training were urged to smoke, and largely to use cigarettes, by every means known, namely, by association, by example, by Red Cross gifts, by other free gifts, and by charitable funds of all kinds. The soldiers were then trained intensively and were subjected, in France, many times to severe hardship, both mental and physical. Physically, excessive use of tobacco could only unfit them, and mentally, it might modify nervous strain; but the action of tobacco on the heart muscle could be nothing but a disadvantage, and in some soldiers, who had irritable hearts and hearts that became rapid on the least exertion, the disability could be traced to tobacco. Also, in the French and English hospitals where soldiers were recovering from serious wounds, they were urged by all visitors, if not actually by those who were caring for them, to smoke cigarettes, and not a few surgeons objected to this on the ground that oversmoking would interfere with their recovery.

Action. When tobacco is smoked by one who is not used to it, it causes more or less nausea and depression, and lowering of the blood-pressure. If enough has been taken, there may be depression, cold perspiration, faintness, vomiting, and even collapse. If the use of tobacco is persisted in, a tolerance develops, and these unpleasant symptoms do not occur.

Acute nicotine poisoning can cause death, and the treatment of such poisoning is dry heat, and strychnine, atropine and caffeine hypodermatically. Probably nicotine causes depression of the suprarenals, consequently injections of suprarenal are indicated.

Chronic Poisoning.-One who is used to the action of tobacco has his blood-pressure raised during smoking, and the increased pressure continues for a longer or shorter time, depending on the individual and the condition of his arteries and heart. He is, also, mentally quieted, if he is nervous, by the narcotic effect of the tobacco. His brain may act better temporarily, and he may think better by the increased pressure causing more blood to go to the brain, provided that he has long used tobacco and is not smoking to excess. How much tobacco is excessive depends entirely on the individual. One cigar, or three or four cigarettes, may be too much for one person, while five or six

cigars, or twenty to thirty cigarettes, a day may be tolerated by another.

The most frequent symptoms of over-action of tobacco are throat catarrh, laryngeal inflammation, and lingual tonsil congestion, with, often, a dry, tickling cough, and more or less mucous or mucopurulent secretion causing expectoration. The next most frequent symptoms of its over-action are hyperchlorhydria and slight gastric disturbances with more or less indigestion. Other symptoms are increased rapidity of the heart, occurring with the least exertion, or even slight palpitation at any time; sharp, momentary cardiac pains; a tendency to perspire freely, especially the hands; and sometimes cold hands and feet. There may be muscle and joint pains, and headache is not infrequent. There may be contracted pupils, and some disturbance of vision at times. Still greater poisoning is shown by a lowered blood-pressure and a weakening of the cardiac muscle. Sometimes with excessive smoking, especially if associated, as it sometimes is, with too much drinking of coffee, the nervous system is irritated, and the patient is sleepless and irritable. Besides the action of tobacco on the blood-pressure, which is more or less constant, tobacco increases peristalsis, and those who suddenly stop the use of it are generally constipated. Tobacco is excreted by the kidneys, saliva, and perspiration, and one who is constantly smoking actually reeks of tobacco.

One's circulation may be affected by tobacco if he simply sits in a room where there is tobacco smoke. Therefore an individual smoking in a room with others smoking, or in a smoking car, or breathing smoke or tobacco emanations in a room where he is working, gets a great deal more tobacco than he believes he is taking. For this reason more tobacco can be tolerated in the open air than indoors. Individuals with high blood-pressure increase this pressure by their tobacco, unless the heart has begun to fail. Consequently, in treating hypertension, besides stopping tea, coffee, and too much meat, and regulating the patient's life, tobacco should generally be entirely withheld.

The smoking of a single cigarette by an habitual smoker will

raise the pulse rate and increase the blood-pressure, but one who is used to much smoking cannot as well sustain exertion as one who is not saturated with tobacco, even if his blood-pressure is normal and his heart apparently normal. He becomes breathless on exertion as compared with the man who is not saturated with tobacco. Especially dangerous, often, is tobacco when a patient has had anginal attacks, due to coronary disease.

To repeat, the most serious disturbance caused by the overuse of tobacco is on the heart, and while smoking may temporarily slow the pulse, if fast, soon, with a weak heart, the rapidity is increased, and very soon the rapid heart action is frequent, and although while smoking the blood-pressure may be increased, with excessive use it is soon diminished. The heart may be irregular or intermittent, and there may be actual dilatation of the heart and an insufficiency of the mitral valve, entirely due to the over-use and over-action of tobacco. Tobacco heart is a recognized condition which can generally be cured by withholding tobacco.

Whether the adverse action of tobacco on the heart rhythm is due to vagus disturbance or due to disturbance of the coronary circulation, or whether due to both, has not been determined, probably both actions occur. It has not been shown that sclerosis of the coronary arteries is due to tobacco, but certainly disturbed circulation in the coronary arteries is suggested when anginal attacks occurring after the excessive use of tobacco entirely disappear after the tobacco is withheld. Also it would be hard to prove that actual degeneration of the heart muscle is due to tobacco, there being so many other associated disturbances occurring in the patient that could be causes of that condition. However, dilatation of the heart from tobacco does

occur.

Whenever it is decided that a patient is using too much tobacco, it should generally be immediately stopped. If the patient is nervous, he should receive a few doses of a bromide. If he craves something in his mouth, he may use chewing gum, or dissolve a 150 grain quinine tablet in his mouth as often as he feels the desire to smoke. Digitalis is often indicated

when the heart muscle shows weakness, and if it is dilated. When a large user of tobacco has a serious illness, and an irregular action of the heart and almost heart failure develops, he should be urged to smoke half a cigarette at a time, three or four times in twenty-four hours. Sometimes a heart so disturbed will be steadied by such treatment better than by any other medication. During the prostration of acute illness is no time to stop a drug habit, and tobacco is a drug and is frequently indicated in serious illness and especially in the convalescence of constant users of tobacco.

If an individual must smoke, the time to smoke is after meals and not before meals, and certainly not before breakfast.

PART X

INDUSTRIAL POISONING

Preventive medicine is perhaps the most important study of the age. Sanitation, care of epidemics, isolation of infections, and the prevention of poisoning and of injuries are subdivisions of this great work. In this section it is aimed to describe the treatment of the chronic poisonings that occur among the artizans of some of the industries.

The most frequent of these poisonings occur from lead, but not infrequently poisoning occurs from phosphorus, zinc, mercury, arsenic, hydrofluoric acid, uranium, manganese, and from aniline in the manufacture and handling of dye stuffs.

Mercury poisoning can occur in workman who make thermometers, and it occurs occasionally in the felt hat industry. The principal symptoms are tremors, ulcerations, salivation and digestive disturbances.

Arsenic poisoning is not now very frequent, but may occur from the fumes in some steel industries.

Hydrofluoric acid poisoning occurs among glass workers, and the symptoms are ulcerations of the skin and mucous membranes.

Uranium poisoning occurs from the dust of uranium oxide, which when swallowed into the stomach is dissolved and absorbed. After absorption uranium is a poison to the kidneys, causing nephritis. Uranium salts are poisonous, and there is absolutely no excuse for uranium as a drug, and the uranium nitrate of the Pharmacopoeia should be dropped from the next revision.

Manganese poisoning may occur among those who work in manganese dioxide. The symptoms of such poisoning are lassitude, drowsiness, muscle twitchings or cramps, and more or less mental and spinal depression. The condition is serious, and such poisoning must be prevented.