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In December, 1911, she reported herself five months pregnant. No untoward symptoms had so far developed, but in the 8th month she complained of headache, dizziness and slight dimness of vision. Urinalysis Feb. 19, 1912: Urine clear, color yellow, acid reaction, sp. gr. 1022, small amount of albumen, no sugar, acetone reaction positive. She was at once placed upon sod. bicarb. in drachm doses, 3 times daily, after meals. Her symptoms gradually cleared up and on March 16, 1912, she gave birth to a lusty youngster. Labor and puerperium were normal in every way and she made a splendid recovery.

In closing I will state as my firm conviction that these four cases would have terminated in eclampsia if the warning given by the presence of acetone in the urine had not been heeded, and I offer this humble contribution in the hope that it may be of some benefit to the brethren engaged in obsteteric practice.

I acknowledge my indebtedness to a paper by Dr. B. W. Rhamy of Ft. Wayne, Ind., entitled, "Acetoneuria and the relation of acetone to acid intoxication" which appeared in the Journal of the A. M. A., March 2, 1912, in which he gives a resume of the work done by investigators along this line-up to the present time. I have made some quotations from same, which is hereby acknowledged.

Conservation of Energy

*By C. C. JOHNSON, M. D., Creighton, Neb.

Abuse in one way or another is perhaps the greatest friend the physican can lay claim to, and it is also one of his worst enemies. Somewhere back in the ages before laboratories, stateboards, clinics, sterilization, anaesthesia, vibrators, automobiles and pathys ex gratia, were in existence, some misguided yet philanthropic physican started the abusive custom of working three-fourths of his time for what pleasure there was in it, trusting to the good will of his clientele and heavenly indulgence to balance the account. Like birth-marks, enuresis and the seventh son it has stuck in the profession, until the present day we have this parasite clinging to our erstwhile aseptic methods. Why a physician should be held to render service without compensation, or why he should compel one party who is able, to pay indirectly the bill of the less fortunate in worldly goods, which is not equitable is more than I am able to determine. That may be because I am the physician and not the patient.

*Read before the Elkhorn Valley Medical Society, at Norfolk, Jan. 21st, 1913.

The erroneous idea that a physcian is compelled to render medical service whether he desires to or not may have something to do with furnishing a nutritive media for this decrepit custom. Be that as it may it is safe to say that the average physician renders thirty per cent. of his services without compensation, at least ten per cent. of this is a total loss and the other twenty per cent. is like mining stock certificates, glittering possibilities. I am forced to believe that the causative factor, which we as physicians must ever keep in mind as being of prime importance in arriving at satisfactory results is the physician himself. It is the general opinion in the commercial world that not more than one out of ten physicians has average business ability, and I believe it is true. It is safe to state that considering the cost of production, time required, and length of time allotted to the physician, he accumulates less than any other professional man, and is appreciated less than any other. It has been the custom for the doctor to be hard up, to be in debt, to be considered poor pay, to, in fact be the goat, and unless he is willing to throw off the shackles, he will be so considered till the end of time.

The facts are, conditions have changed so rapidly that the physician must either change his business methods or so far as the country doctor is concerned, he must fall by the wayside or give up his profession. For example: Take a physician who makes $5,000.00 a year, which is more than the average country doctor makes. His office costs: Rent, $184.00; telephone averages, $48.00; drugs and supplies, $350.00; auto or livery hire, $600.00, magazines and medical books, $100.00, attendance at medical societies, clinics, etc., $150.00; not to include post-graduate work which he should have, it is a total of approximately, $1,450.00, for the office alone. Allow another $1,450.00 for house rent, its as cheap to rent as to own and it makes no difference which way you figure it, household expenses, clothes, etc., and I doubt that it will cover these expenses unless strict economy is exercised, a total of $2,900.00 for living expenses and maintaining his profession. A ten per cent. dead loss leaves from amount earned $4,500.00, a twenty per cent. very questionable, leaves a total net earning in cash of $3,500.00, which, less total net expenses, which must be cash, leaves a balance of $600.00 for a years work. The requirements of the medical man of today are high. The poor young man can hardly hope to get through the course from high school to the diploma on $3,000.00. I know whereof I speak, for I made that grind

on my own responsibility, when the course was only four years. When he is through he has five years to build up a practice, ten years to enjoy it, and five years to be supplanted by the younger man, unless he is a progressive physician, and keeps up-to-date. Now I will agree that were not monetary considerations demanded of the physican, were he not considered by the business world as any other business man is considered, he might if his spirit did not rebel, be willing to give his services gratuitously and trust that those who have plenty would furnish him enough to subsist. Personally I cannot accept the statement that "a profession has for its prime object the service it can render to humanity; reward and financial gain should be subordinate considerations," and from observation even the most straight-laced ethical if they do accept it, do not live by the rule. If it is true, it should apply to journalism, law, dentistry, and other professions. Why should we be singled out from all the rest of these and the application made to us alone? Are we a specific class? If we are, then we should have the benefits as well as the responsibilities. But to maintain that we should bear the responsibilities without any considerations, or the same as are granted to other professions, seems to me to be a trifle unbalanced. There is also another phase of the question. Whenever we accept a case, be it ever so trivial, we incur a liability. We submit ourselves to criticism, to misrepresentation, not to mention civil action for alleged mal practice. And in the event we get our neck in the noose prepared by some professional brother on a contingent fee, we must put up money to another of his brothers, to prevent some party to whom we have placed service above consideration, taking from us a life's earnings, or ruining our professional standing. To my mind physicians are either a necessity or they are not, and sentiment should not be allowed to over-shadow facts. If we are a necessity, we should be protected and encouraged, if we are not, then we should exercise our own prerogatives, do business as any other business man, chill steel our hearts, treat others as we are treated in the business world and stop carrying water on both shoulders. That course however would be more regretable than at first sight may seem apparent, for there are times when the physician saves life, preserves the home, and without a doubt is indispensible. His horizon is broadening year by year, and he must keep pace. To him is due the successful work in the Panama Isthmus, the habitability of many tropic countries, the existence of cities as they are today, the output in the commercial world, efficiency

in the army and navy, and the saving of lives on the field of battle. And to him will be due the education of the children in the schools of America in the principles of infectious diseases and sanitation, which will make us stronger and a better people, and which no doubt will in the future minimize the services of the physician in the capacity he is employed at the present time, but his services will be required under modifications so long as there are civilized nations.

I am of the opinion that it would be a splendid innovation if a business chair were incorporated in the medical colleges. Anyone who knows will agree that it costs close to $1,500.00 to equip an office demanded of the modern physician. Not to mention the modern mode of conveyance; he must attend clinics and keep versed with present day advances or fall behind, he cannot stand still. Up to the present time I have learned of no way in which he can acquire these things without money. I have not been able to learn of any manner by which dead accounts can be turned into money. If any of my hearers can invent a successful plan I will gladly take any amount of stock in the enterprise and devote my time to it rather than to the practice of medicine.

There are several phases of the physician's life which are regrettable, one jealousy

"O beware, my lord, of jealousy,

It is the green-eyed monster which doth mock,
The meat it feeds on."

We are all guilty, it is the curse of the medical profession, and like the jealously mated couple, it works hell twenty-four hours out of the day. Avarice too plays a part, how often we grab another's patient with the avidity displayed by the household cat, and how many times have we been stung by the deadbeat. It is sometimes difficult to derive this knowledge in advance, for this floating class is kept in a school where necessity compels them to be clever, and they are apt pupils.

I have made an arbitrary classification of the poor:

1. The honest poor. In this class I place those who will pay and do pay as quickly as possible, those who depend upon their wages, their crops in season, and who should be given services and much consideration.

2. In the second class, I place aged dependents, and wives. and children of worthless husbands. They are a lamentable class; they may be likened unto miniature business establishments, under ordinary conditions they are able to survive, but

an extra demand upon their resources renders them insolvent. They are not paupers, and should not be made such, a little assistance would tide them over the rocks, and it should be given, but they are not our responsibilities, no more than are they the charges of religious bodies of the universe.

3. In the third class I have placed the "professional poor," the professional man and woman dead-beat, and with them the cuttle fish who have money to meet their obligations, but who will not do so until compelled to, and who then leave the office or court room with a sledge hammer in the air. One is as bad as the other.

In the law under which the second classification could possibly be reached, the fundamental principle is absolutely wrong. Assistance cannot be given these people by the county without pauperizing them, county commissioners are cognizant of conditions, but were you to take the matter up with them they will tell you that their hands are tied by the law, which they cannot go beyond. The section of this law which limits the salary of the couty physican to a maximum sum of $200.00 is ridiculous, it would not pay the mileage. No physician could accept the position at that figure and render honest service. I believe that there should be a county health officer, a physician. That he should be selected by the county commissioners, and that he should be as centrally located as possible; that it should not be made a political position; that it should not carry with it any remuneration excepting that earned by labor performed; that the physician should not accept the position only upon the schedule of fees charged by the majority of physicians of the county, in fact that he should be well paid instead of being compelled to bid for the position, for the cases he would have are harder than any other class of patients. Further to the end that so far as possible the choice of the patient should be respected as we recognize this choice as a large factor in successful treatment, and to the end that expense be reduced to a minimum, he should have power to authorize any legal practicing physician in any city or locality of the county, to work under him and report to him in the following manner.

A dependent patient calls a local physician of any legal creed, he knows these people, he in turn calls the county physician for authority to care for the case. The county physician phones authority, and must within twenty-four hours mail such authority on blanks prepared for the purpose in duplicate form, to the local or requesting physician. The physician who asks

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