Enema

• 1. Introduction

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  An enema is a fluid injected through the anus into the lower bowel, and a Russian spa settlement honors it with a monument. In front of the Mashuk spa in Zheleznovodsk stands a brass statue weighing 365 kilograms. Three cherubs hold aloft a syringe bulb of the kind used to give enemas. A local artist made it, inspired by the Renaissance painter Botticelli. He said: "An enema is an unpleasant procedure as many of us may know. But when cherubs do it, it's all right."

  The statue was unveiled on the 19th of June 2008. A banner on one of the spa walls urged visitors to beat constipation and sloppiness with enemas. The spa lies in the Caucasus Mountains region, home to dozens of spas that treat digestive complaints with enemas of mineral spring water. Its director told reporters: "An enema is almost a symbol of our region." It is the only known monument to the enema.

  How did an unpleasant medical procedure earn a statue? Who first thought of it, who relied on it, and who has been harmed by it? The answers reach back thousands of years and forward into present-day clinics.

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• 2. Words and Healers

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  The English word clyster entered the language in the late 14th century, from Old French or Latin. It descends from the Greek klyster, meaning syringe, which comes from a verb meaning to wash out. The spelling glister appeared in the 18th century. Today clyster is mostly archaic and refers especially to enemas given with a clyster syringe.

  Enema arrived much later, around 1675, borrowed from Latin. There it had taken on the sense of a rectal injection in the 15th century. Its Greek ancestor, enema, meant injection, from a verb meaning to send in.

  The Ebers Papyrus of Ancient Egypt, dated to about 1550 BCE, holds the first mention of the enema in medical literature. Egyptian medicine had many kinds of specialist. One was the Nery-Pehuyt, the Shepherd of the Anus. Another title, Keeper of the Royal Rectum, may have belonged mainly to the pharaoh's enema maker. According to Egyptian myth, the god Thoth invented the enema.

  Cuneiform tablets from Babylonia and Assyria, dated to about 600 BCE, refer to enemas. At first, the treatment seems to have rested on a belief that it could drive the demon of disease out of the body.

  In the fifth century BCE in India, the physician Sushruta counted the enema syringe among 121 surgical instruments that he described.

  Hippocrates, who lived from 460 to 370 BCE, mentioned enemas frequently. When recently eaten food had not gone down, he advised an enema for a strong patient in the prime of life. A weaker patient should receive a suppository instead. In the first century BCE, Asclepiades of Bithynia wrote: "Treatment consists merely of three elements: drink, food, and the enema." He blamed indigestion on food particles that were too big. His remedy was proper amounts of food and wine, followed by an enema to clear out the offending food.

  In the second century CE, Celsus recommended an enema of pearl barley in milk, or rose oil with butter, to feed dysentery patients who could not eat. Soranus prescribed enemas among other techniques, including as an abortion method he considered safe. Galen also mentions enemas in several contexts.

  Around 200 CE in China, Zhang Zhongjing was the first to use enemas. Wu Lien-teh records his directions: "Secure a large pig's bile and mix with a small quantity of vinegar. Insert a bamboo tube three or four inches long into the rectum and inject the mixture."

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• 3. Gourds, Horns and Bladders

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  On the Ivory Coast, healers traditionally use a calabash gourd to give an enema. The narrow neck of the water-filled gourd is inserted into the rectum. An attendant then blows forcibly into the gourd to push the water in.

  A patient on the Ivory Coast can also work alone. Suction creates negative pressure inside the gourd, and a finger seals the opening. Once the neck is in place, removing the finger lets atmospheric pressure drive the fluid.

  In South Africa, the Bhaca people used an ox horn. Along the upper Congo River, a hole in one end of a gourd allows filling, and resin fixes a hollow cane to the neck. The patient takes a posture that lets gravity send the fluid through the cane.

  Early Indian physicians built their apparatus from a tube of bamboo, ivory or horn, attached to the scrotum of a deer, goat or ox. In Persia, Avicenna, who lived from 980 to 1037, is credited with the clyster-purse. This collapsible part of an enema outfit was made from ox skin or silk cloth and emptied by squeezing with the hands.

  Indigenous peoples of South America used a rubber bag with a conical nozzle from an early period. Later they kept using a rubber bag with a connecting tube and an ivory tip. In Europe, by contrast, a syringe was still the usual tool.

  The first illustrations of enema equipment in the Western world date from medieval times. They show a clyster syringe, a tube attached to a pump-action bulb made from a pig bladder. A simpler design replaced it, with the rectal nozzle joined to a syringe with a plunger rather than a bulb. That piston syringe stayed in use from the 15th through the 19th centuries.

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• 4. Ritual and Tradition

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  Between the 10th and 7th centuries BCE, the Olmec of Mesoamerica were already using trance-inducing substances in ceremonies. This began in their middle preclassic period and lasted until the Spanish Conquest. Enemas given with jars were one of several routes.

  Mayan sculpture and ceramics from the late classic age, the 7th through 10th centuries CE, show ritual hallucinogenic enemas in action. The syringes were made of gourd and clay. In the Xibalban court of the God D, Maya artists drew female attendants giving clysters with a characteristic bulb syringe.

  All across Mesoamerica, ritual enemas carried psychoactive substances into the body. These included balche, alcohol, tobacco, peyote and other hallucinogens. Going in this way brought on more intense trance states more quickly. Some tribes continue the practice today.

  The Maya also turned to enemas to fight illness and discomfort of the digestive tract. The Florentine Codex documents this use from the colonial period.

  On the Indian subcontinent, Ayurveda gives the enema the name Basti, or Vasti. It forms one part of Panchakarma, a procedure in which herbal medicines are introduced rectally.

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• 5. Clysters at Court

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  From the 17th century, enema apparatus was designed chiefly for self-administration at home. Many of the designs were French, because enemas enjoyed wide use in France. Clysters were given for constipation and, with more questionable effectiveness, for stomach aches and other illnesses.

  In 1694, François Mauriceau recorded in his treatise The Diseases of Women with Child that midwives and man-midwives commonly gave clysters to labouring mothers just before delivery. There is no evidence that the practice helps, and it is now discouraged.

  In 1753, Johann Jacob Woyts described an alternative to the syringe. It was an enema bag prepared from a pig's or beef's bladder, attached to a tube.

  The Royal Humane Society of London placed tobacco resuscitation kits at various points along the Thames. Each kit held a pair of bellows and a tube. In the 18th century, Europeans began copying the tobacco smoke enemas of North America's indigenous peoples to revive drowned people. Those peoples had injected the smoke through a rectal tube to stimulate respiration. Europeans came to use such enemas for headaches, respiratory failure, colds, hernias, abdominal cramps, typhoid fever and cholera outbreaks.

  The duc de Saint-Simon described how popular clysters were at the court of King Louis XIV of France. The duchess of Burgundy had her servant give her one in front of the King before going to the comedy. An adequate posture preserved her modesty. Even so, the King and Mme de Maintenon were astonished that she took it before them.

  Clysters stayed a favourite of the bourgeoisie and nobility of the Western world up to the 19th century. Medical knowledge was fairly limited, so purgative clysters were prescribed for a wide variety of ailments. In the 19th century, gravity-fed designs became common. A hose with a nozzle at one end connected to a reservoir, either a bucket or a rubber bag, held or hung above the recipient.

  Writers noticed the habit early. In the satyr play Limos, Silenus tries to give an enema to Heracles. In Shakespeare's Othello, Iago says to Cassio: "Yet again your fingers to your lips? would they were clyster-pipes for your sake!" In Cervantes's Don Quixote, a tale tells of the Knight of the Sun, bound hand and foot, given a clyster of snow water and sand.

  In the 17th century, satirists made physicians a favorite target. Molière's caricature prescribed "clyster, bleed, purge," or "purge, bleed, clyster," for anything. In his play The Imaginary Invalid, the hypochondriac Argan is addicted to enemas. Béralde asks him: "Can't you be one moment without a purge?"

  George Orwell's Nineteen Eighty-Four compares sexual intercourse to "a slightly disgusting minor operation, like having an enema." In the film The Right Stuff, astronaut Alan Shepard retains a barium enema during flight training. He rides a public elevator in a hospital gown, holding the enema bag with its tip still inserted.

  The band blink-182 titled an album Enema of the State, with a nurse on the cover. The band Tool named a song "Ænema" after lyrics that wish Los Angeles would be flushed away when the San Andreas Fault collapses. The idea comes from comedian Bill Hicks and his "Arizona Bay" routine.

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• 6. How Enemas Work

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  A patient given a large volume enema is usually asked to hold the solution for five to ten minutes, as tolerated. Some nursing textbooks recommend five to fifteen minutes, or as long as possible.

  The main trick is volume. A large amount of liquid makes the colon dilate suddenly, and the colon answers with general contractions called peristalsis that push its contents toward the rectum. Some solutions also irritate the lining of the intestine, which adds to the stimulation and lubricates the stool. How well an enema works depends on the volume, the temperature and the ingredients.

  A low enema is generally useful only for stool in the rectum. To empty the whole colon, deeper and higher enemas are used. People often call a large volume enema a soapsuds enema, although soap is not necessary. At home it can relieve occasional constipation, but recurring or severe cases may need medical care.

  Plain water works mechanically by expanding the colon. Normal saline is the least irritating choice. Because its concentration matches the body, it neither draws electrolytes from the body, as plain water does, nor pulls water into the colon, as phosphates do. That makes it suitable when a longer retention is wanted, for example to soften an impaction.

  Castile soap is often added because it irritates the lining and raises the urgency to defecate. Liquid handsoaps and detergents should never be used. Glycerol, used in a dilute solution of around 5 percent, induces peristalsis through a hyperosmotic effect.

  One emergency-department recipe mixes equal parts of milk and molasses, warmed to slightly above body temperature. Neither the milk sugars and proteins nor the molasses are absorbed in the lower intestine, so the water stays in the bowel. Studies have found a low complication rate. Mineral oil acts as a lubricant and stool softener, though it can cause rectal skin irritation and oil leakage.

  The disposable microenema, a squeeze bottle, was invented in the early 20th century by Charles Browne Fleet. Sodium phosphate, sold under the brand name Fleet, usually brings a bowel movement in 1 to 5 minutes. It draws extra water from the bloodstream into the colon, and it can cause intense cramping. For constipation, the recommended adult dose of sorbitol is 120 mL of a 25-30 percent solution, given once.

  Several brand-name products combine ingredients. Klyx, developed by Ferring B.V., pairs docusate sodium with sorbitol. Microlax combines sodium citrate, sodium alkyl sulphoacetate and glycerol. Dantron is a stimulant and stool softener that is considered a carcinogen. In the UK, its use is restricted to patients who already have a diagnosis of terminal cancer, and the USA does not use it at all.

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• 7. Beyond the Bowel

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  In a lower gastrointestinal series, better known as a barium enema, the fluid may contain barium sulfate powder or a water-soluble contrast agent. It makes the bowel visible on X-ray. Doctors sometimes consider it the only practical and relatively safe way to view the colon. A patient who cannot pass all the barium may become constipated or impacted. Anyone with no bowel movement for more than two days, or who cannot pass gas rectally, should tell a physician promptly.

  Transanal irrigation, also called retrograde irrigation, uses a water enema to help people with bowel dysfunction such as fecal incontinence or obstructed defecation. Regular emptying can restore controlled bowel function to a high degree. Results vary widely. Some people gain complete control, while others report little or no benefit. An international consensus on the method was published in 2013. The Malone antegrade continence enema is a different procedure, in which fluid enters the colon through a surgically created irrigation port. For people with a bowel disability, a daily enema can set a predictable time and place to evacuate.

  Enemas can also deliver medicine when swallowing a drug is undesirable or impossible. Rectal corticosteroids and mesalazine treat inflammatory bowel disease. This route skips the entire digestive tract and limits how much medicine reaches the bloodstream. Rectal corticosteroid enemas are sometimes used for mild or moderate ulcerative colitis, alone or alongside oral or injected medicines.

  Butyrate enemas have been studied for infectious diarrhea. In shigellosis, an 80 ml sodium butyrate isotonic enema given every 12 hours helped heal the rectal lining and reduce inflammation, though it did not speed clinical recovery. In remote or rural settings, there are a few cases of rectal fluids being used to rehydrate a person. One benefit is that the fluids need not be sterile.

  In 1958, doctors first transferred healthy gut bacteria by infusing stool, a fecal microbiota transplant, using retention enemas. Enemas remained the most common method until 1989, when other methods were developed. As of 2013, colonoscope delivery was preferred, because it can inoculate the entire colon and ileum, whereas enemas reach only to the splenic flexure.

  A nutrient enema feeds a patient who cannot be fed otherwise with predigested food. The technique is ancient, documented by Galen and commonly used in the Middle Ages and the 19th century. As recently as 1941, the United States military's manual for hospital diets prescribed it. Tube feeding and intravenous feeding have since replaced it.

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• 8. Misuse and Harm

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  Repeated enemas can cause an electrolyte imbalance. Improper use can also tear the bowel or rectal tissue, and because the rectum is insensitive to pain, the damage can go unnoticed and bleed internally. These events are rare in healthy, sober adults. Dark or reddish stool can reveal hidden bleeding. The tube and solution may also stimulate the vagus nerve, triggering a slow heartbeat. Frequent use can lead to laxative dependency.

  Someone with undiagnosed abdominal pain should avoid an enema, because the bowel's movement can burst an inflamed appendix. A case series of 11 patients recorded five deaths linked to phosphate enemas in high-risk people. Ozone water, sometimes used in enemas, has been shown to cause microscopic colitis immediately.

  In the late 19th century, Dr. John Harvey Kellogg made sure every patient's bowel was washed from above and below. His favorite device was an enema machine that could run fifteen gallons of water through a person's bowel in seconds. Each water enema was followed by a pint of yogurt. Half was eaten, and half was given by enema, "thus planting the protective germs where they are most needed and may render most effective service."

  Kellogg's thinking rested on autointoxication, the idea that waste in the large intestine poisons the body. That view was orthodox doctrine until the end of the 19th century and has since been discredited. Alternative medicine still practices colon cleansing under that old idea. The Food and Drug Administration has ruled that colonic irrigation equipment is not approved for sale for general well-being.

  Gerson therapy includes coffee enemas, and sometimes enemas of castor oil, hydrogen peroxide or ozone. Coffee enemas have no proven benefits. Medical authorities consider them rash and potentially dangerous. Documented harms include infections, sepsis, severe electrolyte imbalance, colitis, brain abscess and heart failure, and deaths have been recorded. Claims that they detoxify tumors have no scientific support.

  Enemas have also been forced on people as punishment. Political dissenters in post-independence Argentina were given enemas of chili pepper and turpentine, a very harsh purgative. The Senate Intelligence Committee report on CIA torture documented enemas used to ensure "total control" over detainees. The CIA forced nutrient enemas on detainees who tried hunger strikes. One detainee described what he received as "violent enemas."

  Fraud has done its own damage in this century. Chlorine dioxide, a potent and toxic bleach relabeled as MMS or Miracle Mineral Supplement, has been fraudulently marketed as a treatment, mainly for autism. One six-year-old boy needed his colon removed and a colostomy bag fitted. The claims trace to former Scientologist Jim Humble and his 2006 self-published book, The Miracle Mineral Solution of the 21st Century. Promoters say it expels parasitic "rope worms," but these are fragments of damaged intestinal lining. When promoters claimed MMS had fought malaria, the International Federation of Red Cross and Red Crescent Societies rejected the reports "in the strongest terms."

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