CAN PHYSICIANS HONORABLY ACCEPT COMMISSIONS FROM ORTHOPEDIC INSTRU- MENT MAKERS? Reprinted from The Philadelphia Polyclinic Philadelphia, September, 1894. COMMISSIONS TO PHYSICIANS UPON THE SALE OF ORTHOPEDIC APPARATUS FROM THE MANUFACTURER’S STANDPOINT. Rep-infed from Medical News, July 6, 1895. By H. Augustus Wilson, A. M.,M. 1). CL'NICAL PROFESSOR OF ORTHOPEDIC SURGERY IN THE JEFFERSON MEDICAI, COLLEGE OF PHILA- DELPHIA; PROFESSOR OF GENERAL AND OR r HO PE DIC SURGERY IN THE PHILADEL- PHIA POLYCLINIC AND COLLEGE FOR - GRADUATES IN MEDICINE. CAN PHYSICIANS HONORABLY ACCEPT COMMISSIONS FROM ORTHOPEDIC INSTRU- MENT MAKERS?1 The enterprise of manufacturers in in- creasing the sales of their goods is called business thrift, for their relationship to pa- tients is a purely commercial one. Under the guise of being made especially for this pa- tient, they are often enabled to charge ex- orbitant prices for their inexpensive wares so as to pay the secretly understood custom- ary commission to the physician. Dr. Solomon Solis-Cohen2 applies the very appropriate term of “ Sales-agent ” to physicians who thus debase their profes- sion, as to the recommendation of secret nostrums. He says: “When a sick man applies to a physician, thinking that he thereby will secure the benefit of special knowledge brought to bear upon the condi- tions of the individual case, entrusting to the conscience of his medical adviser, his 1. Reid by invitation before the District Medical Society of the County of Camden, New Jersey, 2. "Shall Physicians become Sales-agents for Patent Medicines?” by Solomon Solis-C'ihen. M. I). Read before the Philadelphia County Medical Society, April 27th, 1892. 4 health and his life, he is entitled to the skill and the thought for which he pays and that he deems himself to be receiving. He cer- tainly deserves better treatment than to be handed over to the mercies of or any other of the unholy crew, If such is to be his fate, let him have the satisfaction of buying the worthless or poisonous stuff di- rect, without the sham of a professional consultation, and without paying a pur- chaser’s commission to the medical sales- agent.” The very secrecy that is resorted to con- demns the procedure, for the manufacturer well knows that this form of business thrift on his part is a dishonest practice on the part of the physician. This form of bri- bery which induces physicians to send their patients to “ our store ” for personal gain is strongly condemned by the profession, whether it be commissions from the apothe- cary, the optician, the manufacturer of proprietary or patent medicines, of health- giving natural spring waters, artificial limbs, trusses or orthopedic apparatus—but notwithstanding this condemnation, it ap- pears to be still earned on. The necessity of employing and recom- mending surgical and remedial appliances, many of which for business purposes are patented or so controlled as to favor the ex- orbitant prices demanded, has often been considered, and as there appears to be no 5 way of dispensing with their nse, the ques- tion requiring solution must be, how can they be used honorably and honestly ? If these remedial measures are to be classed with splints for broken bones, spectacles for defective eyes, etc., and not as shoes, cloth- ing or provisions, it must be clearly appar- ent that physicians must not only counten- ance their proper use, but also prescribe and direct their employment as therapeutic measures. The real offense appears to be that of ob* tabling money from patients under false pretenses, and the secrecy with which these so-called business transactions are carried on, is evidence that the physician would not have his patients or colleagues know that he received, in addition to the fee for his professional services, a commission on the sale of the apparatus, truss or artificial limbs that he has ordered his patient to pro- cure, or that he is, to all intents and pur- poses, a silent partner in the shop where he directs his patient to procure that which he has ordered. Is it “ business ” or “ professional ” to in- form patients whose confidence in their physician leads them to trust their health, happiness and honor in his hands, that these forms of appliances are very expen- sive, and that they must settle with the manufacturer at the prices printed in the catalogue, and conceal the fact, not always 6 printed but confidentially understood, that one quarter of that exorbitant charge goes back to the physician as his commission for making the sale ? Would the physician continue in the high esteem in which he should be held, if the patient knew that his money was paying these exorbitant prices so that his physi- cian could get double pay ? Medical laws have been, and are being, enacted to protect the public against un- qualified practitioners of medicine, and thereby discountenancing all forms of quackery and charlatanism, nowhere more conspicuous than in the sale of braces, trus- ses and artificial limbs. The makers of these appliances often assume, in reality, to practice medicine, but, withal, without a li- cense which their absence of training pre- vents them from obtaining. The following paragraph is taken from the ‘ Instructions in Ordering,” contained in a catalogue issued by a manufacturer (italics are mine), and is in marked contrast with the foregoing: “ While we prefer in each case to work under the direction of the attending physi- cian, executing his wishes with all possible accuracy, yet should, advice or consultation be needed, we will always stand ready in any way within our power to assist, that the phy- sician and patient be alike benefitted." Again in the same catalogue will be 7 found “Orthopedic Apparatus” (italics mine) : • ‘ When order is sent to us by the physi- cian, we will allow 25 per cent, discount from the catalogue prices, but when the pa- tient is sent to us to be measured and fitted, we can allow only 10 and 15 per cent, dis- count from prices charged. ‘‘ Physicians will please collect from their patients at least one-third of the amount in advance, and remit same to us when order- ing. Apparatus will then, as soon as fin- ished, be sent direct to the patient, collect- ing the balance C. O. D., thus relieving the physician of all financial 1 esponsibility. In cases of this kind, we collect the full price of the brace, and pass the conunission to the credit of the physician or remit same to him if desired. We suggested this plan some time ago, because of the numerous re- quests made us by the physicians for an ex- tended credit on appliances of this kind, they claiming that they could not afford to pay cash for them and then wait the will and the pleasure of their patrons. “ Experience has shown that the appli- ances of this character are not always com- fortable when first worn, and that the pa- tients are at that time easily discouraged or dissatisfied with trivial matters, and while we will make any changes necessary without charge (where the fault is ours), we must ask physicians to protect themselves' 8 and us to the fullest extent." “ Special note (in regard to trusses) : Fit- ting and adjusting special cases given care- ful attention at our office. Always send a letter of instruction with the patient and get creditfor the sale " This is so perfectly clear that no explana- tion is required, and there is but one omis- sion that should find a conspicuous place : That in order that physicians should be better able to “ protect themselves and us” to the fullest extent, we urge that all knowledge of these transactions should be concealed from their patrons. The word patron is used in the foregoing as it is an accepted business term. Webster defines patron (from pater, a father), ‘‘one who countenances, supports, or protects.” It would generally be inappropriate to use the word patient in such connection, for he ceases to be under medical treatment when he, with or without the order of his physi- cian, goes to the manufacturer of braces for advice or consultation. Webster’s definition of patient is: ‘‘A diseased person under medical treatment; generally used as a correlative to physician or nurse.” It will be noticed that there is a well rec- ognized difference from the business stand- point between the two words, for the state- ment, ‘‘but when the patient is sent to us,” implies that he then ceases to be a 9 patient and becomes a patron or one who supports. Of the duties of the profession to the public, the Code of Medical Ethics says : “ It is the duty of physicians who are fre- quently witnesses of the enormities commit- ted by quackery and the injury to health, and even destruction of life caused by the use of quack medicines, to enlighten the public on these subjects, to expose the in- juries sustained by the unwary from the devices and pretensions of artful empirics and imposters.” It is under the category of empirics and imposters that all orthopedic and artificial- limb makers must be classed who indulge in the reprehensible practices referred to in this paper, i. e., those who have schemed to add to their skill, as manufacturers, a desire to prescribe, direct, give advice to either the patient or physician, and who boldly offer to hold consultations with physicians when such appliances may be deemed desirable. When the physician becomes capable of measuring and fitting his own patients for orthopedic appliances—just as he has been educated to measure and fit his own appar- atus for fractures and other injuries--just as he measures and fits his own medical pre- criptions to the peculiar requirements of the case—just as he measures the patient's errors of refraction and fits the glasses and frames that have been manufactured by the 10 optician, then the physician will occupy his true position and not fear that the secret transfer of commission will be found out, because no commission will then be asked for or given. When the physician decides upon the form of mechanical support that will be best for his patient, and measures the same from his own standpoint of knowledge of disease, and fits and adjusts the appliance as the changing requirements of the patient demand, then he will be in a position to render suitable charges for professional ser- vices rendered to the patient, and can in- form the patient (having his best interests at heart) that the apparatus will cost 25 per cent, less than the catalogue price. The mechanicians occupy honorable po- sitions in making appliances for the relief of suffering, and can hardly be censured for the position they are forced to occupjr by physicians who seem to delight in their ig- norance about braces or mechanical appar- atus, and any reform in this matter must come from the physician, -where it should be expected to originate. If the spirit of the Code of Ethics is understood, the course here suggested is in accordance therewith. Physicians should, unquestionably, adopt business principles and methods in the con- duct of their calling, but this does not mean that those methods should embrace lying to, or cheating, their patients. 11 When physicians have been induced by the commission to send their patients to the manufacturer or shop for treatment that they should themselves apply or direct, how s)on will the process of dispensing with the physician begin? The “lady attendant’’ and private entrance, now provided by some dealers, encourage frequent visits to have repairs and adjustments made, about which it is said “ the physician does not under- stand,” and “has not the time to attend to ” The next step, and one that is already said to be a recognized business necessity to keep in advance of competition, is set forth in another catalogue which has a large lay distribution. The heading is, “Calls Made to Residences.” (Italics mine ) “ We will call upon any one desirous of purchasing (articles advertised in catalogue) residing within the limits of the city, for consultation, measuring, fitting, or advice free of charge ; and upon any party without the city limits, provided they will pay the expense of travelling and a reasonable amount for extra time consumed.” There is but one step more, and that is the retrogression to the time when barbers were surgeons and the “ natural bone-set- ters ” put irons on deformities to such an ex- tent that the deformities increased under the heavy loads their poor afflicted bodies had to carry. Patients are, even now, by bold 12 and luring advertisements, urged to go di- rect to the makers to save extra expense, and that the)’ themselves can obtain full de- scription as to the choice of apparatus and how to make all necessary measurements. Where are the knowledge of pathology, of anatomy, and of the other subjects that physicians are obliged to pass upon before State Boards of Medical Examiners? Where is the diagnostic skill that should decide as to the nature of the disease and the prin- ciples upon which tbe treatment shall be based, that the patient maybe benefitted? The evils that result from the system which appears to be in vogue are that, in order to get the largest commission, the physician must recommend his patient to the manu- facturer whose catalogue prices are the highest. His own judgment, naturally, becomes warped when confronted by an array of steel, leather, felt, aluminum ; and the real benefit to the patient is in danger of being lost sight of, in the desire to increase the re- ward he is offered for bringing another pa- tron to “ our place.” The patient’s deformity too frequently becomes the seat of attack rather than the arrest of the disease which may have caused it, and thus the attempt is made to push in the hump which has resulted from a failure to recognize caries of the spine, or by braces alone to correct in an adult the knock-knee 13 where there is a prolongation of the inner condyle, or to cure clnb-feet by braces alone. The braces are sold to the patient, the phy- sician has obtained his commission, and the patient, not only, often receives no benefit, but, alas, worse, his case progresses so rap- idly that another brace is tried and more money spent, until valuable time is lost and a hopeless cripple results. If the methods that too frequently obtain in the care or supposed treatment, by in- competants, of cripples and deformities, those who are obliged to use trusses or arti- ficial limbs, were adopted in other branches of medicine, more suits for malpiactice would be justly instituted The appreciation of the errors prevalent in this country is shown in the preface cf the catalogue of an English manufacturer of orthopedic appliances, from which I quote : “ I may have to refer to the authors who so ably explained the application of the in- struments in their several works. In doing this, I trust that the profession will view the liberty' I have taken as a desire to assist those medical men who are not familiar with the perfect and exact use of the apparatus, and not with the idea of trespassing on that ground of ‘ advice ’ which is clearly th»i, province of the medical man.” The answer to the question I have pro- pounded as the title of this paper, “ Can 14 Physicians Honorably Accept the Commis- sions so Frequently Offered by Orthopedic Instrument Manufacturers ? ” must be the solution of many of the abuses to which al- lusion has been made. If it is honest to so defraud the patients submitted confidingly to the care of the physician, it is just as right to totally ignore every point of the Code of Ethics that indicates to the con- trary. If it is dishonest, and what physi- cian can dispute it, are we not obliged, by the very words and spirit of the Code, to so proclaim it ? COMMISSIONS TO PHYSICIANS UPON THE SALK OF ORTHO- PEDIC APPARATUS, FROM THE MANUFACTURER'S STANDPOINT, i. Iii the Philadelphia Polyclinic for Septem- ber, 1894, I published a paper entitled ‘‘Can Physicians Honorably Accept Commissions from Orthopedic Instrument-makers?” in which I presented the subject from the stand- point of the physician. The position taken in that article is concisely stated in the clos- ing paragraph, in which I said: ‘‘If it is honest so to defraud the patients submitted confidingly to the care of the physician, it i. Reprinted from Medic. 1 News, July 6th, C95. 15 is just as right to ignore totally every point in the Code of Ethics that indicates to the contrary. If it is dishonest, and what phy- sician can dispute it? are we not obliged, by the very words and spirit of the Code, so to proclaim it ?” A further consideration of the subject demonstrated that there is another stand- point from which the subject should be con* sidered, namely, from that of the manufac- turer or the business man. I therefore sent a copy of my paper referred to, to a large number of manufacturers of orthopedic ap- paratus, artificial-limbs, and tru-ses, with the request that they favor me with their views and opinions candidly expressed. The replies, from which extracts are used, form the basis of this article and are of great value in showing that too often physicians permit themselves to be classed, as Dr. Salomon Solis-Cohen has tersely denomin- ated, “ sales-agents ” Illustrative of this I quote from the Wink- ley Artificial Limb Co-: “ We receive almost daily several letters from physicians, in apparently good stand- ing, asking us how much commission we will pay them if they will send us a patient or an order for an artificial leg, and that they would like to have the limb, if pur- chased, either sent directly to them with one bill in full to show the patient, and one to them personally, less the commission ; or 16 that the limb be sent directly to the patien- for the full amount and the commission sent to them. We recently received a letter from a surgeon having a large practice which read as follows: ‘ I now have five patients with amputated legs who are either ready or soon will be to wear artificial legs. I am going to have them place their orders with the firm that will pay me personally the largest commission. I do not care where they purchase their limbs so there is something in it for me. If you will pay me a larger commission than other firms, I will have them each and all place their or- ders with you.’ We simply answered the latter by stating that we allowed no com- mission whatever, etc." If this were a single instance, it would properly be considered as coming from some contemptible man besmirching the profes- sion, the dignity of which it was his duty to uphold, and consequently beneath notice. In a number of replies from manufacturers, however, it is stated that they have had numerous requests from physicians for com- missions ; therefore the whole matter ap- pears to come back to the starting point, that in reality it is the physicians that make these commissions necessary. This view is substantiated by Sharp & Smith, who state : “Would say if commissions are paid to them it is because it is agreeable to the pliy- 17 sician who controls the order. We believe the whole matter rests with the physician." George R. Fuller, of Rochester, New York, says : “ The custom among the profession of an- ticipating, accepting, and, I might say, ex- acting a commission on artificial limbs, trusses, etc., as a rightful legitimate fee, has become nearly universal, and I am glad to know that there is one of them who has the courage to brand the custom as a fraudu- lent one, an outrageous breach of the faith and confidence extended by the patient, and a violation of the Code." The object of this paper is to reach those physicians who may not fully com- prehend the importance of upholding the dignity of their profession, and who are acting as " sales-agents ” in obtaining money under false pretence, and exposing the profession to just censure. Mr. Frederick M. Bush says : “ I would divide physicians into three classes in the matter of orthopedics. First, those who know what they wish to do and how to do it, including the general mech- anical design. Second, those who know what the}’ want to do, but don’t know how to do it, and leave the designing of the ap- pliance to the instrument-maker. Third, those who don’t know anything about it.. For the first class, and the smallest, it is sufficient that the instrument-maker knows. 18 enough to follow the measurements and di- rections given, with perhaps an occasional suggestion from him on points strictly of mechanical detail. With such a physician it is ordinarily unnecessary for the instru- ment-maker to see the case ; consequently all the business is transacted through the physician and the appliance is charged di- rectly to him. Now his bills with his instrument-maker are probably settled monthly, and if his patients pay on the same terms, well and good. But suppose he is not always so fortunate, and some of his accounts run three, six, twelve months, and some he never gets. Physicians’ bills are not always collected ; where does he get the interest or make up the deficiency Must he lose it out of his pocket became? he has been unfortunate enough to have to advance cash ? Is it not better and more ■equitable that he charge sufficiently more for such appliances to enable him to have a sort of sinking-fund from which he can re- imburse himself for losses so caused? It seems so to me, and where is the need of secrecy ? Business is business the world over, a church or a doctor’s office, a theatre or a dry-goods house should all be run on a business basis, and, though the superficial forms of advertising and dispensing com- modities may differ, the same sound prin- ciples underlie success in any case. “ But does a solid conservative business 19 concern take risks without hope of renum. eration ? Assuredly, no. Somebody has to pay ; and the pay is proportional to the risk ; and there is no thought of conceal- ment. “ The second class of physicians should b2 governed by the rules which govern the first and third class. The more ability the physician requires of the instrument-maker and the less financial risk that is run, the less pay should the physician expect and the more should the instrument maker get out of the work. The third class is not very hard to dispose of, because if they don’t know anything, they can’t do any- thing, and if they can’t do anything they are not worth anything. Of course a good many of the second class and all the third class had better not fool with orthopedics ’’ Of the duties of physicians to each other and the profession at large, Art. I (“ Duties for the -upport of Professional Character”) of the Code of Medical Ethics says : “Every individual, cn entering the profes- sion, as he becomes thereby entitled to all its privileges and immunities, incurs an ob- ligation to exert his best abilities to main- tain its dignity and honour, to exalt its standing, and to extend the bounds of its usefulness.” Art. II. : “ There is no profession from the members 20 of which greater purity of character and a higher standard of moral excellence are re- quired than the medical ; and to attain such eminence it is a duty every physician owes alike to his profession and to his patient. It is due to the latter, as without it he cannot command their respect and confidence ; and to both, because no scientific attainment can compensate for the want of correct moral principles.” The following expressions of opinion condemning commissions are worthy of con- sideration : “ We would be glad to see all commissions abolished, as it opens the door to many me- thods which are rank injustice to patient, merchant, and doctor.”—C. W. White & Co. “ We have never under any circum- stances allowed a commission on apparatus or appliances to anybody, in a business car- eer of over fifty years, although we have had numerous requests to do so, and have likely lost a number of cases in conse- quence.”—J. H. Gemrig & Fon “I wish to inform you that we are heartily in sympathy with the stand you have taken concerning this subject. We believe that the practice, prevalent as it is, of paying and receiving commissions, either from a business or professional standpoint, is rad- ically wrong.”—The Winkley Artifi- cial IylMB Co. 21 ‘ ‘ A physician has a right to be paid for his services, a lawyer his fee, a real-estate agent his percentage, a merchant for his ware. But when a physician is paid for his services and then demands a commission for sending his patient to an instrument-maker for an appliance, to such Dr. Solomon Solis- Cohen’s term ‘ sales-agent ’ is properly ap- plied. T have been struggling against it for years and probably lost the trade of nu- merous doctors on this account.”—William Autenreith. “ We have read your pamphlet with in- terest and think the salient points well taken.”—J. C. Schnottek & Son. “ It gives us great pleasure to indorse your views in regard to physicians taking commissions from instrument-makers. The correction of this abuse will enable all interested to retain their self-respect.”— D. W. Kolbe & Son. ‘‘ I have never conducted my business on any percentage plan, and, unless I am re- quested by the physician, never pay him any. I have met with not a few who have asked for ‘ their ’ percentage, and have paid it rather than lose their influence.”—A. Gustav Gekyekt. “ I enjoy the patronage of many a doctor who desires the welfare of his patient only, but also others who will not advise the use of my truss without expecting a commis- sion. What will a man in my position do? 22 Say no ? I cannot well afford to give a com- mission, but losing the sale is out of the question on account of the influence felt af- terward.”—H. Kunger. “ We do not offer commissions to physi- cians; however, when demanded, we are ob- liged to comply. When he orders an article and it is supplied by us as a piece of merchan - dise, it is sold as such ; but when we must fit it, then in a business sense it is not mer- cantile to underhandedly offer or give a share of the profit.”—Anonymous. “ It seems to us that surgical instrument- makers are about the last ones whose opin- ions towards the rest of the world are of anj- account on this subject. No one believes more fully than we in the old saying, ‘ Let him who is guiltless throw the first stone.' Imperfection pervades mankind to such an extent that it is not reasonable to require absolute, simple purity in any one respect. Moreover, that which disposes of the whole subject, in our minds, is that the medical profession, as a whole, occupies in the social body a position so respected that it be- hooves itself only through its properly con- stituted bodies to lay down each and every feature of its Code of Ethics.”—John Co. ‘‘A _ - ago I reduced the prices of 23 artificial limbs about one-third and made an effort to keep the prices unvarying, without reduction or commission to anyone. I soon found that in order to get any business from the profession it would be necessary to al- low a discount, and I have since made a practice of discounting io percent, from the quoted prices on artificial legs. Taking a financial view of it, I am satisfied that it was a mistake to reduce the prices. I be- lieve that I could more easily sell an artifi- cial leg through the average practitioner at $ioo with a 25 per cent, discount than I could by placing the advertised price at $60 or $70 with a 10 per cent, discount, with every assurance that the construction of the limbs would be the same. “ It is unquestionably true, however, that many physicians give the patients the bene- fit of the discount. Knowing that it is the rule for physicians to expect a commission or discount from the published prices of their products, it is perfectly natural that instrument-makers should make provision for it. These abuses are the result of the growing selfishness and corruption of the age, which, to a greater or lesser degree, en- ter into all classes and professions, and it will undoubtedly continue to increase so long as the possession of wealth is the chief ambition of mankind.”—George R. Ful- ler. “In some instances where physicians 24 claimed that they had been allowed conces- sions of this nature by other instrument- manufacturers, I granted them. To such an alarming extent has the practice been carried that patrons have become aware of it (as they justly should, and have asked me to give them the benefit of the physi- cian's commission. Requests of this na- ture, on many occasions, have put the phy- sician, as well as myself, in a questionable position. Considered either from a profes- sional or a commercial standpoint, the prac- tice, I am convinced, is a most reprehensi- ble one, and an immediate, earnest, honest effort should be made for its abolishment. —William Snowden. Only three manufacturers have frankly and candidly written advocating the giving and receiving of commissions, and they do it by classing physicians, drug-houses, in- strument-houses, and commission-houses as their profitable sales-agents. ‘ The legitimacy of authorizing drug- houses, instrument-houses, and commission- houses to obtain orders upon commissions has always been recognized and has never been placed within the pale of criticism. It has proved to be the most economical way by which articles of great benefit, service, and necessity can be made obtainable, with the least inconvenience to the parties need- ing them. Commissions are granted as compensation for time and labor expended 25 in taking measurements, attending to the details of ordering goods, receiving them when finished, and properly delivering them to the parties for whom they are in- tended, and not as a bribe for favoritism, as I construe your paper to imply. I cannot see why physicians should not have the same privileges and obtain the same com- pensation if they perform the same services, especially as the commissions allowed do not affect the cost of purchase to the wearer. There is one strong argument in favor of granting commissions to physicians which should not be lost, sight of, that is, that a very large proportion of physicians who re- ceive commissions on orders for artificial limbs turn those commissions over to their patients, and thus place the cost of an arti- ficial limb at a lower price than the patient would be able to buy if he bought directly from the manufacturer or if he passed the order through a commission-house, drug, gist or shopkeeper.”—A- A. Marks. ” After duly considering the subject I will give you my candid opinion in the mat- ter, ‘ Can Physicians Honorably Accept Commissions from the Manufacturers to Whom They Send Their Patients?’ They can do so in many cases without the pa- tients paying one cent more for the article than they would if they purchased it them- selves. My opinion being based upon the following facts: The manufacturer pro- 26 duces an article which he finds he can pro- duce at a certain price ; to that he must add at least twenty-five per cent, so that he will have a profit, as it will cost him at least ten to fifteen per cent, to sell the article by agents, advertising, etc. Now we have the wholesale price. To give the retailer a pro- fit there must be added another twenty-five per cent. on the wholesale price so that he can live. Now this twenty-five per cent that is put on to protect the retail- er is generally given in part, or the whole of it, to such people that can bring you trade, which people are generally considered by the manufacturer as his agents.”—Charles A. Bickel. “Being a member of the noblest profes- sion in the world, you are aware of the fact that, though physicians frequently go to considerable trouble in getting an appara- tus made which will suit the case, they uite often receive but little if any remuner- ation for their services. This being the case, we believe that they are entitled to a com- mission, providing the patient or his rela- tives can afford to pay a good price for the apparatus. Should the patient and his relatives, however, belong to that class who are obliged to work hard for their daily bread, we believe that it is the duty of the a:tending physician to notify the manufac- turer to that effect, renounce his commis- sion, and leave the whole matter to the 27 Judgment of the manufacturer.”—The R. Hyde Co. The relative position of the physician and the manufacturer is very difficult to define either from a professional or manufacturer’s standpoint, for the reason that comparative- ly few physicians are sufficiently familiar with mechanics to order definitely an appar- atus, or adjust it after it is made. There- fore the orthopedic apparatus-maker can- not be classed exactly with the apothecary or manufacturer of pharmaceutic prepara- tions—nor can his services be entirely dis- pensed with by those physicians who even compound their own prescriptions. For instance, a physician having a pa- tient requiring some form of apparatus, is very likely to send the patient to the manu- facturer with a note saying, in effect: ‘‘I know my patient requires an apparatus of some kind, and I will a