Arius of Alexandria (256–336 ad): the first reported mortality from rectal prolapse

Abstract

Dear Editor: Rectal prolapse (or procidentia) comprises of intussusception of the rectum through the anal canal and has affected mankind for millennia. Its first description can be dated to the Ebers Papyrus of Ancient Egypt (approximately 1500 BC); however, for the first time in the medical literature, I note the earliest description of mortality from this disorder. Arius of Alexandria (256–336 AD) was North African theologian well-known for disagreeing with the consensus opinion of the Nicene Creed set at the First Ecumenical Council at Nicea. This led to theopolitical disfavor and exile. On the occasion of his pardon and return to Byzantium, he is reported as having died from a defecatory experience that his detractors considered as “divine retribution” for his “daring criminalities.” Socrates Scholasticus details his final moments: “...a terror arising from the remorse of conscience-seized Arius, and with the terror a violent relaxation of the bowels: he therefore enquired whether there was a convenient place near.... Soon after a faintness came over him, and together with the evacuations his bowels protruded, followed by a copious hemorrhage, and the descent of the smaller intestines; moreover, portions of his spleen and liver were brought off in the effusion of blood, so that he almost immediately died.” While there may be some inaccuracy due to observer bias and lack of anatomical training of ancient sources, the events of Arius’ death are clearly identified as rectal prolapse (bowels protruded) and both defecation and hemorrhage that accompany strangulation in such cases. In cases where the prolapsed rectum becomes edematous, rectal blood supply can become compromised such that life-threatening gut ischemia can ensue as a result of strangulation. Emergency surgical management for such cases includes laparotomy and internal reduction where possible or perineal resection. The causes of rectal prolapse include age, injury, neuronal damage, chronic obstructive airway disease, cystic fibrosis, and infections including intestinal parasites such as the helminth whipworm (Trichuris trichiura). Arius inhabited a geographical area that has been reported to demonstrate endemic helminthic disease, which would therefore be prominent differential for the etiology of prolapse in tis case. Arius of Alexandria’s case reinforces the long-standing pathology of rectal prolapse on mankind. It highlights the importance of vigilance for strangulation and the awareness of mortality associated with this disorder.