At the beginning of the winter session Philip became an out-patients' clerk. There were three assistant-physicians who took out-patients, two days a week each, and Philip put his name down for Dr. Tyrell. He was popular with the students, and there was some competition to be his clerk. Dr. Tyrell was a tall, thin man of thirty-five, with a very small head, red hair cut short, and prominent blue eyes: his face was bright scarlet. He talked well in a pleasant voice, was fond of a little joke, and treated the world lightly. He was a successful man, with a large consulting practice and a knighthood in prospect. From commerce with students and poor people he had the patronising air, and from dealing always with the sick he had the healthy man's jovial condescension, which some consultants achieve as the professional manner. He made 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 student was supposed to attend in the out-patients' room every day, see cases, and pick up what information he could; but on the days on which he clerked his duties were a little more definite. At that time the out-patients' department at St. Luke's consisted of three rooms, leading into one another, and a large, dark waiting-room with massive pillars of masonry and long benches. Here the patients waited after having been given their `letters' at mid-day; and the long rows of them, bottles and gallipots in hand, some tattered and dirty, others decent enough, sitting in the dimness, men and women of all ages, children, gave one an impression which was weird and horrible. They suggested the grim drawings of Daumier. All the rooms were painted alike, in salmon-colour with a high dado of maroon; and there was in them an odour of disinfectants, mingling as the afternoon wore on with the crude stench of humanity. The first room was the largest and in the middle of it were a table and an office chair for the physician; on each side of this were two smaller tables, a little lower: at one of these sat the house-physician and at the other the clerk who took the `book' for the day. This was a large volume in which were written down the name, age, sex, 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. There were always a good many of these, and it was necessary to get through as many of them as possible before Dr. Tyrell came at two. The H.P. with whom Philip came in contact was a dapper little man, excessively conscious of his importance: he treated the clerks with condescension and patently resented the familiarity of older students who had been his contemporaries and did not use him with the respect he felt his present position demanded. 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 H.P. and the other to the clerk, handing in their letters: if they were going on well the words Rep 14 were written on them, and they went to the dispensary with their bottles or gallipots in order to have medicine given them for fourteen days more. Some old stagers 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. He reminded one slightly of a clown leaping into the arena of a circus with the cry: Here we are again. 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, looking at them with shrewd eyes as he discussed their symptoms, cracked a joke (at which all the clerks laughed heartily) with the H.P., who laughed heartily too but with an air as if he thought it was rather impudent for the clerks to laugh, remarked that it was a fine day or a hot one, and 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 old men and young men and middle-aged men, mostly of the labouring class, dock labourers, 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 neglect 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.

He handed back the letter and called for the next case.

"But I've got my letter."

"I don't care a hang about your letter; you get out. You've got no business to come and steal the time which is wanted by the really poor."

The patient retired sulkily, with an angry scowl.

"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; they were smaller, and 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 of fact on the hospital letter, 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 centre of attention: he listened confusedly while Dr. Tyrell discoursed glibly on the case. Two or three students listened again to recognise 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 humour 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 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, the good hospital mixtures which had been found by the experience of years to answer their purpose so well, he amused himself by writing an elaborate prescription.

"We'll give the dispenser something to do. If we go on prescribing mist: alb: he'll lose his cunning."

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 H.P. while the porter herded along the old patients. They came in, strings of anaemic 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. The physician looked at his watch.

"Are there many new women today?" he asked.

"A good few, I think," said the H.P.

"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. He found the work of absorbing interest. There was humanity there in the rough, the materials the artist worked on; and Philip felt a curious thrill when it occurred to him that he was in the position of the artist and the patients were like clay in his hands. He remembered with an amused shrug of the shoulders his life in Paris, absorbed in colour, tone, values, Heaven knows what, with the aim of producing beautiful things: the directness of contact with men and women gave a thrill of power which he had never known. He found an endless excitement in looking at their faces and hearing them speak; they came in each with his peculiarity, some shuffling uncouthly, some with a little trip, others with heavy, slow tread, some shyly. Often you could guess their trades by the look of them. You learnt in what way to put your questions so that they should be understood, you discovered on what subjects nearly all lied, and by what inquiries you could extort the truth notwithstanding. You saw the different way people took the same things. The diagnosis of dangerous illness would be accepted by one with a laugh and a joke, by another with dumb despair. Philip found that he was less shy with these people than he had ever been with others; he felt not exactly sympathy, for sympathy suggests condescension; but he felt at home with them. He found that he was able to put them at their ease, and, when he had been given a case to find out what he could about it, it seemed to him that the patient delivered himself into his hands with a peculiar confidence.

"Perhaps," he thought to himself, with a smile, "perhaps I'm cut out to be a doctor. It would be rather a lark if I'd hit upon the one thing I'm fit for."

It seemed to Philip that he alone of the clerks saw the dramatic interest of those afternoons. To the others men and women were only cases, good if they were complicated, tiresome if obvious; they heard murmurs and were astonished at abnormal livers; an unexpected sound in the lungs gave them something to talk about. But to Philip there was much more. He found an interest in just looking at them, in the shape of their heads and their hands, in the look of their eyes and the length of their noses. You saw in that room human nature taken by surprise, and often the mask of custom was torn off rudely, showing you the soul all raw. Sometimes you saw an untaught stoicism which was profoundly moving. Once Philip saw a man, rough and illiterate, told his case was hopeless; and, self-controlled himself, he wondered at the splendid instinct which forced the fellow to keep a stiff upper-lip before strangers. But was it possible for him to be brave when he was by himself, face to face with his soul, or would he then surrender to despair? Sometimes there was tragedy. Once a young woman brought her sister to be examined, a girl of eighteen, with delicate features and large blue eyes, fair hair that sparkled with gold when a ray of autumn sunshine touched it for a moment, and a skin of amazing beauty. The students' eyes went to her with little smiles. They did not often see a pretty girl in these dingy rooms. The elder woman gave the family history, father and mother had died of phthisis, a brother and a sister, these two were the only ones left. The girl had been coughing lately and losing weight. She took off her blouse and the skin of her neck was like milk. Dr. Tyrell examined her quietly, with his usual rapid method; he told two or three of his clerks to apply their stethoscopes to a place he indicated with his finger; and then she was allowed to dress. The sister was standing a little apart and she spoke to him in a low voice, so that the girl should not hear. Her voice trembled with fear.

"She hasn't got it, doctor, has she?"

"I'm afraid there's no doubt about it."

"She was the last one. When she goes I shan't have anybody."

She began to cry, while the doctor looked at her gravely; he thought she too had the type; she would not make old bones either. The girl turned round and saw her sister's tears. She understood what they meant. The colour fled from her lovely face and tears fell down her cheeks. The two stood for a minute or two, crying silently, and then the older, forgetting the indifferent crowd that watched them, went up to her, took her in her arms, and rocked her gently to and fro as if she were a baby.

When they were gone a student asked:

"How long d'you think she'll last, sir?"

Dr. Tyrell shrugged his shoulders.

"Her brother and sister died within three months of the first symptoms. She'll do the same. If they were rich one might do something. You can't tell these people to go to St. Moritz. Nothing can be done for them."

Once a man who was strong and in all the power of his manhood came because a persistent aching troubled him and his club-doctor did not seem to do him any good; and the verdict for him too was death, not the inevitable death that horrified and yet was tolerable because science was helpless before it, but the death which was inevitable because the man was a little wheel in the great machine of a complex civilisation, and had as little power of changing the circumstances as an automaton. Complete rest was his only chance. The physician did not ask impossibilities.

"You ought to get some very much lighter job."

"There ain't no light jobs in my business."

"Well, if you go on like this you'll kill yourself. You're very ill."

"D'you mean to say I'm going to die?"

"I shouldn't like to say that, but you're certainly unfit for hard work."

"If I don't work who's to keep the wife and the kids?"

Dr. Tyrell shrugged his shoulders. The dilemma had been presented to him a hundred times. Time was pressing and there were many patients to be seen.

"Well, I'll give you some medicine and you can come back in a week and tell me how you're getting on."

The man took his letter with the useless prescription written upon it and walked out. The doctor might say what he liked. He did not feel so bad that he could not go on working. He had a good job and he could not afford to throw it away.

"I give him a year," said Dr. Tyrell.

Sometimes there was comedy. Now and then came a flash of cockney humour, now and then some old lady, a character such as Charles Dickens might have drawn, would amuse them by her garrulous oddities. Once a woman came who was a member of the ballet at a famous music-hall. She looked fifty, but gave her age as twenty-eight. She was outrageously painted and ogled the students impudently with large black eyes; her smiles were grossly alluring. She had abundant self-confidence and treated Dr. Tyrell, vastly amused, with the easy familiarity with which she might have used an intoxicated admirer. She had chronic bronchitis, and told him it hindered her in the exercise of her profession.

"I don't know why I should 'ave such a thing, upon my word I don't. I've never 'ad a day's illness in my life. You've only got to look at me to know that."

She rolled her eyes round the young men, with a long sweep of her painted eyelashes, and flashed her yellow teeth at them. She spoke with a cockney accent, but with an affectation of refinement which made every word a feast of fun.

"It's what they call a winter cough," answered Dr. Tyrell gravely. "A great many middle-aged women have it."

"Well, I never! That is a nice thing to say to a lady. No one ever called me middle-aged before."

She opened her eyes very wide and cocked her head on one side, looking at him with indescribable archness.

"That is the disadvantage of our profession," said he. "It forces us sometimes to be ungallant."

She took the prescription and gave him one last, luscious smile.

"You will come and see me dance, dearie, won't you?"

"I will indeed."

He rang the bell for the next case.

"I am glad you gentlemen were here to protect me."

But on the whole the impression was neither of tragedy nor of comedy. There was no describing it. It was manifold and various; there were tears and laughter, happiness and woe; it was tedious and interesting and indifferent; it was as you saw it: it was tumultuous and passionate; it was grave; it was sad and comic; it was trivial; it was simple and complex; joy was there and despair; the love of mothers for their children, and of men for women; lust trailed itself through the rooms with leaden feet, punishing the guilty and the innocent, helpless wives and wretched children; drink seized men and women and cost its inevitable price; death sighed in these rooms; and the beginning of life, filling some poor girl with terror and shame, was diagnosed there. There was neither good nor bad there. There were just facts. It was life.