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Hemorrhoids Throughout History—A Historical Perspective
Hemorrhoids Throughout History—A Historical Perspective Janindra Warusavitarne, and Robin K.S. Phillips
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hroughout written history reference is made to hemorrhoids and their management, the earliest recorded being from the Egyptians, who wrote about painful swellings in the anus and treated them with, according to the Beatty Papyrus (12th and 13th century B.C.), potions containing honey, myrrh, flour, ibex fat, and sweet beer.1 The word hemorrhoid (from the Greek haem meaning blood and rhoos meaning flow) was probably first coined by Hippocrates (460-377 B.C.), who wrote about them in some depth.1 He described their cautery and how pain aided their definition during surgery: “You will recognize the haemorrhoids without difficulty, for they project on the inside of the gut like dark colored grapes, and when the anus is forced out they spurt blood. When the cautery is applied, the patient’s head and hands should be held so that he may not stir, but he himself should cry out, for this will make the rectum project more.” Hippocrates also described excising and binding hemorrhoids by transfixing them with a needle attached to very thick woolen thread. The Romans made few contributions to advance the treatment of hemorrhoids,2 their methods largely being those used by the Egyptians and Greeks. During the Byzantine era, the 7th century surgeon Paul Aegina described surgery for hemorrhoids.2 Like many others before him, a key part of the operation appeared to be in preparing the patient in such a way as to attain maximum protrusion of the hemorrhoidal complex. His methods for attaining protrusion were based on using frequent clysters (enemas) as an anal irritant to initiate evacuation of the rectum and cause protrusion of the hemorrhoids rather than relying on pain as a stimulant for protrusion as described by Hippocrates. However, his method for ligature of the hemorrhoids did not differ from that described by Hippocrates.
From the St. Marks Hospital, Harrow, United Kingdom. Address reprint requests to Professor Robin Phillips, St. Marks’s Hospital, Northwick Park, Watford Road, Harrow, Middlesex, HA1 3UJ, United Kingdom. E-mail: [email protected].
140
1043-1489/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.scrs.2007.07.002
There is little written on hemorrhoid management during the era of the master surgeons (13th to 15th century A.D.), or subsequent Barber surgeons (15th to 17th century A.D.). At this time it was common to associate diseases and their sufferers with patron saints. The patron saint of gardeners, Saint Fiacre (a 6th century Irish monk), was also made the patron saint of hemorrhoids.1
Anatomy and Etiology There has been debate and discussion about the etiology of hemorrhoids since Hippocratic times. Hippocrates believed that if bile or phlegm entered the veins of the rectum, the blood would be heated and the engorged inside of the gut would swell out and also become bruised by feces, causing bleeding.2 The varicose vein theory was a popular theory after Hippocrates, strongly advocated by the likes of Morgagni (1749) and Boerhaave, who stated that hemorrhoids are attributed to the upright posture of man.3 Verneuil (1855) suggested that hemorrhoids were caused at points of obstruction to venous drainage and suggested that anal dilation would be beneficial in their treatment.3 By the 19th century the vascular hyperplasia theory was more popular, piles being thought to result from erectile tissue metaplasia, the anal canal itself being thought to be formed by a ring of erectile tissue. Herbert Allingham (Fig 1) at St. Marks Hospital divided piles into venous, arterial, and capillary based on their appearance clinically and argued that this classification was superior to any anatomical one.4 Much later in 1975 Thomson described the concept of the anal canal having three discontinuous series of cushions, hemorrhoidal prolapse occurring as a result of the lining of the anal canal sliding downwards.3 More recently, there has been the suggestion that degeneration of the connective tissue framework holding up these cushions precedes the sliding that causes their prolapse.5 Frederick Salmon, founder of St. Marks Hospital, believed that the superior hemorrhoidal artery supplied the internal hemorrhoids, while the inferior hemorrhoidal vein, which was connected to the portal vein, was responsible for external hemorrhoids. This anatomical distinction formed the basis for his operation (to be discussed later). Campbell Milligan
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(Fig 2), born an Australian, went on to describe the anatomical basis of the sphincter complex, detailing the subcutaneous external sphincter and the longitudinal muscle of the anus.6 Milligan favored ligating the hemorrhoid onto the longitudinal muscle to avoid the later strictures sometimes associated with Salmon’s operation. However, Parks, who later became President of the Royal College of Surgeons of England, described the subcutaneous external sphincter as a trivial muscle and asserted that the internal anal sphincter forms the inner muscle wall of the anal canal. He believed that the superior hemorrhoidal artery should be ligated above the ano rectal ring to reduce recurrence.7
Stretching of the Sphincters Stretching the sphincters to treat hemorrhoids was first described by Verneuil and was widely practiced in Paris.8 It was advocated as a palliative treatment in those without a great deal of prolapse. The two-finger careful dilation technique was later replaced by rectal dilators invented by Percy Lockhart-Mummery.8,9 The Manx dilators (Fig 3) designed later were used more extensively in the United States as they permitted easy introduction and prevented the dilator from slipping out.8 By the 1930s this technique had lost favor because of the high recurrence rate.9 In 1969 Lord resurrected this procedure on the premise that it was permanent obstruction of the anal canal that caused venous engorgement and that stretching the fibrotic bands (which he termed the pecten band) in the anal sphincter muscle would reverse this.10 He Figure 2 Campbell Milligan.
advised that his procedure was safe and only two patients had fecal incontinence after it, both being blamed on poor technique. We now know this operation can fragment the internal anal sphincter, leading to irreparable soiling.11
Injection Sclerotherapy Andrew Edmunds (1824-1904) provided the first record of injection sclerotherapy. In his address to the Chicago Medical Society in 1879 he stated that he corresponded with many itinerant doctors, many of whom were quacks who practiced injection sclerotherapy to treat hemorrhoids.12 This treat-
Figure 1 Herbert W.M. Allingham.
Figure 3 Manx dilators.
J. Warusavitarne and R.K.S. Phillips
142 ment was thought to be an invention of a traveling charlatan in Illinois (1871), but Anderson suggested that in 1869 a Mr. Morgan, who was a surgeon to the Mercers’ Hospital in Dublin, injected a solution of iron persulfate into hemorrhoids.13 Edmunds was able to gather information on well over 3000 cases of injection sclerotherapy. Of these, nine were said to have died as a result of the treatment. Among the other complications there were 5 cases of dangerous hemorrhage, 10 cases of abscess formation, and 8 cases of embolism to the liver. At least 25% of patients suffered severe pain. The most commonly used substances were carbolic acid and olive oil. After analyzing the data, he concluded that injection sclerotherapy was a useful treatment in some cases of hemorrhoids but was not superior to ligature. He also stated that the hemorrhoids should be injected away from the verge of the anus to reduce pain. In 1888 F. Swinford Edwards (Fig 4), surgeon at St. Marks Hospital, wrote an account of his experience of injecting piles.13 Several American surgeons visiting at the time described a Dr. Kelsey of New York, a well-known contemporary rectal surgeon who injected hemorrhoids with carbolic acid, and these accounts resulted in Edwards trialing the treatment. His paper was of 38 patients, all males, as he was in charge of the male outpatients at St. Marks. He stressed that the treatment was only for internal hemorrhoids; of his 38 patients, only one relapsed. In the 1920s it was well established that a dilute form of carbolic acid, usually mixed with glycerin and distilled water,
Figure 4 Swinford Edwards.
Figure 5 Syringe for injection of haemorrhoids. (Color version of figure is available online.)
was associated with fewer complications than concentrated carbolic acid.9 Specialized syringes were needed as the solution was too viscous to be injected down normal hypodermic syringes (Fig 5).14 By the 1930s injection of piles was common practice but phenol in glycerin or almond oil was deemed a more acceptable sclerosing agent than carbolic acid as there was less slough associated with this treatment.
Ligation Ligation appears to be one of the earliest forms of treatment for hemorrhoids, the Ancient Egyptians using a cotton ligature. Surprisingly, this method was more painful than cautery. In the 19th century there was a widely held belief that internal hemorrhoids were arterial and should be ligated, while external hemorrhoids were venous and should be excised.15 In the mid 1800s Frederick Salmon considered that hemorrhoids were just prolapsed columns of Morgagni. He criticized the established view of ligation alone and went on to devise an operation to ligate hemorrhoids with excision of the skin component.15,16 In his account of this operation, as described by Allingham, the pile was drawn down with a sharp hook and dissected off the submucosa and muscular layer (Fig 6). The pile was then ligated with a waxed silk suture, but it was not removed to obviate the risk of torrential bleeding. As the hemorrhoid was ligated well above the sensate skin of the anus, there was less pain so this became the favored method of surgery in the mid 1800s. Blaisdell from Pasadena, California, was the first to describe office ligation of hemorrhoids.17 He described a special instrument with a loaded tie through which the internal hemorrhoid was pulled through and ligated. This technique was modified by Barron in 1963 and became the mainstay of office management to this day. One of the complications of the Blaisdell method of ligation was that the ligature, which was usually silk, did not stay on for long periods and when it did fall off there was often delayed bleeding. Barron replaced the silk ligature with rubber bands “which provide a much longer period of hemostasis by compression which persists until sloughing of the hemorrhoid is complete.”18 He reported the results of rubber banding in 150 patients: all but seven were treated in the outpatient/office setting and only four suffered bleeding afterward.18 Meta-analysis confirms this to be the most effective of the outpatient treatments, particularly where prolapse is concerned.19
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Figure 6 Frederick Salmons operation.
Surgery for Hemorrhoids By the 20th century there were three fundamental operations described for hemorrhoids with modifications and variations over the years to minimize complications: ligation, cautery, and excision. Ligation has been described above. It was the popular treatment method in the 19th and early 20th century because the risk of bleeding was significantly reduced when the hemorrhoid was not excised. Cautery, advocated by Hippocrates, went out of favor because of the risk of secondary hemorrhage. It then returned, popularized by a Mr. Cusack of Dublin, and was then introduced to London by Mr. Henry Lee.9 A special hemorrhoidal clamp was placed on the pile with special care taken not to include any skin. Once done, a cautery iron or Paquelin blade was used to char the projecting pile. Lockhart-Mummery advised his readers to avoid using a very hot cautery iron to reduce the risk of bleeding. He stated this method should only be used where there was sepsis or great sloughing as other methods were more appropriate in most other circumstances. By the mid 20th century this method of treatment had fallen into disrepute but it has more recently made a resurgence with the advent of newer cautery devices such as the harmonic scalpel and ligasure. Excision of hemorrhoids is by far the most widely described modern technique. In 1882 Whitehead wrote, “there is no disorder of the human economy more frequent than hemorrhoids and there is probably no operation in surgery where procrastination in their removal is more bitterly regretted.”20 He based his operation on the principle that it served to remove the diseased dilated and tortuous vessels and adjacent tissue which rest on the internal sphincter and act as obstructions to defecation. In this version of his operation he
described the hemorrhoids being mapped into four unequal lobes, which were then serially dissected to the healthy mucous membrane of the rectum. When all the lobes were removed, the mucous membrane of the rectum was secure to the denuded border at the anal verge by fine silk sutures.20 He went on to discuss the possibility of stricture formation and stated that he was careful to leave small strips of longitudinal mucosa attached to skin, but in severe cases where the entire mucosa had to be denuded, he felt that the risk of stricture formation was very low. Lockhart-Mummery wrote on the Whitehead operation9: “I have always been an uncompromising opponent of this operation as the right treatment for ordinary cases of internal piles; and I have never been able to see any reason for preferring this operation to the other and simpler methods. Whitehead’s original contention that recurrence was impossible after this operation, has long ago proved to be fallacious.” While Salmon’s operation was widely practiced in the 19th and early 20th century, one of its drawbacks was that the extensive raw areas left at the end of it created scarring and fibrous stenosis of the anal canal. In one of the earliest records of follow-up, Graham Anderson presented the results of 300 cases of hemorrhoids at St. Marks Hospital.21 In this series, 150 ligature procedures, 100 Whitehead procedures, and 50 clamp and cautery procedures were performed. He compared all aspects of aftereffects including pain, the use of urinary catheters, the return of sphincteric control, contraction of the anal canal, hemorrhage, recurrence, hospital stay, and wound healing. Of note he mentioned that 40% of patients who had ligature operations had some contracture which required digital dilation during the third and fourth
J. Warusavitarne and R.K.S. Phillips
144 weeks after surgery and 5% of cases required instrumental dilation for severe contractions. In the Whitehead operation, 56% of patients required digital dilation, while 8% required instrumental dilation. He went on to say that no case of the Whitehead operation healed by first intention and the amount of contraction depended on the amount of retraction from the anal canal.21 Miles (1919) suggested making a scissor cut through the perianal skin rather than the mucocutaneous junction. The mucosal part of the hemorrhoid was then sutured to the skin incision, leaving no denuded area.22 Lockhart-Mummery made a modification to the Whitehead operation which he called a compromise between the ligature operation and excision. In his operation a continuous stitch was placed on the mucosa as the hemorrhoid was being dissected off and the stitch was tied at the apex of the pile. There were several modifications of this technique at the time. Earle’s operation involved clamping the pile, excising it, and running a suture under the clamp.9 Laplace’s operation involved suturing the pile from the rectal mucosa downwards as it was dissected off.9 Lockhart-Mummery’s main argument for performing his operation over the others described at the time was reduced length of stay. His records at the time showed that the inpatient stay for his ligature and excision operation was at least half that of the Whitehead operation (11 days versus 21 days for male patients).9 In 1932 Gabriel wrote that the method of catgut ligature by transfixion was the only operation for hemorrhoids worth describing as this was the only one that did not have the limitations of the other described operations.23 He also stated that the greatest possible credit was due to his senior colleague, Mr. Percy Lockhart-Mummery, for his insistence on the importance of carrying out careful antiseptic
toilet on the rectum. If this was performed appropriately, he claimed, the list of complications reduced significantly to only pain, urinary retention, external tags, and formation of fissures. In 1937, Milligan and Morgan, both at St. Mark’s Hospital, wrote a seminal paper on anal canal anatomy and the operative treatment of hemorrhoids.6 In their description a “V”shaped incision was made extending from the anocutaneous junction to the outer border of the distended external hemorrhoidal plexus. The dissection was then performed away from the subcutaneous external sphincter until the internal sphincter was seen. At the end of the dissection the pedicle contained rectal mucosa, submucosa with the branch of the superior hemorrhoidal artery and vein, and a part of the internal sphincter. This pedicle was then ligated and, because it included a part of the internal sphincter, they argued that there was less upward traction of the pedicle and a reduced risk of fibrosis (Fig 7).6 Bacon in 1943 argued that anal stenosis was a result of removing too much anal skin rather than rectal mucosa and proposed leaving an island of skin between the hemorrhoidal areas removed.24 His main operation for hemorrhoids was a modification of the Earle’s operation where he placed a continuous mattress suture under the clamp rather than over it, as described by Earle. He also went on to say that, although the clamp and cautery operation was considered obsolete, excellent results were associated with its use. One of the biggest criticisms of the Milligan-Morgan operation for hemorrhoids was that there was undue pain caused by including internal sphincter fibers in the ligature. John Goligher, initially working at St. Mark’s Hospital and then later in Leeds, identified that in this operation the pile pedicle
Figure 7 Milligan Morgan operation.
Hemorrhoids throughout history included the submucosal longitudinal fibers at the lower end of the internal sphincter.22 Parks argued that the considerable pain experienced by patients after the Milligan-Morgan operation was due to leaving a sensitive area of stratified epithelium and some of the internal sphincter in the ligated pedicle. Based on this, Parks proposed a submucosal hemorrhoidectomy with a high ligation. Parks’ operation involved dissection of the hemorrhoidal plexus off the rectal mucosa and the internal sphincter.7 In 50 cases he described that the wounds healed within 2 weeks and there was very little postoperative pain.7 However the recurrence rate was high at 12%, but Parks argued that these were due to secondary hemorrhoids that were only noticed by diligent examination by proctoscopy not being done in the immediate postoperative period. Goligher’s comment on the Park’s operation is worthy of mention: “Actually stricture formation is very rare with the latter (Milligan-Morgan) technique, and, so far as that complication is concerned, Parks’ method has no advantage to offer. The main argument therefore in favor of this operation is that it is said to produce very much less pain than do the alternative methods. It is however notoriously difficult to assess a subjective manifestation such as pain and to compare it in any 2 patients. I have yet to be convinced that Parks’ technique enjoys a decisive superiority in this respect. I have been impressed too by the intricacy of the operation in 25 cases in which I have used it, for it converts haemorrhoidectomy from a 10minute operation into one lasting nearly an hour.”22 Goligher’s preferred method was virtually identical to the Milligan-Morgan operation.22 A randomized controlled trial comparing the Parks’ submucosal hemorrhoidectomy with the ligation excision method showed that there was no difference in the complications between the two operations, but in particular, there was no difference in pain between patients having either operation.25 In 1959 Ferguson described the closed hemorrhoidectomy, which is now the favored technique in the United States.26 In this technique, the dissection is performed in a manner similar to the Milligan-Morgan technique, albeit conserving mucosa to avoid stenosis, but when the pedicle is ligated, the suture is not cut. The margins of the wound are drawn upwards into the anal canal by one or more locking stitches and secured to the pedicle. The remainder of the wound is then closed. It has been claimed that the wounds heal with less discomfort and reduced postoperative bleeding, although randomized controlled trials subsequently performed have not supported this contention.27
Recent Treatments for Hemorrhoids Doppler-guided ligation of hemorrhoidal arteries was first described in 1995 and is based on the principle that the hemorrhoidal branches of the superior rectal artery can be
145 identified by a proctoscope which has an incorporated Doppler probe.28 Once identified, a figure-of-eight suture is placed around the artery and the procedure is repeated until there are no further Doppler signals. There is a concern that the theory behind this operation (that there are arterial vessels feeding hemorrhoids that are their ultimate cause) contradicts Thomson’s conclusion that hemorrhoids are natural “cushions” in the anal canal that prolapse when the supporting structures degenerate, unrelated to any arterial blood supply. Stapled hemorrhoidopexy was developed by Longo with the intention of dealing with hemorrhoidal prolapse without excision.29 The main advantage of this procedure is said to be reduced pain, confirmed by most studies, but its longer term efficacy and durability are less certain. In addition, it is also associated with other complications such as anastomotic dehiscence, rectal perforation, and rectovaginal fistula. The premise behind the operation has shifted with time, with an initial claim that it interrupted the feeding blood supply, much as with hemorrhoidal artery ligation, to a “hemorrhoidopexy” hypothesis, that prolapsing but otherwise normal cushions are returned to their natural situation in the anal canal.
Conclusions There are records of hemorrhoids dating back to the dawn of time. The treatment of hemorrhoids has evolved over many years as the understanding of their anatomy and etiology has progressed. Excisional techniques today achieve cure, can be done as day case procedures, are probably no different whether performed open or closed, but on average result in a 2-week period off work.30,31 Newer techniques such as the stapled operation and hemorrhoidal artery ligation are definitely less painful, but doubts remain as to their longer term efficacy and to new side effects.
References 1. Graney MJ, Graney CM: Colorectal surgery from antiguity to the modern era. Dis Colon Rectum 23:432-41, 1980 2. Ellesmore S, Windsor AJC: Surgical history of haemorrhoids, in Mann CV (ed): Surgical treatment of haemorrhoids (ed 1). London, SpringerVerlag, 2005 3. Thompson WHF: The nature of haemorrhoids. Br J Surg 62:542-552, 1975 4. Allingham H: Piles: the importance of recognising the varieties as determining the selection of treatment. Trans Med Soc Londvi:73-80, 1893 5. Hardy A, Chan CLH, Cohen CRG: The surgical management of haemorrhoids—a review. Dig Surg 22:26-33, 2005 6. Anonymous: Classic articles in colonic and rectal surgery. Edward Thomas Campbell Milligan 1886-1972. Surgical anatomy of the anal canal, and the operative treatment of haemorrhoids. Dis Colon Rectum 28:620-8, 1985 7. Parks AG: The Surgical treatment of haemorrhoids. Br J Surg XLIII:337351, 1956 8. Schwarz GG, Crocker JC: Diagnosis and non-operative treatment of the diseases of the colon and rectum (ed 1). London, HK Lewis and Co., Ltd., 1937 9. Lockhart-Mummery P: Diseases of the rectum and colon (ed 1). London, Bailliere, Tindall and Cox, 1923
146 10. Lord PH: Anal dilation treatment, in Mann CV (ed): Surgical treatment of haemorrhoids (ed 1). London, Springer-Verlag, 2005 11. Speakman CT, Burnett SJ, Kamm MA, et al: Sphincter injury after anal dilatation demonstrated by anal endosonography. Br J Surg 78:142930, 1991 12. Andrews E: Edmund Andrews 1824-1904. The treatment of hemorrhoids by injection. Dis Colon Rectum 31:331-2, 1988 13. Anderson GH: The “Injection” method for the treatment of haemorrhoids. Practitioner cxiii:399-409, 1924 14. McAusland S: The cure of haemorrhoids, varicose veins and ulceration, and allied conditions by modern methods of injection and bandaging (ed 1). London, John Bale, Sons & Danielsson, Ltd., 1933 15. Granshaw L: St. Mark’s Hospital, London: a social history of a specialised hospital. (ed 1). London, King’s Fund Publishing Office, 1985 16. Allingham W: A description of Salmon’s operation for internal haemorrhoids, in Allingham W (ed): Diseases of the rectum (ed 5). London, Churchill, 1888, pp 143-8 17. Blaisdell PC: Prevention of massive haemorrhage secondary to haemorrhoidectomy. Surg Gynaecol Obstetr 485-488, 1958 18. Barron J: Office ligation of haemorrhoids. Dis Colon Rectum 6:109113, 1963 19. MacRae HM, McLeod RS: Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum 38:687-94, 1995 20. Corman ML: Classic articles in colonic and rectal surgery. Walter Whitehead 1840-1913: the surgical treatment of haemorrhoids. Dis Colon Rectum 23:125-8, 1980 21. Anderson GH: The after-results of the operative treatment of haemorrhoids: a study of three hundred cases. Br Med J 1276-9, 1909
J. Warusavitarne and R.K.S. Phillips 22. Goligher JC: Surgery of the anus, rectum and colon (ed 1). London, Cassell & Co., Ltd., 1961 23. Gabriel WB: The principles and practice of rectal surgery (ed 1). London, HK Lewis and Co., Ltd., 1932 24. Bacon HE: Essentials of proctology (ed 1). Philadelphia, JB Lippincott Co., 1943 25. Roe AM, Bartolo DC, Vellacott KD, et al: Submucosal versus ligation excision haemorrhoidectomy: a comparison of anal sensation, anal sphincter manometry and postoperative pain and function. Br J Surg 74:948-51, 1987 26. Ferguson DJ, Heaton JR: Closed haemorrhoidectomy. Dis Colon Rectum 2:176-9, 1959 27. Cheetham MJ, Phillips RKS: Evidence-based practice in haemorrhoidectomy. Colorectal Dis 3:126-34, 2001 28. Morinaga K, Hacuda K, Ikeda T: A novel therapy for internal haemorrhoids: ligation of the haemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler flowmeter. Am J Gastroenterol 90:610-3, 1995 29. Longo A: Treatment of haemorrhoids disease by reduction of mucosa and haemorrhoidal prolapse with a circular suturing device: a new procedure. Proceedings of the 6th World Congress of Endoscopic Surgery. Rome, 1998 30. Carapeti EA, Kamm MA, McDonald PJ, et al: Randomized trial of open versus closed day-case haemorrhoidectomy [see comment]. Br J Surg 86:612-3, 1999 31. Carapeti EA, Kamm MA, McDonald PJ, et al: Double-blind randomised controlled trial of effect of metronidazole on pain after day-case haemorrhoidectomy. Lancet 351:169-72, 1998
T
hroughout written history reference is made to hemorrhoids and their management, the earliest recorded being from the Egyptians, who wrote about painful swellings in the anus and treated them with, according to the Beatty Papyrus (12th and 13th century B.C.), potions containing honey, myrrh, flour, ibex fat, and sweet beer.1 The word hemorrhoid (from the Greek haem meaning blood and rhoos meaning flow) was probably first coined by Hippocrates (460-377 B.C.), who wrote about them in some depth.1 He described their cautery and how pain aided their definition during surgery: “You will recognize the haemorrhoids without difficulty, for they project on the inside of the gut like dark colored grapes, and when the anus is forced out they spurt blood. When the cautery is applied, the patient’s head and hands should be held so that he may not stir, but he himself should cry out, for this will make the rectum project more.” Hippocrates also described excising and binding hemorrhoids by transfixing them with a needle attached to very thick woolen thread. The Romans made few contributions to advance the treatment of hemorrhoids,2 their methods largely being those used by the Egyptians and Greeks. During the Byzantine era, the 7th century surgeon Paul Aegina described surgery for hemorrhoids.2 Like many others before him, a key part of the operation appeared to be in preparing the patient in such a way as to attain maximum protrusion of the hemorrhoidal complex. His methods for attaining protrusion were based on using frequent clysters (enemas) as an anal irritant to initiate evacuation of the rectum and cause protrusion of the hemorrhoids rather than relying on pain as a stimulant for protrusion as described by Hippocrates. However, his method for ligature of the hemorrhoids did not differ from that described by Hippocrates.
From the St. Marks Hospital, Harrow, United Kingdom. Address reprint requests to Professor Robin Phillips, St. Marks’s Hospital, Northwick Park, Watford Road, Harrow, Middlesex, HA1 3UJ, United Kingdom. E-mail: [email protected].
140
1043-1489/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.scrs.2007.07.002
There is little written on hemorrhoid management during the era of the master surgeons (13th to 15th century A.D.), or subsequent Barber surgeons (15th to 17th century A.D.). At this time it was common to associate diseases and their sufferers with patron saints. The patron saint of gardeners, Saint Fiacre (a 6th century Irish monk), was also made the patron saint of hemorrhoids.1
Anatomy and Etiology There has been debate and discussion about the etiology of hemorrhoids since Hippocratic times. Hippocrates believed that if bile or phlegm entered the veins of the rectum, the blood would be heated and the engorged inside of the gut would swell out and also become bruised by feces, causing bleeding.2 The varicose vein theory was a popular theory after Hippocrates, strongly advocated by the likes of Morgagni (1749) and Boerhaave, who stated that hemorrhoids are attributed to the upright posture of man.3 Verneuil (1855) suggested that hemorrhoids were caused at points of obstruction to venous drainage and suggested that anal dilation would be beneficial in their treatment.3 By the 19th century the vascular hyperplasia theory was more popular, piles being thought to result from erectile tissue metaplasia, the anal canal itself being thought to be formed by a ring of erectile tissue. Herbert Allingham (Fig 1) at St. Marks Hospital divided piles into venous, arterial, and capillary based on their appearance clinically and argued that this classification was superior to any anatomical one.4 Much later in 1975 Thomson described the concept of the anal canal having three discontinuous series of cushions, hemorrhoidal prolapse occurring as a result of the lining of the anal canal sliding downwards.3 More recently, there has been the suggestion that degeneration of the connective tissue framework holding up these cushions precedes the sliding that causes their prolapse.5 Frederick Salmon, founder of St. Marks Hospital, believed that the superior hemorrhoidal artery supplied the internal hemorrhoids, while the inferior hemorrhoidal vein, which was connected to the portal vein, was responsible for external hemorrhoids. This anatomical distinction formed the basis for his operation (to be discussed later). Campbell Milligan
Hemorrhoids throughout history
141
(Fig 2), born an Australian, went on to describe the anatomical basis of the sphincter complex, detailing the subcutaneous external sphincter and the longitudinal muscle of the anus.6 Milligan favored ligating the hemorrhoid onto the longitudinal muscle to avoid the later strictures sometimes associated with Salmon’s operation. However, Parks, who later became President of the Royal College of Surgeons of England, described the subcutaneous external sphincter as a trivial muscle and asserted that the internal anal sphincter forms the inner muscle wall of the anal canal. He believed that the superior hemorrhoidal artery should be ligated above the ano rectal ring to reduce recurrence.7
Stretching of the Sphincters Stretching the sphincters to treat hemorrhoids was first described by Verneuil and was widely practiced in Paris.8 It was advocated as a palliative treatment in those without a great deal of prolapse. The two-finger careful dilation technique was later replaced by rectal dilators invented by Percy Lockhart-Mummery.8,9 The Manx dilators (Fig 3) designed later were used more extensively in the United States as they permitted easy introduction and prevented the dilator from slipping out.8 By the 1930s this technique had lost favor because of the high recurrence rate.9 In 1969 Lord resurrected this procedure on the premise that it was permanent obstruction of the anal canal that caused venous engorgement and that stretching the fibrotic bands (which he termed the pecten band) in the anal sphincter muscle would reverse this.10 He Figure 2 Campbell Milligan.
advised that his procedure was safe and only two patients had fecal incontinence after it, both being blamed on poor technique. We now know this operation can fragment the internal anal sphincter, leading to irreparable soiling.11
Injection Sclerotherapy Andrew Edmunds (1824-1904) provided the first record of injection sclerotherapy. In his address to the Chicago Medical Society in 1879 he stated that he corresponded with many itinerant doctors, many of whom were quacks who practiced injection sclerotherapy to treat hemorrhoids.12 This treat-
Figure 1 Herbert W.M. Allingham.
Figure 3 Manx dilators.
J. Warusavitarne and R.K.S. Phillips
142 ment was thought to be an invention of a traveling charlatan in Illinois (1871), but Anderson suggested that in 1869 a Mr. Morgan, who was a surgeon to the Mercers’ Hospital in Dublin, injected a solution of iron persulfate into hemorrhoids.13 Edmunds was able to gather information on well over 3000 cases of injection sclerotherapy. Of these, nine were said to have died as a result of the treatment. Among the other complications there were 5 cases of dangerous hemorrhage, 10 cases of abscess formation, and 8 cases of embolism to the liver. At least 25% of patients suffered severe pain. The most commonly used substances were carbolic acid and olive oil. After analyzing the data, he concluded that injection sclerotherapy was a useful treatment in some cases of hemorrhoids but was not superior to ligature. He also stated that the hemorrhoids should be injected away from the verge of the anus to reduce pain. In 1888 F. Swinford Edwards (Fig 4), surgeon at St. Marks Hospital, wrote an account of his experience of injecting piles.13 Several American surgeons visiting at the time described a Dr. Kelsey of New York, a well-known contemporary rectal surgeon who injected hemorrhoids with carbolic acid, and these accounts resulted in Edwards trialing the treatment. His paper was of 38 patients, all males, as he was in charge of the male outpatients at St. Marks. He stressed that the treatment was only for internal hemorrhoids; of his 38 patients, only one relapsed. In the 1920s it was well established that a dilute form of carbolic acid, usually mixed with glycerin and distilled water,
Figure 4 Swinford Edwards.
Figure 5 Syringe for injection of haemorrhoids. (Color version of figure is available online.)
was associated with fewer complications than concentrated carbolic acid.9 Specialized syringes were needed as the solution was too viscous to be injected down normal hypodermic syringes (Fig 5).14 By the 1930s injection of piles was common practice but phenol in glycerin or almond oil was deemed a more acceptable sclerosing agent than carbolic acid as there was less slough associated with this treatment.
Ligation Ligation appears to be one of the earliest forms of treatment for hemorrhoids, the Ancient Egyptians using a cotton ligature. Surprisingly, this method was more painful than cautery. In the 19th century there was a widely held belief that internal hemorrhoids were arterial and should be ligated, while external hemorrhoids were venous and should be excised.15 In the mid 1800s Frederick Salmon considered that hemorrhoids were just prolapsed columns of Morgagni. He criticized the established view of ligation alone and went on to devise an operation to ligate hemorrhoids with excision of the skin component.15,16 In his account of this operation, as described by Allingham, the pile was drawn down with a sharp hook and dissected off the submucosa and muscular layer (Fig 6). The pile was then ligated with a waxed silk suture, but it was not removed to obviate the risk of torrential bleeding. As the hemorrhoid was ligated well above the sensate skin of the anus, there was less pain so this became the favored method of surgery in the mid 1800s. Blaisdell from Pasadena, California, was the first to describe office ligation of hemorrhoids.17 He described a special instrument with a loaded tie through which the internal hemorrhoid was pulled through and ligated. This technique was modified by Barron in 1963 and became the mainstay of office management to this day. One of the complications of the Blaisdell method of ligation was that the ligature, which was usually silk, did not stay on for long periods and when it did fall off there was often delayed bleeding. Barron replaced the silk ligature with rubber bands “which provide a much longer period of hemostasis by compression which persists until sloughing of the hemorrhoid is complete.”18 He reported the results of rubber banding in 150 patients: all but seven were treated in the outpatient/office setting and only four suffered bleeding afterward.18 Meta-analysis confirms this to be the most effective of the outpatient treatments, particularly where prolapse is concerned.19
Hemorrhoids throughout history
143
Figure 6 Frederick Salmons operation.
Surgery for Hemorrhoids By the 20th century there were three fundamental operations described for hemorrhoids with modifications and variations over the years to minimize complications: ligation, cautery, and excision. Ligation has been described above. It was the popular treatment method in the 19th and early 20th century because the risk of bleeding was significantly reduced when the hemorrhoid was not excised. Cautery, advocated by Hippocrates, went out of favor because of the risk of secondary hemorrhage. It then returned, popularized by a Mr. Cusack of Dublin, and was then introduced to London by Mr. Henry Lee.9 A special hemorrhoidal clamp was placed on the pile with special care taken not to include any skin. Once done, a cautery iron or Paquelin blade was used to char the projecting pile. Lockhart-Mummery advised his readers to avoid using a very hot cautery iron to reduce the risk of bleeding. He stated this method should only be used where there was sepsis or great sloughing as other methods were more appropriate in most other circumstances. By the mid 20th century this method of treatment had fallen into disrepute but it has more recently made a resurgence with the advent of newer cautery devices such as the harmonic scalpel and ligasure. Excision of hemorrhoids is by far the most widely described modern technique. In 1882 Whitehead wrote, “there is no disorder of the human economy more frequent than hemorrhoids and there is probably no operation in surgery where procrastination in their removal is more bitterly regretted.”20 He based his operation on the principle that it served to remove the diseased dilated and tortuous vessels and adjacent tissue which rest on the internal sphincter and act as obstructions to defecation. In this version of his operation he
described the hemorrhoids being mapped into four unequal lobes, which were then serially dissected to the healthy mucous membrane of the rectum. When all the lobes were removed, the mucous membrane of the rectum was secure to the denuded border at the anal verge by fine silk sutures.20 He went on to discuss the possibility of stricture formation and stated that he was careful to leave small strips of longitudinal mucosa attached to skin, but in severe cases where the entire mucosa had to be denuded, he felt that the risk of stricture formation was very low. Lockhart-Mummery wrote on the Whitehead operation9: “I have always been an uncompromising opponent of this operation as the right treatment for ordinary cases of internal piles; and I have never been able to see any reason for preferring this operation to the other and simpler methods. Whitehead’s original contention that recurrence was impossible after this operation, has long ago proved to be fallacious.” While Salmon’s operation was widely practiced in the 19th and early 20th century, one of its drawbacks was that the extensive raw areas left at the end of it created scarring and fibrous stenosis of the anal canal. In one of the earliest records of follow-up, Graham Anderson presented the results of 300 cases of hemorrhoids at St. Marks Hospital.21 In this series, 150 ligature procedures, 100 Whitehead procedures, and 50 clamp and cautery procedures were performed. He compared all aspects of aftereffects including pain, the use of urinary catheters, the return of sphincteric control, contraction of the anal canal, hemorrhage, recurrence, hospital stay, and wound healing. Of note he mentioned that 40% of patients who had ligature operations had some contracture which required digital dilation during the third and fourth
J. Warusavitarne and R.K.S. Phillips
144 weeks after surgery and 5% of cases required instrumental dilation for severe contractions. In the Whitehead operation, 56% of patients required digital dilation, while 8% required instrumental dilation. He went on to say that no case of the Whitehead operation healed by first intention and the amount of contraction depended on the amount of retraction from the anal canal.21 Miles (1919) suggested making a scissor cut through the perianal skin rather than the mucocutaneous junction. The mucosal part of the hemorrhoid was then sutured to the skin incision, leaving no denuded area.22 Lockhart-Mummery made a modification to the Whitehead operation which he called a compromise between the ligature operation and excision. In his operation a continuous stitch was placed on the mucosa as the hemorrhoid was being dissected off and the stitch was tied at the apex of the pile. There were several modifications of this technique at the time. Earle’s operation involved clamping the pile, excising it, and running a suture under the clamp.9 Laplace’s operation involved suturing the pile from the rectal mucosa downwards as it was dissected off.9 Lockhart-Mummery’s main argument for performing his operation over the others described at the time was reduced length of stay. His records at the time showed that the inpatient stay for his ligature and excision operation was at least half that of the Whitehead operation (11 days versus 21 days for male patients).9 In 1932 Gabriel wrote that the method of catgut ligature by transfixion was the only operation for hemorrhoids worth describing as this was the only one that did not have the limitations of the other described operations.23 He also stated that the greatest possible credit was due to his senior colleague, Mr. Percy Lockhart-Mummery, for his insistence on the importance of carrying out careful antiseptic
toilet on the rectum. If this was performed appropriately, he claimed, the list of complications reduced significantly to only pain, urinary retention, external tags, and formation of fissures. In 1937, Milligan and Morgan, both at St. Mark’s Hospital, wrote a seminal paper on anal canal anatomy and the operative treatment of hemorrhoids.6 In their description a “V”shaped incision was made extending from the anocutaneous junction to the outer border of the distended external hemorrhoidal plexus. The dissection was then performed away from the subcutaneous external sphincter until the internal sphincter was seen. At the end of the dissection the pedicle contained rectal mucosa, submucosa with the branch of the superior hemorrhoidal artery and vein, and a part of the internal sphincter. This pedicle was then ligated and, because it included a part of the internal sphincter, they argued that there was less upward traction of the pedicle and a reduced risk of fibrosis (Fig 7).6 Bacon in 1943 argued that anal stenosis was a result of removing too much anal skin rather than rectal mucosa and proposed leaving an island of skin between the hemorrhoidal areas removed.24 His main operation for hemorrhoids was a modification of the Earle’s operation where he placed a continuous mattress suture under the clamp rather than over it, as described by Earle. He also went on to say that, although the clamp and cautery operation was considered obsolete, excellent results were associated with its use. One of the biggest criticisms of the Milligan-Morgan operation for hemorrhoids was that there was undue pain caused by including internal sphincter fibers in the ligature. John Goligher, initially working at St. Mark’s Hospital and then later in Leeds, identified that in this operation the pile pedicle
Figure 7 Milligan Morgan operation.
Hemorrhoids throughout history included the submucosal longitudinal fibers at the lower end of the internal sphincter.22 Parks argued that the considerable pain experienced by patients after the Milligan-Morgan operation was due to leaving a sensitive area of stratified epithelium and some of the internal sphincter in the ligated pedicle. Based on this, Parks proposed a submucosal hemorrhoidectomy with a high ligation. Parks’ operation involved dissection of the hemorrhoidal plexus off the rectal mucosa and the internal sphincter.7 In 50 cases he described that the wounds healed within 2 weeks and there was very little postoperative pain.7 However the recurrence rate was high at 12%, but Parks argued that these were due to secondary hemorrhoids that were only noticed by diligent examination by proctoscopy not being done in the immediate postoperative period. Goligher’s comment on the Park’s operation is worthy of mention: “Actually stricture formation is very rare with the latter (Milligan-Morgan) technique, and, so far as that complication is concerned, Parks’ method has no advantage to offer. The main argument therefore in favor of this operation is that it is said to produce very much less pain than do the alternative methods. It is however notoriously difficult to assess a subjective manifestation such as pain and to compare it in any 2 patients. I have yet to be convinced that Parks’ technique enjoys a decisive superiority in this respect. I have been impressed too by the intricacy of the operation in 25 cases in which I have used it, for it converts haemorrhoidectomy from a 10minute operation into one lasting nearly an hour.”22 Goligher’s preferred method was virtually identical to the Milligan-Morgan operation.22 A randomized controlled trial comparing the Parks’ submucosal hemorrhoidectomy with the ligation excision method showed that there was no difference in the complications between the two operations, but in particular, there was no difference in pain between patients having either operation.25 In 1959 Ferguson described the closed hemorrhoidectomy, which is now the favored technique in the United States.26 In this technique, the dissection is performed in a manner similar to the Milligan-Morgan technique, albeit conserving mucosa to avoid stenosis, but when the pedicle is ligated, the suture is not cut. The margins of the wound are drawn upwards into the anal canal by one or more locking stitches and secured to the pedicle. The remainder of the wound is then closed. It has been claimed that the wounds heal with less discomfort and reduced postoperative bleeding, although randomized controlled trials subsequently performed have not supported this contention.27
Recent Treatments for Hemorrhoids Doppler-guided ligation of hemorrhoidal arteries was first described in 1995 and is based on the principle that the hemorrhoidal branches of the superior rectal artery can be
145 identified by a proctoscope which has an incorporated Doppler probe.28 Once identified, a figure-of-eight suture is placed around the artery and the procedure is repeated until there are no further Doppler signals. There is a concern that the theory behind this operation (that there are arterial vessels feeding hemorrhoids that are their ultimate cause) contradicts Thomson’s conclusion that hemorrhoids are natural “cushions” in the anal canal that prolapse when the supporting structures degenerate, unrelated to any arterial blood supply. Stapled hemorrhoidopexy was developed by Longo with the intention of dealing with hemorrhoidal prolapse without excision.29 The main advantage of this procedure is said to be reduced pain, confirmed by most studies, but its longer term efficacy and durability are less certain. In addition, it is also associated with other complications such as anastomotic dehiscence, rectal perforation, and rectovaginal fistula. The premise behind the operation has shifted with time, with an initial claim that it interrupted the feeding blood supply, much as with hemorrhoidal artery ligation, to a “hemorrhoidopexy” hypothesis, that prolapsing but otherwise normal cushions are returned to their natural situation in the anal canal.
Conclusions There are records of hemorrhoids dating back to the dawn of time. The treatment of hemorrhoids has evolved over many years as the understanding of their anatomy and etiology has progressed. Excisional techniques today achieve cure, can be done as day case procedures, are probably no different whether performed open or closed, but on average result in a 2-week period off work.30,31 Newer techniques such as the stapled operation and hemorrhoidal artery ligation are definitely less painful, but doubts remain as to their longer term efficacy and to new side effects.
References 1. Graney MJ, Graney CM: Colorectal surgery from antiguity to the modern era. Dis Colon Rectum 23:432-41, 1980 2. Ellesmore S, Windsor AJC: Surgical history of haemorrhoids, in Mann CV (ed): Surgical treatment of haemorrhoids (ed 1). London, SpringerVerlag, 2005 3. Thompson WHF: The nature of haemorrhoids. Br J Surg 62:542-552, 1975 4. Allingham H: Piles: the importance of recognising the varieties as determining the selection of treatment. Trans Med Soc Londvi:73-80, 1893 5. Hardy A, Chan CLH, Cohen CRG: The surgical management of haemorrhoids—a review. Dig Surg 22:26-33, 2005 6. Anonymous: Classic articles in colonic and rectal surgery. Edward Thomas Campbell Milligan 1886-1972. Surgical anatomy of the anal canal, and the operative treatment of haemorrhoids. Dis Colon Rectum 28:620-8, 1985 7. Parks AG: The Surgical treatment of haemorrhoids. Br J Surg XLIII:337351, 1956 8. Schwarz GG, Crocker JC: Diagnosis and non-operative treatment of the diseases of the colon and rectum (ed 1). London, HK Lewis and Co., Ltd., 1937 9. Lockhart-Mummery P: Diseases of the rectum and colon (ed 1). London, Bailliere, Tindall and Cox, 1923
146 10. Lord PH: Anal dilation treatment, in Mann CV (ed): Surgical treatment of haemorrhoids (ed 1). London, Springer-Verlag, 2005 11. Speakman CT, Burnett SJ, Kamm MA, et al: Sphincter injury after anal dilatation demonstrated by anal endosonography. Br J Surg 78:142930, 1991 12. Andrews E: Edmund Andrews 1824-1904. The treatment of hemorrhoids by injection. Dis Colon Rectum 31:331-2, 1988 13. Anderson GH: The “Injection” method for the treatment of haemorrhoids. Practitioner cxiii:399-409, 1924 14. McAusland S: The cure of haemorrhoids, varicose veins and ulceration, and allied conditions by modern methods of injection and bandaging (ed 1). London, John Bale, Sons & Danielsson, Ltd., 1933 15. Granshaw L: St. Mark’s Hospital, London: a social history of a specialised hospital. (ed 1). London, King’s Fund Publishing Office, 1985 16. Allingham W: A description of Salmon’s operation for internal haemorrhoids, in Allingham W (ed): Diseases of the rectum (ed 5). London, Churchill, 1888, pp 143-8 17. Blaisdell PC: Prevention of massive haemorrhage secondary to haemorrhoidectomy. Surg Gynaecol Obstetr 485-488, 1958 18. Barron J: Office ligation of haemorrhoids. Dis Colon Rectum 6:109113, 1963 19. MacRae HM, McLeod RS: Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum 38:687-94, 1995 20. Corman ML: Classic articles in colonic and rectal surgery. Walter Whitehead 1840-1913: the surgical treatment of haemorrhoids. Dis Colon Rectum 23:125-8, 1980 21. Anderson GH: The after-results of the operative treatment of haemorrhoids: a study of three hundred cases. Br Med J 1276-9, 1909
J. Warusavitarne and R.K.S. Phillips 22. Goligher JC: Surgery of the anus, rectum and colon (ed 1). London, Cassell & Co., Ltd., 1961 23. Gabriel WB: The principles and practice of rectal surgery (ed 1). London, HK Lewis and Co., Ltd., 1932 24. Bacon HE: Essentials of proctology (ed 1). Philadelphia, JB Lippincott Co., 1943 25. Roe AM, Bartolo DC, Vellacott KD, et al: Submucosal versus ligation excision haemorrhoidectomy: a comparison of anal sensation, anal sphincter manometry and postoperative pain and function. Br J Surg 74:948-51, 1987 26. Ferguson DJ, Heaton JR: Closed haemorrhoidectomy. Dis Colon Rectum 2:176-9, 1959 27. Cheetham MJ, Phillips RKS: Evidence-based practice in haemorrhoidectomy. Colorectal Dis 3:126-34, 2001 28. Morinaga K, Hacuda K, Ikeda T: A novel therapy for internal haemorrhoids: ligation of the haemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler flowmeter. Am J Gastroenterol 90:610-3, 1995 29. Longo A: Treatment of haemorrhoids disease by reduction of mucosa and haemorrhoidal prolapse with a circular suturing device: a new procedure. Proceedings of the 6th World Congress of Endoscopic Surgery. Rome, 1998 30. Carapeti EA, Kamm MA, McDonald PJ, et al: Randomized trial of open versus closed day-case haemorrhoidectomy [see comment]. Br J Surg 86:612-3, 1999 31. Carapeti EA, Kamm MA, McDonald PJ, et al: Double-blind randomised controlled trial of effect of metronidazole on pain after day-case haemorrhoidectomy. Lancet 351:169-72, 1998