For the administration of the enema the sole equipment necessary is that of a fountain syringe with its rectal-tube attachment. The syringe should be suspended about five feet above the floor of the bath or lavatory, thus insuring sufficient fall for the water. Examination of the preceding diagram of the intestines will show that there are three positions in which the body may be placed in order that the colon may receive the water injected in such manner as to reach its entire surface, soften its contents, and wash them from its walls. These are the right-side, the knee-chest, and the flat-on-the-back postures. The last, excepting for children and for bedridden cases, is inconvenient to assume, but the two former positions are found to be comfortable and are easily taken.

When the subject in taking the injection lies on the left side, gravity assists the flow of the water only as far as the transverse colon, which in this position is perpendicular to the descending colon and forbids further passage of the fluid. Hence only the lower third of the bowel is affected. The right-side posture allows the water to flow along the descending colon, thence down the transverse colon and through the ascending gut to the cecum, thus completely flushing the organ. The knee-chest and the flat-on-the-back positions, obviously and with even greater ease, insure similar cleansing of the bowel. If, as is usual with those who are ignorant of the advantages of the postures described, the injection is administered while seated, gravity and the contents of the descending colon prevent the rise of the water unless some special device embodying force is utilized; and then again only the lower third of the bowel receives the benefit of the flow, and dilatation of the rectum and flexure is almost certain to occur with possible structural injury.

When a patient is bedridden or is extremely weakened, the knee-chest posture or the right-side position may prove too difficult or too exhausting to assume. In either of these contingencies, when no specially constructed table is at hand, a canvas stretcher upon which the subject may lie can be placed over the bath tub. If this apparatus cannot be procured, a triangular platform of three foot-wide boards covered with oiled cloth and a blanket, its base arranged so as to cross the top of the tub beneath the buttocks, may be used as a substitute. By the means indicated all effort in maintaining position is removed, a matter of importance in states of excessive weakness.

The operator in administering the enema, or the patient himself, in order to insure full benefit, will find it necessary to repeat the injection until the fluid returns comparatively colorless. This may mean that as many as twenty quarts of water may be required to obtain the desired result. Of course this amount of water cannot be introduced into the bowel at one time, but the contents of one bag or can, preferably of three-quart capacity, can be injected in the ordinary case and then evacuated with its accompanying refuse, and this operation may then thereafter be repeated until cleansing of the bowel is assured. Repetition as described is most essential in employing the internal bath, since the injection of only a small quantity of water acts detrimentally in that it serves to render the contents of the bowel readily absorptive, and is not in amount sufficient to be evacuated freely. Because of rapid absorption of the fouled fluid of the injection, retention of the water should be limited only to the time needful for injection and discharge. The latter may be facilitated by kneading the abdomen with the hands over the region traversed by the colon in the abdominal cavity.

Copious discharge from the bladder immediately after an internal bath is the common indication of the rapidity with which absorption takes place through the walls of the bowel, and it is seen that the process is almost instantaneous. For this reason salt, soap-suds, soda, and like substances should be avoided in preparing the fluid for injection. This caution likewise applies to the use of oil or glycerine. The only flushing agent should be water warmed to body temperature or not higher than one hundred degrees Fahrenheit.

When the enema is advised in medical practice as at times it is, invariably too small an amount of water is used, the posture is usually that of sitting, and, when what is known as a high enema is given, a colon tube, which is a long soft rubber hose, is attached to the fountain syringe. This accessory is not at any time needed, and its employment may prove harmful to the bowel. The short rectal-tube mentioned answers all purposes if the injection is taken in any one of the indicated effective positions. In any event the colon tube should be used only by an expert or under his direction.

Ignorance of procedure and erroneous reasoning have occasioned the belief that the use of the enema as recommended in the text will not only cause weakness in the patient, but will also bring about subsequent failure of function of the colon. It is contended that, once the enema is resorted to for any extended period such as is herein advised during a fast, natural movements of the bowels will not again occur, and that thereafter resort to the internal bath for colon evacuation will be compulsory. Natural movements of the bowels are directly dependent upon normal digestion, and in a system organically and functionally correct, peristalsis and subsequent discharge of refuse oecur in sequence. In the course of the long experience of the author in the administration of the enema as described no instance of loss of bowel function nor of colon paralysis has ever occurred. On the contrary, the internal bath has been found to restore natural bowel action and to act as a tonic stimulus upon the muscles of the colon. Objection to the use of the enema advances as its basis the fact that for a day or so after full flushing of the colon no passage from the bowels occur. In the average case all bowel movements are evacuations forced by incoming waste from the small intestines pushing upon the contents of a filled colon, and the boasted daily movement actually consists only of discharge of the fecal matter contained in the rectum, the greater mass being still retained in the bowel. When, however, an enema has been correctly administered, the entire colon is cleansed, is emptied of its contents. The daily habit is consequently broken, and it may not be resumed for one day or several, or until the former condition of fullness has been restored which, if normal peristaltic function is impaired will shortly occur. Natural discharge from the bowels is assured only by attention to diet, to mastication, and to the existence of normal digestive processes, together with normal response of the colon to the irritative stimulus of waste deposited in it from the small intestines. And that man is the exception in whom this healthful sequence of function is the rule.