CONCLUSIONS.

1. Medical and surgical statistics are alike faulty and misleading.

2. A deplorable amount of operative work has been done in purely medical cases.

3. In most instances neither before nor after operative interference has there been a proper scientific use of modern diagnostic or therapeutic procedures.

4. Simple ulcer is always medical. Chronic ulcer is only surgical when persistently recurrent. Cases of moderate stasis and pylorospasm are not primarily surgical. Hemorrhagic cases are seldom fatal and yield a lower mortality under medical than under surgical treatment. Surgical relief is advisable in painful perigastric adhesions which are resistant to medical measures. Perforation is a purely surgical condition.

5. Proper medical treatment and after-control reduces recurrence to a minimum.

6. The absence of this control in public clinics permits and justifies a freer recourse to surgery than would be permissible in private practice.

7. In properly controlled private cases there is but a negligible mortality.

8. The rigid plans of treatment and time divisions are an absurdity and the practitioner should be governed by a knowledge of the fundamental principles involved, the clinical course, known conditions as to gastric secretion, and yet more as to motility, and the individuality of the patient.

9. Absolute rest, mental and physical, the wise employment of alkalies, proper nourishment demanding little of motility and secretion, exciting a potent digestive fluid rather than a profuse one, easily assimilable and nutritious, and proper psycho-therapeutic control comprise all measures usually found necessary.

10. Hospital care and the services of a trained nurse are of great importance.

11. Patients should be kept under direct observation and control for at least one year after apparent cure.

12. Results should be reported after five years.

13. Cure is not complete until all local tenderness, rigidity and pain are relieved, blood absent from the stools and the previous best weight of the patient regained. The requirements on the part

of the surgeon should be quite as definite, and in both the claim to cure should be tested by a long immunity period.-St. Paul Medical Journal, June, 1908.

TOBACCO TOXEMIA.

BY R. V. DOLBEY, M. S. (LOND.), F. R. C. s. (ENG.), VANCOUVER, B. C. Recent anti-tobacco legislation with its special strictures in the case of cigarettes has prompted me to attempt a superficial but more or less scientific investigation of the various forms in which tobacco is used, and to discover in what way these legal discriminations are justified.

In the consideration of the abuse of tobacco it is important that the various methods of using tobacco should be compared in the terms of toxemia or poisoning for which each method is responsible. It is essential that we disregard for the moment the popular prejudices and fallacies which have been so often employed by individuale, of no scientific attainments, toward tobacco in general and cigarettes in particular. The metaphorical "coffin-nail," which one humorist conceived, must not bias us in the consideration of the toxemia derived from a cigarette.

In comparing the relative harmfulness of the various ways in which tobacco is used, the sole index must be the amount of nicotine which can be absorbed from each of the methods in use. There are five common ways in which tobacco can be used: by chewing, by cigar, by cigarette, by pipe, by hookah, and in the form of snuff. It is universally conceded that nicotine is the active and poisonous principle of tobacco, and physiologically it has been demonstrated that, in very dilute solutions, it has an immediately fatal action on low forms of animal life. It has been shown also that nerve endings and ganglion cells in voluntary and involuntary muscle are similarly paralyzed by dilute solutions of nicotine. It is not logical, however, to apply the laws of experimental physiology, in their entirety, to the consideration of the effects on the human organism of tobacco any more than of alcohol.

Nicotine is a complex organic body, made up of atoms and molecules of oxygen, hydrogen, carbon, and nitrogen, and is destroyed by heat. The constituents of nicotine are oxidized by heat into water, carbon dioxide, and nitric oxide. Nicotine is obtainable from tobacco only in aqueous or ethereal extracts of the tobacco

leaf. It follows from this that the safest method of using tobacco is that in which the tobacco is completely burned, and the most dangerous that in which a watery extract of tobacco can reach the mouth.

Let us now consider the various ways of using tobacco, and from our knowledge deduce that form which is most likely to produce the greatest amount of toxemia. In order to bring proof to bear upon these conclusions, a subsequent examination of the various pathologic and functional disorders of the organs of the body which are known to be due to the abuse of tobacco shall be made in this little paper.

The taking of snuff probably arose to satisfy the demand our ancestors felt for a convenient means to counteract the somnolence that over-indulgence in animal food and fermented liquor was apt to induce in the heat of the day. This stimulation of the nasal mucous membrane probably, in many cases, developed into a habit very similar to the continual and excessive use of smelling salts among women. There is also little doubt that fashion stepped in to prolong the use of snuff as an aid to the display of wrist lace that this graceful act engendered.

In chewing, the "quid" of tobacco is rolled into the cheek and the saliva expectorated as it collects in the mouth. In this way quantities of a watery extract of tobacco are swallowed and taken down with the food. In this watery extract is, no doubt, a very poisonous amount of nicotine, and there is ample evidence to show that severe grades of dyspepsia are caused by this habit. That the nicotine or other poisonous principles of the tobacco leaf is altered by the gastric or pancreatic juices is shown by the fact that excessive tobacco chewing does not help to kill intestinal parasites. The prevalence of hook-worm in the Southern States, and the fact that its victims are inveterate tobacco chewers is sufficient proof. The ova of these parasites, as all low forms of animal life, are very swiftly destroyed by dilute solutions of nicotine or tobaccojuice in the laboratory.

Tobacco smoke consists of particles of carbon, various organic and inorganic gases, nitrous oxide, tar and tarry substances, soot and aqueous vapor: in fact, the usual products of the distillation of wood, coal, or other vegetable matter. The nicotine is carried in solution in the aqueous vapor. The well-known experiment of blowing cigarette smoke through a handkerchief to demonstrate

the yellow stain is at first sight very convincing; only when it is known that the yellow stain is due to carbon and tarry products, and not nicotine, is its true value shown.

Thus, when a pipe is smoked the lower and dependent portion of the bowl invariably contains an aqueous solution of nicotine in addition to other irritants, and the more foul is the pipe the more the nicotine. The butt-end of a cigar is always wet and highly charged with nicotine, even though in the burning end the nicotine of the tobacco leaf is being completely oxidized by the heat. In a cigarette, however, not only is the burning end destroying the nicotine of the tobacco leaf, but the butt-end, never wet as in a cigar, contains an aqueous solution of nicotine only in the last damp inch, which is usually discarded.

The cheaper the tobacco and the moister the leaf or the cigar, the greater the proportion of nicotine: the more expensive tobacco and dry cigars contain comparatively little.

The Eastern hookah, in which the smoke is cooled and filtered through a bowl of rose water, is a very harmless method of smoking tobacco.

On the mouth and pharynx the chief effects are seen in a stimulation of the flow of saliva, irritation of the lips, gums, and teeth, a chronic granular pharyngitis, catarrh of the naso-pharynx, and last, but most important, epithelial changes of all grades from superficial glossitis to epithelioma. Cigarettes, without doubt, are responsible for much of the irritation of the lips, by reason of the paper, and for the granular pharyngitis, when the smoke is inhaled. Contrary, however, to popular belief, the irritation of the lips which leads to carcinoma is not so much due to cigarette tobacco or paper as to the roughness of a faulty pipe stem or a cigar. Epithelioma of the lips is also very largely predisposed to by exposure to the weather and to sunshine in exactly the same way as rodent ulcer and sweat gland carcinoma of the face. Cigarettes, if smoked properly, should be smoked with a dry tip, the paper never being moistened: what is more, the tobacco should be shaken down and the edges of the paper so inverted that the tobacco never comes into contact with the lips at all. Quite otherwise is the case with pipes or cigars. The mouthpiece of a pipe is never free from a watery solution of nicotine, and a cigar, unless smoked in a holder, is always wet at the butt-end; not infrequently the butt-end of a cigar is chewed as well as smoked, a most pernicious combination.

Chronic superficial glossitis and epithelioma of the tongue, gums, and cheek is seen probably quite as often in non-smokers as in smokers: when it is seen in smokers it is almost invariably in pipe smokers, and in those pipe smokers who are addicted to a short clay, with a jagged broken mouthpiece. This form of pipe is frequently kept in the mouth while manual work is being performed and, rubbing against the side of the tongue continually, gives rise to chronic irritation. So marked is this in some laborers that one tooth will be found quite worn away for the reception and maintenance of the pipe stem.

The respiratory system is affected chiefly by the inhalation of tobacco smoke, as is seen in cigarette smokers, and a chronic form of laryngitis, tracheitis, or bronchitis supervenes. Apart from a morning cough in healthy people, little harm seems to be done. Individuals with pulmonary diseases, except in the acute stages, are more tolerant of tobacco than would be expected. In pulmonary tuberculosis even the inhalation of cigarette smoke seems to increase the cough extremely little, while, unless there is this evident irritation, this form of smoking is one of the cherished aids in treatment, for it produces, above all things, that tranquillity and peace of mind which is so essential to the absolute rest which must be maintained. It would be a hard matter indeed to keep an irritable, energetic man in the attitude of complete repose for a protracted period, did he not have tobacco to fall back upon. Among those predisposed to asthma, while there are a few in whom the inhalation of cigarette smoke will produce an attack, there are yet more in whom the inhalation of a Turkish or Virginia cigarette produces a complete relief of the spasm. This does not refer in any way to the wonderful relief secured by asthma cigarettes, in which the active principle is tea, nitre, stramonium, or lobelia leaves.

On the digestive system the effect of tobacco is shown in an acid dyspepsia with hyperchlorhydria: this is most marked in tobacco chewers, and correspondingly less in cigar, pipe, or cigarette smokers. This tobacco poisoning produces finally a fibroid condition of the mucosa and gastric blood vessels similar to the effect of alcohol.

The circulatory system supplies a very popular source for the condemnation of tobacco. The effect on the heart and vessels is twofold. There are, first, the evidences of irritation from the