Enema

Enema
Intervention
Rectal bulb syringe to administer smaller enemas
Pronunciation	/ˈɛnəmə/

Enema (plural enemata or enemas) or clyster, is a fluid injected into the lower bowel by way of the rectum.^[1]

The most frequent use of an enema is to relieve constipation or for bowel cleansing before a medical examination or procedure.^[2] In standard medicine an enema may also be employed as a lower gastrointestinal series (also called a barium enema),^[3] to check diarrhea, as a vehicle for the administration of food, water or medicine, as a stimulant to the general system, as a local application and, more rarely, as a means of reducing temperature,^[1] as treatment for encopresis, and as a form of rehydration therapy (proctoclysis) in patients for whom intravenous therapy is not applicable.^[4]

Enemas are used as part of some alternative health therapies and are also used to administer drugs for recreational or religious reasons.

Medical usage

The main medical usages of enemas are:

A soapsuds enema in a can with a typical nozzle and a contrast enema bag with a barium nozzle

A prepared, disposable enema

Bowel emptying

• Transanal irrigation (retrograde irrigation) is the regular use of water and irrigation equipment with a catheter in the person's home to assist in the emptying of feces in individuals with bowel dysfunction, including fecal incontinence and constipation.
• Bowel management is mainly achieved through a daily enema which empties the colon to prevent unwanted and uncontrolled bowel movements that day.^[5] As part of their bowel management regime, some patients also use laxatives and a controlled diet and another alternative is transanal irrigation.
• Enemas have been used around the time of childbirth however there is no evidence for this practice and it is now discouraged.^[6]
• As a bowel stimulant, similar to a laxative – the main difference being that laxatives are commonly thought of as orally administered while enemas are administered directly into the rectum, and thereafter, into the colon. When the enema injection into the rectum is complete, and after a set "holding time", the patient expels feces along with the enema in the bedpan or toilet. The increasing volume of the liquid causes rapid expansion of the lower intestinal tract, often resulting in very uncomfortable bloating, cramping, powerful peristalsis and a feeling of extreme urgency. Although very difficult for some, retaining an enema for 10 – 15 minutes causes a more thorough result.
• Enemas may also be used to relieve constipation and fecal impaction, although in the U.S. and some other parts of the world, their use has been replaced in most professional health-care settings by oral laxatives and laxative suppositories. In-home use of enemas for constipation and alternative health purposes is somewhat harder to measure.
• Bowel stimulating enemas usually consist of water, which works primarily as a mechanical stimulant, or they may be made up of water with baking soda (sodium bicarbonate) or water with a mild hand soap dissolved in it. Buffered sodium phosphate solution draws additional water from the bloodstream into the colon to increase the effectiveness of the enema, but can be rather irritating to the colon, causing intense cramping or "griping." Mineral oil functions as a lubricant and stool softener, but often has the side effect of sporadic seepage from the patient's anus which can soil undergarments for up to 24 hours. Glycerol is a specific bowel mucosa irritant and when introduced in very dilute solution serves to induce peristalsis.
• Other types of enema solutions are also used, including equal parts of milk and molasses heated together to slightly above normal body temperature. In the past, castile soap was a common additive in an enema, but it has largely fallen out of use because of its irritating action in the rectum and because of the risk of chemical colitis as well as the ready availability of other enema preparations that are more effective than soap in stimulating a bowel movement. At the opposite end of the spectrum, an isotonic saline solution is least irritating to the rectum and colon, having a neutral concentration gradient. This neither draws electrolytes from the body – as can happen with plain water – nor draws water into the colon, as will occur with phosphates. Thus, a salt water solution can be used when a longer period of retention is desired, such as to soften an impaction.
• Emptying the lower bowel prior to a surgical procedure such as colonoscopy. Because of speed and supposed convenience, enemas used for this purpose are commonly the more costly, sodium phosphate variety – often called a disposable enema.
• In the western world reusable enema equipment is now rare in hospital and other medical environments because of the expense of the longer time period required of nursing aides to give a gentle, water-based enema to a patient, as compared to the very few minutes it takes the same nursing aide to give the more irritating, cold, packaged sodium phosphate unit.

Contrast (X-ray)

A barium enema in a disposable bag manufactured for that purpose

In a lower gastrointestinal series an enema that may contain barium sulfate powder or a water-soluble contrast agent is used in the radiological imaging of the bowel. Called a barium enema, such enemas are sometimes the only practical way to view the colon in a relatively safe manner.^[3] Following barium enema administration, patients often find that flushing the remaining barium with additional water, baking soda, or saline enemas helps restore normal colon activity without complications of constipation from the administration of the barium sulfate.

Medication administration

• The administration of substances into the bloodstream. This may be done in situations where it is undesirable or impossible to deliver a medication by mouth, such as antiemetics given to reduce nausea (though not many antiemetics are delivered by enema). Additionally, several anti-angiogenic agents, which work better without digestion, can be safely administered via a gentle enema.
• The topical administration of medications into the rectum, such as corticosteroids and mesalazine used in the treatment of inflammatory bowel disease. Administration by enema avoids having the medication pass through the entire gastrointestinal tract, therefore simplifying the delivery of the medication to the affected area and limiting the amount that is absorbed into the bloodstream.
• Rectal corticosteroid enemas are sometimes used to treat mild or moderate ulcerative colitis. They also may be used along with systemic (oral or injection) corticosteroids or other medicines to treat severe disease or mild to moderate disease that has spread too far to be treated effectively by medicine inserted into the rectum alone.
• There have been a few cases in remote or rural settings, where rectal fluids have been used to rehydrate a person. Benefits include not needing to use sterile fluids.^[7]

Adverse effects

Improper administration of an enema can cause electrolyte imbalance (with repeated enemas) or ruptures to the bowel or rectal tissues resulting in internal bleeding. However, these occurrences are rare in healthy, sober adults. Internal bleeding or rupture may leave the individual exposed to infections from intestinal bacteria. Blood resulting from tears in the colon may not always be visible, but can be distinguished if the feces are unusually dark or have a red hue. If intestinal rupture is suspected, medical assistance should be obtained immediately.^[8]

The enema tube and solution may stimulate the vagus nerve, which may trigger an arrhythmia such as bradycardia. Enemas should not be used if there is an undiagnosed abdominal pain since the peristalsis of the bowel can cause an inflamed appendix to rupture.

There are arguments both for and against colonic irrigation in people with diverticulitis, ulcerative colitis, Crohn's disease, severe or internal hemorrhoids or tumors in the rectum or colon, and its usage is not recommended soon after bowel surgery (unless directed by one's health care provider). Regular treatments should be avoided by people with heart disease or renal failure. Colonics are inappropriate for people with bowel, rectal or anal pathologies where the pathology contributes to the risk of bowel perforation.^[9]

Recent research has shown that ozone water, which is sometimes used in enemas, can immediately cause microscopic colitis.^[10]

A recent case series^[11] of 11 patients with five deaths illustrated the danger of phosphate enemas in high-risk patients.

History

A normal clyster syringe (front) and the nozzle for a syringe designed for self-administration (rear). The latter avoided the need for a second party to attend an embarrassing procedure.

Enema comes from Greek ἔνεμα (énema), from ἐνίημι (eníēmi), "(I) inject".

Clyster (/ˈklɪstə(r)/), also spelled glister in the 17th century, rarely "cloister" or "clister" comes from Greek κλυστήρ (klystḗr), from κλύζω (klýzo), "(I) wash". It is an archaic word for enema, more particularly for enemas administered using a clyster syringe – that is, a syringe with a rectal nozzle and a plunger rather than a bulb. Clyster syringes were used from the 17th century (or before) to the 19th century, when they were largely replaced by enema bulb syringes, bocks, and bags.

The first mention of the enema in medical literature is in the Ancient Egyptian Ebers Papyrus (c. 1550 BCE). One of the many types of medical specialists was an Iri, the Shepherd of the Anus. Many medications were administered by enemas.^[12] There was a Keeper of the Royal Rectum who may have primarily been the pharaoh's enema maker. The god Thoth, according to Egyptian mythology, invented the enema.^[13]

The Olmec from their middle preclassic period (10th through 7th centeries BCE) through the Spanish Conquest used trance-inducing substances ceremonially, and these were ingested via, among other routes, enemas administered using jars.

The Maya in their late classic age (7th through 10th centuries CE) used enemas for, at least, ritual purposes, in the Xibalban court of the God D whose worship included ritual cult paraphernalia. It is hypothesized that these enemas were for ritual purification and the ingestion of intoxicants and hallucinogens. The Maya illustrated the use of a characteristic enema bulb syringe by female attendants administering clysters ritually.^[14][15]

Pressure enema from an animal bladder (African wooden sculpture, 19th century)

In the second century CE the Greek philosopher Celsus recommended an enema of pearl barley in milk or rose oil with butter as a nutrient for those suffering from dysentery and unable to eat^[16] and Galen mentions enemas in several contexts.^[17]

In medieval times appear the first illustrations of enema equipment, a clyster syringe consisting of a tube attached to a pump action bulb made of a pig bladder and the 15th century Simple piston syringe clysters came into use. Beginning in the 17th century enema apperatus was chiefly designed for self-administration at home and many were French as enemas enjoyed wide usage in France.^[16]

When clyster syringes were in use in Europe, the patient was placed in an appropriate position (kneeling, with the buttocks raised, or lying on the side); a servant or apothecary would then insert the nozzle into the anus and depress the plunger, resulting in the liquid remedy (generally, water, but also some other preparations) being injected into the colon.

Portable enema self-administration apparatus by Giovanni Alessandro Brambilla (18th century; Medical History Museum, University of Zurich)

Because of the embarrassment a woman might feel when showing her buttocks (and possibly her genitals, depending on the position) to a male apothecary, some contraptions were invented that blocked all from the apothecary's view except for the anal area. Another invention was syringes equipped with a special bent nozzle, which enabled self-administration, thereby eliminating the embarrassment.

Clysters were administered for symptoms of constipation and, with more questionable effectiveness, stomach aches and other illnesses. In his early-modern treatise, The Diseases of Women with Child, François Mauriceau records that both midwives and man-midwives commonly administered clysters to labouring mothers just prior to their delivery.

In the 16th century, satirists made physicians a favorite target, resembling Molière's caricature whose prescription for anything was "clyster, bleed, purge," or "purge, bleed, clyster."^[18] In Roper's biography of his father-in-law Sir Thomas More, he tells of Thomas More's eldest daughter falling sick of the sweating sickness. She could not be awakened by doctors. After praying, it came to Thomas More:

There straightway it came into his mind that a clyster would be the one way to help her, which when he told the physicians, they at once confessed that if there were any hope of health, it was the very best help indeed, much marveling among themselves that they had not afore remembered it.

Utopia, Thomas More

19th century satirical cartoon of a monkey rejecting an old style clyster for a new design, filled with marshmallow and opium

In the 18th century tobacco smoke enemas were used to resuscitate drowned people. Tobacco resuscitation kits consisting of a pair of bellows and a tube were provided by the Royal Humane Society of London and placed at various points along the Thames.^[16]

Clysters were a favourite medical treatment in the bourgeoisie and nobility of the Western world up to the 19th century. As medical knowledge was fairly limited at the time, purgative clysters were used for a wide variety of ailments, the foremost of which were stomach aches and constipation.

Molière, in several of his plays, introduces characters of incompetent physicians and apothecaries fond of prescribing this remedy, also discussed by Argan, the hypochondriac patient of Le Malade Imaginaire. More generally, clysters were a theme in the burlesque comedies of that time.

According to Claude de Rouvroy, duc de Saint-Simon, clysters were so popular at the court of King Louis XIV of France that the duchess of Burgundy had her servant give her a clyster in front of the King (her modesty being preserved by an adequate posture) before going to the comedy. However, he also mentions the astonishment of the King and Mme de Maintenon that she should take it before them.

In the 19th century many new types of enema administration equipment were devised, including the bulb enema. Later there came to be a device to allow gravity to infuse the solution into the recipient, consisting of a rubber bag or bucket connected to a hose with a nozzle at the other end to insert into the patient's anus, the bag or bucket being held or hung above the patient. These continue to be used, although rubber has been replaced by modern materials and the bags, at least in hospital use, as disposable.^[16]

In the late 20th century the microenema was invented, this being a disposable squeeze bottle with contents that cause the body to draw water into the colon, e.g., sodium biphosphate (popular in the United States) or glycerin (popular in Japan).

In certain countries, such as the U.S., customary enema usage went well into the 20th century; it was thought a good idea to cleanse the bowel in case of fever; also, pregnant women were given enemas prior to labor, supposedly to reduce the risk of feces being passed during contractions. Under some controversial discussion, pre-delivery enemas were also given to women to speed delivery by inducing contractions. This latter usage has since been largely abandoned, because obstetricians now commonly give pitocin to induce labor and because women generally found the procedure unpleasant. Now obsolete, the tobacco smoke enema was used for resuscitating victims of drowning during the 18th century.

Nutrient enemas were administered with the intent of providing nutrition when normal eating is not possible. Although this treatment is ancient, dating back at least to Galen, and commonly used in the Middle Ages,^[19] and still a common technique in 19th century medicine,^[20] Nutrient enemas have been superseded in modern medical care by tube feeding and intravenous feeding.

Society and culture

Alternative medicine

The term "colonic irrigation" is commonly used in gastroenterology to refer to the practice of introducing water through a colostomy or a surgically constructed conduit as a treatment for constipation.^[21] The Food and Drug Administration has ruled that colonic irrigation equipment is not approved for sale for the purpose of general well-being^[22] and has taken action against many distributors of this equipment, including a Warning Letter.^[23] The use of enemas for reasons other than the relief of constipation is currently regulated in some parts of the United States while practitioners in other states may go through a voluntary certification process.

Colon cleansing

The same term is also used in alternative medicine where it may involve the use of substances mixed with water in order to detoxify the body. Practitioners believe the accumulation of fecal matter in the large intestine leads to ill health.^[24] This resurrects the old medical concept of autointoxication which was orthodox doctrine up to the end of the 19th century but which has now been discredited.^[25][26][27]

Coffee enemas

Although well documented, the procedure of inserting coffee through the anus to cleanse the rectum and large intestines is considered by most medical authorities to be unproven, rash and potentially dangerous.^[28][29] Coffee enemas can cause numerous side effects, including infections, sepsis (including campylobacter sepsis), severe electrolyte imbalance, colitis, polymicrobial enteric septicemia, proctocolitis, salmonella, brain abscess, and heart failure.^{[30][31][32][33][34][35][36][37][38]}

In the Gerson therapy, coffee enemas are administered.^[39]

Some proponents of alternative medicine have claimed that coffee enemas have an anti-cancer effect by "detoxifying" metabolic products of tumors^[30] but there is no medical scientific evidence to support this.^[29][31][40]

Recreational usage

An aluminium enema nozzle. Specialty enema nozzles are common for non-medical usage, available on the Internet and in sex shops in a variety of sizes, styles, and materials.

An inflatable enema nozzle shown in a harness, but usually used without. Once inserted, the nozzle is inflated to a much larger size than can fit back out, allowing the recipient to relax their muscles while holding the enema, retain a solution they would not normally be able to retain, or to be forced to take an enema as part of BDSM activities.

The paraphilia directed towards enemas is known as klismaphilia, the enjoyment of enemas.

Enemas may be used as part of BDSM (bondage, discipline, sadism, and masochism) activities, or as a regular sexual activity for an individual or between partners. Enemas can be pleasurable to either sex, and in males enemas can stimulate the prostate gland. Unexpected erections are common in medical settings, even if the person would otherwise consider it an unpleasant procedure.

People who wish to become intoxicated faster have also been known to use an alcohol enema as a method to instill alcohol into the bloodstream, absorbed through the membranes of the colon. However, great care must be taken as to the amount of alcohol used. Only a small amount is needed as the intestine absorbs the alcohol more quickly than the stomach. Deaths have resulted due to alcohol poisoning via enema.^[41]

Enemas have also been used for ritual rectal drug administration such as balché, alcohol, tobacco, peyote, and other hallucinogenic drugs and entheogens, most notably by the Maya and also some other American Indian tribes. Some tribes continue the practice in the present day.^[42]

An enema might be used to clean the colon of feces first to help increase the rate of absorption in rectal administration of dissolved drugs, including alcohol.^[43]

An enema may also be used prior to anal sex or anilingus in order to enhance the sensation of intercourse, or to remove feces prior to sex, possibly reducing bacterial transmission and risk of infection, or just to reduce the possibility of fecal material or detritus from sexual activity adhering to the genitals or sex toys used during the subsequent activity. Enemas used for anal sex should not be used consistently and enema bottle contents should be removed and replaced with simple luke-warm water. Continual usage of enema solution may be harmful for the anal cavity.

Punitive usage

Enemas have also been forcibly applied as a means of punishment. In the vastly influential Latin American text Facundo, or Civilization and Barbarism, for example, Domingo Faustino Sarmiento describes the use of pepper and turpentine enemas by police forces as a way of discouraging political dissent in post-independence Argentina.^[44]

The Senate Intelligence Committee report on CIA torture documented instances of enemas being used by the Central Intelligence Agency in order to ensure "total control" over detainees.^[45]

Monument

A 365 kilograms (805 pounds) brass statue of a syringe enema bulb held aloft by three angels stands in front of the "Mashuk" spa in the settlement of Zheleznovodsk in Russia. It is the only known monument to the enema.^[46]

References

1. Cullingworth, A Manual of Nursing, Medical and Surgical:155
2. "Soapsuds enema". Biology-Online Dictionary. Biology-Online. Retrieved 6 August 2014.
3. "Barium enema". MedlinePlus. U.S. Department of Health & Human Services – National Institutes of Health (NIH). Retrieved 6 August 2014.
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5. Peña A, Guardino K, Tovilla JM, Levitt MA, Rodriguez G, Torres R Bowel management for fecal incontinence in patients with anorectal malformations Pediatr. Surg. 33:1 133–7 1998
6. "Enemas during labour". Cochrane Database of Systematic Reviews: Plain Language Summaries. National Institutes of Health (NIH). 4 July 2013. Retrieved 14 June 2016.
7. Tremayne V (2009). "Proctoclysis: emergency rectal fluid infusion" (PDF). Nurs Stand. 24 (3): 46–8. doi:10.7748/ns2009.09.24.3.46.c7271. PMID 19856644.
8. Martelli, ME. "Encyclopedia of Nursing and Allied Health". FindArticles. Archived from the original ( – ^{Scholar search}) on 23 January 2008. Retrieved 11 January 2008.
9. "Colon Hydrotherapy". Aetna IntelliHealth. 1 July 2005. Retrieved 23 April 2007.
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11. Ori Y, Rozen-Zvi B, Chagnac A, Herman M, Zingerman B, Atar E, Gafter U, Korzets A (2012). "Fatalities and Severe Metabolic Disorders Associated With the Use of Sodium Phosphate Enemas". Archives of Internal Medicine. 172 (3): 263–5. doi:10.1001/archinternmed.2011.694. PMID 22332159.
12. Magner, A History of Medicine:31
13. Magner, A History of Medicine:26
14. Parsons and Carlson:92
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17. Mattern, Susan P. (2008), Galen and the Rhetoric of Healing, Johns Hopkins University Press, Maryland, USA: Johns Hopkins University Press, pp. 31, 145, 149, ISBN 978-0-8018-8835-9
18. Magner, A History of Medicine:218
19. Short AR, Bywaters HW (June 1913). "Amino-Acids and Sugars in Rectal Feeding". Br Med J. 1 (2739): 1361–7. doi:10.1136/bmj.1.2739.1361. JSTOR 25302025. PMC 2299894. PMID 20766702.
20. Mackenzie JW (March 1943). "The nutrient enema". Arch. Dis. Child. Archives of Disease in Childhood. 18 (93): 22–7. doi:10.1136/adc.18.93.22. PMC 1987791. PMID 21032242.
21. Locke GR, Pemberton JH, Phillips SF (2000). "AGA technical review on constipation". Gastroenterology. 119 (6): 1766–78. doi:10.1053/gast.2000.20392. PMID 11113099.
22. "Subpart F—Therapeutic Devices Sec. 876.5220 Colonic irrigation system". Code of Federal Regulations, Title 21 Food and Drugs, Subchapter H – Medical Devices, Part 876 – Gatroenterology-Urology Devices. FDA. 1 April 2007.
23. Department of Health and Human Services (21 July 1999). "Warning letter to Dotolo Research Corp" (reprint by Casewatch). FDA. Retrieved 31 December 2007.
24. Whorton J (2000). "Civilisation and the colon: constipation as the "disease of diseases"". BMJ. 321 (7276): 1586–9. doi:10.1136/bmj.321.7276.1586. PMC 1119264. PMID 11124189.
25. Ernst E (June 1997). "Colonic Irrigation and the Theory of Autointoxication". Journal of Clinical Gastroenterology. 24 (4): 196–198. doi:10.1097/00004836-199706000-00002. PMID 9252839.
26. Kaiser (1985). "The Case Against Colonic Irrigation". California Morbidity (38).
27. Chen TS, Chen PS (1989). "Intestinal autointoxication: a medical leitmotif". Journal of Clinical Gastroenterology. 11 (4): 434–41. doi:10.1097/00004836-198908000-00017. PMID 2668399.
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29. Shils ME, Hermann MG (April 1982). "Unproved dietary claims in the treatment of patients with cancer". Bull N Y Acad Med. 58 (3): 323–40. PMC 1805327. PMID 7052177.
30. Lee CJ, Song SK, Jeon JH, Sung MK, Cheung DY, Kim JI, Kim JK, Lee YS (2008). "Coffee enema induced acute colitis". The Korean journal of gastroenterology = Taehan Sohwagi Hakhoe chi. 52 (4): 251–254. PMID 19077527.
31. "Colon Therapy". American Cancer Society. 11 January 2008. Retrieved 13 May 2011.
32. Margolin KA, Green MR (1984). "Polymicrobial enteric septicemia from coffee enemas". The Western journal of medicine. 140 (3): 460. PMC 1021723. PMID 6710988.
33. Eisele JW, Reay DT (1980). "Deaths related to coffee enemas". JAMA: the Journal of the American Medical Association. 244 (14): 1608–1609. doi:10.1001/jama.1980.03310140066036. PMID 7420666.
34. Keum B, Jeen YT, Park SC, Seo YS, Kim YS, Chun HJ, Um SH, Kim CD, Ryu HS (2010). "Proctocolitis Caused by Coffee Enemas". The American Journal of Gastroenterology. 105 (1): 229–230. doi:10.1038/ajg.2009.505. PMID 20054322.
35. "Livingston-Wheeler Therapy". Memorial Sloan Kettering Cancer Center. 9 May 2011. Retrieved 13 May 2011.
36. William T. Jarvis, Ph.D., National Council Against Healthcare Fraud, "Cancer Quackery". Accessed 11 July 2012.
37. Centers for Disease Control (CDC) (1981). "Campylobacter sepsis associated with "nutritional therapy"--California". MMWR Morb. Mortal. Wkly. Rep. 30 (24): 294–5. PMID 6789105.
38. Keum B, Jeen YT, Park SC, Seo YS, Kim YS, Chun HJ, Um SH, Kim CD, Ryu HS (2010). "Proctocolitis caused by coffee enemas". Am. J. Gastroenterol. 105 (1): 229–30. doi:10.1038/ajg.2009.505. PMID 20054322.
39. "The Gerson Institute — Alternative Cancer Treatment". Archived from the original on 1 April 2003.
40. Cassileth B (February 2010). "Gerson regimen". Oncology (Williston Park, N.Y.). 24 (2): 201. PMID 20361473.
41. "The Enema Within". Darwin Awards. 2008. Retrieved 11 January 2008.
42. Diamond, Jared M. (1992). The Third Chimpanzee: The Evolution and Future of the Human Animal (P.S.). New York, N.Y: Harper Perennial. p. 432. ISBN 0-06-084550-3.; pp. 201
43. de Boer AG, Moolenaar F, de Leede LG, Breimer DD (1982). "Rectal drug administration: clinical pharmacokinetic considerations". Clin Pharmacokinet. 7 (4): 285–311. doi:10.2165/00003088-198207040-00002. PMID 6126289.
44. "Ribbons and Rituals". In Problems in Modern Latin American History. Ed. Chasteen and Wood. Oxford, UK: Scholarly Resources, 2005. p. 97
45. Rushe, Dominic; MacAskill, Ewen; Cobain, Ian; Yuhas, Alan; Laughland, Oliver (9 December 2014). "Rectal rehydration and waterboarding: the CIA torture report's grisliest findings". The Guardian. Retrieved 13 March 2015.
46. "Enema monument unveiled in Russian resort". msn.com. 19 June 2008. Retrieved 2 October 2016.

Notes

• Cullingworth, Charles James (1883). A Manual of Nursing, Medical and Surgical. Cambridge, England: Cambridge University Press (published 2009). ISBN 978-1-4590-1939-3.
• Magner, Lois (1992). A History of Medicine. Boca Raton, Florida: CRC Press. ISBN 978-0-8247-8673-1.
• Parsons, Lee Allen; Carlson, John B. (1988). The Face of Ancient America: The Wally and Brenda Zollman Collection of Precolumbian Art. Indianapolis, Indiana, United States: Indianapolis Museum of Art. ISBN 978-0-936260-24-2.

External links

"A professional nursing instructional video demonstrating administering a cleansing enema.". Taber's Medical Dictionary. K. A. Davis Company. Retrieved 17 July 2014.