Mixed Hemorrhoids (Internal and External). In most instances the treatment of this variety of hemorrhoids may be the same as that employed for the internal, as the external hemorrhoid is eradicated by the relief afforded from the removal of the internal portion. The ligature or the clamp and cattery operations are best suited to these mixed hemorrhoids. In applying the clamp care should be exercised to clamp only mucous membrane at one time, then clamp the skin subsequently. This precaution avoids the danger from hemorrhage later as the result of uneven pressure with the clamp.

A radiating incision should be made in a line from the ligated or cauterized hemorrhoid to permit slight oozing, which relieves the edema and pain following the traumatize due to the operation.

External Hemorrhoids. External hemorrhoids are best treated, when not too large, by the correction or relief from the coexisting constipation or diarrhea. As a rule, they do not warrant surgical interference on account of not obstructing the anal canal, as the edema from any inflammation spreads into the surrounding skin and does not annoy the sufferer as much as from the internal variety.

The question of relieving the constipation or diarrhea brings us to the possibility of controlling an strophic or hypertrophy catarrh condition of the rectum or colon. Cascara is best for the constipation or sweet oil in tablespoon doses to adults; and opium with castor oil for the diarrhea. The catarrh conditions are discussed under a separate chapter. The daily irrigation with a twenty per cent. solution of Kramer or witch-hazel for two weeks will give great relief in this form of hemorrhoids. As to the ultimate cure without surgical means the cause will have to be taken into consideration in treating these cases. The surgical procedure is described under the treatment of the internal hemorrhoid.

Internal Hemorrhoids. Internal hemorrhoids are more often treated along the line of non-operative measures because they are so common and the fear of operation or the hope of a cure from the many proprietary remedies in use generally. Internal hemorrhoids when strangulated produce considerable pain and suffering. In the beginning the attacks are mild in character and are relieved within a few days. The attacks through habits of living sometimes become less frequent and finally pass away. In others, no attempt is made to correct the cause, and the attacks become more frequent and more severe. The hemorrhoids protrude more in each subsequent attack until often surgery is the only method of relief.

In all cases of strangulated hemorrhoids rest in the recumbent position should be insisted upon and the diet should be of a non-stimulating character. Highly seasoned foods and stimulation should be restricted entirely. Small doses of some saline cathartic should be administered to regulate the bowels. Frequent cleansing of the rectum, particularly after each movement, with a few ounces of plain warm water will relieve the tenements Pain may be relieved by applications of hot fomentation in the form of flax seed tea or gauze saturated in a twenty per cent. nitroglycerine solution.

The lead and opium wash is very effectual in the early treatment of these strangulated hemorrhoids. The wash may be applied ice cold on cotton or gauze. The following ointment will be found of value which may be varied by the addition of tannin acid to control bleeding as it seems necessary.

After protrusion, the hemorrhoids should be pushed up above the sphincter muscles, and soothing astringent remedies applied to the parts by means of the pile pipe or the finger.

Surgical treatment of internal hemorrhoids should be advised after a trial of palliative measures for a month or two, dependent upon their inflammatory condition and the associated or causative disease. When a fissure or ulcer or polyps exists, which might have caused tenements or expulsion of the hemorrhoids, operative treatment should be instituted without hesitation for the relief of the fissure, polyps and the hemorrhoids at one time.

Palliative Treatment. Palliative treatment or any measure which might be used for the cure of internal hemorrhoids are. as a rule, to be condemned for the reason that the radical operation for their removal is attended with so little danger. In some patients this is out of the question, as the physical condition of the individual or an associated serious disease prohibits the administration of a general anesthetic. In others, the nervous temperament, business, social arrangements and those who lack the courage to undertake surgical treatment are also to be included in the class for palliative treatment.

These patients request relief from the pain, bleeding and protrusion of the mass, and palliative treatment will afford, to a certain extent, temporary relief from all these symptoms. Protrusion is best relieved by regulating the bowels, preventing injury to the parts from hardened stools.

The pain and bleeding may be controlled by rest in bed, cold applications and injection of Kramer, Hydras, tannin acid. Or witch-hazel in solution or in the form of an ointment. The diet should be one that is not excessive, simple in character and exclude the use of intoxicating liquors. Tobacco should be restricted to the smallest quantity that can be used without hardship to the inveterate smoker. Coffee and tea should be taken in moderation. Exercise should be advised for those of sedentary habits, and in the overworked and weak rest proves of great benefit to them. Horseback riding is one of the best forms of exercise for stout persons but in others is apt to induce a prolapse of the hemorrhoid mass. Exhaustion from late hours and nervous strains should be avoided and a regular time for going to bed and arising should be instituted in some cases, while with others care should be taken that the individual does not indulge in too much sleep and rest in bed. Sleep should be limited to eight or nine hours, followed by a cold bath, particularly in the warm weather. The regulation of the bowels is by far of the greatest importance, along with the proper exercise and rest.