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The Use and Abuse of Medical Charities In Late Nineteenth Century America GERT H. BRIEGER, MD, PHD Philanthropia-the love of man-has a long and honorable tradition in the history of medicine. Medical charity has always been one facet of the humanitarian character of the medical profession. It is medicine, said Alexander Stevens in the first presidential address to the newly formed American Medical Association in 1848, that is the link uniting science and philanthropy. Yet when the charitable impulse runs afoul of the medical market place, economics have usually dominated philanthropy. One such encounter between the needs of patients and the needs of their physicians at the end of the nineteenth century was particularly interesting, and engendered the controversy that became known as the dispensary abuse. In discussing the use and the alleged abuse of medical charity in the late nineteenth century, a whole series of medical and social problems must be considered. Income, of both patients and doctors, the supply of physicians, medical education, changing patterns of medical care, especially specialization, regulation of medical practice, and by no means least noteworthy, the quality of medical care are all important facets of the intense arguments over the abuse of medical charities. As discussed by physicians and social workers in the years between the Civil War and World War I, medical charity usually referred to hospitals and their outpatient departments and to free-standing dispensaries. The historical development of both these institutions has already been very well described by George Rosen in "The Impact of the Hospital on the Physician, the Patient and the Community," that appeared in Hospital Administration in the Fall of 1964, and more recently in an article by Charles Rosenberg in the January, 1974 issue of the Journal of the History of Medicine, entitled "Social Class and Medical Care in Nineteenth-Century Address reprint requests to Gert H. Brieger, MD, PhD, Professor and Chairman, Department of the History of Health Sciences, University of California, San Francisco, CA. This paper was presented at the American Historical Association meeting, December 29, 1974. Submitted to the Journal in November 1976, it was accepted for publication December 3, 1976. 264
America: The Rise and Fall of the Dispensary." What they have already so adequately described will not be repeated here. Instead I want only to focus on the so-called dispensary abuse and to point to some of the ramifications of this debate on the broader history of medical care. One of the first questions about the abuse of medical charities is how widespread was it, and why did it occur? Figures vary (and are suspect in any case), but generally were cited to show that around the middle of the nineteenth century in New York City, for instance, 16 per cent of the population received its medical care in the dispensaries, but by the end of the century it was a full 50 per cent.' Not all dispensaries and hospital clinics dispensed their services free or for a token charge, but a large proportion of them did so. Warnings about abuse of this form of charity began to be heard increasingly in the late 1860s and 70s, and reached a furious pitch by the 1890s. The charge against the dispensaries and hospital clinics revolved mainly around the free treatment of patients able to pay. The result, claimed those who became so exercised over this abuse, was to deny the rightful fees to physicians in the community who would otherwise care for these patients. Young doctors, struggling to establish themselves, were thought to be especially hard hit. Most of the physicians who wrote about the abuse of medical charity, however, were older, established men who ostensibly were looking out for their younger colleagues. Today, of course, the younger physicians would be much more apt to press for extension of free clinics rather than their suppression. In addition to simple economic motives for complaint, a large number of physicians urged an end to the abuse of free care for the sake of their patients as well. "Paying taxes," the Boston physician George Gay wrote in 1905, "no more entitles one to free medical treatment than to free water, gas, or any other ordinary commodity. In short, getting something for nothing demoralizes the individual and encourages deceit, laziness, and pauperism."2 This argument, of course, was not unique to the medical profession. Many charity workers concurred, and even during depressions of the AJPH March, 1977, Vol. 67, No. 3
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1880s and 90s, there were repeated calls for the abolition of out-door relief, of which dispensaries were but one kind.3 What had happened, then, in many large American cities by the end of the nineteenth century was that all too often physicians, instead of asking who are the people in need of treatment and how can we treat them most effectively and efficiently, asked how can we keep people from getting free treatment. The problems of every-day life faced by the large numbers of the urban, industrial work-force in the latter decades of the nineteenth century have increasingly interested historians. Economic fluctuations leading to a drop in wages and rising unemployment, while difficult to relate to individual family units, drew the attention of economists and reformers in that day as it still does today. Just how many New Yorkers, for instance, lived at the margins of poverty, and indeed where the so-called poverty line could be drawn has remained a key question. Reading the works of reformers such as Jacob Riis and seeing the even more gripping photographs of that period, leave little doubt that any additional economic burdens imposed by illness were not manageable for a large segment of the laboring force. If one looks at the economic status of the medical profession in New York through the eyes of George Shrady, one of the city's most influential medical editors and a vociferous opponent of the dispensary abuse, one perceives a bleak picture indeed. It is well beyond the scope of this discussion to investigate the economic aspects of nineteenth century medicine with due care. Yet the perspective provided by Shrady explains at least a portion of the felt-reality of the many physicians who honestly believed that much abuse was abroad in the land. Faced by a supply of doctors greater than the demand for their services, plagued by an unfair competition of the dispensaries and hospital teaching clinics, and unable to earn a living comparable to the cartman who might be his neighbor, the average New York doctor, according to Shrady, might be better off in some other occupation. Yet the facts do not bear this out, at least on superficial study. In an editorial in The Medical Record in 1883, Shrady wrote: "We doubt if the average income of the New York City physician exceeds $5,000, and there is a very large number, if not a majority, who do not even get this sum. A doctor has to work hard to make $400 a month, unless he has the better class of patients."4 Since most writers of the time considered that the minimum income required by a family of five people was between $600 and $800 per year, one has to look with wonder at the physicians who were crying impoverishment. The question, of course, is why did (and do) doctors assume they were entitled to an income so much higher than their fellow workmen? A decade later, Shrady seems to have revised his estimates of physician's incomes downward. Writing on "The Pay of Physicians and Surgeons" in The Forum in 1894, he said that the average annual income of a physician in a large city was $2,000 and in rural towns $1,200.5 At least one physician, Dr. Theodore W. Schaefer of Kansas City, did not agree with even those figures. Writing on "The Commercialization of Medicine," in the prestigious Boston MediAJPH March, 1977, Vol. 67, No. 3
cal and Surgical Journal, Schaefer claimed that Shrady's estimates were inaccurate and misleading. "The supposed fabulous income of a great majority of physicians is afiction!", he wrote "The fact is that the young physician, in the first five years of his practice, hardly earns his board, and his income often does not amount to fifteen dollars a month in cash!"6 Whatever future research may reveal, the very economic existence of physicians was closely related to the use and abuse of dispensaries. A related point to be made is that often when doctors discussed income, they reminded themselves and others about the charitable work they performed. The profession as a whole has always prided itself in its charitable tradition.7 No patient, has been the usual claim, was ever denied needed care. The dispute over the abuse of dispensaries brings out the many motives which physicians have had for their charitable work. They wanted to teach, they wanted the title of professor, they wanted to improve their skills in one or another specialty, or they wanted to drum up business for themselves. The bubble of pride in good works was neatly pricked by a Tennessee physician writing to The Medical Record in 1884: "As it now is, the busy active doctor will often attend before, and give more attention to a poor patient than to a well-to-do patient, for the simple reason that he is afraid it will hurt his reputation if he fails to find time to wait upon the poor who call upon him.... He does not attend the poor from a feeling of duty, or honor, glory, or fame, but simply out of policy."8 It is a distorted picture we get by focusing our attention only on the negative aspects of the charity question. There were doctors who argued vigorously for free medical care for all those who needed it. Dr. Charles Emerson of Baltimore, for instance, believed that there was little danger of pauperizing patients. The same arguments, he noted to the National Conference on Charities in 1906, had been used against free concerts, free libraries, free parks, and above all, free schools with free textbooks.9 While some New York physicians were denouncing the abuse of the city's dispensaries, others were calling for an expansion of their activities. Henry D. Chapin, a pediatrician of note, believed that better home services provided by some of the dispensaries might lower the appalling death rates among children. In 1900, for instance, of the 70,872 deaths occurring in New York, over one-third (25,836) were children under age five; another 4,325 victims were claimed from the ages of five to fifteen. The only promise for amelioration, Chapin believed, was an organized home medical service that included doctors and nurses who could instruct families about diet and hygiene. "Many young and competent doctors," he suggested, "could be procured for a small salary to undertake such a work at the beginning of their career. " 10 The fact that Chapin carefully called for competent young physicians was probably no accident. And this leads into the next major issue of concern that grew out of the charity abuse arguments, namely the quality of medical care.
The many outcries against the dispensary abuse, such as George Shrady's widely quoted 1897 Forum article, "A 265
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Propagator of Pauperism: The Dispensary," cited example after example of obviously well-to-do patients who used (or abused) the dispensaries for free or for very low-cost care.11 But none of these authors really explained why these patients turned to dispensaries. Was it simply because they would receive free care? Or, was it that dispensary care was thought to be better care or more readily available better care? In our own day there is much discussion of the quality of medical care. But quality in health care has been and remains an elusive entity. Yet it certainly was a subject of as great interest in 1900 as in 1970. One of the most perceptive discussions of the dispensary abuse may be found in an address to Medical and Chirurgical Faculty of Maryland in 1916 by J. Whitridge Williams, Professor of Obstetrics at Johns Hopkins. 12 Williams clearly saw that the so-called abuse was closely linked to the complexities of changing conditions of medical practice. Urbanism, specialism, hospitals, wider use of nurses, all needed to be taken into consideration. These changes, plus the burgeoning of medical science and the changing patterns of pre-and post-graduate training of physicians were rapidly leading to a decline of the family practitioner. This phenomenon, by the way, was described and bemoaned in the first decade of this century as eloquently as it has been in the eighth. The ready availability of dispensaries and hospital clinics allowed the family doctor to turn over his undesirable and unremunerative patients as well as those with difficult diagnostic or therapeutic problems-a practice that of course continues to exist. Williams pointed to yet another reason for the widespread use of dispensaries. This he maintained was owing to the large numbers of imperfectly trained physicians. Thus not only did the doctors in some cases turn for help to the clinics, especially those associated with medical schools, but the patients sensed that the specialists in the clinics were perhaps a safer gamble in an all too uncertain medical world. Similar data come from an investigation of a thousand dispensary patients sponsored by the Medical Society of the County of New York in 1912.13 In 1911, 665,000 new patients were treated in the Manhattan dispensaries. The total numbers of patients, the numbers of individual treatments, the numbers of prescriptions written, and similar data are obtainable from the annual reports of each dispensary. The New York County Society wished to inquire closely into the circumstances of one thousand patients, randomly chosen from 13 of the larger New York dispensaries. To undertake this study the society hired Miss Anne Moore, a social worker with a PhD degree, who selected 50 to 100 of the most recent applicants of the 13 representative dispensaries. She was immediately confronted with a wide disparity in records and sometimes a woeful lack of information about patients. She was also surprised that many New York City dispensary patients actually lived out-of-town. The average was 25 per cent. During the course of her investigation, Moore tried to see each patient at home so as to gain a first-hand impression of his/her economic circumstances. Of her sample of 1,000, she was unable to locate 255. Eighty-seven of this group could not be found because the admitting dispensary had 266
carelessly or improperly registered the address. Others had moved, and since her survey was conducted during October, a "moving" month in New York, this was to be expected. Dr. Moore estimated that 32 patients, or 12.5 per cent of the 225 not found, deliberately falsified their addresses in order to deceive the dispensaries. Of the remaining 745 cases, 672 or 90 per cent were found to be worthy of free treatment. Almost all of these patients belonged to what she called the laboring class. They were able to subsist until illness occurred. Then there simply was not enough money to buy other necessities if medical fees had to be paid. There is a wealth of economic information in the Moore report, but it is beyond the scope of this paper. What is of direct interest here is that in addition to economic, housing, and some nutritional data, Moore also was able to gain an impression of the quality of medical care her sample experienced. The very poor who can least afford it, she concluded, are most subject to exploitation by unskilled and unscrupulous physicians. "A slight ailment is often aggravated by neglect or maltreatment," she wrote, "when a skilled and responsible physician in the beginning might relieve the trouble in a few minutes. Time is lost and often the job with it. They should be protected from the ignorant practitioner for it is usually into his hands they fall when, feeling they can afford to pay a dollar or two for treatment, they eschew the dispensary and seek a neighborhood doctor." What she actually found, then, is that 90 per cent of those investigated were worthy of free treatment and that many of these patients were willing to pay for care and had already done so. But they needed some assurance that their money would be spent for the best possible care. In the dispensaries they usually found the quality of care they sought. One conclusion that I draw from this is that today's so-called problem of rising expectations had its roots firmly planted more than 70 years ago. It would be unwise and uncritical to accept all of the findings in the Moore report. Yet certainly she provided some hard data about the use and abuse of dispensaries. Arguments against one or another system of dispensing medical care always seem to be filled with heated polemic and very soft evidence. Charges and counter-charges are hurled, usually based on evidence that is impressionistic rather than systematic, specific, or analytic. An excellent example of this was the frequently heard charge that free medical care was apt to pauperize the recipient. Yet nowhere is there a real analysis of the process of pauperization. Repeated frequently enough, such a charge became an article of faith subscribed to by many well-meaning and a few not so wellmeaning physicians and reformers. That this is a much oversimplified look at a complex issue, I am aware. Much of the underlying value structure of the late nineteenth century, tinged for instance with varying degrees of social Darminism, must be examined concurrently. In the early decades of our own century the dispensary as a locus for medical care began to decline, accompanied by an increase in hospitals and their clinics. Rosenberg and Rosen have discussed this as had Michael Davis and A. G. Warner before them. Warner, in 1894, cited among several AJPH March, 1977, Vol. 67, No. 3
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reasons for the rapid development of hospitals the pressures of foreign immigration.14 The foreign influx, that most frequently abused reason for all of America's troubles, in this case was invoked to explain the use of hospitals and other medical charities, because these were the forms of medical care the immigrants were used to receiving in Europe, a point that needs much further study. While Germany, for instance, instituted sickness insurance for workers in 1883, and while friendly societies and provident dispensaries were commonly involved in medical services in England, the precise locus of medical care for the average continental European at the end of the century and the differences among eastern, southern, and northern countries, cries out for a comparative study. Warner maintained that the majority of immigrants sought the familiar modes of medical care, namely the charitable clinics and dispensaries, but there is some evidence to the contrary. Europeans may have looked to America precisely because medical charity was more readily available. Witness, for instance, what Robert Hunter wrote about a Swiss he met: "An itinerant tailor, apparently strong, but afflicted with an uncurable disease, was making his way through the mountains to Davos, where, he said, there was a hospital which he hoped would take him in. When he learned that we came from America he exclaimed: 'How I wish I could get there! The hospitals are free in your country'.'1,5 Warner's other reasons for the rapid development of the hospital were associated with an increasing density of the population, an increased efficiency of hospitals, and improvements in medical care, especially surgery. With an increase in pay beds also came more ward or charity beds. But the hospitals, along with the dispensary, around 1900, were often cited as a reason for the hard lot of physicians. One New York physician, in 1899, longed for the good old days of the general practitioner. The hospital, he complained, had been transformed into a colossal corporation controlling the medical market and freezing out the general practitioner. He drew the interesting analogy between the family doctors and New York's old volunteer fire-fighting companies. Those brave firemen toiled on, animated by pride, patriotism, and charity. But the task was too great; they could not protect the city and provide for their families as well.16 The abuse of the medical charities, this physician believed, was by the rich not the poor. The dispensaries and clinics were turning their backs upon the very class for whom they were founded. Finally, just a few words about one attempted solution to the problem of dispensary abuse. The New York State Legislature in 1899 passed a law to regulate the numbers and conduct of dispensaries. The State Board of Charities was charged with supervision and enforcement. Much of this duty fell to a small committee of the Board headed by the New York City physician Dr. Stephen Smith, who a quarter
AJPH March, 1977, Vol. 67, No. 3
of a century earlier had been the first president of the American Public Health Association. The objects of the law were to limit the number of dispensaries to the real need of the community, to confine their work to serve only the poor, and to improve their physical condition as well as their management. Smith, in 1903, wrote a paper published in Charities entitled "Dispensary Law Effective." He showed that the law had at least put an end to the increasing numbers of dispensaries. Most observers, however, disagreed with their venerable colleague. The law simply'did not attain the objectives for which it was framed. No prosecutions under its provisions took place. The problems of the last decades of the nineteenth century continued to exist in the early decades of our own. Smith himself in 1903 pointed to the increasing use of the hospital clinics as dispensaries. These hospital outpatient departments then became the feeders of the hospital wards. But the rise of hospitals is another story. The ineffective dispensary law was quite typical of a number of similar health and charity measures. That 75 years later we are in the midst of sorting out the problems of Medicaid simply shows that the so-called abuse of charity is a many-faceted problem, very difficult to solve on a once-and-for-all basis.
REFERENCES 1. Smith, S. Report on the condition of the dispensaries of the State of New York, Ann. Rep. N.Y. State Bd. Char. for the year 1897, New York, 1898, pp. 617-650; Davis, M. M. Jr. and Warner, A. R. Dispensaries, Their Management and Development, New York: Macmillan, 1918. 2. Gay, G. W. Abuse of Medical Charity. Boston, M. and S. J., 1905, 152:295-305; p. 303. 3. Folks, H. Problems in Administration of Municipal Charities. Ann. Am. Acad. Pol. and Soc. Sci., 1904, 23:268-80. 4. Editorial, Medical Incomes in New York, M. Rec. 1883, 23:654. 5. Shrady, G. F. The Pay of Physicians and Surgeons, Forum, 1894-95, 18:68-79. 6. Schaefer, T. W. The Commercialization of Medicine, or, The Physician as Tradesman, Boston M. and S. J., 1894, 131:50102. 7. Smith, A. N. The Unrequited Services of the Physician, New York J. Med, 1900, 72:17-20. 8. Sheardown, T. W. Letter to Ed., M. Rec., 1884, 26:109-111; p. 109. 9. Emerson, C. P. Free Medical and for the Poor, Proc. Nat. Conf. Char. and Corr. 1904, pp. 168-75. 10. Chapin, H. D. Home Treatment of the Sick Children of the Poor, Charities, 1901, 7:470-72. 11. Shrady, G. F. A Propagator of Pauperism: The Dispensary, Forum, 1897, 23:420-31. 12. Williams, J. W. Dispensary Abuse and Certain Problems of Medical Practice, JAMA, 1916, 66:1902-08. 13. Thomas, W. S. Report of Committee on Dispensary Abuse, 1912, N.Y. State J. Med., 1913, 13:48-53 plus appendix. 14. Warner, A. G. American Charities, New York, 1894, pp. 239ff. 15. Hunter, R. Poverty, New York, 1904, Harper Torchbook ed., 1965, p. 285. 16. Hillis, T. J. What to Do to Be Saved, Being the Conclusion of an Inquiry into the Causes Leading to the Abuse of Medical Charity, M. Rec., 1899, 55:238-47. 17. Smith, S. Uses and Abuses of Medical Charities, Proc. Nat. Conf. Char. and Corr., 1898, Boston, 1899, pp. 320-27.
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The Use and Abuse of Medical Charities In Late Nineteenth Century America GERT H. BRIEGER, MD, PHD Philanthropia-the love of man-has a long and honorable tradition in the history of medicine. Medical charity has always been one facet of the humanitarian character of the medical profession. It is medicine, said Alexander Stevens in the first presidential address to the newly formed American Medical Association in 1848, that is the link uniting science and philanthropy. Yet when the charitable impulse runs afoul of the medical market place, economics have usually dominated philanthropy. One such encounter between the needs of patients and the needs of their physicians at the end of the nineteenth century was particularly interesting, and engendered the controversy that became known as the dispensary abuse. In discussing the use and the alleged abuse of medical charity in the late nineteenth century, a whole series of medical and social problems must be considered. Income, of both patients and doctors, the supply of physicians, medical education, changing patterns of medical care, especially specialization, regulation of medical practice, and by no means least noteworthy, the quality of medical care are all important facets of the intense arguments over the abuse of medical charities. As discussed by physicians and social workers in the years between the Civil War and World War I, medical charity usually referred to hospitals and their outpatient departments and to free-standing dispensaries. The historical development of both these institutions has already been very well described by George Rosen in "The Impact of the Hospital on the Physician, the Patient and the Community," that appeared in Hospital Administration in the Fall of 1964, and more recently in an article by Charles Rosenberg in the January, 1974 issue of the Journal of the History of Medicine, entitled "Social Class and Medical Care in Nineteenth-Century Address reprint requests to Gert H. Brieger, MD, PhD, Professor and Chairman, Department of the History of Health Sciences, University of California, San Francisco, CA. This paper was presented at the American Historical Association meeting, December 29, 1974. Submitted to the Journal in November 1976, it was accepted for publication December 3, 1976. 264
America: The Rise and Fall of the Dispensary." What they have already so adequately described will not be repeated here. Instead I want only to focus on the so-called dispensary abuse and to point to some of the ramifications of this debate on the broader history of medical care. One of the first questions about the abuse of medical charities is how widespread was it, and why did it occur? Figures vary (and are suspect in any case), but generally were cited to show that around the middle of the nineteenth century in New York City, for instance, 16 per cent of the population received its medical care in the dispensaries, but by the end of the century it was a full 50 per cent.' Not all dispensaries and hospital clinics dispensed their services free or for a token charge, but a large proportion of them did so. Warnings about abuse of this form of charity began to be heard increasingly in the late 1860s and 70s, and reached a furious pitch by the 1890s. The charge against the dispensaries and hospital clinics revolved mainly around the free treatment of patients able to pay. The result, claimed those who became so exercised over this abuse, was to deny the rightful fees to physicians in the community who would otherwise care for these patients. Young doctors, struggling to establish themselves, were thought to be especially hard hit. Most of the physicians who wrote about the abuse of medical charity, however, were older, established men who ostensibly were looking out for their younger colleagues. Today, of course, the younger physicians would be much more apt to press for extension of free clinics rather than their suppression. In addition to simple economic motives for complaint, a large number of physicians urged an end to the abuse of free care for the sake of their patients as well. "Paying taxes," the Boston physician George Gay wrote in 1905, "no more entitles one to free medical treatment than to free water, gas, or any other ordinary commodity. In short, getting something for nothing demoralizes the individual and encourages deceit, laziness, and pauperism."2 This argument, of course, was not unique to the medical profession. Many charity workers concurred, and even during depressions of the AJPH March, 1977, Vol. 67, No. 3
PUBLIC HEALTH THEN AND NOW
1880s and 90s, there were repeated calls for the abolition of out-door relief, of which dispensaries were but one kind.3 What had happened, then, in many large American cities by the end of the nineteenth century was that all too often physicians, instead of asking who are the people in need of treatment and how can we treat them most effectively and efficiently, asked how can we keep people from getting free treatment. The problems of every-day life faced by the large numbers of the urban, industrial work-force in the latter decades of the nineteenth century have increasingly interested historians. Economic fluctuations leading to a drop in wages and rising unemployment, while difficult to relate to individual family units, drew the attention of economists and reformers in that day as it still does today. Just how many New Yorkers, for instance, lived at the margins of poverty, and indeed where the so-called poverty line could be drawn has remained a key question. Reading the works of reformers such as Jacob Riis and seeing the even more gripping photographs of that period, leave little doubt that any additional economic burdens imposed by illness were not manageable for a large segment of the laboring force. If one looks at the economic status of the medical profession in New York through the eyes of George Shrady, one of the city's most influential medical editors and a vociferous opponent of the dispensary abuse, one perceives a bleak picture indeed. It is well beyond the scope of this discussion to investigate the economic aspects of nineteenth century medicine with due care. Yet the perspective provided by Shrady explains at least a portion of the felt-reality of the many physicians who honestly believed that much abuse was abroad in the land. Faced by a supply of doctors greater than the demand for their services, plagued by an unfair competition of the dispensaries and hospital teaching clinics, and unable to earn a living comparable to the cartman who might be his neighbor, the average New York doctor, according to Shrady, might be better off in some other occupation. Yet the facts do not bear this out, at least on superficial study. In an editorial in The Medical Record in 1883, Shrady wrote: "We doubt if the average income of the New York City physician exceeds $5,000, and there is a very large number, if not a majority, who do not even get this sum. A doctor has to work hard to make $400 a month, unless he has the better class of patients."4 Since most writers of the time considered that the minimum income required by a family of five people was between $600 and $800 per year, one has to look with wonder at the physicians who were crying impoverishment. The question, of course, is why did (and do) doctors assume they were entitled to an income so much higher than their fellow workmen? A decade later, Shrady seems to have revised his estimates of physician's incomes downward. Writing on "The Pay of Physicians and Surgeons" in The Forum in 1894, he said that the average annual income of a physician in a large city was $2,000 and in rural towns $1,200.5 At least one physician, Dr. Theodore W. Schaefer of Kansas City, did not agree with even those figures. Writing on "The Commercialization of Medicine," in the prestigious Boston MediAJPH March, 1977, Vol. 67, No. 3
cal and Surgical Journal, Schaefer claimed that Shrady's estimates were inaccurate and misleading. "The supposed fabulous income of a great majority of physicians is afiction!", he wrote "The fact is that the young physician, in the first five years of his practice, hardly earns his board, and his income often does not amount to fifteen dollars a month in cash!"6 Whatever future research may reveal, the very economic existence of physicians was closely related to the use and abuse of dispensaries. A related point to be made is that often when doctors discussed income, they reminded themselves and others about the charitable work they performed. The profession as a whole has always prided itself in its charitable tradition.7 No patient, has been the usual claim, was ever denied needed care. The dispute over the abuse of dispensaries brings out the many motives which physicians have had for their charitable work. They wanted to teach, they wanted the title of professor, they wanted to improve their skills in one or another specialty, or they wanted to drum up business for themselves. The bubble of pride in good works was neatly pricked by a Tennessee physician writing to The Medical Record in 1884: "As it now is, the busy active doctor will often attend before, and give more attention to a poor patient than to a well-to-do patient, for the simple reason that he is afraid it will hurt his reputation if he fails to find time to wait upon the poor who call upon him.... He does not attend the poor from a feeling of duty, or honor, glory, or fame, but simply out of policy."8 It is a distorted picture we get by focusing our attention only on the negative aspects of the charity question. There were doctors who argued vigorously for free medical care for all those who needed it. Dr. Charles Emerson of Baltimore, for instance, believed that there was little danger of pauperizing patients. The same arguments, he noted to the National Conference on Charities in 1906, had been used against free concerts, free libraries, free parks, and above all, free schools with free textbooks.9 While some New York physicians were denouncing the abuse of the city's dispensaries, others were calling for an expansion of their activities. Henry D. Chapin, a pediatrician of note, believed that better home services provided by some of the dispensaries might lower the appalling death rates among children. In 1900, for instance, of the 70,872 deaths occurring in New York, over one-third (25,836) were children under age five; another 4,325 victims were claimed from the ages of five to fifteen. The only promise for amelioration, Chapin believed, was an organized home medical service that included doctors and nurses who could instruct families about diet and hygiene. "Many young and competent doctors," he suggested, "could be procured for a small salary to undertake such a work at the beginning of their career. " 10 The fact that Chapin carefully called for competent young physicians was probably no accident. And this leads into the next major issue of concern that grew out of the charity abuse arguments, namely the quality of medical care.
The many outcries against the dispensary abuse, such as George Shrady's widely quoted 1897 Forum article, "A 265
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Propagator of Pauperism: The Dispensary," cited example after example of obviously well-to-do patients who used (or abused) the dispensaries for free or for very low-cost care.11 But none of these authors really explained why these patients turned to dispensaries. Was it simply because they would receive free care? Or, was it that dispensary care was thought to be better care or more readily available better care? In our own day there is much discussion of the quality of medical care. But quality in health care has been and remains an elusive entity. Yet it certainly was a subject of as great interest in 1900 as in 1970. One of the most perceptive discussions of the dispensary abuse may be found in an address to Medical and Chirurgical Faculty of Maryland in 1916 by J. Whitridge Williams, Professor of Obstetrics at Johns Hopkins. 12 Williams clearly saw that the so-called abuse was closely linked to the complexities of changing conditions of medical practice. Urbanism, specialism, hospitals, wider use of nurses, all needed to be taken into consideration. These changes, plus the burgeoning of medical science and the changing patterns of pre-and post-graduate training of physicians were rapidly leading to a decline of the family practitioner. This phenomenon, by the way, was described and bemoaned in the first decade of this century as eloquently as it has been in the eighth. The ready availability of dispensaries and hospital clinics allowed the family doctor to turn over his undesirable and unremunerative patients as well as those with difficult diagnostic or therapeutic problems-a practice that of course continues to exist. Williams pointed to yet another reason for the widespread use of dispensaries. This he maintained was owing to the large numbers of imperfectly trained physicians. Thus not only did the doctors in some cases turn for help to the clinics, especially those associated with medical schools, but the patients sensed that the specialists in the clinics were perhaps a safer gamble in an all too uncertain medical world. Similar data come from an investigation of a thousand dispensary patients sponsored by the Medical Society of the County of New York in 1912.13 In 1911, 665,000 new patients were treated in the Manhattan dispensaries. The total numbers of patients, the numbers of individual treatments, the numbers of prescriptions written, and similar data are obtainable from the annual reports of each dispensary. The New York County Society wished to inquire closely into the circumstances of one thousand patients, randomly chosen from 13 of the larger New York dispensaries. To undertake this study the society hired Miss Anne Moore, a social worker with a PhD degree, who selected 50 to 100 of the most recent applicants of the 13 representative dispensaries. She was immediately confronted with a wide disparity in records and sometimes a woeful lack of information about patients. She was also surprised that many New York City dispensary patients actually lived out-of-town. The average was 25 per cent. During the course of her investigation, Moore tried to see each patient at home so as to gain a first-hand impression of his/her economic circumstances. Of her sample of 1,000, she was unable to locate 255. Eighty-seven of this group could not be found because the admitting dispensary had 266
carelessly or improperly registered the address. Others had moved, and since her survey was conducted during October, a "moving" month in New York, this was to be expected. Dr. Moore estimated that 32 patients, or 12.5 per cent of the 225 not found, deliberately falsified their addresses in order to deceive the dispensaries. Of the remaining 745 cases, 672 or 90 per cent were found to be worthy of free treatment. Almost all of these patients belonged to what she called the laboring class. They were able to subsist until illness occurred. Then there simply was not enough money to buy other necessities if medical fees had to be paid. There is a wealth of economic information in the Moore report, but it is beyond the scope of this paper. What is of direct interest here is that in addition to economic, housing, and some nutritional data, Moore also was able to gain an impression of the quality of medical care her sample experienced. The very poor who can least afford it, she concluded, are most subject to exploitation by unskilled and unscrupulous physicians. "A slight ailment is often aggravated by neglect or maltreatment," she wrote, "when a skilled and responsible physician in the beginning might relieve the trouble in a few minutes. Time is lost and often the job with it. They should be protected from the ignorant practitioner for it is usually into his hands they fall when, feeling they can afford to pay a dollar or two for treatment, they eschew the dispensary and seek a neighborhood doctor." What she actually found, then, is that 90 per cent of those investigated were worthy of free treatment and that many of these patients were willing to pay for care and had already done so. But they needed some assurance that their money would be spent for the best possible care. In the dispensaries they usually found the quality of care they sought. One conclusion that I draw from this is that today's so-called problem of rising expectations had its roots firmly planted more than 70 years ago. It would be unwise and uncritical to accept all of the findings in the Moore report. Yet certainly she provided some hard data about the use and abuse of dispensaries. Arguments against one or another system of dispensing medical care always seem to be filled with heated polemic and very soft evidence. Charges and counter-charges are hurled, usually based on evidence that is impressionistic rather than systematic, specific, or analytic. An excellent example of this was the frequently heard charge that free medical care was apt to pauperize the recipient. Yet nowhere is there a real analysis of the process of pauperization. Repeated frequently enough, such a charge became an article of faith subscribed to by many well-meaning and a few not so wellmeaning physicians and reformers. That this is a much oversimplified look at a complex issue, I am aware. Much of the underlying value structure of the late nineteenth century, tinged for instance with varying degrees of social Darminism, must be examined concurrently. In the early decades of our own century the dispensary as a locus for medical care began to decline, accompanied by an increase in hospitals and their clinics. Rosenberg and Rosen have discussed this as had Michael Davis and A. G. Warner before them. Warner, in 1894, cited among several AJPH March, 1977, Vol. 67, No. 3
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reasons for the rapid development of hospitals the pressures of foreign immigration.14 The foreign influx, that most frequently abused reason for all of America's troubles, in this case was invoked to explain the use of hospitals and other medical charities, because these were the forms of medical care the immigrants were used to receiving in Europe, a point that needs much further study. While Germany, for instance, instituted sickness insurance for workers in 1883, and while friendly societies and provident dispensaries were commonly involved in medical services in England, the precise locus of medical care for the average continental European at the end of the century and the differences among eastern, southern, and northern countries, cries out for a comparative study. Warner maintained that the majority of immigrants sought the familiar modes of medical care, namely the charitable clinics and dispensaries, but there is some evidence to the contrary. Europeans may have looked to America precisely because medical charity was more readily available. Witness, for instance, what Robert Hunter wrote about a Swiss he met: "An itinerant tailor, apparently strong, but afflicted with an uncurable disease, was making his way through the mountains to Davos, where, he said, there was a hospital which he hoped would take him in. When he learned that we came from America he exclaimed: 'How I wish I could get there! The hospitals are free in your country'.'1,5 Warner's other reasons for the rapid development of the hospital were associated with an increasing density of the population, an increased efficiency of hospitals, and improvements in medical care, especially surgery. With an increase in pay beds also came more ward or charity beds. But the hospitals, along with the dispensary, around 1900, were often cited as a reason for the hard lot of physicians. One New York physician, in 1899, longed for the good old days of the general practitioner. The hospital, he complained, had been transformed into a colossal corporation controlling the medical market and freezing out the general practitioner. He drew the interesting analogy between the family doctors and New York's old volunteer fire-fighting companies. Those brave firemen toiled on, animated by pride, patriotism, and charity. But the task was too great; they could not protect the city and provide for their families as well.16 The abuse of the medical charities, this physician believed, was by the rich not the poor. The dispensaries and clinics were turning their backs upon the very class for whom they were founded. Finally, just a few words about one attempted solution to the problem of dispensary abuse. The New York State Legislature in 1899 passed a law to regulate the numbers and conduct of dispensaries. The State Board of Charities was charged with supervision and enforcement. Much of this duty fell to a small committee of the Board headed by the New York City physician Dr. Stephen Smith, who a quarter
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of a century earlier had been the first president of the American Public Health Association. The objects of the law were to limit the number of dispensaries to the real need of the community, to confine their work to serve only the poor, and to improve their physical condition as well as their management. Smith, in 1903, wrote a paper published in Charities entitled "Dispensary Law Effective." He showed that the law had at least put an end to the increasing numbers of dispensaries. Most observers, however, disagreed with their venerable colleague. The law simply'did not attain the objectives for which it was framed. No prosecutions under its provisions took place. The problems of the last decades of the nineteenth century continued to exist in the early decades of our own. Smith himself in 1903 pointed to the increasing use of the hospital clinics as dispensaries. These hospital outpatient departments then became the feeders of the hospital wards. But the rise of hospitals is another story. The ineffective dispensary law was quite typical of a number of similar health and charity measures. That 75 years later we are in the midst of sorting out the problems of Medicaid simply shows that the so-called abuse of charity is a many-faceted problem, very difficult to solve on a once-and-for-all basis.
REFERENCES 1. Smith, S. Report on the condition of the dispensaries of the State of New York, Ann. Rep. N.Y. State Bd. Char. for the year 1897, New York, 1898, pp. 617-650; Davis, M. M. Jr. and Warner, A. R. Dispensaries, Their Management and Development, New York: Macmillan, 1918. 2. Gay, G. W. Abuse of Medical Charity. Boston, M. and S. J., 1905, 152:295-305; p. 303. 3. Folks, H. Problems in Administration of Municipal Charities. Ann. Am. Acad. Pol. and Soc. Sci., 1904, 23:268-80. 4. Editorial, Medical Incomes in New York, M. Rec. 1883, 23:654. 5. Shrady, G. F. The Pay of Physicians and Surgeons, Forum, 1894-95, 18:68-79. 6. Schaefer, T. W. The Commercialization of Medicine, or, The Physician as Tradesman, Boston M. and S. J., 1894, 131:50102. 7. Smith, A. N. The Unrequited Services of the Physician, New York J. Med, 1900, 72:17-20. 8. Sheardown, T. W. Letter to Ed., M. Rec., 1884, 26:109-111; p. 109. 9. Emerson, C. P. Free Medical and for the Poor, Proc. Nat. Conf. Char. and Corr. 1904, pp. 168-75. 10. Chapin, H. D. Home Treatment of the Sick Children of the Poor, Charities, 1901, 7:470-72. 11. Shrady, G. F. A Propagator of Pauperism: The Dispensary, Forum, 1897, 23:420-31. 12. Williams, J. W. Dispensary Abuse and Certain Problems of Medical Practice, JAMA, 1916, 66:1902-08. 13. Thomas, W. S. Report of Committee on Dispensary Abuse, 1912, N.Y. State J. Med., 1913, 13:48-53 plus appendix. 14. Warner, A. G. American Charities, New York, 1894, pp. 239ff. 15. Hunter, R. Poverty, New York, 1904, Harper Torchbook ed., 1965, p. 285. 16. Hillis, T. J. What to Do to Be Saved, Being the Conclusion of an Inquiry into the Causes Leading to the Abuse of Medical Charity, M. Rec., 1899, 55:238-47. 17. Smith, S. Uses and Abuses of Medical Charities, Proc. Nat. Conf. Char. and Corr., 1898, Boston, 1899, pp. 320-27.
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