The author trusts the reader will not infer that all sufferers from piles, anal fissure, pruritus ani and vulvæ, mucus channels and reservoirs, abscess, fistula, and all similar troubles, require the enema and recurrent douche appliance; the character of the disease and its symptoms must determine the requirement of the treatment. Many of my patients receive office treatment only, omitting home attentions, although this is not always advisable. The reader might conclude that the recurrent douche treatment was simply for the cure of a chronic inflammatory invasion of the bowels and fecal auto-intoxication, and not be aware of another great source of auto-intoxication--that is, from the absorption of large quantities of serous, fibrinous, or albuminous exudation from a large area of tissues invaded by the very insidious inflammatory process, a condition which, in time, may reach the pus-forming stage. Thus we have three very grave pathological conditions to meet and remove before the pus-formation stage is made manifest through the development of abscesses. I have found five aids--perhaps more--to accomplish a cure in which I have been exceptionally successful, as my students and patients will verify; these are: local treatment, local medication, the proper use of the enema, the use of the recurrent douche, and the determination of the sufferer to get well. CHAPTER XIX. HOT WATER IN THE TREATMENT OF EXTERNAL SYMPTOMS. After proctitis has continued for many years it will give rise to painful inflammatory and ulcerative processes at the external anal vent and in the adjoining tissues. The anal mucous membrane and the integument about the anus become brittle, loosened, and detached from the areolar connective tissue by the retention of inflammatory serum. The engorged, indurated, and swollen mucous membrane and integument serve as reservoirs, especially when the chronic inflammation is excited to an acute stage, which stage is often accompanied by a fissure, abscess, or anal ulcer. Soreness and pain in the parts may then be so severe that the sufferer is compelled to stay indoors or in bed. Whatever the symptoms may be--piles, fissure, pruritus, abscess, or fistula--the sufferer desires to reduce the local fever and the acute inflammation, as well as to find relief from the pain. The customary treatment is to use poultices, which are troublesome and ineffective. In the following illustration I give a good idea of a perfect device for relieving quickly the soreness, pain, acute inflammation, and induration, all of which are so very prostrating; and, situated as they are physiologically, they are exceedingly inconvenient to treat properly by the ordinary methods in use: [Illustration: (Patented November 8, 1892.) Fig. 23.]