Tobacco
Categories: UncategorizedSources: 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
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
nonsmokers.
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,
normally.
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
description.
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
well.
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.
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