Abstract When humoral medicine gave way to more scientific approaches in the nineteenth century, the physician’s gaze changed. Amongst the epistemological transformations were representations and perceptions of the poor patient: the pauvre malade—a pauper who happened to be sick and was to be taken care of by traditional medical charities—became a malade pauvre, a sick person who happened to be poor and was to be treated in new institutions. This article explores these changes but in settings beyond the clinic. In three case studies, we explore the practice of the Genevan physician Louis Odier, the management of the poor in the French spa of Saint-Amand and, finally, treatises about British spas. The agency of physicians, administrators and the poor themselves are analysed. Physicians played an ambiguous role. Some resisted innovation and refused to consider the poor as suffering from the same diseases as the affluent; others made opportunistic use of case histories, including those of the poor, to convince richer patients of the benefits of specific treatments, thereby reinforcing ‘class-blind’ ontological conceptions of disease. Administrators, for their part, tended to see the poor foremost as patients and put pressure on physicians to arrive at precise diagnoses.