The American College of Surgeons and the Hospital Rackets

The Surgical Chamber of Commerce

Jn the field of surgery, the American College of Surgeons shares with the A.M.A. control of the monopoly of hospital business. The College is a surgical trade organization which combines the functions of labor union and chamber of commerce. It is a device whereby its members establish for themselves a monopoly of the surgical business, restrict the number of surgeons allowed access to hospitals, maintain the fee scale and costs of surgery at a high level, and otherwise protect their incomes and prevent any encroachment on the field of surgery by the adoption of non-surgical methods of treatment that might develop from medical discovery.

The origin of the American College of Surgeons (A.C.S.) like that of the A.M.A. found its roots in business competition. Barbers monopolized the field of surgery for centuries. Surgery was spurned by the medical profession as beneath its dignity. A survival of this attitude is the British custom of denying to the surgeon the title of doctor.

In the latter part of the eighteenth century and in the early nineteenth, the barbers' practice of surgery had become quite lucrative. The medical profession began to cast invidious eyes at surgery and openly engaged in battle with the guilds of the barbers and "chyrurgiens" for its monopoly. Then cognizance was again taken in the mid-nineteenth century of the ancient and "sinful" practice of anesthesia, and it was reintroduced. Later recognition of Pasteur's proof of the bacterial origin of infections was forced upon medicine, and became the basis of safer, aseptic surgery. These developments made it possible to open and drain abscesses of the abdomen, such as appendicitis, with some hope of survival of the patient. When surgery was thus made more pleasant and lucrative, the organized medical profession grabbed it from the barbers.

Surgery soon became acclaimed as a cure-all. The surgeon became transformed from a scorned barber-butcher to a popular hero, and accordingly his fees and income rose. This brought a grand rush of recruits to the field of surgery.

By the end of the first decade of this century, competition in the surgical business became very keen. Surgical fees dropped steadily to lower levels. Surgeons competed openly for business by paying their colleagues for services rendered them in preparing the case for operation, and in building up their reputations, practices, and incomes. As competition among surgeons grew keener, they offered for these legitimate services a steadily larger share of their fees. Not even the "closed hospitals" and their monopoly of hospital facilities could stem the tide of competition.

At this juncture, a group of politically influential surgeons got together to protect their businesses. They formed the American College of Surgeons. This was about the same time the A.M.A. was engaged in protecting the incomes of its bosses, and reducing competition with the aid of the General Education Fund, by putting out of business the majority of the country's medical schools.

The A.C.S. plan is to lead the public to believe by intensive publicity and advertising that its members are the only honest and competent surgeons, and that they alone are intent upon protecting the lives of the public. The initial membership was restricted to a group of surgeons controlling the hospital facilities of communities, who would pay the initiation and twenty-five dollars membership dues, and, most important of all, who would sign a pledge not to "split fees." They conferred upon themselves the title and trademark, F.A.C.S. (Fellow of the American College of Surgeons).

HOLDING DOWN COMPETITION

As a part of the program of the F.A.C.S. to protect their incomes, they deliberately restrict the number of surgeons to whom they extend the stamp of their approval and the hospital privileges which it implies. They do this more with an eye to a monopoly of surgical business than to the needs of the community. The A.C.S. acknowledged a shortage of its brand of surgeons at its 1939 convention, and announced that it was planning to increase the number by five hundred Fellows a year.

The device that the A.C.S. employs to restrict the number of surgeons and to protect the business of its Fellows is perfect. Through its joint grip on the hospitals shared with the A.M.A. and the Social Service Trust, it bars non-members from appointment to significant surgical positions that yield material returns directly or indirectly. Membership is limited by local boards composed of F.A.C.S. engaged in practice in the same community as the applicants, often in competition with them.

As might be expected under the circumstances, a great majority of the applicants are rejected by the boards composed of their competitors. Thus in October 1929 about six thousand surgeons who had served for years on the staffs of hospitals throughout the country applied for acceptance and fellowship in the A.C.S. with full proof of their experience and skill. Five thousand were turned down and returned to their communities to continue to practice surgery, many in "approved" hospitals, without the seal of "approval" of the A.C.S. The College did not undertake to protect the public from their supposed lack of skill; but the F.A.C.S. did protect themselves from business competition.

The need for this type of restriction for maintenance of large, monopolistic surgical businesses for a small group of F.A.C.S. surgeons is manifest. Surgery per se is a simple mechanical art that can be learned readily by a moron. There are few operations as complicated as rebuilding a pair of shoes. Far more important are diagnostic ability, medical judgment and skill, which require infinitely greater ability than the mechanics of surgery. But these contraindicate operation and dictate medical treatment so often that they are not favored greatly by the surgical gang, for they hurt business.

THE COBBLER SURGEON

An example that illustrates how little exceptional ability is required by the mechanics of surgery is related in a tale, forwarded to the New York Times from Russia by Walter Duranty, about a cobbler, Ivan Kolesnikoff, who posed as a surgeon for eight years. He acquired the documents of a Dr. Nelskij and on their strength became assistant surgeon at the Tashkent Hospital. He was rapidly promoted to the rank of chief surgeon at Samarkand and later made chief surgeon of a group of hospitals around Kieff. Even after he became known as an impostor and prosecution was urged by local physicians who resented the competition, superiors supported him as a man of practical efficiency. When he finally was sent to prison for six years, it was brought out that he was a very rapid operator and that the mortality rate of his six hundred major operations was lower than the average of competing surgeons.

COMMERCIAL ADVANTAGES OF F.A.C.S.

There are very distinct advantages to fellowship in the A.C.S. Because of its acceptance of social service domination* the A.C.S., its appointments to fellowship and its "Approved Hospitals" are widely publicized in the press. This serves as free advertisement of the Fellows as they are appointed.

This selective advertisement of its brand of surgeon does not satisfy the A.C.S. Periodically it attacks the balance of the profession in the press with false and libelous allegations which directly, or by innuendo, stamp all who are not F.A.C.S. as incompetent, dishonest, and not to be trusted.

On this score one of the Fellows of the A.C.S. wrote a letter of protest in 1931 to the magazine Medical Economics reading as follows:

"To the Editor:

"I believe that it may fall to the lot of your publication some day to point the way to the broader methods of business in our professional attitude* instead of our covetous one from which a change is needed if we are to hold public respect and confidence.

"Personally I cannot bring myself to believe that the closed hospital is a just restriction to the younger men. I, as a Fellow of the American College of Surgeons, believed that standardization of our hospitals would work for betterment of all concerned. But I was wrong. "It has made mean and narrow political cliques. It has become a great factor in the creation of medical trust. J. O."

A.C.S. ALIBI

The A.C.S. seeks to justify its activities by asserting that it protects the public by certifying to the superior competence of surgeons on the staffs of hospitals that it advertises as "approved." These representations are often false. When political convenience dictates, the A.C.S. "approves" hospitals from the staffs of which its "approved" brand of Fellows are ousted and replaced by surgeons whom those Fellows openly denounce as incompetent.

Such was the case, for example, at Harlem Hospital of New York City a number of years ago. The surgical director, a political appointee, was publicly charged with "incompetence, inexperience and poor surgical judgment" by veteran members of the surgical staff who were also Fellows of the A.C.S. The protesting F.A.C.S. were ousted together with a large part of the staff of the hospital. For political motives, some were replaced by surgeons who had been denied fellowship by the A.C.S. on the grounds of lack of experience or competence. The allegedly incompetent director retained his position. And the Harlem Hospital continued to be "approved" though neither reply or denial was ever made to the charges, and in spite of deplorable conditions of overcrowding, inadequate equipment, and abuse and neglect of patients.

The A.C.S. misrepresents facts in still another manner. Even the most honest F.A.C.S., the "specialist in surgery," is certain to be biased in favor of surgery, for self-interest compels it. He is emotionally opposed to non-mutilating medical therapy. The most eminent surgical specialists of the A.C.S. perform many needless operations.

NEEDLESS OPERATIONS AT A MEDICAL CENTER

Cases readily come to mind. The most flagrant is that of Mrs. Sadie Rosenberg. She suffered from a serious ailment that progressively paralyzed the muscles of the eyelids so that she could not open her eyes; the muscles of her eyes so that she could not move her eyes; the muscles of her face and jaws so that her mouth would fly open involuntarily and she could not close it; the muscles of her throat so that she could not swallow food, except in the early part of the day, without the sensation or danger of choking; and the muscles of her body so that she tired rapidly and could scarcely muster enough energy to care for herself.

In the first stage of the illness when she suffered only from drooping of the lids, Mrs. Rosenberg placed herself in the care of the Columbia-Presbyterian Medical Center and its associated Neurologic Institute and Eye Institute. There she was treated over a period of four years almost continuously. She was admitted to the hospital eight times. Thirteen different diagnoses of her condition were made by the hospital and professorial staffs, none of which proved correct.

She was operated for correction of the drooping lids and the paralysis of the eye muscles three times by Dr. John Wheeler, one of the most widely and spectacularly advertised eye surgeons in the world; and later was slated for a fourth eye operation by an equally prominent, recently deceased Mt. Sinai eye surgeon. Dr. Byron Stookey, professor of brain surgery, made a tentative diagnosis of tumor of the brain following injection of air into the patient's spine and the taking of encephalograms. Dr. L.M. Davidoff ordered x-ray treatment of the head for one year, at the end of which time cataracts had developed in both eyes. Though numerous x-rays were taken, a tumor in the mid-region of chest was entirely overlooked. Dr. George Crile, called into consultation, diagnosed the patient's condition as glandular but beyond hope on the same day that the patient was brought to me.

In three weeks after I added several items, including vitamins A, B, C, E and G, salt, manganese, and liver to her diet and placed her on glandular treatment, complete motion was restored to eyes and eyelids except where the scars of previous operations interfered. Thirteen years later, still under treatment, Mrs. Rosenberg is active, free of myasthenia and performs fully her household duties.

The correct and obvious diagnosis in this case was myasthenia gravis, a medical disorder which required no operative interference. The treatment which I used was largely my original discovery.

FEE-SPLITTING VS. SURGICAL MONOPOLY

It is characteristic of the bias of the American College of Surgeons that its first activity, according to the story which it has published in numerous newspapers and magazines, was directed against "fee-splitting"

"Fee-splitting" is an epithet which has been coined by the clever publicity men of the A.C.S. for their propaganda to cast a stigma upon the intrinsically honest practice of the payment of a fee by one physician to another for services rendered. This publicity has led the public to believe that though payment for services rendered is honest in every other vocation, if the parties involved be physicians it is dishonest.

They represented to the public that the practice of "fee-splitting" stimulated much needless and incompetent surgery. The truth of the matter is the reverse. The presence of the family physician in surgical cases is often a protection for the patient against incompetent and needless surgery. For the family physician is dependent for his future and his income on the continued relations with a satisfied patient; and no intelligent physician would risk his relations with the patient, his family, and his associates by deliberately jeopardizing life.

The surgeon who gains his cases by virtue of the position conferred upon him by the A.C.S. and his monopoly of hospital facilities can disregard the sensibilities and the vital interests of the patient as completely as he disregards his obligation to the colleague who has had the responsibility and work of preparing the case for him. Certainly there is more inducement to such a dishonest surgeon to do needless surgery in a whole fee than there is in half a fee.

The falseness of the pretended motive of the A.C.S. and its Fellows in their war on "fee-splitting" becomes more apparent when one discovers that among its founders and officers were some of the most notorious fee splitters of their day. One of the ranking executives of the College built up his practice, at the beginning of the century, by paying commissions, or "split fees", to barbers, bootblacks, janitors, bartenders and any merchant who would send him cases.

It is notable that Fellows of the A.C.S. have been leaders in the movement to legitimatize "fee-splitting" during the past decade. A recent president of the New York County Medical Society acknowledged in his inaugural address that "fee-splitting" is not an evil; that it is a necessity under present medical and hospital organization; and that many abuses could be eliminated by placing "fee-splitting" on an open and honest basis, as in the other professions.

The A.C.S. itself acknowledges that its attitude towards "fee-splitting" is false. It acknowledges in its publicity releases that its Fellows, who are not honest enough to openly pay for services rendered to them by colleagues, cannot be trusted not to do needless operations when they receive the whole fee. It confesses the need of a check on its Fellows and asserts that it demands a check-up on the work of its advertised brand of surgeons, in the form of a report of the pathologist's findings on the tissue removed at operation and by other equally ineffective methods of control.

But it is common knowledge how very frequently ill-advised and needless operations, also abortions, are performed upon patients in the most representative "closed hospitals," with apparently full justification in the pathologist's reports. Pathologists must live; and to do so they must continue to hold their jobs. The surgeon in the "closed hospital" is protected by a cloak of secrecy and has only his own conscience to consult on the question of operating. It is but natural that his judgment should be prejudiced in his own favor, especially if the fee be sizeable. This is the significance of the proposals for "scoring" of operations made before meetings of the A.C.S., most recently at the October 1939 meeting in Philadelphia.

"APPROVED" METHODS OF "PURSE-SPLITTING"

It safely can be said that there is no member of the American College of Surgeons, or of any other group of physicians, who does not pay directly or indirectly, in some manner, for services rendered to him by some other physicians. In some cases the payment is made socially; in others it is made by deliberate losses in a game of chance, cards or dice; or it may be made by exchange of consultations, many of which are undeniably a needless tax upon the patients' purse, which practise goes by the name of "purse-splitting."

An amusing variant of the formula for evading the "fee splitting" injunction has recently come into vogue, originated by Dr. B____ a wealthy veteran surgeon who like many others is a "reformed fee splitter." A doctor went to him and said;

"Dr. B____ I wish to refer to you an operative appendix case who is willing to pay one thousand dollars for his operation. What will my share be?"

"You know I do not split fees. I am beyond that," said Dr. B____ with an appearance of indignation.

"Never mind. Do not grow indignant. There is many another equally capable surgeon that I can get to do it who will not hesitate to pay me for my services in the case," said the doctor, walking out of Dr. B____'s office.

When the doctor arrived back at his office, he found a message from Dr. B____ asking that he call back. He called.

"I bet you five hundred dollars," said Dr. B_____ "that your diagnosis of acute appendicitis is wrong."

Needless to say, he got the operation and lost the five hundred dollar bet to the referring physician.

The consultation method of "sharing" the patient's purse is approved, endorsed and recommended by the American College of Surgeons, the American Medical Association and other representative, "ethical" societies. With tongue in cheek, medical "leaders" inform the public that these consultations are all "in the interest of the patient." The patient whose purse is flattened by needless consultations knows otherwise.

The arrant hypocrisy of the pretenses of the American College of Surgeons regarding "fee-splitting" becomes obvious when one considers in how many ways its Fellows pay for the steering of business into their offices. To the extent that the publicity of the A.C.S. in favor of its Fellows serves to build up their business, even the twenty-five dollar annual dues which they pay the organization constitutes "fee-splitting."

The purchase of hospital positions, with whatever coin, constitutes "fee-splitting" with the hospital. It constitutes payment for the advertising, publicizing and boosting by the hospital, and payment of commission for the direct reference of patients to the doctor's office.

Evidently cupidity, that very human failing, made painful to the "fee-splitting" surgeons who had become bosses of the surgical racket, the process of paying out to colleagues of the rank and file money collected. But they did not dare to refuse as individuals to pay their colleagues for the services rendered. They feared that the latter would take their cases to equally competent surgeons who would adopt a more honest attitude. They therefore found it necessary to make "fee-splitting" a sin and a crime, to protect their incomes. "Medical ethics" thus serves medical business.

It is significant that a hypocritical attitude toward "fee-splitting" has gained legal recognition in New York State. In 1927, Henry Stern bequeathed his estate of more than two hundred thousand dollars to seven New York hospitals on the condition that the members of the hospital staffs should donate to the hospitals ten percent of the incomes that they earned in the hospitals. This proviso merely takes cognizance of the fact that doctors regularly do purchase hospital positions and the business which emanates from them. In a contest by the hospitals, the courts overruled this clause of the will on the pretense that such "fee-splitting is not permitted by medical ethics."

"APPROVED HOSPITAL" FARCE

The full extent of the hypocrisy and the dishonest commercialism of the situation comes to light in other activities. The A.C.S., jointly with *he American Medical Association, has annually publicized its "approval of hospitals." They have represented to the public that they inspect the hospitals with an eye to their safety, the quality of accommodations and services rendered, and the protection of life and stimulation to recovery which they offer. Each year the A.C.S. releases for publication in newspapers a list of "approved" hospitals which it advertises to the public as follows:

"Before seeking the services of a hospital, be sure to determine that it has been approved by the American College of Surgeons, so that you may be sure that its condition will in every way contribute to your rapid recovery."

This representation of the American College of Surgeons and its allies often is absolutely false. Kings County Hospital of Brooklyn, for example, became notorious for maltreatment of patients. The food was not fit for humans, and the buildings were dilapidated rat- and fire-traps repeatedly condemned by the Building Department of New York City during more than a decade. The horrible conditions in the hospital were fully exposed in the report of the Commissioner of Accounts Higgins in 1928.

A Grand Jury composed of laymen said of the hospital in a presentment handed up to Judge Algernon I. Nova:

"The chronic and incurable male patients, numbering about three hundred, are housed in a building that was erected in 1869. Fire doors have been installed, but they are not self-closing.

"The chronic and incurable female patients, numbering about two hundred and sixty, are housed in a building that was erected about 1860. The eastern wall of this building is shored up with timber and the eastern wards have been cleared of patients because of the danger of the walls falling.

"Large numbers of these chronic and incurable patients are bedridden. The only outlook in life for all the patients is the day when they pass to their eternity. Pending that day, the County of Kings keeps them in two fire-traps. Could a more horrible picture be painted in words than this? . . .

"No doubt, in making these criticisms we are following the footsteps of many grand juries."

The A.M.A. and the American College of Surgeons gave this Kings County Hospital its highest rating, "Fully Approved." I filed a protest with the American College of Surgeons against the travesty and betrayal of public trust involved in certifying the safety of this hospital. Dr. M.T. McEachern, Director of Hospital Activities of the A.C.S. replied. He acknowledged that the "physical plant of the hospital is not the most desirable but justified the false recommendation of the hospital to the public as desirable and safe because "it has a staff of outstanding physicians, surgeons, and specialists," a majority of which surgeons were honored members of the A.C.S. and the A.M.A.

Dr. McEachern's reply implied that the criterion of the A.C.S. in certifying a hospital as "Fully Approved" is primarily, principally or solely this:

"Is a monopoly of the facilities of the hospital given to surgeons who are F.A.C.S., who have signed the pledge not to honestly pay for services rendered them by colleagues, not to split fees, and to maintain the surgical price scale?"

The degrading picture is not complete without comment on the "outstanding physicians, surgeons and specialists," F.A.C.S., on this "closed hospital's" staff. Not one of them had dared to expose the ugly situation of which they were well aware, or to uphold their "Hypocritic Oath" and protect their patients in a manner commanded by honesty and humanity.

On the contrary, they issued to the press a statement denying the existence of these conditions which were so well confirmed as to constitute a public scandal.

The Kings County Hospital case is not an isolated instance. The Cumberland Hospital of Brooklyn, for instance, had always been rated as "Fully Approved" though it was repeatedly condemned, and was finally closed down by Commissioner of Hospitals, Dr. J.G.W. Greeff as in momentary danger of collapse. Many hospitals that are recommended to the public by both the A.C.S. and the A.M.A. are scandalously unsafe, insanitary and a menace to the health and lives of their patients.

METROPOLITAN HOSPITAL: "APPROVED"

Numerous hospitals widely advertised by the American College of Surgeons as "Approved" place in jeopardy the health and lives of their patients and should be condemned and torn down. And it is equally true that the accommodations, food and treatment accorded the patients in numerous of those hospitals can only serve to impair their chances of recovery.

At the Metropolitan Hospital in New York some phases of surgery were practised, as recently as a decade ago, with no regard to asepsis and as crudely as they might have been a century ago. As a consequence of disregard of asepsis and sanitation, over two hundred cases of cross-infection of scarlet fever, measles and diphtheria, with a number of deaths of children, on one occasion forced quarantining the entire building in which the children's wards were located.

With a reporter for a New York newspaper, George Kenney, I inspected, about that time, the tuberculosis wards of the Metropolitan Hospital. We found that less than half the patients were provided with sheets or blankets. In order to keep the patients warm, the windows of the wards were kept closed at all times. Even the nurses and medical staff agreed that the food which was given to the patients was not fit for humans. The tuberculous patients of the hospital were getting neither fresh air nor proper food, the two essentials for the treatment of the disease.

One amusing episode brightened this grim tour of inspection. News of our inquiries about blankets was relayed to the superintendent of the hospital. On ringing for the elevator at the end of our inspection, the response was long delayed. When the elevator finally arrived, it was loaded with blankets hurriedly brought from a warehouse located on the same island on which the Metropolitan Hospital stands. The Metropolitan Hospital was "approved" by the American College of Surgeons,

USUAL CONDITIONS VARY "ONLY IN DEGREE"

These conditions are not unusual in hospitals. Children admitted for tonsillectomy have been known to leave the hospital with a cross infection of syphilis. The firm which supplied the municipal hospitals of New York City for many years, was successfully prosecuted on several occasions for furnishing to those hospitals milk which had been condemned as unfit for human use. This milk was fed to sick babies. The hospital epidemics among infants, which are publicized from time to time because of an excessive number of deaths, are generally due to such milk causing dysentery or cholera infantum.

When the interns of the City Hospital (New York) complained that roaches floated in their soup and cereals, they were told that they had no reason for complaint, since the patients did not complain about it.

In 1918, Miss Mildred Blackney, a city nurse in Ward CI-E of the Cancer-Neurological Hospital shocked the members of the New York City Board of Estimates by a description of conditions which prevailed in the hospital.

"I had one case of amputation of the breast," Miss Blackney said. "When I came on duty I was told to watch that case. I lifted up her arm and found hundreds of ants crawling over her."

"This should have been brought to the attention of the Commissioner of Hospitals," Councillor Newbold Morris suggested.

"The Commissioner knows about it. I reported it and the night nurse came to me and said, 'Why did you tell on us?'"

"Why can't this be stopped?" asked Deputy Mayor Curran, who represented junketing Mayor LaGuardia.

"You can't stop it because they are coming out of the walls," replied Director Luciel McGorkey of the C.I.O. "That hospital has rats, mice, bedbugs, cockroaches, ants and everything else. This has been brought to the attention of officials repeatedly."

This hospital was "approved" by the American College of Surgeons—lice, ants, rats, mice and everything else. Though the LaGuardia administration has pretended that the City of New York lacks the funds to remedy these wretched conditions, it has found millions to spend on building pretentious Health Centers that serve largely to provide offices for social service agencies and boondoggles. These facilities provided in these wasted and almost empty edifices would do much to relieve the hospital overcrowding. But hospitals do not serve the ends of social service agencies, milk companies, insurance companies and allied organizations that now control health departments. In the meantime the helpless sick are left in wretched misery.

Some idea of the universality of such hospital conditions is given by the preamble of a resolution adopted at a meeting of hospital workers organized in the SMWCA in 1939. It reads:

"Whereas: the twelve and even thirteen-hour shifts prevail in the majority of hospitals; and

"Whereas: hospital employees are frequently required to live in unsanitary fire-trap dwellings; and

"Whereas: the food served hospital employees is usually unpalatable and lacking in nourishment; and

" Whereas: responsibility for the care of 80 to 100 patients is not infrequently placed upon one nurse and one orderly; and

"Whereas: low salaries, long hours, and understating vary in hospitals throughout the country only in degree; and

"Whereas: these conditions do not permit of adequate, safe care for the sick; . .

F.A.C.S. WAR ON PRIVATE HOSPITALS FOR BUSINESS

The commercial motives which underlie the A.C.S. hospital activities are obvious in its attitude toward the generally luxurious private hospitals, which extend their facilities to all doctors and consequently are a menace to the monopoly of surgery which is sought by the A.C.S. This menace was intensified during the depression because the charges of the "charitable," voluntary hospitals were so much higher than those of the private.

To eliminate the competition, the publicity men of the A.C.S. and of its social service allies launched venomous, libelous attacks on the private hospitals, which were freely published in the daily press, though all replies were barred by censorship. It was alleged among other things that all private hospitals endanger the health and lives of the public. The president of the New York County Medical Society, local representative of the A.M.A., in his inaugural address told the public that the majority of operations performed in the private hospitals are needless and illegal. The truth of the matter is that the greater number of such operations is performed with impunity in the "closed hospitals" where the friendly consultations and the cloak of secrecy protect their perpetrators.

The motive for these attacks was clearly announced by the United Hospital Fund, through Assistant Director Dr. Eleanor Conover, as an attempt to remedy the loss of business by the voluntary hospitals and their doctors. The falseness of the charges against the private hospitals was proved conclusively when the A.C.S. was forced to place numerous private hospitals on the "approved" list because of the slump in business of its Fellows who refused to treat patients in the superior and cheaper private hospitals. It is a tribute to the great power of the organization that none of the libeled private hospitals dared to sue for damages done to their businesses. Subsequently when business again slumped, many of the private hospitals were again removed from the "approved" list.

The fight on the private hospitals was continued for a while in a treacherous and underhanded fashion. Social service organizations, such as the Federation for the Support of Jewish Philanthropic Societies of New York City, sought to intimidate and restrain the staff members of hospitals which it supports from patronizing private hospitals by demanding a detailed report of every case which they there treated. The pretended reason was fear that the doctors might "split fees" in the private hospitals, and the Federation-supported hospitals might lose thereby their A.C.S. approval. The falseness of this pretense is made obvious by the fact that physicians do not remain on the staffs of many of those hospitals long, if they fail to make contributions deemed adequate.

F.A.C.S. WAR ON MUNICIPAL HOSPITALS FOR BUSINESS

Another demonstration of the commercialism of the A.C.S. and its social service allies was the war waged in 1932 by the voluntary "closed" hospitals on the municipal hospitals of New York City for Workmen's Compensation Insurance business. A ruling of the State's Attorney General had permitted the insurance companies to hospitalize injured employees as charity cases in municipal hospitals. This cheap business, at which the surgical merchants sniffed in times of prosperity, depression converted into an enviable morsel.

Under these circumstances the F.A.C.S. and the voluntary hospitals, with their social service allies, awakened to the discovery that injured employees were not getting adequate care and were being swindled out of their compensation; also that hospitals were not being adequately paid for the care of the cases. A Committee on Workmen's Compensation Insurance was appointed to investigate the situation by Governor Roosevelt. Mr. Howard E. Cullman, president of the Beekman Street Hospital, a director of the Flower Hospital, director of the Port Authority of New York, and champion of the social service interests, was appointed chairman of the committee.

The American College of Surgeons with its social service allies, issued publicity releases which lamented at great length the abuse of the injured worker; and advocated its "Approved Hospitals" and its own biand of surgeon as a remedy. It failed to state that the municipal hospitals in which these frauds and malpractices were being perpetrated were also "Approved Hospitals"; and that the perpetrators were also F.A.C.S.

The active interest of Mr. Cullman, and of his committee and its allies, in the abuses of the Workmen's Compensation Act ceased when the law and its administration had been changed to bar compensation cases from municipal hospitals, and turned the business over to the voluntary hospitals at a higher per diem rate. In spite of the fact that the injured workers now are being treated under the amended law even more mercilessly than formerly, the F.A.C.S. and their allies are no more interested in the abuses of the law. The American College of Surgeons and the insurance companies are once again allies and "approved" voluntary hospitals are perpetrating the same abuses which were condemned in the Crusade; but now influential F.A.C.S. are profiting from them.

HOSPITAL WARS

Competition for medical business is widespread between the "closed" hospitals themselves, as well as between cliques within the hospitals and between individual members of the hospital staffs. Commercial interests of the profession stew continuously in the corrupt mess of hospital politics, a game of dog eat dog." It matters little to the principals that innocent third parties, the patients, lose their lives in the fray.

On rare occasions the continuous guerilla warfare of the "closed" hospital brigands, that normally is sheltered by the secrecy of the system, flares up into bitter and open battle and emerges into the courts. The press then brings it to public attention. Thus the Fifth Avenue Hospital of New York City, which was built and endowed as a homeopathic hospital, has staged a public battle for the control of the business attracted by that well-built and attractively located institution. The battle has run through the courts for a decade or more.

The homeopaths made the mistake of extending the courtesy of the use of their hospital to allopathic confreres. The latter soon banded together, and with little regard for principle, ethics or decency, proceeded to oust their hosts from the hospital. When Frank N. Hoffstott, with other contributors to the institution, sued the clique to prevent them from eliminating the homeopaths, Supreme Court Justice Peter Schmuck gave them little comfort. They did not regain control of the hospital and its business until depression threatened its bankruptcy. They were enabled to recapture it by virtual foreclosure, thanks to a windfall bequest of millions from the Wendel estate to the homeopathic Flower Hospital Medical School.

Then another allopathic clique, the Johns Hopkins Medical School crowd, gained control of the business of both the hospital and the medical school through the Rockefeller Foundation. A young henchman of the Johns Hopkins group, Dr. Ferdinand Lee, was made the Dean of the Flower Hospital Medical School. He promptly appointed fellow alumni and chums to the heads of the various staffs and they proceeded to demand the wholesale resignation of the veteran staffs.

Similar wars between factions closed the Italian Hospital and rocked the Harlem Hospital in New York City at about the same time.

HOW A HOSPITAL WINS A.C.S. "APPROVAL"

How the A.C.S. serves its ringleaders and their allies is illustrated by the affair of the "approval" of the Beth David Hospital of New Yore City, the conduct of whose business already has been related. In spite of its widely known business methods and in spite of the dilapidation and squalor of its buildings, the hospital was "approved" by the American College of Surgeons.

After collecting unknown amounts of money for many years, the Beth David Hospital moved, in 1936, into a large and modern building that was close to the affluent residential district. This meant competition to the established hospitals and surgeons in times that were trying.

Within a short time after its removal to the new building which was as suited for hospital purposes as the old had been unsuited, the Beth David Hospital found itself in difficulties with the American College of Surgeons. It found its name omitted from the list of "approved" hospitals that is widely published by the A.C.S. in local newspapers. Due to the intense adverse publicity that the College can bring to bear on any institution that it desires, and due to the fear of the F.A.C.S. and those who aspired to that label, the business of the hospital rapidly fell off and it faced another of its series of financial crises.

The management of the hospital entered into negotiations to repair the severe commercial damage which the A.C.S. had inflicted on it. The A.C.S. demanded that the hospital's surgeons be ousted and replaced by other F.A.C.S. In January 1939, the chief of the surgical staff, who was one of the founders of the hospital, was ousted and his place given to one of the influential henchmen of the American College of Surgeons, Dr. Frederick W. Bancroft F.A.C.S. He was given the rank of surgical director, which means boss of the surgical business of the institution, and he brought with him a clique of friends who displaced other staff members. At the very next meeting of the A.C.S. in October 1939, the Beth David Hospital was "approved" and included in the list published in the New York City newspapers.

Among the surgeons whose ousting was required by the A.C.S. were the more reputable members of the hospital staff. The excuse offered was that they were honest enough to pay other physicians openly for services rendered them—"fee-splitting" the A.C.S. calls it. The surgeons with whom the A.C.S. replaced them do not pay directly or openly. The influence of the F.A.C.S. is powerful enough to compel the hospital and its staff to turn over its surgical business to them.

A number of phases of the situation emphasized its glaring character. The hospital was founded and supported by a Jewish sectarian group. The surgeons whom they accepted as the price of A.C.S. "approval" were non-Jews.

Among the surgeons originally on the hospital staff who were acceptable to the A.C.S. were a number of men who are notorious for their Workmen's Compensation insurance activities. One of them has been brought up repeatedly before state officials on charges of solicitation of business, fraud perpetrated upon patients, perjury, and others; and has been threatened with the loss of his license to practice. Though held in disdain, he is employed by Workmen's Compensation insurance companies to do a lot of dirty-work.

Under the new regime, many casualties of industry, Workmen's Compensation cases, have been referred into the Beth David Hospital. Under the amended Workmen's Compensation Law, insurance companies are barred from influencing the choice of physician by the injured; but this does not mean that they can not arrange the appointment of surgeons in their employ to the staffs of hospitals to which the injured are sent.

An interesting phase of the background of this incident is the fact that Dr. Frederick W. Bancroft F.A.C.S. played a similar role, more than a decade prior in the capture of the Fifth Avenue Hospital from the homeopaths. He was ousted from his office on the premises of the hospital and from the position of surgical director and boss when the homeopaths re-seized the pirated hospital with the aid of the Wendel bequest.

F.A.C.S. GANG WAGE FIGHT FOR SYDENHAM HOSPITAL

One of the most malodorous hospital scandals that has come out into the open in recent years, that illustrates the bitterness of commercial rivalry which the lofty pretensions of the American College of Surgeons mask, is the affair of the Sydenham Hospital of New York City. The hospital had been founded by some of the lesser rank medical politicians in conjunction with a group of business men. The doctors on the staff paid for their hospital jobs in proportion to their ranks by contributions and by the purchase of dinner and benefit tickets and their sale to friends, and by soliciting donations and bequests. In return they split among themselves the business lured by the hospital, each man fighting for himself under rules which barred no hold. Though some of the hospital surgeons were F.A.C.S. and the hospital was "approved," they were either sufficiently honest to pay for services rendered them by colleagues, i.e. to "split fees," or were compelled to do so by competition.

When depression hit the medical profession with full force, medical politicians and gangs reached out to hijack and grab the business of less powerful rivals and their hospitals. It became the custom of the more powerful medical and hospital groups to seize control of competing institutions, oust the staff and to turn over the business to their lesser fry. These hospital raids were generally carried out under the banner of the American College of Surgeons on the pretense of "abolishing fee-splitting," and one of the weapons generally used was the threat of withdrawing "approval."

In line with this policy, the entrenched gang reached out and grabbed control of Sydenham Hospital and its business in 1938. Through the American College of Surgeons they threatened to withdraw "approval" of the hospital and to ruin its business unless they were given control of the hospital. They forced over half of the Sydenham's surgeons out on the charge of "fee-splitting" and replaced them with their "purse-splitting" Fellows and their henchmen. The victorious medical clique counted in its ranks such "leaders" as Dr. Alfred M. Heilman, influential politician and president elect of the New York County Medical Society, who became the chairman of the hospital's executive committee; and Dr. David J. Kaliski, past president of the same Society and Director of the Workmen's Compensation Committee of the New York State Medical Society. Workmen's Compensation was one of the baits.

Friends of the ousted physicians withdrew their support from the hospital and it soon was run to the verge of bankruptcy. To regain the old supporters of the hospital, Gustavus A. Rogers, one of the original board of the hospital was made president of the lay board of directors. He undertook to put a stop to the high-handed procedure of the medical gang in packing the hospital with their henchmen and riding rough-shod over other physicians who had built up the hospital's business.

Illustrative of the "high moral, ethical and cultural level" which characterize all the dealings of the American College of Surgeons and of organized medicine was the widely publicized brawl at the mass meeting of the hospital's medical staff reported by the New York World-Telegram of January 10, 1940, as follows:

". . . the case of the physician charged . . . with 'brutally attacking' an other member of the hospital staff . . . breaking two of his ribs. Apparently this was an encounter between Dr. Heilman and Dr. Julius Jarcho, an attending obstetrician, at the hospital. There are various versions of what happened, one being that Dr. Heilman merely shouldered Dr. Jarcho aside, and another that Dr. Heilman used his fists with vigor. "

Dr. Jarcho was appointed chairman of the executive committee in Dr. Hellman's place, even though he did take the count. But the fight was "fixed" by the American College of Surgeons. Dr. Ralph Colp, the local head of the A.C.S. is reported to have threatened Dr. Jarcho with the loss of his F.A.C.S. if he did not surrender his chairmanship and join the insurgents. As this book goes to press, this hospital gang war, like many others, is still under way.

MONOPOLISTIC CONTROL FACILITATED BY HOSPITAL SURVEY

The monopolistic control of hospital facilities by the A.C.S. and its social service allies has been made complete and absolute in New York by the Hospital Survey. The Committee is completely dominated by organized social service and it allies, and in spite of its private character, has official standing. Its decisions determine whether a hospital shall receive public and charitable support; whether it shall be permitted to appeal to the public for funds; or whether it is to shut its doors or to continue to exist. As a consequence of its activities it can be expected that in the future the diversion of hospital funds will be channeled into the coffers of certain groups represented well on the Committee; and that the monopoly of hospital facilities and their use will be concentrated in the hands of their allies. Judging by past performance, profits rather than public interest will determine the future policies in an ever greater degree. The Rockefellers are represented on the Committee by Mrs. Winthrop W. Aldrich and David McAlpine Pyle.

WHAT THE A.C.S. COSTS THE PUBLIC

In still other manners than setting up a monopoly of surgery and upholding needless consultations, does the American College of Surgeons increase the cost of surgical care.

It has added to the mounting cost of hospitalization by requiring many wasteful items such as the keeping of needlessly elaborate records. It requires a multiplicity of "staff conferences" that tax the time of the profession and yield scant benefit other than the publicity derived from advertisement and from announcements, bearing the names of physicians permitted to present cases, that are mailed to the profession.

The gravest cost of the American College of Surgeons is the cost in human life. It is related elsewhere how organized medicine used all the machinery at its disposal to prevent the adoption of methods of treating ear and mastoid infections that would eliminate the need for mastoid surgery and to discredit a method of treatment of glaucoma that would wipe out any excuse for the blinding surgical treatment.

Operative scores, or statistics, required of surgeons and hospitals by the A.C.S. contribute heavily to its toll of lives. Though these statistics be innocuous in themselves, the consequences of the efforts of individual surgeons to hold down their scores results in numerous deaths.

When there is admitted to an "accepted" hospital a grave surgical case involving high operative risk and requiring the most skilled attention, there is a grand rush of surgeons, wishing to uphold their scores, to avoid the case unless it be lucrative. Three methods of escape are usual: either the case is turned over to a member of the intern staff to operate; or is left to die without operation; or is transferred to another hospital.

In either case the life of the patient is jeopardized by denial of the most competent attention available when it is most needed. Transfer is the method of choice in case of patients who appear to be dying after operation. So high is the rate of transfer in some institutions that it is hard to understand why their surgeons' scores should show any mortality; for the cases which die after transfer are not reckoned on the score of the transferring institution. The callous brutality involved in this traffic of the dying, beggars description and cries for a halt.

Such are the contributions of the American College of Surgeons and its allies—social service organizations and hospital associations—to "protection of the health and lives of the public."