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lated to do good to the patient, or to any other subject connected with the patient (than his recovery.)
Thou shouldst never give out (to others) the practices of the patient's house."
and it was deemed necessary to protect the community against them.
As the Roman Empire declined and fell, learning of all kinds went into the
Please note specially the following: long sleep of the Middle Ages, as did
"There is no end (to reach) of Medical Science. Hence, heedfully, thou shouldst devote thyself to it. Then, again,
skillfulness of practice should be acquired from others, without feeling any humiliation.
Unto men possessed of intelligence, the entire world acts as a preceptor.
Unto men destitute of intelligence, the entire world occupies the position of an enemy."
"I swear in the name of God, the Most High, and of his sublime prophet, Mohammed, whose glory may God increase, to be faithful to the laws of honor, honesty and benevolence in the practice of medicine. I will attend to the poor gratuitously and never exact too high a fee for my work. Admitted into the privacy of a house my eyes will not perceive what takes place. My tongue will guard the secrets confided Ever respectful and grateful to my masters, I will hand on to their children the instructions which I have received from their fathers. May I be respected by men if I remain faithful to my vow. If not, may I be covered with shame and despised. God is witness to what I have said. The oat his finished.
In the Langobard Code, A. D. 650, we find: "Whosoever has inflicted wounds upon anyone, he shall supply him with attendance, and likewise pay the fee of the physician at a rate to be estimated by learned men." (Not by physicians, however.) Physicians were made responsible for their want of skill. Their fees were stipulated in advance.
The morality inculcated in the ancient code and oaths is very high. Good character, good morals and professional secrecy are requisites common to all. The low state into which medicine had fallen during the Middle Ages is reflected in the codes and regulations of the times. Doctors too often had neither attainment nor character
ethics and medicine, and the physician
asteries seem to have been men of learning and to have been interested in medicine; but the medical teaching, which, in the ninth century gave the name of Civitas Hippocratica to Salernum and which developed into the uni
versity of that place in 1150, seems to have been purely secular. The monks they added little or nothing to exact as a class preserved literature though knowledge. The Benedictines, however, gave special attention to illness and some of them seem to have possessed medical as well as general learning.
It is interesting to remark that the origin of the first European university was its medical school. To Salernum went William of Normandy, afterwards the Conqueror, in quest of health, which his subsequent career would seem to show that he regained. Frederick the Second, Emperor of Germany, 1194-1250, included in some ordinances relating to practitioners a provision that no one should be lowed to bear the title of physician unless he had passed the examination at Salernum.
But we must hurry on, great as is the temptation to linger. The history of medical ethics is inseparable from the history of medicine, and broadly speaking, no real progress in ethics can take place without antecedent progress in medicine.
During the seventeenth and eighteenth centuries the system-makers, from Van Helmont to Hahnemann, were dominant, the resurrection of ancient literature leading at first to a blind reverence for authority, especially that of Galen, and the expenditure of brains often worthy of better things on hypothesis rather than on observation and experiment. Finally, the foundations of real progress were laid by Harvey, Sydenham and John Hunter, to select the great names of England alone. During the reign of the system-makers the lack of respect in which physicians were held, and part of the reason therefor, are reflected in the literature of the times and in the unsemly to use a mild word-professional wrangles of the day. Contrast the attitude of Moliere toward doctors of physic with that of writers for the modern stage.
A class, as well as an individual, must respect itself to win the respect of others. Too many of the leaders of the profession, garbed in a long, velvet-lined doctor's robe, later with peruke, cane and sword were mere pedants at the best, though they assumed the air of savants and deemed it beneath their dignity to render other services to the sick than to give dogmatic avice and write elaborate prescriptions. They took themselves very seriously. Perchance, had medicine. stood higher in popular estimation, Rabelais. Smollett and Goldsmith might have been lost to literature. Rabelais was for fifteen years a monk, the last five years a Benedictine. The relation of the Order to medicine has already been spoken of. Had Rabelais not left the Franciscan for the Benedictine Order, would he have turned to medicine?
The duel between Doctors Bennett and Williams in the eighteenth century was a forerunner of similar events at a much later period, of events not quite unknown today south of Mason and Dixon's Line. A pamphlet quarrel led to blows, and then to a chal
lenge from Bennett, declined by Williams. Bennett then called on his confrere and called him a coward. Williams opened his door himself and shot Bennett with a pistol and swan shot in the breast. Bennett retreated across the street to a friend's house, followed by Williams, who sho again and then ran him through with his sword. Bennett managed to draw his sword and ran Williams through the chest and scapula, the sword breaking off short. Williams died before he could reach his house, Bennett died in four hours.
In 1830 took place near Philadelphia a duel between Dr. Smith and Dr. Jeffries with pistols. Shot one at eight paces a miss; shot two breaks Smith's right arm; shot three wounds Jeffries in the thigh, causing him to bleed profusely. Bandages and brandy put him. in condition for shot four, which, the men being only six feet apart, was fatal to both.
If there are pessimists among us, let them read of past times. The fundamentals of human nature do not change. Fashion is still potent and always will be. But self-restraint has increased and the fire of passion is less easily lighted in those who are humbly trying to observe the facts and learn the laws of nature than in those whose pride and feelings become enlisted in the advocacy o fa hypothesis or a theory. Contrast the attitude of the profession at large toward inoculation and vaccination, and toward every innovation of past time, with that toward Pasteur, Koch, Lister and other revolutionists of modern times. Contrast the doctor of the stage and fiction in past and present times. Doctors of Medicine still differ, for medicine is not an exact science though it is coming more and more to rest thereon. But now when they differ they do so temperately, recognizing that there is fair ground for difference of opinion in many matters. Doctors of Law are paid to differ. The differences of Doctors of Divinity, to whom the proverb. that doctors differ was probably first
applied and who have succeeded in sloughing it off on us, are patent, and led to the horrors of the Inquistion and of the Reformation.
Our manners are not always good. In some respects they are inferior to those of earlier times, when the liability to be called to account in a duel, made men careful, often ceremonious, even if modesty and respect for the rights of others were lacking. But we are, in the main, far more tolerant in differences of opinions, more open to conviction, far less acrimonious in expressing our differences. Codes of medical ethics have grown shorter and simpler, where they persist, as in my own State. The very word "Code" has been dropped by the American Medical Association, which prints a statement of the "Principles of Ethics" comprising helpful suggestions as to the relation of physicians to their patients, the public and one another. The British Medical Association has no Code. Ethical conduct is promoted by education, culture, example, not easy enforced on the unwilling by law, so full of loopholes for those in search of such. The laity is gradually learning that "professional etiquette," which it has characterized as inhumane, selfish, absurd, in truth rests primarily on the interest of the patient, only secondarily on that of the doctor. The relation of doctor and patient is such, such the interaction of mind and body, so largely does mere perversion of function represent, modify, or complicate definite disease, that the confidence of the patient in the knowledge, skill and character of his physician is always a very important element in the carenot infrequently an indispensable element in the cure-of the sick.
It is harmful to the character of one physician to directly or indirectly sap the confidence reposed in a professional brother. It is harmful to the usefulness of the profession at large so to do. It is harmful to the sick man. dignified silence or reserve as regards quacks, even notorious quacks, is, as a rule, wise. We should certainly not
go out of our way to break such silence. A certain proportion of the community is always ready to worship. false gods, a larger proportion to be temporarily led astray. But as Mr. Lincoln is reported to have said, “you can't fool all the people all the time," and inthe long run truth prevails. The length of this run is shortened by absolute honesty in thought and deed on our part, by freedom fram affectation of power and knowledge which we do not possess, by an attitude of mind which welcomes and recognizes progress, even though it may seem to clash with our personal interests at the time. Most of the ridicule which was unsparingly dealt to our profession in past times was richly earned by the assumption of so many of its members. The gold-headed cane, a portentous gravity of manner, a peculiarity of dress, other than that of scrupulous neatness, are trivialities which have had their day, like the proverbial dog.
The philosophy of life has been well, even if profanely summed up in the advice of the Missouri father to his son: "So live every day that you can look every damned man in the eye and tell him to go to hell." Note that the latter part of the injunction is permissive not mandatory. The important thing is the mode of life. The exercise. of the privilege is secondary, subject to the inhibition of modesty and common sense. Duty is ever paramount. The right which is attached thereto it may be better for us not to insist upon, and then only with careful regard for time and season.
Every rose has its thorn, and one of the thorns of the lovely rose of the practice of medicine is that the daily work of the physician brings him so much in contact with his inferiors, that is, with those who defer to his judgment. He thus comes in danger of being opinionated, intolerant of difference of opinion. Efficient antidotes to this toxin are an active share in medical meetings and the careful reading of at least one first-class medical journal of general scope. I have in mind more
than one physician practising in small who take time-I know not how, save as a triumph of mind over matter-to do these things, and I don't find these men the least ethical of the profession in their localities. We physicians must not only hold our tongues, but, more than men of some other professions, must shut our ears to tales, whether idle or malicious, either of the shortcomings and mistakes of fellow practitioners, or of remarks attributed to doctors or patients and derogatory to us. Such things should, in the majority of cases, pass us as the wind which we regard not.
There is one conspicuous feature in which the ethics of medicine differ from that of nearly every other call ing. The inventor of a machine, or of a process of manufacture, or a device, can patent it and receive legal protection, and receive all the emoluments directly flowing from the invention. It is considered good public policy thus to stimulate human progress by what is virtually a tax or bounty paid by the community. So also human thought embodied in the printed book may be copyrighted. Health and its preservation are matters of such universal and vital import that the profession of medicine itself has decided that its members must forego anything like proprietorship in progress. The Bowles stethoscope is patented and is therefore expensive. Conduct and a profit allowable to Mr. Bowles would not be allowable were he Dr. Bowles.
To the doctor in love with his profession Heaven may sometimes appear as a place where he can exercise his calling without the necessity of taking fees a fully endowed, organized and equipped hospital, if you will. Fees
are the plague of a physician's life, although in the present organization of society, a necessary plague. The price of medical attendance cannot be fixed and uniform to anything like the degree that obtains with other human necessities. He who cannot afford the first cut of beef suffers no real loss or hardship from the second or third. A
skilful manager can fee dhimself or a household sufficiently and wholesomely at small expense. There are those among us who would be the better for taking the advice of Abernathy to the nobleman: "earn a sixpence a day and live on it." So also large expense is not needed to cover our nakedness and protect us from the weather. It is only the rich man, however, who can afford to indulge in second or third rate doctoring. Health is everything to the wage-earner and small salaried man. whose family depends on his daily returns. The poorer a man, the more he needs a good doctor. And it may safely be said that the poor in hospitals are often better attended than the rich in their "palatial residence" as the newspaper says. The poor man is often more thoroughly studied, and therefore probably more intelligently treated. In my own State I know one town where, there being no poor, the poorhouse is rented and thus brings revenue to the town. In such a community fees can be tolerably uniform. Fee tables have their use as representing the minimum which should be charged to those able to pay for attendance. It is neither for the interest of the laity nor of the profession tha fees should be cut for any reason other than the inability of the patient to pay. I have heard a medical friend state with pride that he had never taken a dollar fee. This seems to me a mistake. If a patient can afford a dollar and cannot afford more, is it not wise to accept it? The self-respect of the patient is preserved and the advice is likely to be of more service.
The maximum fee seems to me unlimited, provided that it be agreed on beforehand. Unless it be so agreed on, a rich man should not be charged an unusual fee for a usual service. Lawyers are apt to gauge their fees by the amount of money involved, especially to corporations. Some of them thus receive compensation which makes our hair stand on end. They deal with definite sums of money, we with the inestimable values of life and health.
They render services which, as a whole can be measured in money, we services which very often cannot be measured by that standard. I have heard a very eminent lawyer claim great credit for the legal profession, in that no lawyer takes from any man any more than he has. Remember the injunction of Charaka not to drain the patient.
I repeat that fees are a plague. We are so often at a loss how much to charge and cannot avoid some mistakes. There is greater danger of underrating the ability of the patient to pay than there is of overvaluing our services. Then again, there is the plague of collection. It is not every bill which is settled by a check in the return mail. There are those who try to cheat-and who succeed. But it seems to me that, on the whole, people pay their just debts fairly well, and we must offset those who do so with grateful recognition with those who do so grudgingly, tardily or not at all.
Cannot we abridge the Golden Rule simply into "Let us be gentlemen."
Let us possess our souls in peace when we find that there are those who are not gentle folk, pursuing the even tenor of our way and cultivating that precious quality of equanimity, the merits of which have been so well set forth by William Osler.
Robert Louis Stevenson, who surely had the opportunity to suffer many things from many physicians, and therefore should know whereof he speaks, says: "the physician is the flower (such as it is) of our civilization; and when that stage of man is done with, and only remembered to be marvelled at in history, he will be thought to have shared as little as any in the defects of the period, and most notably anticipated the virtues of the race."
Dr. Irving C. Barnes has located at 160 East Market street for the practice of medicine and surgery. New phone 974. The usual hours, mornng, afternoon and evening.
WHY I WRITE FOR INDEPENDENT JOURNALS.
BY G. FRANK LYDSTON, CHICAGO, ILL., PROFESSOR OF GENITO-URINARY SURGERY, STATE UNIVERSITY OF ILLINOIS.
(Abstract from Texas Medical Journal for August.)
The feaure of the better class of independent journals that appeals most strongly to me is the mere fact of their independence in wearing no brand or collar. As matters medico-literary are now trending, the day is not far distant when the average practitioner of medicine will have no medium of expression, no literary representation and no literary pabulum of practical value within the comprehension of the average medical mind. Medicine is fast becoming so scientific, so turgid with "things that ain't so," or which are at least "under suspicion," that the main purpose of medicine, the healing of the sick, bids fair to be lost in the maze of laboratory experimentation. and illogical deductions from mentally indigestible "facts"-scientific bricks without straw-from which none but a wizard could build an enduring fabric. What boots it to the practitioner of the crossroads that there be opsonins and opsonic indices? He has neither the technical training, the appliances nor the time to practically apply them in his daily work. Beeides, who knows how soon the opsonins will be gathered to the snows of yesteryear?
I fancy I hear the ultra-scientific ones cry, "Let the practitioner of the crossroads and the hamlet hie him to the post-graduate school and cultivate. -at so much a cultivate-'the optic sharp I wean that sees things which are not to be seen.' Let, also, the studen of medicine be more thoroughly prepared in things scientific."
As to the post-graduate school, it often makes confusion worse confounded. Abdominal and other special surgeons "made while you wait"; men