which is then introduced into the fundament of the patient. By this means the smoke is injected until the abdomen becomes distended. They then hang the patient by the feet to the branch of a tree and the smoke is thus enabled by its pressure to force the water, which the patient has swallowed, out of his mouth.

In France Réaumur (1683-1757), who, by the way, is not generally recognized as having been a member of the medical profession, was the first to introduce the use of tobacco smoke in this way. He suggested that this could be accomplished by breaking off the stem of a pipe and blowing the smoke through it. It is duly recorded that one of his colleagues in the Academy testified to the proper and satisfactory effect of this remedy. His article was published in 1740. Incidentally it may be mentioned that he recommended rolling the patient to and fro in an open barrel, a device which owed its usefulness to the effect it had in producing artificial contraction and expansion of the thoracic cavity, although the restoration of this function was not evidently recognized as an important feature at that time.

In Holland the literature on this subject seemed to have been more abundant than in other countries, as might naturally be supposed from its geographical character. The reports of the Society of Amsterdam are filled with many accounts of the use of described by Lobelius in 1576. Speaking of its use by the inhabitants of the West Indies he says, ... "For you see many sailors who have returned from that country who carry little funnels made of a coiled palm leaf, or of reeds, into one end of which are placed curled, broken up and dried leaves of this (nicotiana) plant. They set light to it, and drawing it into their mouths as much as they can, they suck in the smoke by inhalation. They are thereby enabled to endure hunger and thirst to maintain the strength and to exhilarate their spirits. They declare that it soothes the brain with a pleasant form of intoxication and it certainly gives rise to an incredible quantity of spittle." The Quarterly Review, July 1913, p. 139, London.

this remedy. Gobius, a distinguished Dutch surgeon (in his book "Adversaria Varii Argumenti"), employed tobacco smoke in this way for constipation, colic, and strangulated hernia. It is stated that he practiced in a country where the insufflation treatment had been used many hundred times. De Haen had used it two hundred times and for more than one hour at a time, the smoke being introduced with much force and in large quantities, both in experiments on animals and a variety of human ailments. Laurence Heister in his "Institutiones Chirurgicae," Amsterdam, 1750, in a chapter on Clysters, refers to the use of fumigation for incarcerated hernia, and gives a diagram of the apparatus by which tobacco smoke can be blown by the mouth of a surgeon into the intestine, the smoke, according to the author, acting as a stimulus in the intestine and causing the strangulated loop not only to shrink in size, but to retract itself into the abdominal cavity. (Fig 2.)

Dr. Ludwig Knapp (1908) in a modern rendering of Cangiamila's work on Theology and Midwifery, 1754, mentions among the remedies this ancient author laid down for the resuscitation of new-born infants apparently dead, the use of clysters of tobacco smoke "to establish the peristaltic action of the intestines and thus arouse through cooperation of the diaphragm the action of the heart and lungs." If these are the words of the author, and not the translator's, we have here the first indication of the recognition of a physiological purpose in the use of this remedy.

Christopher Keil, in his handbook on Surgery, 1747, Leipsic, describes the use of clysters and recommends long flexible tubing for the purpose. In a frontispiece in this work an illustration is given of such an apparatus, by which an individual is able to administer to himself rectal insufflation. (Fig. 3.)

In the latter half of the eighteenth century (1772) we find an organization was

1774, gives Dr. Tissot's method of restoration of the apparently drowned. Here it is stated that in addition to blowing the warm breath into the patient's lungs, tobacco I smoke may be introduced not only into the fundament, but into the lungs as well. After tobacco has been lighted in the bowl of a pipe, the bowl should be wrapped in a paper in which several holes are pricked and through these holes force the breath strongly. It is also recommended by this author that if a surgeon is present the jugular vein should be opened and about twelve ounces of blood taken.

It may be well to give here examples of the methods employed at this period in

two cases.

René H., 25 years old, while bathing, was rescued from the water three-quarters of an hour after being submerged. He was unconscious, without voluntary movements and pulseless, and supposed to be dead. Taken to the Guard House the soldiers treated him by insufflation of air into the mouth, rectal fumigations with tobacco, friction of the skin, and application of ammonia to the nostrils, a treatment which extended over two hours, when signs of life began to appear, the eyelids moving and the pulse being felt, etc., and finally movements of the body and cries. He was then carried to a house nearby where warmth was applied. Here he was bled from the arm, instead of the jugular vein, owing to his resistance. Tobacco fumigation produced abundant evacuation of the bowels and an emetic brought up a large amount of salad and other food. He was made to swallow brandy, which served the purpose of an "anti putrid cordial," and revived him. His comrades next took him to their inn and carried out further ministrations advised by the surgeon who bled him. After receiving two purgings, he reported on the fourth day at the City Hall to express his grateful acknowledgments, stating that he had had no recollection of what had happened to him.

The following case is stated to show that rectal insufflation can be employed, even when the necessary machinery is not at hand.

A rescued woman's husband, who thought his wife dead, was told by a passing soldier smoking his pipe to dry his tears, that his wife would soon be revived. Then giving the pipe to the husband, he instructed him how to introduce the stem into the anus, then placing his mouth, covered with perforated paper, to the bowl of the pipe, to blow with all of his force. At the fifth insufflation of smoke a loud rumbling was heard and the patient expelled water from the mouth and a moment later regained consciousness.

But this method, even at this time, was not without its critics, for M. Portal, Professor of Medicine at the Royal College of France, claimed that the insufflation impeded the circulation of the vessels of the viscera in the abdomen and thorax and thus acted injuriously. Pia, however, refers in reply to this objection to the quotation of Heister, which we have already mentioned above, to the effect that tobacco smoke appears to irritate the intestine and cause a diminution of its caliber.

In London we find John Aiken (1775), using the rectal insufflation of tobacco smoke and preventing the over-heating of the tube by wrapping cloths wet in cold water around it. The use of this remedy was recommended by him as a "stimulant to arouse the vital motions."

Cullen, Edinburgh, 1784, in a letter to Lord Cathcart, says, "with regard to the stimulants, I must conclude with observing that when a body has laid but a short time in the water and that therefore its heat and irritability are but little impaired, the application of stimulants alone has often been found to be effectual for recovery. But, on the contrary, when the body has lain a long time in the water and the heat of it is very much extinguished, the applica

tion of any other stimulants than that of tobacco smoke to the intestines can be of very little service—and the application of others ought never to interfere with the measures of recovering heat and the motion of respiration."

Goodwyn, (1788) refers to the application of different substances to the skin, the stomach, the intestines, the parts of generation, the nose, the fauces, the extremities of the fingers by Jacob Gummer as based on a mistaken opinion of the principal seat of life.

But Kite, 1795, in experiments on animals rendered insensible by submersion, gives as his opinion, under the head of other remedies, that the "principal of these are electricity, particular stimuli adapted to the different organs of sense and irritating medicines thrown into the stomach and intestines." Here, for the first time, we find powerful stimuli like that of electricity used for arousing vital action. But while the surface of the body thus has the benefit of the new agencies, the interior surfaces are not neglected. Our old friend "rectal insufflation" is still employed with a view to local stimulation.

But a definite reaction had already set in, for we find that Edward Coleman, London, in 1791, speaks in no uncertain terms as follows: "As tobacco smoke thrown up the rectum in the form of smoke was one of the first remedies employed in suspended respiration, and as we see, to our regret, that it is still too frequently made use of, we shall endeavor by a few animadversions on its effects to proscribe its continuance. The history of medical errors scarce affords a more blind and obstinate prejudice than that which still induces us to adopt a mode of practice so obviously destructive. For smoke and fluids of all kinds, when given in large quantities, will distend the intestines, the result of which will be that their mechanical effect in preventing the easy descent of the diaphragm will neces

sarily be productive of mischief." In concluding this statement, he speaks next of the sympathy between the heart and the stomach as being greater than between the heart and intestines. Here evidently was a pioneer in modern therapeusis!

In Dr. Willich's Domestic Encyclopedia, London, 1802, is given the list of articles contained in a box devised by Kite and further amplified by Mr. Redlich of Hamburgh, among which is to be found the machine for injecting the smoke of tobacco. Fig. 4. Willich shows clearly in his article that inflation of the lungs is one of the means of restoring life. "Stimulating clysters consisting of warm water and common salt or a strong solution of tartar emetic, or six ounces of brandy should be speedily administered. We do not consider, he says, injection of the smoke of tobacco, or even clysters of that narcotic plant in all instances safe and proper." ↑

The final touch may have been said to have been placed on this mode of practice by Daniel Legare (1805) who, in an inaugural dissertation, on graduating from the University of Pennsylvania, presented as his graduation thesis experiments upon animals with the rectal insufflation of tobacco. After the insufflation the abdomen was opened and the changes in the circulation carefully observed in a series of cases. He found an increase in the mesenteric arterial circulation, but a diminution of the peristaltic action of the intestines. He concluded that this method was of no value as a means of resuscitation.

Although it is often difficult to repress a smile at some of the medical theories of a bygone period, it is well to pause in this instance before passing final judgment and to ask ourselves whether there may not have been after all some well founded observations which served to implant a thera

4 See "History of the Humane Society of the Commonwealth of Massachusetts," by M. A. De Wolfe Howe, p. 18.