'Blowing Smoke Up Your Ass': The Literal Meaning/Medical Practice Behind The Idiom

Royal Humane Society resuscitation apparatus. (Science Museum, London)
To "blow smoke" has had a few definitions over the years, and the end of the phrase (as well as its meaning) varies. You can "blow smoke in someone's face" to obfuscate a situation. You can "blow smoke" to lie or exaggerate the truth. Yet "blowing smoke up someone's ass" has a very specific meaning: to praise someone in a way that is not sincere. The first two meanings draw a clear reference to how smoke makes it difficult to see, but it's unclear at first blush how butts got involved. The answer, as it often does, lies in history.
Dried, hanging tobacco. (Adobe)

Tobacco Enemas

When European settlers saw Native Americans in the New World use dried tobacco in their medicine, they brought the idea back home with them. In the 1700s, tobacco was thought to cure just about anything, from headaches to cancer to asthma to vague and indefinable "lady's problems." Come 1745, Richard Mead brought forward the idea of taking tobacco's panacean qualities all the way to drowning victims. Since such patients are not known for their great inhalations, however, another ... opening ... needed to be found. One of the first recorded demonstrations of a tobacco enema took place in 1746, when a man placed the mouthpiece of a pipe into the rectum of his half-drowned wife and blew down the other end. By all accounts, it worked, though it's unclear whether it was lifesaving smoke that brought her swiftly back to consciousness or simply the shock of a literal fire under her butt.
A man recuperating in bed at a receiving-house of the Royal Humane Society, after resuscitation by W. Hawes and J.C. Lettsom from near drowning, 1787. (R. Pollard/Wikimedia Commons)

A Common Hobby

By 1774, Doctors William Hawes and Thomas Cogan formed The Institution for Affording Immediate Relief to Persons Apparently Dead From Drowning, later renaming themselves the less fun but significantly more efficient Royal Humane Society. Aside from Monty Python naming conventions, they were dedicated to saving lives by any—and we do mean any—means necessary. They went so far as to offer four guineas to anyone who successfully revived the apparently dead. Four guineas is now in the neighborhood of $756, so amateur emergency medicine—which included the administration of tobacco enemas—became a widespread hobby. Indeed, the practice was common enough that tobacco enema kits were placed regularly along the Thames, and people were expected to know how to use them. It was like a much more intimate version of those defibrillators that dot the walls of airports today.
Drowning victim receiving smoke enema, March 1985. (International Free Press)

How To Perform A Tobacco Enema

After being taken somewhere warm and dry, the victim was stripped of some or all of their clothes and laid on their side in what would now be called a recovery position. Next, smoke was blown into the rectum with the assistance of a long, thin tube sometimes connected to a bellows. If that apparatus wasn't available, a regular pipe could be used. Although tobacco was preferred because of its properties as a stimulant, experts endorsed the use of any type of smoke to heat the body. In fact, only men were deemed strong enough for tobacco enemas. For women and children, the smoke of herbs like rosemary or flowers like marjoram were suggested instead. 
An attempt at reviving a drowning victim via tobacco enema. (Hungarian Rescue Museum)

Did It Really Have To Be The Butt?

Occasionally, smoke was blown into the victim's nose or mouth, but as these areas are often waterlogged in drowning victims, it's hardly surprising that the rectal method stayed in use for decades. Otherwise, the revival process could take hours, ending with small amounts of drinking cordials and even bloodletting. It wasn't until 1811, when Ben Brodie figured out that nicotine was toxic, that blowing smoke up someone's ass began to be less a medical practice than an off-color idiom, but it's actually similar in principle to how we treat drowning victims today.
Treating a hypothermia victim (Seattle Backpackers Magazine)

Drowning Today

During the 1700s, while these theories were being developed, a series of unusually cold winters gripped Britain. Indeed, the 18th century sits at the tail end of an era that's been referred to as the Little Ice Age, with the winter of 1779–1780 being the coldest on record in Scotland for the next 200 years. This is important to note because many drowning victims' true cause of death is not suffocation but hypothermia.
Today, we treat cold-water drowning victims in much the same way as the Royal Humane Society all those years ago, though the order is a little different. Drowning victims are still first taken from the water, then checked for breath and heartbeat. Rescue breaths are administered first, and if the victim is still unresponsive, chest compressions are performed. However, once breath and pulse are established (sometimes with the help of intubation), the hypothermic recovery process begins.
As experts instructed in 1774, the victim is undressed and kept warm and dry, but now, it's done with heating pads, warm blankets, and internal measures like heated irrigation of the peritoneal cavity and warmed oxygen via tracheal tube. In other words, blowing hot air into the body hasn't changed, just the gas and orifice of choice. Now, as then, efforts to recover a hypothermic patient can take hours to succeed, but that success can often lead to a full recovery. The key factor is whether the victim experienced hypoxia (a lack of oxygen) first or hypothermia. The former significantly lowers one's chances of a complete return to health, but if it's the latter, you might just feel better with some smoke blown up your ass.

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