There are unquestionably certain cases in which the colon has become so crippled by inflammations, stretchings, distortions, adhesions and the degeneration of its muscular structures, and consequent weakening of its contractile powers, that it can no longer be made to perform its functions, even by the use of such accessories as act as mechanical or physiological aids. In such cases and in certain emergency cases, the judicious use of the enema is not only helpful, but sometimes necessary. For example, in cases of senile constipation, where as the result of long continued colitis, the muscular walls are thin and greatly stretched, while the colon itself has become abnormally redundant and folded upon itself, the daily or frequent use of the enema may be required.

The best means of administering the enema is the fountain syringe. The tube should be long enough so that the reservoir, if necessary, may be raised to a height of five or six feet above the patient. When it is desired to stimulate the bowel to immediate contraction, the reservoir should be placed high, but when the purpose is to introduce as large quantity of water as possible into the colon, and to have it retained for a time, the reservoir should be placed at a height not exceeding two or three feet.

The position of the patient during the administration of an enema is not a matter of very great importance. In cases in which the pelvic colon is low down in the pelvis, as is shown by examination, it is well to put the patient in a knee-chest position. The water should be introduced very slowly. Ordinarily, however, the patient may lie upon the back or either side, or the enema may even be ad-ministered standing. The water quickly finds its way along the colon, no matter what the position of the patient may be.

The use of the colon tube is quite unnecessary. Indeed, as the writer learned long ago by experience, and as has been abundantly proved by examination with the X-ray, the colon tube can rarely ever be introduced beyond the rectum. It is arrested at the pelvi-rectal fold, and simply returns and coils itself up in the rectum. A tube long enough to pass the water through the anus is as useful as the longest colon tube, unless the long tube is passed into the pelvic colon past the ileosplenic flexure, a procedure which is rarely required, and, of course, should only be undertaken by a physician.

The enema may be employed in a variety of ways adapted to different occasions and purposes, and it may be repeated as many times as may be necessary. Warm water dissolves hardened fecal matters much more readily than cold water, yet in some cases it may be necessary to repeat the enema, at intervals of fifteen to twenty minutes, five or six times before the effect desired is obtained. When used for the purpose of softening hardened fecal matters, the water should be introduced slowly, and the patient should be instructed to retain as much as possible. The enema should be repeated as long as the water contains fecal matters when returned.

The Hot Water Enema

The temperature of the water should be 105° to 115° F. The quantity may be from one to three pints. This is preferable in cases of colitis and when abdominal pain or tenderness is present.

The Hot Soap Enema

The addition of soap to the water somewhat increases its power to dissolve hardened feces, although the advantage of its use is not so great as might be supposed. The amount of soap should be sufficient only to make very weak suds, as otherwise, it may be irritating, especially if the soap con-tains a considerable amount of free alkali. Ordinary soap is best for the purpose.

The Hot Saline Enema

Half an ounce of salt is added to two quarts of water at a temperature of 105° to 115° F.

The purpose of the addition of salt is to lessen the irritation of the mucous membrane. It is of special use in cases of colitis, in which the enema is administered for the purpose of removing mucous and relieving spasms of the intestine. The application should be repeated until no mucous returns with the water. Care must be taken to secure evacuation of the water so as to avoid retention of a large amount of salt, which may do serious injury.

The Cold Water Enema

A cold application to the interior of the bowel is one of the most powerful means of stimulation which can be safely employed. Half a pint of water at a temperature of 50° will usually set up a very strong and painful contraction of the lower bowel. It is on this account necessary to begin with a moderate temperature. The first enema should have a temperature of 80° to 85° F. The temperature may be lowered on each application five to ten degrees, or until sufficient powerful contractions are produced to expel quickly the water introduced. By gradually reducing the temperature in this way, one as low as 40° may finally be used without causing excessive pain. Such low temperatures are very seldom required except in dysentery, in which they often render great service.

The cold enema is of special use in cases in which the colon has become gradually dilated and has become atonic, and contracts with insufficient force to expel its contents. In such cases a warm or hot enema is usually retained. By following the warm enema with half a pint or a pint of water at 60° to 70° F., prompt contraction of the bowel almost invariably follows, with expulsion of the bowel contents. This is a very important practical use of the cold enema, as the retention of the water in cases in which the bowel is filled with putrefying fecal matters is very often followed by very unpleasant and even serious effects, through the absorption of enormous quantities of toxic substances, which are dissolved by the water and brought into contact with the absorbing surface of the bowel. In such cases the hot enema should be immediately followed by a small cold enema, and the cold enema should be repeated several times, if necessary.

The Oil Enema

The amount of oil required is four to sixteen ounces. Either pure olive oil or any sweet oil may be employed. The latter is just as good as the former, and is less likely to produce nausea and vomiting, which sometimes follows the use of olive oil of an inferior grade. The temperature of the oil should be 104°. As a means of softening hardened feces, oil is no better than water; in fact, according to the writer's experience, it is less efficient. It is useful, however, as a means of lubricating the lower bowel, and when introduced at night prevents hardening and drying of the feces. For this purpose 4 to 6 ounces should be introduced at night When used for the purpose of lubrication only, a good plan is to administer the oil before breakfast. This is an excellent means of securing a thorough evacuation of the colon.

Sugar And Water Enema

Sugar is a powerful stimulant of the colon. A very old-fashioned remedy is the introduction of molasses into the colon. To half a pint or pint of molasses an equal quantity of hot water is added. A prompt action of the colon usually follows the introduction of this mixture. The writer has for years used malt sugar for this purpose, and with most satisfactory results. The malt sugar not only acts as a stimulant to the bowel, but at the same time furnishes valuable nourishment. Four ounces of malt sugar should be added to a pint of water.

Paraffin Oil Enema

Liquid paraffin, or paraffin oil, may be used as an enema in place of olive oil and other oils, and has the advantage that it does not produce nausea or other unpleasant symptoms. Paraffin oil is better than any animal or vegetable oil, for the reason that it is not a fat, and is not absorbed, neither will it undergo fermentation. The oil enema often causes nausea, loss of appetite, and coating of the tongue. This may be avoided by the use of paraffin oil. Only the specially purified refined white Russian oil should be used.

The Alum Enema

In cases in which the bowels cannot be made to move promptly by other means, alum has been found to be effective. A teaspoonful of powdered alum is used in a quart of water. By using cool water 70° to 80° the effect may be increased.

The Glycerine Enema

Pure glycerine introduced into the rectum in a quantity of one to four ounces is a useful means of stimulating bowel movements, by bringing about the defecating reflex. When pure glycerine is found to lead to too much irritation, as is sometimes the case, it should be used with an equal quantity of water.