When the Red Cross Societies of the East meet next January in Manila they will be able to investigate at first hand the various interesting questions that have arisen from the recent epidemic of smallpox. This epidemic has provoked a great deal of correspondence in lay as well as in medical papers It is claimed as a triumphant vindication of their position by both the anti-vaccinationists and the health department which practises vaccination. From other points of view also, thanks to the careful observations and accurate statistical methods of the Philippines Health Service, there is matter for study in the events surrounding this epidemic.

The comparative freedom from smallpox of the Islands before the year 1918 has been attributed to the vaccination campaigns carried out under American administration. Therefore when a very severe epidemic broke out that year, the "antis" were only too ready to proclaim that vaccination had failed Some American journals asserted that the Philippines had been protected but that since 1916, when the American administration was handed over to native control, vaccination had been inefficient. This argument is, however, disposed of by the present director of health, Dr. V. Jesus, who shows that the number of vaccinations had been increased from 7,113,963 in the five-year period 1911-1915 to 17,322,927 in the period 1916-1920 (1) The fact is that the population was not well vaccinated in 1918 and though the general immunity may have been sufficient to check ordinary strains of variola, the particularly virulent strain which then visited the Philippines was not to be denied.

While the anti-vaccinators may congratulate themselves that certain sanitarians were prematurely confident, they are not entitled to any more self-satisfaction than they can get from that. The epidemic itself added a lot more evidence to the already large mass which can be used against them.

(1) Monthly Bulletin of Philippine Health Service, September,

1922, P. 274.

Moreover, the epidemic was overcome most rapidly just where vaccination could be most speedily and efficiently organized. Thus it had been stamped out in Manila by the end of the year 1918 but in the Provinces Mindanao and Sulu it lasted for two years longer. In these provinces an unusually large number of families refused vaccination and concealed their children.

It is in the out-lying parts, too that transportation difficulties are greatest. Vaccine rapidly loses its activity in tropical climates unless kept on ice and it is quite impossible to carry ice all over the Philippines. This question of preserving vaccine in the tropics is an urgent one and merits full discussion at the second oriental Red Cross confer

ence.

It is noteworthy too that Mohammedan people sometimes object to the vaccination scar on the ground that it is a sign or stigma of Christianity. If the Red Cross could secure an authoritative pronouncement in favour of vaccination from some influential Mohammedan source great benefit might result.

In 1921 there were still 1,160 cases in the Division of Mindanao and Sulu. All but 8 of these were unvaccinated. And now appears another

The anti-vaccinators are fond of saying that if it is only the unvaccinated who risk smallpox, why not leave them to take the risk if they wish to? Evidence is accumulating that the risk they take is not confined to themselves. Dr. R. G. Padua (1) in a statistical study just published shows that "in general the specific morbidity and mortality rates of smallpox among the vaccinated have been the lowest in the infected provinces where the percentages of immunized population have been the highest, and so conversely". Even in the matter of vaccination we cannot live to ourselves alone.

Experience teaches us that "immunity" is a relative and not an absolute term. Our fathers thought that once vaccinated they were safe for life, no matter how virulent the infection. We know now that immunity wears off and that the question of whether we catch a disease or no depends not only upon how much immunity we possess but on how big a dose of germs we get and how fierce those particular germs happen to be. We can admit all this and still be glad of the protection which vaccination afford us and still insist that if everyone were vaccinated smallpox would be wiped out. It is our unvaccinated neighbours who breed the most deadly infection.

(1) Journal Am. Med. Assoc., May 12th, 1923, p. 1361.

Mr. Sumner Macomber Curtis, editor for two years of the National Red Cross Bulletin of the American Red Cross and well-known American journalist, was killed in a motor accident in the Colorado mountains, June 24th, while travelling in the west with the official party of President Harding. Before entering the service of the Red Cross Mr. Curtis had acquired a wide reputation as a writer on political topics and he brought to his editorial work a genuine gift for felicitous expression. His death is deeply regretted by many Red Cross workers who knew and admired his ability and his devotion.

THE VOLUNTARY WORKER

There is a tendency, with the increasing organization of public health work in all its branches, to crowd the voluntary worker out of existence. Is this justifiable, either on the grounds of efficiency or of economy? It is a problem which all health workers, and particularly Red Cross Societies, are called upon to face, and it is one which cannot be airily dismissed by the assertion that someone "does not believe in voluntary work", or that

one has no hold over voluntary workers".

The war, by a curious paradox, while it saw the apotheosis of the voluntary worker, was also largely responsible for her downfall. The same exceptional conditions which gave volunteers an opportunity such as they had never before experienced to undertake responsible work, also revealed the fact that some of them had grasped very imperfectly what such work entailed, and the enthusiasm of these evaporated in proportion as their work increased. Among other things, the war taught us that an organization, if it hopes to run smoothly, cannot afford to clog its wheels with useless material, and that it is more economical to pay efficient workers than to employ inefficient volunteers.

Fundamentally there is no difference between the volunteer and the salaried worker beyond the fact that the one does not receive a salary and the other does. A volunteer, because she is highminded enough to wish to give her services

for nothing (a quality we are continually seeking to inculcate in our Juniors), is not necessarily inefficient; she has at least one good qualitygenerosity. Is it not worth while to search for others? The fact that she refused payment did not stigmatize her during the war; her services were accepted, and how acceptable! Although war conditions are no more, the conditions following the war are such that the utmost economy must be practised in the outlay of public and private funds. Can we, therefore, afford to neglect this valuable material which lies to our hand?

On the other hand, can we afford to make use of it? Time is valuable; space is valuable, and in this present-day efficient world there is no place for inefficient and irregular workers. The position seems to be this: we can only afford to use voluntary workers if they adhere to the same standards as salaried workers. They must not expect to have their services accepted merely because they offer them; they must be qualified, or willing to qualify, for the work in hand. Furthermore they must not expect to work when they like, but when they are required. They may not be able to follow the hours of the salaried staff, but whatever agreement they make, they must adhere strictly to it, and they must make it a point of honour to submit to the usual discipline. In doing this they will be protecting their own interests.

Given volunteers who are efficient, reliable and stedfast, they can be of the utmost service, and the introduction of an element of self-sacrifice into health and social work lifts it from the rut into which all routine work is too apt to fall.

THE RUSSIAN PROBLEM

During the last six months other events in Europe have driven the Russian famine and its after affects from prominence. The annual report of the A. R. A. (American Relief Administration), covering the period April, 1922, to April, 1923, comes as a timely reminder that relief organizations have been steadily though silently continuing their work. Though it is hoped that conditions after the next harvest will be such as no longer to make it necessary for the Association to continue its work, the report states that no decision in this matter has been taken as yet.

The peak of the feeding operations was reached in August, 1922, when nearly 11,000,000 children and adults in the famine regions of the Volga, the Urals and the Ukraine, and in the cities of Petrograd and Moscow were being sustained by American food. This number has now been reduced to 1,520,160 (March, 1923). Over 12,000 medical institutions with a capacity of more than 800,000 patients, were assisted with medicaments and hospital supplies, and over 7,000,000 persons were inoculated or vaccinated in the campaign against epidemics. The medical supplies were furnished by congressional appropriation and by the American Red Cross.

Reviewing the present programme, the report states that there have been four entirely different relief problems in Russia: first, the emergency famine relief requiring the importation of large quantities of food; second, disease, due in part to famine conditions and in part to general deterioration and lack of medical and sanitary work; third, poverty, which is the result of the economic

demoralization of Russia; and fourth, reconstruction, which is the problem of the rehabiliation of industry and agriculture.

The first problem is already largely disposed of, and if the harvest of 1923 is successful, continued shipments even of special foods for children should not be necessary. Although the spread of epidemics has been greatly checked, the need in this field is so vast that further importation of supplies, either by the Soviet Government or by charitable societies, will be necessary. Fundamentally, the problem of poverty is dependent upon reconstruction and cannot be permanently solved by charity. The reconstruction of Russia's industries and foreign trade is not a problem of relief, but in the field of agricultural reconstruction much has already been accomplished by foreign relief. The report points out, however, that the A. R. A., being an emergency organization solely for famine relief, cannot undertake reconstruction.

A number of national and religious organizations in America have made generous contributions to the A. R. A.'s work and it has been to no small extent due to the solid co-operation of these organizations that it has been possible to mobilize for Russian relief more than $60,000,000.

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WHAT TO EAT (1)

The rapid development of physiological chemistry in recent years has resulted in many new and interesting ideas on the subject of dietetics. Publishers, especially in the United States, have not been slow to produce popular expositions of the new dietetic principles for the benefit of the general public. Dr. Harrow's book is by no means the first in the field. The little « What to eat » covers fairly a wide range of topical essays on such subjects as vegetarianism, infant feeding, constipation and digestive disorders. It is perhaps inevitable that, in dealing with so many subjects in a

(1) What to eat in health and disease, by Benjamin HARROW, Ph. D. New York: E. P. Dutton and Co. 1923. Price $2.00.

popular style, the treatment accorded should be superficial. The informed reader will wonder constantly on what ground the publisher's announcement has enlarged the author's more modest claim into a guide for those who want to know what to eat and why".

Obviously", says the author on page 12, "too much candy is harmful to the system." But it is not obvious what he means by too much candy nor is there any explanation of why it is deleterious unless we accept as such the remark, on a later page, that the "immoderate use of sugar tributes to the condition known as upset stomach ". Although the book abounds in similar disappointments for the curious, there is none the less a goodly supply of up-to-date and useful informa

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tion for those who are not acquainted with the most recent work. The latter will derive more profit from the bibliographies appended to each chapter than from the text itself and all will be interested in the numerous full page portraits of eminent physiologists and chemists in both hemispheres.

The later chapters on what to eat in disease had better have been omitted. The dietetic treatment of such diseases as tuberculosis requires either much fuller treatment or should be left entirely to the physician. On the other hand the final chapter on the digestive tube-a popular treatment of the anatomy and physiology of digestion is the best in the book.

A NEW NURSING JOURNAL

J. R. E.

Interest in public health nursing grows daily and we have been glad to contribute to it recently by publishing articles on the subject by Professor Bernard and Dr. Kuss in this review.

To-day it is our pleasant duty to hail the appearance of a new nursing journal-a monthly technical review entitled L'Infirmière française («The French Nurse ») (1). The first number contains a preface by Professor Calmette from which we quote the following:

"Wherever the nurse goes, be she nun or lay sister, pain is relieved and tears are dried. Her veil, white as angel's wings or blue as the vault of heaven, carries in its folds a message of hope and infinite goodness. What a splendid mission of charity or of fellowship-call it what you willhese fine women are fulfilling, asking for no other love than that of the suffering, in whom some see the image of Christ the Redeemer whilst others, in serving them, find satisfaction for their craving

for self-sacrifice and devotion.

along the way, and to share with them our intellectual and moral experiences. Since union makes for strength, let us unite so that we may be stronger in face of the suffering and ignorance which we must vanquish, of tuberculosis, of syphilis, of the many causes of infant mortality which must continually be fought against, and of the corruption of morals which must be overcome.

"The district nurse, under the direction of the district medical officer, should educate the family in hygiene, watch over the expectant mother, encourage mothers to attend baby welfare centres teach them how to care for their babies, watch over the health of schoolchildren, report cases or suspected cases of illness to the doctor, prevent and track down infectious diseases, and apply the preventive measures prescribed by the doctor and by law.

"Without her no real progress in hygiene can be made among the masses and in rural districts. She is as indispensable as is the teacher. As soon as she comes into being, no one will be able to do without her.

"

No one will be able to and no one can do without her. This new journal fills a great need by spreading this conviction. Its appearance is one more proof of the existence of a growing public interested not only in the practice of nursing but also in public health and social welfare.

The first number contains an article on the feeding of tuberculosis patients which should be of great value to dispensary nurses; other articles are on first aid in case of fracture, on disinfection and on the problems of professional training which were discussed at the Paris meeting of the European Council for the Training of Nurses last March. The fact that Professor Calmette, founder of the dispensary in France and an ardent supporter of public health nursing, is its director and that his colleagues have been chosen among people with wide experience, will give this review a splendid send-off and we hope it will speedily find its way into the hands of all French-speaking nurses.

F. H

Le Gérant: LYMAN BRYSON.