Knew that injuries to the colon and small intestine were often fatal, but they did not know why and did not have the possibility to prevent the deaths. Celsus gave detailed explanations about the treatment of intestinal injuries.

Another important physician was the Greek Claudius Galen, who lived from 131 to 201 AD, who revived the ideas of Hyprocrates and other Greek philosophers

He was an important surgeon of Emperor Aurelius and a school for roman gladiators. He had much experience with injuries to the torso/abdomen. In his dissertation Galen examines the many possible operation techniques in a perforated intestine, the various methods of attaching intestinal injuries. But he believed that there was still little that could be done for injuries of the small intestine.

Emperor Marcus Aurelius (121-180AD)

In military hospitals, doctors throughout the centuries have had many challenges to deal with serious injuries. From the 14th century there were gunshot wounds because artillery began to be used (which probably began with a kind of blunderbuss, a heavy gun). Those who survived serious injuries to the abdomen had mainly their own survival urge/perseverance to thank, and not the qualifications of the doctor.

He described in 1798 in his surgical handbook a surgical approach for the construction of a colostomy. According to him, it was possible to establish a colostomy in the lumbar region without opening the peritoneum. He claimed that this approach reduced the risk of damage to the peritoneum, and hence the chance of peritonitis.

The Frenchman Amussat (1796-1855), continuing on the studies of Callisen, created in 1839 the first colostomy on the left hand side of the lumbar region. For a long time they carried out Amussat’s method, despite the disadvantages that the operation was very difficult, and the stoma was difficult to manage by the person themselves due to the high placement. In addition to this method that of Littre was also still is use. In 1856 at the meeting of the Academy of Medicine in Paris, it was decided that Littre’s method was preferable.

A stoma constructed in the lumbar region, according to Amussat’s method.
Source: the book Een kwart eeuw stomazorg in Nederland.

 

The first British surgeon who created a stoma was George Freer in 1815 who operated on a newborn baby with an imperfect anus. Then in 1817 on a 47 year old farmer with a rectal obstruction. Both patients lived only a few weeks. The farmer died after the operation because they were too zealous with laxatives and clysters though the stoma, which eventually resulted in a damaged appendix.

The second British surgeon to build a colostomy was Daniel Pring, who in 1820 operated on a certain Mrs White. He described in detail the construction of the stoma and Mrs White’s complicated recovery. It is perhaps the first report of post-operative stoma complications such as skin ulcers, prolapse and discussions of stoma devices. It appears that Mrs White felt that what seems to have been a kind of belt with a bucket on it was not as efficient as a cushion with a kind of belt for the reception of her faeces that came twice a day. The comment by Pringe in 1820 already emphasised the necessity for providing specialist stoma care and choosing the best stoma materials was very important. Pring found that the colostomy was a big advantage for Mrs White. He believed that the colostomy:

 

“Granted her a moral as well as a physical advantage because the stoma resolved the intestinal problem.
At the same time the stoma gave her a new life.”

 

Pillore and Fine had in the nineteenth century devised the method to rinse a colostomy. This method was forgotten and was re-discovered in 1917 by Lockhart Mummery (England), which published the same year the experiences of people who rinsed colostomies. The coil method was especially popular in the United States, and later came to The Netherlands.

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The History of the Ileostomy

The ileostomy is a much newer technology, which mainly came from the realisation that surgery could be an effective treatment in severe ulcerative colitis and Crohn’s disease. This surgery requires removal of part or the entire colon, which is called a colectomie. In 1940 surgeons were still uncertain about the feasibility of a colectomie because of technical difficulties of the operation and the problems of post-operative care. Around 1950, however, anaesthesia (general anaesthetic) and postoperative care improved, and a colectomie in combination with an ileostomy manifests itself.

The first recorded instance of an ileostomy was in 1879 by Baum, a German surgeon from Danzig. A temporary ileostomy was created in a patient with a malignant tumour. The patient died 9 weeks later of peritoneum inflammation from a leaky gut seam. A successful recovery after the construction of an ileostomy was reported by Maydi from Vienna in 1883.

Lauenstein (1894) created the first protruding ileostoma, which was pinched closed. This idea came originally from Partsch (1883)

At this time the ileostomy was at least 15cms long so that the faeces could drain into the collecting material (a kind of bowl) without the skin being completely destroyed.

Carl Maydl developed in 1883 a method whereby a piece of intestine was pulled outwards and temporarily attached with a rod that was placed under the intestine. In a second operation the intestine was cut, leaving two openings and the swab was removed. This created a double looped stoma, mainly used in temporary stomas.

 

An ileostomy had to be regularly stretched to prevent the opening from becoming too narrow and closing. Some doctors tried to overcome these problems by applying skin grafts to the stoma, but this had only limited success. Brooke Bryan showed in 1952 that skin grafts are not really useful, but if you turned the end of the small intestine back on itself and attached it to the skin, it prevented the closing. It now seems such a simple and logical solution, but it was a brilliant idea. We still use this technique nowadays.

 

“Most lay persons, as well as all too many physicians and surgeons, have a horror image of the constantly discharging intestinal stoma and frequently think, out of ignorance, that death is preferable to an ileostomy.”

(DR. Albery Lyons, 1952).

 

This was the thinking of many physicians and patients with a stoma until the 50’s. Until that time, this operation also had an unacceptably high number of disease and mortality cases, which was due to the critical condition of the patient through acute or prolonged periods of ulcerative colitis or Crohn’s disease. This idea would still be around today if people had not seen the benefits of a stoma. Fortunately, the safety of surgery and our capacity to care for people who have just been operated on has greatly improved for the last 50 years. While the construction of a stoma is now seen as routine and a relatively low-risk procedure, it is for many people still a difficult choice. The construction of a stoma can be a big change in your daily life and psychologically some people have difficulties. But let us be glad than we live in this time, because people with bowel disease previously had little chance of survival.

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The history of the urostomy

The first report of diverting the urine using the intestines comes from 1851, by Simon in a child with a congenital abnormality. Unfortunately the child later died. In the late 19th century and early 20th century operations using the intestines were very risky due to the lack of antibiotics in connection with peritonitis. Verhoogen and De Grauwe designed in 1909 a replacement bladder from the appendix creating an appendixostomy which was comparable with the urine stoma from the 80’s.

In 1911 the American Robert Coffey (1869-1933) invented a technique in which the ureters were placed in the rectum. Hereby the urine and faeces were removed together. One disadvantage was that there was constantly diarrhoea. However, this technique was often used at that time. In the Netherlands Professor Dr. J A Korteweg used this technique in a somewhat modified form for the first time. The difference was that he placed the ureters in the sigmoid just above the rectum, rather than in the rectum itself as Coffey did.

In the time afterwards Zaayer and Schoemaker described for the first time a technique in which a reservoir was made of the small intestine and created a urinary stoma. The operation technique which these surgeons applied would only become popular in 1950, after Bricker applied the same method in the United States. Schoemaker created in 1909 for the first time in history a urinary stoma for an 18 year old woman with a shrivelled bladder due to tuberculoses. Professor Zaayer announced in 1910 he had carried out 2 operations in which he had built a urinary stoma.

At the left Professor Dr. J.H. Zaayer, 1876-1932. Surgeon, private teacher in the surgical urology department of the State university of Leiden in the period of 1909-1914. He was named primary teacher in the general surgery in Leiden in 1914. At the right Dr. J.Schoemaker, 1871-1940. First working for a while in Nijmegen, later for years at the Zuidwal te’s-Gravenhage hospital as an employee.

Source: the book Een kwart eeuw stomazorg in Nederland.


Then around the same time Ferris and Oedel discovered that in 80% of patients with a Coffey stoma acid poisoning occurred because the urine flowed back into the body. Because of this they chose the urine stoma rather than the Coffey stoma.

In 1950 an American urologist, Eugene Bricker, developed a urinary stoma, which we now know under the name “Bricker procedure”. A reservoir is created from a small piece (10-15cm) of the small intestine to take the urine from the ureters. The stoma exit at the abdominal wall is also made from that piece of intestine. Since the ‘50’s Bricker procedure is the most commonly used technique for a urinary stoma.

The first attempts to create a continent urinary stoma were done in 1888 by Tizzoni and Foggi. In 1895 Mauclaire used the rectum as a reservoir for urine. These 2 findings were essential for the development of the modern continent stoma: Kock conceived the principle of using a piece of intestine to create a low-pressure reservoir, and Lapides made catheterisation popular. By using these two techniques a variety of continent urinary stomas were created. A relatively new variation on the continent urinary stoma is the Indiana pouch. This operation technique was developed by Mr Rowland and was first applied in 1987 in the U.S. state of Indiana. To create the inner reservoir the last piece of the small and the first piece of the large intestines are used. At the transition between these two are a natural valve which prevents leakage from the reservoir.

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The history of the continent pouch and stoma

In an attempt to make the wearing of stoma devices unnecessary, the Swedish surgeon Nils Kock from Gothenburg developed, after years of animal-experimental research in the 70’s, a continent stoma.

An internal reservoir in the abdominal cavity was made of strips of small intestine attached together. The patient had to empty the tank with a catheter through an opening in the abdominal wall. Leakage remained a problem but in 1972 he solved that problem with a kind of flap in the stoma output design, which appeared to be a leakage proof mechanism.

The Kock’s pouch ensured that some people had a choice, but it was still a big difference to going to the toilet normally. In 1933 Berliner Rudolph Nissen had a patient from whom he had to remove the colon. He then attached the small intestine to the anus so that the patient did not need a stoma. Unfortunately this caused diarrhoea meaning that many people were not satisfied with this technique. In an attempt to reduce the diarrhoea in 1971 Peck created a reservoir (pouch) of the last piece of the small intestine. Herewith the storage function of the rectum was simulated, which resolved the problem with diarrhoea. In the years 1979 to 1981 Dr.Lens taught the technique of Professor Kock in the Netherlands. By mid 1991, he has constructed 100 continent ileostomas and built 25 continent urinary stomas. Complications occurred in 10% of the cases.

In 1978 Parks and Nichols from England described the construction of a pouch, as the first choice in ulcerative colitis, making an ileostoma unnecessary. Parks described the pouch which has now been replaced by the J-Pouch and W-Pouch. These are easier to create and they have a larger storage capacity. Many surgeons have developed their own technique which is known as the “pouch alphabet” such as the J, S, W and H. Meanwhile, many more techniques have been developed for people with bowel disease to help as much as possible, such as the INRA, a type of intestinal mucus transplantation of the rectum. There is also the dynamic plastic gracilis, where a new sphincter is made of a muscle taken from the thigh. Who knows what else the doctors will invent in the future!

Different types of pouches, including the B-pouch, introduced by Professor Brummelkamp.

Source: the book Een kwart eeuw stomazorg in Nederland.

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The first self-help groups and patients organisations

The first self-help group for stoma patients was created in 1949. 5 people with a stoma met in the Valley Forge General hospital in Phoenixville, Pennsylvania. In 1954 the first group of stoma wearers was launched in St.Paul (Massachusetts), United States. From these and other initiatives in the U.S. a national movement grew. Finally in 1962 the American Association of Ostomy Patients was established: the United Ostomy Association. There was already in 1951 in Denmark a patient’s organisation formed: Copa Danish Ostomy Association. In 1956 England followed with the creation of the National Ileostomy Association. On 16th April, 1966 in the Netherlands five stoma patients, a surgeon, an urologist and a district nurse decided to create an organisation for stoma patients, called the Harry Bacon Club, now known as the Dutch Ostomy Association.

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In this subject “The history of the stoma” was a co-used source: Ostomy Association
and the book "Een kwart eeuw stomazorg in Nederland".

 

The history of the stoma material

Picture source: the book Baas op eigen buik

 

In the past, much of the inventiveness was left to the stoma wearer as they were often sent home after surgery without any form of collection equipment.

Picture source: the book Een kwart eeuw stomazorg in Nederland 

 

The history of stoma material is not so very old. Modern collection materials only appeared in the 70’s. Before that time, the quality of the collection material sometimes left a lot to be desired. In addition to collection material of rubber, which was already introduced in Germany in 1935, people had to make do with metal, glass or porcelain bowls.

You can see below examples of this type of collection material. Although receptacles of glass were easy to clean, you would not want to consider the consequences if the glass broke. The collection containers were sometimes made with an inflatable rubber edge in order to fit the abdomen. The rubber bags were sealed with an elastic collar to a ring on the abdomen or glued hermetically with cement to the abdomen.

Picture source: the book  Baas op eigen buik

picture source: Combicare nieuws

 

This collection material was very dirty, smelt and was very easily visible under clothing. They did not seal well, meaning that at that time many people suffered from leaks. The materials also caused allergies and skin irritations. Then just before the second world war the first plastics were discovered, it became easier to use lighter materials, which could be thrown away after a single usage rather than having to be washed clean every time.

Overview of rubber-collecting material
Picture source: the book Een kwart eeuw stomazorg in Nederland 

In the 60’s, there were only a few manufacturers that made collecting bags. They were often themselves stoma wearers. Because they knew where the problems were to be found, they decided to develop stoma material themselves. Thus arose the first stoma brands such as Nu-Hope and Marlen. Although the quality still left a lot to be desired (they were cut down plastic sandwich bags from Hema and Vroom & Dreesman which were confined between a plastic ball or ring on a belt, as you can see below), nevertheless it was still a huge improvement over the previous collection material.

Picture source: the book Baas op eigen buik

Picture source: Ostomates.org


Picture source: the book Een kwart eeuw stomazorg in Nederland 

It was the producer Coloplast from Denmark who developed the first disposable plastic bags, this was back in 1954. Due to her sister received a stoma, the Danish nurse Elise Sorensen searched for a better collection material. In 1954 they came up with the idea of using a one-piece disposable ostomy bag. This idea was developed with the help of engineer Aage Louis Hansen from Coloplast. Elise was in contact with him because his wife was a fellow nurse of hers. They were very simple bags with a zinc oxide adhesive, actually the same white waxy layer that previously was under any ordinary plaster. Although many people could not use it (the skin became damaged), it was a huge improvement. It was no longer visible under clothing, and airtight. However, the transparent bag had no filter and rustled terribly.

Hollister (United States) came up in 1960 with collecting bags with Karaya-gum. This is a natural product that is extracted form the bark of a tree species and had strong adhesive and skin protective properties. Initially it melted rapidly under the influence of moisture and heat, but that problem was later resolved. This product had an unprecedented popularity, and is still used in stoma care.

Brand: Hollister

Only in the 70’s were pouches and base plates invented that had a clear improvement for the stoma wearer. It wasn’t until the end of the 70’s that a good two-piece system became available. The composition of the bags was improved so that no undesirable odours came through.

Picture source: left the book Baas op eigen buik, right Ostomates.org

 

By chance in 1970, there came a turning point in stoma care. The Squibb Company introduced in Australia that year the hydrocolloid base (also known as cheese paste) through which the stoma wearer no longer had allergic reactions of the skin. Hydrocolloid was originally on the market as a small patch meant for dentists and oral surgeons to apply as sticky connection for gums. It was only later discovered by chance that this material could also work well on the skin around a stoma. Dr E.S.R Hughes, an Australian surgeon, had seen this adhesive connection at this dentist’s and had the bright idea of applying it the skin around the stoma, and with success. This discovery marked a turning point in stoma care, but also for the Squibb Company. The product for dentists and oral surgeons was almost transferred into other hands, with just the contract needing to be signed. Until Dr. Hughes called them… The slabs were ‘Stomahesive’ and went on the market with a 10cm squared block (without a flange at that time). At that time a slab cost 10 guilders a piece and then the stoma bag still had to be added. From the Squibb company a separate organisation was established for the development of products designed for stoma care: Convatec.

Brand: ConvaTec

In 1977 Convatec came up with system II, renamed in 1978 to Combihesive system. The stomahesive paste was equipped with a kind of Tupperware ring to which an ostomy bag could be attached. This system became a great success.

Picture source: the book Baas op eigen buik

 

There was increasing attention paid to perfecting the product: the flexibility, the adhesive strength and the moisture absorbing qualities of the base plate. The collection bags were also improved: no more crackling, better filters for venting and for the ileostomy a bottom opening. At the end of the 60’s stoma devices were added to health insurance. Dansac, a manufacturer that was formed because of dissatisfaction with the refusal to respond to the needs of users by a worker from one of the largest suppliers of stoma materials in the world, began in 1971, was the first to bring out skin-coloured film and the non-woven back (late 70’s) onto the market.

Picture source: Ostomates.org

 

Of course the developments do not stop. There is now also a convex base-plate for deeper lying stomas (of which Marlen was the first manufacturer), toilet flushable stoma bags, two-piece systems with an adhesive system instead of the click system, systems for people with difficulty handling or visibility problems, double filter bags, a non woven layer to the stoma bag, all kinds of different forms of an Velcro closures for the ileo instead of a clip and a malleable base-plate. Coloplast also introduced the Conseal Plug, which can be used by people with a colostomy. Curious what is soon coming onto the market…

 

Sources used for the subject material: Combicare nieuws and the book Baas op eigen buik.

 

 

We have done our best to express everything as correctly as possible, but of course it could be that certain information is not completely accurate. If you have an addition for this page, we would be grateful if you would let us know.