NOTES ON TOBACCO
It is the purpose of this section to present as fairly as possible the
evidence relating to the effects of tobacco on the human body, so that
those who smoke may correctly measure the probable physical cost of the
indulgence. The extremes of opinion on this subject are well expressed
in the following verses:
"Hail! Social Pipe--Thou foe to care,
Companion of my elbow chair;
As forth thy curling fumes arise,
They seem an evening sacrifice--
An offering to my Maker's praise
For all His benefits and grace."
DR. GARTH.
"A custom loathsome to the eye, hateful to
the nose, harmful to the brain, dangerous to
the lungs, and the black stinking fume
thereof nearest resembling the horrible
Stygian smoke of the pit that is bottomless."
JAMES I.
[Sidenote: What it Is]
Tobacco is a plant, Nicotiana Tabacum of the order Solanaceae, which
includes Atropa Belladonna, or "Deadly Nightshade," Hyoscyamus, or
"Henbane," Solanum Dulcamara, or "Bitter Sweet," all powerful poisons,
and likewise the common potato and tomato, which are wholesome foods.
The cured leaves are used for smoking and chewing, or when powdered, as
snuff.
[Sidenote: History]
Prior to the middle of the 16th Century, the use of tobacco was confined
to the American Indians. In 1560 the Spaniards began to cultivate
tobacco as an ornamental plant, and Jean Nicot, the French Ambassador at
Lisbon, introduced it at the court of Catherine de Medici in the form of
snuff. Smoking subsequently became a custom which spread rapidly
throughout the world, although often vigorously opposed by Governments.
In the 17th Century, smoker's noses were cut off in Russia.
[Sidenote: Composition]
Tobacco contains a powerful narcotic poison, nicotin, which resembles
prussic acid in the rapidity of its action, when a fatal dose is taken.
The percentage of nicotin present varies according to the brand and the
conditions under which it is cultured.
The following figures have been given by the various authorities.
London Lancet[38] .64 to 5.3 per cent.
French Dept. of Agriculture[39] .22 to 10.5 " "
Connecticut Agricultural Experiment Station[40] 2.89 " "
(Home grown--after fermentation.)
U. S. Dept. of Agriculture[40] .94 to 5. " "
(Domestic.)
Aside from nicotin it also contains small quantities of related
substances--nicotellin, nicotein, a camphoraceous substance termed
nicotianin, said to give tobacco its characteristic flavor, and likewise
a volatile oil developed during the process preparation. On heating,
pyridin (a substance often used to denature alcohol), picolin, collidin,
and other bases are formed, as well as carbolic acid, ammonia, marsh
gas, cyanogen and hydrocyanic acid, carbon monoxide (coal gas) and
furfural. Furfural is a constituent of fusel oil, which is so much
dreaded in poor whisky. The smoke of a single cigaret may contain as
much furfural as two ounces of whisky.
The complex constitution of tobacco and the smoke from its combustion
has caused much debate as to the substances that are responsible for its
charm and its ill effects, which are to be described. No one can doubt
the serious injurious effects from such a powerful poison as nicotin if
taken in any but the most minute quantities (one to three milligrams
have produced profound poisoning in man).
It has been maintained by some that nicotin is practically destroyed in
the process of smoking, and that the effects of tobacco are limited to
the decomposition products resulting from the burning tobacco,
especially pyridin. But pyridin is also formed in the burning of cabbage
leaves, and cabbage leaves do not possess any attractions for smokers,
neither do they produce the well-known effects that smoking and chewing
tobacco produce. No doubt pyridin and furfural are factors in the drug
effects of tobacco, but recent painstaking experiments by high
authorities have shown the presence of nicotin in tobacco smoke, and
when we reflect that there is sometimes sufficient nicotin in an
ordinary cigar to kill two men, it is not strange that enough of it may
be absorbed from the smoke passing over the mucous membranes of the
nose, throat and lungs to produce a distinct physiological effect.
Investigators who claim to show by experiments the absence of nicotin
from tobacco smoke must explain why the palpable effects of smoking, in
those who have not established a "tolerance," are those of nicotin
poisoning, and why the symptoms produced by chewing tobacco are
identical with those following the smoking of tobacco, which are: mild
collapse, pallor of the skin, nausea, sweating, and perhaps vomiting,
diarrhea, muscular weakness, faintness, dizziness, and rise in blood
pressure followed by lowered blood pressure.
Nicotin is undoubtedly decomposed by burning, but it may become
volatilized by heat and a certain amount absorbed before decomposition
takes place.
Lehmann,[41] in 1908, found in tobacco smoke the following percentages of
the nicotin contained in the tobacco:
Cigaret smoke 82 per cent.
Cigar smoke 85 to 97 " "
The London Lancet[42] (1912) gives the following figures:
Cigaret smoke 3.75 to 84 per cent.
Pipe mixture smoke, smoked as cigarets 79 " "
Pipe smoke 77 to 92 " "
Cigar smoke 31 to 63 " "
The United States Department of Agriculture[43] found in tobacco smoke
about 30 per cent. of the nicotin originally present in the tobacco.
Contrary to general opinion, Havana cigars contain less nicotin than the
cheaper brands, which augurs ill for the large class of people who
cannot afford to smoke higher priced brands. Many of the cheaper grades
do, however, show a low percentage of nicotin.
[Sidenote: Effects on Animals and Man]
By means of an ingenious apparatus, Zhebrovski,[44] a Russian
investigator, compelled rabbits to smoke cigaret tobacco for a period of
6 to 8 hours daily. Some died within a month, and showed changes in the
nerve-ganglia of the heart. Others established a tolerance similar to
that exhibited by habitual smokers, but upon being killed at the end of
five months, degenerative changes similar to those produced by the
injection of nicotin were found, viz., hardening of the blood vessels.
There is, indeed, no difficulty in producing the characteristic effects
of nicotin by administering tobacco smoke, either in man or in
animals.[45]
Nicotin causes brief stimulation of brain and spinal cord, followed by
depression. There is an increased flow of saliva, followed by a
decrease (large doses diminish it at once) and often nausea, vomiting
and diarrhea. The heart action is at first slowed and the blood pressure
increased. Subsequently there is a depression of the circulation, with
rapid heart action and lowered blood pressure. In habitual smokers, this
preliminary stimulation may not occur. The stimulating effect on the
brain is so brief that tobacco can not properly be termed a stimulant.
Its effect is narcotic or deadening. Those who fancy that their thoughts
flow more readily under the use of tobacco are in the same case with any
other habitue whose thoughts can not flow serenely except under his
accustomed indulgence. That a sound healthy man, who has never been
accustomed to the use of tobacco, can do better mental or physical work
with tobacco than without it has never been shown. Indeed, such
experiments as have been made on students and others show to the
contrary.[46]
The statistics presented by Prof. Fred. J. Pack are of interest in this
connection.
In six educational institutions the students competing for places on the
football team were grouped as follows:
------------------------+-----------+-----------+------------
| Number | Number | Per Cent.
Institution. | Competing |Successful.|Successful.
|for Places.| |
------------------------+-----------+-----------+------------
_Institution A._ | | |
Smokers | 11 | 2 | 18.2
Non-smokers | 19 | 11 | 57.9
_Institution B._ | | |
Smokers | 10 | 4 | 40
Non-smokers | 25 | 17 | 68
_Institution C._ | | |
Smokers | 28 | 7 | 25
Non-Smokers | 17 | 14 | 82
_Institution D._ | | |
Smokers | 28 | 11 | 39.3
Non-smokers | 15 | 10 | 66.6
_Institution E._ | | |
Smokers | 10 | 7 | 70
Non-smokers | 15 | 12 | 80
_Institution F._ | | |
Smokers | 6 | 0 | 0
Non-smokers | 26 | 15 | 57.7
------------------------+-----------+-----------+------------
SCHOLASTIC STANDING
---------+-------+-------++--------+-------+--------
Institu-|Smoker.| Non- ||Institu-|Smoker.| Non-
tion. | |smoker.|| tion. | |smoker.
---------+-------+-------||--------+-------+--------
A | 65.2 | 69.8 || G | 74.0 | 75.0
B | 64.7 | 74.6 || H | 75.2 | 79.4
C | 78.8 | 81.1 || I | 81.6 | 88.4
D | 75.8 | 77.6 || J | 78.5 | 81.3
E | 84.6 | 84.8 || K | 74.0 | 84.6
F | 69.6 | 71.3 || L | 77.3 | 77.6
---------+-------+-------++--------+-------+--------
The following table shows the relative scholastic standing of smokers
and non-smokers:
------------+--------------+-----------+-------------
| Number | Total | Average
| of Men. | Mark. | Mark.
------------+--------------+-----------+-------------
Smokers | 81 | 6,034 | 74.5
Non-smokers| 101 | 8,021 | 79.4
------------+--------------+-----------+-------------
Twelve institutions reporting:
------------+--------------+-----------+-------------
| Number | Highest | Lowest
| of Men. | Marks. | Marks.
------------+--------------+-----------+-------------
Smokers | 81 | 4 | 12
Non-smokers| 101 | 11 | 6
------------+--------------+-----------+-------------
---------------------------+-----------+-------------
Number of | Highest | Lowest
Men. | Marks. | Marks.
---------------------------+-----------+-------------
101 non-smokers furnish | 11 | 6
101 smokers would furnish | 5 | 15
---------------------------+-----------+-------------
------------+------------+----------------+----------
| Number | Total |
| of Men. | Conditions | Average.
| | and Failures. |
------------+------------+----------------+----------
Smokers | 82 | 70 | .853
Non-smokers| 98 | 48 | .439
------------+------------+----------------+----------
[Sidenote: Tobacco Smoking Athletes]
Prof. Pack's conclusions were as follows:
1. Only half as many smokers as non-smokers are successful in the
"try outs" for football squads.
2. In the case of able-bodied men smoking is associated with loss of
lung capacity amounting to practically 10 per cent.
3. Smoking is invariably associated with low scholarship.
There have of course been many notable instances of high scholarship and
prodigious mental achievement by heavy smokers. Such exceptions,
however, do not affect conclusions derived from the study of average
groups.
Hitherto figures on smoking and athletics have been open to question
because comparisons were made between groups that are not of necessity
of the same physical and mental type, having no important difference
except in the use of tobacco. But Prof. Pack has sought to avoid this
objection. As he points out, the football squad is probably as nearly a
homogeneous group as it is possible to find. It seems reasonable to
account for the inferior physical and mental work of these particular
groups of smokers on the theory that in the main the well known toxic
effects of tobacco are sufficient to create this difference.
Dr. George J. Fisher,[47] in a series of careful tests found:
1. Cigaret smoking caused an increase in the heart rate.
2. Cigaret smoking maintained a blood pressure which, under the
circumstances of the experiment, would otherwise have dropped.
3. Cigar smoking caused a considerable increase in heart rate and
blood pressure.
4. In a number of instances, in the cigar test, the heart was
unable to maintain, with a vertical position, the increased blood
pressure found in the horizontal position, showing a disturbance of
the control of the blood vessels. This latter effect was more
pronounced in tests taken on non-smokers.
5. It was also noted that smoking was not conducive to concentration
upon the reading, which the men attempted during the tests.
Bush,[48] in a series of tests on each of 15 men in several different
psychic fields found the following conditions among smoking students
immediately after the period of smoking was completed:
1. A 101/2 per cent. decrease in mental efficiency.
2. The greatest actual loss was in the field of imagery,
22 per cent.
3. The three greatest losses were in the fields of imagery,
perception and association.
4. The greatest loss, in these experiments, occurred with cigarets.
Bush ascribed these effects to pyridin, claiming that his experiments
failed to reveal nicotin in the tobacco smoke, except in a very small
proportion in that of cigarets.
Tests for nicotin in smoke are beset with many difficulties and possible
fallacies which have in the past misled investigators into apparently
determining that tobacco smoke contained no nicotin, but simply
decomposition products.
Pyridin is unquestionably present in tobacco smoke, and is a poisonous
substance, although less so than nicotin. It is not found, however, in
chewing tobacco, and as the clinical effects of chewing tobacco are
apparently identical with those of smoking tobacco, very strong and
universally accepted chemical proof of the absence of nicotin from
tobacco smoke must be awaited before accepting such a conclusion.
(See([41]), ([42]), ([43]) in bibliography.)
Cigaret smoking is a time waster; that is, it breaks up the power of
attention, as few smokers are satisfied with one cigaret and the mere
physical act of lighting a fresh cigaret disturbs the continuity of
thought and work. Dr. W. J. Mayo[49] calls attention to the fact that
according to his observations research scholars who smoke cigarets have
not done well.
[Sidenote: Insurance Experience on Tobacco Smokers]
Only one insurance company, the New England Mutual,[50] has published
any experience on tobacco users. This covered a period of 60 years and a
body of 180,000 policyholders, as follows:
RATIO OF ACTUAL TO EXPECTED MORTALITY.[M]
-------------------------------------------------------
ABSTAINERS. | RARELY USE. | TEMPERATE. | MODERATE.
--------------|-------------|------------|-------------
Tobacco, 59% | 71% | 84% | 93%
Alcohol, 57% | 72% | 84% | 125%
-------------------------------------------------------
[M] The standard here used is the American Experience Table, which is
largely an artificial table upon which premiums are based, but which
provides for a much higher mortality than the average companies sustain.
For example, the actual mortality of the New England Mutual in 1913 was
57 per cent. of the expected.
[Sidenote: Interpretation]
Fifty-nine per cent. of the expected mortality means that where,
according to the premium tables, 100 were expected to die, only 59
actually died.
The general class of risks in this company were of excellent quality, as
the figures show. Nevertheless, the abstainers exhibited a far lower
mortality than that experienced by the general class.
Dr. Edwin Wells Dwight, who presented the figures, urged caution in
their interpretation, suggesting that the low mortality among
abstainers, both from alcohol and tobacco, might well be due to a more
conservative habit of living. Furthermore, as the abstainers from
alcohol were not separated from the abstainers from tobacco in this
analysis a perfect comparison can not be made; but our knowledge of the
toxic effects of both these narcotics and the preceding statistics of
Doctor Pack justify us in assigning to tobacco a positively unfavorable
effect.
[Sidenote: Poisonous Effects]
Experiments on animals with nicotin extracts from tobacco and inhalation
of tobacco smoke have produced hardening of the large arteries. Clinical
observation by some of the world's best authorities indicates that the
same conditions are brought about in man by heavy smoking.[51]
Disturbance of the blood pressure, rapid heart action, shortness of
breath, palpitation of the heart, pain in the region of the heart, are
important effects. Tobacco heart is often lightly spoken of because the
abandonment of the habit will often restore the heart to its normal
condition, but tobacco heart sometimes causes death, especially under
severe physical strain or in the course of acute disease, such as
typhoid or pneumonia. Surgeons[52] have noted failure to rally after
operation in tobacco users, who are, of course, deprived of their
accustomed indulgence immediately before and after operation. It is
probable that many such cases pass unrecognized, although the alcoholic
is usually supplied the narcotic his system demands.
Cannon, Aub, and Binger[53] have also shown that nicotin stimulates the
adrenal glands, small organs adjacent to the kidneys, which secrete a
substance that in excess powerfully affects the blood vessels,
constricting them and temporarily increasing the blood pressure. This
influence may be partly responsible for the change in the blood vessels
noted in heavy smokers.
Excessive smoking is often an important factor in causing insomnia.
Blindness or tobacco amblyopia, a form of neuritis, is not an uncommon
affection among smokers. There is also often an irritant effect on the
mucous membranes of eyes from the direct effect of the smoke.
Catarrhal conditions of the nose, throat and ear have also been noted.
Acid dyspepsia is a common affection among smokers.
Few people realize that so many ingredients in tobacco and tobacco smoke
are deadly poisons. Few people know that one drop of nicotin on the
unbroken skin of a rabbit will produce death.[54] Two drops on the
tongue of a dog or cat will prove fatal; moreover, fatal poisonings
have occurred in man from swallowing tobacco and even from external
application of strong solutions. A case was recently reported from New
Haven of fatal poisoning in a baby,[55] who had been fed from a milk
bottle and milk-mixture in which some tobacco had been accidentally
spilled.
SUMMARY
From the mass of evidence and opinion with which medical literature is
loaded, a few salient facts stand out:
First: Tobacco and its smoke contain powerful narcotic poisons.
Second: It has never been shown to exert any beneficial influence on the
human body in health, and it is not even included in the United States
Pharmacopoeia as a remedy for disease, notwithstanding the claims that
are made for its sedative effects and its value as a solace to mankind.
If these benefits are real and dependable, they should be made available
in exact dosage and applied therapeutically. If they are not real and
dependable in a medical sense, they are not real and safe as a mere
drug indulgence.
Third: The symptoms following tobacco-smoking are identical with the
effects of tobacco-chewing among those not accustomed to its use; hence,
any collateral psychic effect, such as the sight of smoke, the
surrounding, etc., are of minor importance in establishing the habit.
The main charm to the smoker is the drug effect, as in any other similar
indulgence. Nicotinless tobacco is not popular, notwithstanding the
efforts of the French and Austrian Governments to make it so.
Fourth: Fortunately, the sedative drug effect is so slight, as compared
to that of other narcotics--opium, alcohol, cocaine, etc.--that the
tobacco habit is less seductive and may be broken with comparative ease
and is therefore less harmful morally. Men who have smoked or chewed
steadily for 40 years have been known to give up the habit without
experiencing much physical discomfort. Like any other habit, however,
there is a tendency to increasing indulgence, and this is a risk that
the smoker takes, just as does the alcohol user or the opium habitue who
begins with so-called moderate indulgence.
Fifth: The well-known effects of tobacco on the heart and circulation
should lead one to pause and consider the possible cost of this
indulgence, especially as--
Sixth: It is difficult to determine, years in advance, whether or not
one is endowed with sufficient resistance to render so-called moderate
smoking comparatively harmless.
Seventh: The vital statistics show that diseases of the heart and
circulation are rapidly increasing in this country in which--
Eighth: The per capita consumption has rapidly increased in recent
years, while--
Ninth: In the United Kingdom, where these diseases are decreasing, there
has been no material increase in the use of tobacco, and the per capita
consumption is less than one-third that of the United States.
[Sidenote: Increase of Smoking]
In 1880 the annual per capita consumption of tobacco in the United
States was about 5 lbs., while in 1914 it had risen to more than 7 lbs.
In the United Kingdom the per capita consumption is about 2 lbs., and
there has been no material increase in recent years.
The cigaret bill, in particular, has grown enormously, having more than
doubled in the past five years, while there has been a slight increase
in the consumption of cigars, smoking tobacco, chewing tobacco and
snuff, as shown in the following table:[56]
------------------------------------------------------------------------
Fiscal | | | Tobacco, |
Year | Cigars | Cigarets | Chewing and | Snuff
| | | Smoking |
--------+----------------+----------------+---------------+-------------
1910 | 8,213,356,504 | 7,884,748,515 | 436,608,898 | 31,969,111
1911 | 8,474,962,786 | 9,254,351,722 | 380,794,673 | 28,146,833
1912 | 8,350,119,103 | 11,239,536,803 | 393,785,146 | 30,079,482
1913 | 8,732,815,703 | 14,294,895,471 | 404,362,620 | 33,209,468
1914 | 8,707,625,230 | 16,427,086,016 | 412,505,213 | 32,766,741
|----------------+----------------+---------------+-------------
Total | 42,478,879,326 | 59,100,618,527 | 2,028,056,550 | 156,171,635
------------------------------------------------------------------------
Tenth: The poetic effusions of the lovers of the weed are no safer guide
than the exaggerated and intemperate denouncements of people who have
idiosyncrasies against tobacco and simply hate it.
Eleventh: Those who now smoke should have a thorough physical
examination to determine the condition of the heart and blood vessels.
This examination should be repeated at least annually, in order to
detect any adverse influence on the circulation.
_REFERENCES_
[38] _The Toxic Factor in Tobacco_, The Lancet (London), 1912, I,
p. 944.
[39] French Department of Agriculture, Compt. Rend. Acad. de Science,
CLI, p. 23.
[40] Garner, W. W.: _The Relation of Nicotin to the Burning Quality of
Tobacco_, U. S. Department of Agriculture, Bureau of Plant Industry,
Bulletin No. 141, Sept. 30, 1909, p. 15; _A New Method for the
Determination of Nicotin in Tobacco_, U. S. Department of Agriculture,
Bureau of Plant Industry, Bulletin No. 102, July 6, 1907, p. 12.
[41] Lehmann, K. B.: _Untersuchungen ueber das Tabakrauchen_, Munchen,
med. Wchnschr., 1908, LV, pp. 723-25; _The Physiological Action of
Tobacco Smoke_, Med. Rec., 1908, LXXIII, pp. 738, 739.
[42] _The Toxic Factor in Tobacco_, The Lancet (London), 1912, II,
pp. 944-947.
[43] Garner, W. W.: _The Relation of Nicotin to the Burning Quality of
Tobacco_, U. S. Department of Agriculture, Bureau of Plant Industry,
Bulletin No. 141, Sept. 30, 1909, p. 15.
[44] Zhebrovsky, E. A.: _The Effect of Tobacco Smoke upon the Blood
Vessels of Animals_, Russky Vratch, 1907, VI, p. 189; 1908, VII,
pp. 429-431; Med. Rec, 1908, LXXXIV, pp. 408, 409.
[45] John, H.: Editorial, Jour. A. M. A., 1914, LXII, pp. 461-2; _Ueber
die Beeinflussung des systolischen und diastolischen Blutdrucks durch
Tabakrauchen_, Ztschr. f. exper. Path. u. Therap., 1913, XIV,
pp. 352-365; Pawinski, J.: _Ueber den Einfluss unmassigen Rauchens (des
Nikotins) auf die Gefaesse und das Herz_, Ztsch. f. klin. Med., Berl.,
1914, LXXX, pp. 284-305.
[46] Pack, Frederick J.: _Smoking and Football Men_, Popular Science
Monthly, 1912, LXXXI, p. 336.
[47] Fisher, George J. [Monograph not yet published.]
[48] Bush, Arthur D.: _Tobacco Smoking and Mental Efficiency_, N. Y.
Med. Jour., 1914, XCIX, pp. 519, 529.
[49] Mayo, Wm. J.: Personal communication.
[50] Dwight, Edwin Wells: Proc. Assoc. Life Ins. Med. Dir., Oct., 1911,
II, p. 474.
[51] Favarger, Heinrich: _Experimentelle und klinische Beitraege zur
chronischen Tabakvergiftung_, Wien. klin. Wchnschr., 1914, XXVII,
pp. 497-501; _Experimental and Clinical Study of Chronic Tobacco
Poisoning_, Jour. A. M. A., 1914, LXII, p. 1764; Pekanovits. _Effects of
Tobacco Smoking_, Jour. A. M. A., 1914, LXXII, p. 1907.
[52] Bangs, L. Bolton: _Some Observations on the Effects of Tobacco in
Surgical Practice_, Medical Record, LXXIII, March 4, 1908,
pp. 421-23-51.
[53] Cannon, Aub. Binger: _Effect of Nicotin Injection on Adrenal
Secretion_, Jour. Pharm. and Exper. Therap., 1912, p. 381; Editorial,
_Nicotin and Adrenals_, Jour. A. M. A., 1912, LXIII, p. 1287.
[54] Hare, Hobart Amory: Fiske Prize Dissertation, No. 34, p. 1884.
Dixon, A. S.: Proceedings of the Academy of Natural Sciences,
Philadelphia, Nov. 11, 1884.
[55] Reynolds, H. S.: Jour. A. M. A., May 30, 1914, LXII, p. 1723.
[56] Annual Report of the Commissioner of Internal Revenue, 1914, p. 34,
Government Printing Office, Washington, D. C.
* * * * *
Bamberger, J.: _Hygiene of Cigar Smoking_, Abstr. Jour. A. M. A., 1904,
XLIII, p. 706; Zur Hygienie des Rauchens, Munchen. med. Wchnschr., 1904,
LI, pp. 1344-1345.
Current Comment: _Some New Evidence on the Tobacco Question_, Jour.
A. M. A., 1912, LIX, p. 1798.
Editorial: _The Pharmacology of Tobacco Smoke_, Jour. A. M. A.. 1909,
LII, p. 386.
Editorial: _The Use of Tobacco_, Jour. A. M. A., 1910, LX, p. 32.
Editorial: _Tobacco-Smoking and Circulation_, Jour. A. M. A., 1914,
XLII, p. 461.
Hochwart, L. Von Frankl: _Die Nervoesen, Erkrankungen der Tabakraucher_,
Deutsch. med. Wchnschr., 1911, XXXVII, pp. 2273, 2321.
Index Catalogue of the Library of the Surgeon-General's Office, second
series, XVIII, pp. 297-306.
Larrabee, R. C.: _Tobacco and the Heart_, Abstr. Jour. A. M. A., 1903,
XLI, p. 50. Read before the Massachusetts Medical Society, June, 1903.
Pel: _Un cas de psychose tabagique_, Ann. med. Chir., 1911, XIX,
p. 171.