AMONGST THE OUT-PATIENTS.
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._
MOSCA. And then, they do it by experiment,
For which the law not only doth absolve them,
But gives them great reward, and he is loath
To hire his death so.
CORBACCIO. It is true, they kill
With as much license as a judge.
—_Ben Jonson._
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.