The Principles of Osteopathic Technique
A. S. Hollis, D.O.

The use of the Internal Bath.

    The enema is so valuable an asset to osteopathic practice that it may be expedient to describe briefly the main principles that should guide the practitioner in its use and to suggest the few pitfalls that should be guarded against.  First of all, it is extremely important that the thought be borne in mind that a patient who is using the internal bath is very liable to contract a habit of enema taking.  We say this because there is perhaps no habit that the practitioner, who is trying to cure a case of constipation, will find harder to combat than the enema habit when it has once taken a good hold on a patient.  The result of taking enemas day after day for a long period is a paralysis of the bowel, and this condition is almost impossible to handle in many instances.  Indeed in such cases after all ordinary procedures have been resorted to without results, the operation of "short circuiting" the bowel probably offers about the only good chance of relief that can be offered.  We state this in preface to our suggestions because it is very easy for a person to fall into the habit of enema-taking and disastrous resultants undoubtedly follow.  Many of the most intractable cases of constipation are the direct result of the continued use of the enema.  The "Internal Baths" so widely advertised in the various Physical Culture Magazines, although in certain cases they do much good, in many cases will be found to do a great deal of harm because in the end the patient is liable to find himself dependent upon them to an extent that far exceeds any dependence upon such drugs as their use may have supplanted.

    It has been abundantly proved that in very many sick people there is an accumulation of fecal matter in the large intestines; this in some cases becomes so hardened that it adheres to the walls of the bowel and the feces that are excreted daily or so often are passed through a hole tunnelled in this impacted material.  Thus, many patients who assert that they are not constipated are in reality suffering from the worst type of constipation and their condition should be thus diagnosed by the physician.  We have found the following suggestions to be especially valuable: Use an ordinary two-quart syringe, much as can be purchased in any drug store, and procure a soft rubber catheter of a size that will fit snugly onto the hard rubber nozzle that will be provided with the fountain syringe purchased.  This will be found to be about size "15 English" though the best criterion will be that the catheter should fit snugly onto the nozzle.  A catheter of this character will serve ordinary purposes better than the regular colon-tube.

    For ordinary cleansing purposes, that is to say, unless there is great accumulation of hardened and packed feces in the bowel, warm soapy water with a couple of tablespoonfuls of glycerine will be found as good a mixture as any that can be employed.  The water should be about the body temperature, and should have plenty of soapy-suds in it.  Any pure soap, such as Ivory or Castile may be used, and sometimes a good laundry soap will give the very best results.  Before inserting the tube, it is important that the clamp be loosened for a moment, so that the air may be driven out of the catheter as otherwise some unnecessary inconvenience may be experienced.  The end of the catheter should be vaselined, and the bag suspended at not too great a height above the level of the patient as otherwise the water will flow so rapidly that the best results will not be obtained.  As a general statement we may say that the least quantity that will get the results aimed at, will be the best and that under no circumstances should more than two quarts be used.  Also, the more slowly the flow is allowed to enter the bowel, the less discomfort will be experienced by the patient.  The patient should be placed on his right side (many advise the back or left side in preference -- the operator's own experience should guide him), so that if any water gets into the descending column, gravity will tend to enable it to flow down the transverse colon.  The catheter should be inserted slowly for three or four inches before the clamp is opened, and it is essential that the operator remember the direction of the last few inches of the lower bowel.  This direction is toward the umbilicus, and the catheter should be gently inserted through the anal orifice pointing in this direction.   If this fact is not borne in mind much inconvenience and pain will be caused the patient.  As soon as the catheter has been inserted about four inches the water should be turned on; probably the patient will complain almost immediately that be is unable to stand the discomfort of the flow and that he feels as though he must expel the tube and water.  If he does complain in this way, the discomfort can generally be obviated by temporarily stopping the flow until the impulse for expulsion has passed off.  Should this impulse not pass off however, the catheter may be removed and the patient may be allowed to expel the water that has passed into the bowel; the attempt should then be made again.  It will not often be necessary to resort to this expedient however.  While the water is flowing into the bowel the rest of the catheter should be inserted until twelve or fifteen inches have been passed in.  After a quart and a half or so has entered the bowel, the catheter may be removed and the patient should turn for a moment into the knee-chest position, that is to say be should raise himself onto his knees while his chest is kept close to the ground.  Then he may rise and expel the water from the bowel; sometimes it is necessary to repeat the entire procedure, but every effort should be made to obtain the best possible results from each single injection, as the use of several injections, one after the other, is depleting to the patient.  It is a good plan to pass a little cold water into the bowel after the other has been expelled as this tends to tone up the bowel wall.  This of course should be expelled at once.  Some most surprising findings will be obtained in certain instances from a thorough cleansing of the bowel such as may be obtained in this manner.

    To soften impacted masses the injection of half a pint of warm oil is often of great value.  This may be followed by the injection of some soapy water as described above.  The enema bag if used for oil must be cleansed at once after the oil has been run through it, as otherwise the rubber may be destroyed.  A good plan is to use a glass syringe whose nozzle will fit onto the rubber catheter and to inject the oil thus directly into the rectum through the catheter.  The addition of turpentine to water is sometimes advised but it should be employed carefully and understandingly, and never without the  advice of a physician, as it may do considerable harm to the kidneys.  Also it tends to gripe the patient badly.  The addition of the glycerine that we recommended above will be found of especial benefit, as it will tend to soften hardened masses, while it is also soothing to the bowel wall, and overcomes the temporary tendency to constipation for the day or so following the use of the enema.  Although it is exceedingly foul-smelling an enema of one pint of milk of asafoetida is of the greatest value to combat gas in many cases.

    There is more in the few suggestions that we have offered concerning the enema than appears at first sight; indeed the intelligent use of these valuable adjuncts to osteopathic practice can only be appreciated after they have been used successfully in a large variety of conditions.  It is always important, however, to bear in mind the possibility of doing harm by continued use of these baths, and all the way through the gamut of osteopathic practice we must remember that the manipulation that may be used to the greatest. advantage is probably the one that can do the greatest amount of harm if it is not understood and if be wrongly employed.