A rational mode of living is of the greatest importance. Patients with hemorrhoids should have plenty of outdoor exercise, should partake of food with moderation, should avoid all excesses in baccho and in venere, and should endeavor to have a daily evacuation of the bowels. Any condition causing venous hyperaemia of the rectum must be removed. Thus vocations requiring constant sitting, or constant standing, or horseback riding should be entirely or partly given up.

With regard to diet the following general rules may be given: Patients with hemorrhoids should avoid copious meals. They should rather eat often and sparingly. Fish, fresh, well-cooked vegetables, and ripe fruit should form a considerable part of their diet. Alcoholic beverages, strong coffee, and highly seasoned dishes should be avoided. The different kinds of cheese, very coarse brown bread, cabbage, peas, and beans are best eliminated from the diet. Salads, potatoes, beets, spinach, asparagus, cauliflower, are, however, rather of benefit if taken in small quantities, as these articles make the intestinal contents more liquid. Stewed fruits and also raw fruit, as for instance apples, pears, prunes, oranges, grapes, are useful. As a beverage, plain water, best taken between meals in the quantity of a pint, is most beneficial. In some instances, especially in anaemic patients, buttermilk in the same quantity may be taken instead of water. A small amount of light beer is permissible in some cases.

With reference to hygiene or prophylactic measures it is of importance for the patients to have plenty of outdoor exercise, especially walking. The exercise, however, should not be continued to over-fatigue. Gymnastic exercises at home, sawing or chopping wood, and the like, and also massage are best adapted for this purpose. The patients should wash the affected part in the morning and evening with cool water. They should sit on caned chairs, not on upholstered ones, and should sleep on a mattress.

The patient should have a good evacuation of the bowels daily. In case this does not occur, it will be of the greatest importance to secure it by the different therapeutic measures at our disposal (see Chapter X (Nervous Affections Of The Intestines)., on constipation). As a rule, however, powerful laxative and drastic remedies should be avoided. The frequent use of injections had also best be omitted. The purgatives most adapted for these patients are the saline ones, sulphur and rhubarb drugs. Thus compound licorice powder, a teaspoonful in the evening, or sulph. depur., potas. bitartrat. aa, also one teaspoonful in the evening. Rhubarb in the form of tincture or in substance 0.5 to 1 gm., taken once or twice daily, is also advantageous for a prolonged use. The waters of Carlsbad, Kissingen, Marienbad, Tarasp, Saratoga, will also be of benefit, especially if taken at the watering-places themselves in connection with a prescribed diet. If the hemorrhoids have already attained considerable size, local remedies will often be required.

Local Treatment

The irritation or the rubbing of the piles against each other or against the skin must be prevented. For this purpose covering the piles with a small piece of smooth and clean cotton is of benefit; still better, however, for this purpose is cotton moistened in olive oil or covered with vaseline or a soft salve (Hebra's ointment or ointments of zinc, lead, boracic acid). If the piles are inflamed, it is best to first paint them a few times with the following solution:

before applying the ointment. After a movement the anus and the piles should be first washed with cool water and then wiped off with soft cotton or linen. This must be done very gently. Persons suffering with annoying tenesmus after defecation should accustom themselves to go to stool before retiring. The recumbent position which the patients are thus able to assume soon after the passage affords them decided relief.

If there are pains in the rectum caused by a mere hyperesthesia of the mucous membrane, an injection of one to two teaspoonfuis of warm olive oil or of the same quantity of warm water into the bowel will exert a favorable influence. If this fails, or in cases in which the pains are caused by a superficial excoriation of the piles, it is best to apply an ointment containing some narcotic after an evacuation of the bowels, and sometimes even during the intervals. The following salve, recommended by Rosenheim, is very appropriate:

M. f. uugt.

In place of the ointment the piles may be painted with a solution containing equal parts of fluid extracts of opium and belladonna, or with a two-per-cent cocaine solution. Suppositories containing opium, belladonna, or cocaine are also effectual.

Internal piles prolapsing through the anus should be pushed back by the patient after anointing them with olive oil or with vaseline. In case the reposition is not easy, painting of the piles with a two-per-cent cocaine solution will after a while lessen the sensitiveness and thus make reposition possible. In some obstinate cases the patient must be narcotized in order to accomplish this. If the incarcerated piles have already become gangrenous, the pains usually grow less. In order to arrest the necrotic process it is advisable to dust the affected area with an antiseptic powder (dermatol) and to cover it with dry gauze. The pile usually falls off spontaneously and the wound heals of itself.

The inflammatory processes in piles require special treatment in the stage of exacerbation (general antiphlogistic remedies). Thus rest in bed on the side, application of cold in the form of an icebag or a Priessnitz poultice, occasionally leeches in the neighborhood of the anus, not on the piles themselves. Application of cold lead water is also useful. In case there are signs pointing to the formation of pus or the development of a septic process, surgical intervention is imperative. An incision into the hardened piles followed by thorough extirpation is essential. Inasmuch as such an operation must be done under chloroform narcosis, the radical removal of the entire hemorrhoidal area is therefore best performed at the same time.

Hemorrhoidal hemorrhages, if not extensive, and if occurring at long intervals, will hardly require any therapeutic measures. If, however, the quantity of blood is quite considerable or if the hemorrhage is protracted, the following means should be employed: An icebag should be applied to the anus for several hours, or in case the hemorrhage results from internal piles, a cylindrical piece of ice is pushed up into the anus and replaced every half-hour. The rectal refrigerator may likewise be used with benefit. Very cold injections are also useful. In cases with very frequent hemorrhages injections of water, to which an astringent remedy has been added, are beneficial. Thus a two-per-cent solution of tannic acid or of alum, or a 0.3-per-cent solution of acetate of lead may be applied. The following ointment, first suggested by Kossobudskj,1 may also be applied in these cases:

M. f. ungt.

This salve not only checks the hemorrhage, but has also an excellent effect in reducing the size of the pile. In internal hemorrhoids the following suppository may be used for the same purpose:

M. f. Suppository. S. One suppository in the evening.

1 Kossobudakj: Centralblatt fur Chirurgie, 1889.