Hemorrhoidectomy: Past and Present*

MERVYN SMITH, F.R.C.S.

Adelaide, South Australia

THE HISTORY Of the t reatment of hemor- rhoids over the centuries has been written many times and I would hesitate to sug- gest that I could add anything to your knowledge of this subject. Yet I think it is perhaps salutary to pause from time to time and look back over what our pre- decessors did and compare this with what we do today with all our infinitely better conditions.

I t is interesting that Hippocrates, about 400 B.C., wrote much on the subject of hemorrhoids and recommended use of the cautery with a hot iron, a method of treat- ment which was still being advocated by Langenbeck in Germany as late as 1870.

Hippocrates was not, of course, the first one to describe hemorrhoids; reference to them is made in the Papyrus of Eber about 1500 B.C. a n d ' m a n y references are also to be found in the Old Testament . 3 Here the condition is referred to as "ffmerods" and it is implied that this is a particularly un- pleasant condition with which to be af- flicted. Thus, f rom Samuel 1, Chapter 5, we read that " . . . the hand of the Lord was against the city with a very great de- struction and he smote the men of the city, both small and great, and they had emerods in their secret parts." And again, " . . . And they that died not were smitten with the emerods: and the cry of the city went up to heaven."

There is no great wonder that this con- dition should have received early attention, for it was an obvious affliction, easily ac-

* Read at the meeting of the American Procto- logic Society, Pittsburgh, Pennsylvania, June 21 to 24, 1961.

cessible, and thus capable of description and thought. Many of the early writings stressed the opinion that bleeding from hemorrhoids was a desirable thing and Galen, in the second century, was one who believed that "unsound juices" were dis- charged from the body by this route. In- deed, this opinion was widely held until welt beyond the Middle Ages and reference to the "golden veins" of the anus was to the savings in doctors ' fees when these veins conveniently bled and gave relief f rom vari- ous other ailments, z

I t is not uncommon, I think, to find that reasonable t rea tment advocated by the early masters was lost in the Middle Ages only to be refound later. I t is in the Middle Ages that we find reference to t reatment of hemorrhoids by the wearing of amulets of dried toads and other useless symbols. These schemes of so-called t reatment gradu- ally gave way to more rat ional methods which were essentially those which had been in use centuries before. Cautery again became a favored method of t reatment and special clamps were devised to protect the anal margin, the operat ion being thus a more satisfactory one than that practiced in Hippocrat ic times. Excision of hemorrhoids had been found to be too dangerous as bleeding after this opera t ion was frequently catastrophic. T h e objection to ligation, which obviously was a safer method, was the great pain caused by suturing the sensi- tive anal epithelium.

Wil l iam All ingham, I in Diseases of the

R e c t u m published in England in 1879, listed the common operations of that t ime and, as the preferred procedure, he de-

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HEMORRHOIDECTOMY: PAST AND PRESENT 443

scribed the St. Marks method, devised a little earlier by Sahnon, the founder of that institution. T h e great advantage of this method was owing to recognition that the sensitive anal skin could be removed with the pile, by dissecting it up to the pedicle of the hemorrhoid, and subsequently ligating it, thus avoiding the cause of pain. Although this was a painless procedure, as a result of the high ligation, this type of operat ion caused stricturing and was subsequently modified by the St. Marks group under Milligan, who recommended that dissection be stopped at the level of the internal sphincter muscle. At this level some fibrous bands emerge from the muscle and these tend to mainta in the pedicle at that level.4

T h e description of Salmon's operat ion by All ingham is a very good one and his success with it was impressive. His report included the case of a stockbroker who found it essential to go to the city on each of the first three days after operat ion be- cause of % sudden turn of the markets." Shortly after this Joseph Matthews worked under All ingham and later he returned to this country and became the first president of your society in 1899.

T h e operat ion commonly performed in my country (South Australia) is the St. Marks operation and, al though this pro- cedure is no doubt familiar to many of you, I believe it is not the common type of hemorrhoidectomy performed in the Uni ted States. Under general anesthesia, and with the pat ient in the l i thotomy posi- tion as described by Allingham, the anus is first stretched to admit about three fingers. The mucocutaneous junct ion op- posite each of the three pr imary piles is then picked up with a pair of Dunhil l curved artery forceps. Slight traction on each of these brings the hemorrhoids into view and these, in turn, are grasped by other Dunhil l forceps. Commencing with the left lateral pile, the skin at the base is

cut with scissors, one blade of which goes into the furrow made by pul l ing on the two artery forceps. T w o such incisions are made through the skin and the external hemorrhoidal plexus and the pile mass is then dissected off the internal sphincter with scissors. Al though in the St. Marks operat ion it is recommended that dissec- tion stop at the level of the sphincter, it is my impression that convalescence is made a good deal easier if dissection is carried just a little higher before the hemorrhoid is transfixed with heavy chromic catgut. Much of the pain after hemorrhoidectomy is brought on by spasm of the sphincter muscles and I think this is less likely to occur if the pile is freed f rom the muscle as described. Small bleeding points in the raw area are picked up with fine hemo- static forceps and cauterized by diathermy or, if this is not available, by ligating them with fine catgut. Each of the other hemor- rhoids is dealt with in like fashion, care being taken to ensure a good bridge of skin and mucosa 'between the hemorrhoida l masses. After this, each ligated hemorrhoid is removed and the raw pedicles are re- placed within the anal canal. Wi th a t ampon in the anus, each wound is then t r immed and inspected for oozing and an ounce of soft paraffin is squeezed into the anal canal from a collapsible tube. A short length of rubber tube is inserted into the anal canal. Between it and each hemor- rhoidal site is inserted a t ampon wrung out in an antiseptic solution. Other tam- pons are then arranged around the tube in such a fashion that subsequent dressings and a T-bandage provide pressure to this area. Twenty-four hours later the top dressings are removed and the tube is with- drawn without disturbing the dressings in proximity to the wound. T h e following night an aperient is given and next morn- ing a glycerin and oil enema is adminis- tered. After this, the patient, having had a bowel movement , sits in a ba th twice a

444 SMITH

day, the rectal out le t is dilated by insert ing a lubr icated finger on the sixth clay, and he is dismissed f rom the hospital abou t the n in th day.

T o summarize this very brief paper, I migh t repea t that the condi t ion of hemor- rhoids has been recognized f rom the earliest time. Surgical removal of the pile masses in the early days was p robab ly effective al- t hough not wi thou t danger. In more m o d e r n times we still remove the hemor- rhoids bu t only after more careful dissec- tion, made possible by good anesthesia and a bet ter knowledge of the ana tomic char- acteristics. T h e three complicat ions of

opera t ions in this reg ion are pain, hemor- rhage and stricture fo rmat ion . T h e opera- t ion emana t ing f rom St. Marks Hospital , London , has been well tried, proved to be satisfactory and safe f rom these complica- tions.

References

1. Allingham, W.: Diseases of the Rectum. 1879. 2. Edstein, E.: A contribution to the history of

hemorrhoids: And their treatment from the time of Hippocrates to the modern bacteri- ological era. Medical Life. 35: 5, 1928.

3. Holley, C. J.: History of hemorrhoidal surgery. South. M. J. 39: 536, 1946.

4. Parks, A. G.: The surgical treatment of haemor- rhoids. Brit. J. Surg. 43: 337, 1956.