Enemas in home nursing in the early 20th century

This is partly about the history of enemas, partly about my own history with them. After a good deal of net searching I recently identified and obtained a copy of the book from which I first learnt about enemas close on 50 years ago. It was a textbook of home nursing that I found lying around the house around 1964. I believe it had belonged to a grandmother who, like many women at that time, took a course in home nursing during World War II. After her rather early death in the 1950s some of her books came to us.

The full title of the book is worth its own paragraph: ‘Home Nursing: the authorized textbook of the St. John Ambulance Association, being the Ambulance Department of The Grand Priory in the British Realm of the Venerable Order of the Hospital of St. John of Jerusalem. Fourth Edition. Published June, 1932 … Price 1s. 6d. net; by Post, 1s. 7½d. London: The St. John Ambulance Association, St. John’s Gate, Clerkenwell, E.C.1.’

The St. John Ambulance Association is a quite admirable charitable organisation best known for providing ambulance and first-aid services and for training volunteers in first aid. Many people in many countries have taken one of their first-aid courses in their schooldays (as I did). The Venerable Order etc. etc., which coordinates the national ambulance associations, was in origin one of the many rather strange ‘chivalric orders’ set up in Europe in the 19th century (and in many cases claiming much older origins); its somewhat murky beginnings are detailed in Wikipedia.

And so to the book itself. Enemas are dealt with in Chapter XII, ‘Methods of Treatment’, of which I post extracts below. I have transcribed everything about enemas, and enough of the remainder to show how that section fits into the very clearly structured chapter.

CHAPTER XII

METHODS OF TREATMENT

Treatment of illness falls under one or more of three heads :—

(1) Removing or neutralizing the cause; (2) Promoting conditions most favourable to Nature’s effort to effort to effect a cure; (3) Supplementing Nature’s effort.

...

3. SUPPLEMENTING NATURE’S EFFORTS

Medicines are introduced into the body in several ways :—

A. By the mouth – Swallowed

B. By the air passages — Inhaled

C. Under the skin — Injected

D. Through the skin — Inuncted

E. By the rectum — Injected

...

E. — BY THE RECTUM

(RECTAL ADMINISTRATION OF MEDICINE)

Drugs are introduced into the lower bowel in the form of suppositories or an enema (plural, enemata).

Suppositories are small cone-shaped bodies used for administering drugs by the rectum. The anus and suppository are greased with a little oil or vaseline, and the suppository is inserted point upwards into the anus by the nurse’s index finger, which is withdrawn when the suppository is felt to slip away from it.

The apparatus for the administration of enemata is usually (i) a Higginson’s syringe, or (ii) a funnel, tubing and catheter.

(i) A Higginson’s syringe (Fig. 57) consists of (i) a bone nozzle about three inches long; this may be introduced into the rectum, or a catheter may be attached to it, to enable fluid to be injected higher into the rectum; (2) a length of indiarubber tubing; (3) a bulb; (4) a shorter length of tubing fitted with a metal valve (A).

Before using the syringe, insert the valve end into the bowl containing the fluid to be injected, and pump some of it through the syringe to expel the air. When the fluid flows through noiselessly it is safe to proceed with the enema.

ii. Funnel, tubing and catheter (Fig. 5 😎 . Connect a glass funnel with a soft rubber catheter, Number 10 or 12, by means of a length of rubber tubing and a glass union. Test for leakage at the joints by running water through. The rate of flow is regulated by the height to which the funnel is raised above the patient. The catheter is passed for a length of eight inches into the rectum.

GENERAL RULES FOR ADMINSTERING AN ENEMA

1. Make sure that the hot-water bottle in the bed is really hot, as patients sometimes collapse after an action of the bowels.

2. Prepare the apparatus and the enema, which, unless ordered to the contrary, should be at a temperature of 100° F, in a bowl or jug.

3. Put under the patient a mackintosh with a warmed sheet folded in four over it.

4. Place a bed-pan under the bed.

5. Turn down the bed-clothes and cover the patient with a blanket, which can be easily folded back to leave the buttocks free.

6. Let the patient lie on his left side and draw up his knees; then, placing your hand under his hip, draw his buttocks on to the edge of the bed.

7. Smear the nozzle or catheter with oil or vaseline, and gently insert it into the anus, slightly backwards and upwards. Inject the fluid, which should be at a temperature of 100° F., very slowly, never allowing the valve end of the syringe to get uncovered or the funnel to become empty lest air rush in. If the patient cannot be turned on his side, the enema can be administered as he lies on his back by raising his leg, passing your hand under it and inserting the nozzle or catheter into the rectum.

8. Before withdrawing the nozzle or catheter, nip the rubber tubing near it between the thumb and finger, to prevent any escape of fluid into the bed.

9. Press the buttocks together, or press a clean towel against the anus, to assist retention of the enema.

After use (i) wash the syringe by pumping clean water through it, and hang it up with the nozzle downwards by means of a small loop of tape at the valve end of the syringe; or (ii) wash the catheter by holding it eye uppermost under a cold-water tap, and boil it before putting it away.

VARIETIES OF ENEMA

a. Purgative — To produce an action of the bowels.

b. Anodyne — To relieve pain or to check diarrhœa.

c. Stimulant — To stimulate a patient during collapse.

d. Nutrient — To feed a patient when unconscious, or in uncontrollable vomiting, and in some diseases of the stomach.

a. Purgative.

1. Soap and Water Enema.

To prepare:—

Pour 2½ pints of warm water into a basin and stir thoroughly into it 1 ounce of thinly sliced yellow soap. Two pints only should be given, the remaining half-pint being left to cover the valve of the syringe. A child should be given 2 ounces for every year of his age.

To administer:—

i. Use a Higginson’s syringe.

ii. Encourage the patient to try not to use the bed-pan immediately, but never refuse it when asked for.

iii. Remove the bed-pan after use, cover it over and place it under the bed while you wash between the buttocks.

iv. It may be advisable to repeat the enema in two hours if the bowel has been insufficiently cleared.

2. Olive or Castor Oil Enema.

Used when the rectum is full of hard fæces. The amount ordered — usually 6 ounces — is warmed by standing the vessel containing it in a basin of hot water. It is administered by a funnel, tube and catheter, and is followed in half an hour by a soap and water enema.

3. Glycerin Enema.

Used largely as a purgative for children. One or two teaspoonfuls, warmed by standing the glass which contains it in a basin of hot water, are given by means of a small glass or vulcanite syringe, care being taken to avoid the entry of air.

b. Anodyne.

Starch and Opium Enema.

Used to check diarrhœa. A teaspoonful of starch is mixed smoothly with five ounces of cold water. It should be then brought to the boil, a teaspoonful of tincture of opium (laudanum) added, and stirred carefully till the mucilage is translucent. It can be prevented from stiffening as it cools if a teaspoonful of cold water is added while stirring vigorously. It is administered at a temperature of 100° F. with a funnel, tube and catheter.

c. Stimulant.

Saline Enema.

Used in collapse and to counteract shock. One teaspoonful of common salt is dissolved in a pint of water to form “normal saline,” i.e., a salt solution of the same concentration as the blood plasma. It is prepared at a temperature of 103° F., and administered slowly, at low pressure, by funnel, tubing and catheter. The addition of half to one ounce of brandy is sometimes ordered for greater stimulation.

d. Nutrient.

Saline and Glucose Enema.

If an enema of a nutrient nature is required, one ounce of glucose is added to nineteen ounces of normal saline. The lower bowel only readily absorbs water, salts and glucose, and therefore the saline and glucose enema has superseded the former nutrient enemata of peptonized or pancreatized foods, such as milk, eggs or beef-tea. It is administered by a funnel, tube and catheter, and must be given slowly.

Before administering any nourishment by the rectum it is necessary that the lower bowel be clear of fæces, so warm water or boracic lotion (ten grains to one ounce) is slowly poured in with a funnel, tubing and catheter. By lowering the funnel before it is quite empty the water runs out again, and as soon as it returns clear the enema may be given. Patients continuously fed by enemata should, in addition, have the bowel washed out by warm water once in every twenty-four hours.

The above is from the 4th (1932) edition of the textbook. I also have the third (191 😎 edition, which contains largely the same material, though differently arranged. I’ll end with a few notes on the differences between the two editions, reflecting I suppose changes in nursing practice in the intervening fourteen years.

In the instructions for administering an enema the 1918 book says to raise the patient’s buttocks on a pillow after drawing them to the edge of the bed. The 1932 edition omits this point; it sounds rather uncomfortable for the patient, at least.

Where the 1932 edition speaks of an ‘Olive or Castor Oil Enema’, the 1918 book only mentions the Olive Oil Enema.

In 1918 the glycerine for the Glycerine Enema was measured in drachms; by 1932 these had become teaspoons.

The 1918 book describes a Starch Enema, made with just starch and water. I’m surprised to see the 1932 book adds opium (laudanum) to this. I had always associated laudanum with 19th century novels and would have imagined it had long gone out of use by the 1930s.

Likewise, I’m surprised that the 1932 book mentions brandy as an (optional) component of the saline enema. The 1918 book doesn’t mention this.

The biggest difference between the 1918 and 1932 editions is under the heading of nutrient enemas. The extract above refers to a variety of nutrient enemas as having been superseded. The 1918 book gives a number of recipes for these.

The line drawings of the ‘Higginson’s syringe’ and the ‘funnel, tubing and catheter’ are identical in both editions. I’ll see if it’s possible for me to post scans of them somewhere on this site.

A final comment: my grandmother’s copy had a number of handwritten notes in the margins, presumably written down in class from a teacher’s remarks. Of these I remember: (1) raising the foot of the bed will assist in retaining an enema, and (2) a soap and water enema should be retained for at least 5 minutes, and for 10 minutes if possible. If a bowel motion had not occurred at the end of 15 minutes, another enema should be given.

Very interesting book, thanks for sharing. Moreover, I have heard that it was somewhat common practice to walk patients who had just recieved an enema. I don't believe this practice is used much today, but in my understanding, this practice was used fairly often in nursing homes and hospitals many years ago, especially for patients who might have had difficulty in voiding an enema. Can you verify this from your research?

Walking the patient — at least in this situation — isn’t mentioned in the St Johns books that I have. But some nursing ‘lore’ was no doubt passed on by word of mouth or by example rather than via formal instruction. It’s well known that exercise can stimulate the bowels, so I can easily believe walking might have been recommended if the patient was capable of it.

[Added 17 Nov. 2011:] Another ‘trick’ that might have been passed on informally was massaging the abdomen to help expulsion. It’s not mentioned in these books, but both my mother and my grandmother used to do this if I had a tummy ache, and it would surely have been well known to any home nurse.

Thanks for the follow-up comment, it was very insightful. As you mentioned, physical exercise (or walking) can indeed stimulate the bowels, which would have been especially helpful for someone who might have had difficulty in voiding an enema, particularly a young person or an elderly patient. Walking can both stimulate a persons bowels, and tend to relax some of the stress involved, not to mention harnessing the power of gravity as well. I too, learned about this through word of mouth as you suggested. Consequently, I find the process of walking a patient to be rather erotic as well! Thanks again - Stuart

Have been in and out of this site for awhile. Am a used book collector, many of modern ones have Paper Covers. Have to smell, incase of mold and mildew. Books are all over my house, am a retired, widower. My "kids" have their own places. So it's mine.

Possess a very large collection of Enema Equipment - 1750 to Present.

And related to subject title - many manuals, guides on Home Nursing, Basic Nursing, Home Health, Child care, etc. These were found over decades in antique malls, used book stores and sales, etc.

1900 to 1970's. I use to photo copy and trade with other collectors, fans. Always looking for ones I don't have. Some books have photos not seen in decades. Also films - VHS, DVD, CD, 8mm, 16mm. Have 8mm & 16mm Projectors somewhere. It's a shame that enemas have mostly disappeared from public view. Sis and I were raised on them. Also home nursing not taught, especially in schools. I have read still used in Philippines and Mexico. Had a girlfriend in the service, was taking Nursing in High School in PA. Said in letter they were learning to give enemas, "boy are they messy". To each other?

Good imagination

One-eyes...Interesting historical article & text book reference to Australian practices...Because of these documents that are now becoming rare it reminded me of my mothers nursing compendiums...Hopefully sometime in the not to distant future I shall endeavour to post another quite similar & befitting the era.

The excerpt posting copied from The Australian LADIES HANDBOOK of Home Treatment, dated 1939 (of 1038 pages)...Coincidentally the very first edition of these began in 1912 under our Commonwealth Copyright Act of that year, with minor revisions continuing well beyond the following 40 plus years.

My grandmother had a home nursing guide. I think it was written by a Dr. Fishbein back in the 20s or 30s. Enemas seemed to be given for just about every illness, and Mom was the #1 giver. And if a nurse ever needed to visit your home when you were sick (according to my grandmother), chances are she would either give or help Mom give some type of enema.

Regarding Vicki;s post, I do recall reading a newspaper column by Dr. Morris Fishbein, dating back to the 1940s in which he was very pro-enema in times of illness or otherwise. But most moms in those days didn't need his advice before filling up the enema bag or can!

Those home medical and nursing texts were a great source for instructions and illustrations relating to enemas, douching, and other procedures that many of us kids feared and resisted. That is, of course, until we discovered they could be the source of some wonderful sensations. Google Books has many of those archived and accessible on the internet. Many illustrations are copyrighted and unavailable.

I have discovered many of those in rare book stores. I also kept a copy of my favorite text by Dr. Benjamin F. Miller. It contains one of my all time favorite illustrations of enema administration. I have viewed this since the 50's.

Because of my fascination and obsession (fetish?) with enemas, I have read just about anything in print relative to the subject. It has been quite enlightening that enemas were a recognized and legitimate procedure for many different circumstances. Those were the days or "Golden Years" to many. One thing that is seldom discussed is that enemas and suppositories were frequently an aspect of toilet training in addition to addressing any other digestive issues or maladies.

Many came to believe that enemas, suppositories, or soapsticks were too harsh for potty training. It was in these circumstances that they were discouraged due to long term issues that children might face. I suspect that may be partly responsible for my early, and deep seated fascination with the procedure and equipment. At least I have cum to terms with it, and thoroughly enjoy that simple procedure and pleasure.

Home nursing guides were common in "those days." My Mom's mother had one published in the l930s, and when you looked up what to do for most any illness, "give an enema" was usually one of the treatments recommended. Chapters would be detailed on the types of enemas, even giving "nourishment" through a rectal tube. I think what's odd in today's culture is that nudity and explicit sex in movies and other media seem to be widely accepted, but the enema, which I consider a healthy thing to do if you're sick with the flu, fever, etc., is rarely in the books anymore and thought of only as kinky.

As most of you know, Grandma gave my sister and I twice-weekly enemas growing up, until we left home. These were normally strong Ivory soapsuds with a salt & baking soda rinse. Wednesday we usually got two 2 or 3 qt SSE's and a rinse. Saturday AM we got laddered SSE's (2qt, then 3 qt, and as we reached adult body proportioms, 4 qts. She continued the enemas until the water coming out looked like it did going in. Finally, she would administer a salt & soda rinse of the same volume as our largest SSE. If one of us got sick, we both received a 1 qt enema with some sort of herbal tea, delivered through a double balloon nozzle and retained as long as one hour. Once we had the full qt in us, she would clamp off the double balloon nozzle and disconnect the hose. We were then allowed to move about as we held our enemas. Since all enemas were administered in the nude (this included Mom & Grandma), we not infrequently wandered about the house with a "tail" wagging behind. Neither Sis nor I ever asked about the tea. I wish we had, as it usually relieved fever and congestion, and made us feel better. Since we both became chronically constipated, it is good that we both also became klismos. Now older, and both widowed, we live together and rarely wear clothes unless company is expected. Our only "medicated" enemas contain about half a tumbler of vodka per 2 qt bag, in the evening to enhance relaxation. On the other hand, rare is the evening that passes without water in our tummies. Neither of us can ever remember getting a BM without a laxative, suppository, enema, or combo of two or all three. This goes back to our earliest memories. Sis is older, and remembers me getting an enema with an ear syringe before age one.

Vikiv---my father's brother had typhoid fever or something like that probably around the time of WWI or a little later, and could not keep anything down in his stomach. In order to keep him alive, my grandmother gave him enemas of some nourishing substance, I suspect sugar. My father said it was what kept him alive. Today, of course, we have intravenous feeding instead.

hankb

It is interesting that enemas have essentially been written off in most health, nursing, and other medical texts published in the last 20 years or so. While the procedure is covered, the disclaimer about the need for a doctor's order, is really stressed. This is certainly the case in preparations for surgery, L&D, and other tests.

It seems that the decision to give an enema was delegated to nurses for many years. Certainly our moms and grandmas were within their maternal purview to administer enemas as needed. Those preventive or pre-emptive enemas were seldom discouraged in cases of illness or anticipated appointments for various procedures etc. They were in fact, recommended.

It has been refreshing that enema use has been suggested in various natural health and raw food circles. While the medical establishment seems to discount their efficacy, as they do for most alternative care methods, at least some well respected types seem to promote detoxification and a well functioning digestive system.

I fail to see any harm in using enemas as an adjunct, or additional step, in overcoming whatever ails us. If they only make us feel better physically or psychologically, so be it!

Home nursing and first aid books were a prime source of information for most families before the internet. I think most of us had something like it around the house. I am a "baby-boomer" so it was the 50's and 60's when I became interested in enemas but by then enema use was probably already declining from previous generations. As a teen, I would go to the library and look through the various books in the medical and health department to see the different mixtures and procedures for enemas. Of course none of those medical books explained why I got hard every time I gave myself an enema. Heck, I got hard just reading about them. I thought I was weird because I enjoyed giving myself enemas. It would not be until I read in Penthouse sometime in the 70's that I realized there were others who did enemas for fun.

Today, home health books rarely even mention enemas. And if they do, it is usually to tell you they are not recommended or only as part of a colon purge after drinking some quantity of some green slime intended to clean out accumulated stuff in your colon. I can tell you that after years of regular enema use, there is no accumulated stuff in my colon.

Aside from a 1940s Red Cross home nursing book that made only a passing reference to enemas, Mom had an illustrated baby care guide that included a year-old or younger child being given an enema on his/her side with an adult size rubber bag. Not likely to be allowed in print today.

.

Worth noting:

At the time in most places women were actually ENCOURAGED to douche, and honestly for a yeast infection there were few real alternatives to a series of iodine douches.

Feasible alternatives did not really become readily available till the mid 1950s!

That said if you had a female adult in the household, at least one "Feminine hygiene" syringe was essentially required equipment. Since every such syringe came with at least adult and often child rectal pipes as well, the opportunity was always there, and most moms would prefer that to spending money and time on a doctor's house call.

Even I am not old enough to know what happened in the first half of the 20th century, but being a baby-boomer I probably saw the biggest decline in enemas and douching. I know my grandma and my mom were no strangers to a good enema. I got enemas as a girl and some (but not all) of my friends and relatives did too. Our home first aid book certainly had directions for giving an enema but I already knew how, having learned from mom. I remember as I got older reading that enemas and douching were discouraged. By time I had kids the baby books told you not to give enemas to children, but mine did get a few when appropriate.

I have a very good friend who was a LPN in the late 70's and early 80's. I knew she worked at a retirement/nursing home for a while. One day joking around I said, "I suppose all you do is give enemas to those old people." She laughed and said she has never had to give an enema to anyone on the job. She worked third shift and said any needed enemas were given in the morning after breakfast by the first shift. She said she knew they usually used a Fleet. They had a big stock of them. But, she said some of the nurses, including herself, kept one of those plastic disposable bags in their locker and if all was quiet at 3AM they would sometimes use it on themselves. Sort of relief from boredom, I suppose.

I came accross an old Red Cross Home Nursing Manual, 1930's. It had instructions for enemas. Another old Physical Culture Magazine , indicated that a full enema for adults should be 3 qts. I think enemas started get less used as the time went on from the 1960's into the 1970's, I got mine in the 1950's , than began to sneek as time went on.

My parents had a medical encyclopedia in the house - and it advised against enemas and laxatives in general. It did overstate the risks (like all mainstream medical advice nowadays) but I suspect they never read it anyway - their minds were made up re what is constipation and how to treat it.

In retrospect I wish I had used the "suppository-assisted toilet training" regime when my daughter was age 2 to 4 - our current intense bowel-monitoring regime grew slowly, and it started with trauma for all of us during her potty-training era.

With all due respect Cheryl, I am a nurse and I prefer to work either second or third shift and have most of my life. I work in different areas but regardless of what place or the type of patients I work with I don't have time to go pee or eat much less take an enema out of boredom.

Just sayin lol.

Mashie

Am still looking for more vintage photos of being used. Have large number 1900 to 1970's to share. Also can help if needed for a book being produced. Since am abit older, looking for source to pass on a vast amount. Like a German buff said: would be ashame if broken up. Spent decades on this. One rarely can find any of this, I have tried. Went awhile back to a used book store in Towson, Md, all their stuff was new. Even have a number of older German Home Health Volumes. Went to dozens of used book sales over the decades. Many stories.My posting is above. Take Care.

I've found that Google Books has quite a few medical and nursing texts that they've scanned from libraries. However, to see them, what you have to do is add some filters:

1. Look for FREE publications (These are typically the older ones). It's on the sidebar

2. ONLY search for books. You will find lots of nursing books from a former era, meedical books, etc. If you search for "all publications," you will spend a lot of time looking at catalogs of books, magazines, etc.

3. If you want to add these to your library, you must sign in with your Google account, so if you don't want Google knowing too much about you, use a pseudonymus account.

You can also BUY books, but I recommend you search eBay, Amazon AND Google for those. Some out of print books are quite inexpensive, others are VERY expensive.