COLONIC IRRIGATIONS: A REVIEW OF THE HISTORICAL CONTROVERSY
AND THE POTENTIAL FOR ADVERSE EFFECTS
Douglas G. Richards, Ph.D.
(Paper presented at the 9th Annual Cayce Health Professionals Symposium,
(Click here for the Adobe
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Colonic irrigations enjoy widespread popularity
in the alternative medicine community, while being viewed with considerable
skepticism by the conventional medical community. While proponents make
claims of substantial health benefits, skeptics cite the lack of evidence
for health benefits, and emphasize the potential for adverse effects. Yet
historically, there are clinical reports of effectiveness, and virtually
no research refuting these reports. Instead there was a campaign against
exaggerated claims by non-medical practitioners that resulted in a movement
away from this form of therapy without any scientific study of efficacy.
Given the current popularity of colonic irrigations, it is important that
such research be performed, but it is first necessary that a quantitative
estimate of the potential for adverse effects be made for the purposes
of informed consent. Although there is little specific literature on colonic
irrigations, a review of the literature on related procedures such as enemas
and sigmoidoscopies suggests that the risk of serious adverse effects is
very low when the irrigations are performed by trained personnel using
Colonic irrigations enjoy widespread popularity in
the alternative medicine community, while being viewed with considerable
skepticism by the conventional medical community. The medical objections
include a belief that scientific research has proven that colonics are
not effective therapy, and that they pose a high risk of serious adverse
effects (e.g., infection, perforation of the wall of the colon) (Ernst,
1997). Furthermore there is a concern that those administering colonics
are primarily unlicensed, non-medical practitioners who make exaggerated
claims of health benefits, "quacks" (Barrett, 2004; Jarvis, 2004). Our
interest arose from the need for information on the safety and efficacy
of colonics for informed consent for clinicians and researchers. We found
that there is very little information on either the safety or efficacy
of colonic irrigations, and that modern sources have not addressed the
historical debate among medical professionals.
The goal of this paper is to provide a balanced perspective
for clinicians and researchers through a review of the historical information
on the safety and efficacy of colonic irrigations, and bring in relevant
information on adverse effects from related procedures (e.g., enemas and
sigmoidoscopies). Although there have been many books promoting colonic
irrigations and making claims of efficacy for a wide variety of conditions
(e.g., Tyrrell, 1913; Jensen, 19xx), this paper will look primarily at
the peer-reviewed literature, rather than attempting to evaluate those
This paper will use the terms "colonic irrigation,"
"colonic," and "colon hydrotherapy" interchangeably. The term "colonic
irrigation" has never referred to a single procedure, but there are some
common elements. Colonics are distinguished from enemas in that (1) they
are not self-administered, but instead are administered by a person with
some professional training, and (2) they are administered using some type
of device to control the water flow. Their purpose is to infuse the entire
colon with water, in contrast to the more limited infusion of water in
an enema. In its modern form, the forty-five minute procedure involves
a gentle infusion of warm, filtered water into the rectum. The water circulates
throughout the colon, removing its contents, while the client lies on a
table. Water temperature and pressure are closely monitored and regulated
during a series of fills and releases to aid in the peristaltic action
of the colon. As the method involves an enclosed system, the waste materials
are removed without the unpleasant odors or discomfort usually associated
The modern medical attitude toward colonic irrigations
suffers from a lack of information about the historical debate on their
safety and efficacy. The history that has been presented by some modern
authors (e.g., Ernst, 1997; Whorton, 2000) does not address the debate
among physicians regarding the value of colonics, instead focusing on the
campaign against the practitioners with exaggerated claims, called "quacks"
by their opponents. Ernst states that in the early 1900s, "rigorous scientific
investigation into the theory of autointoxication was initiated for the
first time. The hypothesis was soon found to be wrong." A search of the
literature, however, reveals little evidence of scientific investigation.
In parallel with the crusade against quackery, there was a reasoned debate
among physicians, conducted in JAMA and other medical journals, on the
therapeutic value of colonics. That debate was not resolved by scientific
research on colonics, but rather from a combination of hostility toward
colonics by the opponents of quackery that made it difficult for research
to be done, and the shift in medical practice from physical therapies to
drug therapies. Here we look at the literature from the 1920s and 30s that
shows a serious debate on the value of colonics, beginning with a historical
The rationale for colonic irrigation was originally
based on the concept of "autointoxication." Autointoxication is an ancient
theory based on the belief that toxins originating in the intestine can
enter the circulation and poison the body. The idea probably originated
in Egypt or Greece. Until the early 20th century, autointoxication was
widely accepted, and various therapies were commonly used for a variety
of systemic disorders. The modern colonic machine was developed about one
hundred years ago as a gentler alternative to the more extreme treatments
of surgery and purgatives.
Whorton (2000) provides a detailed history of the
concepts of constipation, inner hygiene and colon cleansing. He describes
in eloquent detail the rationale behind regarding the colon as a "toxic
sewer" responsible for disease in the 1800s. In the late 1800s, "Thanks
to the germ theory, constipation was transformed into an even greater menace:
autointoxication" (Whorton, 2000, p. 22). Whorton explains the concept
of autointoxication: "The term was generally understood to denote intoxication
of the body by absorption of poisonous compounds from the large intestine"
(p. 22). "Autointoxication made a great deal of sense. Poisoning from the
bowel had always had a powerful intuitive appeal, and now this age-old
suspicion appeared to have the blessing of modern bacteriological science"
(p. 24). The autointoxication concept enjoyed a golden age from 1900 into
Colonic irrigations as a treatment for autointoxication
became popular in the late 1800s and early 1900s. An early English version
was known as the "Harrogate System of Intestinal Lavage," and in the years
around 1905 15,000 patients annually were receiving irrigations at the
Harrogate spa (Whorton, 2000). According to Whorton, colonic irrigations
were popular among physicans and frequently prescribed. This was quite
reasonable. Enemas and colonics were seen as substitutes for laxative pills
and their dangers. Kelvinson (1995) cites a variety of respected physicians
of the time who advocated colonic irrigations, noting that even the Royal
Society of Medicine in 1913 cited the colon as a major factor in health.
But by 1918, "autointoxication was already falling out of professional
favor, and drug therapy entering an era of revolutionary expansion that
would relegate spa therapy and like traditional methods to quaint obsolescence
in most physicians' minds" (Whorton, 2000, p. 123).
Nevertheless, colonic irrigation remained popular
as a therapy. "Irrigationists flocked to the field from all corners; from
the conscientious MD who still believed in autointoxication but wished
to purify the bowel without harsh drugs, to the amoral quack who saw a
bull market and grabbed it by the horns, an irrigationist of some stripe
was never far from hand during the 1920s and '30s" (Whorton, 2000, p. 136).
Whorton (2000) says, "By the 1930s, most physicians
no longer believed in autointoxication, and doubted that real gastrointestinal
problems would benefit from lavage, either. The majority demonstrated a
'prevalent tendency to ridicule' that frustrated irrigation's proponents..Snide
dismissals of that sort - and they were common - betray an emotional overlay
on the objective medical evaluation of lavage. Even the most sober and
fair minded physicians found it difficult to be dispassionate about colonic
irrigation and evaluate it purely on its merits, because of their anger
at the rampant exploitation of public gullibility by bowel purity hucksters"
The political reaction against lay practitioners
is most clearly seen in the position of Arthur Cramp, in what was originally
called the "Propaganda Department" of the American Medical Association
(Ernst, 1997). The book, Nostrums and Quackery, that he edited for the
AMA Press (Cramp, 1911, 1921), particularly takes issue with Charles Tyrrell's
"J.B.L. Cascade," a home enema device that consisted of a water-filled
cushion with a nozzle. The criticism comes in a chapter on "Mechanical
Fakes." The issue is not that the device does not clean the colon, but
that Tyrrell makes excessive claims in his advertising, such as "there
is only one disease," and "there is only one cause for disease and that
is autointoxication" (Cramp, 1911, p. 312, italics in original). Cramp
says, "It is unnecessary to tell physicians that the claims made by Tyrrell
for his 'J.B.L. Cascade' are as silly as they are false. It is equally
unnecessary to tell them that indiscriminate use of rectal enemas is not
only harmful but may be dangerous" (Cramp, 1911, p. 314). A later edition
of the book says that for enemas, "The common fountain syringe is both
safer and more efficient" (Cramp, 1921, p. 705). The primary criticism,
again, is the excessive advertising, "Tyrrell urges the public to take
rectal enemas both in sickness and in health - in other words, as a routine
part of one's living. This advice is mischievous to the point of viciousness.
The 'enema habit' is just as harmful as the 'cathartic habit'" (p. 705).
Wharton's (2000) book also documents many letters sent by Cramp criticizing
colonic irrigations in general and the J.B.L. Cascade in particular.
Wharton's book may be somewhat biased in favor of
the official position of the American Medical Association; he acknowledges
that a major source of research material was the collection in the AMA's
"Historical Health Fraud and Alternative Medicine Collection" in Chicago.
A reading of JAMA and other journals of the time offers a somewhat different
picture. Despite the concern with "quackery" and the extravagant claims
of lay practitioners, conventional MDs continued to debate the usefulness
of colonics well into the 1930s.
For example, despite the anti-colonic stance of Cramp
and his committee, the editor of JAMA (1927) was willing to provide specific
advice to a medical doctor with a question on whether claims for a specific
colon tube used in high colonic irrigations were extravagant. The response
gave a favorable description of the tube and how it can be passed into
the colon. Again, there seem to be two separate communities, the anti-quackery
advocates, and the doctors seriously interested in the therapeutic possibilities
of colonic irrigations.
There seem to have been several trends that combined
to marginalize colonic irrigation. The first was a change in philosophy
in the medical profession, toward relying more on drug therapy and less
on various types of physical therapies. The second was a political reaction
against lay practitioners, "quacks," distinguished by their excessive claims
and aggressive marketing practices (in contrast to the orthodox medical
shunning of advertising). The third was a lack of scientific evidence for
the efficacy of colonics.
Experimental Research Related to Colonic Irrigations
Notably absent, both from Whorton's (2000) historical
account, and reviews like that of Ernst (1997) are references to objective
research (controlled or otherwise) on either the safety or efficacy of
colonic irrigations. Ernst cites Donaldson (1922) as refuting the autointoxication
hypothesis, yet Donaldson's study involved enemas, not colonic irrigations,
had only five subjects, and ruled out autointoxication only by inference.
In fact, Donaldson demonstrated a strong positive subjective effect from
relief of constipation, for which he could only speculate on the mechanism.
We have been unable to find any other examples of experimental investigation
of colonic irrigations. All the evidence presented on both sides of the
question comes from clinical experience and opinion, not "rigorous scientific
Donaldson's results are actually supportive of the
clinical value of enemas. Donaldson, skeptical of the autointoxication
hypothesis, performed an experimental study in which five subjects voluntarily
made themselves constipated for four days. He then observed (and in some
cases measured) the symptoms of "autointoxication" that appeared. These
included coated tongue, markedly foul breath, canker sores, impaired appetite,
mental sluggishness, depression, restlessness, irritability, unrefreshing
sleep, and headache. He measured reaction time of the nervous system, basal
metabolism, blood sugar, and rate of muscle fatigue - all showed impairment.
The subjects then took cleansing enemas (in this study not full colonic
irrigations). In all cases the sense of oppression and marked mental depression
was gone immediately, and mental alertness and feelings of physical fitness
increased. Post-enema tests of reaction time, muscle fatigue and blood
sugar were all back to their baseline levels. Donaldson concluded that
the rapid relief was in far too short a time to be due to toxins as causative
agents, and concluded that the result had to be due to relief of mechanical
pressure (distention and irritation of the lower bowel by fecal masses).
In this conclusion he was following Alvarez (1919), who had found that
mechanically plugging the rectum resulted in the same sorts of toxic symptoms.
Donaldson replicated the Alvarez finding by packing and unpacking the rectums
of four further subjects, with the same results as the constipation experiment.
Donaldson, convinced of the mechanical explanation for the symptoms, supports
relief of constipation by occasional enemas, but argues against autointoxication
as an explanation.
In another experiment, Donaldson (1922) explored
the effect of rectal plugging on blood pressure in a dog, and observed
a rise in blood pressure from 122 to 138 mm Hg in four minutes. A variety
of other dog experiments demonstrated that there can be toxic substances
in the bowel, but that these are unlikely to be a significant factor in
typical constipation. On the other hand, he does admit that in some cases,
especially persistent diarrhea, autointoxication is likely to be responsible.
He also acknowledges, "It is pretty generally agreed that stasis in the
small bowel probably does give rise to toxemia" (p. 885).
Alvarez (1919), writing in JAMA, discusses the lack
of evidence for the theory of intestinal toxemia, challenging the relevance
of the existing literature, saying, "Although there are many clinical facts
which strongly suggest that poisons are absorbed from the digestive tract
during constipation, we have as yet little actual proof for this assumption"
(p. 10). Alvarez makes a case for the "toxic" symptoms being produced by
nervous system reflexes. He speaks of "how profoundly sensory inputs from
our digestive tracts can influence our emotions, our mental processes and
our vasomotor balance" (p. 11).
"Particularly in sensitive people the brain is profoundly
influenced by afferent impulses coming from a distended, overactive or
wrongly acting bowel. The effects follow so closely on the appearance and
disappearance of the stimulus that we cannot drag in a cumbersome and roundabout
chemical mechanism to explain them; they must be produced directly through
the nervous system" (Alvarez, 1919, p. 11). Alvarez's therapeutic recommendation
is for enemas to relieve the pressure, in contrast to purgatives or surgery.
Although Alvarez is highly critical of the autointoxication hypothesis,
his article could be seen as supporting the concept of colonic irrigation
(or at least enemas) for symptomatic relief.
It is not surprising that there are reflexes from
the colon that affect the entire nervous system, given the importance of
the "abdominal brain" or enteric nervous system (McMillin et al., 1999).
It is estimated that 80% of vagal fibers are visceral afferents (Davenport,
1978). There is also a vast overlap of neuropeptide activity
in the gut and the brain (Pert et al., 1985). As early as 1907, Robinson
documented the vast and complex nervous system of the abdominal viscera.
The enteric nervous system has become an active area in physiological research
with over 600 articles on Medline since 1985. Modern medicine recognizes
abdominal nervous system involvement in several neurological disorders,
including migraine, epilepsy, and autism (McMillin et al., 1999).
What is especially interesting here is the broad
variety of symptoms that can be caused by constipation, and relieved by
an enema. The reflex mechanisms for these phenomena would make a very interesting
study in themselves. If relief in this experimental situation can be obtained
by a simple enema, might a higher colonic irrigation provide more extensive
stimulation to the same reflexes to provide longer lasting relief for more
chronic symptoms? And could the chronic symptoms be due to, not toxins,
but reflexes from other dysfunctional aspects of the colon that can be
treated with irrigations?
In later article, Alvarez and Freedlander (1924)
addressed the question of the transit time of feces through the colon in
an experiment involving ingestion of glass beads. They were surprised to
find that transit time was quite variable, with the colon often retaining
some food residues from the entire preceding week. They were concerned
that this result might be seen as supportive of a mechanism for autointoxication.
However, they found no correlation of transit time with health status.
Their conclusion was that wide variations are perfectly compatible with
good health. It is interesting from a methodological perspective, however,
that while they describe their method and results on transit time in detail,
they provide no information on how they measured health status.
Another issue regarding intestinal toxemia was addressed
by Dragstedt et al. (1922), from the Mayo clinic. They accepted that intestinal
toxemia could cause disorders, but questioned whether administration of
antiseptics was a useful treatment. Working with dogs, by surgically closing
isolated segments of bowel, they were able to produce the symptoms of toxemia,
and showed that the symptoms disappear when the closed segment is removed.
However, they found that the direct application of antiseptic solutions
to the segments of the colon did not effect sterilization or inhibit the
production of intestinal poisons.
Regardless of the correctness of the autointoxication
hypothesis, early experiments like those of Alvarez, Donaldson, and Dragstedt
demonstrate the widespread systemic effects of relatively minor manipulations
of the colon. It is interesting, then, that both proponents and opponents
of colonics have paid no attention to this finding, providing little new
information beyond that from the 1920s.
Clinical Experience with Colonic Irrigations
A variety of books from the 1920s and 1930s by the
proponents of colonic irrigations attest to their clinical value (e.g.,
Russell, 1932; Tyrrell, 1913; Stemmerman, 1928; Wiltsie, 1938). At the
same time, the American Medical Association was zealously attacking "quackery,"
with colonic irrigations as a particular target (e.g., Cramp, 1912). But
in the absence of peer review, there is no way to evaluate the claims that
are made on either side of the debate. Instead we will focus on the articles
in the refereed journals of the time, especially JAMA. Our goal is not
to demonstrate the efficacy of colonics, because standards were very different
in those days, but to show that there was a reasoned debate by professionals
occurring at the same time as the campaign against quackery.
Satterlee and Eldridge (1917), writing in JAMA, discussed
the symptomalogy of the nervous system in chronic intestinal toxemia. Far
from considering autointoxication an outdated hypothesis, they note the
"newly found and rapidly developing relationship between mental and nervous
conditions and disturbances of the intestinal tract" (p. 1414). "It is
a significant fact that in practically all of the cases considered in this
article the nervous manifestations have either cleared up or have been
markedly improved by treatment directed toward intestinal toxemia" (p.
1414). These nervous manifestations included mental sluggishness, memory
problems, phobias, depression and hallucinations as well as others. They
describe a variety of treatments, some far more severe than colonic irrigations
(e.g., surgery to remove parts of the colon). It is easy to see why, given
the apparent relief from symptoms, the far less invasive colonic irrigations
were preferred by many physicians (e.g., Kellogg). In a discussion section
following the paper. Dr. Nathan Rosewater notes that "In cases of headache
due to mechanical causes, particularly from constipation, the relief is
almost immediate after taking a cathartic or enema, showing that there
was a mechanical cause, not toxemia. If it were toxic it would take twenty-four
hours or more before we could remove enough of the toxic matter absorbed
from the bowels into the circulating fluid; so that there is a large class
of cases of this purely mechanical type" (p. 1418). This agrees with the
conclusion of Alvarez (1919) and Donaldson (1922) cited previously.
Further evidence that colonic irrigations were not
universally condemned in the 1920s and 1930s is provided by an article
by Bastedo (1928) in the New England Journal of Medicine. Bastedo was opposed
to the "commercialized irrigation specialists, who are unduly numerous
but do a thriving business" (p. 736). But Bastedo emphasizes that "The
insertion of liquids into the rectum has been an approved therapeutic procedure
since ancient times" (p. 865), distinguishes irrigations of the entire
colon from simple enemas, and gives detailed recommendations for their
administration. It should be noted that he does not advocate antiseptics
in the water, since "experiments have shown that the strongest antiseptics
permissible in the bowel do not kill the bacteria and are prone to be injurious
to the host" (p. 865), though he does not specifically cite Dragstedt et
al. (1922), the most likely source of this information. He recommends plain
water, rather than saline or soda. He sees colonics as "of definite value
in mucous colitis" and other conditions, but does not discuss systemic
conditions such as arthritis. He also recommends against repetitive colonics
because they will irritate the bowel.
Bastedo (1932) writing in JAMA, offered a balanced
discussion of the therapeutic application and dangers of colonic irrigations:
"When one sees the dirty gray, brown or blackish sheets, strings and rolled
up wormlike masses of tough mucus with a rotten or dead-fish odor that
are obtained by colon irrigations, one does not wonder that these patients
feel ill and that they obtain relief and show improvement as the result
of the irrigation" (p. 736). This is a case where autotoxicity is a more
reasonable hypothesis than in Alvarez's 4-day induced constipation study.
And it shows that it is not just the non-medical proponents that have observed
these extreme cases.
Bastedo (1932) notes the positive effect of the colonic
on the blood supply and tone of the colon. He warns of specific dangers,
all resulting from high insertion of a stiff tube; these include perforation,
injury to a polypus, tearing of a rectal valve, and abrasion of the wall.
In contrast, Bastedo sees none of these dangers in colonics employing a
tube inserted not more than six inches, by a trained professional. Bastedo
says, "I trust that my warnings against its improper administration, its
dangers and abuse will not discourage physicians in the proper utilization
of this valuable therapeutic measure" (1932, p. 736).
Soper (1932) responds to Bastedo's JAMA article with
a well-reasoned Letter-to-the-Editor in JAMA, aimed at physicians who might
consider using colonics, which is skeptical of their value, without ranting
about quackery. Soper cites some literature as well as his own clinical
experience. His primary concern is with the administration of repetitive
colonics; in his experience, these result in irritation of the colon and
produce symptoms like excess mucus that colonics are supposedly cleaning.
He summarizes the literature on colonic function, making the point that
the natural function of the colon is to dehydrate feces, and that this
needs no help from repeated colonics. The only disorder that he addresses
explicitly is mucous colitis (today's irritable bowel syndrome), making
the point that colon spasms are related to a multiplicity of factors, and
that irrigations (as well as purgatives and enemas) cause further irritation
and more tendency to spasm. He does not address any of the other claims
for the value of colonics, e.g., as therapy for autointoxication, or to
tone the muscle of the colon.
Arthritis is a disorder where there seemed to be
some clinical evidence of efficacy of colonics. Pemberton's (1935) book
advocates their use. Pemberton (1920), writing a lengthy article in JAMA,
discusses the nature of arthritis and rheumatoid conditions. Pemberton
(1920, 1935) was a proponent of the hypothesis that arthritis was due to
a focal infection, a commonly held viewpoint at the time. He notes early
in the article, "It is true that among the ancients of Greece and Rome
the benefits to be obtained from hydrotherapy were already appreciated,
and it is alleged that the important influence of focal infection was known
to some of the fathers of medicine" (p. 1759). For Pemberton, the appropriate
treatment was removal of the cause, some focus of infection (including
the colon). He concludes, "External measures, such as hydrotherapy, have
undoubtedly real value but have fallen in some disrepute because of their
frequent failure and because of the injurious consequences from them when
pushed in the effort to obtain results. Used cautiously, however, hydrotherapy,
massage and various medicinal agents, when administered in conjunction
with a cautiously reduced diet, may carry benefit far beyond the point
that would otherwise have been reached" (p. 1765).
Snyder and Fineman (1927) give several case reports
suggestive of efficacy in cases of arthritis. Snyder and Fineman's perspective
is that in a subset of cases of arthritis, the lack of response to conventional
treatment may be due to toxin absorption from the gastrointestinal track.
Snyder and Fineman cite several clinicians in addition to Pemberton who
have this perspective (Persson, 1923; Smith, 1922; Carter 1923; Forbes
1924). Thus as late as 1927, the autointoxication hypothesis has not gone
away. Snyder and Fineman clearly state that the colon is not the etiologic
factor in all cases of arthritis, but that, based on clinical experience,
"when indicated the elimination of colonic stasis has been of definite
value in the management of the disease" (p. 28). Another clinical observation
is that cathartics have no positive effect on arthritis, and usually result
in adverse effects. Similarly, home administered enemas produced inferior
results to professionally administered colonics. Snyder and Fineman also
give a call for research: "The ascertainment, however, of the exact value
of each factor in this system of irrigations is a difficult matter and
will require prolonged study with carefully checked controls in a large
series of cases" (p. 31). This is a strong contrast to those physicians
who simply dismiss colonics as "quackery."
Arthritis is no longer thought to be an infectious
disease, and it is likely that the use of colonics for arthritis therapy
became unpopular in the absence of this rationale. However, there is extensive
modern literature linking arthritis to digestive system disorders, particularly
inflammatory disorders (Palm et al., 2001; Lindsley and Schaller, 1974;
Holden et al., 2003; Rees et al., 2004). The modern explanation involves
immune system dysfunction, rather than autointoxication. Bowel dysfunction
is also found in fibromyalgia syndrome, which has much in common with the
"toxic" manifestations treated by colonics in the 1920s and 1930s (Barton
et al., 1999; Triadafilopoulos et al., 1991; Veale et al., 1991). Alba
et al. (2001) even discuss several cases of arthritis as a rare manifestation
of acute sigmoid diverticulitis. They found that the arthritis promptly
improved after surgical resection of the sigmoid colon. This harkens back
to the days of the late 1800s when colon surgery was the therapy of choice
for such problems. Could colonic irrigation provide a less invasive treatment?
Colonic irrigation was also sometimes recommended
for mental illness. Whorton (2000), with a very skeptical tone, notes the
psychotherapeutic effect of simply being treated by an elaborate colonic
machine. But he also cites the report of Marshall (1936) in Medical Record
regarding the efficacy of colonic irrigations on mental illness. "Psychoses
were favorably affected as well, at least according to a Massachusetts
physician who administered 'upwards of fifteen thousand colon irrigations'
to mental patients during the early 1930s, for the 'sedation' they accomplished.
Typical was the manic-depressive woman who received 835 irrigation treatments
between 1930 and 1935; by the end of the regimen, 'her manic episodes are
less violent, she is tidier in her habits and more moderate in her language"
(P. 136). While this sounds like an example of an excessive use of colonics,
there may have been some valid clinical observations, considering the effects
on the nervous system reported by Alvarez, Donaldson, and others.
Colonic irrigations were also a significant component
of the cleansing regimen at the Still-Hildreth osteopathic sanitorium for
mental illness. "Hydrotherapy is another valuable aid for which we are
equipped. Baths and hot packs are used to quiet the nerves, to induce sleep,
and especially to stimulate elimination through the kidneys and skin.Many
patients have a history of long continued constipation with evidence of
resulting autointoxication.some assistance is necessary. For it our main
reliance is colonic irrigation, by which the colon is thoroughly cleansed
by large quantities of normal salt solution.The value of this is obvious"
(Hildreth, 1929, p. 519).
The Friedenwald and Morrison Review
The article by Friedenwald and Morrison (1935) is
especially detailed, and at a relatively late date, 1935, assesses colonic
irrigations very positively. These doctors (from the Gastro-Enterological
Clinic of the Department of Medicine at the University of Maryland) begin
with a historical perspective, noting that only recently (1932) the approval
of the Council on Physical Therapy of the American Medical Association
was sought for a large number of new colonic irrigation devices. Friedenwald
and Morrison identify a number of situations in which colonic irrigations
appear to have some efficacy, including "cleansing the colon mucous membrane
of abnormal mucus, infection, debris and foreign bodies" (p. 1615). They
also note the value of colonics in cases of atony of the colon, using temperature
to stimulate or relax the bowel musculature. They say, "There has always
been, there will, in all probability continue to be considerable discussion
pro and con concerning the use of colonic irrigation in the treatment of
so-called 'intestinal toxemia' associated with constipation. There are
arguments perhaps equally good in favor or and against the measure" (p.
1615). They point out that the subjective symptoms of intoxication seem
to disappear as a result of colonic irrigation. However, they also note
that, "It is interesting that the symptoms of what has been termed 'auto-intoxication'
can be produced by merely distending the rectum with some foreign body"
(p. 1616) (the result of Alvarez and Donaldson). They also point out quite
reasonably that, "The whole problem becomes less controversial when the
physician considers each case individually instead of subjecting all to
the same routine therapeutic procedure without a complete objective examination"
(p. 1616). This statement effectively rejects the "quack" cure-all approach,
while encouraging the use of colonics as a medical procedure.
Friedenwald and Morrison go on to review in detail
the clinical observations of various physicians on the appropriate indications
for colonics, noting a considerable diversity of opinions. They say, "To
omit or even condemn the use of colonic irrigations in their entirety as
a therapeutic procedure is unwarranted.Perhaps the employment of this measure
without proper supervision and study is its greatest single objection"
In contrast to the autointoxication hypothesis often
cited by the skeptics as the only (and erroneous) justification for colonics,
an alternative is the concept that colonics are helpful in restoring muscle
tone to the colon. W. Kerr Russell, for example, is quoted by Friedenwald
and Morrison as writing, "This intensive stimulation reeducates the bowel,
increases the blood supply and improves the tone of the muscles" (p. 1617).
Friedenwald and Morrison partially agree, saying, "It seems that within
limits colonic calisthenics, using the method of irrigation, may have a
tonic effect in certain instances, more often temporary, however, than
lasting, depending largely on the associated treatment. In some cases the
tonic effect of the irrigation may be all-important and actually curative;
this, too, would depend to a great extent upon the type of previous treatment,
the patient and the associated therapy" (p. 1618).
Friedenwald and Morrison conclude by saying, "It
is our opinion that if colonic irrigations are correctly used in selected
cases they fulfill an important therapeutic need" (p. 1628). They call
attention to the possible dangers of mechanical trauma and perforation.
They advise the use of simple apparatus, only plain water, salt solution
and bicarbonate of soda as irrigating solutions, and the desirability of
The Krusen Review
In 1936 JAMA published a review of colonic irrigations
authorized by the Council on Physical Therapy, authored by Frank Hammond
Krusen, Professor of Physical Medicine at the Mayo Clinic. Although generally
skeptical, Krusen gives a balanced review of the pros and cons of colonics.
He acknowledges that "One can hardly fail to be impressed with the violently
opposing views expressed in most of the literature on this subject. One
writer, for instance, tells of 'phenomenal success in the treatment of
many diseases due to consistent and thorough colonic treatments,' whereas
another bitterly and somewhat facetiously decries the existence of too
many 'colon filling stations.'.. One finds that among physicians of unimpeachable
medical integrity there are widely divergent views concerning the value
of colonic irrigations" (p. 118).
On the "pro" side he cites physicians treating a
variety of conditions. For example, he points out that "Pemberton, in a
careful evaluation of the pros and cons of colonic irrigation in the treatment
of arthritis, while graphically outlining the shortcomings, makes clear
that he uses colonic irrigation in conjunction with colonic massage in
some of his cases of arthritis" (p. 119). He also cites Stroud (1932) who
advocates colonics in the treatment of cardiovascular disease, and Weisenberg
and Alpers (1932) who note that "High colonic irrigations are of value
in some cases of so-called toxic myelitis" (p. 119). Krusen comments that
the same effect "can probably be achieved by means of the simple enema,
proper medication, or modification of diet," but he does not deny the value
of the concept of bowel cleansing in these examples. Krusen also cites
Morgan and Hite (1932), who see value in colon cleansing, but notes the
need for recognition that such a treatment can be harmful if carried beyond
limits called for by the specific ailment. Like many physicians, Morgan
and Hite are concerned about administration of colonics by "the unskilled
both in and outside the profession."
Krusen discusses opposing viewpoints on ulcerative
colitis, comparing Lockhart-Mummery (1934), who advocates use of colonics
and gives specific recommendations, to Bargen (1934) who finds that colonic
irrigations are "rarely indicated."
He also discusses viewpoints on the technique of
colonic irrigation, contrasting the "high colonic" where a 52-inch tube
is passed through the colon directly into the cecum, and the type more
common today, where a tube not more than 4 to 6 inches long is used. He
agrees with Bastedo that the short-tube colonic irrigation is far safer.
Regarding colonic machines, Krusen is skeptical of the value of elaborate
colonic machines, preferring a simple system with a glass jar and tubes.
Although Krusen himself found that the machine he purchased for his own
hospital was of little use, he concedes, "In all fairness, it must be admitted
that some of the manufacturers of these devices are sincere in their misguided
belief that their machines will prove a great boon to mankind. It must
also be stated that a great many hospitals have equipped themselves with
some such elaborate device" (p. 120).
On the con side, Krusen has two main points. The
first is that colonics can have adverse effects, such as cramps, irritation,
and perforation of the wall of the colon. It is interesting, though, that
his source for these adverse effects is Bastedo, who is a proponent of
the careful use of colonic irrigations. His second main point is that,
in his own experience, colonic irrigations have little use in the hospital
setting; his preference is for simple enemas to relieve constipation when
Krusen also makes the point that, "One must also
consider that in conjunction with the lavage there are possibly other factors
present (such as pressure, temperature, motion and osmosis) which may act
to influence normal and disturbed physiological processes in the gastro-intestinal
tract" (p. 121). That is, in considering the mechanism by which colonics
produce therapeutic (or adverse) effects, the autointoxication hypothesis
is not the only one that needs to be addressed.
In his 1941 book, Physical Medicine, Krusen continues
with his doubts about the value of colonic irrigations in most situations,
but gives details on the appropriate technique to be used, based on Bastedo
As late as 1939, there were proponents of colonics
among other respected physicians. W. F. Dutton was Medical Director for
the hospital at the Graduate School of Medicine at the University of Pennsylvania.
In the preface to his book on headaches (Dutton, 1939) he speaks positively
of the AMA's campaign against quackery, and says that, "The lay press,
unscrupulous manufacturers and radio advertising of nostrums and cure-alls
to the public present a serious problem" (p. iii). He says that his book,
aimed at physicians, is "a summary of the available literature, with authoritative
references," and that "dogmatic statements on controversial subjects have
been avoided purposely" (p. v). However, he also notes the importance of
"autointoxication products absorbed from the gastrointestinal tract" in
the etiology of some headaches (p. xvi). He includes a section on "enemata"
for headache therapy, illustrating techniques for enemas. He also talks
about more extensive irrigation of the colon, and says regarding colonic
irrigations, "The procedure has become one of the most valuable therapeutic
measures we possess" (p. 97; italics in the original). Dutton's book is
an example of how a physician, writing for other physicians, could be supportive
of the value of colonic irrigations, while acknowledging the problem of
Thus, in the late 1930s, there was a reasoned debate
on colonic irrigations, documented in JAMA, despite the crusaders against
"quackery." The themes in these JAMA articles up through the 1930s are
clear: the problem is not that there is anything intrinsically wrong with
colonic irrigations. Rather, (1) there are clinical observations from a
variety of physicians and studies such as that of Donaldson supporting
the efficacy of colonics for some conditions, (2) the autointoxication
hypothesis is not supported for most apparent "toxicity," although there
is evidence for nervous system reflexes, and (3) while administration under
a physician's supervision is a reasonable therapeutic procedure, the inflated
claims and sometimes extreme procedures employed by non-medical practitioners
are not advised.
As Whorton (2000) has noted, the zealous critics
of quackery tend to offer ridicule in place of specific citations of research
demonstrating the inefficacy of colonics. A prime example is the letter
to the editor of JAMA from Smithies (1926), labeled "Colon Filling Stations,"
in which he primarily makes fun of the "colon therapists," and states,
"This 'new' colon therapy rests on no basis of fact, is employed by none
of the country's leading gastro-enterologists, and is permitted in no institution
of recognized standing" (p. 691). Contrast this with the reasoned discussions
by such authors as Krusen, Friedenwald and Morrison, Pemberton, and Bastedo.
It is important to note that none of these authors is advocating colonic
irrigations as the cure for all diseases, nor for their administration
by personnel who are not professionally trained, but they all see a value
in the procedure and support their arguments with clinical observations.
It is this perspective that appears to have been squeezed out by the crusaders
Modern Viewpoints on Colonic Irrigations
Up through the 1930s, the question of the proper
use of colonic irrigations was at least debated with the help of some experimental
data and clinical observations. Modern medical education, on the other
hand, is characterized by a simple lack of information on colonic irrigations.
An example in JAMA of an attack on colonic irrigations without references
or supporting documentation is the response to a letter to the editor by
Merar (1961), in which he states, "The much vaunted colonic irrigations
used chiefly by cultists and pseudohealth clinics are of no benefit and
may be harmful or even dangerous. Their use was, and no doubt still is,
based on the theory of auto-intoxication and absorption of poisons through
the bowel wall; this is pure nonsense in the light of scientific investigations"
Franklin (1981) in a Questions and Answers column
in JAMA, responded to a question about the efficacy and safety of colonics
with two answers. For efficacy, he looked at three major gastroenterology
texts (from 1976 to 1978) which revealed no mention of colonic irrigations
as a therapeutic technique (i.e., no mention either for or against their
use), and concluded that there is no rationale for their use. For safety
he referred to a single report on the adverse effects of repeated (every
two hours) coffee enemas (Eisele & Reay, 1980); however, the concerns
regarding fluid and electrolyte problems from such extreme measures have
little relevance to colonics as normally administered (see section of this
paper on adverse effects).
Jensen (1995) in a recent review of the medical treatment
of constipation discusses enemas in detail and mentions colonic irrigations.
He lists a variety of substances that have been including coffee enemas
for alternative cancer treatment. He also notes a variety of adverse effects
from soap and coffee enemas (not specifically colonic irrigations) and
mentions the single outbreak of amebiasis spread by contaminated colonic
equipment (Istre et al., 1982). He states, "Little scientific evidence
has been reported concerning the effectiveness of any of these alternative
treatment regimens with respect to constipation. Perhaps their widespread
use has precluded further objective evaluation" (p. 149). Our perspective
is that their widespread use should call for further objective evaluation,
rather than simple dismissal.
As already discussed, Ernst (1997) strongly advises
against colonic irrigations (again citing only the Istre et al., 1982 paper
as a specific example of an adverse effect), yet he offers little evidence
of either scientific research refuting their effectiveness, or a quantitative
assessment of relevant adverse effects.
Current Status of Autointoxication
As Ernst (1997) has discussed, the primary justification
for colonic irrigation (dating back into the 19th century) is usually that
toxic wastes build up in the colon, that toxins leak into the general circulation,
and that these toxins are responsible for a variety of symptoms. This autointoxication
hypothesis was quite controversial; much of the controversy centered around
extreme claims that autointoxication was responsible for all disease (Cramp,
1921). Ernst claims that autointoxication has been refuted, yet there is
significant modern literature that suggests that a modified version of
autointoxication is quite reasonable in some cases.
The modern perspective focuses on dysfunction of
the immune system caused by toxins leaking from the gut, as well as bacterial
translocation from the gut to the systemic circulation caused by a breakdown
of the intestinal wall. This breakdown can be caused by a variety of types
of injury to the body at locations far from the gut. Swank and Dietch (1996)
state, "It is clear that increased gut permeability and bacterial translocation
play a role in multiple organ failure (MOF). Failure of the gut barrier
remains central to the hypothesis that toxins escaping from the gut lumen
contribute to activation of the host's immune inflammatory defense mechanisms,
subsequently leading to the autointoxication and tissue destruction seen
in the septic response characteristic of MOF."
Similarly Person and Bernhard (1986) in an article
entitled, "Autointoxication revisited," invoke an immune system mechanism,
stating, "The pustular dermatitis associated with small bowel bypass surgery
and the cutaneous manifestations of inflammatory bowel disease are well
known and generally assumed to be due to the absorption of microbial antigens
from the bowel. Monomeric serum IgA is assumed to originate in the gastrointestinal
tract, and circulating IgA immune complexes, as seen in dermatitis herpetiformis,
should make us suspicious of a gastrointestinal tract source."
Kelvinson (1995) reviewed several physiological factors
that suggest the importance of the colon in disease processes. These include
evidence of absorption of toxins and macromolecules, and heightened immune
system reactions, due to injured intestinal mucosa.
Numerous drugs can be absorbed from the colon, to
varying degrees (Muranishi, 1984; Riley et al., 1992; Kimura et al., 1994).
Rectal suppositories are a popular way of rapidly delivering medicine to
the circulation without passing through the rest of the digestive tract
(van Hoogdalem et al., 1991). The rate and extent of rectal drug absorption
vary depending on the type of drug and the formulation, and on the presence
or absence of absorption-promoting agents. The suppository route has been
found particularly effective for such drugs as sumatriptan for migraine,
where the effects are comparable to oral doses, and provide relief within
two hours (Bertin et al., 1999). Various toxic substances can also be absorbed
from the colon (e.g., sodium phosphate, Martin et al., 1987; iodine, Kurt
et al., 1996; aspirin, Watson & Tagupa, 1994; cyanide, Ortega &
Creek, 1978). Given that these substances can be easily absorbed, it seems
reasonable that bacterial toxins might be absorbed as well.
It is important to distinguish between (1) the common
observation that a constellation of symptoms (fatigue, headache, joint
pain, etc.) were correlated with constipation, and could be relieved by
enemas or colonic irrigations, (2) autointoxication, a mechanism suggested
for these systemic effects originating in the colon, but expressing throughout
the body, and (3) the recognition that there are problems directly related
to the colon (such as ulcerative colitis) that might or might not benefit
from colonic irrigations. These three are not necessarily related. That
is, there may indeed be system-wide effects originating in the colon, but
autointoxication may not be the correct explanation for the observations.
Autointoxication (including immune system responses) may be a factor in
some cases, but not as the "cause for all disease." It is also possible
that direct treatment of the colon for serious colon problems like ulcerative
colitis is not a useful therapy (and possibly harmful), but that colonic
irrigations are effective for these other, system-wide problems.
The potential for adverse effects from colonic irrigations
must be addressed, both for informed consent in research, and for the purpose
of assessing risk for therapeutic applications. There is a need to determine
to what degree the common medical criticism of colonic irrigations, that
there are serious adverse effects (e.g. Ernst, 1997), is valid. For informed
consent it is important to have a quantitative estimate of the potential
for adverse effects. However, reports of adverse effects from colonic irrigations
of the type we are discussing (performed on individuals without serious
bowel disease, by trained colon hydrotherapists, using disposable nozzles)
appear to be very rare, despite the widespread popularity of colonics as
an alternative health modality. We have found only two reports on Medline.
One is the oft-cited case of amebiasis from improperly sterilized equipment
at a chiropractic clinic in Colorado (Istre et al., 1982). The other is
a case of rectal perforation in Singapore (Tan & Cheung, 1999). Looking
beyond the Medline literature, there is a case of rectal perforation currently
in litigation in Texas, and the Texas Attorney General's website claims
that one death and four serious injuries involving patients with perforated
colons occurred in 2003 following the treatments, with no supporting documentation
(Texas Attorney General, 2003). However, there has been no systematic
collection of data published on colonic irrigations.
Since there is no specific data on colonic irrigations,
the closest comparisons would be enemas and sigmoidoscopies, so it is also
worth a look at the adverse effects of these procedures to determine if
they are relevant to colonic irrigations. Enemas typically only stimulate
the first part of the colon, the sigmoid colon, and are not intended to
cleanse the entire colon as is a colonic irrigation. However, the term
enema is a broad one, and such procedures as a barium enema can introduce
material throughout the colon. Often an enema is given before a more invasive
procedure such as a sigmoidoscopy or a colonoscopy, in which a tube is
introduced into the colon. In a sigmoidoscopy, the tube (with a fiber optic
camera) goes only as far as the sigmoid colon; however, this may be up
to 25 inches. In a colonoscopy, the tube may go as far as the cecum. Both
may include biopsies or removal of polyps. In contrast, the tube for a
colonic irrigation is inserted approximately 3 inches into the colon, and
no procedure such as biopsy is performed. For these reasons, any estimate
of adverse effects based on sigmoidoscopies would likely show a substantially
greater risk than is actually found with colonic irrigations.
The adverse effects from enemas and sigmoidoscopies
can be classified into four types. The first type is perforation of the
wall of the colon. The second type is a reaction to something in the enema,
ranging from an allergic reaction to the nozzle tip, to substances such
as coffee or soap. The third type is primarily a pediatric problem - an
electrolyte imbalance resulting from an enema in a small child - but has
also been seen in geriatric patients. The fourth type is infection from
contaminated equipment (e.g., Istre et al., 1982).
Risk of Perforation
Perforation of the wall of the colon is often seen
as the most serious adverse effect of any procedure that introduces something
into the colon. Perforation can be mechanical, such as when the tip that
injects the water or the tip of the endoscope causes damage, or it can
be from overpressure causing failure of a weak spot in the colon wall.
The risk of perforation is related to the invasiveness of the procedure,
the health status of the patient, and the competence of the person administering
the procedure. Enemas, for example, are the least invasive procedure, but
are also often self-administered. Colonoscopies are the most invasive procedure
and have the highest rate of adverse effects, since they involve deep penetration
into the colon. Sigmoidoscopy, with insertion only into the first part
of the colon, is substantially less invasive. Both procedures are performed
by professionals, with FDA-approved equipment. As noted previously, both
are substantially more invasive than the 3 inch nozzle insertion of the
Colon Perforation from Cleansing Enemas
Cleansing enemas are the closest comparison to colonic
irrigations, but differ in the amount of fluid administered and the high
frequency of self-administration. No systematic data have been collected
on the incidence of perforation compared to the total number of enemas
given. Only case reports exist. Nevertheless, there are far more reports
of injuries from enemas than from colonic irrigations. In the following
discussion, it is important to bear in mind that these case reports of
adverse effects represent a tiny fraction of the enemas given.
Paran et al. (1999) review all the cases of colon
perforation from cleansing enemas over a three-year period in their surgical
unit. These consisted of 13 elderly patients, with a mean age of 64.3,
suffering from chronic constipation. Ten had perforations from enemas administered
by nursing home staff; three had administered the enemas themselves at
home. The authors note that, "Perforation of the rectum and sigmoid colon
caused by cleansing enemas, used by chronically constipated patients, has
not been previously described." This suggests that perforation is a rare
occurrence, but the authors note that the true incidence of enema-induced
perforations is unknown.
Gayer et al. (2002) report on 14 cases of perforations
of the rectosigmoid colon induced by cleansing enemas. It is important
to note that the average age of the patients was 80 years, since perforations
appear to be far more likely in the elderly.
The remaining reports address rare single cases.
Larson (1966) reports a case of a 72-year-old man whose rectum was perforated
by an enema given by a hospital orderly. He also cites the three other
cases of injury caused by disposable enemas that he was able to find in
the literature (Blatt, 1960; Scott, 1960; Turell, 1960). Larson notes that,
"A two-inch enema tip is sufficiently long for satisfactory administration
of an enema and provides a degree of safety" (p. 448), and that a tip constructed
of softer material than the common semi-rigid plastic would be safer.
Wolfe and Silver (1966) discuss a case of rectal
perforation with profuse bleeding following an enema given in a hospital.
They note that that, "The vast majority of enemas produce their desired
effect without any accompanying complications" (p. 715). However, they
cite additional cases reported by Large and Mukheiber (1965), Wechisser
and Putnam (1962), Klein and Scarborough (1963), Roland and Rogers (1959),
and Szunyorgh (1958).
Classen et al. (1975) cite several cases of iatrogenic
perforation of the rectum during cleansing enemas. They note that, "The
vast majority of the rectal injuries and perforations resulting from enema
tubes occur in the anterior rectal wall. This can be readily understood
when one realizes that these injuries almost always occur with the patient
in a sitting position" (p. 1425). Another position, therefore, may be less
Hool et al. (1980) note that only a few cases of
enema-nozzle injuries to the rectum are reported in the literature, but
that they are aware of more that go unreported. They present two cases,
both from enemas given in hospitals. They conclude that, "This injury,
with its very serious consequences, should be entirely preventable if rigid,
hard enema nozzles are avoided. More attention should be given to the design
of disposable enema nozzles. Some disposable enema nozzles which are widely
used are long, and not sufficiently soft and flexible" (p. 381). The example
in their picture appears to be about 4 inches long.
Bell (1990) reports a case of colonic perforation
with a phosphate enema administered at a hospital, and again recommends
that enema nozzles be short and pliable. He also makes the point that the
toxicity of the phosphate solution passing into the peritoneal cavity made
the problem more serious
Perforation may also occur from extreme self-administered
enemas using non-standard means. For example, Topcu (2003) reports a case
where a chronically constipated man administered a rectal enema using a
garden hose directly connected to the water until he felt a sudden sharp
abdominal pain resulting from a perforation.
In none of these reports is there any estimate of
the percentage of perforations compared to the total number of cleansing
enemas. This may be impossible to obtain, given that enemas are often self-administered
at home. However, perforations would seem to be very rare, given that enema
kits are obtainable over-the-counter, and that hundreds of thousands are
probably given every year. Presumably based on the rarity of injuries,
enema kits are classified by the FDA as Class I devices, and do not require
a prescription or any specific training for administration. It is difficult
to see why the FDA would classify colonic irrigation devices as Class III
devices when used for routine colon cleansing, and as "significant risk
devices" when used in research studies (FDA Warning Letter, 2003), since
there is no evidence that the risks are greater than with enemas, and probably
less, given that colonics are usually administered by people with some
professional training. However, it is also important to note that several
authors point out that perforations can occur with enemas even when administered
by trained professionals, and that these professionals need to be made
aware of the potential for injury even from this "benign" procedure (e.g.,
Classen et al., 1975; Paran et al., 1999).
Colon Perforation from Sigmoidoscopy and other Medical Procedures
Better quantitative data is available on medical
procedures such as sigmoidoscopies, colonoscopies, and barium enemas, but
it is much less relevant to colonic irrigations, since barium enemas involve
the introduction of a potentially toxic substance and sigmoidoscopies and
colonoscopies are substantially more invasive.
The two most extensive studies related to colonoscopy
and sigmoidoscopy are those of Gatto et al. (2003) and Anderson et al.
(2000). Gatto et al. (2003) determined perforation rates from colonoscopy
and sigmoidoscopy in a large cohort of people aged 65 and older in the
Medicare program. The incidence of perforation from colonoscopy was 0.196%
in 39,286 procedures, and from sigmoidoscopy 0.088% in 35,298 procedures.
The risk of perforation increased with age and with the presence of two
or more comorbidities, particularly with diverticulosis and abdominal pain.
The authors point out that their findings may not be directly generalizable
to people younger than 65 years.
Anderson et al. (2000) report a substantially lower
rate of perforation in a study of patients at the Mayo Clinic (mean age
72 years, age range 48 - 87 years). There were 20 (0.19%) perforations
and two (0.019%) deaths in 10,486 colonoscopies, and two perforations with
no deaths in 49,501 sigmoidoscopies (0.004%). Of particular importance,
electrocautery injury was responsible for 36% of the perforations; this
is a surgical procedure irrelevant to colonic irrigations. The authors
note, "The most important safety factor is most likely the sensory feedback
from the patient to the endoscopist, which is retained in the alert patient
[during sigmoidoscopy] and blunted by intravenous sedation [during colonoscopy]."
They also note that not all of the perforations were necessarily caused
by the procedures, because, "spontaneous perforations associated with inflammatory
bowel disease or diverticular disease were not at all rare."
Korman et al. (2003) report the incidence of perforations
of the colon occurring within a network of endoscopic ambulatory surgery
centers. A total of 116,000 colonoscopies were performed within one network
of 45 endoscopic ambulatory surgery centers in the United States during
1999. There were 37 (0.03%) perforations; 27 in women and 10 in men. Median
patient age was 75 years (range 39-87 years); 18 patients (49%) had diverticular
disease and 20 (54%) had a history of pelvic or colonic surgery. They conclude
that reported perforations for procedures performed in endoscopic ambulatory
surgery centers occurred most frequently during diagnostic colonoscopy
in older women with a history of surgery or diverticular disease.
Fry et al. (1989) found perforations in 5 of 2200
(0.2%) barium enemas - most patients had active ulcerative colitis or rectal
lesions. Blakeborough et al. (1997) report on a survey of all consultant
radiologists in the United Kingdom over a 3 year period. The 756 respondents
performed a total of 738,216 examinations. There were 30 reported cases
of bowel perforation (0.004%).
In a review by Nelson, Abcarian, and Prasad (1982),
"In eight years at Cook County Hospital, 42,000 barium enemas, 16,325 proctosigmoidoscopies,
and 1207 colonoscopies were performed. All endoscopic procedures were done
by the house staff. There were three perforations due to proctosigmoidoscopy
(0.02%), with one death; three perforations due to colonoscopy, with no
deaths; and seven perforations due to barium enema [0.017%], with no survivors.
The adjuvant effect of barium sulfate is proposed as the most likely cause
for this excessively high mortality in barium-enema perforation."
An important issue relevant to the risk from colonic
irrigations is the occurrence of spontaneous perforation of the colon in
the absence of an irrigation. Spontaneous perforation can occur from various
colonic diseases, e.g., a ruptured stercoral ulceration (Chen and Shen,
2000). Johnson and Baker (1990) report colonic perforation following mild
trauma (being hit in the abdomen during a basketball game) in a patient
with Crohn's disease. Ledley et al. (1988) report perforation of the sigmoid
colon from endometriosis. Avinoah et al. (1987) note that even "severe
untreated chronic constipation may, on rare occasions, cause free perforation
of the sigmoid colon." There are also rare cases of spontaneous perforation
of the colon from Ehlers-Danlos syndrome (a hereditary connective tissue
disorder) (e.g., Sykes, 1984; Kinnane et al., 1995; Fuchs and Fishman,
2004), and of perforation resulting from enemas in patients with this condition
(e.g., Sentongo et al., 1998).
It is also important to note that colonic perforation
can occur in rare cases from events not involving insertion of anything
into the rectum. Farbin et al. (1996) discuss a case of perforation of
the sigmoid colon by hydrostatic pressure resulting from sitting on a public
water fountain. Li and Ender (2002) discuss cases of colon perforation
resulting from the swallowing of a toothpick.
Thus a rare perforation of the colon in association
with a colonic irrigation may have other causes than the colonic irrigation
itself, particularly when there is already colon disease.
To summarize, the most important risk factors for
perforation relevant to colonic irrigations are advanced age and diseases
of the colon such as diverticulitis and inflammatory bowel disease. The
greatest risk (for those over 65 with bowel disease) would be about 1 in
10,000 (based on the perforation rate for sigmoidoscopy), with the risk
for younger people without bowel disease much lower. Given the much smaller
insertion distance into the colon, the perforation risk for colonic irrigations
should be substantially less than for sigmoidoscopy, and probably similar
to that for enemas. Several authors have pointed out that, although such
perforations are very rare, it is important for professionals to be aware
of their possibility, how to minimize the potential for perforation, and
what to do if one occurs.
Risk of Other Adverse Effects
Warnings against colonic irrigations often take the
form of cautions about the adverse effects of substances administered during
enemas. This is not relevant to colonics using only filtered tap water,
which is a common application, but is important if any substances are to
be added to the water. There are no reports of adverse effects from tap
water colonic irrigations in adults, although there is a concern based
on the possibility of depletion of electrolytes.
Again, enemas are the closest comparison available
to colonic irrigations. Schmelzer et al. (2000) have published a small
(25 subject) study on colonic cleansing, fluid absorption, and discomfort
following tap water and soapsuds enemas. Their perspective is that enema
administration is a basic nursing skill, and that (as we agree for colonic
irrigations), nurses need information about possible solutions, their effectiveness,
and possible side effects. Schmelzer et al. point out that both tapwater
and soapsuds enemas have been given routinely for over 100 years, but that
little is known about their effectiveness, the precise indications for
their use, or their side effects.
As Schmelzer et al. describe it, the ideal enema
would effectively cleanse the colon with minimal side effects, essentially
the same as the goal of the colonic irrigation. Enemas, like colonics,
cleanse the colon by stimulating propulsion and secretion. The relevant
factors include enema volume, the presence of chemical irritants, and the
osmolality or tonicity of the solution. The instillation of a large fluid
volume into the colon stimulates propulsion; this is especially relevant
to colonic irrigations which typically use pure tap water with a larger
fluid volume than enemas. Chemical irritants stimulate both propulsion
and secretion to rapidly empty the colon; using a hypertonic solution to
draw fluid from the body into the colon through osmosis, and directly irritating
the mucosa are the principles of the popular Fleets sodium phosphate enema.
Soapsuds enemas use the principles of high volume and chemical irritation.
Schmelzer et al. (2000) found that soapsuds enemas
produced significantly greater output than tap water and were equally well
tolerated. Most subjects who received tap water enemas retained more fluid
than was eliminated. Based on these findings, they advised that nurses
should use caution when giving repeated enemas to patients sensitive to
large fluid loads. This is relevant to the question of the fluid load resulting
from a colonic irrigation, in which a larger volume of water is used than
in the typical enema.
Cohan et al. (1992) also compared tapwater to phosphate
enemas in a study with 66 patients. They found that there was a significant
increase in the serum phosphorus in the phosphate enema group. However,
absolute serum phosphorus values remained within the normal range in all
but one patient, and the changes in other electrolytes, minerals, and venous
pH were insignificant.
Aware of the occasional adverse effects of tapwater
enemas from electrolyte imbalance, particularly in children, Collins and
Mittman (19xx) have performed the only study that has specifically looked
at the effect on serum electrolytes of colonic irrigations as they are
given in naturopathic clinics. Seventeen healthy volunteers free of cardiovascular
disease, kidney disease, and hypertension, as well as bowel disease, were
given before/after measurements of serum electrolytes (sodium chloride,
calcium, potassium and phosphorus) with a tapwater colonic irrigation.
Although there were small changes in some electrolyte levels, the subjects
experienced none of the symptoms of water intoxication. The authors also
note that their experience at the Portland Naturopathic Clinic has been
that even in debilitated and chronically constipated patients, serious
reactions to colonic hydrotherapy have not occurred. They conclude: "The
data presented here may help support the safety of hypotonic solutions
employed in colonic irrigation in normal patients with no known risk factors
for acute water intoxication, such as neurogenic constipation, heart failure,
renal failure and recent fluid electrolyte depletion or dilution."
Phosphate enemas are far more likely than tapwater
colonics to cause adverse effects. They are a common form of self-administered
preparation prior to flexible sigmoidoscopy screening (Atkin et al., 2000),
are also frequently administered in hospitals and nursing homes, and are
considered effective and acceptable. But phosphate enemas can occasionally
cause serious problems in the elderly, especially those with renal failure
(e.g., Korzets et al., 19992; Knobel and Petchenko, 1996). Groskopf et
al. (1991) have reviewed the adverse effects of phosphate enemas and concluded
that Fleets enemas carry a potential risk for acutely ill elderly patients.
There is also a case reported of a pregnant woman who caused serious bone
growth problems for the fetus by self administering multiple hypertonic
phosphate enemas during pregnancy.
Adverse effects due to electrolyte imbalance from
pediatric enemas have also been the source of numerous case reports in
the literature. Ordinary phosphate enemas have caused illness or death
(Walton et al., 2000; Ismail et al., 2000; Helikson et al., 1997;
Craig et al., 1994; Martin et al., 1987). Harrington and Schuh (1997) acknowledge
this problem, and offer specific guidelines for administration of Fleet
enemas in a pediatric emergency department. Another problem seen primarily
in children, is water intoxication (due to hyponatremia - electrolyte depletion)
from tap water enemas (Blanc et al., 1995; Chertow and Brady, 1994).
Adverse reactions (some fatal) to other substances
in enemas have been reported for chamomile tea (Jensen-Jarolim, 1998; Thien,
2001), ozone (Eliakim et al., 2001), hydrogen peroxide (Bilotta and Waye,
1989; Bollen et al., 1998; Meyer et al., 1981), isopropyl alcohol (Barrett
et al., 1990; Haviv, 1998), hot water (Schapira et al., 1996; Sternberg
et al., 1995), iodine (Kurt et al., 1996), glycerin (Chang et al., 1995),
aspirin (Watson and Tagupa, 1994), acetic acid (Kawamata et al., 1994),
hydrofluoric acid (Cappell and Simon, 1993), formalin (Munoz-Navas and
Garcia-Villareal, 1992), magnesium sulfate (Ashton et al., 1990), soap
(Orchard and Lawson, 1986), coffee (Eisele and Reay, 1980), detergent (Kirchner
et al., 1977; Kim et al., 1980), laetrile (cyanide) (Ortega and Creek,
1978), food coloring (Trautlein and Mann, 1978), lye (Unger, 1978), tobacco
(Bele-Binda, 1975), and milk and molasses (Walker et al., 2003)
Eisele and Reay's (1980) report of deaths from coffee
enemas is often cited as an argument against colonic irrigations, but it
has little relevance. In one case, the patient received 10 or 12 coffee
enemas in a single night, as frequently as three or four an hour. In the
other case the patient received coffee enemas four times a day over several
weeks. In both cases, both the presence of the coffee and the extreme frequency
of the enemas could have been contributing factors, but neither is standard
practice for the typical colonic irrigation.
There have also been cases of allergic reactions
to the latex or plastic enema tip itself (Lozynsky et al., 1986; Kokoszka
and Nelson, 1993; Misselbeck et al., 1994), and to the lubricant jelly
Schmelzer and Wright (1996) note that the enema has
evolved through trial and error, not scientific investigation. They examined
current nursing practice by asking 24 experienced registered nurses to
describe how they give enemas, and if they had seen any complications.
They found that the nurses emphasized patient cooperation, preparation,
and comfort; had observed few complications, and had difficulty describing
quantitative aspects of enemas (e.g., amount of solution given, speed of
Schmelzer and Wright (1993) offer advice for minimizing
the risk from enemas, noting that the primary danger comes from a combination
of injury by the enema tip, and the toxicity of the phosphate. They note
that patients at highest risk are those with hemorrhoids. They suggest
precautions including determining if the patient has a history of hemorrhoids
or colon disease, and performing a brief fingertip rectal exam to feel
for hemorrhoids or other abnormalities and to identify the optimal angle
for insertion of the enema tip. They also suggest using tap water or saline
solution in preference to phosphate, since they are less likely to cause
harm if perforation does occur.
To summarize, for colonic irrigations, the risk to
healthy adults of adverse effects from tapwater or saline solutions is
probably extremely small. The risk when other substances are introduced
into the colon varies substantially based on the nature of the substance.
However, it is important not to confuse the basic colonic irrigation with
therapeutic procedures such as coffee enemas that may carry greater risks.
Transmission of Pathogens
The potential for transmission of pathogens through
enemas and irrigations was described as early as 1929 (Hervey, 1929), and
followed by reports by Gilbert (1938), Steinbach et al (1960), and Meyers
(1960), all making the point that pathogens ranging from bacteria to protozoa
can survive on the parts of enema equipment that are insufficiently sterilized,
and be transmitted rectally. Steinbach et al. suggest that the most practical
solution is an inexpensive disposable enema reservoir, tube and tip. Ever
since the cases of amebiasis from improperly sterilized irrigation equipment
reported by Istre et al. (1981), disposable parts have become standard
for colonic irrigation equipment. It seems clear that there is no reason
to use any other type of equipment.
Conversely, it has been suggested that colonic irrigations
might remove beneficial indigenous microflora in the colon, encouraging
the growth of pathogens (Sisco et al., 1988), although there is no evidence
that this actually occurs. In fact, Bornside and Cohn (1969) found that
mechanical cleansing of the bowel (2 Fleet enemas per day for 3 days) and
low residue diet without antibiotics had no quantitative effect on the
bacterial flora preceding bowel surgery. Antimicrobial therapy delivered
through a colonic irrigation (e.g., with an antiseptic solution) might
have a more significant effect. Sisco et al. also point out the possibility
that irritation of the bowel by an irrigation might promote translocation
of indigenous microflora into the bloodstream, again providing no evidence
that this actually occurs. Clearly, research on the effect of colonic irrigations
on bowel microflora would be worth pursuing.
Generalizing from the data on adverse effects of
enemas suggests some contraindications for colonic irrigations. The first
is a lower age limit; colonic irrigations should probably not be performed
on young children due to the potential for electrolyte depletion. Others,
especially the elderly, should be carefully screened for colon-related
problems before a colonic irrigation is performed. The list of contraindications
should include as a minimum diverticulitis, ulcerative colitis, colon cancer,
rectal fissures, and bleeding hemorrhoids. Second, great caution should
be exercised when using anything other than tap water as the irrigation
solution, and patients should be fully informed of the potential for allergic
reactions and other adverse effects from the solutions. Third, as discussed
below, frequent colonic irrigations, like frequent enemas, may interfere
with normal bowel function.
Barloon and Shumway (1995) discuss medical malpractice
cases resulting from adverse events during radiologic colon examinations,
including perforation of the colon. Their strategies to prevent medicolegal
litigation include performing digital rectal examinations on all patients
to detect distal rectal lesions or strictures, recognizing colon perforation,
and obtaining immediate surgical consultation if colon perforation occurs.
Saltzstein et al. (1988) note that injuries to the
anorectum from enemas can be prevented by pre-enema rectal examination
and attention to perianal anatomy and patient complaints of discomfort
during the procedure.
Another issue is that of appropriate equipment.
In the early days of colonic irrigations, a variety of types of equipment
was available, some intended for self-administration (e.g., the JBL Cascade,
Tyrrell, 1913). Some equipment, no longer in use, involved tubes intended
to be inserted all the way to the cecum (e.g., the "high colonic" equipment
judged as unsafe by Bastedo, 1932 and Krusen, 1936). Recently, however,
standards for colonic equipment have been established, and most equipment
in use is registered with the Food and Drug Administration (FDA). This
equipment features temperature controlled water mixing and back flow prevention
valves, pressure and temperature sensors, and a built-in chemical sanitizing
unit and/or water purification unit. The tube is intended for insertion
only about 3 inches into the rectum, and the equipment is designed to prevent
infection by using disposable single-use parts. However, these devices
are approved only as Class II medical devices for bowel cleansing, and
technically can only be sold to a physician or on a physician's prescription.
One of the obstacles to research is that, when these
devices are used for "colon cleansing routinely for general well being"
they are classified as Class III medical devices (FDA, 2004), and it is
the FDA's position that they are "significant risk devices" when used in
research studies of this application (FDA Warning Letter, 2003). The wording
of the FDA classification is rather ambiguous, however. Logically, colon
cleansing for general well being that is being done specifically for a
research project would not be routine. The frequency of colonic irrigations
is certainly an issue requiring study. It would not be surprising if frequent
colonics, like frequent enemas, resulted in adverse effects and interference
with normal bowel function, but "routine" is not a useful word. As noted
earlier in this review, it is also hard to understand why a colonic irrigation
performed for general well being would have a greater risk than one performed
as preparation for a colonoscopy. Since the risk of adverse effects increases
with the age of the patient and the pathology of the colon, one would expect
an occasional cleansing for general well being of an average person to
be far less risky than a cleansing for the typical elderly patient with
colon disease. It seems more reasonable to classify colonic equipment used
for general well being in the same category as cleansing enemas (Class
I), since they perform essentially the same purpose. They are likely to
be somewhat less risky than enemas since they are administered by trained
professionals, not ordinarily self-administered. This raises the issue
of professional standards, since it is clearly possible to cause harm by
improper administration of colonic irrigations, and there is a risk even
with proper administration (as there is with enemas).
The issue of the appropriate training and professional
status to administer colonic irrigations is significant. Our assumption
in this paper is that the person administering the colonic irrigation has
had training at least equivalent to that involved in certification by the
International Association for Colon Hydrotherapy (I-ACT). I-ACT standards
include 100 hours of training for their basic level of certification (I-ACT,
2004). However, the professional status of colon hydrotherapists
varies widely from state to state, and I-ACT is not necessarily recognized
as a professional association.
In Florida, the Department of Health issues a Certification
in Colonic Irrigation, which is an add-on to Certification in Massage Therapy.
For a person currently licensed to practice massage therapy in Florida,
the colonic certification requires successful completion of a course of
study in Colonics at a Board of Massage Therapy Approved Massage School
which is approved to offer colonics, or completion of a Board approved
apprenticeship program in the area of colonics; and must pass the Colonics
Examination administered by the Department of Health. This training includes
completion of a 2-hour course on the prevention of medical errors (Florida
Department of Health, 2004).
As another example, in Nebraska, colonic irrigation
is included under the definition of the practice of chiropractic, with
no additional certification required (Nebraska Health and Human Services
System, 2004). In contrast, in the state of Washington, chiropractic explicitly
shall not include colonic irrigation (Washington State Legislature, 2004).
In some states naturopaths perform colonic irrigations, but naturopaths
are only licensed in a few states. In Texas there is an ongoing lawsuit
where the attorney general's opinion is that a physician's supervision
is necessary (Texas Attorney General, 2004).
Again, professional training is not an issue unique
to colonic irrigations, and is probably a more serious problem with enemas.
Paran et al. (1999), in their study of colon perforations from cleansing
enemas, discuss the importance of information about the possible problem
for making a rapid diagnosis. Vague and misleading information from nursing
home staff made diagnosis difficult, and the authors specifically note
that, "The information given by the nursing homes' personnel who referred
the patients may be misleading, especially when future litigation is considered."
They recommend that, "Awareness of the possible injury should be stressed
to the general population and, especially, to the nursing and medical staff
of institutions for the elderly, where chronic constipation in the patients
and the use of enemas are common" (p. 1612). They note the relevance of
their observations to colonic irrigations used in alternative medicine
as well. Schmelzer et al. (2000) note that enema administration is a basic
nursing skill, and it seems reasonable that administration of colonic irrigations
could also be seen as a nursing skill.
Given these conflicting regulations on training
and certification, there is great potential for misunderstanding by practitioners
and clients. This also makes research on safety and efficacy more difficult.
However, that research must be conducted for there to be reasonable regulations
on colonic irrigation.
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