Intelligent Use Of The Enema
( Originally Published Early 1925 )
There is no dictum in medical literature more common than the advice that the enema is a device that should be resorted to as a temporary expedient only, and that the same rule applies to the use of any laxative medicine.
This is believed by some excellent authorities to be ill-considered advice as to enemas, based on too few or inaccurate observations.
In chronic cases of constipation, especially when associated with the physical weakness of advancing years, how can relief be secured from a temporary use of any method as long as the cause is not removed? The cause is frequently muscular weakness of the abdominal walls and of the intestine and general debility. If the vigor of those parts of the body be restored by the methods set forth elsewhere, then there may be hope based on experience, of securing relief from the temporary use of medicines and irrigation of the bowels. On any other theory it seems idle to talk or write about the temporary use of relief measures.
The use of the enema is a wise measure in a large percentage of cases if properly guarded from abuse. Too frequently the patient has a profound ignorance not only of the anatomy of the parts, and their reaction to treatment, but has no idea of the location of the trouble.
As Hurst has shown, there are two general forms of constipation. The first is associated with the passage of the residue of the food from the cecum to the pelvic colon (that part situated in the left pelvis—sigmoid flexure) and the second with the complete evacuation of this pelvic colon at proper intervals. In the first class the passage through the intestine is delayed whilst defecation is normal; and in the second class there is no delay in the arrival at the pelvic colon but excretion is not properly performed. In the last edition of his book, 1919, the author adds a third class in which the colon content is not full enough to produce an adequate stimulus to these processes. The names applied to the first two types are respectively colic (colon) constipation and dyschezia.
Case says (confirming Hurst) that colon stasis occurs particularly in two places—in the pelvic colon and in the cecum. This is a very important observation by a competent authority who has examined thousands of cases.
If dyschezia is the form with which the patient is afflicted, it is manifest that relief through the stomach should not be expected until the obstruction at the distal (lower) end of the colon is removed. How thorough the irrigation must be to secure such relief depends on the individual case. If the stasis through prolonged neglect extends as far back as the cecum (beginning of the colon), it may take a week or even longer to secure thorough relief from the profound impaction of the con-tents of the colon.
There are two alternative first steps, or, if both of them are taken, all the better. One is a visual examination by means of the barium meal with the fluorescent screen (sometimes called the fluoroscope), which gives more information than is obtainable from skiagrams (x-ray pictures). With the screen the outline of the colon can be traced on a piece of lead glass over the screen, from which the sketch can be later copied. If a small diaphragm (opening) is used and the tube moved about so as to bring each part of the barium shadow successively into the center of the field, accurate measurements can be obtained from the tracing. Skiagrams, on the other hand, produce so much distortion that they are quite useless if measurements are desired. With the screen, moreover, it is not only possible to locate the exact position of the colon, but generally to palpate (explore on the surface with the fingers) the parts which are seen. By this means their mobility, the presence of adhesions, the exact location of tender areas and the location and condition of the contents can be learned. One of the great advantages of this method is that the patient learns the location particularly of the transverse colon, so that in the use of massage it can be applied at the right place. It is also learned whether there is any permanent contraction of the colon, any falling from the normal position, or any other diseased or abnormal condition that requires attention? If this method is resorted to it is of great importance to go to a competent and conscientious operator who performs this service for physicians, as there are many amateurs in this field who should be carefully avoided. Many of them are not competent, in the opinion of Kellogg, to interpret what they see.
The alternative step is to take a sufficient quantity of charcoal (3 or 4 4-grain tablets) about 4 p.m. and ascertain definitely if it goes through in the normal time, and if not the exact amount of delay. Not only the first but also the last appearance of the charcoal should be particularly noted. If some of the charcoal is not passed at the latest the second morning, the patient must be regarded as having intestinal stasis. If food is taken in the evening about nine hours before defecation, some of its residue is likely to be present in the morning. If taken less than nine hours before, none of it can reach the splenic flexure in time to disclose its presence. It continues to advance until it reaches the pelvic colon (sigmoid) where it remains until the next defecation.
With this information at hand, if there has been not only serious delay but imperfect defecation, the next step is a thorough irrigation of the colon (coloclyster) as far as the cecum, as explained elsewhere.
Coincidentally with this step there should be adopted one of the several laxative food regimens described herein, the. proper abdominal exercises and the inauguration of a change in the intestinal flora, of which all the details will be found in the chapters on those subjects.
In addition to the will to succeed a large majority of the chronic cases will require the help of everyone of these expedients before the crippled colon has recovered sufficient strength to resume its normal functions. And even then there will be a considerable percentage of cases that will require the permanent help of the enema from the splenic flexure down, as a secondary, not a preliminary, act.
To give this in the right way, the knee-chest position, so often advised, should not be adopted. That is only for cases that need irrigation as far back as the cecum. For water to reach the splenic flexure after defecation (it seldom should be used before) it should be introduced (at a temperature of 80 °,) in any amount up to two pints, while the trunk is, if preferred, in an upright position, and a recumbent position on the left side then assumed for a few minutes. If there is any uncomfortable reaction to the water at the above temperature, which is not probable, the temperature can be raised slightly, even to 99°, as indicated by a therometer dropped into it, slightly above the body temperature. But in such cases a last enema should drop back to 80°, or even lower, in order to give the bowel the tonic effect of the cool water, as it is not uncommon for a considerable and very annoying chronic distention of the bowel to result from too warm enemas.
The reader should note that this plan (of separating dyschezia from upper colon constipation) greatly simplifies the problem. By relieving the dyschezia, which is generally the predominating trouble, by the temperate, but permanent use of the cool enema by the above method as far as the splenic flexure, very often severer measures will not be required. Incidentally other conditions generally associated with intestinal stasis are benefited. If there be chronic constriction of the descending colon the stricture is much more readily passed after softening of the contents. If colitis, (inflammation of the colon), with discharge of mucus, is present the addition of a dram of salt (a level teaspoonful) to a pint of water with a warm enema, above 90° is 'indicated. In fact, Hare recommends the addition of salt to all large injections. In the treatment of dysentery he observes that by this means we can get into direct contact with the diseased mucous membrane and there is no doubt whatever that the mere passage of normal salt solution at suitable temperatures over the bowel-wall is of value, for in this manner we remove mucus and pus and so dilute the poisons produced by the germs of the disease that their further action is largely con-trolled?.
Kellogg says that when a cleansing effect is desired, as in catarrh of the bowels, a mixture of equal parts of carbonate of soda (employed internally to meet the same conditions as bicarbonate) and common salt (1 1/2 drams of each to the quart of water) may be used. The slight difference here in the quantity of salt is not material.
When all the aids indicated (including abdominal and outdoor exercises, early morning water drinking, bran, oil, if needed, and proper diet) have been summoned, and there is no condition present requiring the attention of the surgeon, the patient can have every hope not only of permanent relief but greatly improved health with an extended life span. And none of the aids alluded to are anticipatory of anything more than the resumption of a normal life for the colon.
There is eminent authority for the permanent use of the cool enema as far as the splenic flexure in chronic cases of dyschezia given under proper condition and in the proper quantity, not, except under necessity, as an aid to defecation but as an act of cleanliness and health.
Thus Case says that when dyschezia is present it seems unreasonable to administer a laxative which will irritate twenty-five feet of bowel in order to evacuate the last twelve or fifteen inches of the colon. Here enemas are indicated. A small, cool enema is often enough to pro-duce a thorough evacuation of the lower bowel. In cases where it is desired to evacuate the whole colon and reach the cecum Case says that probably six thousand times he and his colleagues have watched by means of the fluoroscope the introduction of the barium enema. Only in instances of organic bowel obstruction has the head of the barium enema failed to reach the cecum with-in a few moments. The average amount of fluid necessary is 1200 cubic centimeters (a little over 40½ fluid ounces), the container being 2½ feet above the patient. In the light of Case's experience with the coloclyster (filling the whole colon) it is very rarely that the knee chest position is required, as the resulting distortion of the colon becomes very confusing.
The most important part of the treatment of dyschezia, in Hurst's opinion, is to keep the rectum and pelvic colon empty so that they may in time regain their normal tone. This can be accomplished by the regular use of enemata (plural for enema). Even in the most obstinate cases the ultimate result is often very satisfactory although the enemata may have to be given regularly for a year or longer before the rectum and pelvic colon return to their normal condition. In very exceptional cases the atony (loss of tone) and paralysis of the rectum are so complete that recovery is impossible. In such cases treatment by enemata, though it does not cure, is the only way to procure a regular evacuation. Upon complaint by a nervous patient of exhaustion, or abdominal pain after an enema has been administered, it should be given at bedtime, instead of in the morning, or by the introduction of a belladonna suppository half an hour before the injection.
The cold enema gives rise to strong contractions which are often accompanied by colic. A hot enema cannot be given at a temperature more than a few degrees higher than the body, whereas the cool injection can, on proper occasion, be used without danger. The former is used for its sedative effect or over-activity in cases of colic. It has been said that the regular use of enema is always harmful. This belief is, however, erroneous, Hurst says. In many cases of dyschezia (impaction at lower end of colon) it is the only means which can result in complete recovery. Hurst knows a medical man, 71 years old, who has never failed to obtain an easy evacuation every morning for 24 years by means of enemata of three pints of soap and water.
Hurst says his experiments prove that the true ex-planation of the failure of the rectum to act with feces present is the relaxation of tone which occurs in the muscular coat after it has been subjected to a certain degree of tension for a short period. The call only returns after further material has entered the rectum and produced a rise in intra-rectal pressure. This may occur after any meal but most frequently only after break-fast. The theory advanced by some that the rectum empties itself backwards into the pelvic colon in case of non-defecation has been proved by x-ray examinations to be a mistake.
The coloclyster is used in Kellogg's practice when it is desired to fill the entire colon, or at least to intro-duce the largest quantity of water possible, without over distending the colon. In the ordinary enema, it is difficult to introduce more than a pint and a half to three pints of water; but by placing the patient on the knees with the thighs perpendicular, and the chest within two or three inches of the knee level (knee-chest position) the amount of liquid will flow in freely and may be increased to four, five or six pints, and in some cases to even more, without inconvenience to the patient. The coloclyster is called for in neglected cases where a general colon clean-out is imperative before remedial measures are attempted. In the knee-chest position the water passes downward (owing to the position of the body) through the sigmoid flexure (pelvic-colon) and then runs along the descending colon. On reaching the transverse colon at the splenic flexure (see diagram) it passes across to the hepatic flexure and through it into the first section, or ascending colon, beginning at the cecum, where it accumulates until the colon in its entirety is gradually filled. This complete filling of the colon is necessary in cases in which fecal accumulations are present in the cecum and other remote sections. It is valuable in catarrh of the cecum, a condition often mistaken for appendicitis, and which is doubtless the precursor of appendicitis in the great majority of cases; also in cases where the cecum is infested with thread worms and in cases of so-called membranous colitis. The coloclyster also affords marvelous relief in a class of patients, by no means small in number, who, suffering from atony (lack of tone) and dilation of the colon (frequently from taking warm enemas without following them by cool enemas as a corrective), are always carrying about with them an enormous accumulation of fecal matter. These patients are variously classified as neurasthenics (nerve exhaustion), hypochondriacs (morbidity and moroseness with exaggerated attention to body conditions), simple dyspepsia, etc., and are treated for biliousness, insomnia, exhaustion and a multitude of ailments, by various need-less medicines, when all the conditions are the simple and inevitable result of chronic intestinal intoxication which is promptly relieved by a cleansing bath administered to the colon. The quantity of fecal matter removed in these cases is sometimes enormous. Not in-frequently quantities of old putrefying masses, semi-hardened by long retention, make their appearance after a free coloclyster has been thoroughly administered every day for a week or more, showing that a single irrigation of the colon, no matter how thoroughgoing, is not sufficient. In this class of chronic cases the coloclyster should be administered daily for two or three weeks if needs be, or as long as the patient complains of gaseous distention and flatulence. After the discharge of the warm water first used at a temperature of 92° to 94° (the body temperature is 98.6° F.) one to two pints of water at 60° to 70° should be run in and retained as long as possible as a tonic bath to the colon. Quacks have done much harm in advising the indiscriminate use of warm enemas. Care should be taken to avoid distending the colon with an excessive quantity of water at once. In ordinary cases the coloclyster need never exceed two quarts, and the quantity should be reduced from day to day after the colon has been thoroughly cleaned until only a pint or half pint of cold water is employed. Cold water stimulates and tones the bowel whereas hot water is relaxing. The cold enemamay be used indefinitely without producing constipation if the quantity of water is small. It acts as a sort of gymnastic trainer of the bowel, strengthening its muscular structures and increasing the activity and energy of its controlling nerves and nerve centers.'
The cool enema method (not coloclyster) should be progressive. Starting with 80° the final one can be gradually reduced until 70° is reached. It should as a rule always follow and not precede a natural action. If on occasion the latter fails, a small, cool irrigation of the rectum only is indicated, with the thighs then closely crossed in order to bring a frequently very effective pressure to bear on the pelvic colon and rectum. This should be accompanied by an erect posture of the trunk as an effective way to aid the muscles involved. With the obstruction re-moved the usual procedure in the use of the enema as far as the splenic flexure can then be followed. But this should always be considered as a final hygienic measure and not a preliminary one. If compelled to reverse this order, then the patient needs to direct prompt attention to the condition of the bowels by resorting to some of the measures set forth elsewhere both of examination and treatment. Is the tongue coated? Is the urine concentrated and abnormal in both odor and color? Is mucus present in the dark stools? Have the latter lost their homogeneousness (uniform consistency) as to color, density and continuity? Is there a lack of the buoyancy and efficiency characteristic of an efficient functioning of the intestinal tract? These are some of the questions, all based on detailed information set forth elsewhere, that are to be answered before the patient can hope for intelligent control of the deranged bowel function.
Going back now to the second of Case's and Hurst's two general classes of constipation, (omitting the third class caused by a deficiency in the contents of the colon given by Hurst in his 1919 edition, which will receive attention later), constipation in the neighborhood of the cecum remains to be considered.
In all chronic cases the colon should be first emptied where a digital examination is to be made. Then in the next 24 hours the abdomen and rectum should be examined to ascertain whether there is an accumulation in any part of the colon after an attempt to open the bowels without artificial assistance. An accumulation in the cecum and ascending colon or in the transverse colon indicates stasis (delay) in these situations. If more than a very small quantity is found in the rectum and the patient has no desire to defecate, dyschezia can be diagnosed. If the rectum is almost completely empty, the cause must lie in delay in the passage higher up, except in the somewhat rare cases of dyschezia in which there is inability to pass the contents from the pelvic colon into the rectum. In such cases a hard mass can be generally felt through the anterior wall of the rectum. (By resorting to the use of charcoal lozenges as disclosed in Chapter VI the amount of delay can be easily ascertained.)
Most cases are more or less cumulative, the bowels never being completely emptied, so that more and more feces are retained. In dyschezia, for instance, they collect in the rectum or the adjoining pelvic colon and gradually increase from below upwards. It is consequently possible, even where the higher parts of the colon will function normally if permitted, for partial obstruction to occur as the result of the accumulation below. For this reason it is only after the colon has been carefully emptied that the activity of all parts can be properly investigated. Neglect of this precaution has frequently led to the conclusion that stasis or even organic obstruction exists in the descending colon or splenic flexure, or less frequently in the transverse colon, when none is really present. With the bowels thoroughly emptied both by an aperient (mild cathartic) and enemata for two days, on the third and fourth mornings an enema should be given but no aperient and on the last morning a barium breakfast taken. It should be carefully noted that for the last 48 hours the colon is to be free of aperients as the intestinal function may otherwise be observed while still under their influence instead of under normal conditions. During the examination neither aperients or enemata should be taken but attempts made to open the bowels normally under ordinary dietetic and living condition. The examination can often be completed in three days but in cases of severe delay six are sometimes required. Two hours before the examination two ounces of barium for an ordinary sized person may be given with half an ounce of cocoa, half an ounce of sugar and a quarter ounce of cornmeal flour, to which eight ounces of hot water is added. To examine for stricture or other changes in the colon the barium enema is used, composed of 6 ounces of barium sulphate, 1 1/2 pints of water, 1% ounces acacia mucilage and an ounce of grain alcohol.'
Ileal stasis (small intestine) can be diagnosed if no trace of barium has reached the cecum 6 hours after a barium meal. It is, however, very unusual for nothing to enter the cecum within this period even in well-marked cases of ileal stasis, so that the diagnosis has generally to be made on account of the shadow of the ileum (lower 12 ft. of the small intestine) remaining visible for an unusually long period, at least five hours after the last trace of the meal has left the stomach. As it is difficult for the patient to go for more than six hours without food it is practically impossible to diagnose ileal stasis in a single day unless the stomach empties itself with normal rapidity, except in the comparatively rare cases already mentioned in which no barium at all has entered the cecum at the end of six hours. If the stomach empties itself in three hours and no additional food is taken for six hours and the barium is still in the end of the ileum nine hours after ingestion, ileal stasis can be diagnosed. But if the stomach is not known to have emptied itself in three hours ileal stasis can only be diagnosed with certainty if some barium is present in the ileum 24 hours after the meal.
Although the following case from Hurst has a constitutional history it is nevertheless instructive.
A gentleman, aged 40, had been constipated from in-fancy. Every member of his family, including father, mother and two sisters, suffered from the same cause. For two years he had complained of pain in the left iliac fossa (left flank) which led him to believe that he was suffering from obstruction in that region, though nothing abnormal could be felt. His occupation was indoors. When he had a holiday in the country and took more exercise, specially climbing, he was very much better. Recently he had been able to obtain an action only by continued use of pills and glycerine suppositories.
On examination after the bowels had been well emptied nothing abnormal was found and the rectum was contracted and empty. Instead of the cecum being reached by a barium meal in four hours, nothing had passed into the cecum in ten hours. In 24 hours the cecum, ascending colon and most of the transverse colon were visible, but little progress had been made 8 hours later. The barium had not passed the splenic flexure 48 hours after the meal and the left flank was reached only after 73 hours. On abdominal palpation (feeling with the fingers) scybala (hard material) was then distinctly felt in the descending colon, the latter being somewhat tender but quite movable. The rectum was still quite empty and contracted. The flexures (see diagram) were not at all acute in angularity and the intestinal wall was everywhere normal.
The family history of the patient suggested that he was suffering from constitutional constipation due to defective development of the intestinal musculature existing at birth.
The rectum was still empty 74 hours after the bowels had been opened. There was thus no evidence of dyschezia. The contracted condition of the rectum was probably due to the excessive use of glycerine suppositories. As the condition present could not be benefited by such stimulus to defecation the patient was advised to discontinue them. The small as well as the large intestine required stimulation, so a stimulating diet and auto-massage with a 7 pound cannon ball rolled over the whole abdomen was recommended. The patient was also instructed to take daily exercise and make more regular efforts to get the bowels to act. He was also given a pill containing nux vomica and a small dose of aloes to take three times a day with instructions to diminish the quantity until perhaps finally it could be discontinued completely.'
The method of diagnosis in the above case was excellent, the pill of nux vomica and aloes (the former to tone up the intestine and the latter to stimulate movements of the colon) to be commended, but the exercises with the cannon ball were practically worthless when applied to the colon, as it would in all probability increase the impaction.
In the light of the most advanced and authoritative practice of today, quoted in detail elsewhere, it would seem the above patient needed a proper dietary and free water drinking with change of intestinal flora; the intelligent use of bran and lactose; and carefully selected abdominal exercises; the use of laxative medicaments, changed weekly; and outdoor exercise with habitual practice of deep lung and abdominal breathing and hill climbing.
Although the softening action of oil on feces, says Hurst, is much less effective than water, ail injections are sometimes of undoubted value in detaching scybala (dried feces) from the intestinal walls and lubricating the surface of the contents (not the wet intestinal walls, as is often erroneously asserted), so that the expulsion is facilitated. The oil is only absorbed from the colon to a very slight extent; consequently its injection in the evening retards or prevents the absorption of water from the pelvic colon retained during the night. The colon can be irrigated in the morning.
Spastic constipation, says Kellogg, the result of colitis and spasmodic contraction of the ileo-cecal valve, due to chronic appendicitis or ovarian disease, and pain in the abdomen, no matter what the cause, should be treated by fomentation (an application of warmth and moisture). The electric fomentation heater is a valuable and ever-ready means of application of graduated heat to. the moist compress. The best time for applying the fomentation in spastic trouble is soon after breakfast or shortly before the regular time for moving the bowels, or when it is necessary in persons of delicate physique (but with-out spastic trouble) to increase tolerance of the cool enema. It should be applied for 10 or 15 minutes at as high a temperature as the patient can stand.
Applications can be made two or three times daily, or at least morning and night so as to relax the sharply contracted (spastic) colon. In very pronounced cases of colitis with spasm of the colon, a short, hot tub bath of not more than two to four minutes is of great service. The effect is to lessen the irritability of the nerve centers, and thus relieve the intestinal spasm which may be due to congestion or inflammation of the appendix, ovaries, bladder, rectum, or gall bladder, or still more often to colitis. A most effective variation of this treatment for the relief of intestinal spasms is a bath at 100° F. combined with a spray on the abdomen as hot as it can be borne (115° to 120°) for two to five minutes. It should be followed by a cold spray at a temperature of 80° for one or two minutes, the hands and feet being kept warm'
The hot sitz bath (hip bath in a small tub) at a temperature of 112° to 118° for two or three minutes can-not be too highly praised in the treatment of reflex and spastic constipation, with or without colitis. After the sitz no cold application is made. The best time is upon rising in the morning. In general, prolonged cold baths for as much as even two or three minutes are aggravating to spastic constipation. Also in the use of the enema where there is colitis, abdominal pain or tenderness present the water should be at a temperature of 104° to 115°. Where there is irritation of the mucous membrane, particularly in colitis, half an ounce of salt to half a gallon of water tends to lessen the irritation. The application should be repeated until no mucus re-turns. If the water is not fully evacuated the retained salt may be injurious. In draining it back, where difficulty is experienced, the hips should be elevated with the patient resting on the left side.' These directions as to temperature do not apply to the use of the enema in normal cases, which is fully treated elsewhere.
Kellogg is confident he has saved the lives of a number of persons suffering from suppression of urine by the employment of the hot enema at a temperature of 110° to 120° at periods varying from three to four hours. He has used the hot enema for this purpose for more than 20 years. For pain in the bowels such as intestinal, renal (kidney) and hepatic (liver) colic, enteralgia (pain in the bowels) and hyperesthesia (excessive sensibility) of the abdominal ganglia (subsidiary nerve centers) it is highly useful in a large proportion of cases.