MEDICAL RELIEF 
TO 
THE POOR. 
SEPTEMBER, 187 7 . 
BOSTON: 
PRESS OE ROCKWELL & CHURCHILL, 
No. 39 Arch Street. 
1877. MEDICAL BELIEF TO THE POOHi 
The Boston Dispensary was founded in 1796, or eighty- 
one years ago. The annual subscription for membership 
was fixed at five dollars, thereby enabling the subscriber to 
introduce two patients at the same time for treatment. 
Applicants were to belong to the class called the " neces- 
sitous poor,” and to that class alone. The system sufficed 
for many years, while the population was small, and the de- 
pendent poor comparatively few and well-known. In 1856, 
or sixty years later, when the population had increased many 
fold, and the ranks of the poor had been largely reinforced 
by foreign immigration, it was found that the benefits con- 
ferred by the institution bore no comparison to the increased 
expense. 
The plan of admission by subscribers’ tickets was given 
up ; a Central Office was established, where physicians could 
be found during several hours of the day in addition to the 
services of the district physicians, who visited the sink 
at their own homes when they were too ill to attend at the 
Central Office. The Board of Managers have long known 
that large numbers who could not be included in the ranks 
of the "necessitous poor” have resorted to the Central Office, 
and have held great doubts as to the best remedy for the 
evil. The statistics of the last two years are so startling 
that there seems to be ai\ urgent necessity for putting an end 
to the abuse of this ancient charity, in justice to the really 
poor patients as well as to the interests of the physicians 
who are thus deprived of an important source of income. 
During the year ending October 1, 1876, the number of 4 
patients treated by the Dispensary was 40,591 ; and daring 
three-quarters of the year ending July 1, 1877, 35,535. 
The Massachusetts General Hospital reports the number of 
out-patipnts for the last year to be 17,292. The City Hos- 
pital reports for the same year 9,413, —making in all 73,296 
for the year. 
Adding to this list the numbers treated by other charitable 
associations, and the gratuitous aid afforded by physicians, 
who are never backward in acts of charity, it is safe to say 
that 100,000 persons, or more than one-fourth of the popu- 
lation of Boston, have received charitable aid in the form of 
medical attendance during the year. It is not credible that 
so large a number can be enrolled with the class of " neces- 
sitous poor.” Although the abuses under the present sys- 
tem have been known and lamented for several years past, 
little has been done in this country by way of correction, 
and we are obliged to look to England for progress in this 
direction. 
A friend and subscriber to the Dispensary for the last 
twenty-two years has collected a number of English docu- 
ments on the subject of medical aid for the poor, and has 
caused various extracts to be printed for the use of the 
Board of Managers of the Boston Dispensary, thinking that 
they might throw more light on the subject treated than any 
dissertation of bis own. The extracts given will afford some 
information in regard to "Provident Dispensaries,” which 
have grown in favor in Great Britain, from the fact that the 
large free dispensaries have been found to be nurseries 
of pauperism, and sources of evil rather than good. 
Boston, September 13, 1877. 5 
\From a paper entitled “ Metropolitan Medical Relief.”] 
The radial lines of the Metropolitan Police District, 
drawn from twelve to fifteen miles round Charing Cross, 
include a population of upwards of four millions. Of these, 
upwards of one million, or one fourth, receive gratuitous 
medical treatment, and in the inner circle of Loudon, where 
free dispensaries and out-patient departments of hospitals 
abound, the proportion so assisted is still larger. It may be 
said, without exaggeration, that in the interior of London, 
including its great eastern and southern quarters, nearly all 
below the middle class, and some even of them, are provided 
with medical attendance and medicines by private charity, 
with some assistance from the poor law. This is the central 
fact, from which many unfortunate results naturally flow. 
The main object of securing proper medical treatment 
for the working-classes, who form the majority of our 
people, has not been, and never can be, attained in this way. 
A vast population is encouraged to throw itself for medical 
aid on a few central points. Hence overcrowded wait- 
ing-rooms ; the exhaustion of the strength of the patients by 
delay; mutual infection among large numbers of persons 
brought into close contact in a susceptible state ; the vitia- 
tion of the air of the hospitals themselves ; and, more than 
all, the mockery of medical relief, owing to the impos- 
sibility of giving sufficient time to each case. This last 
result is so widely and painfully known, that I forbear 
to dwell upon it. The main characteristic of this system of 
medical relief is that our population is dealt with gre- 
gariously, instead of being broken into manageable groups, 
or, best of all, treated separately at their own homes. 
The next result is a great misdirection and waste of 
charitable funds. Dr. Meadows, and five other medical men, 
experienced in the work of London hospitals, recorded their 
opinion, in 1870, that "the probable income of half the 
number of out-patients may be estimated at from £1 to 6 
£1 10s. per week, and of one-fourth at more than this.” In 
1874 a thorough investigation was made into the social 
position of the out-patients of the Royal Free Hospital, and 
they were reported to he divisible into two sections : First, 
those who might reasonably be expected to pay something for 
their medical relief; and secondly, those who ought to be 
referred to the poor law. This abuse of medical charity is 
largely promoted by the practice of issuing subscribers’ 
letters, which are too often distributed without proper in- 
quiry, or given avowedly as a matter of personal favor ; and 
many employers contribute to hospitals with the object of 
providing medical assistance for their servants and workmen 
at a cheap rate, so that men with two or three pounds a 
week expect to be furnished with " letters ” to the neigh- 
boring institutions for themselves and their families, and are 
thus relieved from the necessity of joining benefit societies 
and provident dispensaries. This is the true explanation of 
the lamentable appeals constantly made to save our medical 
institutions from insolvency. No funds that coidd be sub- 
scribed would overtake the emergency, because the gra- 
tuitous medical treatment of the entire working-class, and of 
a considerable margin of the lower middle-class, is a greater 
burden than private charity can bear; and the pressure is 
continually on the increase, as additional numbers become 
habituated to dependence. 
To hundreds of thousands this system of medical relief is 
the entrance-gate to those habits of dependence for which 
our London population is unhappily distinguished beyond 
the rest of their countrymen. Every one stands in need of 
medical assistance at some time or other, while in family 
life it is a matter of frequent recurrence, so that, by the 
general application of the eleemosynary principle to our 
London hospitals and dispensaries, they have been converted 
into schools of pauperism. Our people are educated by 
them to improvident and medicant habits, being entirely re- 
lieved, as regards this requirement of civilized life, from all 7 
necessity for forethought and thrift. Subscribers’ letters 
are specially conducive to fraudulent mendicancy. Women 
collect them by begging from house to house, under pre- 
tence of wanting them for their own use; they beg at other 
houses on the evidence of the distress which the " letters ” 
are supposed to afford; and, after all, they sell them, for 
they have a marketable value, which ought to go in aid of 
the expenses of the institutions. All the arts of deception 
flourish in connection with misapplied charity. Mr. W. H. 
Smith stated that 20 per cent, of cases selected by him for 
investigation, from among the out-patients at a large hos- 
pital, "had given false addresses, so that it was impossible 
to trace them.” 
The last evil result of this system to which I shall allude 
is that it deprives the medical profession of its just and 
necessary remuneration. Medical men are expected to do, 
at hospitals and dispensaries, an amount of unpaid work 
unknown in any other profession, although the majority of 
the persons gratuitously treated are perfectly able to pay a 
moderate charge. Both ways, therefore, medical practi- 
tioners suffer. A totally disproportionate share of the bur- 
den of public charity is thrown upon professional persons 
dependent for their subsistence upon the exercise of the 
skill derived from an expensive education; and, by the 
same arrangement, they are deprived of a large portion of 
the practice which wmuld otherwise fall to them. The de- 
pression of this important profession reacts to the detriment 
of the public in many ways. Unpaid labor, or labor which 
is all but unpaid, is sure, in the long run, to be badly done. 
Compare the slipshod work of the out-patient departments, 
at the rate of a minute a patient, with the careful manner in 
which medical men see their patients at home, at the rate 
of five or six an hour at the outside. In poor and densely 
populated districts, where medical aid is most needed, the 
weakness of the eleemosynary system has been made appar- 
ent by the absence of an adequate supply of well-qualified 8 
practitioners, and by a growing disinclination to accept ap- 
pointments in free dispensaries. No expenditure Is grudged 
to give our military officers a fair day’s pay for a fair day’s 
work; and the national interests are certainly not less con- 
cerned in maintaining the professors of the healing art in 
proper efficiency. 
But this part of the subject has deeper roots than I have 
now time to trace; and those who wish to pursue it further 
would do well to read a paper from the " Medico-Chirurgical 
Review,” entitled "The Limits of Unpaid Service.” It will 
there be seen that this is not merely a question of profes- 
sional remuneration, but also of social position, and of the 
spirit with which the exigencies of a life of duty among the 
suffering poor may be expected to be faced. 
The first combined effort to remedy this state of things 
dates from March, 1870. At a meeting presided over by 
the late Sir William Fergusson, at which one hundred and 
fifty-six members of the medical profession were present, 
the following resolutions were passed : 
That this meeting is of opinion that there exists a great and increas- 
ing abuse of out-door relief at the various hospitals and dispensaries of 
the metropolis which urgently requires a remedy; and 
That, in the opinion of this meeting, the evils inseparable from the 
system of gratuitous medical relief administered at the out-door depart- 
ment of hospitals and in free dispensaries can be in great measure met 
by the establishment, on a large scale, of provident dispensaries, not 
only in the metropolis, but throughout the kingdom, and by improved 
administration of poor-law medical relief. 
A large committee was then appointed, which apportioned 
the subject among four strong sub-committees on " General 
Hospitals,” " Special Hospitals,” "Dispensaries,” and "Poor- 
Law Medical Relief,” of which Dr. Meadows, Dr. J. E. Pol- 
lock, Dr. Stewart, and Mr. Spencer Wells, were respect- 
ively chairmen. These sub-committees thoroughly sifted 
their several branches of the subject, and made reports, to 
which I shall frequently have occasion to allude. 
The next move was made by a society, which, having for 9 
its object the improvement of the permanent condition of 
the poor, soon came to the conclusion that one of the most 
powerful of the causes by which their condition had been 
depressed was this system of gratuitous indiscriminate med- 
ical relief, and that every other arrangement for their benefit 
must fail in producing its full effect while this evil remained 
unremedied. In March, 1871, the Council of the Charity 
(Organization Society appointed a committee to act as their 
advisers in all that relates to medical relief. In the follow- 
ing October this committee made a report, pointing to " a 
large development of the provident principle ” as the appro- 
priate remedy for the abuses of the medical charities, and 
submitting model rules for the management of provident 
dispensaries, based upon the experience of those institutions ; 
and in December a conference was hold, presided over by 
Mr. W. H. Smith, and attended by Mr. Stansfeld, Presi- 
dent of the Local Government Board, Lord Josceline Percy, 
Dr. Acland, Dr. Guy, Mr, T. Holmes, Dr. Meadows, Dr. 
Fairlie Clarke, the Pev. Harry Jones, Mr. Gurney Hoare, 
and many others, at which the resolutions come to in the 
preceding year by the professional committee were discussed 
in the enlarged point of view of the Charity Organization 
Society, and reaffirmed. 
In April, 1875, the following memorial was presented to 
the President and Committee of the British Medical Associa- 
tion, with the names of 303 members of the profession, of 
whom 195 were from London, and 108 from the country. 
Of the metropolitan practitioners, 92 were connected with 
hospitals, and 103 were general practitioners, many of whom 
held dispensary appointments. Among the former were Sir 
William Fergusson, Sir William Jenner, Sir William Gull, 
Sir Rutherford Alcock, Mr. Prescott Hewett, Mr. Erichsen, 
and other leading men in the profession : 
To the President and Committee of Council of the British Medical 
Association: We, the undersigned, members of the British Medical 
Association, and others, beg most respectfully to request the Committee 10 
of Council to take into its consideration the relation of the medical pro- 
fession to the hospitals and free dispensaries throughout the kingdom. 
Your memorialists are convinced that the manner in which these insti- 
tutions (with some few exceptions) are at present conducted inflict a 
serious injury upon many most deserving members of our profession ; 
while the indiscriminate (or almost indiscriminate) bestowal of 
gratuitous medical relief upon all applicants lowers the whole scale 
of our professional remuneration, it is far from being a real boon to the 
working-classes themselves, and cannot fail, in the long run, to have a 
prejudicial influence upon the nation at large. The question to which 
we venture to draw the attention of the Committee of Council has been 
much discussed of late years, both in the medical press and in the lay 
periodicals. It is not necessary, therefore, that we should enter into 
any details respecting it. We may, however, mention that there are 
three facts which have a very important bearing upon it, and which 
make the present time particularly opportune for entertaining it. These 
are : 1. The improvement which is now rapidly taking place in the 
social and political condition of the industrial classes. 2. The amend- 
ments which have lately been made in the administration of parochial 
medical relief; and, 3. The increase, within the last few years, in the 
length and expense of medical education. These facts are admitted by 
all; and their concurrence has led, we believe, to a very general opinion 
among those who are conversant with the working of the free dispen- 
saries and hospitals that some changes are necessary, in order to bring 
these institutions into harmony with the altered conditions of the present 
day. As it is desirable that any changes which may be necessary 
should be duly weighed by a body which fairly represents the medical 
profession, and should be recommended by high authority, so as to carry 
along with them the assent of the lay governors of the “ medical chari- 
ties,” your memorialists pray you to take this important subject into 
your consideration. 
A decided expression of opinion from a body so largely 
representing the profession as the British Medical Association 
would have great influence ; but the matter has got beyond 
the stage of inquiry and report, and, as the ablest medical 
men have least leisure, and lay managers are sensitive about 
interference with their rights, I cannot advise any proceed- 
ings which would provoke the extreme advocates on both 
sides to further controversy and delay. The governing 
bodies of the different institutions, lay and professional, 11 
have been sufficiently informed by the discussion which has 
been going on all round the field since 1870, and I had rather 
trust to the unimpeded action of their sense of responsibility 
than to any external official pressure. The subscribers to 
the charities, who hold the purse-strings, have also, to some 
extent, become sensible of their responsibility. We are now 
in the seventh year since Sir William Fergusson’s committee, 
and the public interest in the question has never flagged 
dining this long interval. Public opinion is far in advance 
of the point from which we commenced, and solid material 
progress has been made, although it has been of a varied and 
desultory kind. Evidently the time has arrived for review- 
ing our position, and making a fresh departure upon a well- 
understood plan. 
The out-patient department of St. George’s Hospital has 
been placed upon a fooling which allows of three provident 
dispensaries being successfully carried on in its immediate 
nighborhood, besides a fourth which is in course of formation 
at Brompton. In the words of their report for 1875, "In 
1868 the whole of the out-patient department was made free, 
and this has enabled the executive to exercise much more 
control over the admission of applicants than when they 
brought governor’s letters, when it was difficult, under such 
circumstances, to refuse any.” On each of the four ordinary 
out-patient days, forty new cases twenty medical and 
twenty surgical are admitted by the Resident Medical 
Officer, after which their names, addresses, occupations, and 
any other information that may be required as to their social 
position, are given; and the secretary freely avails himself 
of the assistance of the Charity Organization Society, should 
there be any doubt as to their being suitable objects of 
charity. The cases admitted are, therefore, limited to the 
number which can be effectually dealt with ; and they are 
selected with due reference both to the nature of the pro- 
fessional aid intended to be given at hospitals, and to the 12 
means of the applicants, care being taken that no really 
urgent case is rejected. Stmlefits assist at the out-patient 
work, which is considered a valuable part of the hospital 
teaching. The number of out-patients in 1876 was as fol- 
lows 
Ordinary out-patients . . . 7,398 
Eye patients . . . . . 790 
Aural ...... 294 
Orthopaedic ..... 346 
Erom in-patients . . . . 171 
Dental ...... 1,448 
Casualties ..... 4,216 
14,663 
The two last are exempted from the rule which requires 
information to be given as to name, occupation, etc. 
Arrangements have been made on the same principle at 
King’s College Hospital, by the appointment of a Registrar 
to classify the out-patients and refer doubtful cases to the 
Charity Organization Society, and although the number ad- 
mitted has not been subjected to any fixed limit, it has 
diminished, under the influence of this revision, from 33,866 
cases in 1873, to 21,347 in 1876. In the words of the last 
report, " the whole of these alterations have been carried into 
effect, to the manifest increase of the comfort of the patients, 
and the good order of the department.” At the general 
hospitals in the East and South of London, a different 
principle is apparent from the numbers admitted, which 
were, according to the last published reports: 
St. Bartholomew’s Hospital . . 137,318 
London . . . . . . 40,717 
Metropolitan Free . . . . 39,968 
Guy’s ...... 75,804 
St. Thomas’ ..... 61,824 
355,631 13 
the in-patients at the same hospitals in the same year (1875) 
having been only 21,370. No provident dispensary is 
possible in the districts under the influence of these in- 
stitutions. 
The Special Hospitals have, to a great extent, acted upon 
the recommendation of Sir Win. Fergusson’s sub-committee, 
" that all patients who can afford it should contribute to the 
support of the hospital. The sub-committee think that if 
this plan were carried out, advantage would accrue to the 
general practitioners, for the attendance of out-patients at 
hospitals being lessened, such patients would find their way 
to the various medical men in their neighborhood.” While 
these hospitals are entirely free to the necessitous poor, a 
large proportion of them receive, in some form or other, 
payments from patients who, although they cannot afford the 
usual professional fees, are above the necessity of purely 
gratuitous aid. In this way only could such a large amount 
of truly charitable work have been done, both for those who 
could, and those who could not, pay something, anti that 
without injury to the independence and self-respect of the 
patients. The District Committees of the Charity Organiza- 
tion Society give all the assistance in their power to Special, 
as well as to General, Hospitals ; but, that difficulties may 
not arise from the investigation being carried further than is 
necessary in hospital cases, the inquiries are limited to— Ist, 
The amount of the applicant’s income ; 2d, The number and 
ages of the family dependent on the applicant; and, 3d, 
Whether the applicant is in receipt of poor-law relief. 
The pressure upon the out-patient department of the Or- 
mond Street Children’s Hospital, and the certainty that a 
large proportion of the applicants were not suitable objects 
of gratuitous relief, induced the managing committee to ar- 
range with our society that they should not be admitted to a 
second visit until their letters had been stamped by the or- 
ganization committee of their district. Upon this it soon 14 
became apparent that more than half belonged to the large 
intermediate class between those who can pay the usual pro- 
fessional fees and the necessitous poor; and that, although 
willing to make a moderate payment according to their means, 
they did not like to be treated as objects of charity, or to 
incur the inconvenience and waste of time caused by inquiries 
into their circumstances. The scheme finally proposed by 
our medical committee is, that those who are willing to make 
a small payment should be admitted at once, but that those 
who claim gratuitous relief should have their means investi- 
gated before they are seen a second time. In other words, 
that an alternative should be offered—payment or inquiry. 
So numerous are the claims upon the charity of the public 
in the present day, that institutions which have made ar- 
rangements for giving only to those who are really in need 
certainly ought to be preferred to those which give without 
discrimination. 
We now come to Provident Dispensaries, the increase of 
which, in due proportion to the population, is the key to the 
solution of the complex problem before us. The first con- 
clusion arrived at by Sir William Fergusson’s sub-committee 
was : > 
That a very large propoi'tion of the out-patients of general hospitals 
(variously estimated at from three-fifths to nine-tenths of the whole) con- 
sists of trivial cases which do not require any special skill, and might be 
properly left in the hands of ordinary medical men. An inordinate num- 
ber of trivial cases wastes the time of the consultee, wearies the attention 
of the students, and fosters a habit of hasty diagnosis and careless obser- 
vation, which tend to erroneous and ineffective treatment. In fact, 
out-patient work, as generally conducted, neither conduces to the sound 
advancement of professional knowledge, nor to the advantage either of 
the students or the public. And, bearing in mind that the staff consists 
exclusively of consultees, and that clinical teaching is one of the most 
important advantages derived by the public and the profession from the 
institution of public hospitals, the sub-committee are of opinion that 
some special claim ought to be made out for perfectly gratuitous hos- 
pital advice, such as sudden emergency, surgical requirements, long- 15 
continued ineffective treatment, peculiar, obscure, and complicated 
disease, unforeseen and unavoidable distress, or some other special 
cause, making it desirable that the attention of a consultee should be 
given to the case. ... As the hospital staff consists of consultees, 
not general practitioners, it is only consistent that their services should 
be asked for chiefly in cases of peculiar difficulty, prolonged anxiety, 
deep professional interest, etc., and it is altogether unreasonable to call 
upon them to treat case after case for many hours together, without, it 
may be, the occurrence of any single point of interest. . . . The 
sub-committee therefore believe that the foundation of a series of prov- 
ident dispensaries is a necessary condition of any improvement in the 
out-patient department of our public hospitals. The law has, in their 
opinion, amply provided for the careless and improvident, and the funds 
contributed by the benevolent should be given in preference to the 
assistance of those who ai-e inclined to help themselves. 
The real question, therefore, is, how to provide for the 
ordinary medical treatment of the lower middle and working- 
class. The hospitals will always be open to serious and dif- 
ficult cases, but these bear a small proportion to the every- 
day class of trivial ailments (including those of women and 
children) which must be properly attended to if our popula- 
tion is to be maintained at a high average of health. The 
first condition of success is that the payments should be 
suited to the circumstances of the patients. The slender 
resources of a working-man are soon broken down by " doc- 
tors’ bills,” but there are few who cannot afford a small con- 
tinuous payment made from month to month on the principle 
of mutual assurance. For this each family obtains, not as 
an act of charity, but by right, medical attendance and 
medicines at their district dispensary, or, if need be, at their 
own home; and they also have the privilege of selecting 
their own medical attendant from among the officers of the 
dispensary. Not the least advantage of this system is that 
the homes of the people are brought by it into just promi- 
nence. Much has been said of late years about the salutary 
influence of a trained nurse upon a working-class menage. 
The practised eye of a well-instructed medical officer from 16 
the district provident dispensary, in the numerous cases 
better treated at home than in any instilution, would not be 
less efficacious, and would much promote the object we all 
have at heart, of providing improved dwellings for the work- 
ing-class. The advantage to medical men is that there are 
no bad debts, and no small bills to collect, all the payments 
being made in advance, not to the doctor directly, but to the 
secretary ; and that all the patients who are well enough are 
seen at the dispensary where the medicines are provided. 
If the mass of our people are to obtain willing service from 
highly educated men, the conditions must be adjusted to the 
feelings and habits of the practitioners, as well as to those of 
the patients. 
Provident dispensaries are impossible in the interior of 
London in the face of unlimited gratuitous relief at the out- 
patient departments of hospitals and at free dispensaries; 
but it will be seen, from the statement prepared by Dr. Ford 
Anderson, that they have made considerable progress in the 
suburbs, where such competition is felt in a minor degree. 
Of the twenty-seven provident dispensaries now existing 
within the Metropolitan Police District, fifteen have been 
established, or converted from being free dispensaries, since 
Sir William Fergusson’s committee. 
It is agreed on all hands that the ordinary medical treat- 
ment of the destitute should be left to the poor-law author- 
ities. This has of late years been greatly improved in the 
Metropolitan District. In-door medical relief is now based 
upon a system of separate infirmaries, which are really well- 
appointed hospitals, under suitable regulations, having each 
its staff of infirmary officers and trained nurses. When the 
bread-winner, or any member of his family, becomes dis- 
abled by sickness, the quickest way of being restored to 
health and the power of self-support is to go into the infirm- 
ary for the necessary time. Out-door medical relief, although 
curtailed of some of its abuses, is still given on the same 17 
liberal terms as before, including not only medical advice 
and medicine, but also a liberal diet for the support or res- 
toration of the health of the patient; and it has been 
reinforced by the establishment of fifty-seven poor-law dis- 
pensaries, at which patients and medical officers meet to 
give and receive the benefits provided. This action of the 
poor-law authorities has greatly facilitated the reform of the 
entire system of medical relief; for, as the upper and middle 
classes take care of themselves, while the lowest class is now 
satisfactorily cared for by the poor-law, the question has been 
narrowed to the working-class, who can all contribute some- 
thing towards a common purse for their medical treatment. 
All who desired the reform of this vast system of medical 
relief looked forward with hope to the Hospital Sunday 
Council. The funds already available for medical relief 
were more than sufficient if they were properly applied and 
properly reinforced by payments from patients well able to 
pay; and in this central representative body, armed with 
the power of the purse, an authority was recognized capable 
of restoring the financial equilibrium by suitable adminis- 
trative arrangements. These hopes have not been realized. 
The grants made by the Council are based upon the average 
of each institution for the last three years after 
making-certain deductions, with this important reserve, that 
the merits and needs of each institution are to be fully in- 
quired into, and the award is to be determined according to 
the judgment of the Distribution Committee upon them; 
but this great influence has not been used to induce the 
institutions to act in concert upon a well-arranged plan, 
without which there can be no general improvement in the 
system of medical relief. 
On two points the action of the Council has been dis- 
tinctly retrogressive. One of Sir William Fergusson’s sub- 
committees reported that "the system of admission by 
governors’ and subcribers’ letters is radically wrong as 18 
regards out-patients, and ought to be abolished. This prac- 
tice is one of the chief sources of hospital abuse.” And 
another remarked : " There is often a difficulty in the poor 
procuring a letter of recommendation; and, besides, when 
obtained, it is generally after many hours spent in walking, 
which may materially increase their malady, and hinder that 
very recovery they are striving to secure.” A great exten- 
sion was given to this practice by the distribution of letters 
by the Council in proportion to the amounts collected by 
them, which has been only partially corrected by limiting the 
letters to half the number claimable by annual subscribers. 
The first Distribution Committee reported, that " a large 
number of the inhabitants of this great metropolis apply 
annually for gratuitous medical relief, and it is scarcely pos- 
sible to refrain from expressing the hope that the time is not 
far distant when very many of these applicants may be in- 
duced to associate together to secure for themselves efficient 
medical relief in time of need, as a matter of right, rather 
than to be so constantly dependent upon purely charitable 
assistance. The great step in this direction would appear 
to be to make a large number of our local dispensaries self- 
supporting to a great extent, if not entirely ' provident dis- 
pensaries.’ ” The disappointment, therefore, was great when 
the list appeared with full grants to the free dispensaries, 
while the provident dispensaries were stinted to a propor- 
tion based upon that part of their income which is' con- 
tributed by honorary subscribers. This was the unkindest 
cut of all, because it seemed to be directly aimed at the 
provident principle. The object of provident dispensaries 
is to encourage habits of forethought and independence, by 
inducing our people to rely for medical treatment rather 
upon their own thrift than upon the charity of others, 
whereas, instead of helping those who help themselves, the 
grants of the Hospital Sunday Council varied in the oppo- 
site ratio, growing larger as the eleemosynary principle was 19 
developed, and smaller as self-support was exhibited, until 
they vanished altogether. The remonstrances made against 
this decision were so far successful that, according to a 
revised rule "payments made by, or on behalf of, patients, 
are left to the discretion of the Distribution Committee, to 
be dealt with in each case as they may see fit.” And the 
footing on which the matter now stands is, that while grants 
in aid of institutions on the eleemosynary principle can be 
claimed as a right, they can be hoped for only on sufferance, 
and by favor, when the object is to help those who help 
themselves. The provident dispensaries also seriously suf- 
fer in this way. An annual sermon used to be preached on 
their behalf in the churches of their respective districts, 
which not only produced more than they get from the Hos- 
pital Sunday Fund, but brought the wants of the local 
institutions periodically before the inhabitants of the neigh- 
borhood. In the absence of this, there is an increasing dif- 
ficulty in obtaining fresh subscribers in place of those who 
die or leave the district, and many refuse on the ground that 
they give to the Hospital Sunday Fund. 
Those only who have seen what must be endured on out- 
patient days at general hospitals, notwithstanding every 
effort to reduce the suffering crowd to order, can appreciate 
the blessing of the prompt treatment obtainable through the 
medium of provident dispensaries, on any day and at any 
hour, either at the dispensary itself or at the homes of the 
patients, according to the nature of the case. On the other 
hand, the hospitals themselves, being relieved from the 
pressure of trivial dispensary cases, would more fully per- 
form their true function of bringing the highest skill and 
the largest experience to bear upon serious and difficult sur- 
gical and medical cases. One of the incidental advantages 
of the provident dispensary system is that, being based upon 
payments made from month to month, without any balances 
accruing to the credit of members, as in savings-banks and 20 
benefit societies, members changing their residence can enrol 
themselves wherever they happen to be without any special 
arrangement being made for the transfer. 
After so many years of searching investigation and dis- 
cussion following upon Sir William Fergusson’s strong pro- 
fessional committee, sufficient common ground may surely 
be found to serve as the basis of future action. The specific 
practical proposals I am going to submit will, I hope, be 
accepted, not as my private opinions, but as the conclusions 
which must be drawn from the ample experience which has 
been acquired. 
1. Out-patient letters should be abolished, and admission 
to the out-patient departments of hospitals should be con- 
fined to those cases which, on account of their urgency, 
difficulty, or other peculiarity, require hospital treatment, 
while ordinary trivial cases should be referred to provident, 
or, if the applicants are paupers, poor-law dispensaries. 
When patients suitable for hospital treatment appear to be 
unsuitable as objects of charity, they should pay at pre- 
scribed rates, or have their circumstances inquired into. 
2. The existing free dispensaries should be converted 
into provident dispensaries, and new provident dispensaries 
should be established in proportion to the wants of the 
population. For this purpose the upper and middle classes 
should come to the aid of the working-class until the dispen- 
saries become entirely self-supporting; and some portion of 
the abundant resources derivable from obsolete metropolitan 
charitable endowments might with advantage be applied to 
providing the requisite buildings; but, from the first, not 
less than half the managing committee of each dispensary 
should be elected by the members, the remainder being 
appointed by the honorary subscribers. 
3. For the double purpose of securing the prompt ad- 
mission of cases requiring the special resources of a hospital, 
and of increasing the supply of instructive cases for medical 21 
education, the medical officers of provident and poor-law 
dispensaries should he authorized to recommend for treat- 
ment in the neighboring hospitals such cases as, from their 
peculiar or difficult character, or from their requiring pro- 
longed clinical treatment, can best be dealt with in a 
hospital. 
Beyond these I am not aware of any indispensable condi- 
tions of the reform of the present system of metropolitan 
medical relief. The managing committees, and the sub- 
scribers who supply them with the necessary funds, best 
know how to adapt these general principles to the individual 
circumstances of each institution. 
By drawing closer the connection between hospitals and dis- 
pensaries two desiderata of the present state of the medical 
profession would be supplied. Regular means of instruction 
would be provided in the domiciliary treatment of disease, 
including the every-day class of domestic complaints which 
form so large a part of the business of the medical prac- 
titioner ; and the difficulty of surmounting with safety and 
credit the critical interval between the completion of pro- 
fessional education and the establishment of a satisfactory 
practice would be diminished. When students have finished 
their course at the hospitals, they could not have a more 
suitable field for acquiring varied experience and laying the 
foundation of a professional reputation, earning meanwhile 
an income, which, although moderate, would suffice for their 
support, than by obtaining an appointment at a provident 
dispensary, and engaging actively in visiting patients at 
their own homes, as well as attending them at the dis- 
pensary. 
The evils with which we are familiar here have also 
appeared at Manchester, Liverpool, Glasgow, and other 
centres of population ; but, in dealing with them, these pro- 
vincial cities have two advantages over us. Although their 
population is large, and their medical institutions are 22 
numerous, compared with any other place except London, 
yet each is pervaded by a corporate spirit, and forms a real 
autonomy, so as to be perfectly manageable on a question of 
this sort affecting the general municipal interest; whereas 
London is not so much a city as a province of houses, which 
can only with the utmost difficulty be influenced from a 
single centre; and, secondly, these northern communities 
are more strongly constituted than the corresponding stratum 
of London society, being chiefly composed of large bodies of 
well-paid workmen who have not been corrupted by a vast 
indiscriminate system of public and private charity. The 
provident dispensary system first took root in these northern 
parts, and to them we still look for an example in all that 
concerns thrift and independence. 
Last year the members of the Northampton Provident 
Dispensary entitled to attendance were 17,849 —more than 
one-third of the population of the town. The payments 
made by them amounted to £2,218; the attendances on 
patients at the dispensary were 5,903 ; at the medical offi- 
cers’ houses, 15,062 ; and the visits paid to patients at their 
own houses, 29,804. The payments to the three medical 
officers for the year were £1,696. At the Derby Provident 
Dispensary there were 5,696 members, who paid £997, and 
voted £497 to the medical officers. But of late years Man- 
chester has taken the lead. In July, 1873, Sir Rutherford 
Alcock and Dr. Ford Anderson were deputed by the Charity 
Organization Society to attend a meeting of the subscribers 
to the hospitals and dispensaries at Manchester, at which it 
was resolved, " That, as there is a large class of working- 
men above the condition of pauperism who, while unable to 
pay the ordinary medical fees, are yet well able to make 
small periodical payments for medicine and medical attend- 
ance, it is desirable to establish provident dispensaries, by 
which these cases may be provided for.” Manchester and 
Salford were then divided into districts, with a view to a 23 
provident dispensary being placed in each, to be managed 
by its own committee, consisting of ordinary members, 
honorary members, and medical men. Up to the present 
time seven such dispensaries have been established, with 
13,759 members, who subscribed last year £2,881, and paid 
£1,492 to their medical men. Lists of applicants to the 
hospitals and free dispensaries are daily sent to the Provi- 
dent Lispensary Society, by whose inspectors they are 
visited at their homes ; and those who are able to pay the 
small subscriptions required under the provident system 
have their cards stamped in such a manner as to preclude 
them from receiving gratuitous relief a second time, and are 
referred to the provident dispensary of their district. 
Extract from the Eleventh Annual Report of the Royal Albert Hospital, 
Devonport, 1873-4. 
The provident dispensary is still worked in a very satis- 
factory manner. The annual subscriptions are increasing, 
and the fines for non-payment of subscriptions are diminis- 
ing. The Keyham employes are supporters of the 
provident dispensary, in addition to their other contribu- 
tions to the hospital. 
The special account of the provident dispensary shows 
that in the year ending September 30, 1874, £509 19s. 19tZ. 
was received from members, whilst £B6 13s. lOd. was re- 
ceived from other sources; £256 14s. was paid during the 
same year to medical officers. 
From the “ British and Foreign Medico-Chirurgical Review,” 
January, 1875. 
The reports of the several medical charities free hos- 
pitals and dispensaries show how enormous is the number 
of persons who annually seek advice and medicine from these institutions. Several writers have computed what is 
the total number of individuals who annually apply to the 
medical charities of the metropolis, and they tell us that it 
is over a million. We have ourselves gone carefully through 
the figures for the year 1873, and we make the total 
1,288,085. This is altogether exclusive of the Poor-Law 
and of a great number of private and semi-private insti- 
tutions which publish no reports. Beyond the medical 
charity which can be estimated in figures there is a large 
amount which cannot be tabulated. We may therefore 
rest assured that the total at which we arrive by adding 
together the figures given in various published reports is 
not an exaggerated one; but that, on the contrary, it rep- 
resents only a proportion a very large proportion, no 
doubt, but still only a proportion —of the whole chaiity of 
the metropolis. And what is true of London is true also, 
though in a less degree, of the provincial towns and of the 
country at large. We may therefore safely conclude that 
a very large percentage of the community rely upon medical 
charity in time of sickness. In the metropolis this propor- 
tion amounts to something like a quarter. 
This, then, is the first fact to which we call attention, 
the enormous number of persons who expect to receive their 
medical attendance and medicine at the expense of their 
neighbors, as a matter of charity. It needs no argument 
of ours to prove that this is a very undue number. In 
exceptional circumstances for example, when famine dev- 
astates a country a great part of the population may 
have to rely upon charity in one shape or another for the 
necessaries of life. But if such a state of things became 
chronic, we should think that it augured very ill for the 
prosperity of the people. Soup-kitchens are excellent insti- 
tutions on an emergency, but it would not be beneficial to 
have them always in operation for the supply of all comers. 
And the principle is the same with regard to medical charity. 25 
Sickness is not one of the necessities of life, and yet it may 
truly be said to be one of its necessary accidents. It is a 
contingent event, but a contingent event which, speaking 
generally, is certain to come sooner or later. Is it wise, 
then, to re>t contented with a state of things which permits 
so large a proportion of the population to rely upon the 
charitable help they can obtain from others in a matter which 
is, sooner or later, a practical certainty, almost as much a 
certainty as that another meal will be needed or another suit 
of clothes? It seems to us that no thoughtful person can 
acquiesce in a state of things which, under the name of 
charity, is in truth pauperizing a large section of the com- 
munity, and inducing them to depend, not upon their own 
prudence and forethought, but upon the aid they can derive 
from others. 
The establishment of facts such as those referred to shows 
both the extent the unreasonable extent—of this medical 
charity, and also the deteriorating effect that it has on the 
population. Those facts indicate the evils of which we have 
lately heard so much, and which afford a just ground for 
urging that the medical arrangements for the lower middle 
class should be in a great measure altered. 
Now, how do these facts affect the medical profession? 
They affect us at many points. It is impossible that a large 
seel ion of the community should get into the habit of expecting 
to receive gratuitous advice without our profession being 
touched by it in many ways. We shall mention what ap- 
pear to us to be some of the most important. 
Perhaps we ought at the outset to allude to that which 
affects, not ourselves only, but the whole community, and to 
state, first of all, that gratuitous work is often very indif- 
ferently done. No one will deny this who is familiar with 
the way in which patients are seen at crowded hospitals and 
dispensaries. If no more time is expended upon private 
patients than is proper and becoming, then what shall we 26 
say of the manner in which hospital patients are seen ? The 
busiest men cannot see their private patients at home at the 
rate of ten an hour. But hospital patients are frequently 
seen at the rate of fifty an hour. It is true that private 
practice demands some little amenities which are not 
required in public practice. But still, after making all due 
allowance of this kind, we hold that one great evil of the 
present system is that patients do not receive the time and 
attention which their cases demand. In other words, they 
do not receive what the hospital professes to give them. 
The patients do not get the careful advice which they fancy 
they will gain by resorting to a large institution, and this 
last does not carry out the object for which its founders or 
governors have given their money. Such slipshod work as 
much of that which is performed in the out-patient de- 
partment of hospitals is a fraud both on poor and rich. 
But how comes it that this work is so indifferently per- 
formed ? In some cases there can be no doubt that it is on 
account of the vast number of applicants. The physicians 
and surgeons are overwhelmed. A long day would not 
suffice to see the patients properly at the rate of twenty an 
hour, and so means are devised of seeing them at the rate 
of fifty an hour. Who can blame the medical man? He 
gives up two or three whole afternoons every week tq this un- 
paid service. It would be unreasonable to expect him to 
give more. He must have time to earn his bread, and it is 
not wonderful that he should so hasten through his hospital 
work as to secure time for more remunerative labor. 
This leads us to another point, a point which is of more 
general application, and which touches all who are engaged 
in practice, whether their clientele, be so large as to be over- 
whelming or not. It is this : unpaid labor, or labor which 
is all but unpaid, is sure in the long run to be badly done. 
In the ordinary affairs of life wre all recognize and act upon this 
principle. It has become almost a proverb that unpaid ser- 27 
vice is worth just what it costs. Nothing can be got for 
nothing. But in our medical arrangements we proceed upon 
an opposite principle. We expect the doctors to be always 
ready to give their best advice, we expect that all who come 
and ask for it shall receive a valuable commodity, and all 
this is demanded from medical men, not occasionally, but 
constantly. Regularly, day by day, twice a week, or three 
times a week, as the case may be, from year’s end to year’s 
end, the physician or surgeon is expected to be at his post, 
bestowing his services upon all comers. Is it wonderful if 
this regular and constant gratuitous service, extending, it 
may be, over a quarter of a century, —is it wonderful if it 
sometimes degenerates into a mere routine ? Is it wonder- 
ful if it is occasionally badly done? Is it wonderful if it 
falls under the general law that unpaid service is worth just 
what it costs ? 
Intimately connected with the preceding objections to our 
present system of out-patient medical relief is another. Not 
only is the number of applicants out of all reasonable propor- 
tion to the population, and not only is an excessive burden 
of unpaid labor thrown upon the medical officers, but the 
patients themselves are in many instances such as ought not 
to be encouraged to resort to a charitable institution. We 
do not speak now of those cases in which gentlemen and 
ladies betake themselves to hospitals. We do not speak now 
of the gentlemen who leave their broughams at the corner of 
the street, or of the ladies who come habited in silk dresses 
and seal-skin cloaks. Such cases do, no doubt, occur. Most 
of us have occasionally come across something of the kind. 
But these are quite exceptional, and it would certainly not be 
worth while to propose any great change in the arrangement 
of our out-patient departments in order to get rid of such 
gross cases of abuse. These are properly cases of abuse, and 
of an abuse so flagrant that it can hardly become very wide- 
spread. What we allude to is the habitual misuse of the 28 
hospitals by a large number of the lower middle class, who 
certainly do not belong to that section of the community for 
whose benefit the hospitals were originally founded, or are 
now carried on. This evil has, no doubt, grown up gradually, 
chiefly in consequence of the very faulty medical arrange- 
ments of the old poor law, and partly also in consequence of 
the pernicious habit one that even the first-rate hospitals 
and dispensaries have adopted —of advertising the number of 
their applicants as a means of exciting the sympathies of the 
public. But, however it may have arisen, the fact is indis- 
putable that the hospitals are now used to a large extent by 
those for whom they were never intended. In other words, 
they are greatly misused. 
These, then, are some of the chief grounds why we say 
that great changes are needed in the mode of administering 
out-patient relief. The relief is inefficient, partly because 
the medical men are overwhelmed by numbers, and partly 
because the amount of unpaid labor is excessive ; and this 
inordinate amount of unpaid work tends to cheapen the 
whole of our professional services, and to lower both our 
scale of remuneration and our social position. 
The remedy which we would propose for this unsatisfac- 
tory state of things is a large extension of the provident 
system of medical relief. This system, as our readers are 
aware, has been in operation for nearly half a century; but 
during the last few years public attention has been specially 
called to it, and it has undergone a great development. This 
is the best proof we could offer to the soundness of the prin- 
ciple. It has stood the test of time, and increased consid- 
eration of the subject has only brought it the more into 
favor. 
We need scarcely explain to our readers how provident 
dispensaries or provident sick societies are carried on. They 
are now so numerous that most medical men have had their 
attention called to them. Suffice it to say, that each member 29 
makes a small but continuous payment from week to week, 
or from month to month, and that this entitles him to medi- 
cal attendance and medicine when he is ill. The payment is 
usually about a penny or a penny halfpenny a week for each 
adult, and a halfpenny a week for each child ; but it is seldom' 
that more than four children in a family are charged, for. 
These payments are so small that they are obviously within 
the reach of the great mass of the working-classes, and 
where they can be induced to join in sufficient numbers the 
dispensaries are reasonably remunerative to the medical men 
who are connected with them. 
Thus, at Northampton there were, in 1873, 12,820 
members, and £1,619 were divided among the three medical 
officers. 
At Altrincham there were 2,920 members, and £533 
were divided among four medical officers. 
At Camberwell (London) there were 5,606 members, 
and £555 were divided among six medical officers. 
At Haverstock Hill (London) there were 2,326 mem- 
bers, and £320 were divided among three medical officers. 
At Leamington there were 3,436 enrolled members, and 
£336 were divided among the throe medical officers. 
In the Laborers’ Self-aiding Medical Club, which com- 
prises the parishes of the Grantham Union, there were 4,577 
enrolled members, and £689 were divided among nine 
medical officers. 
At the Royal Albert Hospital, Devonport, an experiment 
is being tried which is well worthy of attention, and which 
may exercise a most important influence upon the hospital 
system of the country at large. There the out-patient 
department is itself on the provident footing, and the way in 
which it is spoken of in the last report is very encouraging : 
"The progress of the Provident Dispensary has been rapid, 
almost beyond expectation. In the first complete year of 
its working, ending on the 30th September, 1869, the receipts 30 
from all sources were in round numbers £351; they are now 
increased to £538. The committee are more than ever con- 
firmed in their view of the advantages arising from the 
institution; there can be no doubt whatever that its principal 
merit is to establish and increase habits of providence and 
forethought among the working-classes, but great relief is 
also afforded to the suffering poor. Several cases have been 
admitted as in-patients of the hospital on the recommenda- 
tion of the junior surgeons, not as a matter of charity, but 
as a part of the relief purchased by their original subscrip- 
tions. In this way the members have the benefit of the 
superior appliances of the hospital, and the latter is a gainer 
as a medical school by being supplied with a succession of 
important and selected cases.” 
In all these provident institutions there is a charitable 
element. Donations in one form or another are given by the 
richer neighbors. But in time we may hope that they will 
become altogether self-supporting. It only needs that such 
institutions should be naturalized among our working-people, 
so that they may enroll themselves in greater numbers, 
and then the provident sick societies would be able to stand 
firmly upon their own feet. 
Any institution of this kind in which the interests of the 
medical man can be reasonably guaranteed, in wThich he has 
a fair voice in the management, and in which he receives an 
adequate remuneration, seems to us to offer great advantages 
as a means of carrying on practice among the humbler 
classes of society. For example, the payments are all made 
in advance. There are no bad debts. And the payments 
are made, not to the doctor directly, but to the secretary. 
The medical man has no small bills to send out and to 
collect. Again, the patients —at least, such of them as are 
well enough are seen at the institution, and there also all 
the medicine is dispensed. These are no small advantages, 
as any one who is conversant with the harassing details of 31 
general practice among the lower middle class will readily 
allow. 
To sum up. We ought upon every ground —in justice 
to ourselves, in justice to our patients, in justice to the com- 
munity at large we ought to insist upon strict limits being 
placed to the unpaid service which we are required to per- 
form. We ought to insist upon the hospitals and dispen- 
saries making some inquiry as to the social position and 
circumstances of those who apply for out-patient relief. 
We ought to insist upon it that all those who can, without 
hardship, pay three halfpence a week should be referred to 
provident sick societies, and that those who can afford to 
pay the charges of a general practitioner should be directed 
to apply to one. This ought to be our programme, and 
there can be no doubt that if we were united in making 
these demands they would speedily be acceded to. By 
these means the total of out-patients would be reduced to a 
more manageable number, while a large proportion of those 
who were drafted off would be enrolled in a self-aiding sys- 
tem, which would pay adequate salaries to its medical 
officers. Nor let it be thought that these changes would 
impair the efficiency of the hospitals as places of medical 
education. Whether the proposals we have made were 
carried out by placing the out-patient department upon the 
provident footing, or by encouraging the establishment of 
provident sick societies in relation with the hospitals, by 
either plan the supply of acute cases for the wards would 
probably be more regular than it now is. This, as we have 
seen, has been proved by the experience of the Royal 
Albert Hospital at Devonport. 
Now, we maintain that our public duty is to see that the 
lower middle class is not pauperized in the matter of medical 
advice, and to insist upon it that the hospitals and dispen- 
saries shall put strict limits to the gratuitous relief that they 
offer to out-patients, so that they shall no longer impose an 32 
unreasonable amount of unpaid labor upon their staff, or 
give the general practitioners of their neighborhood any 
just cause of complaint. And, further, we ought to see 
thht the country is well supplied with provident sick socie- 
ties, so that those upon whom the hospitals shut their 
doors may have no lack of opportunities for obtaining good 
medical attendance on terms which they can well afford out 
of their weekly wages. If these things were done, it would 
be much for the benefit of the nation, for it would tend in 
one important particular greatly to strengthen the moral 
fibre of the nine or ten millions who form the wage-earning 
class of this country, namely, by encouraging in them habits 
of self-reliance, forethought, and prudence. It would also 
tend to improve both the pecuniary remuneration and the 
social status of our profession, by transforming a great part 
of the work which is now done gratuitously into remunera- 
tive service. The work itself would be better done than at 
present, and when the pay of the profession was better, and 
was received in a more dignified manner, a higher class of 
men would be attracted towards it, scientific and profes- 
sional education might be carried to a still higher point, and 
thus the changes we have advocated would be advantageous 
in all their bearings. 
REPORT. 
The Medical Committee of the Charity Organization 
Society was appointed by a Resolution of the Council, dated 
March 17, 1871, to deliberate and advise with reference to 
Medical Charities, and consisted at first of the following 
gentlemen, Dr. Ilawksley, Dr. A. P. Stewart, Mr. Fairlie 
Clarke, Mr. J. B. Curgenven, and Mr. Alsager 11. Hill. 
Power was afterwards given to it to add to its numbers, 33 
and the following four gentlemen have been added : Dr. 
Ford Anderson, Dr. Hey wood Smith, Mr. W. Spencer 
Watson, and Sir Charles Trevelyan, K.C.B. 
The committee has met fifteen times, and it has given par- 
ticular attention to Medical Provident Institutions. In order 
to obtain the best information on this subject, it invited 
several gentlemen, who are connected with existing provi- 
dent dispensaries, to meet it in conference; and the Rev. 
H. F. Mallett, Dr. Westmacott, Mr. E. P. Young, Mr. 
Walter Smith, Mr. F. H. Gervis, and Mr. Conquest have 
most kindly attended some of its sittings, and given it the 
benefit of their experience and advice. The committee has 
also received valuable suggestions from Dr. Rumsey (Chel- 
tenham), Dr. Nankivell (Torquay), Dr. Ogle (Derby), 
Dr. Heslop (Birmingham), Dr. McVeagh (Coventry), Mr. 
Beck (Northampton), Mr. Jonathan Hutchinson, and the 
Rev. J. F. Kitto. 
Before using any means to increase the number of provi- 
dent institutions, the committee thought it best to go 
through the rules of the existing provident dispensaries, 
and to draw up a code of laws which they could put into the 
hands of those who were anxious to start such institutions, 
and which they could recommend as the best that can be 
devised by the united experience of the provident dispensa- 
ries which are already in operation. In this work they have 
received most valuable assistance from the gentlemen who 
have just been named, and to them they return their sincere 
thanks. 
As the result of its labors the committee now lays before 
the Council the accompanying code of laws, with appendices. 
The rules which the committee recommend have been 
framed so as to admit into the managing committee of the 
dispensaries a certain proportion of the benefited members, 
who should act as representatives of the whole body. In 
this way they would have an opportunity of expressing the wishes of the members and making suggestions. This is a 
comparatively new feature in the government of provident 
dispensaries, but it has been already adopted at Hampstead, 
Wandsworth, and elsewhere, with considerable success. 
The committee hope that the time may come when provi- 
dent dispensaries will be entirely self-supporting, and when 
the management may rest altogether with the members. 
But at present it does not seem right to take the control of 
them out of the hands of those who have set them on foot 
from motives of wise benevolence, and without whose aid 
they could not maintain themselves in a state of efficiency. 
The Medical Committee trust that this code of laws will 
meet with the approbation of the Council, and that they will 
give it the weight of their sanction. The more the com- 
mittee have considered the pauperizing influences of the 
existing medical charities, the more fully are they persuaded 
that the most hopeful remedy is a large extension of the 
provident principle. 
By a reference to Low’s Handbook it will be seen that 
the sixteen general hospitals of the metropolis are credited 
with a total of 541,775 out-patients during the year 1870, to 
say nothing of the attendances at special hospitals and dis- 
pensaries. Of this number there can be no doubt that many 
are well able to defray the charges of a local practitioner, 
while a still larger number are in a position to pay the 6s. 
or Bs. a year which is all that the provident dispensary 
demands. In return for this trifling outlay, the member is 
entitled to receive advice and medicine when he is ill; and 
he can obtain the same advantages for his wife and children 
upon still easier terms. Probably, of the hundreds of 
thousands who frequent the out-patient waiting-rooms of 
our hospitals, only a very small proportion are unable to 
pay anything for themselves, and it may be a question 
whether these ought not to be directed to the poor-law 
dispensaries. It is the out-patient departments of hospitals 35 
that are most abused, and it is in these departments that 
your committee desire to see the indiscriminate relief at 
present given largely curtailed. They believe that this 
could be done without seriously affecting the supply of cases 
which are needful for clinical instruction at those hospitals 
which have medical schools attached to them, and without 
limiting the true province of Christian charity. 
Under present circumstances, when there are in the 
metropolis about 105 free hospitals and dispensaries to 
which the artisan or laborer can turn at any moment, and 
which may almost be said to be bidding against one another 
for his patronage, it is obvious that the inducements to 
providence and self-reliance are entirely taken away. 
This state of things your committee regard as a very great 
evil; and they believe that there is no one class of charities 
which is doing so much to pauperize the population, to 
undermine their independence and self-respect, and to dis- 
courage habits of providence, as the medical charities. The 
committee are well aware of the great benefit that these 
institutions, if properly used, are capable of conferring 
upon the humbler ranks of our population. These benefits 
it would be difficult to exaggerate ; but the committee deplore 
the almost indiscriminate relief which is given, —an evil 
which is fostered by the present method of appealing for 
subscriptions by advertising the numbers who are admitted 
week by week, or year by year. It cannot be too strongly 
urged upon the attention of the public that the mere state- 
ment of the number of applicants to a hospital forms no 
proper index to the amount of good which it does; nay, 
rather, it may tell in the opposite direction, for the highest 
good is to discriminate the cases, to weed out those that are 
unsuitable, and to give relief only to that comparatively 
small number who are really fit applicants, and to whom the 
advice and medicine thus given will be an unmixed boon. It 
is the ability of its staff, the skill of its nursing, the excel- 36 
lence of its general arrangements, and the wisdom of its 
benevolence, which ought to recommend a hospital to the 
support of the public, and not merely the numbers wTho 
have passed through its consulting rooms in a week or a 
year. The committee are of opinion that the applicants to 
any hospital might easily be discriminated by means of some 
such agency as that which your society has set on foot; and 
that hospitals would not act unwisely if they were to lay 
down some such rule as this, that, with the exception of 
accidents and cases of emergency, all applicants should pass 
through the district office of your society. Your officers 
are acquiring an intimate knowledge of the poor of their 
districts, and a little practice would soon enable them to 
judge which were suitable cases for the hospital, which 
ought to be sent to the poor-law dispensary, which to the 
provident institution, and which were above the level of all 
these means of assistance. Your committee believe that this 
system, or some modification of it, is the only one which 
will serve to stay the abuses of out-patient hospital relief. 
They have heard with pleasure that in some districts isolated 
cases have been referred for investigation from large hospi- 
tals to your district committees ; but until all applicants 
have, as a matter of course, to pass before an officer whose 
duty it is to investigate the cases, and who is specially 
qualified for this work, they believe it would be impossible 
to put a check upon the present evil. 
If, however, this were done, they feel sure that it would 
not merely rid the hospitals of many abuses, but that it 
would enhance the value of all the charities in the neighbor- 
hood, by directing to each the particular grade of applicants 
which it is designed to assist. 
But while the committee are anxious to exclude all un- 
suitable applicants from our hospitals, they are equally 
desirous of seeing provident institutions opened, where the 
industrious poor could get good advice and medicine on 37 
terms proportioned to their wages. At present there are 
in the metropolis, as we have said, about 105 hospitals and 
dispensaries which are practically free; but there are only 
about 27 provident dispensaries. That is to say, there is 
one free hospital or dispensary for every 44,000 of the 
population, while there is only one provident dispensary for 
every 300,000; and yet the success which has attended 
these institutions in Derby, Coventry, Northampton, and 
elsewhere, shows that they can flourish when in the propor- 
tion of one to 40,000 inhabitants. In other words, the 
metropolis might well be expected to support more than 
seven times as many as it now has. 
But, it may be replied, are there not many benefit clubs 
where the working-classes make a weekly payment, and 
which undertake to support them in time of sickness? True, 
there are many such benefit clubs, which give members a 
weekly subsidy during illness, but the medical arrangements 
of these clubs are of the most unsatisfactory kind. In the 
first place they admit only men. Very few indeed make any 
provision for attending the wives and children of members 
during sickness; and yet it is these who most frequently re- 
quire medical treatment. Again, many artisans and laborers 
are altogether excluded from the benefit clubs because the 
trades at which they work are injurious to health or danger- 
ous to life. Again, many clubs have no medical man at- 
tached to them, and send their members, as a matter of 
course, to the nearest hospital or dispensary, thus tending 
to pauperize a high class of work-people. 
It is evident, therefore, that the benefit club serves most 
imperfectly to meet the wants of the industrious poor in 
time of sickness. But the provident dispensary seems ex- 
actly suited to their requirements. It offers good medical 
attendance and medicine at a price which even the day- 
laborer can afford to pay; it receives all comers, men, 
women, young persons, and children, who are not earning 38 
more than a fixed sum per week; and it rejects none because 
their manner of life is beset by more than ordinary risks; 
while at fhe same time its moral effect is excellent, for it 
tends to encourage habits of forethought and sell-reliance. 
For these reasons the committee are anxious to see a lan>;e 
increase in the number of provident dispensaries, both in 
the metropolis and throughout the country; and if these 
provident dispensaries could be connected together so that 
the artisan, the laborer, the domestic servant, and the 
factory girl might find an institution at hand, of which they 
would be considered members, wherever personal circum- 
stances or the demand for labor might lead them, the com- 
mittee believe it would be an incalculable boon to the work- 
ing-classes. At present, under the club system, it frequently 
happens that a workman is unwilling to leave a particular 
district because he would thereby lose the benefits of his 
club; or, if he does follow the demand for labor, and go to 
another part of the country, being far from the head-quarters 
of his club, he is tempted to apply to charitable institutions 
in forma pauperis. 
The success which has attended the provident dispensaries 
in the central parts of London has hitherto not been such as 
their friends could desire. But this is easily accounted for, 
if vve remember two things: (1.) They have been placed 
in competition with an excessive number of free medical 
charities; and (2.) Their honorary subscribers do not obtain 
the right of recommending patients, which, as governors of 
purely charitable institutions, they have been accustomed to 
exercise. Their money must be given simply for the sup- 
port of the institution, and not to gain advantages for them- 
selves. That provident dispensaries herein act upon a prin- 
ciple which is gaining ground is shown by the letter from 
the Secretary of St. George’s Hospital, which has lately ap- 
peared in the "Times,” in which he announces that the gov- 
ernors of that institution have given up their right of 39 
recommending out-patients, because it was liable to so much 
abuse. 
The committee believe that the Charity Organization 
Society affords an agency remarkably well fitted for thus 
extending the provident principle. One of the great hin- 
drances which those who desire to reform our medical chari- 
ties have to contend with is the difficulty of bringing about 
concerted action among the leading dispensaries and hospi- 
tals ; but your society offers facilities for this purpose which 
have never before existed. The committee would therefore 
submit the following suggestions as to the line of action 
which the society might take : 
1. To draw attention to the abuses of the medical chari- 
ties, and to indicate, as the appropriate remedy, a large 
development of the provident principle. Also, to advise 
the public to support the existing provident dispensaries in 
preference to those which stand on a purely eleemosynary 
footing. 
2. Through its district committees to draw the attention 
of the managers of hospitals to the facilities which the 
Charity Organization Society offers for investigating doubt- 
ful cases; or even to suggest that all applicants for out- 
patient treatment (except accidents and cases of emergency) 
might easily be thus sifted, either by your district office or 
by an officer of the hospital specially appointed for the 
purpose. 
3. The committee further suggest that, wherever it is 
possible, the local provident dispensaries should be affiliated 
to the hospital of the district, as has been done at Devon- 
port, so that members might be entitled to the advantages 
of hospital treatment if it were deemed necessary. This 
plan of affiliation might also be extended to the poor-law 
dispensaries; and in this way the hospitals would be 
protected against their present abuses, while their impor- 40 
tance as centres of medical education would be increased 
rather than diminished. 
4. Through its district committees to induce the govern- 
ors of existing free dispensaries to consider whether they 
might not with advantage convert their institutions into 
provident dispensaries,—a step which has already been 
taken at the Westbourne Dispensary, Cayswater, and at one 
or two others in the provinces. The existence of the free 
dispensaries has greatly retarded the development of the 
provident principle; and they seem to be less needed than 
ever, now that poor-law dispensaries are being opened in 
various parts of London. 
5. In some districts where there is an urgent want of a 
provident dispensary, the local committee might, perhaps, 
take the initiative in the formation of such an institution. 
6. As it is the opinion of the committee that these sug- 
gestions can only be carried out by combined action, they 
advise that a conference of the governors and medical 
officers of hospitals and dispensaries should be called by the 
council at as early a date as possible. 
Your committee have not been unmindful of other evils 
connected with the administration of medical charity, but in 
this report they have thought it best to confine their remarks 
to one subject, viz. : the development of the provident prin- 
ciple; for this, they believe, is that which is most urgently 
needed, and that which is most likely to strike at the root of 
those abuses which have now become notorious, and which it 
is the object of your society to remove. 
A conference was held on Tuesday, the 12th of December, 
1871, in the House of the Society of Arts, under the presi- 
dency of Mr. W. H. Smith, M.P., to discuss the best 
methods of checking the abuses now incidental to out-patient 
hospital relief, with special reference to the expediency of 
extending the provident principle. 41 
Mr. Fairlie Clarke, of Charing Cross Hospital, as Hon. 
Sec. of the Medical Committee of the Charity Organization 
Society, said : " In order to show those who have no personal 
acquaintance with the management of hospitals the mag- 
nitude of the evils of which we complain, let me lay before 
you a few statistics to indicate the number who use our out- 
patient hospital relief, and the proportion which they bear 
to the population. In compiling these statistics I have ob- 
tained ray information either from the secretaries of the 
hospitals themselves, or from the returns given in the 
'Medical Directory.’ I have endeavored, as far as possible, 
to avoid sources of error, and I have tried to ascertain the 
number of individuals (not of attendances) treated at each 
hospital. I find that last year the out-patients treated at 
15 general hospitals were 500,151; 34 general dispensaries, 
305,491 ; 39 special hospitals and dispensaries, 261,374: 
total, 1,157,016. This is exclusive of 17 hospitals and dis- 
pensaries which make no return, and of course it is exclusive 
also of those who are assisted by the medical services of the 
poor law. 1 think, sir, that if this figure is anything like 
correct, it represents a percentage upon the population which 
is far larger than can be considered fit objects for gratuitous 
charitable relief. I said a moment ago that in preparing 
these statistics I had endeavored to avoid sources of error; 
but there are some sources of error which it is impossible to 
eliminate. Thus, some of the out-patients may have been 
entered two or three times in the same year for different 
illnesses; some may have been attending more than one 
hospital at the same time. To allow for these cases let us 
say that the number of out-patients is one million. But if 
any one thinks that the deduction of 150,000 is not sufficient, 
I am willing, for argument’s sake, to make still further allow- 
O1 O 
ances, because, if we even state the figures as low as 820,000, 
it would still form a quarter of the three millions and a 
quarter at which the population of London is estimated, 42 
i.e., it would show that one person in four is receiving gra- 
tuitous medical treatment. Now, sir, I cannot think that our 
social state is so bad, that our national industry is at such a 
low point, that one-fourth of our population would be cor- 
rectly described as the 'really indigent,’ the 'necessitous 
poor,’ for whom these institutions are intended. (Hear! 
hear !)But this is not all. Not only have the numbers attend- 
ing the out-patient department reached this enormous figure, 
but the rate at which the increase has proceeded is very se- 
rious. In order to ascertain what has been the increase in a 
generation, I have made inquiries at most of the hospitals 
which were in operation before 1830, and I have obtained 
the following striking statistics. The hospitals I applied to 
were St. Bartholomew’s, St. Thomas’s, Guy’s, the London, 
Middlesex, St. George’s Westminster, Charing Cross, Moor- 
fields Ophthalmic, and the Boyal Hospital for Diseases of 
the Chest. Of these Guy’s and Middlesex could give no 
reliable information. At the eight other hospitals the total 
number of out-patients in 1830 was 46,435. In 1869 it had 
risen to 277,891. During that period of 39 years the pop- 
ulation of the metropolis had a little more than doubled, 
while the attendance at these eight hospitals had increased 
more than five-fold. But it will make the rate of increase 
still more apparent if 1 mention that at the same eight hos- 
pitals there were, in 1870, 43,368 more out-patients than in 
1869. These eight hospitals were chosen simply because 
they were in operation in 1830. If I had been minded to 
select examples in which the increase from 1869 to 1870 had 
been the greatest, I might have made my figures still more 
telling. As six of these hospitals are general and two 
special, I think they might be taken as a fair specimen of the 
whole. Now, of this enormous number there can be no 
doubt that many are able to pay the charges of a local prac- 
titioner, while a still larger proportion are in a position to 
pay the 86-. or 10s. a year which is all that the provident 43 
dispensary demands. 1 suppose we shall all agree that the 
former class ought not to be admitted to the hospital at all. 
Here let me mention that the Charity Organization Society 
will gladly undertake to investigate all doubtful cases, as it 
has already agreed to do for St. George’s Hospital. But 
how are the latter class to be dealt with? This, as it 
seems to me, is the very point of our conference. Is it de- 
sirable that they should be induced to flock year after year 
to our hospitals in ever-increasing numbers ; or would it 
not be better to encourage them to enrol themselves in prov- 
ident dispensaries, where they would obtain, by their own 
small but regular payments, the medical advice and attend- 
ance that they may require? The Charity Organization 
Society considers that there can be no doubt that it would be 
best to extend the provident system. I suppose that all 
who are present are familiar with the idea of a provident 
dispensary. It is an institution which receives all comers 
men, and women, and young persons alike, who secure for 
themselves by small but continuous payments medical attend- 
ance and medicine when they are ill. It is, in fact, a mutual 
assurance against sickness, conducted in part on a commercial 
footing, but at present needing to be supplemented by the 
charitable. Such institutions as these were originated about 
forty years ago, and they have been tried in various parts of 
the country as well as in the metropolis. In the manufac- 
turing districts they have flourished the most. In London 
there are about a dozen; but here, at least in the central 
districts, they have been placed in such unfair competition 
with the free charities that it is not to be wondered at that 
they have not proved so successful. When there were 
free hospitals and dispensaries on every side eager to re- 
ceive him, it was scarcely in human nature that the artisan 
should volunteer to pay for that which he could easily obtain 
for nothing. Yet, if we would not pauperize our working- 
classes by encouraging them to rely on others for medical 44 
relief, some form of cooperation such as we have described 
must be adopted. The success of the movement in other 
places shows what might be looked for in London, if the 
provident principle had a fair chance.” 
Sir Charles Trevelyan said : "My claim to stand here is 
that I belong to a society which is endeavoring to grapple 
with London pauperism and to give it a Cornish throw. 
Having undertaken such an audacious task, it became our 
duty to investigate the conditions and causes of this awful 
problem, and we soon arrived at the conclusion that the ex- 
isting system of gratuitous, indiscriminate medical relief was 
one of the most powerful of those causes. Other modes of 
relief only affect the poor, but this includes every class of 
society except the highest, and educates them to habits of 
dependence, while those who are already pauperized are 
precipitated by it to a lower depth. It is a mistake to sup- 
pose that the class of malades imaginaires is only to be 
found among the rich. For one fine lady who pays her two 
or three guineas a week for the luxury of frequent conferen- 
ces with her physician, hundreds of poor women are tempted 
by our medical charities to live upon drugs, tonics, and 
cordials, to the neglect of the real sources of health, —reg- 
ular employment, good food, cleanliness, and roomy, well- 
ventilated dwellings. Clergymen and district visitors, in 
their visits to the poor, constantly see rows of phials, ob- 
tained some from one and some from another hospital or 
dispensary, which are appealed to as evidence of a low state 
of health. 'My doctor,’ they say, 'bids me do this or 
that.’ Thus the abuse of medical relief works in with the 
abuse of other kinds of relief. But this whole system is 
breaking down by its own weight. With two or three ex- 
ceptions, the hospitals are all out at elbows. They are 
spending more than they get, and are constantly making 
lamentable appeals to be rescued from bankruptcy. How 
can it be otherwise? The burden to be borne is nothing 45 
short of the medical treatment of the entire community, 
with the exception of a narrow upper margin. The great 
bulk of the community who lie between those who pay the 
ordinary fees and those who can pay nothing at all, includ- 
ing the entire working-class, are not only exempted from 
contribution, but matters are so arranged that they would 
find it difficult to contribute even if they wished to do so. 
However practicable it may have been in former times, such 
a medical system is totally unsuited to the present vast pop- 
ulation of London. Another evil arising from it is, that the 
medical profession is to a great extent unpaid. Gratuitous 
service is proverbially bad service; and it has always 
appeared to me highly honorable to our medical profession, 
and through it to the nation itself, that, although in large 
part very insufficiently paid, they have performed their part 
in so conscientious and zealous a manner.” 
Dr. Meadows seconded the resolution. He said that ''the 
more he had studied the system of out-door hospital relief 
the more convinced he was of the great and glaring abuses 
existing in it. (Hear! hear!) Now, the proposed reform 
would affect the poor, the public, and the medical profession. 
In regard to the first, it was unquestionably the fact that 
the poor were now being gradually ousted out of the con- 
sulting-room by well-to-do persons ; and he knew, as a fact, 
that persons in the possession of incomes of £l,OOO a year 
came as out-patients to receive advice, and that the wives 
and daughters of men almost as wealthy actually borrowed 
their servants’ clothes in order to apply as out-door patients. 
(Hear! hear!) That was an injustice upon the public, and 
not less so upon the medical profession, because, in fact, 
thousands and thousands of pounds were taken annually out 
of the pockets of practitioners, who were expected to give 
up hours every day in gratuitously advising persons who 
were perfectly well able to pay the usual fees. (Hear! 
hear !) The profession were perfectly convinced of the evils 46 
of the present system, and it hoped that the public generally 
would take the question up with the earnestness that it de- 
served. (Hear! hear!)” 
From Report of Royal Pimlico Dispensary. 
Another year brings the Committee of the Royal Pimlico 
Dispensary again before the governors and friends of the in- 
stitution, and they are happy to state that they have a good 
report to offer respecting the provident principle, as shown 
by the following statistics : 
In 1873 the payments made by provident members 
amounted to £203 ss. 11 d., in 1874, to £241 Bs. 2d., in 
1875, to £312 ss. 4d., and in 1876, to £364 Os. IGd. 
These results are much better than the committee could 
have hoped for at the commencement, and go far to prove 
that wherever the provident principle is introduced, the 
working-classes will take advantage of it. 
The number of provident dispensaries is increasing all 
over the country, and the committee have been applied to for 
advice and guidance in the formation of several others. 
This they consider a proof of the success and good arrange- 
ments of their own institution. 
From Report of Manchester and Salford Provident Dispensaries. 
In the opinion of this meeting the progress already made, 
demonstrates the importance and usefulness of provident 
dispensaries, and fully justifies the council in the endeavor 
to provide them for every district in the boroughs of Man- 
chester and Salford. 
Those persons living outside Manchester and Salford, and 
those who while living in Manchester and Salford do not 47 
reside in provident dispensary districts, have not been 
visited. 
It will be seen that in 1,056 cases out of 6,861, erroneous 
or insufficient information has been given, as the persons 
could not be found at the addresses supplied. Out of the 
5,805 persons who were seen, 2,417, or per cent., were 
found to be quite able to become provident dispensary 
members, and were referred to those institutions. The 
proportion of these cases to the total number is now much 
smaller than when the investigations commenced. During 
the first ten weeks at the infirmary, it was 51 per cent, of 
the total number visited; during the second ten weeks it 
was 37 per cent. ; and during the third ten weeks it was 31 
per cent. 
The same results are observed in connection with the 
Children’s Hospital and the Clinical Hospital. 
Notwithstanding that these investigations have been made 
only during the last half of the year, except at the In- 
firmary, where they began at the end of May, the decrease 
in the number of out and home patients at the free char- 
ities in the association is very considerable. 
The council have every reason to be satisfied with the 
result of their efforts during the past year. 
It was feared by many that a considerable time would 
elapse before the working-classes would connect themselves 
in large numbers with the new dispensaries. It is, there- 
fore, a gratifying fact that notwithstanding the suspicion 
and indifference with which any unknown system is sure to 
be regarded, more than twenty thousand members have 
o 7 
been enrolled in the few months the dispensaries have been 
established. 
The system is gradually becoming known and appre- 
ciated, and there is good reason to hope that before the 
three years for which the guarantee fund was formed have 
expired, the seven dispensaries now in operation will have 48 
become self-supporting. The council are so satisfied with 
the progress that has been made that arrangements are in 
process to establish three or four new branches in order that 
the system may be brought within reach of all the working- 
people of this city and the neighboring borough. In order 
to provide for the increased expenditure which this exten- 
sion will involve, and to carry on the new branches until 
they reach the self-supporting stage, special donations, 
amounting to £1,050, have been given within the last few 
weeks, and a second guarantee fund for three years has been 
commenced. 
In conclusion, the council express the belief that if their 
efforts result, within the next few years, in establishing upon 
a sound and permanent basis, this system of self-supporting 
provident dispensaries in Manchester and Salford, and in 
thereby placing medicine and skilled medical advice within 
reach of the poor, without causing any undue strain upon 
their resources, and in reducing to a minimum the amount 
of pauperizing charitable relief bestowed by the free hos- 
pitals and dispensaries, the labor and money which may be 
spent in the process will not be wasted. 
From an article in the “ Quarterly Reviewentitled “ London Alms and 
London Pauperism ” : 
Loudon may be safely declared to be the most extraor- 
dinary capital in the world, equally as to size and contents. 
It is the great heart not only of the British empire, but also 
of the known globe. 
It covers within its jurisdiction 576 square miles; its area 
embraces 78,0U0 acres. It contains 4,000,000 of inhab- 
itants, increasing at the rate of 75,0U0 a year. 
Above £2,000,01)0 have been expended annually on the 
poor in the shape of legal relief, not including paupers in lunatic asylums and vagrants, and little less, if at all less, 
than £7,000,000 in the shape of private charity. It is 
reckoned that one-eighth of the metropolis is assisted by 
the other seven-eighths, the average received by each in- 
dividual being 111. a year, or by each family of five persons 
851. This population is largely intermingled with various 
nationalities. London contains more Jews than Palestine, 
more Irish than Dublin, more Scotch than Edinburgh, and 
more Roman Catholics than Rome. More largely still is it 
diversified in its moral strata. 
Every degree in the scale is filled: from riches to desti- 
tution, from luxury to filth, from learning to ignorance, 
from refinement- to savagery, from goodness of which the 
world is not worthy, to wickedness which is -a disgrace to 
humanity. Where is there another city where a woman 
may so easily get rid of a burdensome child just old enough 
to steal and beg for himself? She has but to take him 
through a few miles of intricate streets, and disappear round 
a corner, and that child and his unnatural parent never 
meet again. On the other hand, so extensive, however 
unequally distributed are the charities, the best chance some 
Loudon children can have in life is to be turned into the 
streets. 
Of late the overworked staff of some of the London hos- 
pitals have seen the policy of availing themselves of the 
investigating machinery offered by the Charity Organization 
Society. These efforts have been chiefly directed at present 
to the class of out-patients. It would seem that this depart- 
ment has been an abuse which has gradually crept in and 
grown to its present dimensions. 
In every way it works iIK Subscribers give their out- 
patient tickets, with the utmost carelessness, to parties they 
know nothing of, or for trivial complaints. These help to 
swell the mob of applicants afflicted alike with dirt, drink, 
and disease, sometimes suffering from infectious com- 50 
plaints, —to whom it is impossible for the medical officers to 
do individual justice. Many mistakes are therefore made, 
for unqualified lads have to prescribe, and many faint and 
deserving creatures wait for hours, and that in an atmosphere 
of impurity, which, generated at the very entry of the build- 
ing, finds its way into the sick-wards, to the serious injury 
of the operation cases. The result of investigation at the 
Loudon Hospital, Whitechapel Road, was that 49 per cent, 
of the out-patients were persons who had no right to apply 
for charity at all. Nor must it be forgotten that there is a 
limit to the liberality of the most liberal profession in the 
world. In some instances, in addition to their gratuitous 
services, the medical officers are known to relinquish even 
the fees due to them from their clinical students, in favor of 
chronically bankrupt institutions. 
In Brighton, where the Charity Organization Society has 
spread, as it has largely throughout England, it has been 
ascertained that one-fourth of the population are in receipt 
of gratuitous medical relief! Thus, in the anxiety of the 
public to provide for the supposed sick poor, it virtually 
robs Peter of what is his due, in order to give to Paul what 
is not good for him. As now constituted, the hospital not 
only does the work which belongs to the parochial author- 
ities, but usurps and intercepts much of that which rightly 
appertains to an expensively educated professional class. 
The ventilation given to these subjects in the columns of the 
" Reporter ” has already led to changes. St. George’s 
Hospital and, also, we believe, Westminster Hospital, have 
closed tjieir out-door department. The Board of Jewish 
Guardians also, who, in many respects, set us an admirable 
example, equally in judgment and benevolence towards their 
poor, have closed all out-door relief at their dispensaries. 
And’ this brings us to a more becoming use of the 
mechanic’s earnings, and the best remedy for hospital abuse ; 
namely, the support by the lower orders themselves of a 51 
class of institutions now happily becoming more known, called 
"provident dispensaries.” These mainly owe their sugges- 
tion and existence to the report of a medical committee 
appointed by the Charity Organization Society. The rules 
of management require that the members should be persons 
who, on the one hand, are not in receipt of poor-law relief; 
and whose means, on the other hand, are insufficient to pay 
for medical attendance at the usual rate of charges. 
The subscription is on the principle of an insurance during 
health, for sickness; and is regulated on a scale varying 
from sixpence to a shilling per month. 
For this the subscriber has his choice of the medical staff 
attached, either to prescribe for him at the dispensary, or to 
attend him at his own home, as the case may require ; all 
medicines being supplied. About 15 per cent, of the re- 
ceipts are set aside for expenses of management, drugs, etc. ; 
the rest is divided among the medical staff. 
These dispensaries are in course of being affiliated to the 
general hospitals, so that in cases requiring extra appliances 
or skill, it is optional with the doctor to draft patients into 
the hospital best adapted to them. There are, we believe, 
already upwards of 24 of these capital institutions in and 
around London, greatly in favor with the better-disposed of 
the London poor, who are thankful, for this small monthly 
sum, to be spared the labor and humiliation of hunting about 
for hospital tickets. The Royal Pimlico Free Dispensary, 
for instance, which had existed above 40 years, and which, 
with the active aid <*rf the Duke of Westminster, was con- 
verted in 1873 into a provident dispensary, enrolled within 
the first six months 1,731 paying members. As to the re- 
muneration of the medical men, the Haverstock Hill Dis- 
pensary divided among them, the first year, above £400; 
and the Camberwell Dispensary above £SOO. These insti- 
tutions are superintended by managing committees, careful 
to prevent their abuses on the part of a higher class. Mean- 52 
while there is no fear that the free hospitals should not be 
adequately filled, or that the benevolence of their suppoiters 
should be checked by the knowledge that it is more honestly 
applied. 
As a means of education also in thrift and forethought, the 
value of these provident dispensaries is incalculable. 
From the “ Boston Medical and Surgical Journal 
How to prevent charitable institutions from being imposed 
upon has always been a hard question to solve in cities of 
any size, and it is not a matter of surprise that New York 
forms no exception to the rule. 
As long as men have to struggle for subsistence there will 
always be a class, and that not a small one, who seem to 
make it their business in life to live as much as possible on 
others. 
The larger the population of any city, the more voluntary 
pauperism there will be, and this class is constantly being 
increased by ill-advised assistance. We no sooner start a 
new charity than we ask to be protected against this much- 
encouraged class, the willing pauper. I may shock some 
of your readers when I express the opinion that we in New 
York begin to educate the children of the poor for a life of 
dependence as soon as they are able to go about. As soon 
as a child is old enough, some kind-hearted but short-sighted 
lady makes it an "object” for the parents to send the little 
one to a Sunday school in the morning; another kind- 
hearted lady makes it an "object” for the parents to send 
the same child to another school in the afternoon; so that 
between the two schools the children of that family get 
clothed, and perhaps fed ; and can you wonder that in time 
some of these come to consider that they are to be looked 
after and cared for in this way all their lives ? 53 
If we turn to those institutions with which the medical 
profession is more intimately connected, we meet with 
abuses which certainly require correction. 
There are eleven general dispensaries incorporated in the 
city, besides four eye and ear infirmaries. 
At the former there were treated last year 194,000 in- 
door patients, and 9,900 were visited at their homes, at an 
expense of $200,000. At the four eye and ear infirmaries 
there were treated over 21,000 patients, at an expense of 
over $73,000; making a total of 225,000 free patients 
treated, for whom $221,000 were spent. Those who are 
best informed in regard to the class of patients going to 
dispensaries state that at least sixty per cent, are well able to 
pay something for medical treatment. 
In looking over the receipts and expenditures of the 
different dispensaries for the past year, I find that only 
three were able to pay expenses; that one ran behind 
$5,500, while another had a deficit of $1,300. All the 
dispensaries taken together exceeded their receipts by over 
$lO,OOO. Every patient treated who is able to pay a fee is 
imposing on the dispensary, and it is just this class that 
keeps the dispensary in debt. I was recently told that a 
man, the owner of four tenement houses, was an attendant 
upon a dispensary, receiving medicine and advice gratis, and 
it is no unusual thing that those who come to these places 
have money laid up in the savings-bank or are keepers of 
small stores; they are certainly not entitled to gratituous 
treatment. 
There is a large class between those who are able to pay 
a full fee to a physician and those who are absolutely desti- 
tute, of every grade of comparative comfort or poverty, 
comprising mechanics, laborers, etc,, some of whom 
get more than enough to support their families, and who 
are abundantly able to lay by weekly or monthly a sum 
of money towards a fund that may be used to provide 54 
remuneration to the physician who may take care of them 
when sick. For this class the subject of starting medical 
provident associations is being discussed. 
From 15th Annual Report of North-eastern Dispensary, New York. 
Recently, however, a plan has been adopted by which 
every patient applying for treatment, if able to do so, is 
required to contribute the sum of ten cents towards the sup- 
port of the institution, on receipt of which a ticket is given 
entitling the holder to treatment for one month. 
From 87th Annual Report of N. ¥ Dispensary. 
An important question has been raised in this as well as 
other benevolent institutions of the same character, whether 
the charge of a small sum to such patients as seem to be 
able to pay for attendance and prescriptions, would not 
serve to increase the self-respect among the applicants, and 
to diminish the number of unquestioned cases of fraudulent 
application by those who are fairly able to pay for medical 
assistance. This question has been fully considered in 
similar institutions in England and in this country, and 
although the trustees are not at present fully prepared to 
recommend so important a change in the system under which 
they have for so long a period acted, it must be confessed 
that there are many good and cogent reasons for making a 
change of this kind, now applicable to the great population 
of a metropolis like New York, which did not exist when 
the city was comparatively much smaller, and when the 
means of learning the real necessities of the poor were more 
easy and accessible.