Unsuitable cases: the debate over outpatient admissions, the medical profession and late-Victorian London Hospitals.

In 1836 a meeting of the nascent British Medical Association (BMA) expressed concern over the "vast amount of gratuitous medical assistance" offered by London's voluntary hospitals.' Seventeen years later, the British Medical Journal printed Edward Crossman's presidential address to the Bath and Bristol branch of the BMA, which highlighted the issue as one of professional concern.2 In the intervening years there was little comment on the subject, but Crossman's address marked the start of a protracted and circular debate. Initially, few medical journals took up Crossman's lead. In 1856 the Medical Times and Gazette noted in passing that the resident medical officer of St Thomas's Hospital had written to The Times to complain about the odious position of the capital's outpatient departments. He declared that donations and subscriptions were being misapplied and used to fund the treatment of patients who could afford to pay for their medical care.3 No systematic solution other than a restriction of governors' admission privileges, or "letters", was proposed and the Gazette took the issue no further.4 Within ten years the idea that metropolitan outpatient departments were being abused by undeserving and, above all, middle-class patients had become a matter of widespread anxiety within London's medical profession. Similar concerns had been expressed in the 1840s and 1850s over friendly society medical schemes and sick clubs.5 By 1889 the debate had reached such an intensity that the British Medical Journal felt it necessary to inform its readers that moderation should be exercised in a discussion that had become