and in every way considerate-but (only with a view. I am personally acquainted with examples of the latter, who are constantly studying the interests of general practitioners, hoping to get work from them in the near or distant future. One I am thinking of at the moment is called a "really good chap" by senior students and residents. He pats most of them on the back, calls them smart men, and tells them he is sure they will do well in practice. He has found that by this means he gets a good deal of consulting work from old student acquaintances who have in time got into practices of their own. I often wondered whether this man's expressions of solicitude for the welfare of the young general practitioners were from his heart, or whether it denoted shrewd business acumen, until I had the question answered by an observant friend of mine, who told me that he noticed that this consultant invariably asked any young graduates he conversed with where they were going to practice : if they mentioned Scotland-his own country-he had a high opinion of their abilities and qualities; if they said England or the colonies he had no further interest in them.

I am bound to bear firmly in mind my space, and cannot deal with the subject of consultants as fully as I should wish; therefore perhaps the reader will pardon me if I merely give an illustration of the kind of conduct an ordinary medical attendant may have to submit to at the hands of a “leading specialist" without making any comments thereon. The following communication was addressed to the Editors of the Lancet :

"Sirs-About two months ago I sent a patient to a leading London specialist for operation. Last week I met him (my patient) driving through the town. Enquiring whether he was just arriving back from London he informed me he had come home a week ago. Also that Dr. B. had sent a nurse with him to continue the treatment. Surely, it was not too much for me to expect that Dr. B. would advise me of the patient's return, and at the same

time give me some notes of the case; but what do you think, sirs, of his sending a nurse with him to continue the treatment to the exclusion of the ordinary medical attendant?

Sept. 26th, 1899.

I am, sirs,

Yours faithfully,

AN ORDINARY MEDICAL ATTENDANT.

I may mention a trick which one general practitioner sometimes plays against another, which depends for its success on the relationship which subsists between the two and a consultant. Make a study of the three men in the following situation: A second general practitioner is called in to see a case which a certain general practitioner has had in hand for some time, and the friends request the continuance of attendance of the second man. He, wishing to make a sensation, and desirous of aggrandising himself at the expense of his diminished fellow practitioner, propounds new theories regarding the nature of the case. Having by this means created astonishment and anxiety, on the part of the patient and friends, he recommends a consultant to be called in-who, of course, is a friend, and a man who has acted as an accomplice on other occasions. The consultant with eminent emphasis confirms the diagnosis of the second attendant and approves fully of his treatment. I do not hesitate to remark that this is as wicked a procedure as any I know, and it is, comparatively speaking, not altogether an uncommon one. Only rarely does the first general practitioner, after retiring from the case, learn what further trick he has been the victim of.

But amid all this, as between medical attendants and consultants, orthodox and heterodox, where does the unfortunate public come in? What a game of cards over dying bodies! While doctors are differing humanity goes on groaning. Could there not be a better organised profession having charge of the common-health?

CHAPTER XIV

MEDICAL ETIQUETTE

WHOLE books have been written on the subject of medical etiquette and ethics-the conduct of medical men towards their professional brethren and the laity respectively; therefore I shall only refer to a few points that have been particularly interesting to me in my experience, points which appear to have been somewhat neglected by previous authors.

Medical etiquette has caused the death of a good many people. The reader may possibly pause here a moment and think, "How true that is !" but allow me to make the further observation that the laity would suffer much more if there were no such thing as medical etiquette of any sort or degree. Patients or their friends will often be afraid to make suggestions to their doctor for fear of offending him, because at some time or other he has met perhaps a very reasonable and sane suggestion by the reply that "it would not be according to the strict rules of medical etiquette" to do this, that, or the other. The truth is, that the general public is protected from charlatanry, and even crime, on the part of irregular practitioners, by this very medical etiquette which is so ridiculed. Still "Strict rules of medical etiquette" is an expression that has always amused me as well as the great general public, and I have ever had the greatest sympathy with those who have clamoured for explanations as to what the "strict rules" were. Not one doctor in a dozen knows

what they are. They certainly are not all of them very strict: they could not be. Only laws are really strict. There are very few rules governing the medical profession which could bear the adjective strict, and nearly all do not belong to the medical profession only, but are such as would be applicable to any profession or business. Take this example, that a doctor shall not attend a patient whom another doctor is attending without either the latter's invitation or acquiescence. This unwritten law prevents patients from calling in another doctor unknown to the one already in attendance; for the second doctor, bearing in mind the etiquette, will ask if another has been, or is still, in attendance. A patient might see no harm in two medical men attending, the attendance of the one unknown to the other, until it is explained that doctors differ and it is not wise for a patient to have two disjointed opinions and treatments. This is hardly a matter of medical etiquette, therefore, but rather a matter of simple common sense, that might apply to almost anything.

Medical men can do the best work on behalf of their patients when working either alone, or together and in harmony. If there be discord a patient's life may be in jeopardy. When doctors differ, as they are sure to do if attending the same case separately, then the last state of the patient is likely to be worse than the first. Doctors must be friendly towards one another when considering a patient, if the patient is to derive full benefit from their joint advice. Medical etiquette conduces to this friendship, and is therefore of the greatest value, not only to medical men themselves but also to patients. Medical etiquette is too often considered to be nonsense by individuals of the laity; but it is really a very powerful and very valuable force acting in the interests of all concerned.

A keen barrister friend of mine recently made an effort to get out of me some elucidation of the mysteries of medical etiquette. He asked me if there were any freemasonry sort

of secrecy about the thing, and if only medical men were allowed to understand it. Absolutely irrepressible, he had gone forth to search our medical library for information. He brought me a paragraph taken out of the very latest book on Medical Etiquette, written by an eminent consultant for the guidance of doctors, and asked me to explain it. The paragraph belongs to a chapter dealing with the relationship which should subsist between a medical attendant and a consultant while they are together considering a patient's case. It runs :"It is greatly to be desired that the medical attendant should, in his statement of the case, mention any opinions to which he may have committed himself, so that the consultant may not unwittingly contradict him.”

"Is that not a fair specimen," asked my friend, "of what you doctors call medical etiquette? You suggest that it is desirable for a consultant to be well informed previously so that he may agree with what the family attendant has said?" "I admit that the paragraph does somewhat startle me," I replied.

"Why should the consultant not wittingly contradict the attendant if the latter is wrong?" the barrister continued.

"I think the author's idea is this," I answered, "that a contradiction would lead to the medical attendant being distrusted by the patient."

"Quite so. But why should the medical attendant not be distrusted if he has displayed ignorance over the case according to the consultant's finding?"

"Because he might yet remain the best man to remain in ordinary attendance, especially as he would continue under the guidance of the consultant."

"Ah, I see, you mean that when a patient is at the mercy of ordinary medical attendants he is left with a choice of evils."

"No, I mean that the original attendant, provided he be a