Neither of the cases of aortic stenosis knew he had heart disease, and but one reported having experienced palpitation. Neither had suffered from inflammatory rheumatism, but one had passed through the exanthemata. In one the pulse-rate was practically normal, 66 sitting, 72 standing, although in character the pulse was irregular and weak. In the other, the pulse was the same when standing as when sitting. (Equality of the standing and sitting pulse appeared in one other case.) It would be unwise to consider the aortic stenosis due to tobacco simply because of the absence of a history of inflammatory rheumatism. I have seen a number of cases of idiopathic valvular disease. The fact of their symptomless existence is of no special significance, inasmuch as compensation was fairly perfect. It is the everyday experience of physicians that valvular lesions are discovered by systematic examinations, the existence of which had never been suspected by the patients.
In twenty cases there existed a considerable abnormal disparity between the pulse when sitting and when standing, viz.: 56 standing, 68 sitting (hypertrophy); 76 standing, 60 sitting; 100 standing, 80 sitting; 100 standing, 72 sitting; 100 standing, 84 sitting; 72 standing, 52 sitting, 84 standing, 68 sitting; 100 standing, 76 sitting; 72 standing, 54 sitting.
A peculiarity was observed in thirty cases. The power of the impulse seemed to be less than the apparent muscular strength of the heart; and the first sound lacked a proper amount of booming quality. This character is more readily appreciated than explained. I have noticed this peculiarity in other tobacco-users than those whose examination are tabulated. This alteration was also noticeable in the cases of hypertrophy; that is, the impulse was less strong and booming than would naturally be anticipated from the amount of enlargement. It is not simply the lessened strength due to increased rapidity of action; it is something more than that. The sign appears most explicable by a mechanical illustration; It seems as if a systole capable of exerting a 65- pound force was exercising only 40-pound power, and, associated with this lack of power, even while the heart is acting rapidly, the idea of sluggish movement is conveyed to the ear. The blow of the systole is not well delivered.
Summarizing the apparent effects of tobacco on the heart, we find that the pulse was increased in rapidity (twenty-two cases), rendered irregular (twenty), and occasionally intermittent (seven); that no special symptoms accompanied the cardiac changes; that the normal disparity between the pulse when standing and when sitting seemed to be abnormally increased; that the impulse seemed to be peculiarily diminished in force, and that the first sound appeared to lack sufficient booming quality for the apparent amount of muscle present.
The toxicity of tobacco ascertained, and the power of the plant to produce cardiac derangement reasonably assured, it is next necessary to inquire into the diagnostic data.
The diagnosis of the tobacco-heart is by no means easy. As a rule, an irritable heart is discovered, and the dependency of cardiac signs and symptoms upon the use of tobacco is positively ascertained only by the amelioration following the cessation of the habit. A history of the habit, and of palpitation following speedily upon indulgence, is of signal service. The difficulty in diagnosis arises from the attempt to make out a specific disease entitled to a separate and distinctive place among cardiac maladies. The diagnosis of an irritable heart is, in itself, very easy. All that is needed is rapidity of action, irregularity of rhythm and occasional palpitation. If the tobacco-heart, and not an irritable heart from the abuse of tobacco, is to be diagnosed, I regard as of especial value the peculiarity noted in the impulse and first sound a peculiarity, by the way, which I had observed in tobacco-users’hearts before I made any attempt at this special study. Until the investigations reported in this paper, I had never looked for not noted abnormal disparities between the pulse when sitting and when standing. Hence the value of the observation from a diagnostic standpoint remains to be established or disproved by clinical experience. If the examined heart be hypertrophied, and that hypertrophy gives rise to symptoms, insignificant when compared with the amount of enlargement, I believe that the unusual sedation is of value, not in determining that the hypertrophy was caused by tobacco, but that the heart was under the weed’s influence.
A few general observations concerning the cases investigated are: That all those examined began their work in and use of tobacco in adolescence or childhood, a period most likely to develop the ill effects of occupation and of bad habits.
That the chronic toxic effects of tobacco on the heart do not closely resemble the acute effects in animals.
That tobacco increases the action of the heart and diminishes its force, and that the force is diminished proportionately more than the diminution that physiologically follows increased action.
The irregularity of rhythm is nearly as characteristic as rapidity.
That intermittency is only of occasional occurrence.
That palpitation is not nearly so frequently caused by tobacco as is professionally and popularity believed.
That there is no indisputable evidence that tobacco causes organic heart disease per se.
That, theoretically, tobacco cannot cause hypertrophy, because, while increasing the rapidity, the muscular power of the heart is diminished.
That, practically, the existence of the traditional tobacco hyper-trophy is not proved, all other causative factors not having been excluded.
That there is a strong presumptive evidence that tobacco can cause functional disorder of the heart.
That tobacco is one causative factor in irritable heart.
That the tobacco-heart is an irritable heart, plus probably a peculiar alteration in the impulse and first sound, a disproportionate disparity between the pulse when sitting and when standing, a history of the habit, and minus other causative factors.
That it is questionable, in the present state of our knowledge, whether it would not be a needless refinement to consider the so- called tobacco-heart as entitled to a distinct classification.
That the cardiac disturbances caused by tobacco can exist without symptoms, and that, therefore, it is not fair to assume that because no symptoms exist no disorder is present.
That the absence of subjective circulatory symptoms is not characteristic alone of the influence of tobacco on the heart.
That the exaggeration of the normal disparity of the pulse when standing and when sitting is worthy of further investigation.
That the peculiarity in the impulse and first sound promises well in a diagnostic point of view.
That conclusions drawn from the investigation of thirty-one cases are simply suggestions of possibilities.
That thirty-one sedentary subjects, not working in tobacco, and not users of the weed, should be examined, and the result tabulated in parallel columns with those already investigated, before conclusions should be assumed to possess positive value.
Concerning the therapeutics of the irritable heart, we shall have nothing to say at present. Read before the Homoeopathic Medical Society of the State of Pennsylvania, 1888.
Hale wrote Lectures On Diseases Of The Heart, Materia medica and special therapeutics of the new remedies Volume 1, Materia Medica And Special Therapeutics Of The New Remedies Volume 2, Saw Palmetto: (Sabal Serrulata. Serenoa Serrulata), The Medical, Surgical, and Hygienic Treatment of Diseases of Women, New Remedies: Their Pathogenetic Effects and Therapeutic Application, Ilex Cassine : the aboriginal North American tea, Repertory to the New Remedies with Charles Porter Hart, The Characteristics of the New Remedies, Materia Medica and Special Therapeutics of the New Remedies, The Practice of Medicine, Homoeopathic Materia Medica of the New Remedies: Their Botanical Description etc.