Tobacco Documents Online

© ., ~ 0 YI FEE ~ .. ~ ~ ~~~~` ~ lS4, .~ f2^'' f Reprinted from The Mrlstary SusgPon, Vol 89 No 1, July, 19411 1 t '{ THE CIGARETTE, THE SOLDIER, AND THE PHYSICIAN FUNDAIWIENTAL FA CTORS OFTHE PROBLEM A 7: ? 4=' Blr MAJOR C. WARD CRAMPTON, Med, Res ~ U'S Army, New `York Cicy '~ HE NATION is preparing for ;#f .,A LARGE SCALE PROBLEM ~~'~ , e~'~defense A _million men `are un " The heightened~ tension of camp life f `Y . ..- ... .r:. ._.. ._. , ; der arms and a milllon or more` ~ ~ ' and war consciousness ``certainly in= ~ '~may,follow 1The heaIth and fitness of- >~ creases the urge for tobacco:,During ~~ these men is of the utmost importanae.t~ the World War years,'>i9t6 to ~ ~ Tobacco has alwa s been la l °+ y a rge e e cigarette consumption in the U'.S more" ~~~ ent in the corrlfort `and happiness of, han doubled-risin from 2 bilhon the m soldier. But questions may arise as to, 53 billion annual g l . ~ to'the effects of tobacco on the soldier's y ~ In this period men in uniform h l ffi h a d i 1 w ea t n e c enry These qhestions . ~~ smoked 70 er cent more tobacc thari' p o ~- ~ must be met. They are primarily of a, ~ *{a~ at- ~~vilian life, while civilian consump medical nature. The d m d th , e an e y %tion increased, only 20 per cent?_ i y tention of the.physician. ' Wartime or anizations al n b ht V g o e oug 4 The situation in tobacco smoking is 4 billion cigarettes a year. Estimated {4 4 full f nfli t b t f t n th n o co c ween e ac s o e o e purchases b national or ani ti y g za ons '_hand, and their interpretation on the 'during a six-month wartime period in other-between laboratory experiments a, 19 i g were as follows: Arirr~-62 i mil- fand their application to human affairs r lion. Navy-i 25 million. Red Crosi, ,:' liti b t e d we n rea ~y- = e es an escape from 'and Y.M.C.A.-i billfion 120 millaon. ~,~_ ~ ~' ~. I ' '_ li e b ind l '' d . ; r , a ty etween u gence an conse H ~~ Total-i billiony 866 million.3 These y Y~e ; ~. quences organizations recognized the soldier's 4 ~; It is the purpose of this paper to ~` need ~ ~: ,review the matter briefly-to outline ,. Since the first Wor1dJ War, elvihari'~ ~~ the topography of this much disputed ; consumption of cigarettes has increased. ,~ erritor -to oint out som ll itf ~~ ~ t y p e p a s- Bastedos reports that in the year t93o` r and erha s to clarif some reliable o- ~ p p y <s_ 123 billion cigarettes were manufa ~ "' 4, la.ndmarks, in the hope that our course ; tured, i,e.;` soo a year for every Amer- z`~~ ~ - " ma be scientific reasonable and hu- Y ~ can man, woman and child over i¢ ~ ~~ man wise. _ The dis, ssion will be years of age ~~ ~ divided as follows: l( i) The, soldier's r From 1930: to ~>i 94o the American; ~ -TcI ~ _ 'viewpointy 2 the research field, (3) annual consumption rose 6o billion the heart and, circulation, (4) the ` more.* This is impressive. We are now : soldier's heart, (5) the respiratory , in a war-conseious period with a basic ~ tract, (6) summary and recommenda- rate of cigarette consumption eight tions. times that of 1916. Press reports a1- K f I?S' .ie v7~t~' ' Y n -\ ~:.

~ The Alilitary Surgeon-July, 1941 ready indicate an increased urge for baeco, They have been subjected to ari tobacco among military men in the cur- enormous amount of technical'research. rent war. : Diff'erent kinds of tobacco have been Already the war influences are seen ; found to vary in constitution, depend- in America's use of tobacco. ' Late fig- ing on aging, curing, etc. But unless ures show a 12 per cent gain in c}ga- tobacco is chewed or snuffed, none of rette consumption for the 4 months its constituents make the slightest dif- ending April, 1941, over' the same ference whatsoever to the smoker, or to period last year. the physiciany unless they make a dif Just recently a shrewd Dutch ref ference in the smoke itself. ugee tobacco merchant quietly reported (2) Smoke: The chemical composi- to the British Intelligence, Service the tion of tobacco smoke differs from the increase in the withdrawal of tobacco `~chemical composition r of the tobacco stored in Holland. The amount of this Jrom which it rises: It varies as deliv- r i increase gave an indicatiori to the Bnt, ered to the smokethrough the ciga= ihhbf .s of te numer o Gserman soldiers e rette or pipe, water ' pipe, cigarette Idiers Y 1I~ m the Netherlands. holder, or filter It varies as to its =. If the nicotine of cigarette smoke is '_ source-from the endy middle, :or harmful, and it is-if soldiers amoke butt' of the cigarette. Other factors are '~ more than civilians, and they do-the ` the speed of combustiony temperature ` ' physician's duty in the situation is clear : of combustion, packing, moisture con' ~ L The search for truth about tobacco ' tent, chemical constituents of cigarette begins in the laboratory of pure chem- paper. istry and physics. It coritinues in the Not all smoke constituents are ab- sorbed~ by the body. Hence, the ele- mentary components of tobacco are :,modified at least twice before they af- fect' the srnoker,,and all data on tobacco and smoke must be valued~ and~ applied to man accordingIy. (3) Experiment on animals: This covers a wide range. Each constituent element of tobacco and of smoke can ; be tested singly and in combination on ., ~ various animals. However, such re --ry divided into four areas L for considera ° search is one stage removed from ap- ~ ti ()b ()khlii h welfhih i : on,i toacco,2 sfrnoe, (3) te pcaton toumanare wcs . ` ' effects on animals, (4) the effects on ` our only concern It must be so re- man. Each willi be reviewed briefly. garded. ~' Man differs widely in many respects RESEARCH ix TosACCO _ `'from laboratory animals, and againy (i) Tobacco: There are many di- laboratory animals differ among themr. verse chemical constituents of to- selves. One observer18 reports that laboratory of experimental biology, and expands into several fields of physio= logical research and clinical experi- mentation. It' includes large areas of semi,statistical observation. Tobacco research may then become dissipated in glowing atmospheric clouds of pure speculation. The voluminous literature - runs the gamut from pure science to pure phantasy,, sometimes well mixed. The scientific field may,,~with profit, be

A 1 1 711__1_1T.- :.~;e.:V M The Cigaretse, the Soldier~;'an~~ the Physiciara 3 . most of his experimental rabbits showed immediate 'and remote effects ; ~ 3) signs of irritation and distress on being health versus disease or . disturbed subjected to smoke from a mechanical physiological state of subject (often un P, f~$,_st3~; .' 6> t = smoking apparatus, but some were in- ` controllable or indefinable); (4) sin ,._. ~ different• One of them, however, ° gle versus repeated toxic impacts, i:e sought out the source of the smoke, habituation versus cumulative effect. applying his nose to the aperture and -These are considerations which pre stayed there with every sign of enjoy sent an almost infinite series of permu ment and comfort• "He loved it" ~. . tations and combinations. Skill, expen Human beings are like that, too: In ence, and scientific attitude are essen Bogen's3 excellent research he reports tial, and all these matters must be kept on the "Pains and Pleasures" of Smok mn mind in evaluating all research, opin a ~ ~* ~'= t, irig• Here are tlie smoker's own ratings Ion, and teaching concerning tobacco in Wl of the leasures of smokin sociabilit an form. ~' p g Y i Y 6$ per cent, fragrance 6o per cent, re ~ On this basis some of the more pert 37 ... . , .,:.. .r , ,. laxation 50 per cent, stlmulatlon 5o nent and interesting data in the fiel~ ~ be considered. There _ are four a•~~x+ per cent, steadying nerves 45Per cent ~"may ~ smoothness, mellowness -soothing 35 - principal' physiological reactions to ` r er cent uietin hun er o er cent ei arette smoke: i circulato rss- ~~~ : P r~l g g 3 P ~, , sight of the smoke 25 per cent, feel temy (2) nervous sy tern; (3) respira '„£~~~; in the lips 25 per cent, feel in the hand tory system; (4) mental, emotional, ~ i'o per cent, taste 5 per cent. " ., and other psychological considerations. ~~ ; - These subjects smoked in spite of the fact that they recognized the fol THE CIRCULATORY SYSTEM ~ lowing ill effects: shortness of breath There is an amazing variety of sci . +w+7r,; r r~. 35 per cent, biting and irritation 30 per •" entific data and statement and other cent hin 30 per cent, burning iS ublished statements in this field. We cou ~ g g 3... P per cent, nausea io per cent, palpitation `can~ find the way through this maze :Z, of heart 5 per cent, hoarseness 5 per only by keeping in view the landmarks cent, salivation 5 per cent• and the different categories of observa "' (4) Exyeriment,on Human Beings • tion we have suggested• Smoking has ~A~~ This has the advantage of presenting immediate effects upon the physiologi data directly applicable to man• How- cal action of the circulation, the heart ever, human experimentation may in- beat the blood pressure the vaso tone clude subjective opinion as a datum of tf of arteries, veins, and ~perhaps most record, and results must be strictly ` important, the capillaries• Not all of evaluated accordingly in this field high these fractional functions which go to ~. ~1,- in variability, and low in reliability. make the total circulation are a$ected (Hominum sententia fallax•) in the same way and direction,`nor are In~ human experimentation there are `" they invariably affected at the same several contrasting pairs of categories time• Different parts of the same in which might well be evaluated: ( t) dividual differ on sensitivity as in subjective versus objective data; (2) dividuals differ from each other. In

addition, each individual may change his state and condition from day to day and his reactions will vary accord- ingly. NtRVOUS SYSTEM Nicotine primarily and~ energetically affects the autonomic nervous system. It also affects both the brain and the cord. By increasing spinal reflexes nicotine removes certain inhibitions ; -Dunlap and Carver28 showed that smoking, through its nicotine action, ' effect upon men with high blood pres- Iowered the accuracy ' of finely co-, sure. ordinated reactions and association- thought processes. However, the speed of complicated reactions was without ` change : = a Smoking did not seem to have any obvious effect on the output of routine muscular work amongst glass blowers. Palman,'e however, found that ciga- than the normal cases) and r¢ mm. rette smoking at first increased muscu- more than non-smoking hypertensives. ; lar energy, but that fatigue set in',_Therefore,'hypertensives differ among earlier, and the total work was less. -- themselves in tobacco response in~ ac- Increased nicotine action due to ex- i cord with~ their tobacco habituation. cessive smoking may result in irrita- This is true in life as well as in the - bility, restlessness, impaired memory, laboratory. It' introduces a complex mental depression, insomnia, headache, series of factors in the coqsideration and tremor. However, Dixone states of toleration, habituation, accumulation - that ordinary smoking in normal peo- of tobacco effects. It also has an impor- ple -does not lead to nervous disturb- tant relation to the total effect of smok- ances. ing, on the soldier while in service, and~ upon his return to civil life ' Hines22 continued his analysis, dis- cussing, a further difference in men as to their tobacco 'response. The "nor- mal" group was divided into two sub- groups, ( r) Those who re-acted to the Haines Test, and (2) those who did not. In this test the subject puts his hand or wrist into cold water. If the THE HUMAN FAC'TOR . I repeat that men differ in their re- sponse to tobacco. This is of the essence, and it must be foremost in mind when conducting research, interpreting data, and especially when endeavoring to give counsel to individuals. Recognition of this human factor is essential in or- ilitary Surgeon-July, 1941 der to deal wisely with troops, canton- ments, armies, and the indulgent pub- lic. In a three dimensional research at the Mayo Clinic22 men with high blood pressure were contrasted with normal persons after smoking a cigarette. The normal group showed an average in- crease of 2I.r/i3 mm. The blood pres- sure cases, however, rose on the aver- age 3i.t/I8 mm., about 5o per cent more. Therefore, tobacco has a greater HIGH BLOOD PRESSURE ,.: The men with high blood pressure differ among themselves in tobacco re- action. Those who were already . smokers had a greater increase, i.e., ° '40.9/23 mm. (a rise ioo% greater

r~~. . .. . ... , Hines found that those who were mild, moderate, or severe reactions18 1' "= : reactors and potential hypertensives Just as some people are allergic to `varl were also reactors to tobacco. Their in- ~eties of fruits or berries, so some people Y e crease was 29.6/i'7.¢ mm~ compared are "allergic" to cigarette smoke. There ,. The Cigarette, the Soldier,. and the Physician t 5 blood pressure then rises materially, need for consideration of individual .he is a reactor. This means that he variation of tobacco response. It refers will, almost without fail, develop a tot blood pressure alone. There are high blood pressure. This test is many striking differences. Some per '_ prophetlc ~ #' sons are ~~allergic" to tobacco;'and give ` =with the normal non-reactors i'7.2/'7 6- is a small percentage of people who can- ~ `'-found from kymographic recordings obliterans from smoking while others . - ofblood pressure that small increments " do not. of nicotine injected intraperitoneally ~ The response of the soldier to the resulted, in profound changes in the cigarette will be various, and our 'ad- blood pressure. Small increases of only vice to him must be based upon this " the diastolic.) Men differ greatly in to- -age of smokers who can over-indulge bacco response `as to their degree of without any appreciable ill effects IB It inherent potentiali hypertenslon. is a notable and significant fact that Haag; 3 in experiments on rats, ` some persons develop thrombo angiitis mrn~ (Note the disproportionate rise of not smoke at all, and a large percent ; 25 per cent were enougn to nring atiout tact. these changes. There is still another evidence of ' how human subjects vary in this type of research. It is stated that in each one of these groups, for which~ an` average sensitiveness is reported, there is a great variation among individuals. For example, the highest tobacco re- action group was the hypertensive smokers. Their increase on the average was 40.9 mm. but in this group some showed a far greater blood pressure rise, while others registered a much ., lower blood pressure rise. The differ- ences among them were in some cases greater than the differences in the aver- ages of groups. Againy individuals dif- fer. 01 ALLERGIES ' The foregoing research report is se- lected to illustrate the fundamental DRAMATIC VARIATIONS AMONG INDIVIDUALS . ~ _. Such variations may strikingly and completely overshadow the selected and experimental variable, and seem to confuse, distort, and invalidate re-" ' search results. Heeded, however, they will give the scientist invaluable aid. A single striking episode incidentali to the author's experimental work in . orthostatic hypertensionFl , "wiIl illus .~ , _,;: trate the point as follows: A "neurasthenic patient" in a sanitarium was studied as to his blood pressure, and pulse rates daily at I i A.M. for io days ` for standardization. On the `i'rth~day, after the usual records were taken, he was given a cigarette to smoke. His systolic blood pressure (standing posi- tion) promptly fell from II4i to 7o, a C7 =K~r , .? 9!p 0 0

7; f ~ 6 ~ ~T he Military Surgeon-July, 1941 drop of 44 mm., and continued down- physiologically harmful. This is also ward past observation~ as the patierlt said of cigarette smoke, nicotine being got progressively faint, dizzy, and the only constituent present with meas- nauseated. urable physiologicali effects other than The incident covered a io-minute local irritation (Bastedo). Nicotine is period. The next day told an entirely a true physiologic irritant. l Y :t different story. The same patient was Nicotine is an alkaloid with a most' given another cigarette (of the same remarkable affinity for the autonomic kind). In 2/ minutes, the blood pres- ganglia, which it first stimulates then sure instead of falling had risen from depresses. It is the most characteristic 434 to i jo, Le., 26 mm. He was serene, constituent of tobacco,,and is most toxic~ comfortable and enjoyed smoking!__ in solution. Therefore ` a cigarette had two o-- posite effects upon the same subject. It NICOTINE 1VIOST IMPORTANT IN THE_ ': made the blood pressure fall violently SiuoxE on one day, yet rise vigorously the next (I) Cigarettes vary in nicotine iosir d'ay, a difference of more than 70 mm. tent. Domestic brands (Virginia, etc.) of mercury-in the same man, smoking 2.So per cent, blends i.9o; Oriental the same kind of cigarette! There were 1.4, "de-nicotinized" i.io, (sic! ) to- and EhrenfeldZ' 66 per cent, Popp and' Contzen 50 per cent?& ; <..aj ~ three important and instructive reasons bacco free o.oo (Bogen'). "for this. They will be referred to later.. (2) Not all the nicotine in the to- - bacco gets into the smoke.`y 32 Straub24 NICOTINE ;, gives the percentage 34-56, Haberman Tobacco smoke includes nicotine, pyridine, and pyridine derivatives, car- bon monoxide and carbon dioxide, am- monia, aldehydes, and a number of organic tarry compounds in varying amounts. Dixon° places most stress on the nicotine, pyridine and carbon monoxide in the smoke. Rolleston1e emphasizes the nicotine and aldehydes. McNally's points to the nicotine and carbon monoxide. Most scientific authorities, however, agree that the outstanding pharmaco- logically active constituent of tobacco smoke is the alkaloid, nicotine. Ac- corddng to Bastedo5 and Chapman,20 nicotine is the only active constit'uent' of tobacco present in large enough quanti- ties to have the potentialities of being ~(3) Not all the nicotine in the smoke ~' gets into the body. Chapman2°'reports 66 per cent (887o for inhalation) i Dixon, 75 per cent " ' ` (4) Not all of the cigarette . tss smoked. One-quarter to one-half is thrown away. This is a good thing as we shall see. The smoker consuming ~ , 4~. ~ T F A i o to i s cigarettes a day, each produc- ,~ ~~, ing 1.3 to 3.'J8 mgs. of nicotine in the smoke (75% of which is absorbed) , may take up from around ro to 4o mgs. 'of nicotine. <u " (S) There are two kinds of smokee coming from the cigarette: the "side- stream" and the "main-stream." The "side-stream" comes from the tip of v ® ® © ,

rn:..T; -:---1:fi-''"7'=; : : T he Cigarette, the Soldiez, " and the Physician 2 the cigarette- It is alkaline, ammoni- "-:tent filt'ers its own smoke. Nicotine in w,,~ , .~ .%-'too smoke in the open air, or in a well f9und to contain 16 per cent more, ie., :ventilated room in order to avoid the J.8 to i.o mg.' Here again fast burn inhalation of the "side-stream" smoke ing (S minutes as against Io minutes) and the re breathing of both "side- ' increased this additional amount of stream" and "main-stream" smoke nicotine by 75 per cent. Continuous again and agalm and again suction (laboratory) burning, how „ever stepped up this additional nico NICOTINE IN TOBACCO No CRITERION . tine by 400 per' cent (BOgeriy3 Ver1 OF NICOTINE IN SMOKE ;fied by Wenusch, Bruekner,ss and ~ (6) The nicotine inithe tobacco is Schmuck38). This illustrates another ... . . . -'g - . . s. _' no criterion of the nicotine passing into Y~advantage of slow burning, ; the smoke.', 3° The manner of smoking ''.. It is also obvious that he who throws "° makes a real d'afference.3. 5°> 51 Burning ' away the last half or one third of his . a cigarette in S minutes produced io cigarette avoids much nicotine. But the times as much nicotine as one burning cigarette butt must be thrown away or, ~ slowly in to minutes. (3) Slow burn-,put out, otherwise it will continue to ing is of great and obvious advantage. distill nicotine into the air to be In this connection, it is interesting to breathed. The provision of a filter in -:.note later laboratory work on this sub- especially devised cigarette-holders has" ject. An unpublished report39' of recent been shown to be an advantage, but ; date states that the smoke of one popular cigarette-holders are seldom used by , domestic brand of cigarettes contained the soldier approximately one-quarter less nicotine than the average of four other brands " tested! Also that it burns -slower than the average of the four other brands ;• by approximately the same percentage given above. These are factors that benefit the smoker. Efforts of this TEMrERATURE OF SMOKE Filter factors and slower combustion ? reduce irritation of the mucous mem- ' n. branes in another fashiony namely: diminution of heat. The temperature of the smoke at the source is probably kind should be encouraged. ~ i,423° Fahrenheit'.'0 (7) Again, the cigarette to some ex- Ordinarily, and contrary to common < acal, irritating and contains cornpara- ` the "main-stream" is condensed as the 'tively more nicotine than the "main- smoke is drawn through the unburned stream.". of the cigarette. For the mo- - , "_The smoke -drawn " through the ment this nicotine fails to reach the _ "main-stream" contains more carbon snioker: But, however, when the burn monoxide but less hicotine. But the non- ing spark overtakes it, it is burned and smoker, sitting in a confined smoky turned to smoke again. Therefore, the room gets both by deep inhalation. So cigarette is progressively loaded~ up "does the smoker himself, whether he with the increased concentration of its .inhaies" or not. Obviously, it is better own nicotine. The last one-third was I ~•u^lY x ,

The Military Surgeon-July, 1941 belief, the smoke is cooled to body erally conceded to be the most impor- temperature before it reaches the lips. -Yet, rapid combustion may result in smoke reaching the mouth at the tem- perature of Ir2° to I35°. This greatly increases irritation. Nicotine absorption, which is the main damaging tobacco elelrbent, is also increased by fast burn- ing, as we have seen. = ~ ELIMINATION OF NICOTINE Reasonably extended intervals are recommended between 'indulgence in amoking to allow the body opportunity to rid itself of the nicotine. This elimi- nation is normally quite rapid. Weath- erby41 reports that a i mg. per kg. dose at i minute intervals was eliminated at the rate of one quarter mg. per kg. a -minute. With the interval twice as long (2 minutes) the rate was 33 per cent IRRITATION While nicotine is the essence of the tobacco problem, irritation of the mu- cous membrane of the upper respira- tory tract is of some, though minor, importance. There is some evidence to indicate that (a) smokers have more colds,, (b) colds last longer (c) sinus involvement' is more frequent and per- sistent. The smoker's cough of chronic pharyngitis is common. There is, how- ever, no apparent casual relationship - "SOLDIEx's HEAxT" ~ of smoking to the onset of tuberculosis . The draft board's examination o in soldiers.'z the soldier's heart and circulatory ef& It has been~ demonstrated by Haag23 ciency are necessarily brief, as it is in- that small increments in absorbed expedient for the examiners to test the nicotine have an increasing effect upon functional efficiency of the heart or the the nervous-circulatory system, Bal- circulatory system. Gross disturbances lengerl' also states that nicotine is gen- -tachycardia, dyspnoea, cardiac'over- tant element in tobacco smoke having systemic effect. One cigarette maker endeavors reduce irritation by substituting dI ethylene glycol for glycerine as a hygroscopic agent (used to keep to= bacco moist), thereby reducing acro-' lein, a prominent local irritating substance of the aldehyde class. Much scientific and statistical work has been done on this point since I934- Mulinos and Osborne', 11inject'ed smoke-treated solutiions into 'rabbits' eyes, and examined them subjectively ' for edema. They found some advantage for the smoke of diethylene-glycol treated tobacco. But Haagg could not duplicate the results. ~ - Flinn9,10 agreed with Mulinos and Osborne. Ballenger and JohnsonI$ and ' ,;Sharlitl' disagreed with Flinn. Holck ,' and Carlsonls tried the effect on saliva, and found no significant difference in cl the irritating effects. of different hygro- ` scopic agents: Haag's most recent sum- mary40 casts doubts on the possibility of a hygroscopic agent affecting the physi-- ologic potentials of smoke. While the hygroscopic-agent theory is disputed'y efforts to reduce tobacco irritation are mueh to be commended and should be continued.

The Cigarette, the Soldier, and the Physician action, dizziness-may easily be noted. THE SOLDIER'S CIRCULATION AND It is not practical to give the func- ;' NICOTINE ~ tional tests (Crampton Sehneider `` ,, Basic Data: Long ago in the Ameri- Barringer), or to use the very valuable ~n' Civil Da Costa noticed sol- flarimeter. But we must not delude War, dier's heart" ourselves into believing that mere test- among the troops. He ing of the heart will give adequate in- recommended' that a gradual training pe"riod be instituted in the orientation formation about the circulation. It does of soldlers not. -' A great many men who are, or will `t,`Soldier's heart" is a cardiac neuro- get into service will develop "effort sis. There are subjective feelings and complaints of cardiac disord But d' "ers. syndrome" disorerly action of the , there is no organic disease of heart ("DAH") "soldier's heart" the heart. ... or neuro-circulatory asthenia. These Indeed, Grollman43 points out that an Increased' cardiac output is expected In . cases may give us trouble later on ~ They are likely to be nervously, the last war, Britain established a spe- cialized hospital for these eases in whieh mentally, and emotionally unstable, Lewis did careful work . exhibiting symptoms which easily run ~ toward the psycho-neurotic and psy- He found 77,000 soldiers reported chobia Some of these men are typically as cardiovascular cases. By the summer . viscero totic and' asthenic. From a mili- °f I q i 8 about 80% of the cases had "soldier' tary standpoint they are likely to be as heart." About 44,00o men nuisance, inclined to be either moody were pensioned! b4 aause of this effort or noisy, over-conscientious or unrelia-thsyndrome. ~Lewis . sees nv, evidence ble. They will probably be too fast or at soldier s heart will be less prevalent in 1939 than in i9I¢ - too slow, markedly introvert or extro- From data already disclosed' vert, sympathetieotonic or vagotonic,y Lewis finds that the syndrome is as prevalent autonomically unstable, excitable or as it was in i9I¢ even though the , stupid . physicalstrain imposed i war-n modern In general such men will make poor . soldiers. They are likely to smoke not times (with possible exceptions) is less at all or excessively, with periods of than in 1914. Fraser'S at Mill Hill slowing off which may aggravate the Hospital reports that men reporting : symptoms, especially tremor. Tobacco for enlistment in~ the British army had . has an important influence on the hap the syndrome with same proportion as piness, health, and efficiency of these ln IqI¢, and the condition was due to meny for nicotine is notably an auto- the same etiological facts as in the last nomic nerve system stimulant and war. sedative. The subject is important, for Lewis showed that the soldiers in it is by no means agreed that smoking the last war who had symptoms of car- is a vital factor in the progress of these diac neuroses = enlistment gave no disturbances. better service than men with actual

,,.-. , 10 ,~: The Military ,Surgeon-July, 1941 . .. ,.- ,:. . . _ . _.. ~._ . : . _.: .p _. -.. . ff~ .... . __,. . . . . . , =;# cases of heart disease. Lewis found cigarettes daily `' 27% that those recruited~ from sedentary 20 cigarettes daily ;5 work were most likely to develop the .25 cigarettes daily io i F;- symptoms on exeraise Lewis found that the smoking by ETIOLOGICAL FACTORS o~~ =•such patients is small. Many patients ' In the ^ i 94 British Army 5770, } of believe that smoking aggravates the the men who develbped the symptoms symptoms. He reaffirmed Parkinson's of "soldier's heart" were in sedentary ` findings that the reaction of the pulse work, 2o°fo in moderate work, and rate to exercise is increased by smoking ~r The return to normal is slowed down "~ 23 ofo in heavy work Because of these' adverse effects this Lewis thought that previous infec 5 tion ' such as rheumatic fever, influ group of patients smoke less although '~ en2a, pneumonia, etc., was the etiologi~ they will not give up smoking entirely ' Lewis concluded' that smoking was not ; ~ : cal factor in o o to 60 0 of the 1914 ~s~. S% %,- .`a major etiological factor. " Many physicians believed smoking TREATMENT ` to be a primary etiological factor in the The rivalry of psychologists and car production of "soldier's heart" symp- -diologists in the service of neuro toms. Yet Parkinson and' Koefod's after, circulatory asthenia cases indicates an a series of tests on affected and unaf- approach to the subject from two sides, fected soldiers concluded that smoking both important. But both sides are ;~NJ .was not the chief nor even a frequent wrong only when they exclude each cause of the typical "effort syndrome," , other. Soley and Shock" showed the . <:: or "soldier's heart." However, they, «"effort syndrome" to ~ be an anxiety did conclude that smoking was a con- state complicated by hyperventilation - tributory factor to breathlessness and syndrome. Sargent suggests that hyper- y w precordial pain. This is based on the -ventilation~ ma sometimes be a con,' fact that the pharmacological action of _ tributing factor in the production of ~" ~ nicotine is in a direction unfavorable to ,~-symptoms of acute anxiety. Yet the effort or exertion. = major effort should be in trying to pre % "' MacGregor doubted that tobacco was vent the syndrome, by finding it out an etiological factor in the production before men get into the army. Lian of the syndrome. He showed that Sikh (Presse Medicale Apr. 16:385, t94o) soldiers, who do not smoke, have the showed the value of his marking-time symptoms of neuroacirculatory asthenia. test to diagnose latent "effort syn ` r Lewis studied the smoking habits of drome" ini the French Army recruits. ~ effort syndrome cases. He found the This subject needs the services of '. following distribution: " 'four specialists working together, ( i) " non smokers = 6ofo the cardiologist, (2), the neurologist, 2 cigarettes daily 2o~fo ' (3) the psychiatrist, (4) the internist. 5 cigarettes daily 42 ofo And all four men should, be soldiers. ~' ~. 9 ® K=