Some persons will tell you, with an air of the miraculous, that they recovered although they were given over; whereas they might with more reason have said, they recovered because they were given over.—Lacon.

While engaged during their first year at the medical school dissecting, learning their bones, and listening to lectures on physiology, the students were encouraged to attend the out-patient department of the hospital. Hundreds of poor suffering folk attend at noon daily to consult the physicians and surgeons on the staff. Very arduous is the work these gentlemen perform. Many hours a week are given by them gratuitously for this purpose, and half their lives may be said to be passed here or in the wards. Such of them as in addition are lecturers at the school receive fair but not very liberal fees, but the purely hospital work is without monetary reward. Yet the appointments are eagerly sought for by medical men, because of the publicity and private practice which are sure to follow a successful hospital practitioner; and above all, on account of the great number of rare and interesting cases which occur in hospitals, giving great scope for the trying of new remedies, new apparatus and modes of treatment, new operations and new methods of dealing with obscure forms of disease. Every inducement is held out for sick folk to attend the out-patient department of a large hospital. The great majority of the cases may present no new feature, but there will certainly be a fair proportion of strange and curious maladies, inviting the attention of the penetrative skill of some member of the staff. You see, you are sick of some grievous disorder which your family doctor fails to cure. You demand to see some specialist who has had larger experience of your class of case. He sends for such a one who has passed half his life hunting up this malady in its every phase; it is reasonable he should know more about it than the man who has to attend to everything that comes in his way. It is, therefore, very well worth the while of the aspirant to “consulting practice” to spend every spare moment where he can see most cases. This is the way the hospital pays him for his services. He attends a hundred cases which cannot interest him, because of their frequency; the hundred and first is a variant of the peculiar complaint on which he is writing his great monograph. And there are ways by which every one of the hundred others may be made to contribute their quota of information. If you have not suffered from the complaint forming the subject of the monograph, you will be lucky if you escape exhibiting the genesis of the disease or one of its stages for clinical purposes.

The out-patient departments of the great general hospitals stand more in need of reform than perhaps any of the charitable institutions of our time. To the contributors and subscribers they appear, doubtless, to be the one great means of affording poor persons the highest medical and surgical advice, and the best medicines and appliances free of charge. The poor believe this, the well-to-do middle classes, and even the rich believe it. The out-patient department day after day is thronged by several hundreds of men, women, and children, who go there at noon and wait hour after hour, often till five o’clock in the evening, for an interview with the physician or surgeon who, between the hours of two and four, will probably see one hundred cases. Well-dressed women and men, whose aspect proves them to be at least above the necessity of obtaining medical assistance gratuitously, occupy the time of the staff, and deplete the resources of the hospital in respect of valuable drugs to the extent of many thousands of pounds’ worth annually in London alone. Vast numbers of patients attend who are suffering from trifling ailments which need but the simplest home remedies for their cure. On the other hand, children and adults of both sexes go week after week to the out-patient department, when every time they leave their room for the purpose, the exposure, the necessary fatigue, the long waiting in draughty and over ventilated rooms, does them more harm than any medical treatment they can receive, under such circumstance, can do good. All this happens within the perfect knowledge of the staff, who, so far from discountenancing the system, encourage the patients to attend regularly, and seldom dissuade them till the last days of the poor creatures’ existence. The reasons for such policy, held to be paramount are these:

First; the greater the number of patients who seek the aid of the charity, the greater claim the committee can make on the purses of the charitable.

Again; the greater the number of the cases in hand day after day, the more chance there is of getting hold of rare and interesting complaints for their own notes and statistics; and for clinical teaching for their students, who attend the out-patient department with great assiduity. But even the simplest and least complicated case has its uses for demonstration to the students. Here is a case of commencing phthisis; there is one still more advanced; another is in the last stage; and all afford good opportunities for demonstrating a multitude of points useful for the tyros in medicine to know. A half-dead woman, with lungs far advanced in the destructive changes of pulmonary consumption, applies for treatment. She is examined with care and kindness by the physician, who, having satisfied himself as to the nature and progress of the disease, makes the requisite notes of her case, and hands her over to his class for perhaps a dozen more fatiguing examinations. She has been waiting probably two or three hours for the interview, for another hour or more she must be stethoscoped, percussed, pounded and pummelled, while the students are picking up from her emaciated and wasting frame the elements of their profession. Nobody at the hospital supposes for a moment they can do her any good, but she offers herself in her ignorance, day after day, a sacrifice on the altar of science, that her abnormal breathing sounds, and other phenomena of disease may teach young men how to earn a respectable living. Then, again, there are a vast number of minor operations, for the performance of which, by novices, the out-patient departments afford peculiar facilities. How much it adds to the terror, nervous apprehension, shame and mental distress of the patients, who cannot but feel often how greatly their trouble and risks are increased by their performances as school experiments, can be readily imagined. No doubt medical men do as much work for nothing as other professional men, but certainly not more—not nearly so much as clergymen, for instance. Yet, the hospitals do not pay their staff for all the time and labour devoted to its work. How, then, are they paid? In the first place, their students are constantly going into practice on their own account; they will require well-known and trusted consultants and operators to assist them in difficult cases occurring in well-to-do and affluent families; they will introduce them in this way to lucrative practice, ever increasing if they are skilful men. Every one of their students, therefore, becomes an agent for their success. Even the patients who have received benefit will often be able to recommend to richer relatives or friends, masters or mistresses—as in the case of workpeople or servants—the doctor who has helped them to a cure. It is in this way the great practices of the greatest men attached to the hospitals have all been founded and maintained. That they should devote themselves to the interests of their pupils is, then, of the first importance, as, in a few years, the kindnesses shown to them will be coming back in a steady flow of guineas.

At the close of the second winter session, the men are expected to be ready for the first professional examination at the College of Surgeons, in anatomy and physiology. It is the desire of both teachers and the hospital itself, that as large a proportion as possible of the students shall present themselves for examination at the regular time, as the credit of the school depends on the proportion of passes. Every effort is made to urge the men on, and the teaching staff take the utmost pains to perfect the knowledge of their pupils, and thoroughly instruct them in the subjects they will be required to know. They hold test examinations, and send the men up in batches; those of most promise go up first, while the backward ones are detained till the last efforts have been put forth to fit them for the day of trial. Elsworth was sent up in the first batch, and passed creditably. Having thus proved that he had a sufficient knowledge of the rudiments of his work, he was at once permitted to act as a dresser or surgeon’s assistant in the wards of the hospital proper. This is the first bit of promotion which the successful student obtains. The nurses could do pretty well all the work he has to do, as far as the dressing goes; but this is purposely left to him, that he may pick up instruction and experience.