Canon* also discusses conditions such as bloody stools, diarrhea, intestinal dysentery, and intestinal tumors. The *Fifty-Two Prescriptions* mentions "jiao bai" (roundworms). The *Lingshu Ju Bing Chapter* further states: "There are parasites and roundworms in the intestines." The pronunciation of jiao is similar to hui, which shares the same meaning as yin and hui. The *Shuowen Jiezi* says: "Long worms in the abdomen." This is the earliest description of intestinal parasites. The *Shennong Bencao Jing* first mentioned the disease name for prolapsed anus. Zhang Zhongjing from the Eastern Han Dynasty (*Treatise on Cold Damage Disorders*) was the first to invent anal suppositories and enema techniques. He invented the honey-fried guide method, where honey is refined, shaped into a rod with a pointed end, about the size of a finger, approximately one inch long, becomes hard when cooled, and is inserted into the anus, making it an excellent anal suppository for treating constipation. He also used the root of Trichosanthes and pig bile juice to irrigate the anus to relieve constipation, thus inventing the enema technique. From the records in Ge Hong's *Handbook of Prescriptions for Emergencies* (*Elbow后备急方*), it appears that at that time, there were already enema devices—"tubes". The *Treatise on Cold Damage and Miscellaneous Diseases* established principles for differential diagnosis and treatment, prescription formulation, and medication use for conditions such as diarrhea, bloody stools, constipation, anal abscesses, cold extremities, and hemorrhoids. Huangfu Mi's *Methematical Principles of Acupuncture and Moxibustion* (*Zhenjiu Jiayi Jing*) documented acupuncture and moxibustion methods for treating prolapsed anus, hemorrhoids, and dysentery. It was the first to record: "If any hemorrhoid communicates with the vagina, it is fatal." This is the earliest discussion on complications involving the vagina and urethra in anorectal diseases. Chao Yuanfang's *Discussion on the Etiology and Symptoms of All Diseases* (*Zhubing Yuanyou Lun*) (610 AD) provided a detailed list of forty types of dysentery, offering a comprehensive account of intestinal diseases and deeper insights into certain conditions. For example, after prolapsed anus: "Prolapsed anus refers to the protrusion of the anus. It is often caused by chronic dysentery leading to cold deficiency in the large intestine." Under the section on anal ulcers: "The anus is the waiting place for the large intestine. Weakness in the large intestine leads to heat stagnation at the anus, causing ulcers." Under the section on anal itching: "Anal itching is caused by weak stomachs and deficient intestines, leading to pinworms infiltrating the anus. Severe cases involve feeding on the anus, while mild cases cause slight itching. Pinworms are extremely fine and resemble snail worms." These descriptions are very specific and accurate. Among the various hemorrhoid diseases, it points out that the five types of hemorrhoids are external, internal, vascular, intestinal, and bloody hemorrhoids. Another text proposes gas hemorrhoids and wine hemorrhoids, believing that "if hemorrhoids persist untreated, they will turn into fistulas." "Chronic fistulas occur when ulcers persist untreated and become fistulas." The term "hemorrhoid-fistula" originates from this point. In terms of preventing and treating anorectal diseases, the earliest records describe the practice of "one foot stepping on the ground, one knee bent, hands embracing the calf's nose below, pulling towards the body forcefully, alternating left and right four to seven times, removing hemorrhoids, relieving fatigue, and ensuring the three-mile qi does not descend."

During the Tang Dynasty, Sun Simiao (580–682), in his works *Qianjin Yaofang* and *Qianjin Yifang*, first documented the organotherapy method using carp intestines and hedgehog skin to treat hemorrhoids. He also described diagnosing intestinal diseases and parasites based on eruptions and spots appearing on the nose, face, tongue, and lips. Wang Tao's *Waitai Miao Yao* cites Xu Renze’s discussion on hemorrhoids: "This disease has internal hemorrhoids and external hemorrhoids. Internal hemorrhoids bleed only during defecation, while externally there is no difference." This scientifically divided hemorrhoids into internal and external categories for treatment. The book also cites *Gujin Luyan* for treating urinary retention: "Boil three liters of water with three he of salt until boiling, adjust the temperature, and use a bamboo tube to irrigate the lower part, immediately achieving relief." This was the first to use a bamboo tube as an enema device for saline enemas.

From the Song, Yuan, and Ming Dynasties, China's anorectal specialty experienced significant development. First, the *Taiping Shenghui Fang* (982–992) created the cauterization method for hemorrhoids by dissolving arsenic in yellow wax, rolling it into sticks, and inserting it into the fistula orifices of hemorrhoids, thereby advancing the ligation method for hemorrhoids with: "Use spider silk to tie around the hemorrhoid nodules, and they will fall off unnoticed." The Southern Song *Wei Shi Jiachu Fang* (1220) further detailed the specific methods and processes for using the cauterization powder. From the story in the Ming *Pu Ji Fang* (1406) about Lin'an Cao Wu curing Emperor Gaozong's hemorrhoids using the Qian Jin Fang method and being promoted to the rank of observer general, it can be seen that during the Song Dynasty, there were already experts specializing in treating hemorrhoids and fistulas. In terms of diagnosis and classification, the Song Dynasty had deeper insights compared to earlier periods. For example, the *Taiping Shenghui Fang* separately discussed hemorrhoids and fistulas, pointing out: "Hemorrhoids and fistulas are caused by toxic qi from various types of hemorrhoids accumulating around the anus, forming ulcers, sometimes resembling mouse nipples or developing into nodules and perforations. After the wound fails to heal, it discharges pus and blood, causing swelling and pain in the intestines. If it persists untreated for a long time, it is called hemorrhoid fistula." This provided a relatively detailed discussion on the formation and main symptoms of anal fistulas. The Southern Song *Chuang Yang Jingyan Quanshu* (1281) further classified hemorrhoids into twenty-five types based on the five types of hemorrhoids, although seemingly overly complex, reflecting the author's meticulous and in-depth study of anal diseases. For example, the term "mother-child hemorrhoids" accurately reflects the relationship between hemorrhoidal nodules, which has been adopted by later generations.

In the Ming Dynasty, Xu Chunfu's *Gujin Yitong Daquan* (1556) cited the hanging thread method for treating anal fistulas from *Yonglei Linqian Fang*, pioneering a new path for treating anal fistulas. He said: "I suffered from this illness for seventeen years, reading numerous books and following ancient treatments, but with no effect, almost poisoned by arsenic, worrying day and night. Later, I met Li Chunshan from Jiangyou, who only used evodia root boiled thread to hang and break the large intestine, taking over seventy days to fully recover. Reflecting deeply during my recovery, I realized the truth revealed by heaven. Later, I treated several people, regardless of the number of wounds, using grass probes to insert through one hole, pulling a line tied to the outside of the colon, hanging a lead weight to achieve quick results. The medicinal thread descends daily, the intestinal muscles grow accordingly, the damaged area heals, water follows the thread flow, unpenetrated wounds heal internally within the goose tube." Modern medicine still lacks satisfactory solutions for postoperative complications like anal incontinence from high-complexity anal fistula surgeries. However, the hanging thread method avoids these issues, fully reflecting the ingenuity of Chinese physicians.

Chen Shigong's *Authentic Treatise on Surgery* (1617) comprehensively summarized the achievements of previous generations in surgery, discussing anorectal diseases under the sections of hemorrhoids and visceral toxins, proposing a relatively complete set of methods combining internal and external treatments based on differential diagnosis. His prescriptions are still widely used in clinical practice today, having a significant impact on later generations. The book developed cauterization and hanging thread methods, proposed many new internal and external prescriptions, and specifically discussed the prevention and treatment of tuberculous anal fistulas, anal diseases combined with syphilis, and arsenic poisoning. For example, it says: "There are cases of prolonged coughing due to consumption, where phlegm and fire accumulate in the anus like chestnuts. Breaking them will inevitably result in fistulas, depleting qi and blood, ultimately leading to death." This is a specific description of tuberculosis of the entire body complicated by fistulas. In the Ming Dynasty, Xue Yi's *Xue's Medical Cases* (1528) proposed that the occurrence of anal diseases is related to insufficient local circulation of qi and blood. He said: "The buttocks belong to the bladder meridian, located behind the lower abdomen, representing the yin within yin. Its path is distant, and its position is secluded. Although the sun meridian has abundant blood, the circulation of qi and blood is difficult to reach, especially rare in middle age and beyond, leading to concerns about this ailment (referring to visceral toxins, hemorrhoids, and fistulas)." This perspective aligns with modern scholars' observations based on animal studies and anatomical research, suggesting that hemorrhoids result from humans evolving to stand upright, where localized evolution lags behind, easily causing venous reflux obstruction and stagnation of blood flow, leading to the development of hemorrhoids.

Although the Qing Dynasty lacked innovation in academic terms, it still did much work in organizing literature and conducting in-depth observations. Among these, Qi Kun's *Great Compendium of Surgery* (1665) made significant contributions, stating: "Locking anus hemorrhoids refer to the anus inside and outside being tightly locked like bamboo joints, resembling sea cucumbers, causing urgency and heaviness, thin and flattened stools, constantly discharging foul-smelling water, with no treatment available." This can be considered a vivid description of anal and rectal cancer. Another statement reads: "Hooked intestine hemorrhoids refer to internal and external hemorrhoids at the anus. When torn, they produce sheep-like feces, followed by bleeding, foul odor, and severe pain." This can be considered a specific description of anal fissures. The *Complete Collection of Ancient and Modern Books Integrated* (*Yibu Quanshu*) (1723) systematically organized historical literature, collecting more than ten methods for treating hemorrhoids, including internal treatment, external treatment, cauterization, ligation, fumigation, washing, ointments, acupuncture, and guidance (as shown in the figure). The book recorded 242 internal prescriptions, 317 single and verified prescriptions, totaling 559 prescriptions, providing convenience for research work. Notably, Gao Wenjin's *Illustrated Explanations of Surgery* (1834) depicted various surgical instruments independently designed and created in China, including curved knives, hook knives, willow leaf knives, pointed scissors, small cautery irons, anal probes, and anal needles. These instruments are uniquely designed, delicate, practical, and still in use today. Zhao Lian's *Medical Door Supplement* (1883) further improved and developed the surgical methods for anal fistulas, foreign objects entering the anus, and congenital imperforate anus, reflecting new progress in anorectal surgery in China during the Qing Dynasty. From these historical materials, it is evident that China made unique contributions to the development of the anorectal discipline in ancient and medieval times, once leading the world. By the Tang and Song Dynasties, these methods had already spread to Southeast Asian countries and Persia, with disease names such as hemorrhoids and fistulas proposed by China being adopted by world medicine. Unique treatments originating from China, such as cauterization for hemorrhoids and the hanging thread method for anal fistulas, solved some difficult problems in the treatment of anorectal diseases and made significant contributions to the development of the world's anorectal discipline (see table below). Today, as long as we inherit these valuable legacies well and improve them through our own practices, we will certainly be able to make new contributions to the development of the world's anorectal discipline.

Year

Historical Evidence

Main Progress

770-221 BC

*Classic of Mountains and Seas*, *Zhuangzi*

First proposed the disease name for hemorrhoids in the world, later adopted by world medicine

*Fifty-Two Prescriptions*

Earliest records of ligation and excision methods for hemorrhoids. Proposed the naming of pinworms

*Inner Canon*

First described intestinal polyps, intestinal tumors, and the anatomy and physiology of the large intestine and anus

*Difficult Classic*

Described anal anatomy

*Shennong Bencao Jing*

Proposed the disease names for prolapsed anus and five types of hemorrhoids

25-220 AD

Zhang Zhongjing *Treatise on Cold Damage and Miscellaneous Diseases*

Invented anal suppositories (honey-fried guides) and enema techniques. Proposed the principle of differential diagnosis and treatment for anorectal diseases

251-282 AD

Huangfu Mi *Methematical Principles of Acupuncture and Moxibustion*

Described acupuncture and moxibustion methods and acupoints for treating anorectal diseases. First recorded complications involving the anus and vagina, urethra

610 AD

Chao Yuanfang *Discussion on the Etiology and Symptoms of All Diseases*

Detailed accounts of multiple anorectal diseases, proposed the disease names for hemorrhoids and fistulas, described exercises for hemorrhoids, and discussed the names of five types of hemorrhoids

581-682 AD

Sun Simiao *Qianjin Yaof