VOL. II.-No. 7.

Index.

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In Funk's Standard Dictionary the term "Ethics defined as "the science of human duty," "moral science," "the science of right and of right character and conduct;" and that aspect of it which deals with the Medical Profession we call Medical Ethics, and it includes the variety known as Etiquette.

Just as Ethics in general are absolutely necessary to the cohesion of the human race, to the possibility of concerted action in national, social and domestic life, so is a Code of Ethics essential in business and professional life.

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Thus, Rules must be laid down, accepted and acted upon, drawn from the principles of Ethics in general, and others framed to meet the special conditions of our work.

It may seem to the egotistical or needy that Ethics are all very fine in theory, but in practice decidedly inconvenient or contemptible. Calm and deliberate consideration, however, will surely convince the most egotistical or needy that some standard of moral conduct is as essential in professional life as in social.

It will be found, I think, that those who affect to disdain the trammels of Ethics mostly belong to the ranks of these two classes-the one from an over-weening sense of his own superlative importance, and the other (the more pardonable of the two) from an acute sense of the necessity of earning his salt.

The young practitioner going into the world armed with (what appears to him) an omnipotent set of Diplomas generally makes the painful discovery that he is received with severe politeness by his neighbouring brethren, and decided shyness by the ailing public. His liabilities grow large and his capital small. Thus the temptations to depart from the letter and spirit of a code he was never taught and practically knows little of, are occasionally considerable.

There are people who are so sordidly constituted that all they do and all they aim at is bound by the immediate material advantage to self. They may even be wealthy but they view their profession as a business project only, and their motto would seem to be "get patientshonestly if you can, but get them," and they care not whom they trample down in the process.

Warped as we all are more or less by prejudice, our likes and dislikes towards other professional men, to some extent, control our conduct towards them. Especially if we conceive ourselves to have been wronged by another, are we prone to disregard the dictates of professional honour in our desire to give as good as we get.

This brings us to the consideration of our point of view.

If I regard every sick individual within the sphere of my work as belonging by right to me, feel annoyed if some prefer to consult a neighbouring practitioner, and regard every other practitioner not as a professional brother but as an opponent to be jealous of, then I am in a miserable frame of mind indeed and one altogether unjustifiable.

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for supposing that there is scope for another. To many it is undoubtedly a trial to find a stranger setting up his brass plate in a locality where they have long been accustomed to regard themselves as possessing monopoly and even a vested interest; and it is a still ruder shock to find some of their best patients preferring the "interloper," as they would call him. Professional honour and gentlemanly feeling ought however to restrain them from committing any act or adopting any attitude towards the new-comer which would lower him in the eyes of the community, and so drag the profession in the mud. Nothing pleases some people more than to see medical men at war with each other, and they delight in retailing to their own doctor little bits of scandal more or less exaggerated about another doctor. Such mischief makers should be firmly suppressed.

The subject of Medical Ethics is no new thing. It had its origin in ancient times and has grown with the advance of the Art of Healing. It ought to be brought to the notice of every student of medicine and practitioner and not left to be picked up anyhow. A few years ago the necessity of this was seen by the Medical Authorities of New York, for they caused 5,000 copies of an abridged edition of a Code of Medical Ethics to be distributed among the students of the State; and in France, Germany and elsewhere special lectures are now delivered on the subject.

In the days of ancient Greece, before the time of Hippocrates, the oldest written monument of the Greek Art of Healing (according to Baas) is the Oath which the pupils of the Asclepiadian Medical Schools were bound to subscribe to on completion of their course. It runs as

follows:

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THE OATH.

"I swear by Apollo, the physician, and Esculapius, and Health and Panacea, and all the gods and goddesses, that according to my ability and judgment, I will keep this Oath and this stipulation to reckon him who taught me this art equally dear to me as my parents, to share my substance with him and relieve his necessities if required, to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction. I will impart a knowledge of the art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, and to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patient, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practise my art. I will not cut persons labouring under the stone,* but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from any voluntary act of mischief and corruption; and further, from the

Some authorities say this passage should be rendered "I will not perform castration."

seduction of females or males, of freemen or slaves. Whatever, in connection with my professional practice, or not in connection with it, I see or hear in the life of men, which ought not to be spoken of abroad, I will not divulge as reckoning that all such should be kept secret. While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art. respected by all men, in all times. But should I trespass and violate this oath, may the reverse be my lot!"

In this oath are embodied many important Ethical principles: (1) The normal obligation the physician is under to reverence and minister to the wants of his teacher, his teacher's sons and his own sons; (2) the obligation to act to the best of his ability in the interests of his patients; (3) the obligation to abstain from infamous conduct in a professional sense; (4) to live an honourable life towards men and women; (5) to observe professional secrecy.

There is nothing expressly stated regarding the conduct of the physician to other practitioners, but the clause which says "with purity and with holiness I will pass my life and practice my art" undoubtedly inculcates the practice of all the virtues towards professional brethren.

We have here an admirable foundation to build up a sound and beneficial code of Medical Ethics.

An oath is still administered in the United Kingdom to the graduates in medicine, but one shorn much of its ancient glory. In some Universities it is administered in Latin, as at Edinburgh; in others in English, as at Glasgow.

The Edinburgh "Sponsio Academica" is as follows:

Ego Doctoratus in Arte Medica titulo jam donandus, sancte coram deo cordium scrutatore spondeo, me in omni grati animi officio erga Universitatem Academicam Edinburgensem ad extremum vitæ halitum perseveratarum. Tum caste, porro Artem Medicam cante, probeque exercitaturum, et quoad potero omnia ad ægrotorum corporum salutem conducentia cum fide procuraturum. Quæ, denique, inter medendum visa vel audita sileri conveniat, non sine gravi causa vulgaturum. Ita præsens spondenti adsit Numen."

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In Glasgow we all stood round the officiating professor with right hands upraised and repeated the following declaration after him: "I make this solemn declaration in virtue of the provisions of the Permissory Oaths Act, 1868, substituting a Declaration for Oaths in certain I do solemnly and sincerely declare that as a Graduate in Medicine of the University of Glasgow I will exercise the several parts of my profession to the best of my knowledge and abilities, for the good, safety and welfare of all persons committing themselves, or committed to my care and direction; and that I will not knowingly or intentionally do anything or administer anything to them to their hurt or prejudice, for any consideration or from any motive whatever, and I further declare that I will keep silence as to anything I have seen or heard while visiting the sick which it would be improper to divulge."

The advantages of the Modern as against the Classic vehicle in which to convey such solemn declarations are obvious. Graduates in medicine were not as a rule brilliant enough in their Latinity to translate by the ear; the consequence was that while at Glasgow we

knew what we were swearing to, at Edinburgh they didn't, and probably never took the trouble to find out.

The above declaration was the first and the valedictory address was the last item of instruction we ever received officially in the morals of our profession.

Genius, we are told, is always modest, and puffing is the hand-maiden of mediocrity.

The quack, in or outside all professions, is always noisy, proclaiming his own excellencies either in the newspapers or viva voce. We are all familiar with the puff direct and the puff indirect in the Press; while the tall talk indulged in by the professional man occasionally, descriptive of wonderful and often apocryphal triumphs of his forensic or medical skill, is the outcome of a morbid fear of a lack of appreciation by a confiding public or a desire to bestow a fictitious value on his services, which is, in either case, dishonest.

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John of Salisbury, in the 12th century, says of the physicians: "They will tell you all they know and perhaps out of their great kindness a little more. . . . In a word when I hear them harangue I am charmed. I think them not inferior to Mercury or Esculapius, and almost persuade myself that they can raise the dead.. They speak aphorisms on every subject, and make their hearers stare at their long, unknown and high-sounding words. The good people believe that they can do anything, because they pretend to all things."

John of Arden, a noted London surgeon of the 15th century, gives a long description "of ye manere of ye Leche" in which he counsels him not to "be yfounden temerarie or bosteful in his seyingis or in his dedes."

Again, Thomas Vicary, the first master of the United Company of the Barber-Surgeons and Surgeons, advises That a Chirurgeon must take heed he deceive no man with his vayne promises, nor to make a small matter great, because he would be accounted the more famous. .. And see they never prayse them selves, for that redoundeth more to their shame and discredite than to their fame and worship. For a cunning and skilful Chirurgeon need never vaunt of his dooings, for his work wyll ever get credite ynough." Thomas Gale of about the same period writes to a like effect.

In these modern times we must have become more modest, for the only reference I find in either Styrap's Code or in Saundby's, to the pompous pretentiousness of the practitioners in former times occurs in Styrap's. He says: "A mere varnish of sympathy, a regulated mode of dulcet speaking, the tricks of stimulated interest, are among the pitiable artifices of professional manner which it is often difficult to observe without pain and contempt. On the other hand, the abrupt self-assertion, the pretentious egotism, the obtrusive acuteness which are oft but vainly intended as an impersonation of intellectual superiority and philosophic eminence, are alike offensive. Happily neither of these types are common!" Again he says:

"A practitioner should not be prone to make gloomy prognostications, inasmuch as they not only exert a depressive influence on the invalid, but savour strongly of empiricism by unduly magnifying the importance of his services in the treatment or cure of the disease."

In short, we find that the teachers of Ethics both in ancient and modern times counsel us to avoid blowing our own horn, but rather to let our works speak for us.

Not only is the honour of the profession involved in the manner in which we comport ourselves towards the public and our patients, but also in the friendliness, or the lack of it, among ourselves. This point has received considerable attention and is of great importance. I have already deprecated the mental attitude involved in regarding other medical practitioners as "opponents."

Old John of Arden says: "Skorne he no man ffor of that it is seid He that skorneth other men shall not go away unskorned.' If there be made speche to hym of any leche nouther sette he hym at nout, ne preise hym to mich or comende hym but thus may he curteysly answere, I have not any knowleche of hym, but I lerned not ne I have not herd of hym but gode and honeste, and of this shal honour and thankyngis of eche party encresse and multiplie to hym."

On the same subject Vicary wrote: "Likewise that they (the Chirurgions) despise no other Chirurgion without a great cause, for it is meete that one Chirurgion should love another, as Christ loveth us all." And in Styrap the following occurs: "Every one who enters the profession, and thereby becomes entitled to its privileges and immunities, incurs the obligation to exert his abilities to promote its honour and dignity, to elevate its status and extend its influence and usefulness. should therefore strictly observe such laws as are instituted for the guidance of its members, and avoid all disparaging remarks relative to the faculty as a body or its members individually, and should seek by diligent research and careful study to enrich the science and advance the art of medicine."

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As a means of promoting that friendliness which is of so much use and advantage both to ourselves and others, social intercourse is of great value. These meetings of ours in each other's houses do much in that way. Our work being to a great extent carried out apart from each other, assistance at operations, consultations, and intercourse by means of societies form our tangible bonds of union, and all these ought to be encouraged.

Among the ordinances of the Surgeons of London in Henry VI. reign we the following: "Ordained that every freeman of the craft of surgery pay yearly to the dinner of the craft;" and so our predecessors encouraged social intercourse with the express object no doubt of rubbing off angles, and smoothing down ruffled tempers.

On this point Styrap says: "The social principle which in the Medical, unlike all other professions, is specially weak, should also be earnestly cultivated, and friendly habits and unity of action carefully fostered, for by union alone can medical men hope to sustain the dignity and extend the influence and usefulness of their profession." He further says that "in their intercourse with each other, practitioners will best consult and secure their own self-respect and that of society at large, by a uniform courtesy and high-minded conduct towards their professional brethren."

Differences and asperities will occasionally arise, but their memory should be discouraged, and their amicable adjustment attempted. In the old days in England, Flint South informs us, "personal quarrels among the craft (of Surgeons) were punished. No one was to be malicious or excite malice which might be cause of disturbance of the good peace among the fellowship of

the said craft, upon the pain to pay to the Box twelve pence." Drawing a weapon, a noble; smiting, 20s.; and if the offender be a master the penalty was double, and so on. Although the fines appear small to us, still they indicate that the craft intended to stand no nonsense from the members of the noble and honourable profession of surgery.

Apart from ungentlemanly conduct in general, there is nothing which engenders ill-feeling more than the practice of supplanting. For some reason or other the patient may decide to dismiss his medical attendant and request the services of another, and the questions for the latter to consider are "Am I justified in taking up the case? Is it entirely wrong to do so, or entirely right, or permissible under certain conditions?"

In this connection Styrap says "the right of a patient to change or to discard his medical adviser is unquestionable, but, like other rights, it is limited by the legitimate claims of others, and a priori, a medical practitioner is justly entitled to expect that he shall not, sine causa, and without reasonable courtesy and explanation, be superseded in attendance. In such event, moreover, the superseding practitioner is morally and ethically bound to take care that the same courteous respect which he individually would exact be paid to his discarded confrere alike by himself and by those whom he has been called in to professionally advise." Saundby agrees on this question, and adds another condition to the obligations of courtesy: that no one is at liberty to take over the treatment of a case in which he has been called in consultation, or where he has acted as a substitute for the ordinary medical attendant, except with the assent of the latter; while Styrap says, "should the practitioner who has been called in consultation be subsequently requested to take sole charge of the patient, he should courteously but firmly decline."

In the Ordinance of the Craft of Surgeons already quoted from, surgeons were forbidden to " put any man out of his cure otherwise than the honesty of the craft will," but everyone shall honourably help one another, and if any do otherwise he shall pay to the surgeon he has supplanted the value of the case and pay to the box 6s. 8d. for his trespass.

Then in Queen Elizabeth's time we find that "Mr. Ffenton complayned of Robert Money for supplantinge him of divers cures, and for slandering him in his profession" and was fined for his evil practices. Later on another was fined 2s. 4d. for defrauding one, Gorston, of a patient. While in a third instance the fine of 5s. was inflicted and handed over to the practitioner supplanted, because the supplanter did not take the precaution of seeing that the bill for the services of the first man had been paid. These were good old

times!

South says that during the whole existence of the Company this esprit de corps was insisted on.

The older practice was to view supplanting in its relation to medical men themselves; the recent view is to insist on the right of the patient. While admitting the rights of the patient we must not lose sight of the undoubted right of practitioners to refuse to take over a case and supplant another. There are circumstances under which it is quite legitimate, c.g,, where the first medical adviser refuses to go on with the case; but

in other circumstances it is a question that would form a suitable point for discussion and agreement among the members of the profession in each locality, for without such an agreement the practice of supplanting will always be apt to cause heart burning. This much may be said, that it is always wise to offer first to meet the medical adviser in consultation rather than to accept the case and supplant him. I certainly agree with Saundby and Styrap when they say that a man, once having seen a case in consultation or as a substitute, should never take it over without the consent of the other man.

One point worthy of consideration in this connection. is, how far is it dignified or to one's interests to try to hang on to a case where one knows that the patient or friends are not satisfied? If any sign appears of dissatisfaction, a consultation should at once be proposed, and so clear the air; but if such is rejected, the only correct course is to give up the case, and in such an eventuality another man might fairly take it over.

The limits of this paper forbid me to do much more than indicate a few of the many further duties and obligations devolving on the profession. There is, eg. the relations between the Doctor and Chemist, which in my opinion are far from being satisfactory. At present we hand all our dispensing over to the chemist, who not only makes an illegitimate use of the prescriptions frequently, but carries on a flourishing trade in counterprescribing, and so trespasses on our province and infringes the law. The chemist has thus the whip hand As a quid pro quo it is alleged that some medical men exact a commission on their prescriptions from the chemist, but that is a practice condemned alike by the profession and the public. The only remedy to put matters on a satisfactory footing, if chemists will persist in counter prescribing, etc., in spite of remonstrance, is for medical men to combine and keep a joint dispensary of their own.

of us.

Other points worthy of consideration are the strict observance of our social duties to each; the attitude of District Surgeons, Health and other officers, to private practitioners and their patients; clubs and benefit societies; the ethics of operating and prescribing etc.

Since the writing the above I find in the British Medical Journal, of August 15th, 1903, an article on the American Medical Association and Medical Ethics. This American Association unanimously adopted "The Principles of Medical Ethics," of which the text is given in the article. Its three chapters are (1) the duties of physicians to their patients; (2) the duties of physicians to each other and to the profession at large; and (3) the duties of the profession to the public. The principles laid down are in close agreement with those of the other writers quoted.

I trust I have said enough to justify the existence of Medical Ethics, and the advisability of each of us endeavouring to abide by them. Any points of difference are better brought to light, discussed and agreed upon, rather than allowed to become bones of contention.

While we as a profession live on the public, and owe the public obligations on that account, we should ever remember that in purely intraprofessional matters the public is our natural enemy, and for our own honour and security we should uphold the reputation of each other and

The symptoms of this condition are many and varied, and I intend to limit these few remarks more to a description of these symptoms than to a treatise on the subject itself.

The patients themselves when affected with this weakness usually tell us "When I begin to read or "write, at first I see very well; but, after using my eyes "for some time, I suffer from a feeling of heaviness in "them and of pressure on the forehead, the letters of the book which I am reading get mixed together and I am obliged to stop. After a short rest, after rubbing my "eyes, I can begin anew, only to feel again fatigued; and, having struggled on for a short time, at last I "feel quite unable to continue my work. In the morn"ing I am less easily fatigued; the same is true on Morday after the rest on Sunday." (Donders).

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What we gather from this is that a patient may have perfect acuteness of vision, may be a "First class shot," and yet may be unable to use his eyes over close work for more than a few minutes at a time. This sometimes depends on an hyperasthesia of the retina (Retinal Asthenopia), sometimes on a relative loss of accommodaten (Accommodative Asthenopia), and sometimes on an insufficiency of the internal recti muscles (Muscular Asthenopia). I shall continue to use this nomenclature rather than the newer and better one of Ametropic and Heterophoric Asthenopia as I feel sure the older form is better known and better understood.

There are a few symptoms which point pretty conclusively to one or other of the varieties but the majority of complaints by the patients do not point further than that there is asthenopia of some sort.

This

The commonest complaint of all is headache. may be complained of as "in the eyes," "at the back of the eyes," "in the brow," or even occipital or in back of neck, and it also has various characters, each patient translating it in his own particular way. This pain when

very severe at the back of the eyes and combined with photophobia, will often point to the first named variety viz., Retinal Asthenopia, and is supposed to be due to some reflex origin, as uterine or intestinal derangement. Hysterical manifestations are common in this condition. As a case in point-Miss G., aged 16, undergrown, not commenced to menstruate, refraction completely corrected, had severe frontal pains and photophobia regularly at monthly intervals for some considerable time.

The pain of accomodative asthenopia from hypermetropia pure and simple is not usually of any great severity. It is of an aching tiring nature and it is, curiously, enough, rarely referred to the eyes but generally to the supra-orbital region.

The headaches which are due to the asthenopia in astigmatic patients are caused by efforts to correct that astigmatism by strain of the accommodation, and also to the confusion and tiring consequent on seeing distorted and partially indistinct images of objects. This pain is often of a severe type and may be referred to almost any part of the trigeminal and second cervical nerve distributions. It occasionally leads to such prostration that brain disease or meningitis may be thought of. An interesting case is that Mr. N., wearing + 0·5 sphr. each eye, complained of such severe and constantly recurring headaches that he was unable to work for several days in succession, these recurred once or twice a month, with occasional vomiting. He contemplated going to Europe to consult a brain specialist. I found that 05 sph. + 0.5 cyl. at 180° gave complete relief to all symptoms, though the difference in vision with the two corrections was only with spheres and with cylinders and spheres.

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Pain at the back of head with giddiness will very often demonstrate a muscular weakness, which is particularly annoying in myopes, because seeing things close to, that is having their near point so close to their eyes, necessitates greater convergence in proportion to the amount of accommodation required, which very often is nil.

Some of the symptoms are so obscure that they do not always lead the man who is not constantly engaged in eye-work, to suspect that an optical defect is at the bottom of the evil. In some of these cases the symptoms are brought into prominence by the patient being of a delicate and sensitive organisation or in patients reduced in health by exhausting diseases or by pregnancy or prolonged suckling; also in neurotic, anæmic, and toxæmic subjects. When such a patient is run down a tonic will give temporary relief, but directly he is again below par in mind, body, or estate, (and I say advisedly estate, because worries, pecuniary or otherwise, lessen the tone as soon as anything,) he will again complain. and then it is necessary to give permanent relief by a proper correction of his ocular defect.

We will now take the more local or pathological symptoms as Conjunctivitis, Marginal Blepharitis, or Hordeola. We know at once that there is a slight error, probably an astigmatism, and yet we find the patient gets temporary relief with a lotion or perhaps a poultice, and then after some extra eye-strain the irritative conditions recurs. Hyperæmia of the conjunctiva is a condition met with in South Africa over and over again,