Dr. J. Glenn Knox BA, DC

Enemas fill the colons of people from every creed, culture and socioeconomic background. As far back as man has used tools to make his life and health better there is evidence that healers sought to unplug and let flow the waste from their patients. Giving enemas to treat the sick dates back to a time before writing. Water flowed from the gourds of medicine men and women into the bowels of the ancients as it still does today. The euphoria that commonly follows a good enema and the level of health that accompanies good elimination is known now as then. The cleaning of waste from within the body with an occasional washing is healthful and not to be poo pooed--- well, may be poo pooed, but at least not underestimated. Enemas relieve constipation, diarrhea, dysentery, painful menstruation, depression, toxicity, colitis, diverticulosis, common migraines, tension headaches, acne, allergies and fevers. They stimulate the immune system in infectious disease. The enema is used in preparation for child birth, for internal cleansing, as preparation for religious rites and experiences and more. Although it is not a very commonly asked question, most people would admit to having their rectums visited by an enema nozzle at least once.

With all this history, experience and success, the enema is yet to be studied with any degree of rigor. This is unfortunate. The simple enema is one of the least expensive, proven therapies in the modern medicine chest. Even with the frequency of its use and benefits, it is not talked about or written about. This is unfortunate on two levels. First, many people who would greatly benefit from having two or three cents worth of warm water correct their problems, instead take more dangerous, expensive, unnatural cures. Second, the enema is not entirely safe in the hands of the uninformed or not so smart. The giving of enemas requires knowledge. Giving enemas requires an understanding of the body. For those things that we take in by mouth, the Lord was wise enough to give us warning systems to detect danger. We can feel cold, heat, burning and cutting in the mouth. We can taste bad things. Still, with all these warning systems, we manage to poison and injure ourselves occasionally. The colon and introduction of liquids by way of rectum is not so safe. The colon has no taste, cold, heat, burning or cutting nerve sensation. It only responds to stretching such as gas pains. The colon is also much less defended by the immune system from the invasion of microbes and parasites. For this reason enema equipment should never be shared. Every person, even in one family, needs their own bag. The standards of cleanliness of this bag are more important in preventing spread of disease than the dishes from which you eat. Shared bags mean shared germs. Unclean nozzles, tubing and bags mean bacteria cultures.

A familiar site in many homes is the family enema bag hanging on the back of the bathroom door. This tradition has probably been with us as long as there have been bathroom doors on which to hang these bags to dry. A group of bags hanging up drying would be better, one for each person on the receiving end. This time honored tradition has a good reason. Its presence there is much more than just for the amusement of your brothers, sisters, school chums, neighbors, etc., that see it there. A little drop of water hanging from the draped nozzle tells all passers by that it has recently been in someone's fanny. The bag once used should not return to the privacy of the linen closet until it is clean and dry for some very good reasons. Most mothers and nurses, before the age of knowledge of germs, were concerned about the condition of the bag. Wet bags, left wet, crack and deteriorate more quickly. We now know more important reasons for drying them.

I was chatting with an internist the other evening. He pointed out something new. Although in the many billions of enemas given over the years, to my knowledge, no incidents of toxic reactions to contaminants from enema bags have been reported. This is true in the medical literature during the era when enemas were very common. It is possible now with a focus on eliminating safer alternative forms of treatment in favor of more profitable treatments that such data could be published in "scientific" journals funded by drug companies, with or without scientific merit or reliable proof. Real concerns do exist. His particular concern was mildew. Bags or tubing put away wet could quickly contain mildew. So the old family bag hanging on the door with its tubing draped over it does have a good purpose. Dry bags and tubes don't mildew. Dry bags and tubes fill all their nooks and crannies with air and are aerobic. They are filled with oxygen. Most disease pathogens are anaerobic. They don't like oxygen and die when dried out in open air. It is important to dry and clean enema bags after use. In hospitals before the seventies there were a room for drying enema cans and similar instruments. While this doctor's logic, particularly in this age in which we fear all bacteria beyond physiologic reason, does come in line with current medical thinking. It does not square with observed fact. In many billions of enemas administered during this century, few if any problems relating to this have ever been noted. I have seen no articles published on this in any scientific medical journal. Many people are highly allergic to mildew. If mildew were even a rare problem in the administration of enemas, it would have been observed. Allergic reactions to hospital administered enemas during the many decades of using the standard stainless steel enema cans and rubber hoses would have been reported in the literature. Still concern with sterile technique is the current vogue, and worth observing. Now in hospitals enemas used are all disposable. This is safer.

Hospitals charge to give an enema, so throwing away used equipment is no big deal. The insurance companies, patients or tax payers will pick up the bill. Those, who don't want to buy a new bag every time an enema is needed, need to know how to keep it clean. Fecal material reaching the bag is possible and common. This can be prevented in two ways. One, hold the bag high enough to keep the pressure above that that can be applied from pressure in the patient's colon. The second, is to stop the flow before the bag is completely empty, or to hold the bag up for the last few ounces and then close the clamp before lowering the bag to prevent back flow. Dropping the bag while the clamp is open and attached to the patient, insures that the bag is contaminated The tubing and hose are another matter. Normal surges in pressure in the patient's rectum during the enema make it almost a certainty that the tubing will have some back flow of fecal material into the tubing.

This is why I strongly recommend running a bag full of chlorinated water through the bag and tubing after use. This will remove most of the contamination. There is no way to be certain that this area of the tubing is completely clean and disease free. They designed all the old bags and hospital enema equipment for years of useful service. Cleaning the equipment and protecting the patient, were designed into the structure. After use, the last of the water can be emptied with the hoses still attached. This flushes fecal material that may have back flowed into the tubing. The hospital enema cans or open top syringes made this particularly easy. Hot water bottles require more effort. Rinsing both the bag and tubing with a bag, or few bags full of tap water is a good idea to be sure it is clean.. Washing out as much fecal material as possible is important. Then, dry the bag to protect it and the patient during future use.

Some simple and yet effective techniques in safeguarding the health of more healthful patients are worth practicing. One thing I do that should help keep all this safer is the use of a little baking soda in the water. On drying it leaves an alkaline coating on the inside of the bag and tubing. This also helps prevent the growth of bacteria, or mildew, and is not toxic as would be many other bactericidal additives. If the bag is rinsed and dried well and used by only one person, any bacteria or pathogen introduced into the patient will probably already be present in their own colon or they will already have developed resistance to it. This avenue easily transmits parasites of others and could share bacteria.

If the recipient, user of this bag is in any way immune system compromised, either use disposable equipment, or ask your health care provider about methods of sanitation or sterilization. The presence of a piece of fecal material remaining in the tubing or bag is impossible to totally avoid. I mentioned earlier that in billions of enemas have been given to patients with this type of equipment over this century in America. No one has shown me any records of this causing problems in unshared equipment. However, immune system failures, such as AIDS are common now. This type of disease was very rare before the 1980's. Failure of the immune system is also a problem near the end of life. During the last few years of most people's lives that die of "old age," their immune systems function increasingly poorly. The use of sterile techniques with these patients may be indicated in postponing the inevitable. Some infection or virus usually claims them with even heroic efforts. It is possible for them to be very susceptible to infection from common bacteria. Certainly most of this contamination comes to them via mouth. It could come via colon. You do not want you and your enema bag blamed. Use uncommon caution with fragile patients. The health and well being of an enema patient is very much in the hands of the person holding the bag. Reasonable care is necessary.

A healthful colon can be damaged by too much heat or cold or chemicals in the water. The unhealthy colon is more vulnerable. Only give enemas to patients with colon disease or serious health problems on the advice and consent of a chiropractor, medical doctor or other trained health professional. Do not give enemas to others for any health problems unless you understand those problems and the effects of filling the colon with water on those problems. Patients have died in hospital from electrolyte (salt) imbalances from excessive enemas. Patients have died from ruptured colons due to too much water injected with excessive pressure or punctures with an enema tube. Patients have died from infection, alcohol poisoning and other reactions to foreign substances used in enemas. That being said the enema is a very common home treatment. Given with simple precautions and common sense, enemas are less dangerous than most over the counter non prescription drugs. It is important that the administrator have a respect for the uses and misuses of the enema. It is a simple thing to fill an enema bag, attach the hose. It is a simple thing to empty the bag when someone else's colon is being filled as has been done since before the first block was laid for the Great Pyramid. The protection of those left holding the contents of the bag is important. Seek advice when needed.

Congestive heart failure and kidney disease may make it difficult to deal with the water loads put into the body by taking enemas. Patients suffering from these diseases may also greatly benefit from having enemas. Seek the advice of a chiropractor, doctor or other person knowledgeable in these areas of health and disease. The purpose of a chiropractic or medical physician is to be a resource. Their years of training give them knowledge of specific diseases that nurses, mothers and lay enema practitioners are not expected to have. For example, some diseases such as multiple sclerosis may affect the colon by allowing it to be filled with an enema, but not allowing the contraction of the walls of the colon to expel it. The patient will absorb this water. This can cause an electrolyte imbalance. A healthful person can have their heart malfunction and die if they succeed in rapidly drinking a large enough quantity of water to imbalance their electrolytes (salts in the blood). The colon absorbs water very much more rapidly than the stomach. This makes this problem more acute when administering an enema. A healthful person on taking and absorbing too much enema will feel sick, weak or dizzy. They usually let you know they feel bad. I have found this to be a common problem with patients with abnormally large colons. On the one hand they need enemas because they do not have good elimination. On the other, they hold and absorb more water creating a danger of electrolyte imbalance. Babies, some old people and others that lack the ability to communicate their feelings can become over hydrated and suffer heart failure from absorbing too much water.

The use of exotic solutions has been and continues to be a problem in the administration of enemas. Soapy enemas are recommended by many old text. Castile soap continues to be supplied by disposable enema bag vendors. I do not use or recommend soap in enema water. Soap is a decided irritant to the bowel. A good bowel movement can be obtained without the use of soap. I believe the historical and continued use of soap is just that we relate washing to soap and water. The colon and the skin differ in their needs to be washed. The skin is a protective barrier to the outside world that is fairly resistant to irritation and directly smelled by others. The bowel is a water absorption and holding organ that has some special functions. It is not intended to be washed like a dirty face. It will never be free from odoriferous bacteria or feces. These are the normal contents of the colon. The function of enemas is to remove most old waste or have some therapeutic effect. This does not require soap.

Plain water, when only one or two injections are required, is usually perfectly acceptable. However, never forget that the standard of purity of the water is much higher than that required for drinking. If there is concern about electrolyte imbalance adding one level teaspoon of table salt or baking soda per quart of water is a good idea. Also, the more exotic enema liquids are not without high risk. Coffee enemas are given for specific therapeutic purposes and are highly useful for the diseases and conditions for which they are used. However, I do not recommend their use unless specifically called for in your doctor's instructions. Coffee is a stimulant and stimulants are counter indicated in many conditions. It is also an organic substance. It will set up a medium for bacteria to grow in the bag used for the enema, possibly making the enema bag unsafe to reuse.

The injection of any substance via rectum bypasses the body's defense systems and has risk. The use of any other substance than plain water, or isotonic water is questionable. One substance that has caused some severe injuries and deaths is alcohol. The colon absorbs water many times faster than the stomach. This is good when rehydration or absorption of electrolytes or medications is needed. If the colon is filled with wine or other alcohol this also is absorbed much more rapidly than if it is drunk. Those that take wine enemas get very drunk, very quickly. They can also, and have died of alcohol poisoning. Giving these kinds of substances is no more difficult than ordinary cleansing enemas but can change a safe, innocuous procedure into a very dangerous one.

Giving an enema to a conscious cooperative patient is not that difficult. Every day totally untrained patients help teach the procedures to student nurses and nurse's aides. Teaching home health care is part of the mission of many nursing programs. The appropriate use of the home enema historically has been a part of that mission. Given that encouragement the home enema's benefits are often shared with families. A former patient and mother may sit reading the instructions written on the box containing a combination syringe. Then she takes the bag out of the box. A wide-eyed son or daughter begins this process sitting on the bed beside her looking at the picture of the kind faced nurse looking right through them out of the empty box. Twenty minutes later their mother holds the bag up and coaxes the last few ounces into their bowels. Their first enema churns within them. Mother smiles empathetically. Receiving enemas is a very common experience. From teaching hospital, to x-ray room, to maternity ward and may be even to an upstairs bed room in her mother's house, she has been there. She smiles for two reasons. Now she has just given her first enema. This chapter is to give a foundation in the physical methods of giving and receiving enemas, for that no doctor's degree is required. The enema is a warm wet filling experience that is neither painful nor unpleasant if given properly in the absence of disease.

Giving them is not so common or so readily learned by all that are taught. This has caused much misinformation and fear of the procedure. The use of the enema is only vaguely broached in nursing education. The procedure accounts for rarely more than a few pages in most nursing text. It is almost unmentioned in medical education. Our young mother having read how to from the drug store box and successfully given an enema is probably as well prepared to give enemas as many professionals. This is especially true since she has experience on the other end of the procedure. Receiving one requires even less training. Those that are bright enough to be able to remove their panties, have good sphincter tone and lie quietly for five minutes usually do quite well. The success or failure of the procedure depends patient cooperation.

The first principle is gentleness and a respect for the dignity and apprehensions of the patient. Receiving an enema does not require great intelligence. It does require a bare bottom and sharing the function of the bowels with another person. Many people are quite embarrassed by this and the whole process. Communication, reassurance and a kindly manner help. Preparation of the patient involves first informing them of what is to be done and gaining their cooperation. They should urinate and attempt to have a bowel movement before the enema. Preparation includes having a warm place to receive the enema. A patient that is cold will usually have difficulty in receiving a good enema. Temperature should be at least 72 degrees, and if there is fever or chills warmer would be good. Having an enema in a sauna is a good location. Most enemas are given in bed with feet kept warm under blankets and sheets protected by a water proof pad.

The bed, treatment table or floor may be used so long as it is comfortable. If given on the floor, a mat or blanket will make the surface more palatable and avoid chilling the patient. A floor can drain the heat from a person when the room is quite warm. On the bed or treatment table, protect the surface with towels or if possible a vinyl or rubber sheet covered with a towel. Not all patients hold their enemas equally well and cleaning a bed can be difficult. Treatment tables can vary extremely. Most are flat massage tables and work very well. I particularly like the chiropractic high-low table for the positions it allows.

The advantage of a high-low table is the position of the patient. It is possible to elevate the hips, take the weight completely off the stomach and let the patient lie face down in a very comfortable position. The table could also be difficult to clean, but it is a great place to have an enema. Patient positioning involves one principle. That is that water does not run up hill. Any position for an enema that requires water to run up hill will require a very motivated patient with a strong sphincter muscle to be effective. The effective administering of an enema requires that the nurse not make such unnecessary demands of the patient. Let water flow down hill. The chiropractic high-low table elevates the hips and the weight of the body is removed from the abdomen. Water flows in and if there is no obstruction and the patient relaxes and the entire colon fills with the rectum remaining virtually empty until the end of the enema. The relaxed patient will have little or no sensation of having to evacuate until the colon fills completely. If they do a short stopping of the enema and a little encouragement is all that is needed.

Most people do not have such equipment available, and it is unnecessary. All that is necessary to remember is that the point of putting the water in should be higher than the rest of the colon. The various positions that accomplish this are the knee chest, in which the patient rests their chest on the floor or bed and stands on their knees. Obviously the rectum and bottom are above the rest of the body. Any variation of this is good. Being taken over the knee has the same advantage of elevating the buttocks above the rest of the colon. This works for children and those intimate and small enough to be comfortable over the knee. It is also important that the abdominal muscles be relaxed. Any position that requires muscular effort to maintain will be self defeating. Gravity will contest with muscle tone and may in the short run lose resulting in a less than adequate enema.

Lying down is a chosen favorite. As a famous actor said in an interview I watched many years ago, "If you can walk rather than run, walk. If you can stand still, stand still. If you can sit down, sit down, and if you can lay down lay down." Lying down consumes very little muscular effort. However lying on the back puts the rectum lower than the rest of the colon, but is a very good position if you have a patient that leaks. You can pour away while they drip into a bed pan and still have a moderately successful treatment. Lying on the right side also puts the rectum below the sigmoid and descending colon and requires water to flow up hill. Lying on the left side makes half of the colon below the rectum and is a good position. It also keeps the weight off the abdomen. Lying on the stomach puts the rectum above the colon in most people, especially women whose hips are hopefully larger than their midsections. It does have the disadvantage of compressing the abdomen. I have found on many patients having been prepared in Sims' position for having a barium study, that many take more water on their stomachs than on their sides.

The classic position to receive an enema is Sims' position, presumably named after a patient named Sims that required many enemas. One would hate to think that all that was worthy to note about a physician is that he discovered lying on the side, but that is probably the case. Most procedures or diseases are named for the physician that discovered them. In any case Sims' position is most easily achieved by having the patiently on their stomach with any clothing pulled up to the level of the waist and removed from there down. Then lift the right hip and bend the right leg until the thigh is at about 90 degrees to their body. The left leg should have the knee bent a few degrees also. This position puts the colon lower than the rectum. At worse the cecum and ascending colon are at about the same level as the rectum. This position removes their weight from their abdomen. This position is the best for giving an enema on a flat surface with the patient completely relaxed, and is standard in most nursing manuals.

Positions that are recommended in others, but defy the rule of water not running up hill are: sitting up to receive an enema, standing or any other position that puts the abdomen and colon above the rectum. However if you are comfortable with these positions and can fill the colon, do not be dissuaded by logic. All scientist and theorist strive to describe the workings of complex things like anatomy and enemas to those that know from experience what works best for themselves. What works for you is right for you. You may want to experience orthodoxy, and see if there is validity to our arguments. If you can take more water comfortably, then change. If not, use the procedure that you know works for you. Whatever the disadvantages of forcing water to flow up hill, taking an enema in one of these positions is a great test of the holding power of the patient. The rectum fills to capacity from the beginning and the urge to release the enema should be unremitting.

Now you have the enema tube in hand. You are ready to pour it into your patient. Now you have to do your part. The patient has undressed, gone to the bathroom. They are in position. They are waiting to have the most private part of their body exposed. They are waiting for an enema hose to slide in. They are waiting to be holding on while every nerve tells them that they should rush to the toilet. They know they will have a massive diarrhea like bowel movement. It is up to you to keep putting more enema into them until they "take hold of as much water as possible." If the enema is really effective, they will take hold until they really can't take any more. The goal of a good enema in a healthy patient is just that, a colon filled with a water and comfortably stretched to the point that it cannot hold more. This is the goal of the enema the patient and nurse achieve it together. I have given many enemas. Patients are usually pleased with themselves when they have taken a good enema. It is the goal that they have literally put their fannies on the line to do. After the patient has assumed the position, they need to relax to have a good enema, but the rest is up to the nurse.

You begin by inserting the tube or hose. Lubricate it with olive oil, Crisco, KY jelly or any other inert lubricant. A small tube or hose will usually pass easily with little lubricant. Most people have large enough buttock muscles to hide the anus, so you lift the upper buttock away. You can lift with the fingers of your non dominant hand and spread their lower cheek with your thumb. After you get a good view of the anus, gently insert the tube into the center, avoiding any hemorrhoids. The direction with most patients is toward the umbilicus (belly button), but people vary, aim in and use no force. The tube will slide in with no resistance. If it doesn't, you are going in the wrong way or there is an obstruction. Change the direction, or move the tube to another spot. The internal sphincter muscle may resist, if it does very lightly hold the tube and wait for it to relax. Once the tube goes in, a standard enema tube will go in a couple of inches. It is not wise on necessary to go any deeper than that.

The colon is not designed to take impact of hard objects. Force can rupture the wall of the bowel. Hospital patients have died as the result of enema tubes being forced into the abdominal cavity. The safe way is very gentle insertion just into the rectum. Deeper insertion while dangerous does have the effect of making the enema unfelt. Inserting water deeper in the bowel causes only the sensation of bloating until the rectum fills. The feeling of urgency that is the hallmark of enemas is due to the rectum being filled and then the water flowing deeper with the short insertion. It is this sensation that lets us know we have to go to the bathroom and with the enema commands the patients whole attention. While having an enema, most people focus on the happenings within their rectum. There is usually some shyness or other interaction on beginning the enema. After the rectum fills the patient usually forgets all their worries, except holding the enema. I have given hundreds of enemas. I can remember only one person that read a book during a 4-quart enema. At this point the patient is ready to fill.

As I said earlier the enema is not painful or unpleasant, but the patient should have the colon filled. This means that the healthy patient should usually receive enough water to fill the colon to the cecum or end of the colon if a complete clearing or systemic therapeutic effect is sought. To this end if you know the person, and have occasion to administer a number of enemas to them you will become conversant with what that quantity is for them. As in the example of our young mother earlier, mothers who give good enemas usually know the exact capacities of their children and family members whom they treat. If you don't know the patient's capacity, it is usually best to continue filling them until they tell you to stop. If you notice they are having urgency that does not pass if you stop the flow for a few minutes, if may be time to stop. People vary a lot in their responses. Most will obediently take water to their limit for a nurse. They may protest more with a member of their family or someone with whom they feel less inhibited. A few will protest during the entire procedure while continuing to take the enema, and a few will insist on stopping. Much the difficult in giving a good enema is technique.

To give good quantities once you are beyond the dynamics of psychology between nurse and patient there are two usual reasons for good or bad enemas. The temperature and flow rate determine just how comfortable and effective an enema is. Normal temperature of a person is 98.6 degrees Fahrenheit, correct? No. That is oral temperature. The rectum and body core is 99 degrees. So the enema to be neutral to the body must be slightly above 99 degrees Fahrenheit. This would tend to the higher side in fever. I usually use 103 degrees Fahrenheit for the enemas I give. This is my guesstimate of what the average inter colonic temperature should be. In case of sickness, in which I want to stimulate the immune system I will move to 107 degrees. In cases of atonic colons or overheating, I will move to 95 degrees. When attempting to give a full colon it is important to remember that heat relaxes and cold spasms. A small cold enema can cause the colon to empty itself by reflex spasm. However to fill the colon the use of heat is best. Too high a heat can over relax the colon and allow it to stretch to the point of injury by giving too much water. Muscles, including colonic ones can't contract at over 115 degrees, so anything above this heat may cause rupture, not to mention burning of sensitive tissue. Tissue proteins also derange at 115 degrees. So I strongly recommend against using anything near 115 degrees. The administration of a 107-degree enema makes the body warm this should be the maximum ever used. In poor health don't assume a hot enema will restore warmth. In heart failure and the associated chills it will likely make the problem worse, possibly fatally worse. In any case our discussion here is for a healthy patient whose condition is usually a simple one. Do not give enemas unless you have a bath thermometer, and can get exact temperatures. These are available from medical supply houses. They should be sold with every enema syringe. Too cold an enema will be difficult for the patient to hold and basically ineffective. Too hot, and they will take a great enema, then suffer for days due to the injuries from the heat. Just right temperature, from my experience, 103 degrees Fahrenheit, and the patient will have neither chills, cramps nor sweats and will have a full colon when done.

The second factor is rate of flow. In a truly perfect enema, the heat sensitive cells in the anus feel the change in temperature of the enema nozzle. The colon fills with almost no sensation in a steady stream. The colon has no heat, cold, burning or cutting sensation. It responds almost solely to rapid stretching. This is what gas pains are. If you use a large caliber hose and tube and hold the enema bag high up, the patient will usually have cramps. This can tear the colon if the pressure is too great. The standard tubing and tubes available in drug stores is great. It reduces the flow rate to a tolerable level, unless the bag is hung too high. The level of the bag is recommended to be 18 to 24 inches above the level of the anus. This is a good height. At this height the flow into the rectum is almost imperceptible. The patient properly positioned may not even realize the enema is in progress until they feel the warmth of the water through their abdomen or the tube between their cheeks change temperature. Holding the bag higher makes for a quicker enema as the water flows in faster. This adds to the excitement of the enema as the patient has waves of pressure in the rectum and feels the imminent need to visit the toilet.

Hospital nurses are notorious for being in a hurry with the enemas and lifting the bags up to speed the process. It is difficult to take a good enema at rapid flow, but the effort is usually memorable. Despite protest, most remember the rapid fills as good enemas on review. It is in the nature of humans to like some forms of roller coaster rides. Some of the old text compromise by pouring away then stopping a minute to let the rectum empty its liquid into the deeper recesses of the colon, then pouring away again. It also adds a bit of excitement for both the patient and nurse.

The enema patient nurse role is one of parental power. It is one of the situations in life where there is no question of who wears the pants, or at least the underwear. Once they are off and the bag is dangling above a bare bottomed recipient whose role is to not go potty until permission is given, the nurse plays the role of parent. He or she has parental power and authority. The holding high of an enema bag is an ensign of power. The patient's legs quiver and goose bumps makes every hair stand on end. A torrent of water fills their rectum. They squeeze and hold on with an intensity not often remembered since toilet training. The enema nurse plays a role taken from Freud's anal phase. Few people in their usual occupations control the bowels of another. Commonly mothers reserve this role for themselves. Virtually every mother of young children does. Taking a patient to the edge of losing control of their bowels for the first time since they were two years old and continuing to fill them peels away the stages of life leaving the emotions and thoughts of the toddler within each of us.

Patients from all levels of life become as young children again. It places the patient in a childish position, begging to go potty. Few generals or presidents ever exercise such personal power as a nurse and her enema bag do in controlling the bowels of a patient. Those patients that had good relations with their personal toilet trainer in their time of shortness and training pants often revel in pleasing their enema nurse. They rarely turn down the offer of a good enema. Those that fared less well with their personal toilet trainer and have significant emotional blocks to this activity are emotionally challenged by the process. The nudity and filling of the bowels reaches these levels with all that hold the tube in the end. The joys or challenges that patients feel in having enemas are as internal for them as the enema itself. In giving hundreds of clinical enemas I have observed that almost all patients quietly take their quarts. Whatever they feel, if anything, is rarely expressed.

For those that hold the bag it is less clear. There is usually empathy with the patients. For the nurse there is less psychological exposure. Nurses give enemas in uniform. Mothers give enemas in slacks or dress. Early childhood enemas usually occur over mother's skirted knee. This makes the giving of enemas a safe introspective role for the giver. The patient quivers and may beg. As they beg, the nurse is quiet at ease. She stands and encourages. With the flick of a finger she controls the flow. So long as her patient holds the enema, she has no exposure or stress. The only psychological aspects of nursing enemas are within the mind of the giver. She may enjoy giving as she was given. She may enjoy controlling as she was controlled. Whatever she feels it exist within her mind. Most nurses have experienced the enema and identify with their patients. The giving of enemas has been a mother's role for most children. The identity of the mother with the enema nurse is strong with most patients. A desirable trait for most enema nurses is the assumption of that role. Most of us desire a motherly nurse when sick. When she gives an enema, this is especially true. The real experience of the enema is the patient's. Only vicarious satisfactions occur for the nurse. It is as it is for the mother who in presenting regular panties to her 3-year-old shares the joy but not the experience of being dry. Enemas are for health as are many other routine health procedures that all can have psychological aspects. The purpose of the enema is to promote health.

A third note on quantity, what is a good enema for some is inadequate for others. The size of colons is as variable, perhaps more, than the size of people. In hundreds of barium studies we have had the opportunity to evaluate many colons for size and structure. While it may be true that the average colon can hold about two quarts, that is only an average. We have seen a few people that had one and half quart colons. We have seen many that hold about three quarts and a number that hold more than four quarts, and are healthy. These larger colons tend to lead to constipation, and are best treated by increased roughage to give enough bulk to make them work. When this fails, as it often does, a few sessions with the enema cleans the colon and gets it working again. Laxatives for these people create new problems in the rest of the digestive system while not getting directly to the colon. To clean the colon and have a good enema each person's needs are different. A person that has a small colon may leave a standard syringe bag partially full and be at their limit. A person with a larger colon can drain it flat and not have a good enema. When you are determining how much enema to give, always bring plenty of water. With a new patient I always prepare four quarts of water and keep pumping until they are full. The majority of people need to stop at about one and three fourths quarts and after a short break take a little more. When you reach the point that each time you start to give more they are too full, you have probably reached the end. Others I have pumped in the whole four quarts and there is no urgency or discomfort. For enemas for these people they need to take four or more quarts for a good enema.

Although there are people with large healthy colons, there are others that can take a large amount of water because they have a problem with their colons. Hospital and drug store syringes are bags or cans of about one and one half quarts capacity. I don't feel that this is an adequate amount to give an enema to most adults. The enema should reach the cecum, and it won't unless the colon is filled. However, in giving larger enemas, do be careful. If the patient becomes dizzy, or feels bad after a large enema, stop the process. While almost all healthy people can benefit from a larger enema there are some counter indications. Multiple sclerosis or other diseases in which there may be paralysis of the colon, large amounts of water may be given, but not released. This water absorbs into the body. This can be very dangerous since it can throw the person into electrolyte imbalance and possible shock. The procedures of fully filling the colon should only be used on patients with healthy bowels and a general state of good health. It should never be used on young children or others that cannot communicate how they feel or that may have an impaired sense of what is going on in their bodies. Also the presence of colonic tumors, or cancer, creates a potential danger. Cancerous masses can rupture and bleed easily. They will spontaneously do this. This may be hastened by the pressure of an enema even though it is more likely to occur from constipation. It is often wiser to not give a treatment that may be questioned by others, than to be blamed for giving the treatment.

To use standard enema bags, I recommend that you buy a combination douche enema syringe that is an open topped bag with the hoses connecting to the bottom, or a hospital enema can. Prepare a pitcher or container of water and have it close by when giving an enema. After you have almost emptied the bag, close the cut off and pour in another bag full. Keep repeating this until your patient has to stop because they are unable to hold any more enema, as I described above. There should never be any pain on this procedure. They will either tell you they have to go or they will tense up. Stop and wait a minute, talk to them, or massage their stomach until it eases, then give them more until they have to stop again. At the end of a good enema as soon as you start to put a little more water in, the patient's rectum will feel full and they will be uncomfortable. At this point you quit.

A technique that I use in giving enemas that helps me gage how the patient is doing is that I hold the tubing without touching the patient. I keep it in place with one hand. Being a chiropractor and always adjusting backs, I massage the low back during the enema, or gently rock the hip to aid the flow of the enema. This relaxes the patient and helps them have a good enema, and it also lets me gage how they are doing without constantly asking. When they tense up after being relaxed, you know they are having trouble holding it. If you ask a person having an enema if they are full, they will invariably say yes whether they need two quarts more or not. This was brought home to me by a patient with large colon. I got an inadequate colon X-ray on and had to repeat it because I hadn't given her a large enough enema. I told her we needed to do another x-ray that she needed more barium. She said that I shouldn't have asked, but just filled her till she had to stop. I did and got a good film.

Other techniques for giving the enema are patient instructions. This begins when you tell them they are going to have an enema. When a neighbor drops by and has a problem that you offer to fix with a good enema, it requires a bit of salesmanship. When they drop by and ask you if you would help them with an enema, a simple OK will do. In a position of authority a simple statement will do. Many enemas are given in hospitals. These are preceded by a simple "You are going to have an enema now." The drapes draw, and in a minute you are bottom side up without any question of whether you need or want it. If you are to give a good enema, you must assume a role of authority. If you are to receive a good enema, you must submit to it. The first instruction is to go to the bathroom and urinate and defecate. A full bladder makes taking an enema very difficult, and fecal material in the colon makes it hard to fill. The less there is in there to start, the easier and more comfortable the enema will be. While the patient is in the bathroom prepare their place to have the enema. Protect the bed. Get some blankets, etc.

After they come out, advise them of the enema dress code. Contrary to school codes in which no dress above the knee and long pants are required, it is difficult to be underdressed in the enema dress code. All clothing should be loose, with nothing below the waist. In clinics gowns are provided with suitable frontal modesty and suitable posterior immodesty. Panties or underwear around the knees is not such a good idea, unless the enema is given in the bathroom so that it is a short step to the toilet. These can get tangled around the ankles, and foil a perfect run to the bathroom. Having an enema is an experience that is difficult for many people as it damages their modesty. Be sensitive to the person. Unless you are dealing with a husband, wife or lover, and even then, respect their modesty. Cover the patient with a sheet or blanket to reduce their exposure.

After they return from the bathroom go in and prepare the enema if you haven't already done so. It is also a good time to go yourself if you have a one bath home. Good enemas often result in frequent and lengthy trips to the bathroom. A constipated person once well filled may make frequent and long trips to the toilet as the dam of material flows out over time. The rules of etiquette always state the a person having just received an enema has priority on use of the bathroom. Then bring all the enema equipment into the treatment room and explain the process to the recipient, if they don't already know it. The first timer is usually, as in all such events nervous. Explain that it doesn't hurt. They will feel the need to go to the bath room, but that they will relax and breathe deep and it will pass. Tell them that the enema will make them feel better or whatever end the procedure is to accomplish. There is usually no need to spend much time on this initially. You can talk as they are having the enema.

Put the patient in position if you haven't already done so, hang the enema bag. Insert the hose or nozzle and open the valve. Be sure that in the bathroom you drained some water through the nozzle, otherwise you will inject a slug of air, and air can cause gas pains. Tell the patient to breathe deeply through the mouth and keep encouraging them to relax. Coaching skills are necessary to a good enema nurse. Pour new bags full of water as necessary until they have had a good enema. When they have the enema in, have them roll on their back and gently massage the abdomen in a counter clock wise fashion to distribute the water to the cecum. The patient should hold the enema for five to 10 minutes to allow the water to be most effective then go to the toilet.

The enema is a multiple word. It doesn't really mean just one injection of fluid into the rectum. It describes an enema session. Though cleaning of the colon may take several enemas. Often in preparations in hospitals, enemas are ordered until clear, so that the patient has one good enema, a rest and another and another until the colon is cleaned completely. I feel that this may be the best way to have occasional enemas. Remember the caution I have already given on being careful not to imbalance the body's salt by allowing the patient to absorb too much water. I would not recommend it more than once per week unless under a competent chiropractor, or other doctor's direction. If you want to have a clean colon, it certainly makes sense to spend an evening or morning taking a series of enemas until the more undigested food from the cecum washes out. This also applies to constipation and illness and is a necessity, in my opinion, in the treatment of Candida. An enema series can be tiring, but it is very refreshing and beneficial for many conditions. It is time consuming. It has been my experience that the fastest rate one can give enemas is about one every half an hour. It is probably much better to give them each hour, to allow a rest time. This is also an area when having enemas administered makes more sense than self administered. I have found that most people have difficulty giving themselves "good" enemas. It requires a great deal of will power. It is even more difficult to take a series. A helping hand makes it easier to continue. Taking a good enema, requires rolling over, taking off your underwear and relaxing. If you are having a series, why put them back on? When you go back to rest cover up with a blanket. When your next enema is ready, you roll over and take it. It takes much less will power to motivate yourself to make the walk to the toilet after an enema.

As a patient the five minutes spent squeezing a gurgling enema nozzle with your sphincter is only the beginning. This is followed by five to ten minutes of holding it. Then comes the run to the toilet, often followed by more runs to the toilet. This can easily take half an hour or more, and is tiring. After that you are ready for some juice or mineral drink to balance your fluids again and a nap. Giving a series of enemas is not that time consuming or tiring for the nurse. Once the enema bag and other apparatus are out and waiting it should take less than seven to ten minutes an hour to give hourly enemas. One nurse in a clinical setting can easily keep a ward of patients bottom up or on their bedpans for hours. The filling the enema containers should take no more than a minute. Carrying them to the bedside, another minute. The patient is undressed. The bed is made for the occasion. A quick roll over, insertion and five minutes or less discussing the urgency of their need to visit the toilet and they have had their enema. By this time the nurse has insured the urgency and can be preparing the bag for its next use. If there are to be more than two or three enemas, a glob of Vaseline on and in the anus is nice. Repeated enemas tend to make the anus sore. Again more than a single morning or evening a week of two or three enemas is not recommended unless it is ordered by someone trained and knowledgeable in the procedure and its purposes.

Enemas are a very common treatment. They are used for many conditions, constipation, diarrhea, painful menstruation, headaches, dysentery, depression, toxicity, colds, parasitic infections, flu, sore throats, premenstrual syndrome, fever, dehydration, preparation for child birth, etc., as well as just to maximize health. Used with common sense and gentleness they are not unpleasant. They leave a sense of euphoria and clearness. Having an enema is like having a bath, when you have one and are dirty, cold, hot or tired, you feel better. If you have a bath and don't need one you still feel better and possibly smell better. Enemas are the same. Not used to excess or wrongly they are just cleansing when given to a person in basic good health and really have few counter indications commonly seen in the general population. 

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