restrain the erring and to support the dying. Make the most, therefore, of those opportunities which come to medical men far oftener than they do to other workers, and let your visits to the sick not merely afford relief to the body but comfort to the mind and solace to the soul.

Live and be happy in thyself, and serve this mortal race, thy kin, so well that men may bless thee."

CHAPTER VIII

EXAMINATION OF THE PATIENT;

NEW PATIENTS, ETC.

TAKING ON

Examination of the Patient.-Almost every patient when he first sees his doctor is nervous and anxious. Having allayed this and got him into a calm and tranquil frame of mind, the doctor now proceeds to make careful examination into his case, first by question and answer and then by physical examination. It is advisable to take a few brief notes of the case as you proceed, so as to keep a more or less permanent record. If you delay and endeavour to rely on your memory to make this summary in the evening, you will find that it often fails you or no later opportunity of recording your impressions may present itself because of other pressing business.

Let your examination of the patient be complete and thorough and satisfactory to yourself. Your duty is to diagnose what disease your patient is suffering from, as well as to estimate the stage at which it is, and this can only be done by a thorough application of clinical methods. Perhaps you hear numerous very audible rhonchi and râles in the chest ; do not rashly conclude that he is suffering from bronchitis alone, there may be patches of consolidation present also, or valvular disease of the heart, or such other diseases as diabetes, nephritis, etc., may complicate

the case. Only a very careful investigation will reveal all that may be present.

On the other hand, if the patient is obviously very ill, we must limit our examination to what is absolutely necessary for diagnostic purposes. We must not subject him to the perhaps dangerous exertion of making a detailed investigation. I remember one case in which a well-known specialist was examining the chest of a man far advanced in phthisis; he had asked him to turn over on his face so as to examine his back, and when he had done so, he requested him to take a deep breath. On the patient not responding, we looked at his face, only to find that he had died from the strain of the examination and the exertion of turning round.

One ought not suddenly to announce to the patient that we mean to employ some new method of diagnosis or treatment. Most patients have a fixed objection to be "experimented upon," as they term it. If it is your own discovery, then certainly you will try its effect on some unfortunate, but if it is another's discovery, then he will have made his own investigations and you are not then making new experiments, except in so far that with every patient the exhibition of a drug new to him is an experiment. I remember a young enthusiast who, seeing for the first time a lady suffering from weakness of the legs, stated that he would return next day to perform a lumbar puncture, to verify his diagnosis. Needless to say, he did not get the opportunity, as the patient had meanwhile sent for another doctor who was less heroic in his methods of investigation.

Patients, and especially nervous patients, require to be treated with great tact. One must lead them gently from one investigation to another, and, unless the case is one of great urgency, there ought to be no undue hurry. After a few days, when the patient has confidence in you, then you may intimate to him or to his relatives what further methods of investigation you mean to employ, or you may suggest the advisability of obtaining the opinion of a specialist or of a surgeon to do this for you.

Taking on your List New Patients. When you receive a summons to call on a patient, it is your duty to find out how long he has been ill and whether he has already been attended by a doctor. If he has, then you expect him to give you a reason why he has discontinued the services of this medical man. The reason may be quite a good one, as, for example, the distance is too great for the old man to travel; the family desire to have a doctor close at hand because their mother is subject to sudden attacks of illness, and so on. In such a case, the patient or one of his family must intimate to the former medical attendant the reason why he is transferring his patronage to another doctor. If you take over the case, it is your duty to intimate to the doctor that you intend to do so, if he has no objection. He will probably give you a history of the case and how he has treated it. In the transfer of patients all should be done openly and above board.

The family may, however, have quarrelled with their previous medical attendant. If called to visit them, then you must communicate with him by telephone, call or letter and intimate the facts He

may be able to give you valuable information, not only as to their diseases, but as to their eligibility as patients.

It is not only a very unwise, but also a very unfair proceeding to take over patients from other doctors without reason, and without first acquainting them with the fact. Of course, no doctor with any self-respect would wish to continue professional services to a patient who has shown obviously that he would prefer another medical attendant. To take over attendance on a family without their being able to give an adequate reason why they wish to terminate the services of the former practitioner is, from a medical point of view, a grave breach of medical ethics and would receive general disapprobation. The patient may make statements regarding his former medical attendant as to his neglect, incapacity and so forth. Accept such assertions with great reserve and always hear what the doctor has to say. This may alter the appearance of circumstances entirely. Yet again it might be asked, why should patients not change their doctor if they wish? They may not be able to give any very adequate reason. They may say that they do not like him; that they feel no confidence in him; that his treatment has done them no good; that he pays far too many visits, etc. In other words, mutual confidence is lacking between patient and doctor, and if so, from both points of view a change of medical attendant is desirable.

Having found the reason why the patient has terminated the attendance of the former doctor, and having communicated with the latter, then it is