Volume XL. Number 11.

NOVEMBER 1917.

THE HOME-TRAINED NURSE Every doctor realizes with what relief he always leaves a serious case, attended by a trained nurse, knowing full well that his instructions will be carried out to the letter-that she will be vigilant to the slightest sign of danger in the progress of the disease, which, when detected, will be promptly noted and faithfully reported.

But all cases, especially among the great middle classes, will not, for financial reasons, permit the engagement of a trained nurse. The poor are provided for by State or charity; only the well-todo can afford to employ her, and there are cases among all classes which are not sufficiently sick to warrant engaging her. How shall we take care of this class of cases, and of the great middle class of patients who can not meet the expenses of a nurse without great detriment to themselves and family?

Back in those delightful misty days of our childhood, neighbors came in and "set up" with the sick, a sort of festive accasion for a few friends. Their prime duty was to give the right medicine at the exact time prescribed. In this they took great pride. It was thought that the varying of the time one-half minute might prove disastrous to the patient, the while other and more vital points were neglected.

The mother is the natural nurse of the family, and her degree of proficiency varies with her intelligence, sympathy, kindness, firmness and training. Anyone, indeed, who possesses these qualifications can do a certain amount of common-sense nursing. It must be borne in mind that in discussing the home nurse the so-called practical nurse is not considered, for, with few exceptions, she is an abomination in the sight of all, and a twin sister of the meddlesome midwife. Possessing a little training, she requires more watching than the patient himself.

How shall the home nurse be trained? The world of today is a reading world. Through magazines and journals much is being acquired concerning health, hygiene and nursing. With the laity possessing this limited fund of knowledge for the care of the sick, it remains for the

physician to add to it and direct it along the line of practical application.

The instruction in the home is not to be given in lecture form. The teaching must be done without even a suspicion that they are being taught. Thorough instruction in the care of each individual case is given, and they "learn to do by doing." During a protracted case of confinement is the most propitious time to discuss what to do in a case of emergency, as well as what not to do, and in this way avoid the common gossip on such an occasion. Here you will find plenty of mothers who are anxious to learn anything that will help their family in sickness.

That good nursing is the sine qua non of good medicine is thoroughly appreciated by every physician. If, then, in the great majority of cases, the nursing must be done within the home by some member of the family, let it, as nearly as possible, be done properly.

VACCINE TREATMENT IN GENERAL

PRACTICE

In a previous editorial on the subject of vaccines and drug therapy, we called attention to the tendency on the part of physicians to regard these two modes of therapy as being antagonistic to each other, or at least as supplanting each other, and endeavored to show the erroneousness of the idea. Our purpose was to remind our readers that drugs had still a place, and a major place, in the treatment of infectious diseases, from which the vaccines have by no means dislodged them, and that their usefulness is in no wise invalidated by the introduction of vaccine therapy.

Lest our position on this subject should be misunderstood, or our remarks should mislead our readers in the other direction, we take this occasion to say a word or two upon the value of vaccines, or, as they are more properly called, bacterins, in the treatment of disease. It is far from our intention to belittle the value of these important therapeutic agents, or to suggest that they should be neglected by the general practitioner. On the contrary, it is our firm conviction that the general practitioner does not adequately

appreciate, or sufficiently avail himself of, this wonderful addition to his therapeutic armamentarium. Indeed, whenever we hear a physician pooh-poohing vaccine therapy we are sure that one or two things is to blame for his attitudeeither he has not given it a proper trial, or else he has unfortunately not had a good reliable bacterin.

Nothing in all medicine is so scientifically positive, within the limits of its applicabilty, as vaccine therapy; nothing so truly specific as a properly applied bacterin, and nothing more certain in its results. So positive, so specific, so certain, that nobody needs to write articles or to read papers to demonstrate that a clean-cut vaccine, in a clean-cut infection, is rational and effective therapy.

Their applicability is, of course, sharply limited to bacterial infections; but, as the infectious etiology of disease becomes more and more widely established, and a large number of diseases heretofore obscure in their origin have now been demonstrated to be due to infection, the usefulness of bacterins embraces a pretty wide field. Their therapeutic principle, and their mode of action, are exceedingly simple. It has been conclusively shown, beyond all further dispute, that when the body is attacked by a micro-organism of a given type and strain, the introduction of killed germs of the same type and strain induces the production by the tissues of anti-bodies, which counter-attack the invading bacteria and defend the body from their ill effects.

The application of vaccine therapy, to be sure, is not as simple as its philosophy. Like every other mode of therapy, it is an art as well as a science. All infections, for example, are not clean-cut and definite, and it is not by any means always possible to determine the precise type or strain of the germ or germs involved. One meets quite often with cases that show all the signs of infection, but none of the classical signs of a definite infection, so that one is inclined to say, with the farmer who saw a giraffe for the first time, "There ain't so such animal." And it is these doubtful, obscure conditions which afford a field for discussion, and experimentation, and often disappointment.

On the other hand, however, there are quite a large number of definite infections, in which the indications for bacterin treatment are clear and well-defined, and the results, if properly applied, unquestionable. But, even in these cases, the success of the treatment depends upon the judicious administration of the bacterin-its dosage, interval, time of administration, etc.-and, last, but not least, upon the quality of the bacterin itself.

For the commoner, straight-forward infections, stock bacterins, prepared by manufacturers from stock cultures, are generally quite satisfactory. Indeed, there are many reasons why they are preferable to autogenous bacterins made from the patient's own blood or discharges. In certain rarer cases an autogenous bacterin is essential. The stock bacterins, or vaccines, are those which are of the widest availability to the general practitioner; and he must see to it that he procures them from a reliable manufacturer.

We repeat, the practising physician is not availing himself of this agent of treatment in infectious diseases nearly as much as he might and should. He who neglects it is doing himself and his patient grave injustice. We reiterate what we said in our previous preachment on the subject, that the adoption of vaccine therapy need not, and should not, lead to an abandonment of drug therapy. They are not antagonistic, but synergistic. But neither should his faith in drugs lead the physician to neglect bacterins. This he ought to do, and not leave the other undone. The most successful treatment of infectious diseases is that which utilizes both, intelligently and discriminately.

XXX

MEDICAL BIOGRAPHY

There are few professions or occupations which brings so little return in reputation or honors, considering the energy, skill, learning and ability necessary for success in it, as medicine. The names of distinguished lawyers, soldiers, inventors, captains of industry, even of ward politicians and labor agitators, are familiar to every newspaper reader, almost to every school child, in the country; while the most able and honored physician is hardly known outside of his own community and is forgotten by succeeding generations, even of his own kind. Only when the physician shines by the reflected glory of some great man whom he is called upon to attend does he rise from the dull level of obscurity into the light of the public eye; and even then he is as likely to be damned as to be praised, and sure to be damned if his distinguished patient has the bad taste to die.

To a certain extent, this lack of repute, good or bad, is due to the physician's relation to the community-in most instances a purely personal one, which does not invite publicity and does not "write up" well for the newspapers. There are few professions so utterly devoid of sensationalism as the dull routine of professional work or scientific investigation. Unless the quiet of the study is broken by some great discovery, like that of Morton or Roentgen, it is not likely to be disturbed by notoriety. But to quite as great an

extent this lack of reputation is due to the excessive, and we believe mistaken, reticence of physicians themselves. Even among themselves they have a hypertrophied conception of the ethical proprieties, so that while they may not be averse to publicity as regards their work they succeed in robbing it of its personality, and therefore of much of its human interest.

We need to inject more of the human element into our medical studies; to know, ourselves, more about the men who are making and have made medical history, as well as of the work they have accomplished. In other words, we need to study the biography of medical men. But few books of this kind have been written, and it is to be feared that such as have been written have not met with a very large sale. The statement may be ventured that not one medical man in a hundred has a single work of medical biography or history on his shelf. With the possible exception of the great universities, no medical school makes any systematic effort to give instruction on the subject. And yet such study would serve to emphasize the great human factor in medical research as nothing else could. Laennec, conceiving the stethescope while observing children at play; Pasteur, paralyzed and half crippled, indomitably pursuing his studies in fermentation; McDowell, performing his first ovariotomy in the backwoods of Kentucky; Bell at Waterloo and Senn at Santiago; these are heroic scenes, full of human interest, which takes the dryness out of scientific study.

In looking into this matter of medical biography, one cannot help being struck with the dearth of material concerning the lives of eminent medical men. Except for the stereotyped obituary notice, with its bare record of birth, death, college connections, and principal published works, too often nothing is told about the man himself. It is still harder to find pictures of eminent medical men of a generation or two ago. This, of course, is not to be wondered at in the days when it took the art of a Sir Peter Lely, or a Gilbert Stuart, to fittingly create this human record; but even in the more recent days of cheap photography there are still those who withhold their features from the press through excess of modesty, or for some other reason. The story of the life of an able man has something in it of more than passing interest; it may be an inspiration to others to emulate his career; and the picture which reproduces his form and face is a human document which often tells more than the written text of the methods by which he achieved it.

THE DOCTOR'S FINANCES We confess we are growing a trifle weary of the perennial crop of gratuitous preachments concerning the doctor's finances-usually delivered either by men who, through a fortunate combination of fortuitous circumstances, have amassed swollen bank accounts, or else by those who, knowing practically nothing themselves of the struggle for existence, are paid to turn out advice on every problem connected with it. They remind us very strongly of the lectures on "how to succeed," which successful men complacently deliver to audiences of young men.

The monotony of the question, Why is the doctor poor? is equaled only by the sameness of the invariable answer-Because he is a poor manager. Personally, we think the question bears answering by a counter-question. Is he poor? We have yet to be convinced that the physician, as a class, is any poorer in this world's goods than any of the other professions and trades. Our observation has been that the doctor is usually about as prosperous and well-to-do a member of his community as any of his fellow citizens, taking into consideration, of course, the personal factors in the equation, his ability, intelligence, and general sociological capacities. He is, in fact, these personal factors being equal, generally a fair reflection of the financial and industrial prosperity of the community and time in which he lives.

In no calling or profession are large incomes the rule. The great bulk of fairly intelligent and capable men in all walks of life make a decently comfortable living, and no more. It would be just as pertinent to ask, Why is the grocer poor, or the lawyer, or the butcher, or the baker, or the candle-stick maker? And while it is possibly true that the extreme financial successes of medicine never reach the high-water mark attained in some other callings, neither do the extreme financial failures in medicine as a rule touch the low-water mark reached in other lines of endeavor, and we venture the assertion that the general financial average among medical practitioners will compare favorably with that obtaining in most, if not all, other modes of in

come.

Failures, by which we man legal bankruptcies, among physicians, are comparatively rare, indicating first, that they are generally able to keep their incomes well ahead of their expenses, and second, that their imputed bad management does not, at all events, extend to the debtor side of their exchequer whatever may be true of the creditor side.

Suppose, for the nonce, that the physician is

not as well heeled as the rest of the world that are in his sociologic and economic class. Even so, there are plenty of reasons to account for it without attributing it always to his lack of management. For instance, there is the important practical handicap which forbids a medical man from lifting his finger to increase his own business-hardly even to make known his readiness to do business. Under such a handicap as this, how many merchants would ever become rich? We are not impugning the wisdom of the condition, but simply pointing out its restrictive influence upon the physician's money-making capacity. It is significant, by the way, that wherever wealth is accumulated by a physician the accumulator has either circumvented this advertising restriction or has reached a degree of prominence where it is no longer imposed upon

him.

Another condition which tends to limit the money-making faculty of the physician is that the nature of his work prevents his doing any of it by proxy, or from reaping the profit of other men's labors. Practically every stroke of his work must be done by himself-not only personally, but in person. Organization, in the industrial sense of the term, is barred to him. Again, we ask, in the face of such a handicap, how many merchants would attain wealth? And again we note that wealth begins to flow into the physician's and surgeon's lap precisely as his prestige and prominence gives him some degree of license in this respect.

Finally, it should be remembered that the nature of the physician's work is such as to subordinate, on the one hand, the pecuniary aspect of his relations with his clients to the higher obligations he bears to them, and to prohibit, on the other hand, a proper monetary valuation of the service which he renders-a factor in the equation which no other calling has to reckon with, save only the ministry of the gospel.

For the rest, the financial problem among physicians is the same as it is among other classes of men, a personal problem, depending upon individual rather than upon class factors. In the medical profession, as in all other callings, there are men who have the faculty of getting and saving money, and men who are destitute of the faculty. There, as elsewhere, the main element in the money-getting faculty is but one-the imperative desire. The physician, as well as the layman, who purposes to get rich, who wishes it to the extent of making it his paramount aim, will assuredly compass wealth. The man, on the contrary, be he physician or layman, who makes other considerations superior to the getting of

Ascending Lymphogenous Renal Infection.— Eisendrath and Schulz, in the Boston Medical and Surgical Journal, states that:

1. Anatomical studies have demonstrated the presence of an anastomosing network of lymphatics in the wall of the bladder and of the ureter, communicating above with a similar lymphatic network in the renal pelvis and parenchyma. At its lower end this system communicates also with the lymphatics of the pelvic structures, in both the male and female.

2. Infections of the bladder or lower ureter may reach the renal pelvis or the kidney, either by way of the lumen of the urinary tract or by way of the mural lymphatics.

3. Experimental and clinical evidence indicates that almost complete obstruction to the free passage of urine is necessary for ascent of infection by way of the lumen of the uninary tract.

4. Experimentally we have shown that infection, set up by the simple introduction of bacteria into the bladder without injury or without obstruction, may pass upward by means of the interstitial lymphatics of the ureter.

5. The degree of involvement following the introduction of bacteria into the bladder depends upon the virulence of the organism and upon the susceptibility of the animal. The subsequent tissue reaction may remain limited to the bladder and ureter, it may pass upward to the tissues of the renal pelvis, or even the parenchyma of the kidney itself may become involved.

6. When the kidney tissue is involved in ascending infection brought about experimentally, as described, the path of travel is from the subepithelial tissues of the pelvis to the kidney by way of the inter-tubular and perivascular lymphatics.

7. From the kidney the perirenal tissues may become involved through the capsular lymphatics, which anastomose with those of the cortex.

8. The experimental evidence indicates that, in cases of pyelitis and pyelonephritis in the human, secondary to infection of the bladder, the lymphatics constitute the most important course of upward travel of the infection, especially in those cases where there is no hindrance to the urinary outflow.

9. Pyelitis and pyelonephritis, not secondary to cystitis, may also be the result of lymphatic transport of infection from the pelvic organs in the male and female, and from the lower intestinal tract.

Before dealing with the prevention of infantile diarrhea, it will be necessary to say a few words on the nature of that disease. It goes by other names: gastro-enteritis, infective diarrhea, intestinal intoxication, cholera infantum. It is mainly a disease of the first two years of life, but attacks all ages, and accounts for a not inconsiderable number of deaths toward old age. It is most fatal during the first year, and in Australia probably directly or indirectly accounts for fifty per cent of the deaths under one year. It is epidemic in the hot months of the year, but occurs sporadically or in small epidemics right through the year. It is a disease of the subtropical regions. It is less severe in cold climes, and shows an inverse relation to rainfall.

The trend of modern opinion is to regard infantile diarrhea as an acute infectious disease with a short incubation period. To this proposition I must give, after a wide and continuous experience over a period of fifteen years, my unreserved support. The casual organism or organisms, for it is probable there is more than one of an allied group, have not been definitely ascertained. Anatomically, the disease is an ileocolitis; there is congestion of the mucous membrane, with swelling of the solitary and aggregated glands which may go on to ulceration; the stomach and upper portion of the small intestine is not affected. The problem of the prevention of infantile diarrhea is, then, that of protecting the infant, against infection by the causal organisms of that disease. Now, although our knowledge is by no means complete on the cause of the infection in infantile diarrhea, we know sufficient to draw some practical conclusions.

We have, first of all, the comparative immunity of breast-fed infants to the disease. This is so striking that we can say if all infants were breast-fed during the greater part of the first year of their lives, diarrhea as a serious problem would cease to exist. I am aware that the immunity conferred by breast-feeding is not absolute, and that the disease is rife after weaning in the second year, but its ravages in such cases are comparatively light. Even where the surroundings are bad, for example, in slum areas where there is domestic over-crowding and defective domestic and perhaps municipal, sanitation, breast-feeding offers an effective barrier to the

disease. One indication, therefore, is the encouragement of breast-feeding, a performance which carries with it other benefits both for the child and mother. Most mothers can, if they wish, suckle their children. There are two classes, however, with whom it is difficult-unmarried mothers and married women who have to work in factories for their living. It should be a matter of public policy to provide means for their being able to do so. Fortunately, the latter class is not much in evidence in, Australia and New Zealand, but in the older countries it is fairly large, and I think its claims are coming to be recognized. For many reasons illegitimate children are weaned early. The death rate amongst them is three times that of all infants. In New South Wales, owing to the efforts of Sir Charles McKellar, the State Children's Relief Department has provided cottage homes where unmarried mothers and their babies may live free of charge for six months after the birth of the infant. This is a step in the right direction, although many refuse to profit by it.

Next, it has been established that domestic overcrowding encourages the prevalence of infective diarrhea. Domestic over-crowding means the common sharing of rooms or houses by too many people. Newsholm makes out that the number of people or houses to the acre does not matter so much. Even in tenement houses the number is not important so long as there is isolation of families and no over-crowding in rooms, as exemplified in the Peabody buildings, where the infant mortality has not been excessive. The worst form of over-crowding is where a number of artificially-fed infants are housed together. The universal experience is that babies' homes and foundling hospitals always result in a huge mortality. The question of over-crowding is a social and economic problem difficult but not incapable of solution if the public conscience be aroused. With regard to babies' homes and foundling hospitals, it is time that philanthropically disposed persons should learn that they do not save, but waste infant life.

Next, the importance of domestic and public cleanliness in preventing diarrhea is well known. The necessity of good drainage, the proper disposal of excretia and garbage is recognized by all public authorities, but in the case of infantile diarrhea these are of no avail unless accompanied