any other way. One case in which normal vision was preserved, and while in this case the foreign body might possibly have been removed with forceps, an iridectomy would have been necessary, and the magnet was undoubtedly safer and better.

COMMERCIALISM IN MEDICINE.

NATHAN MAYER, M.D.,

HARTFORD.

By the title of this paper I would describe a condition that should exist in the practice of medicine at the present day as largely as it does in every other profession or calling, but which practically enters into it but to so limited an extent, that those engaged are deprived of an appreciable part of their earnings with vexatious regularity. I mean strict business methods, and the conduct of practice on approved commercial principles. It is a well-known and deeply-felt condition among general practitioners that a portion of their charges never comes to collection, and the worst quarter of an hour which a physician of forty, thirty, or even ten years' practice can prepare for himself is the study of his old account-books in which he can map the people that might, should, and could have paid, and never did pay; and the accounts, which by his own trustfulness or tardy efforts he has lost absolutely; and then afterwards considers. First, the physical work and mental anxiety, the nights and rides he has devoted to these cases; and, secondly, the fine houses or income bearing bonds he might have acquired if he had been justly dealt with. Such a scanning of old accounts is enough to give most doctors an attack of moral colic. Dr. Ellsworth used to tell of an old physician of the early times of practice here, who was found to have charged but ten cents a prescription. The City Medical Society rallied on him, and a committee of inquiry came to his office. The old man gave but a single excuse. He said: "I charge now more than I can collect," and they were satisfied. That is undoubtedly true of every practice; we charge

more than we can collect, and far more than we do collect. And to investigate somewhat the reasons is the aim of this inquiry.

Permit me to stop a moment in order to congratulate the specialists, those fortunate people who are largely exempt from loss. They have limited hours, they have definite and single lines of study, and their goods are paid for on delivery. When the office hours are over the specialist has in his pocket the results of his brain work, and if he is called in consultation people pay him at once, while it does not yet enter into their remotest consciousness to pay the man who is at their beck day and night. The latter, like the poor, is always with

them.

To return to the subject. While the general practitioner does not feel so acutely the reduction of bills, which is frequently insisted on, and most so in cases that have been most harrowing. the absolute loss cuts deeply into his calculations. Reduction is not so much the fashion now as formerly.

In my early practice the leading surgeon of this city hardly ever sent out bills, and the largest practitioner habitually reduced them one-third or one-half. That set a pace which proved almost ruinous to beginners. It is the entire loss of bills we deplore, bills that were incurred by people who could and would pay their doctor as well as their grocer or landlord if they knew that the debt should be pressed by similar business methods, or if the efforts of their creditor were strongly exerted before their gratitude and honest intentions had been dimmed and withered by the effects of time. How came it so?

To begin with, in times long past, but which are still perpetuated in a manner in Europe, especially in small, close communities, the doctor received for his services a "honorarium," not a fee. The debt for medical services was then a debt of honor, that is, a debt depending

for its payment on sentiment. "We" endeavor to make it a debt of honesty, that is, a debt depending for its satisfaction on duty. Then the honorarium was according to the means of the patient, not the value of the services. Old Parè tells what bags of gold he received from counts and dukes for attending their wounds, while the soldier paid nothing. It was in the shape of a present; no bill was asked, no price set, the wealthy gave according to means and degree of gratitude. The poor never thought of giving, but the middle class honored the doctor's services by gifts in kind, a pig, or especially nice farm products, or articles of clothing, or personal services, or any old thing that came handy.

The services of a doctor were held high, he occupied a leading position in the community, but no commercial rules applied to his remuneration. The well-situated gave generously, and this was supposed, by the people, to cover his services to the poor. There was a certain distinction and ideality in this, but no true return for labor. But, as above indicated, in retired portions of Europe, the back countries, such conditions exist to this day, and even with our own, wide-awake, twentieth century nation, the impression of this former patriarchal state lingers in mind with sufficient force to lead folks to consider their financial obligation to the doctor far lighter than any other they have incurred. "The doctor's bill always gets paid last" is a phrase I have often heard; and also this: "He makes enough on the rich, and don't need our money." Both are residual ideas of a former condition where payment depended on gifts. Allow me to tell an anecdote of Nelaton, the famous surgeon of the second empire, whose clinics I was fortunate enough to attend.

but also a business man.

He was a very lovely man, After an operation that had

saved the life of the only child of a great house the mother called on him and presented a keepsake, a pouch beautifully embroidered by herself. Nelaton listened

to her professions of gratitude and then said: "Pardon me, I do not practice for keepsakes! My charge is 10,000 francs." "Very well," replied the lady, stiffening, then took from the pouch 20,000 francs and presented him with ten. "Thank you," said the great surgeon as he wrote a receipt. "That is right. This is my property. The other would have been a gift and a favor." I present to you then these impressions of former days, which still leave their mark on the public mind, as the first obstacle to a square deal with the doctor.

Another condition might well be considered, which dulls financial appreciation of his services, in the consid eration of the unintelligent. What he gives is nothing palpable. It is simply advice. It takes nothing from him. Except for his time it leaves him as rich as before. It is not like a ham or a pound of coffee, something that weighs and measures, hence it becomes manifest honesty to pay for the ham and coffee first, since they must be paid for in turn; and for the doctor's advice, which seemingly cost him nothing at any old time when you are ready. So do they reason. Dr. Lewis Sayre was once called to Brooklyn to consult in the case of a boy with a bad leg. He came, examined, gave his tremendously distinct orders, and charged two hundred and fifty dollars. "Why," said the father reproachfully, "you have only been twenty minutes about it." "True," replied Sayre, "but I don't charge for the time spent, I charge for knowing how." And this "knowing how contains the matter in a kernel. It means the college, the clinic, the time and capital spent, the technic and judgment, the fruit of much thought and of rasping experience, and it also means the shouldering of a tre mendous responsibility and liability for life and health. Nothing of all this can be put on the scales, but they weigh at least as heavy as the ham and the coffee and should, in honesty, be as well paid for and as promptly. In counting up the handicaps to a commercial policy in