The Hot Rectal Douche by yr JAMES R. CHADWICK, M I). BOSTON REPRINT PROM VOLUME V. (©nnrralDgttal CrauSacttotiS 1SS1 THE HOT RECTAL DOUCHE. BY JAMES R. CHADWICK, M. D., Boston, Mass. In selecting a title for this paper I have intentionally rejected the term “enema,” lest it should suggest that the practice of injecting hot water into the rectum has for its purpose the removal from that viscus of its fecal contents. I have, moreover, sought to ally my use of hot water in the rectum to the well-known hot vaginal douche, because their chief purposes and results are similar, though I believe the hot rectal douche to be in many cases more efficient. The first group of cases, in which I have of late been in the habit of relying upon the hot rectal douche as the sole therapeutic means, includes cases having for their promi- nent symptom diarrhea, whether acute or chronic, charac- terized by small, frequent evacuations, the cause of which has seemed attributable to inflammation, or at least irrita- tion, of the mucous membrane lining the rectum and large intestine. Reasoning from the marked benefit derived from the use of water to wash out the morbid secretions of the mucous membrane of the bladder, in cystitis, I have for three years been employing the same means for the same purpose in analogous conditions of the lower segment of the alimentary canal, with a like remedial effect. Of course, we all know that cold or warm enemata have been resorted to from time immemorial in the treatment of rectal irrita- bility, yet the chief avowed purpose has been the removal of the fecal masses, which, when present, have very prop- erly been regarded as one source of the irritation. In the cases which I shall detail, the dependence of the diarrhea upon the irritation produced by fecal scybala was definitely eliminated. 2 THE HOT RECTAL DOUCHE. I will here say that these and all subsequent cases have been selected, not at hap-hazard, but because they show most markedly the beneficial effect of the remedy ; in other words, they are avowedly typical cases. Cases of Diarrhea. Group I. Case I. — October 15, 1877. Mrs. M. C. had given birth to her second child, after a normal labor, six weeks before, since which time she had had excessive diarrhea, dejections often taking place every five minutes, and always being attended with pain. Examination by the vagina showed the pelvic organs to be healthy and in their proper positions, but pressure toward the rec- tum elicited expressions of pain. Nothing abnormal was found in the rectum or at the anus. The hot rectal douche, twice daily, arrested the diarrhea at the end of four, days, and there was no subsequent recurrence. Case II. — November 20, 1878. Mrs. A. P., who had a uterus bound firmly in retroversion by adhesions resulting from old in- flammation, had had diarrhea and abdominal pains for several days. The dejections were very frequent, but occurred only at night. They were attributed by me to the irritation excited by the increased pressure of the fundus upon the rectum when the patient was in the recumbent posture. The diarrhea and back- ache ceased immediately on use of the douche. Case III. — June 28, 1878. Mrs. K. K., whose cervix uteri was bound to the sacrum, had a chronic diarrhea of a year’s duration, which was arrested in a week by the use of the douche once a day. Case IV.— 3, 1879. Miss A. J. was referred to me by Drs. Weir Mitchell and A. H. Smith, of Philadelphia. She had been for several years in a state of nervous prostration, for which a cause had recently been found in a retroverted uterus and a prolapsed ovary. The uterus was held in anteversion and the ovary kept in position by one of his pessaries, which had been introduced by Dr. Smith six weeks before. Her condition had been much aggravated by a chronic diarrhea of several years’ du- ration, which had only been kept partially checked by the steady use of opium and salicylic acid. Without disturbing the pessary, I had the patient stop the opium at once, and take the hot rectal JAMES R. CHADWICK. 3 douche twice daily for about two weeks, during which time there was but little diarrhea ; since then she has taken no opium, but on several occasions, when the diarrhea has been brought on by over-fatigue or mental emotion, has checked it at once by one or ■two hot enemata. The benefit derived from disuse of the opium upon which she had become dependent, and from securing im- munity from the exhausting diarrhea, hardly needs to be pointed out. While still far from well, or robust, the patient has gained many pounds of flesh and freedom from many of her pains. To sum up the causes of the diarrhea: In Case I., prob- ably laceration or contusion of the rectum during labor ; in Cases II. and III., a continuance of the inflammation or congestion of the rectal mucous membrane, originally caused either by the contiguous inflammation, or by the passage of hardened feces through that portion of the canal which was constricted by the uterus and the peritoneal effusion at an earlier stage in the history of the cases ; in Case IV., atony or spasmodic action of the rectum, due to the deranged condition of the general nervous system. The douche has in my hands proved useful in many other cases of similar character, with one exception, of which I have notes. It was a case of neurasthenia, at one time complicated with retroversion ; the douche arrested the di- arrhea at first, but failed utterly to do so on subsequent occasions. My experience has, however, been so generally satisfac- tory that I now rarely resort to internal remedies for the arrest of such diarrheas as can be attributed to conditions of the rectum and large intestine, by which practice I avoid the deleterious effects of opiates, astringents, etc., upon the general system. I come now to the second and far more important class of cases in which the hot rectal douche has proved emi- nently successful — pelvic inflammations of all kinds. Having been brought up to believe that the hot vaginal douche, as carried out and extolled by Dr. Emmet, should be the chief reliance of physicians in the treatment of all inflammatory conditions within the pelvis, I was early in 4 THE HOT RECTAL DOUCHE. my practice disappointed with the results of its use, con- sidering the great labor and no little expense involved in the carrying of it out. Dr. Emmet says that the injections cannot be properly taken by the patient unaided; there must therefore be a nurse or friend; the woman must be upon her back ; the bed or couch must be so arranged that the hips will be higher than the head ; she must have a syringe and bed-pan, both of which will probably require filling or emptying more than once during each injection, or must be exceptionally large and cumbersome, or else the bed-pan must be supplied with an overflow pipe, discharg- ing into a vessel by the side of the bed. Among the greater part of my patients I have found it impossible, for one rea- son or another, to secure the requisite attention to all these details. The result was disappointment to me, as well as lack of benefit to the patient. Seeking to circumvent these obstacles to success in treatment, my attention was drawn to the very limited extent of the organs and tissues com- monly affected, with which the vaginal walls come in con- tact. These two cuts of frozen sections, after Pirogoff,1 show with how restricted an ex- tent of the peritoneum the vagina is in contact, and consequently how limited must be the effect of a vagi- nal douche in allaying per- itoneal inflammation, and promoting the absorption of effusions. The rectum and large intestine, on the other hand, are seen to occupy the greater part of the pel- vic and lower portion of the abdominal cavities. These intestines are normally in close apposition with all the pelvic organs, whence originate Fig. I. Section of a Female Cadaver with distended Rectum. 1 Wilhelm Braune, Der mannliche und weibliche Korfter im Sagit- talschnitte. Leipzig, 1872. JAMES R. CHADWICK. 5 most inflammations peculiar to the parts. Now when the peritoneum investing all these organs becomes inflamed, it is manifest that the ali- mentary canal, as the route by which hot water may be brought into close propin- quity with the inflamed sur- faces, has an incalculable superiority over the vagina, except, perhaps, in the acute stage of inflammation, when the peristaltic action, which is liable to be excited by a rectal douche, might be pro- ductive of more harm than the heat and moisture of good. In consequence of this one contra-indication, I have restricted my use of the hot rectal douche to the post-in- flammatory stage of disease. At such a period, hot water, introduced into the rectum in the manner hereafter to be described, will fill the whole pelvic and part of the abdom- inal cavities, disseminating a grateful warmth, relieving pain, — producing, if Emmet’s theory be correct, anemia of the tissues with which it comes into close propinquity, and promoting resolution and absorption of effused lymph. The effect, moreover, does not cease with the injection, for a large part of the water will often be retained for a con- siderable period of time. Incidentally, the removal of feces, thus rendered certain, is of benefit. The morbid state in the following groups of cases, de- spite the diversity of the prominent symptoms, I believe to have originated in intra-pelvic inflammation. Fig. 2. Section of a Female Cadaver, with Re- troflexion of the Uterus. Group II. Case V. October 6, 1877. — Mrs. A. D. had had some time ago an attack of perimetritis, the only trace of which was an ex- tremely tender nodule (probably the prolapsed and adherent Cases of Backache and Painful Defecation. 6 THE HOT RECTAL DOUCHE. ovary) at the bottom of Douglas’ pouch, to which I attributed the constant severe backache, and the pain during defecation, of which she chiefly complained. The hot rectal douche was pre- scribed morning and night, which at once arrested the backache, and greatly relieved the pain attending defecation. At the end of thirteen days she reported herself relieved of all symptoms. The douche was intermitted, but later used occasionally for back- ache, which came on whenever she was constipated. The ovary could no longer be felt, and Douglas’ pouch was no longer tender. Case VI. April 17, 1878. — Mrs. A. G. had been kept awake two nights by intolerable backache. Examination revealed ten- der pseudo-membranous bands crossing Douglas’ pouch. The backache was relieved within a few days by the hot rectal douche. Case VII. October 8, 1877. — Mrs. J. F., with a history of pel- vic inflammation, and an enlarged tender ovary bound immova- bly at the bottom of Douglas’ pouch, complained chiefly of pain- ful defecation, backache, and abdominal pains. On the third day of using the hot rectal douche she was relieved of all her pains. The womb, under treatment, gradually regained its normal mo- bility, and she was discharged at the end of three months. Case VIII. October 29, 1877. — Mrs. B. M. had a retroverted adherent uterus, which could be but partially elevated. The backache, of which she complained, ceased on use of the douche, which was kept up without interruption for four weeks. The re- troversion was subsequently cured. Case IX. fuly 24, 1878. — Mrs. K. McK., who had excessive pain in the abdomen and back, due to a uterus retroverted on top of a tender ovary, found relief from the use of the douche persisted in for a week, but experienced a sense of uncomfortable relaxation of the rectum after each injection. Case X. September 11, 1878. — Mrs. A. U., with a uterus congenitally anteflexed, had intense backache every night without assignable cause, which ceased after five days’ use of the douche. Case XI. Decetnber 3, 1877. — Mrs. B. E. had been suffering from pain in, and sense of pressure on, the rectum since a mis- carriage, followed by pelvic inflammation, six months ago. The supra-vaginal cervix was bound immovably to the sacrum, press- ing against and moderately constricting the rectum. The hot rectal douche caused some soreness for a time, but had relieved Case of Pain referred to the Rectum. JAMES R. CHADWICK. 7 the painful sensations at the end of a week. A month later pain recurred in the back and abdomen, but speedily yielded to the douche. Group III. Case XII. January 8, 1880. — I was requested by Dr. Hans- com, of East Somerville, to take charge of Mrs. D. H. D., whom I had previously seen at her home in consultation with him. Her womb was retro-sinistroverted and partially bound down by adhesions, the result of a former pelvic inflammation. She was weak and extremely emaciated, and one of her chief complaints was of an intolerable burning sensation in the left ovarian re- gion. This was entirely relieved by the use of the douche for one week, the patient asserting that she could “ feel the water go straight to the spot and arrest the burning.” She is still under treatment, but improving daily. Cases of Pain and Burning Sens At ion in the Abdo?nen. Case XIII. September 12, 1878. — I was summoned to Mrs. J. H. W. at the suggestion of Dr. F. A. Harris, of this city. She had just had an attack of inflammation about the right ovary, and was extremely hysterical; after treating her with opium for a few days, until the inflammatory stage had passed, I ordered the rectal douche with a view to promoting absorption of the re- maining effusion, and more especially to afford immediate relief to the intense burning sensation and pain at the seat of inflam- mation in the right side of the abdomen. The water was felt by her to pass directly to this spot and assuage the suffering. After a few days I heard no more of this pain. The effusion was speedily absorbed, and the cure complete. Case XIV. October 26, 1877. — Mrs. C. had symptoms of pel- vic inflammation a week ago while wearing a ring pessary, but no traces of effusion or induration were discoverable. She com- plained of severe pains in both sides of the abdomen. The ring was removed without relief to the pain, which, however, yielded speedily on use of the hot rectal douche. Case of Pelvic Effusion. Case XV. October 23, 1878.— Mrs. M. C. K., whose uterus was found to be crowded against the pubes by an intra-peritoneal effusion, attributable to recurrent attacks of inflammation for the past five years; had had diarrhea for six months, with occasional 8 THE HOT RECTAL DOUCHE. passage of pus, blood, and hard fecal scybalae from the rectum. She used the hot douche twice a day, for eighteen days, with en- tire arrest of the diarrhea, and rapid diminution in the size of the effusion. A small collection of pus behind the uterus was evacuated through the vagina by the trocar a year later, the only symptom then being painful coitus. The method of administration of the hot rectal douche, with a view to attaining its utmost benefits, aims at secur- ing the passage of the water in large volume to as high a point as possible in the alimentary tract, and its retention for as long a period as possible. Water is taken at as high a temperature as can be borne by the hand (no0 F.) ; the patient is placed upon her side, preferably the right, in bed ; a fountain syringe holding two quarts is employed, sus- pended quite low, so that the flow of water may be sjow ; as soon as the patient has a sensation of a desire to defe- cate, or the rectum is felt by the finger in the vagina to be distended, the current of water is arrested for a few min- utes, without withdrawal of the nozzle from the anus. In this way one or two quarts of water may commonly be in- troduced without exciting peristaltic action. The patient must remain quiet for a quarter to half an hour, when, if not sooner, the rectum will generally have expelled a por- tion, if not all, of the water. I do not deem it wise for the patient to resist the expulsive action of the intestine, be- cause it will thereby be incited to more violent efforts, which will counteract in a measure the beneficial action of the douche. I am unable to state how high in the intes- tine the water usually passes, but I am satisfied that it oc- casionally traverses the whole large intestine to the ileo- cecal valve. Whether in its ascent the water is propelled in part by retrostalsis, to which our attention was called two years ago by Dr. H. F. Campbell, I am likewise in doubt, although I am fully convinced by Dr. Campbell’s argument, as well as by my own experience, that retrostalsis actually does occur under some circumstances. I generally direct that the douches shall be taken two or three times a day for one to three weeks, then to be inter- JAMES R. CHADWICK. 9 mitted for a week, although this last precaution I hardly think necessary, for I have several times continued the in- jections four or five weeks without causing any ill effect to the rectum. In a certain number of cases the douche has given rise to pain at the time of injection, or immedi- ately afterwards, when I have considered it as contra-indi- cated. Once or twice, after long use, mucus was brought away by the water, when I have likewise forbidden its use. In conclusion, I would reiterate that I recommend the douche chiefly for two entirely distinct classes of cases, — First, inflammatory conditions of the rectum and large intestine — acute or chronic — characterized by diarrhea, pain, backache, etc. Second, the conditions that follow inflammations of the pelvic organs, and of the pelvic peritoneum or cellular tis- sue, characterized by painful defecation, backache, pain, or burning sensations in the abdomen, etc.