History of Hemorrhoid Surgery

The word “hemorrhoid" is an old one. The origin of the word comes from the Greek haema or blood and rhoos or flowing. It was probably first used as a medical description by Hippocrates in 460 BC. The term “piles”, derived from the Latin pila or ball, was widely used as early as 1370 AD.

Indeed, since the beginning of written history, mankind has suffered from – and devised many treatments for, hemorrhoids. The Egyptians concocted “an ointment of great protection”, the Greek invented a procedure strikingly similar to today’s rubber band ligation, and European the barbers/surgeons of the mid 16th century conducted crude excision surgeries!

Below is the history of hemorrhoids treatments throughout various ages in the world:

The Egyptians

The earliest record of hemorrhoids comes from Egyptian Papyrus dated at 1700 BC. The document recorded the first treatment for pile, an herbal poultice: “if thou inspecteth a man in his anus, whether standing or sitting, suffering very greatly with seizures in both his legs. Thou shouldst give a recipe, an ointment of great protection; Acacia leaves, ground, titurated and cooked together. Smear a strip of fine linen therewith and place in the anus, that he may recover immediately.”

The Greeks

Hippocrates wrote some of the earliest medical descriptions of hemorrhoids. The Hippocratic Treatises, written in 460 BC, described hemorrhoids as being caused by “bile or phlegm be determined to the veins of the rectum, it heats the blood in the veins; and being gorged the inside of the gut swells outwardly, and the heads of the veins are raised up, and being at the same time bruised by the faeces passing out, and injured by the blood collected in them, they squirt out blood, most frequently along with the faeces.”

Hippocrates also wrote of a hemorrhoid treatment similar to today’s rubber band ligation procedure. He wrote “And hemorrhoids in like manner you may treat by transfixing them with a needle and tying them with very thick and woolen thread; for thus the cure will be more certain. When you have secured them, use a septic application, and do not foment until they drop off, and always leave one behind; and when the patient recovers let him be put on a course of Hellebore.”

The Romans

In a medical treatise De Medicina, a Roman physician named Celcus (25 BC – AD 14) described the ligation and excision surgeries, as well as possible complications. Another description of hemorrhoids was provided by Galen (AD 131 – 201), who also promoted the use of severing the connection of the arteries to veins in order to reduce pain and avoid spreading gangrene.

The Far East

Hemorrhoid is not limited to the Western world – it is acknowledged as a disease in India by the Susruta Samhita, an ancient Sanskrit text dated between the fourth and fifth century AD. The description in this text is comparable to the Hippocratic Treatise, but with advancement in surgical procedures and emphasis on wound cleanliness.

The Master & Barber Surgeons

By the 13th century, there is a lot of progress in the surgical procedures, led by European physicians called the Master Surgeons. Renowned figures such as Lanfrank of Milan, Guy de Chauliac, Henri de Mondeville, and John of Ardene greatly expanded and refined surgical procedures.

However, the progress of science & surgery stalled for about 350 years when barbers start to routinely conduct surgeries! Between 1500 and 1850 AD, in an era later known as the era of “Barber Surgeons”, hemorrhoids are commonly called the “Curse of St. Fiacre”. The story is that St. Fiacre, who later became the patron saint of gardeners, was told by his church that he could farm on all of the land that he could cultivate in a single day with a very small shovel. In his zeal to obtain the maximum amount of land, St. Fiacre developed a terrible case of hemorrhoids. According to legends, after praying for a miraculous relief, St. Fiacre sat on a stone and found that his problem was cured and an image of a hemorrhoid is imprinted on the stone. Today, hemorrhoid sufferers continue to sit on the stone and pray for relief!

The Renaissance

During the Renaissance, surgeries returned the realm of the scientists. A celebrated physician, Lorenz Heister, wrote about the crudeness of past procedures to treat hemorrhoids, and described a detailed procedure for ligation: “he is then to tie up the bleeding tunercles with a needle and thread, cutting off those parts which are distended beyond the ligature, taking care at the same time to leave a few of the smallest veins open as before observed.”

Acknowledging that hemorrhoids and varicose veins seem to affect only the upright humans, a physician-scientist called Morgnani wrote: “without doubt, it was not very easy for the blood to pass through a liver of that kind. But why, then, you will say, did it not stagnate equally in the other veins which go to the trunk of the vena portarum? And for this very reason it was that I said you would immediately understand it, or at least in part. Add therefore, to omit other things, the very great length, which is peculiar to this one vein among others, so that it is much more difficult for the blood to be carried upwards, from this vein, than from the others, especially as the situation of the human body requires it, which without doubt is one of the reasons why other animals are not subject to piles. And if you ask why, in those bodies in which there is any impediment to the quick motion of the blood upwards, the veins of the legs in particular are dilated into varices, you will find the same thing to be the cause of them chiefly which we assign for the piles.”

The Eighteenth / Nineteenth Century

In 1774, Jean Louis Petit wrote a three-volume treatise on surgery, in which he noted that the skin of the anus is very sensitive. He reasoned that excision surgery alone should be avoided due to the pain and the possibly fatal complication of hemorrhage, whereas ligation procedure alone should not be performed because of the pain and the possibility of gangrene.

However, other physicians such as Brodie, disagreed with Petit’s concern on ligation, noting that “the application of ligature to internal piles in general causes by little pain, and only a slight degree of inflammation follows, for the mucous membrane has nothing like the sensibility of the skin, and does not resent an injury in like manner.” Sir Astley Cooper also supported ligation after complications from hemorrhoid excision surgeries claimed three of his patients’ lives.

During the nineteenth century, another treatment for hemorrhoids called anal stretching or rectal bouginage, became popular. In this treatment, a bougin – a cylindrical medical device used to stretch muscles and tissues, is inserted in the anal canal to enlarge the rectum as well as to “relax” the sphincter muscle and diminish hemorrhoids.

In 1888, Frederick Salmon, the founder of St. Marks Hospital, expanded the surgical procedure of hemorrhoid surgeries into a combination of excision and ligation. In this technique, the perianal skin is incised, the hemorrhoidal plexus and the anal muscles are dissected, and the hemorrhoid is ligated.

The Twentieth Century

So successful is Salmon’s excision/ligation surgery that it remained virtually unchanged since its introduction in late nineteenth century. Even today’s Ferguson and Milligan Morgan hemorrhoidectomy – considered the gold standards in hemorrhoid surgery – was a modification on Salmon’s techniques.

In late twentieth century, three further developments were introduced: the diathermy hemorrhoidectomy by Alexander Williams, rubber band ligation by Baron, and the stapled hemorrhoidectomy or Procedure for Prolapse and Hemorrhoids (PPH) by Longo.