CAN PHYSICIANS HONORABLY 
ACCEPT COMMISSIONS FROM 
ORTHOPEDIC INSTRU- 
MENT MAKERS. 
By H. Augustus Wilson, A.M., M. D., 
PROFESSOR OF GENERAL AND ORTHOPEDIC SURGERY 
PHILADELPHIA POLYCLINIC; CLINICAL PROFESSOR 
ORTHOPEDIC SURGERY JEFFERSON 
MEDICAL COLLEGE. 
Reprinted from 
The Philadelphia Polyclinic, 
Philadelphia, 
1894. •CAN PHYSICIANS HONORABLY 
ACCEPT COMMISSIONS FROM 
ORTHOPEDIC INSTRU- 
MENT MAKERS?1 
By H. Augustus Wilson, A.M., M. D., 
OF GENERAL AND ORTHOPEDIC SURGERY 
PHILADELPHIA POLYCLINIC; CLINICAL PROFESSOR 
ORTHOPEDIC SURGERY JEFFERSON 
M! DICAL COLLEGE. 
The enterprise of manufacturers in increas- 
ing the sales of their goods is called business 
thrift, for their relationship to patients is a 
purely commercial one. Under the guise ot 
being made especially for this patient, they 
are often enabled to charge exorbitant prices 
for their inexpensive wares so as to pay the 
.secretly understood customary commission to 
the physician. 
Dr. Solomon Solis-Coheu applies the very 
appropriate term of “ Sales-agent ” to physi- 
cians who thus debase their profession, as to 
the recommendation of secret nostrums. He 
says: “ When a sick man applies to a phys- 
ician, thinking that he thereby will secure 
dhe benefit of special knowledge brought to 
bear upon the conditions of the individual 
case, entrusting to the conscience of his med- 
ical adviser, his health and his life, he is en- 
1 Read by invitation before the District Medical 
.■Society of the County of Camden, New Jersey. 4 
titled to the skill and the thought for which 
he pays and that he deems himself to be re- 
ceiving. He certainly deserves better treat- 
ment 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 satis- 
faction of buying the worthless or poisonous 
stuff direct, without the sham of a profes- 
sional consultation, and without paying a 
purchaser’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 bribery 
which induces physicians to send their pa- 
tients 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 pro- 
prietary or patent medicines, of health-giving 
natural spring waters, artificial limbs, trusses 
or orthopedic apparatus—but notwithstand- 
ing this condemnation, it appears to be still 
carried on. 
The necessity of employing and recom- 
mending surgical and remedial appliances, 
many of which for business purposes are pat- 
ented or so controlled as to favor the exor- 
bitant prices demanded, has often been con- 
sidered, and as there appears to be no way 5 
of dispensing with their use, the question re- 
quiring solution must be, how can they be 
used honorably and honestly? If these re- 
medial measures are to be classed with splints 
for broken bones, spectacles for defective 
eyes, etc., and not as shoes, clothing or pro- 
visions, it must be clearly apparent that 
physicians must not only countenance their 
proper use, but also prescribe and direct 
their employment as therapeutic measures. 
The real offense appears to be that of ob- 
taining 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 service, a commission on the sale 
of the apparatus, truss or artificial limbs 
that he has ordered his patient to procure, 
nr that he is, to all intents and purposes, a 
silent partner in the shop where he directs 
his patient to procure that which lie 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 expensive, and 
that they must settle with the manufacturer 
at the prices printed in the catalogue, and 
conceal the fact, not always printed but con- 6 
fidentially understood, that one-quarter of 
that exorbitant charge goes back to the phy- 
sician 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 physician 
could get double pay ? 
Medical laws have been, and are being, 
enacted to protect the public against unqual- 
ified practitioners of medicine, and thereby 
discountenancing all forms of quackery and! 
charlatanism, nowhere more conspicuous 
than in the sale of braces, trusses and arti- 
ficial limbs. The makers of these appliances 
often assume, in reality, to practice medicine, 
but, withal, without a license which their 
absence of training prevents them from ob- 
taining. 
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 he 
needed, we will always stand ready in any 
way within our power to assist, that the physi- 
cian and patient be alike benefited.” 7 
Again in the same catalogue will be 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 
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 asfinishedr 
be sent direct to the patient, collecting the 
balance C.O. D., thus relieving the physician 
of all financial responsibility. In cases of 
this kind, we collect the full price of the 
brace, and pass the commission to the credit 
of the physician or remit same to him if 
desired. We suggested this plan some time 
ago, because of the numerous requests made 
us by the physicians for an extended 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 patients 
are at that time easily discouraged or dissat- 
isfied with trivial matters, and while we will 
make any changes necessary without charge 
(where the fault is ours), we must ask physi- 8 
-dans to protect themselves and us to the fullest 
extent.” 
“ Special note (in regard to trusses) : Fit- 
ting and adjusting special cases given careful 
attention at our office. Always send a letter 
of instruction with the patient and get credit 
for the sale.” 
This is so perfectly clear that no explana- 
tion is required, and there is but one omission 
.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 inap- 
propriate to use the word patient in such 
•connection, for he ceases to be under medi- 
cal treatment when he, with or without the 
order of his physician, goes to the manufac- 
turer 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, quoted above, says, “ but when the 9 
patient is sent to ns,” implying that he then 
ceases to be a patient and becomes a patron 
or one who supports. 
Of the duties of the profession to the pub- 
lic, the Code of Medical Ethics says : “ It is 
the duty of physicians who are frequently 
witnesses of the enormities committed 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 injuries sustained by 
the unwary from the devices and pretensions 
of artful empirics and impostors.” 
It is under the category of empirics and 
impostors that all orthopedic and artificial 
limb makers must be classed who indulge in 
the reprehensible practices referred to in this 
paper, i. e., those wbo 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 prescrip- 
tions to the peculiar requirements of the 
case—j ust as he measures the patient’s errors 
■of refraction and fits the glasses and frames 10 
that have been manufactured by the optician, 
then the physician will occupy his true posi- 
tion 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 dis- 
ease, 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 inform 
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 posi- 
tions in making appliances for the relief of 
suffering, and can hardly be censured for the 
position they are forced to occupy by physi- 
cians who seem to delight in their ignorance 
about braces or mechanical apparatus, 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 sug- 
gested is in accordance therewith. 
Physicians should, unquestionably, adopt 
business principles and methods in the con- 
duct of their calling, but this does not mean 11 
that those methods should embrace lying to,, 
or cheating, their patients. 
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 soon 
will the process of dispensing with the phy- 
sician 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 traveling 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-setters” put 
irons on deformities to such an extent that 12 
the deformities increased under the heavy 
loads their poor afflicted bodies had to carry. 
Patients are, even now, by bold and luring 
advertisements, urged to go direct to the 
makers to save extra expense, and that they 
themselves can obtain full description 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 princi- 
ples upon which the treatment shall be 
based, that the patient may be 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 man- 
ufacturer 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 reward he is 
offered for bringing another patron to “ our 
place.” 
The patient’s deformity too frequently be- 
comes the seat of attack rather than the 
.arrest of the disease which may have caused 13 
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 
where there is a prolongation of the inner 
condyle, or to cure club-feet by braces alone. 
The braces are sold to the patient, the physi- 
cian has obtained his commission, and the 
patient, not only, often receives no benefit, 
but, alas,worse, his case progresses so rapidly 
that another brace is tried and more money 
spent, until valuable time is 1 jst and a hope- 
less cripple results. 
If the methods that too frequently obtain 
in the care or supposed treatment, by incom- 
petants, of cripples and deformities, those 
who are obliged to use trusses or artificial 
limbs, were adopted in other branches of 
medicine, more suits for malpractice would 
be justly instituted. 
The appreciation of the errors prevalent 
in this country is shown in the preface of an 
English manufacturer of orthopedic appli- 
ances, 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 14 
ground of “advice” which is clearly the 
province of the medical man.” 
The answer to the question I have pro- 
pounded as the title of this paper, “ Can Phy- 
sicians Honorably Accept the Commissions 
so Frequently Offered by Orthopedic Instru- 
ment Manufacturers?” must be the solution 
of many of the abuses to which allusion 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 contrary. If it is dis- 
honest, and what physician can dispute it, 
are. we not obliged, by the very words and 
spirit of the Code, to so proclaim it?