Historical Perspective On Hemorrhoids
The Merck Manual defines hemorrhoids as Varicosities of the veins of the hemorrhoidal plexus
, often complicated by inflammation, thrombosis, and bleeding. It has been suggested this is an oversimplification of the nature of hemorrhoids. A more recent definition is, Vascular cushions, consisting of thick submucosa containing both venous and arterial blood vessels, smooth muscle, and elastic connective tissue.
While everyone has this tissue, it is the enlargement, bleeding and protrusion that create pathology. The crossroads to the development of varicose veins and hemorrhoids is the loss of vascular integrity. Considering the combined prevalence of varicose veins and hemorrhoids, venous insufficiency and its manifestations are an extremely common medical problem that every physician should be prepared to treat.
As mentioned, there are variant definitions of the histology of the hemorrhoid tissue, but they are universally classified according to anatomical origin. Internal hemorrhoids consist of redundant mucus membrane of the anal canal with the origin above the dentate line. External hemorrhoids have an epithelial component and originate below the dentate line. Internal hemorrhoids are further graded based on the extent to which the tissue descends into the anal canal.
First degree: The mucosa barely prolapses, but with severe straining may be trapped by the closing of the anal sphincter. Subsequently, venous congestion occurs occasionally, resulting in discomfort and/or bleeding. Clinically speaking there is no obvious external abnormality.
Second degree: With further protrusion of the mucosa, the patient complains of an obvious lump, but this disappears spontaneously and rapidly after defecation unless thrombosis occurs.
Third degree: In chronic hemorrhoidal disease, the persistent prolapsing produces dilatation of the anal sphincter and the hemorrhoids protrude with minimal provocation and usually require manual replacement.
Fourth degree: These are usually described as external hemorrhoids and are protruding all the time unless the patient replaces them, lies down, or elevates the foot of the bed. In these fourth degree hemorrhoids, the dentate line also distends, and there is a variable external component consisting of redundant, permanent perianal skin.
Hemorrhoids are mentioned in ancient medical writings of every culture, including Babylonian, Hindu, Greek, Egyptian, and Hebrew. The word hemorrhoid is derived from the Greek haema = blood, and rhoos = flowing, and was originally used by Hippocrates to describe the flow of blood from the veins of the anus.
Prior to the 1800s hemorrhoids were treated simply by poultice, bed rest, or, in difficult cases, by the application of a red hot poker. A simpler method was prayer to the patron saint of hemorrhoid sufferers, St. Fiacre, an Irish priest who lived in the seventh century. Injection therapy was begun in 1869 by Morgan of Dublin using iron persulfate, and was a relief to many who had endured the medical treatment of the time.
As late as 1888 the only other recommended treatment (apart from the above mentioned) was abstinence from alcohol, sitting in cane chairs, and half a pint of cold spring water injected into the rectum after a morning fast. The founding of St. Marks Hospital in 1935 by Fredrick Salmon, who is given credit for the first ligation of hemorrhoids, marked a turning point in the treatment of hemorrhoids.
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