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The intestinal

CHAPTER IX.

tract-Enemata-purgative—refrigerant-anthelmintic

- astringent - nutritive-Care of appliances-Suppositories— Vaginal and rectal douches.

THE intestinal canal is formed by the folds of a single long tube, some twenty-five or thirty feet in length. That part of it nearest the stomach is called the small intestine-various subdivisions, respectively, the duodenum, jejunum, and ileum; the last five or six feet are of much greater diameter, and therefore spoken of as the large intestine. This also is subdivided into the cæcum, the colon-ascending, transverse, and descending-and the rectum. It is not directly continuous with the small intestine. The enlargement is abrupt, at right angles to the ileum, and separated from it by a valve. This ileo-cæcal valve allows free passage to the contents of the small intestine, but firmly resists pressure from the cæcal side. At the end of the cæcum is a small closed tube, called the vermiform appendix, whose uses are unknown. A continual motion is kept up in the intestines, by means of which their contents are propelled along. These movements are termed peristaltic. The process of digestion is completed in the small intestine; whatever passes beyond this is merely the waste and innutritious residue of the food, and undergoes no further digestive action. The intestines and all the other abdominal viscera are bound together

and held in place by a strong membrane, the perito

neum.

An enema, or clyster, is a fluid preparation for injection into the rectum. Enemata may be used to secure or control evacuations of the bowels, to obtain remedial effect, local or general, or for the administration of nourishment. According to the purpose for which they are given, they may be classified as purgative, emollient, astringent, sedative, anthelmintic, refrigerant, nutritive, etc.

Purgative enemata are in general use for the relief of constipation. They produce the desired result not simply by washing out the accumulated fæcal matter, but by distention of the rectum and lower part of the bowel, occasioning a reflex stimulation, and increased peristaltic action of the whole intestinal tract. They are found to act efficiently even when the matter is lodged high up in the intestine, beyond the ileo-cæcal valve. A small enema often fails when a large one would be operative. To an adult should be given from one to four pints; a child requires but half as much, and for an infant one or two ounces will be sufficient. Having carefully protected the bed, place the patient on the left side, with the knees flexed. In an obstinate case, an advantage will be gained by adopting the Sims, or the knee and chest position. If the rectum is packed, it may be necessary to remove some of the fæcal matter with the fingers before the tube of the syringe can be introduced. Ordinarily, the rectum will be found empty, the accumulation being in the lower part of the colon, above the sigmoid flexure.

Pass the fluid several times through the syringe to expel the air; oil the nozzle and insert it very gently upward, slightly backward, and toward the left. Un

der no circumstances use force. See that the end of the tube moves freely in the rectum, neither pressed against the sacrum, nor imbedded in a fæcal mass. Give the injection very slowly; sudden distension of the rectum will produce an immediate and imperative desire for relief. It is a process about which it is impossible to hurry. If the patient complains greatly of pain, rest a little; after a delay of a few moments you can usually go on without distress. The anus may be supported by a folded towel, or, where there is little control of the sphincter, two or three fingers will have to be passed into the rectum by the side of the tube. After the desired amount has been injected, remove the tube gently, and, continuing to support the anus, keep the patient perfectly quiet for ten or fifteen moments. If a full enema can be retained for this length of time, there will in ordinary cases be little doubt of a satisfactory result. A bulb syringe, as the Davidson, is the best for giving a purgative enema. Water alone may be used, or, where something more stimulating is called for, various medicaments are added, as soap, salt, olive or castor-oil, ox-gall, etc. Soap-suds are excellent and convenient. An enema of this sort may be rendered more certain in its action by the addition of a couple of ounces of oil and half an ounce of turpentine; these, with a small quantity of the soap-suds, should be first injected, and followed by the bulk of the fluid. An injection of olive-oil, 3 iv-3 vj, may be given half an hour before one of water, and allowed to remain, in order to soften the fæcal mass. After any operation upon the genital organs, or the anus, where there is likely to be a strain upon sutures, such an enema may be given before each movement. Oil should always be first warmed, as, when cold, it is too thick to pass through the syringe

readily. Another enema exceedingly useful for softening scybalous masses in the rectum is of a solution of inspissated ox-gall. It should be retained for about an hour, and then be followed by a large enema of soapsuds. This is used especially after operation for laceration of the perinæum through the sphincter.

As to the best temperature for evacuant enemata, authorities differ. Hot or cold water will naturally excite the intestines to more vigorous action than water of the same temperature as the body. Either may be used without inconvenience to the patient. The daily injection of a pint of cold water is often advised, in case of constipation attended by bleeding hæmorrhoids.

The habitual use of large evacuant enemata is to be discouraged, as causing undue distention, and a somewhat torpid condition of the bowels.

When there is an irritable condition of the mucous membrane, enemata of a more soothing nature are indicated. Thin gruel is often used, or a decoction of flaxseed, starch, or barley. Emollient enemata should always be warm.

A refrigerant enema is an injection of clear cold water, given to reduce a febrile temperature. Injections of ice-water are also given to check hæmorrhage from the bowels.

Anthelmintic enemata are given to destroy worms. Only a small quantity need be used; for an adult half a pint is sufficient, for a child still less. The remedy to be employed will be prescribed by the physician to suit the case. Salt, quassia, aloes, tincture of iron, and weak carbolic acid are among those used. Avoid making the solution too concentrated, as it may excite inflammation.

To check diarrhoea, are frequently given enemata of

starch thin enough to pass readily through the syringe, to which has been added a prescribed quantity of laudanum, usually about thirty drops to two fluidounces of starch. These may be ordered after each movement, or regularly every few hours. The action is at once sedative and astringent. Other astringents, as sulphate of copper, or acetate of lead, are sometimes similarly employed.

Sedatives are given by rectum for the relief of pain in the region of the pelvis. It takes, as a rule, a third more of any drug than the dose given by mouth, to produce the same effect per rectum. Any rectal injection intended to be retained must be given very slowly, in quantity not exceeding four ounces, and of a temperature not less than 100° Fahr. Quiet must be enforced for some time after it is taken. The best instrument for such is a hard-rubber syringe holding the exact quantity. Especially do these directions apply to nutrient enemata, which are used when sufficient food can not be received or disposed of by the stomach. The possibility of nourishing in this way is often the means of saving life. Any highly concentrated liquid food may be given-milk, beef-tea, whipped eggs, etc. Defibrinated blood has been thought valuable. A variety will be better than any one kind exclusively. A useful mixture is three ounces of beef-tea, half an ounce of brandy, and one of cream. Brandy, or some other form of alcoholic stimulant, is often given together with the nourishment, as in this formula, but it is so irritating that its use can not be long continued. As food given by rectum has not been through the regular digestive processes, it must, to be easily assimilated, be subjected to artificial digestion. Therefore, pepsin or pancreatic extract is commonly added to it. Beef-juice, prepared

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