Maimonides’ full Arabic name was Abū ‘Imrān Mūsā bin Maimūn bin ‘Ubaidallāh al-Qurt.ubī, or Mūsā ibn Maymūn in short. His full Hebrew name was Rabbi Moshe ben Maimon whose acronym forms “Rambam,” his nickname. In Latin, the Hebrew “ben” (son of) becomes the Greek-style suffix “-ides” to form “Moses Maimonides.” He was born in Cordova, Spain in 1138. His family was forced into exile in 1148, finally settling in Fez, Morocco after traveling for 10 years. Little is known of Maimonides’ formal education, but it is thought that he was essentially self-educated, evincing knowledge of Greek and Muslim writers. Hippocrates, Galen, Aristotle, Al Rhazes, and Ibn Zuhr were quoted frequently in his works. Maimonides moved again in 1165 to Fustat (now part of Old Cairo). He was later appointed court physician to the Regent of Egypt while the sultan was fighting in the crusades, and later became physician to the sultan’s son. He was also known for declining an offer from Richard the Lionhearted to be his personal physician. Maimonides was well recognized as a spiritual leader of the Jewish community in Egypt. He was one of history’s most famous rabbis. He wrote numerous books, the most famous of which was the Mishneh Torah (“Repetition of the Torah”). Compiled between 1170 and 1180, this code of Jewish religious law (Halakha) in 14 books is regarded as Maimonides’ magnum opus. He also wrote 10 medical works. His fourth such effort was a Treatise on Hemorrhoids, written for a nobleman who was thought to be a member of the sultan’s family. The paper provides an early insight into the etiology and management of hemorrhoids. Maimonides believed that surgery should be reserved for severe hemorrhoids or “closed” type (strangulated hemorrhoids). He describes the importance of changes to one’s lifestyle, diet alteration to soften stool, topical treatments, and fumigation. Maimonides died on December 12, 1204. He was buried in Tiberias, in what is now a city on the western shore of the Sea of Galilee, Israel. (Magrill D, Sekaran P. Maimonides: an early but accurate view on the treatment of haemorrhoids. Postgrad Med J. 2007;83(979):352-354; Rosner F. The Medical Legacy of Moses Maimonides. Hoboken, NJ: KTAV Publishing House; 1998; Davidson HA. Moses Maimonides, The Man and His Works. New York, NY: Oxford University Press; 2005; Picture. htpp://www.pneuro. com/publications/oaths/[Courtesy of Hussna Wakily, MD.])

Morgan was born in Bath, England, the son of a physician. After the death of his father, he moved to London and entered King’s College. As was the custom of the day, he became apprenticed to a surgeon and attended lectures, especially at St. George’s Hospital. He established himself as a surgeon in London in 1845 in the neighborhood of Hyde Park, the area being the “resort of the wealthy and successful.” Little is known about how Morgan came to employ the technique of injection, but he did achieve a significant reputation in the medical community as an anatomist and surgeon. (Morgan J. Varicose state of saphenous haemorrhoids treated successfully by the injection of tincture of persulphate of iron. Med Press Circular. 1869:29.)

Andrews was born in Putney, Vermont. At the age of 16, he moved to Detroit and completed his literary studies at the University of Michigan, graduating in 1849. He received his medical degree 3 years later from the same university. After several years on the faculty in the department of anatomy at the university, he joined the Department of Surgery at the Rush Medical College. In 1854, Andrews founded the Chicago Academy of Sciences. During the Civil War, he served as chief of surgery at one of the camp hospitals and directed mobile surgical units in Tennessee and Mississippi, with the responsibility for maintaining the records of surgery during the war. As professor of surgery at Rush, he ultimately became dissatisfied and severed his connections there. With several other well-recognized physicians in Chicago, Andrews established the Lind University Medical School, which eventually became the Medical School of Northwestern University; for 46 years he was professor of surgery. An innovative surgeon, Andrews developed many instruments, including braces for correction of spinal curvature, an appliance for trephining, and an early endoscope that paved the way for modern cystoscopy. Following a trip to England in 1867, he was the first surgeon in the West to use and promote Lister’s antiseptic methods.

Kelsey was born in Farmington, Connecticut, the son of a Protestant minister. He received his medical degree from the College of Physicians in New York in 1873 and became a house surgeon at St. Luke’s Hospital in New York. There followed a period of 5 years in the department of anatomy at his alma mater as a demonstrator, during which time he developed a commitment to the treatment of anorectal diseases. In 1880, he was instrumental in the establishment of a hospital in New York that was “founded on the same general plan as St. Mark’s Hospital in London.” St. Paul’s Infirmary for Hemorrhoids, Fistula, and Other Diseases of the Rectum survived for only a few years, but Kelsey became recognized as one of the leading authorities on rectal surgery in the United States. His books, Surgery of the Rectum and Pelvis and Diseases of the Rectum and Anus: Their Pathology, Diagnosis and Treatment, were considered the most authoritative texts in the United States at the time on the subject of rectal disease. Kelsey became professor in the Department of Diseases of the Rectum at the University of Vermont in 1889 and 2 years later occupied the same chair at the New York Postgraduate School. (Kelsey CB. Surgery of the Rectum and Pelvis. New York, NY: W. Wood; 1902; Kelsey CB. Diseases of the Rectum and Anus: Their Pathology, Diagnosis and Treatment. New York, NY: W. Wood; 1890; Banov L Jr. St. Paul’s infirmary for haemorrhoids, fistula, and other diseases of the rectum. South Med J. 1978;71(12):1559-1561.)

Few reports of sclerotherapy have been published in contemporary English language publications. Khoury and colleagues conducted a randomized trial that compared single versus multiple phenol injections in the treatment of hemorrhoids.¹⁵² Results were assessed up to 1 year later. Most patients fell into the category of mild-to-moderate hemorrhoid disease. The authors demonstrated that a single session of injection treatment using “adequate doses of sclerosant” (i.e., 3 to 5 mL) was as effective as multiple treatments. Dencker and colleagues reported on the comparative results obtained from three forms of treatment of internal hemorrhoids—ligation, operation according to Milligan, and injection—and concluded that the results obtained with injection were poor.⁷⁸ Only 21% of patients were well at the time of review. Santos and coworkers assessed the outcome following single-session sclerotherapy with 5% phenol in almond oil in 189 patients.²⁶¹ With a 4-year follow-up, the authors concluded that this approach to the management of hemorrhoids provided only shortterm benefit for the majority of individuals. Additional
studies demonstrate sclerosant therapy to be less effective than a number of other options.^{7,105,168,272} Because other methods afforded Dencker and colleagues better results, they did not think that injection treatment should be used routinely for internal hemorrhoids.

Alexander-Williams and Crapp, in a report on conservative management of hemorrhoids, stated that they had used sclerotherapy extensively in the past and as part of clinical comparative trials. They found that it gave satisfactory shortterm results, particularly in the treatment of patients with first-degree hemorrhoids.⁴

In 1977, Bartizal and Slosberg published a retrospective review of the records of 670 patients who underwent 3,208 rubber ring ligations for internal hemorrhoids.²⁶ The degree of discomfort after banding and the presence and amount of rectal bleeding were assessed. All were followed for a minimum of 1 month after the completion of banding.

Complications were confined to pain and bleeding. Only 21 patients (4%) had any pain. Mild pain was defined as that which did not require treatment; moderate pain required analgesics, and severe pain caused limitation of activities. No bleeding at all was reported by 642 (96%). Bleeding to a slight degree was noted by 19 (3%) but required no specific treatment. Bleeding to a significant degree occurred in 9 patients (1%). Most were treated successfully with bed rest, but two required hospitalization. When those patients who had moderate and severe pain were combined with those who had severe bleeding, only 13 (2% of all patients treated) had complications severe enough to interfere with daily activity.

Bat and coworkers performed a prospective study involving in excess of 500 patients who underwent rubber band ligation.²⁸ The hospitalization rate was 2.5%, with approximately half of these admissions based on delayed massive rectal bleeding. There was no incident of overwhelming sepsis. An additional 4.6% suffered minor complications, including thrombosed hemorrhoids, mild bleeding, and urinary retention.

Steinberg and colleagues, by means of a questionnaire answered by 125 of 147 patients, conducted a long-term assessment (mean, 4.8 years) of the value of rubber ring ligation as a treatment for hemorrhoids.²⁸⁰ Most (89%) considered themselves cured or greatly improved; however, only 44% were completely free of symptoms. Intermittent mild discomfort, occasional spotting of blood, and an awareness of lumps at the anus were the principal residual symptoms. Nevertheless, many were reportedly happier with this condition than with their state before treatment. Patients who suffered persistent or severe recurrent symptoms after rubber ring ligation were treated by further conservative measures. Fifteen patients (12%) had another rubber ring ligation, anal dilatation, or lateral sphincterotomy.

My colleagues and I reported our long-term results with rubber ring ligation (mean, 60 months).³¹⁸ Of 352 patients who were sent a questionnaire, 266 (76%) responded. Although many continued to have some symptoms, the condition of 80% of the respondents was improved by the procedure. The best results were obtained in patients who had grade I hemorrhoids. Patients with grade IV hemorrhoids were less likely to have had a good result (P < .02). The effectiveness of treatment did not depend on the number of hemorrhoids ligated. Those who had a single pile site treated were as likely to have had a good result as those in whom two or more bands were applied. Perhaps the most meaningful conclusion of our study is that a single treatment can achieve satisfactory results.³¹⁸ If more than three sessions are required to control symptoms, the procedure should probably be abandoned and hemorrhoidectomy performed.

The Cleveland Clinic group reported that 77% of their patients were asymptomatic following treatment.¹⁰⁷ Their technique differed in that approximately 90% of patients were treated by multiple ligations in a single session. Although the long-term results indicated fewer symptoms, pain after treatment was more frequently observed and was more severe.

Lau and colleagues performed rubber ring ligation on all three primary hemorrhoids at each single outpatient session.¹⁶⁴ Good to excellent results were noted in 91%, but moderate to severe pain was reported by 58 patients (29%). Although the authors strongly endorsed this approach, their rate of complications (i.e., hemorrhage, urinary retention, anal stenosis) was 3.5%. Khubchandani conducted a controlled study of single, double, and triple bandings.¹⁵³ There was no significant difference in the incidence of complaints of bleeding or pain following any of these three approaches; however, some patients had to have the rubber bands removed because of discomfort. Poon and colleagues compared single versus multiple ligations in a prospective, randomized trial.²³⁵ Both methods were effective, and the incidence of complications and complaints was similar. The authors recommend multiple ligations—the patients are less inconvenienced, and they anticipated there should be some cost savings. The Mayo Clinic experience also reflects an acceptably low rate of complications.¹⁶⁵

Other studies have demonstrated that rubber ring ligation is far superior to sclerosing agents.¹⁰⁵,²⁷² Better long-term results, significantly more effective management of symptoms of protrusion, and greater likelihood of control of bleeding symptoms can be anticipated with this method of treatment. Chew and colleagues, however, recommend combining sclerotherapy with rubber band ligation.⁵³

In order to compare this modality with surgical hemorrhoidectomy, Murie and colleagues randomly allocated 80 patients to ligation or to surgery.¹⁹⁸ Follow-up results at varying intervals for up to 3 years revealed no significant difference in the frequency of amelioration of symptoms, although it was not clear to me whether patients with more severe hemorrhoidal manifestations were excluded.

It should be noted that many of the following references are older. Wilson and Schofield reported 100 consecutive cases of hemorrhoids treated by cryosurgery.³¹⁰ All were managed on an ambulatory basis, usually without an anesthetic. A nitrous oxide cryoprobe was used. Watery discharge has been said to occur in all patients, but in this study many did not notice a discharge at all, and only one complained that the discharge was a nuisance. Four patients experienced immediate pain during the freezing process; three required a general anesthetic. An additional six patients underwent elective general anesthesia. Only one complained of pain during the first 5 days after treatment, and many returned to work the following day. No major hemorrhages were encountered, although the watery discharge was sanguineous in some. The patients were assessed at 6 weeks and 3 months, with satisfactory results obtained in 94%.

Savin reported 444 operations performed with a nitrous oxide probe.²⁶³ Excellent results were obtained, according to the author, in that all hemorrhoidal tissue and symptoms were eliminated in 431 of 434 patients. Ten patients were lost to follow-up study, and 3 patients had some residual hemorrhoidal tissue. Additionally, cryosurgery was successful in removing 97% of the concomitant pathologic conditions treated, such as anal fissure, anal fistula, hyper-trophied anal papilla, condyloma acuminatum, and mucosal prolapse. Of 155 patients evaluated 1 to 2 years after operation, 151 were graded as having excellent results; 3 had small, asymptomatic internal hemorrhoids; 1 had an external hemorrhoid; 3 were found to have hypertrophied anal papillae not present before; and 2 patients still had persistent hypertrophied anal papillae.

O’Connor reported results of nitrous oxide cryohemor-rhoidectomy in 117 patients.²⁰⁹ Skin tags larger than those the patients had before the procedure were found in 4;

5 had persistence of internal hemorrhoids. Three of the 5 complained of bleeding with bowel movements and were subsequently treated by ligation. The major complications after cryosurgery were pain, bleeding, and fecal impaction. Six patients complained of pain lasting longer than 2 days, 2 of them experiencing discomfort for as long as 14 days. Bleeding necessitating hospitalization occurred in 3 patients, and fecal impaction also developed in three individuals. No urinary retention, ulceration, stenosis, or incontinence was reported. The average time lost from work was 2 days, with a range of none to 14 days. O’Connor concluded that inter nal hemorrhoids were easily treated by cryosurgery, and that thrombosed and edematous hemorrhoids should be managed by methods other than cryosurgery. He further advised that thick skin tags and large prolapsing hemorrhoids should be treated by excisional surgery. It would appear from the author’s subsequent report, however, that he had abandoned this method for the indications outlined in favor of infrared coagulation (see Infrared Coagulation).

Oh initially reviewed 100 patients who had undergone cryohemorrhoidectomy, and he subsequently reported on 1,000 of these individuals.^212,213 In his original report, two-thirds experienced pain, 2 suffered massive hemorrhage, and 5 encountered urinary difficulties. Effectiveness of cryotherapy was 90%, similar to that for rubber ring ligation, but the discomfort, prolonged drainage, and prolonged recovery were believed to be distinct disadvantages when cryohemor-rhoidectomy was compared with ligation. MacLeod, in his report on 528 patients treated by cryotherapy, recommended that this modality be used only on internal hemorrhoids and that the treatments be staged.¹⁷⁷

Traynor and Carter reported a prospective study on the treatment of second- and third-degree hemorrhoids by cryo-therapy.²⁹² Approximately half of the 125 patients analyzed were hospitalized for less than 24 hours. Profuse serous discharge was reported by two-thirds; more than 90% returned to work within 3 weeks. The principal long-term disadvantage appeared to be the failure to eliminate skin tags.

Smith and colleagues reported a study in which closed hemorrhoidectomy and cryotherapy were performed on 26 patients.²⁷⁷ One side of the anus was designated at random for surgery and the other for cryotherapy. Although pain was initially less after cryosurgery (only 1 patient noted severe pain on the cryotherapy side), 12 had pain for more than 2 weeks on the cryotherapy side, compared with only 3 patients who experienced pain after 2 weeks on the surgical side. Interestingly, patients could determine which side had been surgically treated and which side had been “frozen.” Of 24 patients examined 1 year after treatment, 13 had residual hemorrhoids, 12 of which were at the cryosurgical site. Six of these 13 patients requested further treatment. When patient opinion was ascertained, 65% said they preferred operative hemorrhoidectomy and 35% said they preferred cryosurgery.

Infrared coagulation of hemorrhoids has an excellent record of safety with minor bleeding and some discomfort occasionally observed. There have been no reported incidents of sepsis or stricture. Ambrose and colleagues compared photocoagulation and rubber ring ligation in the treatment of hemorrhoids by means of a randomized controlled study of 268 patients.⁶ There was no difference in the symptomatic outcome between these two groups up to 1 year following the procedure. A higher incidence of bleeding and pain was noted following banding that was statistically significant, but additional outpatient procedures were more frequently encountered with photocoagulation. Another study from the same surgical unit compared photocoagulation with injection sclerotherapy.⁷ The results were considered comparable, although the injection group required fewer additional treatments. Weinstein and colleagues noted a different result in their prospective, randomized trial of rubber ring ligation and infrared coagulation.³⁰⁵ A significantly better result at 1 month and at 6 months was achieved by the former method. There was no difference with respect to pain, although banding was associated with two complications: thrombosed hemorrhoids and delayed bleeding. In the manufacturer’s rebuttal to this article, Osur noted that the infrared coagulator was not designed to achieve optimal results in a single treatment session.²¹⁹ In their survey, only 3.7% of users employed just one session.

Comparison studies of the use of infrared coagulation and of bipolar diathermy (BICAP; see Bipolar Diathermy) revealed no significant difference in rate of complications
and number of treatments required.⁸² In a three-armed report involving the infrared technique, the heater probe, and the Ultroid device (Microvasive, Watertown, MA; see later), it was concluded that all three methods are effective modalities for first- and second-degree hemorrhoids, but that the Ultroid was associated with less discomfort and fewer complications.³²¹ Furthermore, the authors believed that this last method may be more applicable for larger piles.

Norman and colleagues reported the application of this technique in 120 patients.²⁰⁶ Ablation of the hemorrhoids was directly correlated with the amount of current employed and the duration of the treatment. The procedure was completely successful, according to the authors in every patient (i.e., all became asymptomatic), and there were no complications. Most hemorrhoid disease (78%) was successfully treated with one application of direct current. The group included 46 individuals with grade III hemorrhoids and 37 with grade IV, a most remarkable accomplishment indeed.

Dennison and colleagues comment that they achieved results comparable with those of other techniques in their 25 patients, but the time required for treatment was a particular disadvantage.⁸¹ In addition, the operator is required to hold the probe quite still for a period of time.⁸⁰ Zinberg and colleagues noted good results in 85% of those with grade III hemorrhoids, but none of four persons with grade IV disease could be classified as having good results.³²¹ As previously stated, Zinberg and colleagues affirmed that Ultroid therapy was associated with less discomfort and fewer complications than either infrared coagulation or heater probe coagulation therapy. Hinton and Morris observed that the technique was effective in 26 patients, including those with large, prolapsing piles.¹³⁰ Wright and coworkers reported a prospective study from the Division of Gastroenterology at the University of Louisville, Kentucky, comparing direct current electrotherapy with standard medical therapy for symptomatic hemorrhoidal disease.³¹⁷ Those who did not respond to initial treatment were crossed over at 8 weeks, receiving alternate therapy twice. The authors concluded that no difference could be found between the standard medical therapy and that of direct current electrotherapy. The obvious extension of this conclusion is that because direct current electrotherapy is no better than standard medical treatment, it cannot be recommended for the management of symptomatic hemorrhoid disease.³¹⁷

Numerous controlled trials have been published comparing BICAP with other ambulatory methods in the management of hemorrhoids. Hinton and Morris randomly allocated patients with third-degree hemorrhoids to either this technique or to the Ultroid.¹³⁰ Both were believed to be effective, essentially equally so. There were no particular complications in either group, but the time advantage, and therefore better patient
acceptability, was enjoyed by BICAP. Dennison and colleagues compared BICAP with infrared photocoagulation.⁸² The authors opined that BICAP permits multiple applications to the same site without producing excessive tissue penetration, whereas infrared photocoagulation produces further penetration under these circumstances. Overheating and breakdown were problems more frequently encountered with the infrared coagulator. Griffith and colleagues randomized 110 patients to receive either BICAP or rubber ring ligation.¹²¹ There were no substantive differences in the results when the two methods were compared.