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.