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28 Cataldo
Figure 10 Brown ileostomy. (From Brown JY. The value of complete physio-
logical rest of the large bowel in the treatment of certain ulcerative and obstructive
lesions of this organ. Surg Gynecol Obstet 16:613, 1913. By permission of Surgery,
Gynecology, and Obstetrics.)
the right lower quadrant. The use of skin grafting around the stoma to pre-
vent serositis gained some brief popularity [57] (Fig. 11). However, sub-
sequent stenosis of the grafted skin led to ileostomy obstruction and dys-
function, and therefore the idea was abandoned. No significant advances
occurred until the 1950s, when Crile and Turnbull [58] of the Cleveland
Clinic described ileostomy dysfunction and Bryan Brooke of the University
of Birmingham in London described the now famous Brooke ileostomy [59].
In a 1952 paper entitled “Management of the Ileostomy and Its Com-
plications,” Brooke (Fig. 12) described the ileostomy that remains in use
today. One sentence, “A more simple device is to evaginate the ileal end at
the time of operation and suture the mucosa to the skin; no complications
have occurred from this” [59], accompanied by a single illustration, changed
the ileostomy from a chronically inflamed and ulcerative stoma, frequently
associated with dysfunction, to the functional “rosebud” we know today. In
his article Brooke described the classic technique of primary eversion and
maturation of the ileostomy, which eliminated ileoserositis and stomal
dysfunction.
However, Crile and Turnbull were the first to fully understand and
describe ileostomy dysfunction. Ileostomy dysfunction consisted of partial
stomal obstruction manifest by watery diarrhea, abdominal pain and disten-
tion, and dehydration. They attributed this obstruction to serositis of the
“naked” ileal serosa now exposed to ileal effluent [58]. The serositis led
History of Stomas 29
Figure 11 Skin-grafted ileostomy as described by Lester Dragstedt. (From Drag-
stedt LR, Dack GM, Kirsner JB. Chronic ulcerative colitis: A Summary of evidence
implicating Bacterium neocrophorum as an etiologic agent. Ann Surg 114:655,
1941.)
Figure 12 Bryan N. Brooke. (Courtesy W. C. McGarity, M.D.)
30 Cataldo
to a rigid stoma without peristalsis, which caused a functional intestinal
obstruction and resolved only when the ileostomy had matured. Maturation,
as described by Crile and Turnbull, was the natural process of eversion of
the ileal mucosa to reach the abdominal wall. For the treatment of ileos-
tomy dysfunction, they recommended catheter drainage of the ileostomy as
having good results.
Unaware of Brooke’s work in London, Crile in 1952 suggested “mu-
cosal grafted ileostomy” to prevent ileostomy dysfunction. He described
removing the distal 3–4 cm of serosa and muscle from the ileostomy and
folding over and suturing the redundant mucosa to the abdominal skin in
order to “mature” the ileostomy at the time of surgery [58]. Through the
work of Brooke, Turnbull, and Crile, we now have an easily matured ileos-
tomy rarely associated with dysfunction.
CONTINENT STOMAS
Even when functioning well, the Brooke ileostomy drained constantly and
required the full-time use of a pouch. Many patients were disturbed by this
feature, which led Nils Kock (Fig. 13) to begin work on a continent ileos-
tomy. In 1969 Kock [59] described the creation of an ileal reservoir drained
by a tiny stoma brought through the rectus muscle. This method, however,
did not lead to complete continence. Therefore in 1972 he added a nipple
value of intussuscepted ileum. Dozois et al. [60], at the Mayo Clinic, fol-
Figure 13 Nils G. Kock. (Courtesy W. C. McGarity, M.D.)
History of Stomas 31
lowed a series of patients and found that most were fully continent, their
stomas requiring only intermittent catheter drainage. Initially, valve spillage
rates were high, but they were later reduced to less than 20%.
More recently, Barnett has developed a new continent ileostomy. A
reservoir of ileum similar to the Kock pouch is created; to this is added a
collar of functioning ileum. This collar functions similarly to a Nissen
wrap, generating higher pressures (and therefore preventing leakage) when
the intestine is distended with fluid. Early results with this method were
encouraging. However, since the advent of J, S, and W pouches combined
with ileoanal anastomosis, continent ileostomies are rarely required.
In 1974, Drs. Feustel and Henning in Germany developed a “colos-
tomy plug,” the Erlangen magnetic ring. This involved implanting a mag-
netic ring subcutaneously around the stoma neck. Following recovery from
surgery a magnetic plug was inserted into the stoma opening, thereby main-
taining continence. Removing the plug led to convenient stoma emptying.
Unfortunately, complications with this system outweighed benefits, and it
was therefore abandoned.
ENTEROSTOMAL THERAPY
In the 1950s Brooke in England and Turnbull and Crile at the Cleveland
Clinic changed the ileostomy from a procedure of last resort to a well-
tolerated solution for the treatment of ulcerative colitis. As the Brooke
ileostomy gained popularity, the number of patients with long-term ileosto-
mies increased dramatically. These patients required specialized care that
needed to be continued long after hospital discharge. Because of this need,
the field of enterostomal therapy developed. Rupert Turnbull had a special
interest in intestinal stomas and realized the need for trained professionals
dedicated to stoma care.
In 1954 Turnbull operated on a young mother of three, Normal Gill
(Fig. 14), for ulcerative colitis, leaving her with a permanent ileostomy
[61]. Since Gill’s mother had a colostomy, Gill was well aware of the
problems of living with a stoma. During her own recovery period she be-
came interested in helping other ostomy patients. When Gill returned to her
home in Akron, Ohio, she began to volunteer her services to individuals
with stomas in her local area. In 1958 Turnbull hired Gill as an ostomy
technician. Together they later coined the term enterostomal therapist.As
the word spread, other hospitals became interested in sending personnel for
specialized training with Turnbull and Gill.
In 1961 Turnbull opened the first school of enterostomal therapy be-
cause of increasing demand for trained enterostomal therapists. Only people
with stomas were accepted as students, but many were also trained nurses.
Joy Richey, a registered nurse from California, was the first graduate of the
32 Cataldo
Figure 14 Rupert Turnbull and Norma Gill. (Courtesy W. C. McGarity, M.D.)
school in 1961. Similar schools opened in Grand Rapids, Michigan (Fergu-
son-Droste-Ferguson Hospital) and in Harrisburg, Pennsylvania.
At the United Ostomy Association (UOA) national meeting in Phoe-
nix, Arizona, in 1968, the American Association of Enterostomal Therapists
(AAET) was born. The first national meeting of the AAET was held at the
Cleveland Clinic in 1969. Edith Lenneberg, who had had an ileostomy and
was instrumental in the development of the UOA, was elected president,
and Norma Gill was named as secretary. In 1969 the name of the organiza-
tion was changed to the North American Association of Enterostomal Ther-
apists (NAAET) and in 1971 to the International Association of Enterosto-
mal Therapists (IAET).
In 1976, Annelise Eidner, a nurse working in the proctology depart-
ment at the University Hospital Erlangen, Germany, attended the Enterosto-
mal Therapists Nursing Education Program (ETNEP) at the Rupert Turn-
bull School of Enterostomal Therapy. She attended at the suggestion of
Dr. Thorlolph Hager, who had just returned from training visit with Dr.
Turnbull.
The training of nurse Eidner led to the origin of an enterostomal ther-
apy program in Germany, the first in Europe. Patients throughout Germany
were referred for combined specialized proctological and stomal care. In
addition, advanced ostomy management systems became available in Ger-
many for the first time.
In 1977 Anneliesse Eidner and Dr. Hager established 2-week courses
in enterostomal therapy. Participants attended from all over Europe, as this
was the first time specialized enteral stomal therapy training was available
in continental Europe.
History of Stomas 33
In 1978 a more extensive 8-week course began at the Heinrich-Heine
University of Du
¨
sseldorf, led by Professor Kievelitz and ET nurse Nortrud
Schienzilorz. This eventually lead to the founding of the first enteral stomal
therapy association in Germany, the German Association of Enterostomal
Therapists.*
OSTOMY MANAGEMENT SYSTEMS
Although spontaneous stomas had occurred for centuries, the first mention
of an ostomy pouching device was not until 1795. In France, Dageusceau
created an inguinal colostomy in a 57-year-old farmer who had impaled
himself on the stake of a wheat cart. For the following 24 years, the farmer
“collected his feces in a small leather pouch” [10]. In 1824 Martland of
Blackburn, England, created an ostomy device from a self-adjusting truss
containing a tin box in the center for the collection of feces [62]. However,
the advances in stoma surgery were not accompanied by advances in stoma
management. As late as the early twentieth century, patients were using
Model-T inner tubes, tunafish cans, and bread bags with talcum powder,
cornstarch, or aluminum gel to prevent leakage. Vanilla and peppermint
extracts, mouthwash, perfume, parsley, and bicarbonate of soda were used
to diminish odors [61].
Despite the fact that colostomy irrigation had been reported in the
early 1800s, it did not gain popularity until the 1920s. In 1924 Dudley
Smith, a California surgeon, and John Greer, who worked for a surgical
supply company, developed the Colostogator [63]. This device, which con-
sisted of a metal cup held around the colostomy by means of a belt, was
the first commercially available irrigation system. Attached to the cup was
a long rubber sleeve that ran into a bucket placed at the patient’s feet. The
colostomy was irrigated by a rubber catheter placed through a hole in the
sleeve. With this device patients were able to irrigate once every 24 hr,
between which they wore a “simple belt of plastic webbing...[with] sev-
eral pieces of absorbent paper” [61]. The John R. Greer Company also
developed a device for people who did not wish to irrigate. It consisted of
a canvas bag lined with several thicknesses of toilet paper and a single
sheet of oiled paper attached to a stoma ring in a belt.
In 1944 Henry Koenig of Chicago, who had undergone an ileostomy,
was encouraged by his surgeon to create a pouching device. The revolution-
ary result was a rubber bag attached to a circular faceplate that was fixed
*Personal communication: Alexander Fleischmann, RN, ET and Klaus Matzel,
MD, Ph.D., Surgical Department, University Hospital Erlangen, Germany.
34 Cataldo
to the skin with rubber-based cement (Fig. 15). This instrument was the
first pouching device that could be drained while still in place. Eventually,
Koenig recruited H.W. Rutzen, who had also had an ileostomy, to market
his invention. The H.W. Rutzen & Son Co. remains in business today.
Another person who had an ostomy, Murle Perry, at the urging of his
surgeon, developed a line of stoma management devices. The Perry Model
51, which was introduced in 1951, consisted of a plastic pouch with absor-
bent papers combined with a close-fitting rubber gasket designed to keep
irritating stoma output away from the surrounding skin [61].
Despite these advances, skin irritation continued to be a significant
problem, particularly for ileostomy patients. Just as had happened with Al-
exander Graham Bell and the telephone many years earlier, an accidental
discovery led to a great advance in stoma surgery by Rupert Turnbull.
Figure 15 Rutzen bag, 1944. (Courtesy H. W. Rutzen & Sons, Inc., Chicago,
IL.)
History of Stomas 35
In 1952, he [Turnbull] was cleaning out the desk of his former chief,
Tom Jones, and accidentally knocked over a small canister of Jones
dental powder into spilled coffee on the desk. The karaya immediately
absorbed the coffee and stuck to Turnbull’s wet hand. He thought the
powder might also absorb ileostomy effluent and protect the skin from
excoriating effects of the liquid stool. [61]
Thus the use of karaya was introduced. Karaya powder (and later wafers)
was a major advance in peristomal skin care.
Another dental product was found to be useful in stoma care. In 1964
Squibb (Princeton, NJ) developed Orahesive paste and powder for use as a
paste and dental fixative. E.S.R. Hughes, an Australian surgeon, realized
the usefulness of this product in stoma care and conveyed his experiences
to Turnbull, a close personal friend. The result was the Stomahesive wafer,
introduced in 1972, a product that was particularly useful for patients with
watery ileal effluent (which diluted the karaya) or those with an allergy to
karaya. Recently, stoma adhesive wafers have been combined with a flange
apparatus (Sur-Fit; ConvaTec, Princeton, NJ) to create a two-piece ostomy
management system. This system allows for easy stoma access since the
pouches can be removed and the faceplate can be left intact. In addition,
the pouches can be washed and reused.
CONCLUSION
Over the past 200 years intestinal stomas have developed from “last
chance,” lifesaving efforts to well-planned, technically refined artificial
anuses. Colostomies can be “trained” to function once every 24 to 48 hr.
Ileostomies and urostomies can be made “continent” if the patient so de-
sires. Although stomas formerly were foul-smelling and offensive, today
they are rarely noticeable, even to the patient’s closest contacts.
These advances in stoma management are the result of an increased
understanding of intestinal physiology, refinements in surgical techniques,
advances in ostomy management products, and the development of enteros-
tomal therapy. It is hoped that the overview of these developments provided
by this chapter will add perspective to the information found in the follow-
ing chapters.
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