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 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.
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oil or vaseline, and the suppository is inserted point upwards into the anus by the nurse’s index finger, which is withdrawn when the suppository is felt to slip away from it.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.
1. Soap and Water Enema.
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.
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.
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.
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.
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.