Ritual-enema-induced Colitis*
ISIDOR SEGAL, M.R.C.P., LEONARD OU TI-XL F.C.P.(S.A.), DONALD G. HAMILTON, M.R.C.PATH.(L), HUGH H. LAWSON,F.R.C.S., ALBERT SOLOMON,M.MED. (RAD.D.), FREDERICK KALK, F.R.C.S., STANLEY A. R. COOKE, F.R.C.S.
THE USE OF ENEMAS by S o u t h A f r i c a n blacks is c o m m o n ? "7 A m e m b e r of the Zulu tribe m a y use e n e m a s as often as three times per w e e k ) a n d Swazi tribe infants may receive as m a n y as 50 e n e m a s per year3 E n e m a s are self-prescribed or prescribed by witch doctors for a wide variety o f reasons including: for ritual purposes; as an aphrodisiac, emetic or aperient, and for the t r e a t m e n t of i m p o t e n c e febrile s y m p t o m s , a b d o m i n a l pains, d y s m e n o r r h e a and dysentery. 1"2 T h e traditional ingredients o f these e n e m a s include roots, herbs, tree bark, bulbs and leaves. With the migration o f rural people to the sophisticated u r b a n e n v i r o n m e n t o f J o h a n n e s b u r g , however, o t h e r substances are b e i n g used, including Dettol (Chloroxylenol, 4.8 g/100 ml), vinegar, caustics, soap, potassium d i c h r o m a t e , c o p p e r sulfate, potassium p e r m a n g a nate, and b r o w n sugar. T h e h o r n o f a cow is occasionally used to dispense the e n e m a . This may result in mechanical p e r f o r a t i o n o f the bowel. Most people now use the conventional Higginson-type syringe. In a study at B a r a g w a n a t h Hospital s involving a r a n d o m selection of 148 adult patients who did not have gastrointestinal disease, 62, 8 per cent a d m i t t e d to the r e g u l a r use of enemas, e x t e n d i n g o v e r m a n y years; o f these, 2.7 p e t cent used e n e m a s daily; 8.1 per cent, weekly; 3.4 per cent, biweekly; 23.6 p e r cent, monthly; 2 per cent, bimonthly; 23 p e r cent, occasionally i.e., one to three times per year (Table 1). T h e s e findings are in a g r e e m e n t with those o f Oettle, 7 who f o u n d that the use of enemas was widespread, a n d we r e p o r t an incidence higher than that in B r e m n e r ' s 1964, study, which showed that 36 p e r cent of B a n t u patients used e n e m a s ?
From the Department of Gastroenterology, Baragwanath Hospital, South African hzstitute for Medical Research, Joha~znesburg General Hospital and tAe University of the Witwatersrand, Johannesburg, South Africa T h e r e are relatively few complications associated with the use of these enemas, but those that do occur can be e x t r e m e l y serious, and at times even fatal. Such complications were seen in 11 patients t r e a t e d at B a r a g w a n a t h Hospital d u r i n g 1977. A s u m m a r y o f these cases is p r e s e n t e d in T a b l e 2.
Discussion Clinical Presentation: T h e cEnical h a l l m a r k s o f e n e m a - i n d u c e d injuries are peritonitis a n d rectal bleeding. Perianal e x c o r i a t i o n p r o c e e d i n g to gangreene of the p e r i n e u m and anal canal may occur. In severe cases, patients may go into shock, leading to h e p a t o r e n a l f a i l u r e a n d e v e n death. L a p a r o t o m y findings include necrosis o f the r e c t u m a n d sigmoid TABLE I. Freque*zcyof Enema Usage iu 148 Adult Patient.s at Baragwanath Hospital (1978) Frequency No enema usage Daily Weekly Biweekly blonthly Bimonthly Occasionally (one-three t{mes per year)
* Received for publication October 10, 1978. Address reprint requests to Dr. Segal: Gastroenterology Unit, Baragwanath Hospital. P O Bertsham, 2013, South Africa.
TOTAL
Nunaber
Per Cent
55 4 12 5 35 3 34
37.2 2.7 8.1 3.4 23.6 o 23
I48
ion
00 I2-3706/79!0400/0195/$00.75 9 American Society of Coton and Rectal Surgeons 195
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ISIDOR SEGAL, M.R.C.P., LEONARD OU TI-XL F.C.P.(S.A.), DONALD G. HAMILTON, M.R.C.PATH.(L), HUGH H. LAWSON,F.R.C.S., ALBERT SOLOMON,M.MED. (RAD.D.), FREDERICK KALK, F.R.C.S., STANLEY A. R. COOKE, F.R.C.S.
THE USE OF ENEMAS by S o u t h A f r i c a n blacks is c o m m o n ? "7 A m e m b e r of the Zulu tribe m a y use e n e m a s as often as three times per w e e k ) a n d Swazi tribe infants may receive as m a n y as 50 e n e m a s per year3 E n e m a s are self-prescribed or prescribed by witch doctors for a wide variety o f reasons including: for ritual purposes; as an aphrodisiac, emetic or aperient, and for the t r e a t m e n t of i m p o t e n c e febrile s y m p t o m s , a b d o m i n a l pains, d y s m e n o r r h e a and dysentery. 1"2 T h e traditional ingredients o f these e n e m a s include roots, herbs, tree bark, bulbs and leaves. With the migration o f rural people to the sophisticated u r b a n e n v i r o n m e n t o f J o h a n n e s b u r g , however, o t h e r substances are b e i n g used, including Dettol (Chloroxylenol, 4.8 g/100 ml), vinegar, caustics, soap, potassium d i c h r o m a t e , c o p p e r sulfate, potassium p e r m a n g a nate, and b r o w n sugar. T h e h o r n o f a cow is occasionally used to dispense the e n e m a . This may result in mechanical p e r f o r a t i o n o f the bowel. Most people now use the conventional Higginson-type syringe. In a study at B a r a g w a n a t h Hospital s involving a r a n d o m selection of 148 adult patients who did not have gastrointestinal disease, 62, 8 per cent a d m i t t e d to the r e g u l a r use of enemas, e x t e n d i n g o v e r m a n y years; o f these, 2.7 p e t cent used e n e m a s daily; 8.1 per cent, weekly; 3.4 per cent, biweekly; 23.6 p e r cent, monthly; 2 per cent, bimonthly; 23 p e r cent, occasionally i.e., one to three times per year (Table 1). T h e s e findings are in a g r e e m e n t with those o f Oettle, 7 who f o u n d that the use of enemas was widespread, a n d we r e p o r t an incidence higher than that in B r e m n e r ' s 1964, study, which showed that 36 p e r cent of B a n t u patients used e n e m a s ?
From the Department of Gastroenterology, Baragwanath Hospital, South African hzstitute for Medical Research, Joha~znesburg General Hospital and tAe University of the Witwatersrand, Johannesburg, South Africa T h e r e are relatively few complications associated with the use of these enemas, but those that do occur can be e x t r e m e l y serious, and at times even fatal. Such complications were seen in 11 patients t r e a t e d at B a r a g w a n a t h Hospital d u r i n g 1977. A s u m m a r y o f these cases is p r e s e n t e d in T a b l e 2.
Discussion Clinical Presentation: T h e cEnical h a l l m a r k s o f e n e m a - i n d u c e d injuries are peritonitis a n d rectal bleeding. Perianal e x c o r i a t i o n p r o c e e d i n g to gangreene of the p e r i n e u m and anal canal may occur. In severe cases, patients may go into shock, leading to h e p a t o r e n a l f a i l u r e a n d e v e n death. L a p a r o t o m y findings include necrosis o f the r e c t u m a n d sigmoid TABLE I. Freque*zcyof Enema Usage iu 148 Adult Patient.s at Baragwanath Hospital (1978) Frequency No enema usage Daily Weekly Biweekly blonthly Bimonthly Occasionally (one-three t{mes per year)
* Received for publication October 10, 1978. Address reprint requests to Dr. Segal: Gastroenterology Unit, Baragwanath Hospital. P O Bertsham, 2013, South Africa.
TOTAL
Nunaber
Per Cent
55 4 12 5 35 3 34
37.2 2.7 8.1 3.4 23.6 o 23
I48
ion
00 I2-3706/79!0400/0195/$00.75 9 American Society of Coton and Rectal Surgeons 195
196
SEGAL,
ET
AL.
Dis. CoL April&Rect. i979
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