Past exam of the medicine course of the University of Oxford / 1867 / Second examination / Surgery and midwifery / 4

What are the modes adopted for the cure of Hæmorrhoids? Describe the most frequent causes of the affection.

Normal anal cushions contain vascular channels and supporting tissue and help seal the anal canal. Haemorrhoidal disease is symptomatic enlargement, bleeding or displacement of these cushions, not simply the presence of normal veins. Internal haemorrhoids originate above the dentate line; external haemorrhoids lie below it in sensitive skin. This explains why an uncomplicated internal lesion can bleed painlessly, while an acutely thrombosed external lesion can be very painful.^[ref]

Constipation with hard stools and repeated straining increases pressure and shearing stress in the anal canal. Prolonged sitting on the toilet and frequent abnormal bowel movements can aggravate symptoms. During pregnancy, pelvic venous congestion and constipation may contribute. Historical explanations often emphasised “congestion” from sedentary habits, abdominal pressure or obstructed venous return. These contain plausible mechanical observations but do not establish every old dietary or constitutional theory. In particular, portal hypertension can produce rectal varices, which must not be equated with ordinary haemorrhoids.

An 1867 surgical answer should distinguish relief of irritation from destruction or removal of the troublesome tissue. Measures then used included regulation of the bowels, avoidance of straining, local cleansing and soothing or astringent applications, and reduction of a prolapsed internal mass where appropriate. Operative approaches included tying the base with a ligature so that the tissue sloughed, excision with control of haemorrhage, and destruction by a heated cautery or clamp-and-cautery apparatus. Historical chemical cauterisation belongs to the same destructive principle. These describe period practice; indiscriminate caustics, cutting without haemostasis and tissue strangulation below the dentate line are not a modern treatment scheme.^[ref]

In current care, increased dietary fibre, adequate fluid and better toilet habits are first-line measures; medicines may provide temporary symptom relief. Persistent internal haemorrhoids can be treated by rubber band ligation, sclerotherapy or infrared coagulation. Rubber band ligation interrupts the blood supply of a small portion above the dentate line and produces healing that fixes the displaced tissue. Advanced prolapse, substantial external disease or failure of less invasive treatment may justify haemorrhoidectomy; the operation must preserve enough intervening tissue to avoid anal stenosis.^[ref]

The usual internal severity grades describe prolapse: grade I does not prolapse; grade II returns spontaneously; grade III needs manual replacement; grade IV cannot be reduced. These grades help select treatment but do not measure every patient's burden.^[ref] Selected acutely thrombosed external haemorrhoids benefit from early excision; others settle with conservative treatment. A blanket promise of a permanent “cure” is inappropriate because recurrent provoking conditions and recurrent symptoms remain possible.^[ref]

Finally, rectal bleeding must be investigated on its own merits. Examination, including inspection and suitable assessment of the anal canal, determines whether haemorrhoids explain the symptoms; other causes include colorectal cancer and inflammatory bowel disease. Persistent bleeding must not simply be labelled “piles”.^[ref]