SOME BEMABKS ON HOSPITAL ABUSE. 
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BEFORE THE ASSOCIATION OF AMERICAN PHYSICIANS, 
AT THE ANNUAL MEETING IN WASHINGTON, 
MAY 4, 1898. THE PRESIDENT’S ADDRESS. 
SOME REMARKS ON HOSPITAL ABUSE. 
By FREDERICK C. SHATTUCK, M.D., 
OF BOSTON. 
Hospitals are so beneficent, and the lives of many of us are so 
bound up in them and their work, that we may at times fail to realize 
that they have any possibilities of evil, either as regards the public 
in general or our own profession. 
With your permission I shall venture to lay before you a few 
thoughts which came into my mind on this question, some general 
subject pertaining to medicine seeming to be more suitable for the 
address with which it is my great privilege, thanks to your unmerited 
kindness to me, to open our session. 
Though it is over four hundred years since this country was dis- 
covered, and more than two hundred and fifty years since real settle- 
ments by highly endowed members of the Anglo-Saxon race were 
elfected, the first hospital was founded not much more than a century 
ago. Until approximately fifty years ago the population was rela- 
tively homogeneous, and even the largest cities were small enough 
for the inhabitants to know each other and each other’s affairs. There 
were few poor, and neighborly succor efficiently met illness and the 
distresses which so often follow in its train. Then began the great 
Irish immigration, followed by that from almost every overstocked 
European country; the older cities grew apace, and new cities sprang 
up as the tide moved westward. The conditions of life changed with 
enormous rapidity, and every large city developed a class whose earn- 
ings or whose lack of thrift do not permit provision against the almost 
inevitable day when the bread-winner, afflicted with acute or chronic 2 
SHATTUCK, 
disease, can win no bread, while the requirements of himself and his 
family can be but little, if at all, diminished. 
We all know from personal experience how wonderfully helpful the 
members of this class are to each other in trouble of all kinds; also, 
that their helpfulness has clearly defined limits. The larger the class 
grows the more imperfectly are its members acquainted with one 
another and with one another’s special needs; and much less are 
they, as individuals, known to the easier classes. Thus, organized 
and public must supplement private and individual help in time of 
need, and it is natural that the hospital should take a high, if not the 
first, place among the forms of help. We are all mortal; the vast 
majority of us are unsound somewhere; illness and disability come to 
many without any fault on their part. Health is an almost indis- 
pensable condition of support and usefulness. Its preservation, there- 
fore, appeals directly alike to the head and heart of the community. 
All the first hospitals in this country were founded by private 
individuals, public spirited, anxious to benefit their less fortunate 
fellow mortal and fellow citizens. But as cities grow large it is often 
found necessary for the taxpayers to aid and supplement private 
elfort. We see, then, that the original cause for hospital foundation 
lay in charity—charity in its best and highest sense. Hospitals were 
designed to help those who could not help themselves; and it has 
been and is the pleasure as well as the duty of the medical profession 
to contribute its full share by rendering its services without direct 
pecuniary reward. But we should never forget that no physician can 
do conscientious work in a hospital without indirect reward, a portion 
of which is pretty sure to be pecuniary. The gain in knowledge, the 
stimulus to its acquirement, the development of the man and doctor 
alike, which the honest performance of hospital work surely brings, 
almost as surely lead to the better performance of private work, and 
hence to the demand for it. As hospital physicians, we are, I think, 
sometimes inclined to strike a false balance between the sacrifice of 
time and strength which hospital work demands and the return, which 
is none the less real because it is indirect and cannot be estimated with 
mathematical accuracy. Personally, I believe that this natural return 
is ordinarily ample, and that any conscious and deliberate attempt on 
our part to enhance it can only be lowering to ourselves and unfair to 
the general body of the profession. SOME REMARKS ON HOSPITAL ABUSE. 
3 
And just as there are indirect advantages flowing to physicians 
from hospitals, so also do they flow indirectly to the rich who endow 
and maintain them, in that the rich profit by the skill acquired by 
the staff and by the advance in 'scientific knowledge secured by the 
minute study of collected cases of disease. Virtue may be its own, 
but it is not necessarily its only, reward. 
I repeat that the primary purpose of hospitals is charitable; hence 
their immediate benefits should be reserved for the poor, for those 
who are unable to pay for medical attendance. Poor and rich are, 
of course, relative terms, and not easy of exact definition. A person 
may be able to pay one fee, perhaps several fees, but totally unable 
to pay for prolonged attendance. Medical attendance, moreover, 
stands on quite a different footing from almost every other necessary 
of life. There are different grades of food and clothing, even of fuel 
and light, between which, within certain limits, one can choose with- 
out detriment to health but with advantage to the pocket. The first 
cuts of meat are no more nutritious than the lower grades, and style 
alone may be the larger element in the cost of clothing, to say noth- 
ing of the choice of material. But the poorer a person is, the more 
purely dependent he and his are on his own exertions, the more im- 
portant is it for him to have the best medical care attainable. Here 
economy may be the wildest extravagance. This is an aspect of hos- 
pital abuse which cannot be lost sight of. There is no clearly dis- 
cernible line of cleavage, and, therefore, abstract justice cannot be 
done in every case; as in most other branches of human activity, 
substantial justice is the best we can hope at present, at least, to 
attain. Medical charity in hospitals and dispensaries should be freely 
extended to those who require it, denied to those who do not and 
from ignorance or parsimony demand it. The community suffers if 
provision is insufficient or proper access is difficult. The community 
also suffers if no questions are asked, the independence and self-respect 
of the laity being undermined, and the medical profession failing to 
receive returns which justly belong to it. Alike as citizens and pro- 
fessional men, we should carefully scrutinize the claims of every new 
charitable medical institution, and refuse our aid and countenance 
unless satisfied that it is likely to meet a real need in the community. 
The same care should be exercised with regard to abuse creeping 
into existing institutions. The matter lies really in the hands of our 4 
SHATTUCK, 
profession. If no physician would serve or aid in promoting a medi- 
cal charity, so-called, founded mainly on sentimental or selfish con- 
siderations, such would soon cease to exist, and the millennium would 
be at hand. There is too much reason to believe that hospitals and 
dispensaries are sometimes started purely in the selfish interest of 
members of our profession. 
The second great function of hospitals—second in point of time 
evolution, though not, I believe, in point of importance—is the edu- 
cational function, the advancement and dissemination of knowledge. 
On this function I need not dilate to this audience. It is, of course, 
more obvious to us than to the laity; but their attention is being 
more and more called to it. They are quick to see the truth and to 
recognize the powerful stimulus to the staff to do first-class work 
afforded by the critical eyes of bright students. The clinical teacher 
must study his cases carefully; compulsion acts more imperatively on 
him than on the hospital physician who is not also a clinical teacher. 
The necessities of teaching and the demand for much material from 
which to select has been used as an excuse for the abuse of hospitals 
and dispensaries, and to a certain extent such excuse may be valid. 
Students should become familiar with as wide a range of disease as 
possible. The didactic lecture in medicine and surgery is slowdy but 
surely falling into the background, teaching becoming more and more 
clinical Patients may be made to pay in their persons if not from 
their pockets. The student and clinical teacher demand material; the 
practitioner wants patients. When the student becomes a practitioner 
his point of view changes. But he should not forget that he, when a 
student, probably gained in remunerative knowledge more than the 
equivalent of a few cases which, after he has gone into practice, seek 
advice at a hospital instead of paying his fees. Our direct losses 
loom up larger than our indirect gains. I do not mean to imply that 
a teaching hospital is free from responsibility in regard to this matter. 
I merely want to indicate that there are two sides to this question, at 
the same time stating my conviction that very little injustice need be 
done if a due sense of responsibility is felt and influences action. 
Complaint in the medical press of hospital out-patient departments 
and dispensaries seems to be endemic in England, and there has been 
of late an epidemic in this country; legislation on the subject has 
even been seriously considered. It is claimed that the doors of these SOME REMARKS ON HOSPITAL ABUSE. 
5 
institutions are thrown open so widely as to entail great hardship on 
many worthy members of the profession. That there is some ground 
for these complaints I fear there can be no question. For some eight 
years I did out-patient work in the Massachusetts General Hospital, 
and have no reason to believe that the conditions are materially differ- 
ent now from what they were at that time. The number of cases of 
deliberate intention to avoid payment for advice was, as I remember, 
small. Some residents of the city, apparently able to pay, came, 
seemingly without wrong intent, to get an opinion and see how far 
it coincided with that of their doctors. More came thus from the 
country, under the impression that the city must contain more wis- 
dom, not knowing whom there to consult, and not having told their 
regular advisers that they wanted further advice. The reputation of 
the hospital, and sometimes the idea derived from the name— 
“ Massachusetts General ”—that it is a State institution, to the bene- 
fits of which as taxpayers they had a right, determined their coming. 
Not infrequently patients would come, more commonly from out of 
town, either with their physician or with a letter from him, asking for 
a consultation, and perhaps a detailed opinion in writing—no light 
demand, considering the number of patients requiring attention. 
For some years now at the Massachusetts General Hospital a paid 
medical officer questions applicants to the out-patient department as 
to their circumstances, and refuses entrance to those who do not seem 
to him proper cases for free advice. It is also his duty to exclude 
such diseases as measles, scarlet fever, and the like from the waiting- 
rooms, in order that their spread may be limited. This is a plan 
which does not involve a hospital in great expense—five hundred 
dollars per annum at the Massachusetts General Hospital, with an 
average of about one hundred new patients a day—as the services do 
not require more than a couple of hours a day, seems to me as efficient 
as any plan which has been suggested, and one which it is not unrea- 
sonable to expect all similar institutions to carry out. 
There is another ground for complaint against hospitals about which 
less has been said. I refer to the growing practice of attaching pay- 
wards to hospitals, which, let me repeat once more, are founded and 
exist for charitable and educational purposes. Patients who pay from 
twenty to fifty dollars per week for private rooms ordinarily serve 
neither of the above purposes, and provision for them here seems to 6 
SHATTUCK, 
me unfair and improper unless to a very limited extent. This is not 
a legitimate mode of providing revenue for the care of the sick poor. 
Our well-to-do citizens are amply able, and I am convinced more than 
willing, to provide for such cases through gifts, bequests, and taxes. 
The chances are strong that a hospital that cannot be maintained 
without the resort to this practice is in whole or in part unnecessary to 
the community in general, and should, consequently, in whole or in 
part, close its doors until the community in which it is situated grows 
up to it. One great and well-known hospital derived fifty-five thou- 
sand dollars from this source last year. I am told that other great 
hospitals are making large investments in this field. I am perfectly 
well aware of the fact that strangers in the city fall ill in hotels, and 
that residents are for one reason or another sometimes so situated at 
their abodes that proper care is difficult or impossible to secure. I 
know- what a boon it sometimes is to patient and physician alike to 
fyave access to a well-organized hospital. But this need not and 
should not be a charitable hospital. This class of patients is suffi- 
ciently large in every considerable city to maintain one or more hos- 
pitals or infirmaries: private in that they are designed for private 
patients, public in that any physician can send his patient thither and 
assume personal care of him, making such professional charges as his 
wisdom and conscience dictate. This is free-trade in medicine. In a 
large hospital it is, from an administrative point of view, impossible to 
allow physicians other than members of the staff to care for patients 
within its walls. The small private hospital or infirmary can be made 
to yield a good return on the investment, and no injustice is done to 
anybody. And it seems to me that injustice to somebody is inevi- 
table when well-to-do patients are admitted to hospitals designed for the 
sick poor. If the staff is allowed to receive fees for attendance on such 
patients its members are given an unfair advantage over those mem- 
bers of the profession without hospital appointments, and the hospital 
becomes a sort of medical trust. The indirect benefits of hospital 
service are quite sufficient. If the members of the staff are not allowed 
to take fees the well-to-do patient is injured by receiving gratis ser- 
vices for which he is able to pay and should pay; the time and skill 
of the attendant is diverted from the sick poor or from such use as he 
might wish to make of them, and the sum of professional earnings, 
now none too large, is unfairly diminished. Commercialism tends to SOME REMARKS ON HOSPITAL ABUSE. 
7 
degrade the medical profession, and if well-to-do patients are to be 
cared for in our great hospitals, it seems to me that the evils of free 
are less than those of paid professional service. 
The Massachusetts General Hospital has eight private rooms of 
the class I now allude to. Years ago the staff itself established the rule 
that no fees should be received for attendance on inmates of the hos- 
pital, and a printed notice to that effect is placed in each of the private 
rooms. 
The hospital physician can keep his private hospital if he will, or 
he can, just like any other physician in the town, send his patients to 
an infirmary. The charitable and educational institution should not 
step in to save its staff the trouble of housekeeping and of providing 
and superintending nursing for patients in easy circumstances. It 
should not demand of its staff unrequited service save for the sick 
poor. It should not place any unnecessary obstacles in the way of 
full and free competition between members of our profession. To the 
exaction of the payment of a few dollars a week from patients who 
can afford it, who are treated in the ordinary wards, and who can be 
used for teaching, if suitable cases, I can see no valid objection. The 
self-respect of the patient is maintained by rendering some return for 
much needed care, which his circumstances preclude his securing at 
home, and no just ground for complaint is afforded practising physi- 
cians unattached to hospitals. 
In this whole question we have a responsibility which we cannot 
escape. The more fortunate a man is the more mindful should he be 
of the rights of others, especially of his professional brethren. The 
staff of the hospital or dispensary should co-operate fully with the 
trustees, giving them the full benefit of their more intimate knowledge 
of all professional matters, and always remember the broad thera- 
peutic principle—une quid noceat."