amount of spitting becomes an indicator of a reasonable amount of indulgence in the weed. Tobacco is probably never beneficial, but it need not be carried to the harmful stage. The very fact that expectoration is looked upon now so widely as an unsafe and disgusting act will help to inhibit the smoker and cause him to follow the advice of the physician. Thus a virtuous circle may be established in which the final result is good for all concerned, both from the point of view of hygiene and of æsthetics. It is becoming a recognized vulgarity to spit, and a man who is a man should and will lend himself to anything which will remove the cause for it in himself, even to the giving up of a few cigars.

THE CAREER MEDICAL.

II.

THE FIRST YEARS OF PRACTICE.

(Continued from page 712.) EVERY man when he has once passed the "milk and barley-water stage," that is, when the strictly preparatory period lies just behind, and he launches forth into the great world of ideas, needs most of all to work out for himself a philosophy of life which shall furnish him with the guiding principles of conduct upon all occasions.

To most youthful practitioners there is one thought always uppermost in the mind, viz., how to command the confidence of patients so that a paying practice may quickly be built up. No hard and fast rule can in the very nature of things be set down which will apply to most or even many; for both the personal equation and the requirements of the individual are so diverse as to make this quite impossible, but it is safe to say that very few men in any calling attain any eminence worth having which was not purchased at the cost of tremendous effort. How well the poet Longfellow describes this in his pleasing

stanza:

“The heights by great men reached and kept
Were not attained by sudden flight;
But they while their companions slept
Were toiling upward in the night."

Now the practitioner once safely ensconsed in his new office chair is apt to find it all too comfortable, and to settle down "until something comes along." He has served his period of apprenticeship and has come to a more or less definite conclusion that he is entitled to a living as the reward of his past labors. Moreover, if he is to be "ethical," which he very much wishes. to be in his first few weeks, he is forbidden to advertise, and therefore sees no alternative but to watch the passers-by from an inconspicuous place near the window in the hope that "a windfall" will bring some rich client to his door. This seems to be a thoroughly rational position for a scholar and a gentleman whose dignity must be preserved at all hazards, and thus is begun the "waiting period" which drives many a well-intentioned physician into obscurity. Of all tedious and trying conditions in this world so beset with the tedious and the trying, this waiting for something to turn up is just about the most exasperating; but the element of chance is very untrustworthy, and he who relies entirely upon it finds that what he calls chance is in reality a concrete example of the energy of somebody who is or has been trying for months to "turn up something" through sheer individual effort. Patience and perseverance, when allied with character, exact knowledge, a pleasing personality, and the proper setting, will break through the strongest barrier to success which an unkind fate can build. He who idles his time away over a game of poker with friends he has made in the bar-room, who swaps stories at the grocery store, or walks aimlessly down the streets, is, if he persists in what seems to him merely "innocent pastime," doomed to certain failure. The man who quickly tucks away his hospital diploma, gets down his Gray or Osler, and goes to work is starting out well, for he is sure to find in them many things of which he has never before heard, or has completely forgotten and which he ought to know. Half of his time may very well be spent in the hospital clinics, where he will meet men eager like himself to be use

ful to all humankind, and where simultaneously he will have opportunity to acquire some little degree of perfection in the art of healing. There will still be left a few leisure hours in which he cannot do better than cultivate a few good friendships, especially among professional brethren of lofty aims; and when the conversation turns toward medicine, as it is sure to do, he had better be a careful listener rather than a purveyor of half-baked opinions, reserving his coup d'etat until some favorable moment when a keen diagnosis or some useful therapeutic hint may prove his worth. Tact is one of the most graceful and helpful of all human attributes, and its successful cultivation has made the fortune of many a man whose real talents may have been of an indifferent order. It is so indispensable to the young practitioner as to offer no comparison whatever with so-called brilliancy; and not infrequently does it happen that the brilliant man who does not possess it is left very much to himself both by the laity and the profession. Tact, character, earnestness of purpose, generosity, industry, forbearance, gentleness, and a love for the best that one can find in art and life, these are essentials upon which a successful career may be built; and seldom is it indeed that one finds a young doctor in possession of all these things who does not succeed within a rea

sonable period dating from the actual beginning of his public career. It was Buffon who said that in literature "style is the man," and just as in letters so in medicine the man who is becomes the man who does. One must be ever a thinker, must secure a proper perspective of what the world requires of him and how far he falls short of this requirement; then, with an eye single to these faults of omission or commission, let him study to perfect himself as becometh a wise man.

It was Henry Van Dyke who has said:

"Life is an arrow

Therefore you must know
What mark to aim at,
How to use the bow;

Then draw it to the head
And let it go."

Surely he who complains because luck is against him, who spends his days in idleness and his nights in brooding over the hardness of his lot, has neither seen the mark nor learned the bow. So much of what we have and are is of our own making that one may be tempted to declare that "every man is the architect of his own fortune." While not strictly true in the broadest sense, it is true within certain limits, and each of us can find among our acquaintances one or more examples which may lead us to do a bit of profitable thinking.

THE ancients had a pleasant way of blaming all their evils on wicked deities or devils; hence, perhaps, our present habit of calling the woes of the morning after "blue devils." They had a fable about Pandora and the box in which all the ills which have since afflicted mankind were said to have been safely imprisoned, until her woman's curiosity led her to take off the lid, when the numerous monsters jumped out all except Hope, which for once seems to have been in bad company, and this she kept confined by hastily clapping on the lid again.

The modern Pandora's box is the kitchen cupboard, whence comes a very large part of our present diseases. Guiltier still than Pandora is the chef, who, instead of merely accidentally letting them out, helps to create them by striving constantly to concoct new and more enticing dishes which tempt people to gorge themselves with an excess of food. In consequence many eat not only twice as much as they need or have the ability to digest or assimilate, but also much more than they could possibly utilize in any way except by accumulating burdensome fat, even if it could be digested and assimilated.

It is now believed that one of the main causes some careful investigators say the principal cause of disease and premature death, apart from accidents and the acute infections, is overloading the digestive organs and the consequent serious overtaxing of both these and the equally important excretory organs which have to get rid of the surplus by casting it out of the body, if possible, before it ferments or putrefies, and thus poisons the system.

The earliest and least immediately dangerous of the resulting troubles is indigestion. This, at first, is often temporarily relieved by treatment. Resting after meals, with more exercise between

meals, will generally enable the system for a time to dispose of the excessive intake, and there may be a relief then of the bloating and pain; but if the gormandizing continues, the dyspepsia is sure to recur and persist, with much worse evils to follow. The walls of the stomach and intestines, overdistended daily, finally weaken and dilate, after which remedies are much less effective and often fail entirely.

Appendicitis is a frequent complication of the resulting intestinal catarrh and constipation. The latter being seldom cured. radically in large eaters, leads on to a slow form of blood poisoning. An exceedingly common later consequence is hardening of the arteries, with involvement of the heart and, sooner or later, often the kidneys also. In other cases the more manifest results, with or without other contributing causes, may be obesity, liver disease, gout, or rheumatism, diabetes, eczema, neurasthenia, etc. Often suddenly or, less mercifully, after long confinement to a wheeled chair, apoplexy, dropsy, or heart failure closes the scene many years, nearly always, before, in the normal course, death should occur.

While the average span of life is being lengthened by better care of the babies, by the recent marvellous advances in both medicine and surgery, and especially by improved sanitation for the entire population, including a stricter quarantine against contagious diseases-in spite of the senseless efforts in some quarters to hamper the activities of the medical profession along these altruistic lines-the ailments largely attributable to overindulgence in the pleasures of the table are increasing. The maladies just enumerated are decidedly more prevalent than formerly; and cancer, as well as insanity, is increasing at an alarming rate among the most highly civilized nations, though rare among savages who

must perforce fare less sumptuously. Cancer is said to be practically unknown in non-meat-eating tribes.

Of late there has been a large amount of health literature in the popular periodicals, some of it valuable and encouraging, but much of it by writers of no medical or scientific standing. Many of them advocate bizarre methods of preserving the health and curing disease, ranging all the way from Christian Science with its teaching that there is no such thing as disease or any importance in diet, to the prescription of an exclusive diet of fruit and nuts, and from the advice to live as high and richly as one can afford, to fasting from thirty to sixty days without any previous medical examination, and without being under the supervision of any competent physician.

I once had the opportunity of examining a lady who had just completed a fast of forty days, which was said to have been complete except for the addition of orange juice to her drinking water. She had not been previously examined because she was a disbeliever in both doctors and medicine, and was very vague as to the ailment for which she had undertaken the fast. She was found to have a markedly displaced stomach, which would be likely to keep both her digestive and nervous systems in an abnormal condition. Fasting, of course, could not possibly have helped her.

There are witty writers who have become popular by recommending for everybody the widest latitude in diet, advising that we should learn from "the man in the street," who, by the way, generally eats anything and everything he can get, regardless of quality, or of quantity up to the limit of his capacity, who feasts and gets drunk when in funds and is ordinarily sober and abstemious at other times. However, the majority of conservative, scientific physicians who have had a large clinical experience and are not given to fads, are more and more impressed by the real dangers which they observe to result from overeating. Quotations might be

multiplied from eminent medical authors by way of proof, but the following from a standard English work, "The Senile Heart," by Balfour, must suffice:

"There is nothing ages a man or woman so certainly, and there is nothing that embitters the latter days of life so much as overindulgence in food. To those who can afford thus to transgress-to the well-todo excess in food is a much more serious menace to health and life than excess in drink, and it is specially so in respect of senile affections of the heart, some of which have been distinctly recognized to owe their origin to overindulgence, while all are distinctly aggravated by it."

The appetite is popularly supposed to be a sufficient guide as to the amount of nourishment one needs, and under normal conditions probably would be; but in most families of the so-called better class it is unduly stimulated, even from childhood, by the prevalent unhygienic fashions in eating and drinking, till now a simple, natural appetite is exceptional in persons over 20. Eating, which nature intended to be, like breathing, merely a normal function for maintaining life, has become perverted into a principal means of sensual gratification. To obtain "something good to eat" is with many people a chief object of existence.

The result is the prevalence of depraved appetites, jaded, over fastidious palates, and also a sadly large number of debilitated and dilated stomachs and bowels, with an abnormal craving for stimulating foods and beverages. The chefs and cooks, therefore, have had excuse for establishing such fashions in the preparation of our food and the arrangement of the menus as have proved most agreeable and satisfactory to the gourmands who demand the hottest possible condiments and stimulating accessories in order to get any work at all out of their exhausted digestive organs.

Hence the highly seasoned meat soups, with often a previous cocktail, served at or near the beginning of dinner, and the lavish use of cayenne pepper and other drug excitants in cooking most viands, besides

more of the same or similar gastric irritants added at the table, and the liquid stimulants of various kinds with which so many persons garnish the meal. The soup, besides the excessive amount of added condiments, is mainly a solution of meat extractives, which Pawlow and others have proved by repeated experiments to be the strongest stimulant of the gastric glands so far known. Yet the healthy stomach needs no such goading. The digestive specialists agree that many of the dilated stomachs at first secrete excessively; that, anyway, a very large proportion of the dyspeptics who seek their advice have either dilatation or atony of the stomach along with too much gastric juice. In these dilated or weak-walled stomachs with an excessive secretion there is a strong tendency toward ulcer of either the stomach or small intestine, or both; and it is now an established fact that cancer frequently develops in the site of neglected ulcers.

Therefore, the powerfully exciting treatment which our epicures have prescribed for themselves, and the chefs in turn insist upon supplying to everybody, no more suits all of the old bon vivants than it does the children, youths, and others with yet unspoiled stomachs and unperverted palates. Indeed, it is distinctly harmful to all of the latter and actually dangerous to those having an excessive gastric secretion.

If all the people from childhood to old age had a deficient gastric secretion, there would be more excuse for the general prevalence of a highly stimulating diet, though even then the final consequences would be questionable. But children and young people generally are certainly better without such active drug treatment; while for the considerable proportion of even the older ones who have overactive gastric glands, with, not very infrequently, a latent, unrecognized ulcer in the upper digestive tract, its effect is likely to be disastrous.

The irrational and unscientific fashionable dinner, besides providing for such an

extraordinary and harmful amount of stimulation, with a resulting overindulgence, contains in its numerous proteid courses a proportion of albuminous substances amounting often to one-half of the whole, instead of the one-fifth part considered necessary by the older authorities, or the one-tenth part shown by the experiments of Chittenden and others to be all-sufficient even for laboring men. Such a dinner, with its exciting accessories, usually provokes the taking of an excess of the substantials even before the dessert, with its rich sweets, is reached, so that the latter are then mere surplusage. Yet, if they have not been so attractively concocted as to make the diners crowd much of them into their already overloaded stomachs the chef would be in danger of losing his job.

Breakfast in the majority of American families is also excessively hearty. The French accuse us of beginning the day with a dinner. The luncheon is often nearly as superabundant as the dinner and generally equally unhygienic.

Then, on top of all this, our society women, when they entertain callers or go out calling themselves, must have afternoon tea, with cake, candy, etc., as usual accompaniments. Finally, at the frequent evening gatherings or after the play or opera, there must be a supper. And this is a daily routine for many. The men generally skip the afternoon teas, but more than make up for this by their numerous banquets, which are worse. Is it any wonder that our social leaders break down while yet young or in middle life, and that our statesmen and masters of finance, who must almost unavoidably attend many formal dinners, so often die suddenly at an age when they should be at their best? Even that tough old Japanese sailor, Admiral Togo, was knocked out by one short round of American dinners.

Thomas A. Edison, in a recent interview, commented on the untimely death of a celebrated financier at the age of 55, and upon the published report that another