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Sources: Disturbances Of The Heart

In spite of the fact that a large number of men today do not smoke,

more and more frequently every clinician has a patient who smokes

too much. The accuracy with which he investigates these cases

depends somewhat on his personal use of tobacco, and therefore his

leniency toward a fellow user. Perhaps the percentage of young boys

who smoke excessively is larger than the percentage of men. Whether

or not the term "excess
ve" should be applied to any particular

amount of tobacco consumed depends entirely on the person. What may

be only a large amount for one person may be an excessive amount for

another, and even one cigar a day may be too much for a person is as

much for him as five or more cigars for another. If one is to judge

by the internal revenue report it will appear that, in spite of the

public school instruction as to the physiologic action of tobacco

and its harm, and in spite of the antitobacco leagues, the

consumption of tobacco is enormously on the increase.

Alexander Lambert [Footnote: Lambert, Alexander: Med. Rec., New

York, Feb. 13, 1915] in studying periodic drinkers and alcoholics,

finds that most patients are suffering from chronic tobacco

poisoning, and if they stop their smoking, their drinking sometimes

ceases automatically.

Howat [Footnote: Howat: Am. Jour. Physiol., February, 1916.] has

shown that nicotin causes serious disturbances of the reflexes of

the skin of frogs.

Edmunds and Smith [Footnote: Edmunds and Smith: Jour. Lab. and Clin.

Med., February, 1916.] of Ann Arbor find that the livers of dogs

have some power of destroying nicotin, but their studies did not

show how tolerance to large doses of nicotin is acquired.

Neuhof [Footnote: Neuhof, Selian: Sino-Auricular Block Due to

Tobacco Poisoning, Arch. Int. Med., May, 1916, p. 659.] describes a

case of sino-auricular heart block due to tobacco poisoning.

Intermittent claudication has been noted from the overuse of

tobacco, as well as cramps in the muscles and of the legs.

A long series of investigations of the action of tobacco on high

school boys and students of colleges seems to show that the age of

graduation of smokers is older than that of nonsmokers, and that

smokers require disciplinary measures more frequently than


Some years ago investigation was made by Torrence, of the Illinois

State Reformatory, in which there were 278 boys between the ages of

10 and 15 years. Ninety-two percent of these boys had the habit of

smoking cigaretes, and 85 percent were classed as cigarete fiends.

The most important action of nicotin is on the circulation. Except

during the stage when the person is becoming used to the tobacco

habit, in which stage the heart is weakened and the vasomotor

pressure lowered by his nausea and prostration, the blood pressure

is almost always raised during the period of smoking.

The heart is frequently made more rapid and the blood pressure is

certainly raised in an ordinary smoker, while even a novice may get

at first an increase, but soon he may become depressed and have a

lowering of the pressure. While a moderate smoker may have an

increase of 10 mm. in blood pressure, an excessive smoker may show

but little change. Perhaps this is because his heart muscle has

become weakened. If the person's blood pressure is high, the heart

may not increase in rapidity during smoking, and if he is nervous

beforehand and is calmed by his tobacco, the pulse will be slowed.

It has been shown that the blood pressure and pulse rate may be

affected in persons sitting in a smoke-filled room, even though they

themselves do not smoke. The length of time the increased pressure

continues depends on the person, and it is this diminishing pressure

that causes many to take another smoke. The heart is slowed by the

action of nicotin on the vagi, as these nerves are stimulated both

centrally and peripherally. An overdose of nicotin will paralyze the

vagi. The heart action then becomes rapid and perhaps irregular. The

heart muscle is first stimulated, and if too large a dose is taken,

or too much in twenty-four hours, the muscle becomes depressed and

perhaps debilitated. The consequence of such action on the heart

muscle, sooner or later, is a dilation of the left ventricle if the

overuse of the tobacco is continued.

There is, then, no possible opportunity for any discussion as to the

action of tobacco on the circulation. Its action is positive,

constantly occurs, and it is always to be considered. The only point

at this issue is as to whether or not such an activity is of

consequence to the individual. The active principle of tobacco is

nicotin, besides which it contains an aromatic camphor-like

substance, cellulose, resins, sugar, etc. Other products developed

during combustion are carbon monoxid gas, a minute amount of prussic

acid and in some varieties a considerable amount of furfurol, a

poison. From any one cigar or cigaret but little nicotin is

absorbed, else the user would be poisoned. It is generally

considered that the best tobacco comes from Cuba, and in the United

States from Virginia. While it has not been definitely shown that

any stronger narcotic drug occurs in cigarets sold in this country,

it still is of great interest to note that a user who becomes

habituated to one particular brand will generally have no other, and

the excessive cigaret-smoker will generally select the strongest

brand of cigarets. The same is almost equally true of cigar smokers.

Besides the effect on the circulation, no one who uses tobacco can

deny that it has a soothing, narcotic effect. If it did not have

this quieting effect on the nervous system, the increased blood

pressure would stimulate the cerebrum. Following a large meal,

especially if alcohol has been taken, the blood vessels of the

abdomen are more or less dilated by the digestion which is in

process. During this period of lassitude it is possible that

tobacco, through its contracting power, by raising the blood

pressure in the cerebrum to the height at which the patient is

accustomed, will stimulate him and cause him to be more able to do

active mental work. On the other hand, if a person is nervously

tired, irritable, or even muscularly weary, a cigar or several

cigarets will increase his blood pressure, take away his circulatory

tire, soothe his irritability, and stop temporarily his muscular

pains or aches and muscle weariness. If the user of the tobacco has

thorough control of his habit, is not working excessively,

physically or mentally, has his normal sleep at night and therefore

does not become weary from insomnia, he may use tobacco with sense

and in the amount and frequency that is more or less harmless as far

as he is concerned. If such a man, however, is sleepless, overworked

or worried, if he has irregular meals or goes without his food, and

has a series of "dinners," or drinks a good deal of alcohol, which

gives him vasomotor relaxation, he finds a constantly growing need

for a frequent smoke, and soon begins to use tobacco excessively. Or

the young boy, stimulated by his associates, smokes cigarets more

and more frequently until he uses them to excess.

Just what creates the intense desire for tobacco to the habitue has

not been quite decided, but probably it is a combination of the

irritation in the throat, especially in inhalers; of the desire for

the rhythmic puffing which is a general cerebral and circulatory

stimulant; for the increased vasomotor tension which many a patient

feels the need of; for the narcotic, sedative, quieting effect on

his brain or nerves; for the alluring comfort of watching the smoke

curl into the air or for the quiet, contented sociability of smoking

with associates. Probably all of these factors enter into the desire

to continue the tobacco habit in those who smoke, so to speak,


The abnormal smokers, or those who use tobacco excessively, have a

more and more intense nervous desire or physical need of the

narcotic or the circulatory stimulant effect of the tobacco, and,

consequently, smoke more and more constantly. They are largely

inhalers, and frequently cigaret fiends.

It is probable that tobacco smoked slowly and deliberately, when the

patient is at rest, and when he is leading a lazy, inactive,

nonhustling life, such as occurs in the warmer climates, is much

less harmful than in our colder climates, where life is more active.

Something at least seems to demonstrate that cigaret smoking is more

harmful in our climate than in the tropics.

It has been shown by athletic records and by physicians'

examinations of boys and young men in gymnasiums that perfect

circulation, perfect respiration and perfect normal growth of the

chest are not compatible with the use of tobacco during the growing

period. It is also known that tobacco, except possibly in minute

quantities, prevents the full athletic power, circulatorily and

muscularly, of men who compete in any branch of athletics that

requires prolonged effort.

The chronic inflammation of the pharynx and subacute or chronic

irritation of the lingual tonsil, causing the tickling, irritating,

dry cough of inhalers of tobacco, is too well known, to need


Many patients who oversmoke lose their appetites, have disturbances

from inhibition of the gastric digestion, and may have an irregular

action of the bowels from overstimulation of the intestines, since

nicotin increases peristalsis. Such patients look sallow, grow thin

and lose weight. These are the kind of patients who smoke while they

are dressing in the morning, on the way to their meals, to and from

their business, and not only before going to bed, but also after

they are in bed. It might be a question as to whether such patients

do not need conservators. The use of tobacco in that way is

absolutely inexcusable, if the patient is not mentally warped.

Cancer of the mouth caused by smoking, blindness from the overuse of

tobacco, muscular trembling, tremors, muscle cramps and profuse

perspiration of the hands and feet are all recognized as being

caused by tobacco poisoning, but such symptoms need not be further

described here.

The reason for which physicians most frequently must stop their

patients from using tobacco, however, is that the heart itself has

become affected by the nicotin action. The heart muscle is never

strengthened by nicotin, but is always weakened by excessive

indulgence in nicotin, the nerves of the heart being probably

disturbed, if not actually injured. The positive symptoms of the

overuse of tobacco on the heart are attacks of palpitation on

exertion lasting perhaps but a short time, sharp, stinging pains in

the region of the heart, less firmness of the apex beat, perhaps

irregularity of the heart, and cold hands and feet. Clammy

perspiration frequently occurs, more especially on the hands. Before

the heart muscle actually weakens, the blood pressure has been

increased more or less constantly, perhaps permanently, until such

time as the left ventricle fails. The left ventricle from tobacco

alone, without any other assignable cause, may become dilated and

the mitral valve become insufficient. Before the heart has been

injured to this extent the patient learns that he cannot lie on his

left side at night without discomfort, that exertion causes

palpitation, and that he frequently has an irregularly acting heart

and an irregular pulse. He may have cramps in his legs, leg-aches

and cold hands and feet from an imperfect systemic circulation. In

this condition if tobacco is entirely stopped, and the patient put

on digitalis and given the usual careful advice as to eating,

drinking, exertion, exercise and rest, such a heart will generally

improve, acquire its normal tone, and the mitral valve become again

sufficient, and to all intents and purposes the patient becomes


On the other hand, a heart under the overuse of tobacco may show no

signs of disability, but its reserve energy is impaired and when a

serious illness occurs, when an operation with the necessary

anesthesia must be endured or when any other sudden strain is put on

this heart, it goes to pieces and fails more readily than a heart

that has not been so damaged.

If a patient does not show such cardiac weakness but has high

tension, the danger of hypertension is increased by his use of

tobacco, and certainly in hypertension tobacco should be prohibited.

The nicotin is doing two things for him that are serious: first, it

is raising his blood pressure, and second, it will sooner or later

weaken his heart, which may be weakened by the high blood pressure

alone. Nevertheless a patient who is a habitual user of tobacco and

has circulatory failure noted more especially about or during

convalescence from a serious illness, particularly pneumonia, may

best be improved by being allowed to smoke at regular intervals and

in the amount that seems sufficient. Such patients sometimes rapidly

improve when their previous circulatory weakness has been a subject

of serious worry. Even such patients who were actually collapsed

have been saved by the use of tobacco.

Whether the tobacco in a given patient shall be withdrawn

absolutely, or only modified in amount, depends entirely on the

individual case. As stated above, no rule can be laid down as to

what is enough and what is too much. Theoretically, two or three

cigars a day is moderate, and anything more than five cigars a day

is excessive; even one cigar a day may be too much.