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 t 2. 
 
 METEOPOLITAN 
 PROVIDENT DISPENSAEIES. 
 
 LETTEKS 
 
 FROM 
 
 ME. TIMOTHY HOLMES 
 
 AND 
 
 SIE CHAELES TEEVELYAN 
 
 TO THE EDITOKS OF THE 
 
 ' LANCET ' AND ' BKITISH MEDICAL JOUKNAL,' 
 
 AND 
 
 CORRESPONDENCE IN -THE TIMES.' 
 
 1880-1. 
 
 METROPOLITAN PROVIDENT MEDICAL ASSOCIATION, 
 24 BEDFOED STREET, COVENT GARDEN, LONDON, W.C. 
 
 1881.
 
 LBTTEES. 
 
 To the Editor of <■ The Lancbt/ July 30, 1881. 
 
 Sir, — In your number for July 23rd there is an article on the Provident 
 Medical Association, which met the other day at the Duke of West- 
 minster's, and in which I am proud to own myself deeply interested. lu 
 that article you ask (and ask very properly) for information as to important 
 medical details ; and as the article is written in a very kindly spirit, and 
 witb an evidently sincere appreciation of the general object of our associa- 
 tion, I have the greater pleasure in complying with your request. In the 
 first place, you say that my name is the only medical name you recognise 
 in the report. I am glad, however, to say that it is by no means the only 
 one connected with the association. The day selected for the meeting 
 was unluckily that on which the opening ceremony of the International 
 Sanitary Exhibition was held, so that few medical men were present 
 except myself, but several of our medical brethren have already joined, 
 and more will no doubt do so if the scheme commends itself to public 
 confidence. In the second place, it is a misapprehension to suppose that 
 our association proposes to supply its members with medical attendance in 
 all emergencies except 'the capital operations of surgery.' We recognise 
 that there are many other cases, both medical and surgical, besides 
 those calling for surgical operations, which are most legitimate subjects for 
 hospital treatment, and still more for hospital consultation. But we say 
 that the ordinary ailments of the poor neither need be treated at hospitals, 
 nor can be so treated efficiently ; that domiciliary visitation, knowledge 
 of the habits of the patient, and advice as to his food, clothing, &c., are 
 absolutely necessary — in fact, the sort of treatment that the family doctor 
 gives to the rich man; and that a bottle of medicine once a week, and a 
 hurried word or two, are a mockery both of charity and of medical treat- 
 ment in a very large proportion of the out-patient cases. If there is any 
 hospital officer conversant with such practice who denies this I have not 
 yet met with him. Another matter on which you comment is, that each 
 dispensary is to pay something to the Central Association. This payment, 
 however, will only be on account of preliminary expenses, with, I presume, 
 a certain interest until paid. We hope to make the dispensaries self- 
 supporting, but no one expects or wishes that they should be turned into 
 sources of commercial profit to the managers. Next you say that you are 
 not told how many shares have been taken in the new company. I hope I 
 am not violating any confidence in telling you that a little over 5,000 are 
 as yet taken up out of 50,000, which, considering the short time that we 
 have been before the public, and the fact that our operations are only just 
 beginning, is, I think, a very encouraging proof of public confidence. That 
 our company will pay a dividend of 6 per cent, is not a certainty, but I 
 see no improbability in it. At the same time, the persons who have 
 hitherto taken shares have done so more from interest in the scheme than 
 in hope of profit. But what you seem most doubtful about, and what is 
 certainly the most important feature in the new scheme, is as to the 
 adequacy of the remuneration ofiered to the medical officers. I quite 
 agree with you that a medical institution such as you describe^ 'in which 
 whole families are to be attended for Is, M. per quarter and two doctors 
 are employed to do the work of twelve,' would be a disgraceful imposition. 
 If, as you say, language has been employed at some of the meetings of 
 our association and company implying that any such arrangements are to
 
 rk 
 
 OFFICE: 24, BEDFORD STREET, COVENT GARDEN, W.C. 
 
 Chairman of Council : THE RIGHT HON. JAMES STANSFELD, M.P. 
 
 REPORT 
 
 SHOWING THE MINIMUM NUMBER OF MEMBERS NECESSARY TO MAKE A DISPENSARY SELF-SUPPORTING. 
 
 This question can obviously only be dealt with by ascertaining what fixed charges will have 
 to be met, and what items should be provided for by a percentage of net income under ordinary 
 average circumstances. 
 
 The items of expenditure likely to arise may be stated as follows : — Medical Officers, 
 Secretary, Postages, Printing, &c.. Drugs, Rent and House Expenses, and Dispenser. All but the 
 tw^o latter should be met by a proportionate percentage on net income, and the question therefore 
 turns on the estimated fixed cost for Rent and House Expenses and Dispenser. These latter, on 
 an average, may be computed at — 
 
 Rent, &c. ... ... ... ... ... £(^o o o 
 
 Dispenser ... ... ... ... ... 60 o o 
 
 £t-5o o o 
 
 Experience tends to show that the proportionate payments may be calculated as follows : — 
 
 Medical Officers ... ... ... ... ... 47 per cent. 
 
 Drugs, Instruments, &c. ... ... ... ... 21 ,, ,, 
 
 Secretary, Printing, &c. ... ... * ... ... 7 ,, ,, 
 
 Total ... ... 75 per cent. 
 
 As 25 per cent, would thus be left to meet the necessary fixed charges, and as these would 
 require ^150, it is evident the minimum income compatible with solvency would have to be £boo 
 per annum, which should be allotted in the following proportions : — 
 
 Medical Officers 
 Drugs, Instruments, &c. 
 Secretary, Printing, &c. 
 Rent and House Expenses 
 Dispenser ... 
 
 282 
 
 
 
 
 
 126 
 
 
 
 
 
 42 
 
 
 
 
 
 90 
 
 
 
 
 
 60 
 
 
 
 
 
 ^600 o o 
 
 This would require either of the three following groups, each of which would give a small 
 surplus : — 
 
 1,000 Family Members ... ... ... £bso o o 
 
 2,000 Single Cards (Ordinary)... .., ... 650 o o 
 
 3,000 ,, ,, (Friendly Society) ... ... 650 o o 
 
 Or a Membership of the various classes combined, such as, for example : — 
 
 500 Family Members ... ... ... £^,2^ o o 
 
 800 Single Members (Ordinary) ... ... 260 o o 
 
 500 ,, ,, (Friendly Societies) ... 108 6 8 
 
 Total 
 
 £G9Z 6 8 
 
 Of course these combinations are capable of almost infinite variation, while the whole of tlic 
 estimate is based on the assumption of the minimum clientele necessary for solvency. An increase 
 number would probably give a considerable reserve surplus. 
 
 Prepared by C. KADLEY, Organizing Secretary; Considered and approved 
 by the EXECUTIVE COMMITTEE of the Council.
 
 be imported into London, it must have been in my absence, nor would I 
 ever consent to be connected with any such proceedings. In this attempt 
 to substitute for the present indiscriminate gratuitous relief a system of 
 payment by the poor for their medical attendance, on the principle of 
 insurance, it is obvious that the rates of payment must be low, but I am 
 glad to say that we have anticipated your advice to take the well-established 
 sick clubs as our guide. We can only enlist the necessary number of 
 members by the co-operation of the large friendly societies, and we propose 
 to admit their members on the terms which ttiey now pay for their sick 
 clubs, and other members on terms slightly higher. The reason for the 
 difference is, that the members of friendly societies are male adults, and 
 most of them have very little illness. Other members would consist largely 
 of women and children, and require more attendance. That these terms 
 can adequately remunerate the medical men we conclude, not merely from 
 the experience of the provident dispensaries in London, the majority of 
 which, as you truly say, are not at present self-supporting, but from the 
 large institutions in the manufacturing districts, which are now linnly 
 established and are perfectly independent, and whose offices are sought tor 
 by the most respectable practitioners of the district. There is no con- 
 ceivable reason why what pays so well in those counties should not be 
 equally successful in London, except the prevalence here of a vast system 
 ot indiscriminate out-patient relief. If we could obtain the assistance of 
 the medical press and the medical public in reforming the abuses of this 
 svstem, I have no doubt that something would take its place, in respect to 
 the relief of the mass of ordinary sickness, which would be far more just 
 to the profession, and far more satisfactory to the poor. But we have 
 DO wish whatever to abolish or even cripple the out-patient practice of 
 the hospitals. On the contrary, we fully recognise their value in medical 
 education, and only want to improve them. tStill less have we any wish 
 to do injustice to medical men. The present gratuitous system, we believe, 
 deprives them, in London alone, of a very large sum of money annually, 
 which we wish to restore to them ; and with patience, &c., wish on all 
 sides to treat the question fairly. We do not despair of success. It would 
 be a good augury of success, and a long step towards it, if we could enlist 
 the powerful support of llie Lancet for a plan, the general objects of which 
 you are pleased to stamp with your approval. I am yours, &c., 
 
 T. Holmes. 
 Great Cumberland Place, July 2&th, 1881. 
 
 P.S. — As an example of the income which may be derived from a 
 really self-supporting provident dispensary, allow me to instance that at 
 Leicester. Their balance-sheet for 1880 (which I enclose and shall be 
 glad to send to anyone interested in the matter) shows that they received 
 £4,263, of which £2,601 was paid to the medical officers — viz., £2,206 for 
 ordinary attendance, and £395 for midwifery fees. Their rates of payment 
 are, I think, somewhat lower than ours. Why should that be impossible 
 in London which is easy at Leicester ; or how is the dignity of medical labour 
 violated in the persons of the medical men (twelve in number) who work 
 the dispensary ? 
 
 To the Editor of ' The British Medical Journal,' July 30, 1881. 
 
 Sir, — The attention of our associates can hardly fail to have been called 
 to the scheme which is now being developed under the auspices of Sir C. 
 Trevelyan, Sir Sydney Waterlow, Sir R. Alcock, Mr. E. Hart, myself, and 
 others interested in hospital reform, for the purpose of founding a great 
 association in London of provident medical dispensaries. A meeting was 
 held for this purpose on July 16th, at the residence of the Duke of West- 
 minster, where the progress of the effort hitherto was described, and resolu-
 
 tions adopted for the purpose of promoting its further extension. A 
 succinct account of the nature and prospects of this scheme will not be 
 unacceptable, I hope, to your reader.^. The scheme contemplates the ulti- 
 mate establishment in every part of London of self-supporting- dispensaries, 
 to which all persons are to be admitted at a rate of payment about the same 
 as that now paid by the friendly societies (only a little higher), and paid, 
 as in those societies, during health as well as thickness ; but admitting also 
 the wives and children of members, whom the friendly societies as a rule 
 exclude. The payments are at present to be allotted half to working ex- 
 penses, and half to the medical officers ; and when the dispensary has 
 cleared itself from debt, all the surplus will be diyisible among the medical 
 officers. As, however, it is impossible for the funds to be forthcoming at 
 once, it is necessary that these should be advanced by a company, which 
 accordingly has been founded side by side with the association on the model 
 80 successfully furnished by the similar institution for the Girls' High 
 Schools, and which will advance to the association the funds required for 
 each dispensary, to be returned to the company by the association out of the 
 earnings of the dispensary, with such interest as may be found possible. 
 Such, in the fewest possible words, is the object of the scheme. Its aims 
 are, of course, to relieve the present overcrowded out-patient departments, 
 to enable the working classes to provide themselves with that necessary 
 medical attendance which they now most improperly receive as charity, and 
 to bring this 'family doctoring' to the houses of the patients themselves, 
 instead of continuing the farce of pretending to cure dietetic, climatic, and 
 other chronic ailments by the ready-made prescription and the half-minute's 
 advice of the out-patient room. Thus the three main advantages which 
 the promoters desire to secure are — 1. That the doctor shall be paid 
 his due, inj^tead of being obliged to attend gratis those who can afford ta 
 pay him, and many of whom are perfectly willing to do so. 2. That the 
 efficiency of the voluntary hospitals shall be increased, and their teaching 
 powers strengthened, by relieving them of the incubus of numbers which 
 row oppresses them ; and 3, that the work shall be better done. 
 
 The first question is whether the rates of payment are sufficient to make 
 it worth the while of medical practitioners to join the dispensaries. Now, 
 it must be recollected, in considering this matter, that the system is intended 
 to replace one of indiscriminate gratuitous relief; and that is proposed to 
 those who are already treated at the general hospitals and free dispensaries. 
 The rate must, therefore, be a minimum one. Besides, as the men of the 
 families now for the most part are members of sick clubs, the scheme 
 cannot come into general acceptance with the working classes, except with 
 the co-operation of such clubs, which, of course, can only be secured by a 
 rate, for them, not higher than what they now pay. The co-operation of 
 the great friendly societies has, it is hoped, been secured on these terms, 
 and the rates have been fixed with reference to those now paid in such 
 societies. As these members are all adult males, it has been considered 
 equitable to admit them at the rates they now pay, while for other persons 
 a slightly increased rate is charged {6d. a month, instead of 4d., and an 
 entrance fee of Is.). That such rates will provide a fair remuneration for 
 the medical attendants is proved by the experience of similar rates of pay- 
 ment in similar institutions in the manufacturing districts, provided only 
 that a sufficient number of constant contributors is secured. It is calculated 
 that 1,200 members to each dispensary would give a respectable income to 
 the medical officers; but with the active co-operation of the friendly 
 societies a much larger number of members can be secured in any part o'f 
 the metropolis, provided that the dispensaries can be relieved of the com- 
 petition of the great gratuitous institutions. We cannot but believe as well 
 as hope that this will be given to them; for it is obvious that the working 
 of these provident dispensaries, if successful, would relieve the hospitals of 
 exactly the class of cases which are not only useless to them, but which, 
 more than anything else, impede the efficiency of that great school of 
 
 ^\
 
 diagnosis — the out-patient room. Strange indeed is it, as showing the 
 power of any habit, even when really of only recent date, to see how some 
 hospital physicians and surgeons still cling to the idea that it is necessary, in 
 order to keep up the supply of cases for the school, that a mass of people 
 should be encouraged to crowd into out-patient and casualty rooms, where 
 it is impossible that they should receive any proper attention, or the students 
 any proper tuition from them. To what a ridiculous excess this system now 
 prevails in our great hospitals, those know who have read Dr. R. Bridge's 
 account of the casualty department in the 14th volume of the St. Bartholo- 
 mew's Hospital Reports. 
 
 No excuse for maintaining such an outrage on common sense and charity 
 ought for a moment to be admitted by anyone who thinks it unjustitiable 
 * to do evil that good may come.' But the truth is, that the excuse is as 
 falhicious as the practice is indefensible. This system is the growth of 
 yesterday, and in former times, when London was much smaller, the 
 hospitals had no difficulty in procuring a proper supply of material for 
 teaching, without any such overgrown out-patient departments ; nor is any 
 such difficulty experienced in Scotland, France, and other countries, where 
 the system is unknown. Nay, a proper understanding with the dispensaries 
 of the district would always ensure an adequate supply of the cases wanted 
 for tuition. It is a great mistake, though one constantly made, to imagine 
 that the hospitals want only rare, or difficult, or dangerous cases. They 
 want, for out-patient purposes more especially, such cases as present salient 
 points for diagnosis and treatment ; cases, in fact, for consultation ; and 
 what would more enlighten the student, or forui a more apt introduction to 
 practice, than a weekly consultation between the officers of the out-patient 
 department and the dispensary, over cases furnished by the latter ? Would 
 not a quarter of an hour so passed do more to instruct a student on the 
 principles of diagnosis and treatment in the affijction before him, than 
 v/atchiug his master labouring for any number of hours in writin^: hiero- 
 glyphics on bits of paper hastily thrust under his nose, and scrambling at 
 hot haste through dozens of cases which he has neither time, nor strength, 
 nor inclination seriously to attend to ? 
 
 Two points more are all that I can at present notice. One of the ob- 
 jections which have been made to this scheme is, that it admits all comers ; 
 that a duke can, if he please, join the provident dispen*sary ; and that, 
 though probably no such exalted member will really enroll himself, yet 
 that a great number of small tradesmen and others will, who are quite 
 able, and who in fact are quite used, to pay their medical attendants at the 
 ordinary rate. Now, it is quite possible that some such abuse may prevail, 
 but it can only be to a very limited extent, and cannot balance, or even 
 seriously diminish, the great gain which would result to medical men from 
 deriving a regular settled income, free from all bad debts or trouble of 
 collecting, from that very large class which now pays nothing at all. The 
 alternative of an inquisitorial investigation of everyone's private circum- 
 stances before he could be allowed to join the dispensary, is too odious to 
 be accepted by the working classes, while it would probably be very in- 
 efficient. However, to guard against any gross abuse, a power is given to the 
 committee of each dispensary (on which the medical staff is, of course, pre- 
 sent) to refuse any member. On this head, I may refer to a letter from Sir 
 C. Trevelyan, in the Journal for July 31, 1880. 
 
 The other point is, as to the relations of the provident dispensaries to 
 the gratuitous charities. It is here alone that 1 feel any misgiving as to the 
 success of the movement. It is useless to conceal from ourselves that the 
 poor of London are not so exceptionally constituted as to wish to pay for 
 what they can get for nothing ; and, although the fatigue of waiting, the 
 loss of time, and the scanty attention they receive when at last they appear 
 before the out-patient officer, may make a few prefer the paying dispensary 
 to the gratuitous hospital, yet provident dispensaries can never be so 
 successful in London as they are in the country, unless the hospitals will
 
 6. 
 
 assist them bj limiting their so-called charity. We shall soon see whether 
 they are sincere in the desire to do this, which they have often professed 
 The paper we have referred to, by Dr. Bridges, remains on the otiicia 
 records of St. Bartholomew's Hospital, as a standing protest against th e 
 present system, and one which for very shame they must attend to. The 
 new association will, I hope, ask the co-operation of the authorities of that 
 hospital in founding two or three dispensaries in their neighbourhood, where 
 the poor, who are mocked with the caricature of medical treatment 
 described by Dr. Bridges, can obtain deliberate advice and appropriate 
 remedies. The co-operation required would involve limitation in numbers 
 in the out-patient room, refusal of trivial cases, and transference of such as, 
 after a proper inspection, do not seem appropriate for out-patient treatment, 
 to the dispensary. If this reasonable offer were refused, the public would 
 know where the blame lies. 
 
 Meanwhile, I cannot doubt that the scheme promises equal benefits to 
 the sick poor and to the medical profession, and I think its promoters deserve 
 the support and assistance of the profession in their dithcult and hitherto 
 thankless labour. I am, sir, yours faithfully, 
 
 T. Holmes. 
 
 To the Editor of ' The British Medical JouRisrAL,' July 31, 1880. 
 
 Sir, — The meeting, in March, 1870, of 156 members of the medical 
 profession, presided over by Sir William Ferguson, and the Committee and 
 Sub-Committees appointed by it, have at last found their appropriate 
 outcome in the formation of the above-mentioned association, and the 
 promulgation of its rules. The professional agency wliicbi commenced 
 the movement was powerfully seconded by lay support during ten years 
 of patient obscure labour ; and the end was at last attained by inviting 
 the co-operation of the great corporations of the Foresters, Oddfellows, 
 Hearts of Oak, and other friendly societies, which represent the better 
 half of the working classes. 
 
 A large proportion of the population of London, occupying the wide 
 interval between the paupers who are provided for by the Po(U'-Law and 
 the well-to-do classes who pay the usual professional fees, obtain gratuitous 
 medical attendance and medicines at free dispensaries and at the out- 
 patient departments of hospitals. The evil consequences which flow from 
 this practice, in the concentration of the sick in unmanageable masses 
 on a few central points, and the break-down of their habits of self- 
 respect and independence, are well known; but sufficient attention has 
 not been paid to the depressing effects of this state of things upon the 
 medical profession itself. Upon this point, I would refer to Dr. Fairlie 
 Clarke's able article on the ' Limits of Unpaid Service,' in the Medico- 
 Chirurgical Revieio of January 1875, republished in the appendix to my 
 paper on Metropolitan Medical Relief. 
 
 The Metropolitan Provident Medical Association may be described as 
 a final effort to decentralise this congestion, and to bring this middle portion 
 of our population into practical effective relation with the medical profession. 
 As they belong to the classes who live by weekly wages, or by the pre- 
 carious profits of small trades, they are soon broken down by doctors' bills ; 
 but it is possible for them to make a small continuous payment, in health as 
 well as in sickness, on the principle of mutual assurance. At tliis point, the 
 provident dispensary comes to the rescue, and arranges a tnodits vivendi for 
 both parties. As the payments are made, not to the doctor direct, but at 
 the dispensary, there are no bad debts, and no small bills to collect, while 
 opportunities are afforded of acquiring valuable experience, especially in the 
 domiciliary treatment of disease, as well as professional reputation. Com- 
 pare this with the shifts to which young medical men are often put to make 
 themselves known and to establish a practice, and it will be admitted that
 
 the Council of the Association has solid grounds for saying that * the popu- 
 larity and usefulness of the medical profession will be increased, and its 
 general position will be improved, by the proposed arrangements.' 
 
 The payments are higher than those under the * club doctor ' system, 
 and they have a bond Jide character given to them by several subsidiary 
 regulations. All payments have to be made in advance ; applicants 
 actually suffering from illness requiring medical treatment pay a special 
 entrance fee of ten shillings; and ordinary members are not entitled to 
 medical treatment until one month after admission. Besides midwifery 
 fees and a contingent interest in any net surplus there may be after the 
 annual accounts are made up, the medical officers are to receive, at the 
 end of every quarter or half-year, a fixed proportion of the amounts 
 paid by the members registered under their respective names ; and two 
 representatives of the medical officers are to be on the managing com- 
 mittee. Only self-supporting dispensaries are to be admitted into union 
 with the Association. In a mutual assurance society, self-support depends 
 upon numbers. Four thousand members, of both sexes and every age, 
 ' would ffive an income of at least £1,200 a year. If the alliance with the 
 friendly societies, which has been happily commenced, is steadily developed, 
 and the members of the lodges in each dispensary-district join the in- 
 stitution with their wives and children, the success of the undertaking 
 is assured. 
 
 As this is not a charitable but a commercial system, there is no 
 ground for drawing fine distinctions between the applicants for admis- 
 sion to it. If a preliminary investigation into the circumstances of 
 applicants had been insisted upon, the Friendly Societies would have 
 refused all co-operation, and would probably have established friendly 
 societies' medical institutions, which are merely associated club-doctor 
 systems, after the example of the central and northern towns. Durino* 
 the five long meetings occupied in the consideration of the rules, various 
 proposals were made for allowing applicants to enter under different 
 scales of payment, according to their pre^iumed means, but they were 
 all open to the fatal objection that an inquisition into private 
 circumstances would have been necessary, besides the temptation to 
 deception, and the sanction which a distinctive rate of contribution, 
 however moderate it may be in positive amount, woulcf appear to give 
 to persons who can aftbrd,. but grudge to give, the usual professional 
 fee. But it would be a mic^take to suppose that no check is intended. 
 Although every person residing within a dispensary-district, who is willing 
 to make the prescribed payments, and to comply with the other rules, is 
 * eligible' as a member, his actual admission is ^subject to the approval of 
 the managing committee of the dispensary'; and 'to decide upon the ad- 
 mission and removal of members ' is elsewhere stated to be one of the 
 functions of the managing committee. After all, the line between those 
 who avail themselves of the mutual assurance system, and those who pay 
 professional fees, must be drawn by personal and social feeling and local 
 public opinion ; and the managing committees could usefully interpose only 
 by making an occasional example of a more than usually flagrant case. 
 Hovt'ever this may be, there will be some check under the proposed arrano^e- 
 ments, whereas at present there is no check at all ; and the laborious and 
 deserving portion of the medical profession, whose interests are concerned, 
 may feel assured that their cause was maintained to the last point by 
 several members of their own profession, as well as by non-medical members 
 of the Council, and that the compromise finally arrived at is the best of 
 which the circumstances admitted, and will certainly result in great benefits 
 to all concerned if it is cordially supported by them. I am, &c., 
 
 C. E. Treveltan, 
 
 Honorary Secretary to the Metropolitan 
 London, July nth. Provident Medical Association.
 
 To the Editor of *■ The Times/ September 9, 1881. 
 
 Sir, — A lad in our employ had to be at Guy's Hospital at a quarter past 
 11 yesterday ; he never left till a quarter past six. At four he was seen by a 
 doctor, and at six some strapping was put on his leg. This time he was seven 
 hours at the hospital ; on two previous occasions we hear he got away after 
 four and fi ve hours respectively. Had he been a man, with a family dependent 
 on him, he would yesterday have lost eight hours including going and coming. 
 Many working-men could not afford to attend on such terms. It is, of 
 course, not the fault of the doctors, but we think the management might 
 lighten this tax on out-door patients with a little thought, else the charity 
 of the thing is almost nullified. Your obedient servants, 
 
 September 8. J. C. & S. 
 
 To the Editor of ' The Times,' September 14, 1881. 
 
 Sir, — Your correspondents who sign * J. 0. «& S.' complain that a boy 
 in their employ has been compelled to wait seven hours at Guy's Hospital 
 for surgical relief, and on two other occasions periods almost as long, and 
 proceed to say that in the case of a man with a family a similar delay would 
 be simply unbearable from the value of the time wasted. 
 
 This is but the re-statement of an evil the existence of which has long 
 been acknowledged, and which is, I think, the result of several causes. In 
 the first place, it is due, in a certain degree, to the readiness with which a 
 large proportion of the population run after anything for which no direct 
 payment has to be made, and is a curious illustration of their unreasoning 
 inability to appreciate the value of lost time and other indirect expenditure. 
 But, on the other hand, no small share of the responsibility rests upon the 
 system of hospital management, which has devoted a large proportion of 
 the funds — subscribed with the noble -t motives for the relief of exceptional 
 pain and distress — to the cure of the trivial ailments of persons who have no 
 claim to be the recipients of charity. That this is so no one who has 
 seen comfortable middle-class people with their children drive up to our 
 hospitals in cabs, or who has noted the dress and jewellery of the people 
 waiting in the out-patient departments, can doubt. And this indiscriminate 
 charity has brought its own punishment, for nearly all our hospitals are now 
 suffering from a crowd of out-patients with which they are utterly unable 
 to deal, and who are treated in such a manner as to compel the more candid 
 portion of the medical profession to confess the system of relief a ^ sham.' 
 In fact, these institutions are being strangled by an evil of their own 
 creation. 
 
 The question is, then, Where is the remedy to be found ? My answer is, 
 in the establishment of a chain of independent and self-maintaining provi- 
 dent dispensaries on the principles of mutual insurance. This can be accom- 
 plished by the payment of rates well within the reach of the great bulk of 
 the working classes, and would bring prompt and skilful medical aid near to 
 the homes of all. Such institutions are now being founded under respect- 
 able and responsible auspices, and if, as I hope, they become shortly success- 
 ful and general, there will be no excuse for the continuance of the present 
 abuse. It will be equally a reproach to the individual to beg .for what he 
 is perfectly able to provide himself with, and to the hospitals to devote a 
 larjie portion of their income to purposes which the bulk of their sub- 
 scribers disapprove and never intended to support. 
 
 I am, Sir, yours truly, 
 
 C. J. Eadley, 
 Organising Secretary to the Metropolitan 
 Provident Medical Association. 
 
 24 Bedfo.id Street, Covent Garden. 
 
 Spoltifwoode d: Co., Printers, Ntw-street Square, London.
 
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