AN ADDRESS 
Delivered at the Opening of the Twenty-first Annual Meeting 
of the Medical Society of the State of 
California, April, 1891. 
BY 
W. R. CLUNESS. M. D., President, 
Sacramento, Cal. 
SACRAMENTO, CALIFORNIA : 
| Reprinted from the Occidental Medical Times, May, 1891.] CITY. 
Is such a practice 
known or suspectec 
among you as com 
missions paid by 
apothecaries to 
physicians 
on their 
prescriptions ? 
If so (i) how general is it, and (2) what per cent, do you sup- 
pose is paid ? 
Has your loca 
Medical Societj 
dealt with 
this matter? 
If so, what action ? What result? 
Birmingham- 
Mobile __ 
Hot Springs- 
Alameda 
Los Angeles - 
Marysville 
Oakland 
Sacramento- 
— Ala 
- - Ark 
Cal 
Yes - 
Suspected 
Yes „ 
Suspected 
Suspected 
Suspected __ 
Yes — — 
Yes 
Yes 
- 1. Only one instance. 2. Unknown — 
- 1. Very limited. 2. Not stated- _ 
- 1. About one-half. 2. 25 to 50 percent _ 
- 1. Two only suspected. 2. No answer _ 
_ 1. Very limited. 2. No answer 
- 1. One apothecary. 2. Not stated 
_ 1. One apothecary. 2. Not stated 
- 1. No estimate. 2. 30 to 50 per cent 
No 
-No _ 
No 
No. 
No- 
No 
No - — — 
Yes- - 
- Not done by members of Medical Society. 
- Only case in ten years. 
Resolutions. No result. 
San Francisco 
San Jose 
Santa Barbara -. 
Stockton .. 
Denver 
Pueblo — 
Bridgeport 
Columbus 
Aurora 
Chicago . — _ _ 
Decatur 
Elgin 
Col. 
—Conn. 
Ga. 
— 111. 
Yes- . 
Suspected 
Yes _ 
Suspected — — 
Suspected __ .. 
Yes _ 
Suspected 
Suspected 
Yes 
Yes 
Yes 
Yes_ 
. 1. One-third to one-half physicians. 2. 11 to y; per rent 
. 1 Unknown. 2. 20 to 40 per cent _ _ 
. 1. Not general. 2. Unknown 
- 1. Suspected of two only. 2. Unknown 
. 1. Rare. 2. Unknown 
_ 1. Not stated. 2. Generally office rent 
1. Not general. 2. Unknown — — 
1. Not general, 2. No answer 
1. Two of four M. Ds. 2. 10 per cent 
1. Common. 2. As high as 25 per cent 
1. Two or three instances. 2. Not stated 
No . — — 
Yes- -_- 
No 
No Society 
No Society - - 
No 
No _ 
No 
No Society 
No 
No - - 
No — .. — 
No result; too many involved. 
- 
1 No action needed. 
Evansville _ _ . 
Fort Wayne 
Indianapolis _ 
Jeffersonville 
Ind. 
Suspected 
Yes_ - - . 
Yes 
Suspected - 
No answer 
1. About two per cent of drueerists. 2. Unknown 
1. No answer. 2. 10 per cent 
No 
No 
Yes _ .. 
Not for years 
No 
No _ 
No 
No- 
No Society _ . 
No Society 
No 
No - — 
No 
1. Resolutions. 2. None. 
No members implicated. 
Members of the local Society are the ones. 
Medical Association indifferent. 
No members implicated. 
Almost effaced. 
Too recent for much result. 
Beyond remedy. 
The “suspect” not a member. 
Resolution. No result. 
No reputable physician suspected. 
No reputable physician suspected. 
Logansport 
Cedar Rapids _ _ 
Des Moines 
Emporia-- __ 
Ottawa-- 
Wellington _ 
Winfield 
Lexington 
Newport . 
New Orleans .. 
- Kan. 
Ky. 
La. 
Yes- . 
Yes — 
Yes - — _ 
Yes- — 
Yes . _ - 
Yes 
Suspected 
Suspected 
Suspected 
1. Three or four of 35 M. Ds. 2. 10 to 25 per cent 
1. Uncommon. 2. 25 percent _ 
1. Less than formerly. 2. No answer 
1. Not general. 2. About 10 per cent 
1. Only one M. D.; one druggist. 2. 10 percent 
1. Less than formerly. 2. Unknown 
1. About one-third. 2. Not stated- _ 
1. Very limited. 2. Unknown „ - 
1. Three M. Ds. 2. Unknown 
Biddeford 
Boston 
North Adams — 
Waltham__ 
Saginaw 
Brainard 
Minneapolis - _ 
Red Wing 
St. Paul 
-Me. 
Suspected _ 
Yes — 
Yes. _ — 
Suspected 
Suspected- 
Suspected only - 
Yes 
Suspected __ 
Yes 
1. One' druggist of 20. 2. No answer _ 
1. Not general. 2. Six to 10 per cent _ 
1. Most druggists. 2. No answer 
No answer - _ „ 
1. Very limited. 2. Unknown 
1. Not general. 2. Unknown. 
1. Less than one M. D. in ten. 2. is to 2s per cent 
No answer. 
1. No answer. 2. About 20 per cent 
No 
No . 
No — 
No 
No answer __ _ 
No 
No - . - 
No 
No answer _ 
No 
Nevada 
St. Louis 
Yes 
Yes 
Yes - - 
1. Only a few. 2. 20 to 25 per cent; some take whisky 
1. Only one case heard of. 2. No answer 
1. Very limited. 2. 10 to 50 per cent _ 
No Society _ . 
No — 
bedalia. “ 
Grand Island City__Neb. 
Lexington “ 
Yes- 
Suspected 
1. Mai’ority get office rent. 2. 25 per cent 
1. Confined to mongrel practitioners. 2. 2s to so per cent 
No _ . 
Yes — 
No Society 
Lincoln “ 
Yes_ - 
1. Not common. 2. No answer 
Omaha “ 
Yes— — 
No 
Manchester 
-N. H. 
Yes. 
1. Four-fifths of M. Ds. 2. 20 per cent 
Nashua “ 
Yes — 
Camden ...... 
-N.(J. 
Yes 
1. Not general. 2. 10 to 20 per cent __ 
Yes 
Paterson “ 
Yes 
1. Not general. 2. Unknown 
No - . 
No 
Trenton “ 
Yes 
1. Scarcely at all. 2. No answer 
Albuquerque 
Brooklyn 
—N. M. 
— N. Y. 
Yes. 
Yes. - _ . 
1. Prevalent. 2. About 10 per cent 
1. Almost ceased. 2. About 25 per cent 
No 
uunaio “ 
Cohoes “ 
Suspected 
Suspected - _ _ 
1. Not general. 2. 20 per cent 
Unknown! 
No 
No 
Jamestown “ 
Yes 
1. Not general. 2. Presents rather than commissions 
1. No answer. 2. 10 to 20 per cent _ 
No answer 
Middletown “ 
Yes. — 
1. Limited. 2. Unknown 
New York “ 
Yes. —_ _ 
1. Less than formerly. 2. 10 to 25 per cent 
Ogdensburg “ 
Suspected . _ 
Unknown . _ _ „ 
Oswego • ‘ 
Suspected _ 
1. Not general. 2. Answer indefinite 
Poughkeepsie “ 
Suspected . __ 
1. Not general. 2. Unknown 
Rochester “ 
Yes — . 
Watertown “ 
Yes _ - — 
1. Not general. 2. 25 to 50 per cent _ 
Asheville 
N. C. 
Suspected 
No answer 
No .. . 
Cincinnati _ 
Yes_ „ 
No - 
Cleveland ** 
Suspected 
1. Not general. 2. Unknown 
£t° ~ 
Columbus “ 
Yes-_ _ 
1. Confined to quacks. 2. No answer 
Delaware- _ “ 
Yes- _ — 
1. Not general. 2. 10 per cent 
Hamilton “ 
Suspected 
1. One case only. 2. No answer 
No 
Lima - “ 
Mansfield “ 
Yes ... 
1. Four or five M. Ds. 2. No answer 
No - 
Yes , 
Toledo 
Zanesville _ 
East Portland 
Portland 
Or. 
Yes- 
Yes- . 
1. Only one druggist known. 2. 20 per cent 
No 
1. Confined to a few. 2. 25 per cent- _ 
Formerly I 
1. Discontinued ; once paid 
Yes 1 
Suspected j 
Alleghany 
- Pa. 
No particulars _ 
No . — 
Carbondale “ 
Danville. “ 
Lancaster “ 
Yes- | 
1. Not stated. 2. Presumed 12 per cent 
Yes 1 
1. Not general. 2. Unknown 
Yes- 
No answer _ _ 
Newcastle _ — 
, “ 
Suspected _ ... 1 
1. Not general. 2. 12 to 20 per cent _ 
Oil City - 
Yes-. 
1. Not general. 2. 20 per cent- 
Philadelphia — 
“ 
Suspected — | 
Unknown 
Pittsburg 
“ 
Yes — _ - - .I 
1. About five per cent. 2. About 15 per cent 
No 
Scranton . _ .. 
Yes - 
1. Limited to a few. 2. Unknown 
Titusville 
Yes | 
1. One of eig-hteen suspected. 2. Unknown 
Wilkesbarre - - 
“ 
Yes. . 
1. Confined to a few. 2. xo per cent 
Refuse membership. 
Providence. .... 
-R. I. 
Suspected 
x. Uncommon. 2. 10 per cent 
Charleston „ _ 
- S. C. 
Suspected . __ 
1. To limited extent. 2. No answer 
San Antonio 
-Texas 
Yes .. _ 
1. Ten per cent of physicians. 2. 10 to 20 per cent 
No result. 
Salt Lake City _ 
-Utah 
Yes 
1. Confined to quacks and one Mormon. 2. 10 per rent 
Rutland . . 
— Vt. 
Yes . 
Answer illegible _ - 
Seattle 
Wash. 
Yes 
Tacoma . . _ _ 
Suspected 
1. Limited. 2. 20 to so per cent 
Action intended soon. 
Chipewa Falls 
-Wis. 
Suspected 
Mo answer - — _ 
Milwaukee — - “ 
Yes 
1. One M. D. only. 2. No answer- - 
No member would be allowed to do so. 
Racine “ 
Yes- 
Cheyenne 
—Wy. 
Yes. 
1. No answer. 2. 50 per cent 
No 
Table A.—Commissions on Prescriptions. Reprinted from the Occidental Medical Times, May, 1S91. 
AN ADDRESS, 
Delivered at the Opening of the Twenty-first Annual Meeting of the 
Medical Society of the State of California, April, 1891. 
By W. R. Cluness, M. D., President, Sacramento. 
Fellow Members of the Medical Society of the State of California: I 
deem it appropriate at the outset of the address, which custom aud our 
regulations require of the presiding officer, to remark that this is the 
twenty-first anniversary of the organization. We have, therefore, the 
right to congratulate ourselves on a maturity of years, which warrants 
increased confidence in our corporate strength, in our capacity for public 
usefulness aud for mutual support, and in our hope for popular appreci- 
ation as a factor in human progress. This fact carries no newly acquired 
rights, no additional claims to recognition; it is only the beginning of a 
new era, which may or may not be distinguished by some event or ac- 
complishment of signal interest or influence to the physicians of Cali- 
fornia. What this may be, to what extent it may operate, or whether it 
may become in anywise manifest at the present meeting, I shall not un- 
dertake to predict. Time alone can demonstrate. 
Before coming to the main subject, I desire to call your attention to a 
point in our internal regulations, which ought to be definitely settled at 
this meeting; that is, the question whether membership in a local or 
county medical society, wrhere such society exists, is an indispensable re- 
quisite to acquire or to retain membership in our State Society. This has 
generally been accepted in the affirmative, for the following reasons: (i) 
The local society is much more competent to judge the physician’s pro- 
fessional and social standing than the State Society; and, (2) It is the 
duty of physicians, especially in the less populous counties, to assist in 
keeping alive a local organization. To aid in reaching a reasonable con- 
clusion the principal permanent officers of the American Medical Asso- 
ciation have been asked to define the requisite qualifications for member- 
ship in that body. The concurrent testimony shows clearly that 
membership in some medical body, local or State, or both, is indispens- 
able; and it is to be presumed that the object is to have a guarantee of 
the candidate’s professional and personal standing at home, among those 
who know him best. The same rule should govern here; but exception 2 
must be made in favor of a few sparsely populated counties, where it is 
found impracticable to maintain a local organization. 
With these preliminary remarks I now invite your attention to a sub- 
ject which I deem worthy of your serious consideration, in the hope that 
present discussion and future deliberation elsewhere may lead to the 
eventual solution of problems, which I confess myself at present, unable 
to compass. 
The and Derelictions of Medical Practitioners to 
Professional Character. 
Is the practice of medicine a profession or a trade? To this I assume 
that all regular physicians will give the same answer, though they may 
not agree upon definition of the terms. Here, then, is the important 
point at issue, and a few words are appropriate in its elucidation. What 
is the distinction? The code of ethics of the American Medical Associa- 
tion and the Hippocratic oath throw some light upon the subject. The 
Golden Rule is more conspicuous in a profession than in a trade; but let 
us look further. 
Before the decadence of the French nobility, the dictum ?ioblesse oblige 
was a pledge to honorable conduct. We have no such motto, but most 
of us feel an inward prompting to habitual acts of beneficence. The 
universal brotherhood of mankind finds more recognition amongst us than 
with any other calling, for our services are rendered to all classes and 
conditions of men. From time immemorial the poor in their sickness have 
asked relief at our hands, and their calls have been heard; the highest of 
the land give us their confidence, and it is not betrayed; victims of their 
own misconduct come to us in their troubles and we are often sorely 
tried in deciding upon the right course between conflicting claims. At 
all events confidence must not be violated, and the service required must 
be rendered, provided it involves no infraction of law and public inter- 
ests. These considerations rise above personal comfort, and money often 
makes no figure in the transaction. Surely these are not trade dealings. 
Since we hold, then, that medicine is not a trade but a profession, it fol- 
lows that physicians must refrain from the artifices usually resorted to in 
commercial pursuits to secure and to increase business; that they must be 
known by their works and not by their words; that they must not cheapen 
their services in order to compete with others, however much they may 
abate fees as a concession to poverty and distress; above all, they must 
not resort to deception and fraud to increase their gains. It has not been 
my purpose to dwell upon this part of the subject, but rather leave it to 3 
your enlightened sense to supply all particulars after a few general re- 
marks. 
As to the derelictions, it was my original intention to deal only with 
two, which are believed to be rather common in our large towns and 
cities. In order to investigate them thoroughly, and speak with some 
degree of certainty, I have prepared and sent out nearly one thousand 
circulars of inquiry. Of these, nearly 50 per cent, have been returned, 
and the accompanying tables, together with the list of places where 
commissions on physicians prescriptions and society practice are reported 
not to prevail, have been compiled from a careful analysis of the replies. 
In the circular these practices are styled “reprehensible and avoidable 
business dealings,” and I have been gratified to find an almost 
universal concurrence in their condemnation, a general wish that this 
effort might conduce to their abatement, and a frequent request for advice 
upon a plan to break up the abuse of “society practice.” But I have 
found it incumbent upon me to enlarge the scope of this exposition, as a 
large number of correspondents have called attention to other derelic- 
tions, and I shall here quote some of the statements made in connection 
with the various practices in question. 
Percentages on Prescriptions. 
The practice of paying a commission to physicians by apothecaries is, 
of course, rather presumptive than capable of actual proof, and this is 
plainly shown by the table; but there can be no reasonable doubt that it 
is even more prevalent than the returns indicate. A San Francisco phy- 
sician remarks: “I have been repeatedly approached by them (apothe- 
caries), and commissions ranging from from 30 to 75 per cent, have been 
offered; indeed, many druggists openly maintain that they can afford, and 
in fact, do give physicians all the receipts of the first prescriptions, con- 
tenting themselves with what they call ‘the repeats.’ * * * In order 
not to have patients go to another drug store, one druggist has envelopes 
which are given to the physician, who seals the prescription in the en- 
velope; another apothecary has prescriptions telephoned to him directly 
from the doctor’s office, and pays for the rental of the telephone. I had 
one patient tell me that his drug bill was larger than his physician’s bill 
(of course, while under another physician’s care).” A correspondent at 
Chicago, and another at Elgin, 111., alludes to a practice of writing pre- 
scriptions in cipher, so that they can be understood and filled only at a 
particular store. The plain inference is that the prescriber and the drug- 
gist are leagued to fleece the unfortunate patient. This is no novelty, and 4 
is probably known wherever “percentage” prescribing is done. A cor- 
respondent at Racine, Wis., writes: “It is a systematic way of robbing 
the public, and any society of medical men ought to denounce it, and 
refuse to affiliate with members who persist in the practice. I hope you 
will arouse a public feeling which will spread from Maine to California, 
and finally break up this robbery of the sick aud unfortunate.” 
It is probable that the abominable system is as prevalent in San Fran- 
cisco as in any city in the whole world, and it is an “open There 
are now two druggists who announce their revolt from the system by 
conspicuous placards, one of which reads: “People’s Drug Store; No 
Commission paid to Physicians on Prescriptions;” and another bears the 
legend: “No Percentage Drug Store.” But this is not the sole wrong 
done the confiding patient. The “percentage doctor” is irresistibly im- 
pelled to order more medicine than his patient ought to swallow, so as to 
increase his gains. Some are known to prescribe gratuitously with great, 
apparent, liberality; but their benevolence is rewarded by the percentage 
on the bulky and baneful excess of drugs which the simple patient had 
to pay extortionate prices for. I say extortionate, for the druggist is sure 
to recover the doctor’s commission by adding it to a fair price for the 
medicine, either then or on future occasions. 
I am informed that percentages are given to physicians in all large 
towns of England, varying from 35 to 50 per cent., though it is not a 
general custom; also that the same is done by some druggists in Edin- 
burgh. Advices relative to Berne, Switzerland, and Bucharest, Roumania, 
mention this dealing as “suspected.” 
The following cities and towns are reported free of “percentage” deal- 
ings: Alabama—Anniston, Montgomery. Arkansas—Fort Smith, Tittle 
Rock. California—Chico, Grass Valley, Livermore, Riverside, Santa 
Rosa, Woodland. Connecticut—Danbury, Hartford, Middletown. Del- 
aware—Wilmington. Dakota—Sioux Falls. Georgia—Atlanta, Macon, 
Savannah. Illinois—Alton, Belleville, Bloomington, Cairo, Englewood, 
East St. Louis, Galesburg, Rockford. Indiana—Anderson, Crawfordsville, 
Elkhart, Frankfort, Kokomo, Laporte, Marion, Richmond, Vincennes, 
Washington. Iowa—Agency City, Burlington, Council Bluffs, Iowa City. 
Kansas—Atchison, Leavenworth, Salina. Kentucky—Bowling Green, 
Paducah. Maine—Auburn, Portland. Massachusetts—Lawrence, Lynn, 
Malden, New Bedford, Taunton. Mississippi—Greenville. Missouri— 
Carthage, Kansas City, Sedalia, St. Joseph. Montana—Helena. Nevada— 
Virginia City. New Hampshire—Portsmouth. New Jersey—Atlantic 5 
City, Newark, Plainfield. New York—Binghamton, Geneva, Glenn 
Falls, Hornellsville, Hudson, Kingston, Middletown, Rome, Schenectady. 
North Carolina—Wilmington. Ohio—Columbus and Dayton (regulars), 
Marion, Portsmouth, Sandusky, Tiffin, Wooster. Oregon—Eugene City; 
Pennsylvania—Alleghany, Braddock, Carlisle, Curry, Easton, Hazleton, 
I arkersburg, Pittston, Pottsville, Reading, Steelton, Uniontown, West- 
chester. Rhode Island—Pawtucket, Newport. Tennessee—Knoxville. 
Texas Austin, Gainsville, Galveston, Houston, Waco. Vermont—Brat- 
tleboro, Burlington. Virginia—Charleston, Danville, Lynchburg, Rich- 
mond, Roanoke. Washington—Spokane Falls. Wisconsin—Ashland, 
Madison, Plymouth, Waukesha. West Virginia—Wheeling. 
To the above are to be added Kingston and Toronto, Province of 
Ontario; and it may be inferred that the Dominion of Canada is nearly or 
quite exempt. Advices from Berlin and Munich make it presumptive 
that Germany is free of the “percentage” business; and the same may 
be said of Holland, by a report pertaining to Leyden. 
In the following cities and towns “society practice” is said to be un- 
known: Alabama—Anniston, Montgomery. Arkansas—Fort Smith, Hot 
Springs, Little Rock. California—Chico, Riverside, Santa Barbara. Col- 
orado—Pueblo. Connecticut—Middletown. Delaware—Wilmington. Da- 
kota—Sioux Falls. Georgia—Atlanta, Macon, Savannah. Illinois—Alton, 
Aurora, Bloomington, Cairo, Decatur, East St. Louis, Elgin, Galesburg, 
Ottawa, Rockford. Indiana—Crawfordsville, Elkhart, Fort Wayne, 
Frankford, Kokoma, Laporte, Marion, Richmond, Vincennes, Washing- 
ton. Iowa—Agency City, Burlington, Council Bluffs, Des Moines, Iowa 
City. Kansas—Atchison, Emporia, Leavenworth, Ottawa, Salina, Well- 
ington, Winfield. Kentucky—Bowling Green, Newport, Paducah. Maine— 
Auburn, Biddeford, Portland. Massachusetts—Lynn. Michigan Kala- 
mazoo, Muskegon, West Bay City. Minnesota—Minneapolis. Missis- 
sippi—Greenville. Missouri—Carthage, Hannibal, Kansas City, Sedalia. 
Montana—Helena. Nevada—Virginia City. New Hampshire—Ports- 
mouth. New Jersey—Atlantic City, Newark. New York—Cahoes, Glen 
Falls, Hornellesville, Hudson. Middletown, Ogdensburg, Oswego, Pough- 
keepsie, Rome, Schenectady, Watertown; North Carolina—Wilmington. 
Ohio—Cleveland, Dayton (among regulars), Hamilton, Lancaster, Lima, 
Marion, Portsmouth, Sandusky, Wooster, Zanesville. Oregon Eugene 
Citv, Pennsylvania—Alleghany, Braddock, Carlisle, Corry, Easton, 
Hazleton, Lancaster, Oil City, Parkersburg, Pittston, Pottsville, Read- 
ing, Steelton, Titusville, Uniontown, Westchester, Wilkesbarre. South 6 
Carolina—Charleston. Tennessee—Knoxville. Texas—Austin, Gains- 
ville, Houston, San Antonio, Waco. Vermont—Brattleboro, Burlington. 
Virginia—Charleston, Danville, Lynchburg, Richmond, Roanoke. West 
Virginia—Wheeling. Wisconsin—Ashland, Chippewa Falls, Plymouth, 
Waukesha. Wyoming—Cheyenne. 
To the above I have the pleasure of adding Toronto, Province of 
Ontario, Canada. 
The moral turpitude of this business, I do not hesitate to say, attaches 
more to the physician than to the apothecary, for the latter is half, often 
more than half, a tradesman; and if the strictures of Herbert Speucer, in 
his essay on the “Morals of Trade,” fit a particular druggist, we little 
wonder. But the public have a right to expect better conduct of the edu- 
cated members of a liberal profession. The druggists of San Francisco 
have taken the lead in setting two laudable examples of reform; and it is 
now the turn of the physicians to act. I shall not undertake to advise 
them how to proceed; but something ought to be doue, both in the me- 
tropolis and in other towns of California, to abate a practice which is so 
common as to cast a cloud over the whole body of medical practitioners. 
What family now knows surely whether its medical adviser is or is not 
concerned in this traffic? What honorable physician would not be glad 
to stand clear of the color of suspicion? 
Society Practice. 
This system, to my knowledge, has existed in England for more than 
thirty years, flourishing under the appellation of “Friendly Associations,” 
“Sick Clubs,” “Frovident Dispensaries,” etc.; and America has probably 
borrowed it from the mother country. The subject has been discussed in 
English medical journals for many years, and has been justly regarded as 
a crying abuse. In the United States it dates back about twenty-five years, 
is now rapidly growing in the cities and large towns, and is gradually 
invading new territory. The following, from a practitioner in California, 
vividlv describes the system as existing in England: “Having myself 
held society appointments and been physician to a Provident Dispensary, 
from which I used to derive half my income in England, I can speak 
ex cathedra. I used to make about $3,000 a year from such appointments. 
The system is simply accursed all round; the doctor being worked to 
death and the patient being treated for symptoms only, as his physician 
hasn’t time to make a diagnosis. The Provident Dispensary in England 
is intended to meet a great want; but, like other good things, it is much 
abused. Nobody earning more than 25 shillings a week is supposed 7 
to belong to it. There is always a rule to this effect; and, ih fact, 
in several places—e. g. in Pimlico, one of the districts of London, the 
Provident Dispensary had a sliding scale of fees to suit incomes of 
25 to 50 shillings a week. * * * The Provident Dispensary is 
really intended to relieve such people; but the public seem to have no 
conscience when doctors’ fees are concerned, and quite well-to-do people 
join such institutions in every place. Then, on the other hand, if the 
physician of such an institution is popular, and keeps clever assistants, 
he can starve his brother practitioners. * * * The Provident Dispen- 
sary system has had my life’s blood, and I fled here to escape it. The 
working man of California is much too well off to descend to such mean- 
ness, I trust, as medical attendance at society rates.” 
A correspondent, residing in London, writes that the “dispensary” prac- 
titioner is often paid a fixed annual salary, ranging from /T50 to 
together with house, coal and gas, and without special reference to num- 
bers entitled to his services. In London one-tenth or one-twelfth of the 
general practice is of this sort; in other English towns one-third. The 
number of practitioners engaged in this business is comparatively small, 
most of them being Scotchmen. In its early history there was an attempt 
on the part of medical men to oppose the business and make it disrepu- 
table; but this has died out, and the system is rapidly gaining ground. It 
is especially flourishing in the manufacturing districts of England and 
Scotland. 
With reference to other foreign countries, I learn the following: At 
Leipsic and most other German cities, large numbers of working people 
are organized into the Krankenkasse, or “Sick Fund,” and have the 
choice of relief at hospital or of attendance and medicine at home, to- 
gether with an allowance of $1.75 a week for maintenance. The physi- 
cian receives 7j( cents for a visit to such patients, or 5 cents for office 
consultation. The poorest class are attended gratuitously by government 
physicians. In Switzerland there are no such voluntary associations, but 
government provides gratuitous medical relief to those who need it. In 
Holland young physicians take family practice among the poorer classes 
for 10 to 20 cents a week, according to size of family, medicines included, 
and collect weekly. I11 Roumania “society practice” is confined to the 
Jewish population. The contributions vary from 2 to 5 francs per capita 
annually. 
At New Orleaus the “society” system arose about twenty five years 
ago, and probably is more prevalent there than elsewhere in this coun- 8 
try. One of my Louisiana correspondents informs me that he has retired 
from that city to the country, solely to escape “the daily contact with the 
things I loathe;” i. e., society practice. There the societies are numbered 
by hundreds; and one practitioner may have the medical business of 
twenty or more. They take all they can get; and I am informed that one 
of the leading physicians there avowed, in his earlier experience, that 
he took all be could in order to keep them out of the hands of others—in 
other words, to starve out his rivals. The most debasing feature of this 
business is the degradation of professional character involved in the 
annual canvass for these positions; for in general they go to the lowest 
bidder, and the canvass is quite as eager as in political office seeking. 
The over-work and under-pa}' of this system, as hardships to the med- 
ical man, have been sufficiently exhibited; and also the superficial char- 
acter of the service which must needs be rendered. But these are not the 
only evils. The physician becomes the bondsman and common drudge 
of the society, whose pitiful wages command his attendance for the most 
trivial ailments. The hired servant must go or lose his place at the next 
election, and must bear with becoming humility the fault-finding of his 
ungrateful patients. On the other hand, it virtually denies to members 
the choice of medical attendant. The descendants of the early settlers of 
New England, who fled from the oppression of an established church, 
now, with strange inconsistency, voluntarily assume the yoke ot an 
established medical relief. It is the proud boast of the model Republic, 
that every one here can choose his own religion, and physic his soul after 
his own fashion; but the “society” system takes charge of his body, and 
puts it down to the lowest bidder to be physicked. There is no reason- 
able doubt that most of these “societies” are organized for the chief, if 
not the sole object of cheapening medical services; and many well-to-do 
people are not ashamed to be found in their ranks. 
I am informed that in one of our prosperous California cities, persons 
who enjoy an income of more than $1,000 a month are base enough to 
take such “society” benefits, thus pauperizing themselves, and impover- 
ishing their doctor. They are styled “Benevolent Associations,” but the 
benevolence is extracted from the medical profession by superior finesse. 
Wage-workers in all the handicrafts successfully organize for the common 
good—especially to prevent reduction of their earnings; but hitherto 
physicians have made a conspicuous failure in their attempts to combine 
for mutual protection. At New Orleans want of success was attributable 
to attempting too much at the beginning, and to the refusal of a very few 9 
to cooperate. These few made an abundant harvest of the “societies” 
abandoned in the enthusiasm of reform. At San Francisco there has 
been no rebellion among “society” doctors. At New York there has 
recently been organized the “Medical Practitioners’ Association of New 
York City,” whose objects are: (r) To abolish, at such time as the Asso- 
ciation may decide, in accordance with the laws hereafter enacted, medi- 
cal attendance to members, or their families or both; of clubs, including 
lodges and societies of any kind, paying the medical attendant a stipu- 
lated fee per member, or stipulated amount per annum by contract. 
(2) To elevate the professional standing of its members. (3) To eradi- 
cate charlatanism. This organization has 75 members out of a total of 
about 3,000 practitioners. Obviously it would now’ be premature to pre- 
dict its future, but the inherent incapacity of physicians to organize in 
large numbers for a simple business purpose makes the outlook highly 
unpromising. 
To be plain and candid, I hope for relief only in a natural reaction 
among the class of people who compose these societies. The inevitable 
result will be gradual, if not rapid, deterioration in the quality of service 
rendered by “society” doctors, until in time its value will approximate to 
its cost. Then people will begin to wake up to the discovery that “cheap 
and nasty” service is poor economy in the face of disease and death. 
Inasmuch as the practice is evidently spreading, like a contagious disease, 
it seems likely that all our cities and towms must suffer an attack of 
greater or less severity; and it is to be hoped that one experience may 
suffice for at least an average generation. Most likely the malady next 
time will take new shape under a different name. 
In a somewhat less objectionable form the contract system is in vogue 
among mining and manufacturing companies in many places. Thus, at 
Evansville, Indiana, mining companies employ physicians at an annual 
salary for their employees. At Kokomo, Indiana, the Diamond Plate 
Glass Company employs a contract physician. Married men contribute 
a dollar a month, and single men fifty cents. At Kansas City, Mo., sev- 
eral large manufacturing companies pay about two-thirds regular fees; 
others unknown salaries. At Elmira, N. Y., mill and mining firms sup- 
ply medical service to their employees at reduced rates, they being 
charged with the cost. At Cleveland, Ohio, and Minneapolis, Minn., 
corporations employ contract physicians extensively. At Braddock, Pa., 
the steel works employ four physicians for $800 per annum to do practice 
worth four times as much. The phosphate companies in malarious regions 10 
of South Carolina employ physicians to make weekly visits to their negro 
employees at so much per capita. In the coke regions of Pennsylvania 
phvsicians form lists of workmen at a dollar a month for married men 
with families, and seventy-five cents for single men. Obstetrical cases 
are charged five dollars. Surgical cases are at the expense of the corpo- 
rations. It has become customary for hospitals in charge of the Sisters 
of Charity in Wisconsin, Oregon and Washington, to sell annual tickets 
for ten dollars, entitling the holder to treatment and maintenance at the 
hospital. The customeis are mostly men working in saw mills and in 
logging camps. These variations of contract business are less degrading 
to medical men than the societies before mentioned, but they are open 
to the serious objection of virtually denying the privilege of choosing 
one’s physician. 
I have not space enough here to dwell upon various devices for adver- 
tising and gaining notoriety brought to my notice by correspondents at 
several of the smaller cities and towns. They could be dealt with by the 
Code of Ethics, provided the perpetrators be members of a medical soci- 
ety; but these sharpers keep clear of such restrictions, at the same time 
contriving to be inside of the Penal Code of their respective States. At 
this date the most dangerous and troublesome offenders are licensed and 
regularly educated physicians. Unfortunately, a medical education does 
not correct such a moral malformation or arrest of development as con- 
genital absence of conscience, though it undoubtedly encourages the 
growth of this faculty when present. Besides, the newspapers encourage 
a practice that contributes so liberally to their gains, and affects to believe 
that medical knowledge is as legitimate a subject for public boasting as 
the excellence of a horse, the quality of groceries, or the attractions of 
popular amusements; and it must be added that a large share of the public 
fail to comprehend why physicians must cultivate reputation, and uproot 
notoriety as a noxious weed. The same persons who understand that 
their wives, sisters and daughters must eschew gaudy dress and forward 
manners because these are the signs of harlots, wonder why regular phy- 
sicians must abstain from advertising, which is the badge of quacks. The 
Medical College Faculty Organization, as a mode of publishing the names 
of a list of professors, while supplying an imaginary want of educational 
facilities, is an old device and does not require notice. But here is some- 
thing new from a Chicago correspondent: “Possibly you know of an 
aggregation of regular physicians here, which bids fair to outdo all the 
societies in contract work. The so-called benevolent scheme is to get 11 
needy young physicians to do the work, while the money goes into the 
pockets of their seniors, who are more adept in politics (medical and 
otherwise) than in the legitimate practice of their profession.” I suppose 
that this ought to be called a “medical trust,” and, like other “trusts,” is 
something to be distrusted by plain, honest folk. This is an American 
variation of the English method already mentioned, by which the dis- 
pensary doctor employs young assistants at beggarly salaries, while he 
attends to the business management. 
It has recently been said of us that, in no country, perhaps, has char- 
latanism, licensed and unlicensed, been more rampant, and yet in no 
country are the best men—the men who love medicine as an honorable 
profession surely based on the certainties of Science—more certainly 
winning the day. Of the stars of the brilliant galaxy of names that adorn 
the pages of the history of medicine, think you there is one deserving the 
name of physician, or who stands out as a beacon light for the guidance 
of his less favored brethren, who has .ever been guilty of the reprehensible 
practices under consideration? Surely not one. Yet I believe with Dr. 
Eootnis that in the near future the medical profession will play even a 
larger part in the public life of the country, and any one who has watched 
the growth of a healthy professional spirit in America during the past 
decade must be persuaded of the truth of the prophecy. 
But it is a common complaint among physicians that the medical pro- 
fession is held in low esteem by the public, and some of my correspond- 
ents make this an excuse for their own shortcomings. This way of get- 
ting even is bad policy and bad morality. We share the common lot. To 
be respected we must be respectable, and self-respect is the foundation. 
He who barters his self-esteem and his good name for pelf is in worse 
plight than he of whom the great dramatist wrote: 
“Who steals my purse, steals trash: ’tis something, nothing; 
’Twas mine, 'tis his. and has been slave to thousands; 
But he that filches from me my good name, 
Robs me of that, which not enriches him, 
And makes me poor indeed.” Table B.—Society Practice. 
Is it customary for so-called 
CITY. Benevolent Societies to em- 
ploy physicians by the year? 
Is the compensation usu- 
ally a fixed salary, or ac- 
cording to service ren- 
dered ? 
If the latter, what are the 
usual fees ? 
If by salary, how much is 
usually paid for each 
member annually? 
Are the families of mem- 
bers included in medi- 
cal benefits. 
On the salary plan, please give 
an estimate of the average included 
amount realized for each visit - ,,q • t,,, 
and office prescription. m tes? 
Do “Society” 
physicians usually, 
or ever, 
provide medicines 
at agreed rates? 
What fraction of the general 
practice of your city do 
you suppose is included in 
these Societies? 
What fraction of your prac- 
titioners do you suppose is 
engaged in this business ? 
Has your local 
Medical Society 
or any body of 
practitioners 
taken any 
action in this 
matter ? 
If so, in what way ? With 
what success ? 
Is this kind of bus- 
iness increasing 
or diminishing 
in your city ? 
Birmingham _ Ala. 
Mobile — ___ “ 
Alameda - -Cal. 
Grass Valley “ 
Livermore “ 
Los Angeles - — “ 
Marysville — - “ 
Oakland . . - “ 
Sacramento “ 
San Diego _ “ 
San Francisco 
San Jose. 
Santa Rosa “ 
Stockton “ 
Woodland “ 
Denver - Col. 
Bridgeport _Conn. 
Danbury _ — 
Hartford - - 
E. Sioux Falls. Dakota 
Columbus Ga. 
Belleville _ - 111- 
Chicago “ 
Englewood — 
Anderson . _Ind. 
Indianapolis _ — “ 
Jeffersonville _ — 
Logansport ‘1 
Cedar Rapids _ Iowa 
Lexington Ky. 
New Orleans La. 
Boston Mass. 
Lawrence 
Lynn \\ 
Maulden 
New Bedford _ - “ 
Taunton “ 
Waltham. - ‘ 
Detroit .Mich. 
Grand Rapids — “ 
Saginaw 
Brainard __ Minn. 
Yes 
_ _ _ . No . 
Very small .. ____ 
Yes 
f No way of preventing ex-1 
( elusion from fellowship, j 
Increasing. 
Increasing. 
Increasing. 
Stationary. 
No answer. 
Increasing. 
Stationary. 
Increasing. 
Increasing. 
Increasing. 
Increasing. 
Diminishing. 
Not increasing. 
Not increasing. 
Increasing. 
Increasing. 
Increasing. 
Increasing. 
Not stated. 
Not stated. 
Not stated. 
Increasing. 
Not increasing. 
Stationary. 
Increasing. 
Not increasing. 
Stationary. 
Unknown. 
Not increasing. 
Increasing. 
Increasing. 
Increasing. 
Increasing. 
Stationary. 
Increasing. 
Diminishing. 
Increasing. 
increasing. 
Not stated. 
Stationary. 
Diminishing. 
Diminishing. 
Not increasing. 
Increasing. 
Increasing. 
Increasing. 
Increasing. 
Increasing. 
Increasing. 
Diminishing. 
Increasing. 
Increasing. 
Increasing. 
Not increasing. 
Increasing. 
Ans. conflicting. 
Increasing. 
Diminishing. 
Increasing. 
Increasing. 
Increas’g largely. 
Not increasing. 
Diminishing. 
Increasing. 
Increasing. 
Very small . . 
$1 50 to $3.00 - 
Yes .' _ 
Unknown 
No 
$2.50 
1. Reduced rates _ 
No 
Yes. . 
About one-twelfth 
Is none . . 
$3.00 _____ 
No answer 
No answer 
No . . _ _ 
Unknown... .. _ 
Perhaps 3-iooths .. 
No ._ 
$1.00 . 
No 
1. No. 2.-Yes 
No. 
No . . _. _ _ 
5-iooths or less _ __ 
No 
No 
Unknown ... 
No 
Yes ; Foresters and Chosen Fr__ 
-i 
No 
Yes. . . 
Variously est’d % to 
Yes _ 
No . 
Very small _ 
No _ _ 
By resol’n ; success doubtful- 
1. No. 2. Yes 
Variously est’d 5 to 80 per ct_ 
12 to 15 per cent 
Variously est’d 5 to 90 per ct. 
Variously est’d 5 to 16 per ct. 
One only of the Med. Soc 
Yes 
No __ _ _ 
No ... 
One-fifth 
No 
Foresters and Sons of St. George 
No __ 
Ans. conflicting 
I-200ths - - - _ _ 
No 
j 
No 
No. 
About one-tenth 
No _ 
No 
No_ 
Yes 
Very small 
No _ 
About $1.25 ” 
No 
No 
No. _ . 
One-twentieth 
Yes . ... 
Discus’u exe’d too much opp. 
Yes. 
50 per cent 
No 
i. No. 2. Unk’n__ 
No _ . 
2 to 5 per cent . 
No 
Married men, $12; single, $6_ 
No 
Not stated 
No. _ 
Very small 
No 
Unknown _ _ . 
Yes 
Visit, fi ; prescription, 50c. — 
Visit 15 cents; prescrip. 7 cents__ 
Homeopaths only— 
No 
About 75 per cent 
No _ 
No. 
Very small _ 
No ... 
r ry 
$2 with family; $i without 
No 
About 1 in 120 
No 
Yes 
25 per cent 
No. _ 
No . 
No 
Very small 
No 
No 
No 
Very small 
No 
Two-third« 
Yes 
Yes 
About 20 per cent 
No 
Small; mostly negroes 
No _ 
Whites, salary; col’d service. 
ioc. or less to 15c ; occas’ly more. 
Reports vary, % to % _ _ 
Twice 
Concerted action vainly att’d. 
Iuvestigation ; no action 
$1.00 to $3.00 - - 
One-fiftieth to one-tenth 
No 
No 
No _ 
One-fortietli 
Yes. 
Discussion ; no action 
No 
About one-fortieth _ 
Yes ._ 
No 
No 
No 
Answer not clear 
No 
No __ __ 
Small 
No... 
TTtikii^ 
Not stated 
No 
No 
Very small 
No .. . 
Ansv er n )t 
Not Stated 
Answer obscure __ 
Very small 
No 
Visit, {1; prescription, 50c. — 
Very small 
No 
Very small 
No 
Visit. $r 
No 
About one-twentieth _ 
No 
C . v 
Unknown 
No _ . 
Half rate* 
No 
Not stated 
St. Paul — “ 
Sal r 
No __ _ 
About one-twentieth 
No 
Very small 
No. ... 
Half rates 
- _ 
Visit $1.00; prescription gratis— 
Yes 
No . 
Not stated 
No 
q , 
No 
15-iooths 
No 
St. Louis 
Grand Island City—Neb. 
service 
Visit, Si 
No 
Yes 
Not stated _ ... 
No 
Answer indefinite 
No 
One-twentieth or more 
No 
Manchester N.H. 
Nashua 
Camden N. ( J. 
One-seventieth 
No 
No _ _ 
Very small 
No 
1. Unkn. 2. Yes 
No _ 
About i-iooth 
Yes 
Cited for trial; result unsat’y. 
No 
Yes. 
Unknown 
No 
Newark 
Paterson 1 
Plainfield “ 
Trenton 
Albuquerque N. M. 
Brooklyn .. N. Y. 
Sal** 
No _ . . 
Yes 
About 6-iooths 
No 
TTnk 
Unknown 
Less than one-fiftieth 
Yes. 
Forbidden 
Sal r10W 
No 
No 
Very small 
Yes. _ 
Discountenanced _ . 
0 
No 
Unknown 
No 
TVf fl - 1 t- 
Not stated 
No _ 
Very small 
No 
so cents 
3 or 4 cents . ... _ .. 
1. No. 2. Yes.. _ 
No 
About 2-iooths. 
About *2 per cent . _ 
No 
. . 
No 
No _ 
Yes 
One-fourth 
No 
Yes 
Unknown 
No ... 
Not stated 
$1; usually more for families 
Yes _ _ - 
No _ _ 
About one-tenth . 
No . 
Visit about 4c; presc’p. about ioc. 
1. No. 2. Always. 
No . 
Yi whole city; bel. 14th st_ 
Very small 
Yes _ _ _ 
Soc. of 75 mem. pl’g’d to abs. 
q . 
No 
Salary 
Unknown 
No _. 
About one-sixteenth 
No 
No 
Perhaps i-sooths 
No . . 
Other particulars unknown. 
Salary ...... 
Visit 25 cents; prescrip, gratis.— 
Nn 
Not stated .... 
No. 
Increasing. 
Increasing. 
Increasing. 
Not increasing. 
Stationary. 
Increasing. 
Increasing. 
No answer. 
Unknown. 
Increasing. 
Stationary. 
Increasing. 
Not increasing. 
Stationary. 
Existed 3 or 4 yrs. 
Not increasing. 
Increasing. 
Diminishing. 
Diminishing. 
Increasing. 
Stationary. 
Increasing. 
Stationary. 
Diminishing. 
Increasing. 
Increasing. 
Increasing. 
Increasing. 
No _ _ 
Yes 
Not stated _ 
Yes 
Both . . .. 
Yes 
No 
Yes 
Salary 
No _ _ 
No 
Very small _ 
No. 
Salary . . 
No 
Very small 
Perhaps 4 or 5 per cent 
No 
Last Portland Or. 
Salary 
St. Geo. yes; Fores. no__ 
1. No. 2. Yes _ 
No 
No — 
Salary 
No 
Very small _ . 
No. 
Service 
No 
Service 
Visit $1 — - 
No 
Very small 
No 
> 
Salary 
1. No. 2. Yes 
Yes 
Unknown _ .. 
Unknown 
(Agreed to form no new ) 
-< contracts ; expect good > 
( results. ) 
Salary 
1. No. 2. Yes 
About one-fifteenth. 
Yes 
Both. ...... 
Visit 50 cents to $i_... 
Very small 
No ._ _ _ 
Salary ... 
Visit 50 cents; prescrip. 25 cents. 
No 
Very small ... ... 
No 
Salary ; lowest bidder 
No 
Very small ... 
No 
Salary _ 
1. No. 2. Yes 
Very small 
About one-fourth 
No 
Salary . 
No _ _ 
No - 
No 
One-twentieth to one-tenth— 
One-fifteenth . 
One-eighth to one-sixth 
No _ .— 
Salary mostly _ ... 
1. No. 2. Yes 
No 
IS of 250 
No _ 
Salary _ 
No 
Very small ... _ 
No _ _ _ — 
Galveston 1 exas 
XeS ”■ • . 
Salary . _ 
No _ 
Very small _ 
One M. D. only 
No _ _ 
Salary _ ... .... 
No 
No - - 
One-tenth 
10 per cent 
No 
Salary _ 
No 
No answer .... 
4 per cent _ _ 
No 
Salary __ ______ 
No 
10 per cent 
No _ _ 
Salary . - 
7 
Nol - 
Nr. 
5 per cent . — 
No 
Salary .... 
No - - 
No 
1-200th 
1 per cent 
No — 
Yes 
Salary _ ... 
No 
No 
About one-half - 
No 
Salary ... . 
Yes 
1 No. 2. Yes 
Yes 
95 per cent _ _ 
Yes 
Salarv generally ... 
No 
1. No. 2. Yes 
10 per cent, laboring class ___ 
Allgen.practi’rswhocan _ 
Yes 
Salary __ _ . 
No 
1 No. 2. Yes 
One-fifth or one-sixth 
Yes