In 1897 Somerset Maugham (1874–1965) qualified as a physician but never practiced medicine and became a full-time writer.¹ In his 1915 novel Of Human Bondage he drew on his experiences at St. Thomas’s Hospital to describe what it was like to be a medical student at that time.

He first has his young protagonist practice bandaging on out-patients, glad to earn a little money, learning auscultation and how to use the stethoscope, preparing to take the examination in Materia Medica, learning dispensing, concocting mixtures, rolling pills, and making ointments.

He then becomes an out-patients’ clerk to the popular Dr. Tyrell, who saw patients two days a week, a successful physician with a large consulting practice and a knighthood in prospect. With students and poor people he had a patronizing air; with the sick he had a jovial condescension, making the patient “feel like a boy confronted by a jolly schoolmaster; his illness was an absurd piece of naughtiness which amused rather than irritated.”

The students had to attend the out-patients’ room every day, seeing cases in a large, dark waiting-room where patients waited in long rows, some tattered and dirty, others decent enough, sitting in the dimness and suggesting the grim drawings of Daumier in an atmosphere of disinfectants mingling with the crude stench of humanity. The examining rooms had a table and an office chair for the physician and two smaller tables for the house-physician and for the medical student who did the clerking in a large book where was written down the name, age, sex, and profession of the patient and the diagnosis of his disease.

At half past one the house-physician came in, rang the bell, and told the porter to send in the old patients. It was necessary to get through as many of them as possible before Dr. Tyrell came at two. He set about the cases. A clerk helped him. The patients streamed in. The men came first. Chronic bronchitis, “a nasty ’acking cough,” was what they chiefly suffered from; one went to the house physician. and the other to the clerk… and they went to the dispensary to have medicine given them for fourteen days more. Some patients held back so that they might be seen by the physician himself, but they seldom succeeded in this; and only three or four, whose condition seemed to demand his attention, were kept.

Dr. Tyrell came in with quick movements and a breezy manner. His air seemed to indicate: What’s all this nonsense about being ill? I’ll soon put that right. He took his seat, asked if there were any old patients for him to see, rapidly passed them in review, cracked a joke (at which all the clerks laughed heartily), then rang the bell for the porter to show in the new patients.

They came in one by one and walked up to the table at which sat Dr. Tyrell. They were mostly of the laboring class, dock laborers, draymen, factory hands, barmen; but some, neatly dressed, were of a station which was obviously superior, shop-assistants, clerks, and the like. Dr. Tyrell looked at these with suspicion. Sometimes they put on shabby clothes in order to pretend they were poor; but he had a keen eye to prevent what he regarded as fraud and sometimes refused to see people who he thought could well pay for medical attendance. Women were the worst offenders and they managed the thing more clumsily. They would wear a cloak and a skirt which were almost in rags, and some neglected to take the rings off their fingers.

“If you can afford to wear jewellery you can afford a doctor. A hospital is a charitable institution,” said Dr. Tyrell, and called for the next case. “You get out. You’ve got no business to come and steal the time which is wanted by the really poor.”

“She’ll probably write a letter to the papers on the gross mismanagement of the London hospitals,” said Dr. Tyrell, with a smile, as he took the next paper and gave the patient one of his shrewd glances. Most of them were under the impression that the hospital was an institution of the state, for which they paid out of the rates, and took the attendance they received as a right they could claim. They imagined the physician who gave them his time was heavily paid.

Dr. Tyrell gave each of his clerks a case to examine. The clerk took the patient into one of the inner rooms. Each had a couch in it covered with black horse-hair: he asked his patient a variety of questions, examined his lungs, his heart, and his liver, made notes, formed in his own mind some idea of the diagnosis, and then waited for Dr. Tyrell to come in. This he did, followed by a small crowd of students, when he had finished the men, and the clerk read out what he had learned. The physician asked him one or two questions, and examined the patient himself. If there was anything interesting to hear students applied their stethoscope: you would see a man with two or three to the chest, and two perhaps to his back, while others waited impatiently to listen. The patient stood among them a little embarrassed, but not altogether displeased to find himself the center of attention: he listened confusedly while Dr. Tyrell discoursed glibly on the case. Two or three students listened again to recognize the murmur or the crepitation which the physician described, and then the man was told to put on his clothes.

When the various cases had been examined Dr. Tyrell went back into the large room and sat down again at his desk. He asked any student who happened to be standing near him what he would prescribe for a patient he had just seen. The student mentioned one or two drugs. “Would you?” said Dr. Tyrell. “Well, that’s original at all events. I don’t think we’ll be rash.”

This always made the students laugh, and with a twinkle of amusement at his own bright humor the physician prescribed some other drug than that which the student had suggested. When there were two cases of exactly the same sort and the student proposed the treatment which the house-physician had ordered for the first, Dr. Tyrell exercised considerable ingenuity in thinking of something else. Sometimes, knowing that in the dispensary they were worked off their legs and preferred to give the medicines which they had all ready, he amused himself by writing an elaborate prescription.

“We’ll give the dispenser something to do.” The students laughed, and the doctor gave them a circular glance of enjoyment in his joke. Then he touched the bell and, when the porter poked his head in, said:

“Old women, please.”

He leaned back in his chair, chatting with the house physician, while the porter herded along the old patients. They came in, strings of anemic girls, with large fringes and pallid lips, who could not digest their bad, insufficient food; old ladies, fat and thin, aged prematurely by frequent confinements, with winter coughs; women with this, that, and the other, the matter with them. Dr. Tyrell and his house-physician got through them quickly. Time was getting on, and the air in the small room was growing more sickly. Dr. Tyrell looked at his watch.

“Are there many new women today?” he asked.

“A good few, I think,” said the house physician.

“We’d better have them in. You can go on with the old ones.” They entered. With the men the most common ailments were due to the excessive use of alcohol, but with the women they were due to defective nourishment. By about six o’clock they were finished. Philip, exhausted by standing all the time, by the bad air, and by the attention he had given, strolled over with his fellow-clerks to the medical school to have tea.

Notes

1. JMS Pearce. Somerset Maugham. Hektoen International Spring 2021.
2. By 1962 the arrangements in English outpatient departments were still in part reminiscent of what Somerset Maugham had described in his book. (Editor-in-Chief, Hektoen International)