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( Originally Published 1923 )

WHEN a man is an inveterate smoker, his passion for tobacco may obtain sometimes such a hold upon him that it would seem nearly impossible for him to deliver himself from its nefarious influence. This accounts for the fact that when, several centuries ago, the smoking habit was prohibited with heavy punishment and fines, it was found impossible to put a stop to its propagation.

Neither the most severe castigations of the church, nor the legal punishment of years of prison and bodily chastisement, nor even the penalty of death that was inflicted upon smokers in the first years after the introduction of tobacco from America to Europe, were able to deter the ancestors of present-day smokers. They persisted in the habit, and if unable to smoke in public, continued to do so secretly.

It would appear that, at least in the central parts of Europe, the martyr smokers of the sixteenth century have worthy successors, for on a winter journey to Italy and France last year I saw on the way through Austria and Germany a number of people standing for an hour or more in the cold wind and rain in front of the tobacco shops merely in order to obtain a few cigarettes or a handful of tobacco, sometimes consisting simply of beech leaves.

I fear that in the face of such an overpowering habit my admonitions will not be of great avail, and am far from hopeful of complete success, but I would be glad even of the partial success if this lenten sermon were to induce inveterate smokers to a certain degree of moderation, especially in the use of strong tobacco.

It would certainly be going too far to pretend that smoking is harmful to every one, for I know personally of instances of old men in the seventies and even in the eighties, who had been smoking several rather heavy cigars each day for years, and were nevertheless in good health. I have known of the case of a gentleman one hundred years old who was a heavy smoker.

But while smoking even to a rather pronounced degree causes no apparent harm in many persons, there are, on the other hand, not a few persons who suffer injury to their health even from the smoking of small amounts of even light tobacco and whose lives may be considerably shortened by daily smoking. Too often this is, unfortunately, recognized only at a late period, when the symptoms of a dangerous disease, the occurrence and development of which may be very closely related to smoking, viz., arteriosclerosis, are already plainly present.

Tobacco exerts a very harmful influence upon the condition of the blood-vessels, both in animals according to a series of investigations in them and in man. Perhaps even more than alcohol, it is, next to syphilis, the most frequent cause of arteriosclerosis. The most serious type of this condition, that which involves hardening of the coronary arteries supplying blood to the heart muscle, and which results so exceedingly often in sudden, premature death, is commonest among heavy smokers, particularly if syphilis has previously been present.

In this connection I would like to mention the fact that there are people who, when asked, will admit that ten or twenty years before they had an insignificant lesion, small scratch, or erosion on their organ, but that as nothing further happened they paid no attention to it. Naturally such persons are dumfounded upon learning from the result of the Wassermann blood test that the insignificant sore they had had so many years before meant that they had acquired syphilis.

It is a strange and tragic fact that as a rule it is precisely these light cases, in which syphilis in its earlier stages has led to no manifestations what-ever, that are in many instances the ones most to be feared, for they seem to be predestined to develop the most fatal consequences of syphilis, viz., the serious degenerative changes in the blood-vessels and such terrible diseases of the nervous system and brain as locomotor ataxia and general paralysis of the insane.

Not only the blood-vessels, but even the heart itself, may be harmed by heavy smoking continued for many years, especially if strong tobacco has been used.

Manifestly, there is no sense in delaying a warning to these people against the use of tobacco until it is already too late and they can no longer be saved. Why postpone examination of the heart and blood-vessels until they are suffering from the most characteristic symptoms of advanced arteriosclerosis, together with those ominous attacks of cardiac oppression or angina pectoris? There can be no doubt but that these attacks of angina pectoris these most dreaded manifestations of arteriosclerosis very often appear as the heralds of approaching death. In this I refer, of course, to the attacks of true angina pectoris and not the attacks of pseudo angina which nervous persons sometimes complain of.

Now, what I would suggest to prevent the insidious development of these deplorable cases is that every man before he begins to smoke should be examined by a physician to ascertain whether he is fit to smoke and whether there is anything in the condition of his heart or blood-vessels which would contraindicate his doing so. All persons descendant from families in which disease of the blood-vessels has frequently appeared should be considered unfit. Such persons should likewise be considered unfit for smoking in whom there are found, in addition, irregularities of heart-action, which not infrequently appear rather early in life in the descendants of such families, e.g., irregular pulse, intermittences, a very low or very high pulse rate, etc. Persons thus predisposed to arteriosclerosis can often be recognized from their external appearance.

Especial caution as regards smoking is necessary where there is a history of syphilitic infection, for the germs of syphilis, the spirochetes, establish them-selves by preference in the blood-vessels and there exert their devastating influence. If with this are combined smoking and also the consumption of large amounts of spirituous liquor, arteriosclerosis may often set in quite early in life; at least, such individuals are certain candidates for this disease.

Where active mental labor is performed in con-junction with immoderate smoking, there is a marked tendency, according to my observations, to the production of arteriosclerosis of the brain. With this comes the danger of apoplectic attacks, especially if the mode of life is imprudent in other respects, if inveterate constipation exists, etc. Thus, as I have had occasion to observe, the sleeplessness, dizziness, headache, and failure of memory complained of by heavy smokers engaged in hard mental labor are exceedingly often related to a beginning arteriosclerosis of the brain, of which they constitute the initial symptoms. This influence of immoderate smoking in conjunction with hard mental labor upon the state of the circulation in the brain vessels may be held to account for the fact that, as I was able personally to ascertain, many instances of previous heavy smoking are to be found among patients suffering from progressive paralysis. Aside from alcohol, immoderate smoking thus plays a very important rôle in this terrible sequel of syphilis, which generally brings life to a fearsome ending within a few years.

Thus the habit of smoking, if followed to excess for years, strong cigars and innumerable cigarettes being used up to the very end, smoking indulged in on an empty stomach before breakfast, or short pipes employed all conditions which distinctly enhance the dangers of heavy smoking is capable in some persons of promoting the development of mental disorders.

Nevertheless it cannot be denied that smoking under certain conditions exerts a quieting, soothing effect on the nervous system, especially during excitement, and thus greatly facilitates mental work, so that, e.g., many office workers, if deprived of cigars or cigarettes, are not able to carry on their labors as easily. In spite of this fact, it is advisable to exercise great caution before declaring a neurasthenic qualified to smoke, especially among the descendants of families in which nervous or mental disturbances are the rule.

Particularly unfit to smoke are the children, upon whose delicate organism tobacco exerts an especially harmful effect, even greatly impeding bodily growth and development. This applies no less to their mental than to their physical development. In this connection the observations of the Dutch clinician, Professor Pel,2 are highly instructive. There should be a general legal prohibition against the selling or giving of tobacco to children.

The habit of smoking acts even more injuriously upon the delicate organisms of young girls than it does on boys, and yet, unfortunately, one may now observe this harmful habit gaining ground, doubtless as one of the numerous unpleasant results of the late war. Smoking by women and even young girls must be considered from a far different standpoint than smoking by men, for not only is the female organism by virtue of its much more frail structure and its more delicate tissues much less able to resist the poisonous action of tobacco than that of man, and thus, like many a delicate flower, apt to fade and wither more quickly in consequence, but the fecundity of woman is greatly impaired by it, as tobacco exerts a very pernicious influence on the various ductless glands, including the thyroid gland and the sex glands. In view of the large number of men lost in the late fearful war, the authorities cannot be expected to look on unmoved while a generation of sterile women, rendered incapable of fulfilling their sublime function of motherhood, is being produced on account of the immoderate smoking of foolish young girls.

If, in addition, such girls and women who are smokers remain for long periods, e.g., entire afternoons, as is now often the case, in restaurants filled with tobacco smoke, the injury to health induced by the smoking per se may be further increased.

Air laden with tobacco smoke in confined spaces is capable of exerting a very harmful effect on human beings if they breathe it for any length of time. Such an atmosphere, indeed, contains not inconsiderable amounts of carbon monoxide and may therefore have a definitely harmful action.

This applies not only to man, but also to animals. Thus, the Dutch investigator, Fokker,3 found that if animals are kept in such an atmosphere for merely one hour, demonstrable amounts of carbon monoxide may be found in their blood. This is doubt-less in some degree related to the rather frequent cases in which persons who have been sitting for a long time gambling in crowded coffee-houses, thickly filled with smoke and overheated in addition, suddenly collapse and die. The marked excitement occasioned by the game itself, acting upon a heart originally much weakened, doubtless also plays an important rôle in such instances.

Among professional gamblers such sudden deaths are not uncommon, for in this deplorable and irregular occupation frequent and violent mental emotions are unavoidable. These, in turn, exert a most unfavorable influence upon the heart muscle and the circulation in general. At the same time, staying for long periods in rooms full of smoke, overheated, and often lacking the necessary amount of oxygen may likewise contribute toward a fatal issue.

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