The idea that the user of tobacco and other injurious substances will be cognizant of the injury inflicted by habitual use in moderate or even excessive amounts is an undoubted fallacy.  The daily, weekly, or monthly injurious effect may be entirely unobservable to even trained physicians, and yet the ultimate cumulative effect may be fatal.  I can instance numerous cases of physicians directly fatally injured by the use of alcohol, who have never had the slightest cognizance of the fact; and I can also instance cases of grave disease from the use of tobacco where the patients never have believed that tobacco has been the cause of their troubles, even after a unanimous opinion to that effect has been expressed by a number of competent medical advisers.  The habitual consumption of opium, in doses of any amount, is generally admitted by most people to be physically injurious outside of its strict medicinal application.  Moderate indulgence in alcohol as a beverage is beginning to acquire a very widespread evil reputation.  But how about tobacco?  Tea and coffee we can confidently leave to the consideration of a somewhat remote posterity of a considerably advanced intelligence and elevated hygienic ideals.

The relation of tobacco to the physical welfare of man can only be fairly estimated by viewing the subject in its broadest aspect; by considering its effects upon the race as a whole rather than in individual cases; by taking into consideration economical and other social conditions that at first sight might be considered as having little relevancy to the medical side of the subject.  But there can be no just consideration of the matter otherwise.  The direct deleterious effects of the immoderate use of tobacco are readily observable; but the great bulk of the evil physical effects due to the moderate use of this plant are of an intermediate nature and not directly noticeable; nevertheless, they are real, and worthy of medical attention.  The plainly marked results following the use of tobacco in relatively large amounts seem to be due to quick and extreme interference with nutrition, and a diminution of function of all kinds, which may be represented by anything from a slight decrease of appetite and digestive ability up to a complete loss of function of almost any important organ.  Tobacco has stimulating as well narcotic properties, but as ordinarily used its stimulating effect appears to be slight as compared with its narcotic influence.  In this respect it differs from alcohol, the use of which, owing to the usual method of introduction in large amounts through the stomach, produces directly, by stimulation, readily noticeable structural changes.  But with tobacco the direct evil results are mostly of a functional character, and are more generally diffused, owing to the usual slow manner of introduction into the body.  These two properties have an effect upon the body in moderate use as well as in immoderate use, the effect being simply in proportion to the