PREFACE.

Within the last three decades the diagnosis and treatment of bowel troubles have been greatly changed through improved instruments, technique, hygienic measures, and various remedial agents.

The domain of surgery of the anus, rectum, etc., has been surprisingly limited, and that of gastro-intestinal hygiene enlarged, together with knowledge of man’s assimilative and eliminative organs. Systemic and local hygiene has supplanted drugs and surgery in the treatment of diseases of the anus, rectum, sigmoid flexure, and vermiform appendix. Indeed, the domain of surgery will be restricted to what are still considered incurable diseases if the suggestions of this volume are widely adopted. From a clinical experience extending over a period of thirty-three years, however,—as a specialist in diseases of the anus, rectum, and intestinal machinery generally,—the author feels warranted in maintaining that, if hygio-therapic measures were taken by both physicians and laymen, surgical clinics and hospitals for “operating” on anal and rectal diseases and the administering of countless medicinal remedies would enter the stage of therapeutic oblivion.

The present work is more comprehensive in its scope than its title, Intestinal Irrigation, would at first thought seem to indicate. It is a practical book on home relief for all the symptoms of that form of internal inflammation known as proctitis and colitis. The measures that may safely be taken by the victim himself, without consulting a physician, are minutely explained; and, that he may understand his own case, every chapter goes more or less extensively into anatomical, physio­logic­al, and pathological details.

The author has kept abreast of the advancement of science in relation to his special branch of the healing art, and as the outcome of his large daily experience in this line he feels qualified to speak with authority. Victims of any of the symptoms described in this book may therefore have confidence in its statements. It conveys a message of common sense to the world at large and to the victims of intestinal ills in particular. It is a compilation of clinical talks to the author’s patients, making plain a variety of symptoms arising from a single primary cause.

As the purpose of the book is pre-eminently practical, the author felt warranted in describing minutely his own clinics, so far as any patient could apply the results to his individual needs. This, therefore, is the author’s excuse for introducing his own appliances and describing their features and uses. Certain work must be done by the sufferer himself, and no other invention in the market will aid him so materially in doing this work scientifically and efficiently.

Furthermore, it was found impossible for the author to describe what he himself was doing as a rectal specialist, or to direct sufferers on the road to relief, unless he stated how certain appliances should be employed. In the following pages, consequently, the reader will learn just what to do, for the work is above all things simple and direct, and in the writer’s judgment has the sterling quality of common sense.

Some of the chapters have already appeared, in abridged form, in the magazine Health, as contributed essays; but the text has been elaborated in the following pages and much new matter added, in order that the work should present the most mature information concerning the subjects discussed.

A. B. J.

New York, March 2, 1914.

CONTENTS.

INTESTINAL IRRIGATION.

CHAPTER I.
Efforts to Overcome Constipation without Seeking its Cause.

In the year 1496 an Italian, Gatenaria, invented an appliance for taking an enema; since that time depuratory instruments have had more or less vogue in all civilized countries. Of late years inventive powers have been taxed to construct more convenient and effective appliances, and now perfection has been almost reached, and the poor civilizee, whose habits are really very bad from the savage point of view, may enjoy the delicious privilege of an internal bath whenever he feels the need of it. By any other name this bath is just as purifying: call it irrigation, injection, lavement, clyster, enema—its many names and what they mean testify to the fact that it is for the disease of civil­iza­tion.

The medical profession is really behind the layman in genuine therapeutic measures. It still cares more for the pill-and-powder-prescription-earning fee than for the real health of the patient. When it shall wean itself from its sordid commercialism, it will make the use of the enema a fundamental factor in most forms of therapeutic treatment, and then the enema will become universal.

From the origin of the enema to the present day, the layman has not been unmindful of this valuable resource for removing morbid matter from his physiological sewer. The great relief he thus obtained, and the invariably good results that followed its use, established as a necessary toilet article some form of depuratory apparatus in many homes for all time to come.

But of the nature of the disease that had occasioned its use, both layman and physician were, and for the most part are, ignorant. Local obstruction and discomfort were sufficient to suggest this mode of relief; yet no truly scientific inquiry seems to have been instituted to discover the cause of the obstruction. The author, during an experience of over twenty-three years as a specialist in diseases of the bowels, rectum, and anus, has found the true cause, namely, Proctitis; that is, the chronic inflammation (dating often from infancy and childhood) of the anus, rectum, and frequently of a portion of the sigmoid flexure and colon. Proctitis is practically the universal cause of chronic con­sti­pa­tion. Victims of con­sti­pa­tion have more or less haphazardly resorted to the enema as a ready means of relief—a recourse that was often, nay generally, against the advice of their medical counselor: a professional opposition that indicates either ignorance, mistaken judgment, or fear of losing a profitable patient. But the layman has not been uniformly wise. He is an experimenter on his own hook—encouraged in his experiments by the most promising and seductive of advertisements in the whole gamut of advertising. He experimented on his organism, tinkering it now with cathartics or purgatives of multiform nature, and again with digestive and other agents. This tinkering habit seems to have become all but universal with civilized man. Constipation—which is caused by proctitis—will, of course, bring indigestion and bilious­ness and diarrhea and nervous­ness and headache and a host of other maladies in its train; all of these induce the civilizee to increase his tinkering with his divine abode until it eventually falls in ruins. The tinkerer loses sight of the fact that his abode is not a body like the bodies of wood, stone, and iron that he handles and putters with daily; he forgets or ignores the fact that it is a vital organic machine, which, when tinkered too much, will stop, “never to go again.” It is poor consolation when you have reached your last gasp, after a chronic invalidism, to feel that you have done the best you knew how. You have not sought the cause, nor, having learned it somehow, sought to remove or avoid it. For the last four hundred years this tinkering, this futile medication, has been kept up at a furious pace without even a hope of permanent cure. Poor, outraged human nature dimly knew that it was simply doctoring a symptom, a consequence of something or other—for that is all that con­sti­pa­tion and its host of symptoms really are.

The writer is of the opinion that con­sti­pa­tion is the fundamental disease that afflicts mankind; that, at all events, there are more cases of proctitis than of any other disease; that very few “civilized” persons are free from it; that so prevalent a disease must have a common origin, which he traces right back to babyhood, to the wearing of soiled diapers, a practice that cannot but result in inflammation of the buttocks and mucous membrane of the anus and rectum; and that this inflammation continues and finally becomes deepened and established, producing in after years chronic con­sti­pa­tion and its train of evils. Of course, there are other causes that bring on proctitis among children and adults; but careful examination shows that the severity of the malady with its train indicates long duration in the tissues comprising the wall of the anal and rectal canals and the adjoining tissues of the bowels.

Proctitis, with its extension, colitis, is by no means a slight disease, as it is supposed to be by a few members of the medical fraternity who are beginning to apprehend its existence; on the contrary, it is so serious that its gravity cannot be impressed too forcibly upon both laymen and physicians. During the many years of special attention the writer has given to diseases of the anus, rectum, colon, etc., he has not ceased to wonder how it was possible that the victim of deep-seated proctitis could have so dreadful a disease and not be greatly alarmed at its ravages and dangers. The anatomy, physiology, and hygiene of the parts involved in this inflammation continue in some manner to permit the passage of excrement along the diseased canal; and the victim continues to swallow drugs and tinker with these—his irreplaceable “inards.”1

It is not my purpose at present to go into a detailed description of the organs involved in this inflammatory process, but to make plain why the enema is superior to all other means of securing cleanliness. When we know why we do a thing, the task is not so difficult and annoying as when we go it blind or simply obey the behest of a physician. Ignorance has no business bothering with anything; experience, however, is usually a painful if not a fatal instructor. The human race at large is ignorant concerning the normal and abnormal processes of its internal organs. “Out of sight, out of mind” seems to be the maxim of almost every one as to our vital organs and the conditions for their hygienic functioning. The purpose of the writer will be achieved if he succeed in sounding a note of warning that will be heard and heeded by those whose influence will extend the echoes till the world listens and learns the claims of the inner physiological economy.

Those that possess even a modicum of sense will easily understand how a muscular tube like the anus, rectum, sigmoid flexure, etc., when invaded and traversed for eight to ten or more inches by disease, will offer obstruction to the descent and escape of gases and feces. All are familiar with the contraction that occurs when a finger, hand, or limb is inflamed; how little we can then use the diseased part until all of the inflammation has left the muscular tissue. Why do we give so much attention to an inflamed external part and none at all to the all-important internal organ for the expulsion of the sewage of the body? The parts are not “weak” when contracted with inflammation: weakness is not what is the matter with them. The trouble is that the muscular fiber is then too active, made so by the excessive irritation of the local disorder. Irritation of muscular tissue always causes contraction of its fiber. Such contraction well accounts for con­sti­pa­tion.

We are a nation of con­sti­pated people, so con­sti­pated indeed that we have developed dyspepsia and neurasthenia. As I have already stated, the chief ill of “civilized” people is proctitis; the chief symptom of proctitis is con­sti­pa­tion; the chief symptom of con­sti­pa­tion is dyspepsia; and the chief symptom of dyspepsia is neurasthenia, and so on and on—all of them the outcome of imperfect elimination of morbid matter from the intestinal canal.

The common sense learned in the treatment of external parts should be applied to such diseased portions of the body as the anus, rectum, etc. Common sense declares that an enema ought to be used on all occasions of undue retention of the contents of the bowels. It is the only sensible thing under the circum­stances. Yet, for the last four hundred years, only independent men and women have had the courage to proclaim its merits, since the subject was under the ban of both laymen and physicians. Now that we have learned the absolute necessity of such a device, it is to be hoped that the taboo will be removed, and that the numerous victims of proctitis will be instructed in the wisdom of availing themselves of the valuable aid of the enema in either curing proctitis or preventing it from growing worse, while they are at the same time securing relief through its use by the removal of feces and gases several times daily, thus preventing the absorption of poison, which the retention of waste invariably facilitates.

CHAPTER II.
Pathology of the Anus and Rectum; or, The Genesis of Constipation.

When an affliction is seemingly universal it is reasonable to conclude that it springs from universal conditions. Proctitis, the most widespread disease of civilized man, originates very early in life, and develops in after years numerous painful symptoms—such as piles or hemorrhoids, con­sti­pa­tion, etc.

Now, what is the most common exciter of proctitis, which, as has been said, is an inflammation of the mucous membrane of the anus and rectum? In my earlier work, Intestinal Ills, I have shown that inattention to the soiled diaper is generally the original cause of this most grievous of ills, with its train of malign consequences continuing throughout the victim’s life on earth. Unnoticed by nurse or mother, the inflammation of the anus and rectum makes headway with each subsequent soiling; and thereafter, when the use of the diaper is dispensed with, inattention to the normal action of the bowels, improper food, the resort to purgatives, stimulants, and opiates, play no small part in aggravating the existing malady.

The first care-taker of the infant is therefore responsible for the initial process, which progresses to a chronic condition by subsequent inattention. She is indeed solicitous over the inflamed buttocks of her charge, but overlooks the far more dangerous inflammation of the mucous membrane of the anus and rectum, or she does not realize its insidious and subtly progressive character. Candidates for motherhood should be instructed on this momentous subject.

The muscular coat of the rectum consists of two layers: an inner circular and an outer longitudinal band. The inner circular layer of muscular tissue of the rectum forms the internal sphincter muscle; and the outer longitudinal bands merge with those of the external sphincter. The anal orifice is closed or guarded by two strong sphincter muscles, as shown in Figs. 1, 2, and 3. These muscles are abundantly supplied with nerves, of which branches are distributed to the bladder and other adjacent organs, which accounts for the sympathy of these organs and their grave disturbance when disease inheres in the anus and rectum.

The orifice used for the elimination of undigested food and waste matter plays quite as important a part in the organic economy as the orifice that is employed for receiving food. Normal elimination, physiological and psychological, is the correlative process to prehension (seizure or appropriation), and the concord of the two forms the key-note of the organism.

The muscles and tissues constituting the anal vent should be as flexible and responsive to the will or desire of the rectum for relief of its contents as the lips are in permitting the saliva to escape. In like manner the upper portion of the rectum (Figs. 6 and 8) should respond with instant readiness to the effort of the sigmoid flexure to expel its contents. But an abnormal condition like inflammation rooted in the anus and lower part of the rectum (Fig. 1, 4–4) will inhibit the passage of the pressing burden above them, which inhibition will cause the inflammation to extend to the sigmoid flexure, and thence on to the colon proper; and sooner or later the inflammation will penetrate the submucous coat (Fig. 1, 3–3), which is composed of fatty or areolar connective tissue in which trunks of nerves and blood-vessels are imbedded.

The first symptom of inflammation is undue redness, followed by slight puffiness of the anal and rectal mucous membrane (Fig. 1, 4–4), with more or less sensitiveness of the tissues involved; and as its irritability increases there is more or less contraction of the muscular tissue forming the anus and rectum, which lessens the diameter of their bore. And the consequence of this contraction is of physiological concern to the victim, for in proportion to the contraction the normal demand of the victim for relief of the impending feces and gas is modified and lessened.

In health, the anal canal is from two to three inches in length, and it will distend about two inches—an elasticity quite equal to that of any other orifice of the body. As the anal tissues are usually the first to be invaded by disease, it is but natural that the ob­sti­pa­tion or con­sti­pa­tion should occur right above it—namely, in the rectum. The average length of the rectum is about six inches, and when the disease invades its whole length the con­sti­pa­tion occurs in the sigmoid flexure and may thence extend to the colon.

The filling of the intestine with feces and gases usually occurs just above the diseased portion of the gut; but at the same time the walls of the affected part of the canal are more or less coated with feces, and its abnormal pouches here and there contain more or less liquefied or dried feces. A diseased canal cannot expel all of its contents, since its normal expulsive power is gone. Some of the feces somehow or other gets down and out, but a larger portion inevitably remains. It is for this reason that a diseased intestine always reminds one of the Augean stable. It is simply marvelous that the human body continues as a living organism with so much filth and bacterial poison stored in its alimentary canal, and the vaults that result from abnormal pressure during periods of fecal impaction (Fig. 4).

When the inflammatory process extends up the rectum and at the same time into the spongy, fatty, or areolar tissue under the mucous membrane (Fig. 1, 3–3), thence to the muscular and serous layers (Fig. 1, 2–1), or through the four layers of tissue comprising its wall, we have a more marked and serious occlusion (closing) of the organ than when only the mucous membrane was affected. When muscular tissue is inflamed, its tendency is to contract and become solidified by an adhesive inflammatory product secreted between the circular and longitudinal muscular fibres (Fig. 1, 7, and Fig. 7). Often the circular or sphincter muscles forming the anal canal have to be distended to bring about a more normal vent. The same pathological conditions that occasion contraction of the anal bore or caliber occur, more or less, as far up the gut as the disease has advanced.

In a normal state of the lower bowel the sigmoid flexure passes its contents into the rectum, and the desire to defecate is reported—that is, the impulse to stool becomes more or less urgent until it is performed. But when all four coats of the anus and rectum are diseased, with perhaps a portion of the sigmoid flexure also, it is very difficult for the healthy portion of the sigmoid flexure and the colon to discharge their contents into the rectum; consequently no call, impulse, or desire reaches the mind. Constipation will then ensue, for the stool, not being called for, is not performed. Every demand of a healthy portion of the intestine is answered by increased contraction of the muscles of the diseased portion of the rectum. While the war between the healthy and the diseased sections of the bowels goes on, the victim naturally concludes that there is no occasion or demand for defecation, and he attends to other affairs, ignorant of the fact that he is thus making a fatal mistake.

The first condition that ensues is the tendency of the rectum to fill unduly with feces and gases, impelling the victim to “strain” in order to force the feces through the constricted anal canal. After a while the sigmoid flexure and colon will fill unduly, and then the victim will form the habit of waiting for the feces to descend, and of straining to expel what little manages to escape through the diseased gut.

A portion of the imprisoned feces in the healthy section of the intestine sometimes, at an unguarded moment, manages to distribute itself along the length of the diseased and constricted canal, where it is retained indefinitely, increasing the local irritation. And when the fecal mass accumulates sufficiently in both the healthy and the diseased portions of the intestines to set up a vigorous excitement, the victim may, by the aid of his waiting and straining habit (which habit, by the way, only torments and bruises the chronically diseased organs), bring on some sort of evacuation. In the early history of the disease this habit may serve for a time; but, as the disease progresses, the “laxative” habit is formed, which, in turn, settles into a chronic “drug” habit for all sorts and conditions of gastro-intestinal and other ills, which inevitably ensue. As the ravages of chronic inflammation of the anus and rectum increase, the symptoms rapidly multiply, till finally the victim, in desperation, feels that he must find additional sources of relief—and, among other habits, he forms the “diet” habit.

The order of abnormal habits brought into existence by ulcerative inflammation of the anus, rectum, and colon is about as follows: (1) the habit of unduly retaining the feces in the rectum; (2) the habit of straining at stool; (3) the habit of unduly retaining the feces in the sigmoid flexure; (4) the habit of resorting to the use of purgatives, pepsin, and other drugs; (5) the chronic “physic” habit; (6) the foolish “diet” habit; (7) the gastro-intestinal neurasthenic habit; (8) the health-resort habit; (9) the habit of trying desperately to appear agreeable while feeling really ill; (10) the habit of blaming the liver for all direful feelings, physical and mental.

It is but natural that the lower portion of the rectal and anal structures should be affected more severely than any other portion of the intestines by the ulcerative, inflammatory process. The sphincter muscles are very strong, as a rule, and fill their office only too well when the anal and rectal canals are in a diseased state, for they effectually prevent the contents from escaping. Often their contraction or stricture is so great that their expansion is limited to from one-fourth to one-half an inch. This virtually permanent closure of the anal vent naturally results in an accumu­la­tion of feces just above it, or in the lower portion of the rectum, which accounts for the dilatation, stretching, or ballooning of the anal and rectal tissues immediately above these muscles, as shown in Fig. 4.

Similar dilatation of the sigmoid flexure occurs as the result of the severe contraction of the upper half of the rectum, and especially at the bend shown by Fig. 6 and Fig. 12. This bend forms quite a sphincter for the normal receptacle—the sigmoid flexure. Here also prolapse, distention, and dislocation of the sigmoid flexure may occur, somewhat similar to the anal prolapse from disease and abuse.

Piles and itching of the anus are symptoms of proctitis, or inflammation of the anus and rectum. Why should we find such dissimilar symptoms proceeding from the same cause? The reason is plain when we consider the results following chronic inflammation of the mucous membrane of the anus and rectum and the deeper tissues. Those who suffer from catarrh of this membrane are familiar with the discharge of mucus that appears from time to time during the progress of the inflammation. But, as the inflammation penetrates the mucous membrane and the underlying tissues of the anus and rectum, the escape of the inflammatory product is prevented; and this imprisoned fluid must either be absorbed by the system or retained in reservoirs or in channels wherever the least resistance is offered to its invasion.

The mucous membrane of the anus and rectum is loosely attached to the subjacent parts by areolar tissue (Fig. 1, 3–3), which is sufficiently lax to allow an expansion of two inches; and in a puckered or contracted state the membrane is thrown into folds, or into shallow or deep wrinkles. The loose areolar attachment and folds of various depths afford space for lodgment of the inflammatory discharge, which channels its way down along the folds through the areolar tissue under the mucous membrane to that of the integument, and so on for a distance of a foot or more from the anus in some cases.

CHAPTER III.
The Formation of Channels, Piles, and Fistulas.

Should channels, of varying length and numbers, form early in the development of proctitis, the sufferer is usually found to be free from piles, or hemorrhoids, for the reason that the channels have afforded an outlet to the inflammatory product. The formation of lengthy channels also prevents to a great extent the development of skinny tabs round about the integument of the anus. This is some compensation to the sufferer for the labor of scratching and for enduring the painful itching so often present. Some suffer only from pain along the channels themselves, while others experience a slight disturbance of the nervous system; yet all must be more or less poisoned from the absorption of so large an amount of the contents of the channels and cavities.

In the cavities and along the channels the areolar tissue is of a mahogany color, and no channel is traced to its end so long as the tissues present a bruised, inflamed appearance. In some cases the inflammatory product has destroyed the areolar tissue attached to the integument at and near the anus, frequently to the extent of leaving a hollow space or cavity of surprising dimensions. I have met only a few cases in which the channels were opened by pus forming in them. Those that are very shallow, the walls being friable, may break and form a fissure of the anus; or a little anal fistula may arise from a slight suppuration at its end in the integument near the anus.

In cases where the channels are few and short, whether itching be present or not, the pile tumors are likewise few and of moderate size, demonstrating the intimate relation of the aggravation of either of the symptoms or the moderation of both in the same case. Very frequently pile tumors have channels extending from them to the junction of the mucous membrane and integument of the anus, or even under the integument about the anus, forming rugæ, or tabs.

The number and size of pile tumors would seem to depend on how completely the inflammatory product is imprisoned in the tissues in what is termed the “pile-bearing” region. Often the treatment of piles, or hemorrhoids, aids very much in the cure of itching at the anus—by destroying a part of the channels involved in the pile structures in the mucous membrane of the lower end of the rectum and extending along under the anal membrane and the integument of the anus.

The meshes and layers of the mucous membrane, as well as the space occupied by the areolar tissue, are stretched or pouched by the inflammatory product.

My observation forces me to conclude that the inflammatory product imprisoned in the areolar meshes, between the mucous membrane and the muscular layers, is the principal factor in forming piles and the channels so often found in the same region. Of course, obstructed circulation, congested veins, capillaries, and arterioles, and a more or less apparent varicose condition, increase the size of the pile tumors and the general thickness of the mucous membrane over the region affected by the disease.

The process occasioning the separation of the mucous membrane from its areolar attachment or bed often extends the whole length of the rectum, giving the mucous membrane the loose and raised appearance that a piece of thin silk would have if laid on over that surface. The fatty or areolar tissue under the skin about the anus suffers likewise by being destroyed, leaving a hollow cavity or a large channel of great length under the skin. The separation of the mucous membrane and integument about the anus from their areolar attachment permits of prolapse of the mucous membrane and integument that form the anal canal and skin around the orifice.

It would seem that the channels, pile sacs, and cavities serve as temporary reservoirs for the inflammatory product, a portion of which the system absorbs and another portion of which escapes through the mucous membrane and integument. In escaping in this way it occasions itching and pain. The itching or soreness does not in all cases extend throughout the whole length of the channel. A few inches of the channel farthest from its origin may be the seat of the greatest disturbance, and the sufferer and physician alike are usually unaware that the source of the trouble is in the tissues of the anus and rectum.

The marked improvement in the health of those that have been cured of both the morbid condition produced by the inflammatory product and the cause of that condition is evidence that the general vitality of the system had been greatly lowered, even though the most annoying of the symptoms, such as piles, itching, or acute pain, had not been present. The lack of annoyance along the channel for a certain period may be due to a limited production, or to a rapid absorption of the inflammatory product by the system.

Proctitis and the attendant symptoms just described have been overlooked by the medical profession. Physicians have confined their attention to two symptoms—piles and fistula. After undergoing a surgical operation for these, the patient is considered cured. What ignorance, or rather short-sightedness, to remove only the annoying symptom, and then to pronounce the patient healed! Let me ask my professional brethren why they do not concern themselves with the underlying cause of the symptom or symptoms, and whether they suppose this cause is going out of business. Surely it is a grave mistake to concern one’s self with the leading symptom merely—to remove that, and to leave its cause intact. When the disease-producing cause remains to generate its poisonous effects in the system, opportunities exist for further symptoms to develop.

The system may be already depleted of vitality, and the harsh treatment for the purpose of removing a mere symptom may only make the sufferer’s condition more deplorable—if it does not indeed cause death.

There are other symptoms of proctitis than piles and fistula, which remain after the conventional surgical operation for their removal. Obstipation and con­sti­pa­tion are usually symptoms of proctitis, and will persist until the inflammation in the upper half of the rectum and sometimes in a portion of the sigmoid flexure is cured.

The victim of proctitis has two marked sources of poisoning of the system: one proceeding from the absorption of the inflammatory product, and the other from undue retention of the waste matter of the body that should pass out by the lower bowel.

Inflammation of a mucous membrane causes structural changes in the tissues involved in the morbid process, and not infrequently it becomes the seat of a malignant disease.

The reader may be familiar with the white, loose, alveolar (honeycomb-like) network of elastic tissue (called fat) just under the skin and mucous membrane. Consult in this connection the cut on page 24.