Neal Chan
Boston, Massachusetts, United States

King Louis XIV—also known as the Sun King—ruled France from 1643 to 1715. He not only expanded France’s territorial and cultural influence but solidified his status as a sovereign ruler only a half-step below a god. Through absolute control of the nobility, gentry, and landowners, he made France the dominant power on the world stage. Given Louis XIV’s outsized influence on European history, his anorectal fistula is not often mentioned in discussions of the major events of his life. And yet, his fistula spurred surgical innovation and brought surgery into the spotlight of the Scientific Revolution in Europe.¹

In January 1686, Louis XIV started to be bothered by a painful lump adjacent to his anus; an abscess was beginning to form. To twenty-first-century readers, this may seem like an immensely unpleasant but endurable illness. However, before the discovery of infectious disease and antiseptic practices, abscesses resulted in significant complications. Louis called on court physicians for treatment; this largely consisted of conservative remedies like enemas and warm compresses with barley, beans, flax, peas, and rye. Despite these measures, the abscess continued to grow and worsen, causing physicians to attempt to control the inflammation by draining the pocket of pus and filling it with toxic compounds.

This was also ineffective; by May, feces began to drain through the abscess, leading the physicians to suspect a fistula had developed between his anus and the abscess. To confirm this diagnosis, court physicians injected St. John’s wort into the fistula and noted the red liquid seep from the King’s anus, thus confirming the presence of a connection between the abscess and the anus. The head surgeon, Charles-Francois Felix de Tassy, was brought in to invent a new operation to treat the fistula. He spent six months experimenting on seventy-five volunteers to perfect his technique before attempting the operation on the most important man in Europe.²

After having practiced his operation seventy-five times, Felix de Tassy confidently operated on Louis. Considering the density of nerve endings at the external anal sphincter, the operation was undoubtedly incredibly painful for the King. The operation went as follows:

At 7:00am on November 18, Louis XIV … was placed face down on the bed … an almost three-hour-long operation ensued without anesthesia or antisepsis. To start, Félix positioned a custom-built three-pronged metal retractor deep inside the king’s anus and spread it wide … Once Félix visualized the fistula’s orifice within the anus, he used a scalpel to enlarge the fistula’s other opening on the skin. He then introduced ‘le bistoury à la Royale,’ his newly devised scythe-shaped surgical knife, through the skin and guided its curved blade along the fistulous track/tunnel, into the anus. With one adroit slice with the bistoury’s razor-sharp cutting edge, Felix divided the tissue. He inspected the opened track/tunnel and, using a scalpel and scissors, removed the calloused and necrotic matter. Félix finished by packing the wound with linen soaked in olive oil and egg white.³

The surgeon’s ingenuity and precision prevented Louis’ fistula from worsening into a possible fulminant infection. However, surgery at the time was not a well-regarded science; in fact, it was not performed by men of science at all. Through antiquity and the Middle Ages, surgery was largely seen as a last resort, often performed by barber-surgeons with no formal training. These barber-surgeons were not part of the upper class or nobility and were treated as such. Meanwhile, physicians focused primarily on diagnosis and prescribing treatments such as potions, rinses, and bloodletting. The devaluation of surgery was influenced by the legacy of Galen, the prominent Greek physician whose teachings shaped medical education for centuries. Galen emphasized theoretical medicine and internal treatments, favoring techniques like balancing bodily humors over hands-on surgical procedures. He developed standardized therapeutic strategies, such as the use of herbal emetics to induce vomiting in cases of indigestion.⁴

Meanwhile, surgery—painful, crude, and often fatal—was regarded with disdain. Infections were rampant, anesthesia was nonexistent, and anatomical understanding was limited. Surgical interventions during this period were simple and largely restricted to abscess drainage, amputations, and wound care. However, in King Louis’ time, medical remedies did little to address structural problems like fistulas. It is no surprise that Louis’ doctors were unable to help him, forcing Louis to call in a surgeon. After witnessing the King’s successful procedure, people began to ask: why didn’t physicians know how to perform something as direct and effective as a fistulotomy?

The implications of Louis XIV’s operation went beyond personal healing. His case helped elevate surgery from a disrespected trade into an academic and clinical discipline.⁵ The public began to recognize that surgeons—unlike physicians clinging to outdated methods—offered practical, anatomical solutions to real problems. Louis’ recovery from the procedure was celebrated throughout France, in sometimes unusual ways; it became briefly fashionable among French noblemen to stuff their culottes with bandages in imitation of Louis, perhaps an indication of their zealous adoration of Louis as much as a sign of the far-reaching influence of Felix’s successful procedure.⁶ Louis’ willingness to undergo such a procedure brought surgery into the public eye and gave it unprecedented legitimacy.

​​Louis was grateful for Felix’s ingenuity and raised him to the level of nobility, placing him at the level of a royal physician.⁷ Newly appreciative of the art of surgery, Louis then funded the construction of an amphitheater for the study of surgery and anatomy, which added the study of surgical sciences to the Académie des Sciences that Louis formed in 1666.⁸ This shift helped dismantle the old “craft-guild” model of surgical training. Instead of being apprenticed in informal settings, future surgeons began entering universities and medical colleges. This transformation continued under Louis XV, who formally established the Royal Academy of Surgery (Académie Royale de Chirurgie) in 1731.⁹ In the spirit of competition, the innovation in surgery that took place in France spurred a similar movement in England.¹⁰ Louis’ painful fistula and Felix’s successful operation was a steppingstone for the elevation of surgery to the level of medicine. After the procedure, French monarchs sponsored advances in surgery; what was once viewed as a practical and simple job carried out by barbers became a science studied in royal academies. During the Enlightenment, surgery took on a more evidence-based bent as surgeons recognized the importance of studying anatomy and drawing conclusions from experimental data.¹¹ Thus, although a single moment in history, Louis XIV’s fistula garnered crucial respect for surgeons and spurred the movement to study and refine surgical practice, eventually giving rise to the surgery of today.

End notes

1. Van de Laar, A. (2019). Under the Knife: A History of Surgery in 28 Remarkable Operations. John Murray Publishers LT, 285.
2. Van de Laar, A. (2019). Under the Knife: A History of Surgery in 28 Remarkable Operations. John Murray Publishers LT, 275-279.
3. Rutkow, I. (2023). Empire of the Scalpel: The History of Surgery. Scribner, 93.
4. Rutkow, I. (2023). Empire of the Scalpel: The History of Surgery. Scribner, 34-35.
5. Ibid, 97.
6. Van de Laar, A. (2019). Under the Knife: A History of Surgery in 28 Remarkable Operations. John Murray Publishers LT, 281.
7. Rutkow, I. (2023). Empire of the Scalpel: The History of Surgery. Scribner, 95
8. Schneider, D. (2021). The Invention of Surgery: A History of Modern Medicine: From the Renaissance to the Implant Revolution. Coronet, 46.
9. Rutkow, I. (2023). Empire of the Scalpel: The History of Surgery. Scribner, 96
10. Ibid, 97.
11. Ibid, 97.