The theory of autointoxication claims that by-products of incomplete digestion may poison the body and, therefore, cause disease. It can be traced back to most ancient cultures of medicine. In the Western world, humoral medicine was based on the idea that all diseases were caused by the imbalance of the four body humors. Conversely, health constituted a balanced mix of these humors. Waste products formed in the intestinal tract were thought to be a major potential contributor to such imbalance. Both Hippocrates and later Galen viewed "autointoxication" as a major etiologic factor of disease (1).
The cure seemed all too obvious: To minimize the threat of autointoxication, the contact time of the toxic material in the intestines had to be shortened. Purgatives of all sorts were the answer. Clysters (enemas) of various types, therefore, formed an important part of Chinese, Hindu, Sumerian, Egyptian, and other medical traditions. Throughout the history of medicine, the colon was treated "with attacks from above with purges, attacks from below, with douches and frontal attacks by the surgeon (2)."
During the 19th century, the theory of autointoxication represented the ruling doctrine of medicine. French physicians such as Charles Bouchard (1837-1915), who coined the term (3), and Frantz Glenard of Lyon (1848-1920) were leading the field (4). German doctors such as Ludwig Brieger (1849-1919) and Herman Senator (1834-1911) enriched the theory by apparently identifying the chemical process underlying toxin formation: intraintestinal putrefaction of proteins.
The list of symptoms of autointoxication was long: fatigue, depression, anxiety, neurasthenia, poor appetite, headache, and epilepsy, to name a few. Regular bowel movements remained the key to good health (5). The obsession of many patients with their intestinal tract made them easy prey for quacks and charlatans in all thinkable guises. By the late 19th century, the markets were flooded with pills and tonics as well as enema devices and practitioners of abdominal massage, all aiming at ridding the colon of its contents and the patient of his or her money.
Evacuation enemas were given for immediate results, and retention enemas offered the additional option of administering therapeutic agents. Anything from honey, wine, and beer to less benign substances such as urine or tobacco was used. Therapeutic claims became more daring as "colonic quackery" grew.
TWO EXEMPLARY PROPONENTS
Charles A. Tyrell (1843-1918) was particularly aggressive in promoting himself, his books, and, most importantly, his therapeutic device, the "Cascade" (6). This was a rubberized water bottle that held 5 quarts (about 5 liters) of liquid. The patient would insert its nozzle into his or her rectum and sit on the instrument. The patient's body weight would then create the pressure to drive the fluid into the patient's colon. Tyrell led huge advertising campaigns promoting his "Cascade" as a cure for anything from cholera to rheumatism. Like most quacks, he emphasized that his treatment was natural and hence harmless. At the same time, he attacked mainstream medicine for using poisonous remedies that merely harmed the patient. Like most quacks, he compensated his lack of medical knowledge with a sound know-how in business matters. More than 100 editions of his book were published, his "Cascade" was sold by the millions worldwide, and his institute earned him a fortune. Like most quacks, he promoted his treatment as a veritable panacea without ever providing convincing evidence.
John Harvey Kellogg was a slightly more respectable, albeit overoptimistic proponent of autointoxication. This physician from Michigan, claimed that colon therapy prevented surgery in all but 20 of 40,000 patients suffering from gastrointestinal disease (7).
A TOUCH OF SCIENCE
By the turn of the century, the market for devices, laxative pills, and tonics was booming as never before. An endless profusion of remedies, sold in shops and by mail order enterprises, promising health through regularity of bowel movements, "opened men's purses by opening their bowels" (8). At that stage, the notion of autointoxication even received support from unexpected quarters: Metchikoff, who had previously received the Nobel Prize for his theory on phagocytosis, thought that "chronic poisoning by intestinal microbes weakens our cellular elements ... and might provoke senile phenomena" (9).
Colonic quackery was quick to take up this apparent sanction from the ivory towers of science. Henceforth, its promoters were keen to point out that autointoxication was supported by the very best of medical expertise. Millions used colonic irrigation not least because science had apparently given its blessing.
There had been surprisingly little objection from mainstream medicine. This changed dramatically in 1906 when the American Medical Association formed its Propaganda Department, which later became the Bureau of Investigation. One of its leading members, Arthur J. Cramp, initiated a campaign against the "proprietary evil" that existed within the medical profession. The Journal of the American Medical Association joined the "continuous, relentless, excoriating critique of quackery." A particular focus of Cramp's campaign was against colonic irrigation and the fallacy that "autointoxication produced by intestinal obstruction ... was ... the only cause for disease (10)." The dangers of colonic irrigation were systematically exposed and the truth was distributed widely. Simultaneously, rigorous scientific investigation into the theory of autointoxication was initiated for the first time. The hypothesis was soon found to be wrong (see, for example, Donaldson ). For a while, "colonic quackery" seemed to be an issue of the past, but charlatanism, it seems, dies hard.
THE PRESENT REVIVAL
Today colon therapy is almost as popular as it was in its heyday. It forms an integral part of the therapeutic armamentarium of most (nonmedically qualified) alternative practitioners around the world who have, during the past three decades, experienced an unprecedented resurgence in this popularity (12). Based on a four-star rating system, colonic irrigation has received two stars in terms of popularity (13). Another source states that it "is once more gaining in popularity and is now commonly used by alternative health practitioners" (14). Accurate data on its prevalence are not available.
Aggressive advertising and promotional texts abound (see, for example, Plant ). Many of the outlandish claims of yesterday are echoed today: "If bowel movements are not consistent, waste products and toxins are not eliminated in a regular manner, and health can be compromised" (14), to cite a book modestly entitled The Ultimate Guide. According to this text, the therapy cleans the colon in its full length, detoxifies it, reconstitutes intestinal flora, and even rids the body of parasites and prevents bacteria from entering the blood stream. Today's list of indications for colon therapy is impressive (14,16,17): alcoholism, allergies, arthritis, asthma, backache, bad breath, bloating, coated tongue, colitis, constipation, damage caused by nicotine or other environmental factors, fatigue, gas, headache, hypercholesterolemia, hypertension, indigestion, insomnia, joint problems, liver insufficiency, loss of concentration, mental disorders, parasite infestation, proneness to infections, rheumatoid arthritis, sinus congestion, skin problems, and ulcerative colitis. False claims, a lack of evidence, big money, aggressive advertising, disregard of risk-little seems to have changed. In the hope of finding some type of evidence, I have written to the two professional organizations for colon therapy in the United States. The fact that no reply was received may speak for itself. Most proponents of colonic irrigation deny any adverse effects, but one text (17) states that possible side effects are nausea, diarrhea, and nervous disturbances. The risks of electrolyte imbalance (18) or water intoxication (19) are either omitted entirely or downplayed (17).
Coffee enemas are a hazardous derivative of colon therapy. As part of an unorthodox anticancer diet (20), a coffee enema is administered on a 4-hour basis "to help relieve pain, nausea and other symptoms accompanying detoxification" (21). Its proponents claim that caffeine is absorbed in the colon and leads to a vasodilatation in the liver, which in turn enhances the process of elimination of toxins. None of this is proved, nor is there any evidence of the clinical efficacy of coffee enemas. Coffee enemas are associated with severe adverse reactions (22), and even its proponents speak of a "healing crisis" that occurs in many patients (21).
The ancient theory of autointoxication has been the basis of today's colon therapy. There is no evidence that it conveys true benefit in any condition. Even a recent "review of the available literature" by a proponent of colonic irrigation provides only theories and anecdotes (17). Yet good proof exists that it is associated with considerable risks. Physicians should know about the dangers of colon therapy some of their patients might be using. In such cases empathy, reassurance, and factual information will be helpful.
E. Ernst, M.D., Ph.d., F.R.C.P. (Edin)
Department of Complementary Medicine; Postgraduate Medical School, University of Exeter; Exeter, England.
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