The following paper was head before The Medical 
Society of the State of New York, February 4th, 
1879, AND WAS BY VOTE OF THE SOCIETY REFERRED TO 
the County Medical Societies for tiieir considera- 
tion. It is desired that the County Societies take 
SUCH ACTION, AS SHALL, IN THEIR JUDGMENT, HAVE A 
TENDENCY TO ABATE THE ABUSES TREATED OF IN THE 
PAPER. 
RESPONSIBILITY OF THE MEDJCAL PROFESSION FOR THE ABUSES OF 
F*REE MEDICAL SERVICES. 
BY FREDERIC R. STURGIS, M. D., OF NEW YORK CITY. 
Mr. President and Gentlemen of the State Medical Society: 
Where there is so much already presented before medical 
societies upon subjects'purely scientific, I trust it will not be 
considered inapt if I call the attention of my professional 
hearers to a subject which is, in my opinion, of much impor- 
tance and interest to them—I refer to the effect which gra- 
tuitous medical services have upon the profession, not only 
in the present, but in the future. 
It is hardly necessary for me to do more than touch, in the 
lightest manner, upon the enormous abuse which exists in 
New York and, if we may believe what we hear and read, in 
almost every city of any size in the United States. You, of 
all people in the world know that. In some statistics which 
I prepared in 1873, I found that the number of presumably 
free xiatients treated in the Dispensaries and Hospitals of 
New York City was 280,536, and in the report of the com- 
mittee on the Abuses of Medical Charities, appears the fol- 
lowing : 
“In fact the number of persons receiving such (Dispensary) aid, has been estima- 
ted at from 250,000 to 300,000 in a year, and it was stated at a meeting held April 
12, 1877, that from 30 to 35 per cent, of the whole population of New York was re- 
ceiving medical advice gratuitously. 2 
Frederic It Sturgis. 
There is no need to multiply instances, the abuse is patent 
enough ; many people come for free medical advice who are 
amply able to pay a doctor, who, when asked as to the fact, 
admit it but palliate the offence by some such lame excuse as 
that they “thought the Dispensary was free to all,” or that 
they “ wanted the best advice, therefore they came,” etc., 
etc. But one question I want to bring forward prominently 
in this connection, amt that is, who is chiefly responsible for 
the greater portion of this abuse, which is so freely acknowl- 
edged and the checking of which has been the subject of 
consideration by Social Science and Medical Associations ? 
I say it is the doctors who are in the main responsible for 
this abuse, as but for their acquiescence in it, it could not 
exist for one day. I have often been surprised in conversing 
with physicians to see the absolute apathy which some of 
them exhibit on this subject, and were this the universal feel- 
ing there would be no hope of remedying the trouble; but I 
believe that the majority of doctors are anxious to prevent 
this abuse notwithstanding the many in their own ranks who 
assiduously foster it, and to them 1 appeal. 
Many medical men, whether from timidity or ignorance, 
believe that Trustees of Dispensaries take delight in perse- 
cuting their medical officers and in covering them with con- 
fusion. This I believe to be in the main a false impression, 
although I confess that in Boards of Trustees there are ob- 
structive and impracticable men as there are in many other 
Boards ; still Trustees, as a rule, are ready and willing to 
listen to reasonable remonstrances from their medical men ; 
they are themselves reasoning men and amenable to argu- 
ment, and in cases where they treat the doctors with indig- 
nity it is, I am forced to believe, but too often the doctors’ 
fault. A man seldom receives insult except he has brought 
it upon himself and the meekness with which medical men 
stand prepared to pocket kicks, if they can get an appoint- 
ment, the haste with which they rush for place, the wire- 
pulling, log-rolling and pipe-laying which go on to get a po- 
sition, would tend to disgust any Board of Trustees and to 
lower its estimate of the medical profession. And small 
blame to them ! It would seem incredible, but from actual 
observation, to see how almost impossible it is to get medical 
men to pull together in any questiou which concerns their Abuses of Free Medical Services. 
3 
common good where they have to give lip some private in- 
terest, but such, I believe, is fully the fact, and Trustees of 
public institutions, knowing this, usually ignore medical men 
in questions where, from their special knowledge and train- 
ing, the}7, would be eminently fitted to give advice. 
Although they are the prop and support of public medical 
institutions, doctors are, I believe, the most ignorant people 
in the world touching the workings of a dispensary, outside 
of the purely medical pait of it and it is with the purpose 
of giving them information which I believe will be of inter- 
est to them, that I have selected this topic as the subject of 
my paper. 
In May, 1876, during the incumbency of Dr. W. T. Bull, 
the New York Dispensary began charging its male venereal 
patients the sum of ten cents for each prescription, with the 
understanding that the medicine should be furnished gratis 
to those really unable to pay. In June, 1S76, the same rule was 
extended to the female venereal class and, in addition, bottles 
were sold to such as wished them, at five cents each. This 
experiment resulted at the end of the year, in the sum of 
$617.93. 
The percentage of paying venereal patients in the total 
number of cases in these two classes for 1876, was 
Of maleR 00 
Of females 50 
During 1877, the charge of ten cents was still continued in 
the two same classes with the result of yielding the sum of 
$1,007.05. 
This year the percentage had also increased, the percentage 
of paying venereal patients in the total number of cases in 
these two classes for 1877 being 
Of males 05 
Of females 77 
On October 29, 1877, I came on duty as House Physician, 
and in the following January (1878) I strongly urged that 
this rule should be extended to all classes attending the Dis- 
pensary ; that it was unjust to charge one set of patients, 
with the exemption of the rest; that a large number could 
well afford the charge, and I moreover claimed that, as many 
could and did indulge in strong drink, for which they paid, 
there was no hardship in making them pay for medicine at 4 
Frederic R. Sturgis. 
least. The recommendation was acted upon, commencing 
April 18th, 1878, and on December 31st, 1878, showed the 
following result: total amount received, $3,462.25. 
The percentage of paying patients of those charged was: 
Of males 95 
Of females 93 
I must apologize for carrying you, gentlemen, through the 
dry details of figures, but as they are necessary for a con- 
sideration of my argument, I must ask you to bear with me. 
It is of importance to remember that this class of patients 
who have been appealing to your time, skill, and knowledge 
are, with no great tax to themselves, able to furnish the dis- 
pensary with an annual income of several thousands of dol- 
lars—a fact from which, later on, we may be able to deduce 
some valuable suggestions. The dispensaries, it is true, claim 
to treat only those who are unable to pay a doctor, and, al- 
though I have, in my capacity as House Physician, refused 
treatment to all who, upon examination, I believed could 
pay one; still, what is to prevent the dispensaries from en- 
larging their sphere of action,—admitting all persons, no mat- 
ter from where, or what their social or pecuniary condition, 
to the benefits of gratuitous treatment ? In other words, 
what is to prevent them from competing directly with the 
doctors? This is not an idle fear. Something very much 
like it is now going on in New York City. One of our large 
and rich hospitals is now actively engaged in the cheap medi- 
cal business, and takes any and every patient, irrespective, 
as I understand it, of position or money, for a small monthly 
stipend, and without having the grace to pay their medical 
men for their services ; and the medical gentlemen, I believe, 
quietly acquiesce in this arrangement. The step from de- 
manding a small sum for medicines from those who cannot 
pay a doctor and rigidly excluding those who are found to 
be able to afford a fee, to making no distinction whatever, 
but treating all alike for a small monthly payment, has been 
made in one case : how soon will it be general ? Gentlemen, 
I have little wish to take a gloomy view of matters, but I be- 
lieve sincerely that unless the medical profession gets some 
control over this question of public medical charities, the 
public medical charities will get control of the medical pro- 
fession. Abuses of Free Medical Services. 
5 
I know that it is much easier to point out abuses than to 
suggest a remedy for them, but I trust that the medical pro- 
fession, by united action, either through their State Medical 
Societies, or, better still, through their County Societies, will 
insist upon a thorough and radical change in the management 
of the medical charities, and I believe that this can better be 
done at the present time than at any period which has here- 
tofore presented itself. The non-professional public is waking 
up to the existence of these abuses, and I am very sure that 
the State Board of Charities would heartily co-operate with 
medical men in the correction of them. 
There are two points, particularly, to which strenuous op- 
position should be made; the first is to the increase of free 
dispensaries, and the second is the use of public monies for 
the support and maintenance of private charitable institu- 
tions. On the first point the report of the Committee on the 
Abuses of Medical Charities is unanimous, as can be seen 
from the following remarks. In the suggestions it makes in 
its report the Committee says: 
“Their [i. e. the Dispensaries’] claim to the support of the public is the stronger 
when it is understood that each Dispensary, if properly supported, is able to care for 
all the sick poor within its limits, and there is no need for the creation of any fresh 
institutions of the same nature.” 
And again on the next page : 
“No necessity exists for more general Dispensaries in districts already occupied.” 
The number of hospitals and dispensaries in New York 
City is something marvelous. In 1873, I reckoned up forty 
of these institutions, both public and private, and even then, 
I believe the list was incomplete. 
The second point, viz : the diversion of the public monies 
for private charities, an abuse against which I most earn- 
estly protest. There is the so-called Excise Fund, obtained 
from the sale of licenses for the privilege of selling spirits 
and malt liquor in New York City ; and being derived from 
this source devoted to the use of charity, much on the 
same principle, I suppose, as that which actuated the barons 
of the middle ages to endow monasteries and churches with 
the proceeds of their plunder, as an atonement for their 
sins. 
If the money is taken at all for charitable uses, it should 
be expended upon the public city charities not upon private 6 
Frederic R. Sturgis. 
ones, which should not be supported at the public expense, I 
care not how much or what good they do. In 1873, taxes 
were levied, among others, for 
Charities and Corrections $1,160,000. 
Asylums, Reformatories, and Charitable Institutions 948,840 
Total $2,108,840 
Reckoning for Corrections 1,160,000,* a balance is left of 
$948,840 for Charities. In addition, for the same year, $111 , 
571 was paid by the Controller of New York City for dispen- 
saries, asylums, &c. Now I say that this is absolutely wrong 
and unjust to the tax-payers, and contrary, as I believe it, 
to the public good. 
Touching any remedies which can be devised for the cor- 
rection of these abuses, I have, I acknowledge, rather sug- 
gestions to offer than any matured plan, and it may be that 
in the discussion which I trust this subject will provoke, 
some good plan may be hit upon for adoption. One point 
to be borne in mind is, that in fighting these abuses we have 
to contend against a long and time-honored custom which 
has almost grown into a right, as well as the vested interests 
inherent to Dispensaries through their charters, by which all 
have, I believe, permission to acquire property up to a cer- 
tain annual amount. Still, by a proper vigilance, I think, 
the evil may be prevented from extending now and, perhaps, 
the entire system may be radically altered. One important 
step would be taken by the various County Medical Societies 
protesting against the granting of charters to Hospitals and 
Dispensaries where they deemed them unnecessary. The 
next point would be that the Dispensaries and public medical 
charities should, unless good reason to the contrary exist, 
rigidly exclude from the benefits of their institutions all 
those cases which, upon examination, are found able to pay 
the minimum fee of a doctor, say one dollar, as is 
done in some of the Dispensaries, and will shortly, I trust, 
be common in all ; and to charge those who are unable to 
pay a doctor even the fee of one dollar, a small sum for 
medicine, furnishing the latter gratuitously to such as are 
absolutely destitute. The number of these, however, I be- 
lieve, to be exceedingly small. The third step would be a 
modification of the medical staff of the Dispensary, instead 
* I have purposely made this item unduly large. Abuses of Free Medical Services. 
7 
of making the services, as now, on alternate days, changing 
it to a continuous one, and paying the doctors for their ser- 
vices. This would, it is true, throw half the staff out, but, 
on the other hand, it would make the service a more valuable 
one both in a medical point of view and pecuniarily, besides 
making it better for the patients. 
But perhaps it will be urged that this is putting the chari- 
table aspect of the case entirely out of the question? So 
much the better. 1 unhesitatingly state as my belief that a 
very large percentage of medical charity is a delusion and a 
snare, and the sooner it is swept away the better for a correct 
understanding of the subject. I believe that if medical men 
were to give a candid answer to the question, how much has 
charity to do with your connection with a dispensary or hos- 
pital, as compared with your desire to see cases and study 
disease? the question of charity would “kick the beam.” 
I fail to see any good reason why the doctors should be the 
only unpaid employes of a dispensary or hospital. Their 
time and skill are as valuable as any in the community, and 
their education has cost them money as well as time, and for 
a long period is unremunerative. Why, then, should they 
not receive a compensation ? 
These considerations touch only upon the relations between 
the dispensaries and their medical attendants, and really 
leave the management of the former in the hands of a non- 
professional Board. One other plan I have to propose, viz.: 
that medical men shall have the full control of the dispensa- 
ries in which they work, and in this manner : Let any given 
number of doctors (one or more) start a dispensary for them- 
selves—not a free dispensary, but a paying one, one that will 
be self-supporting (and this would not be difficult of attain- 
ment, I think), under a Board of their own attending staff, 
asking no one for money for its support, but making those 
resorting to it pay (when able) for the services rendered. 
The sick poor have to be attended to somehow or other, and 
that could and would be done in a private dispensary, but 
the number of the absolutely destitute would be very small, 
the bulk of attending patients would be able to pay a fee, 
varying according to their circumstances. This would, in my 
belief, pay expenses, and in a short time after its inception 
allow of a surplus to be divided among the doctors, remuner' 
ating them, to a certain extent, for their time. 8 
Frederic R. Sturgis. 
The time allotted for papers is of course too short to allow 
of more than a rough outline of any plans to be submitted, 
the details must be left to be filled in by circumstances and 
mutual agreement among the physicians themselves; but one 
thing, gentlemen, I think should be done : enlist the co-ope- 
ration of the County Societies, and through them of the 
State Medical Society, as the exponents of medical opinion, 
to check the abuses adherent to medical charities, and to in 
sist upon their rectification. You are the persons who give 
credit and renown to dispensaries and hospitals, and in your 
hands rests the power to correct their abuses. 
To some of you, perhaps, a great deal contained in this 
paper may seem novel and startling, and if I have spoken 
strongly, it is because, from my long connection with and in- 
terest in these institutions, I have seen the growth of these 
abuses in them, and because, also, I feel strongly in the 
matter.