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INTRODUCTORY  LECTURE
Clinical  Course
PHILADELPHIA   HOSPITAL,
FOR THE WINTER OF 1855-6. r. uO^/A
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    r>i?,. robert  k:.  sis4[iTia:3

Chief Resident Physician and President of the Medical Board of the Philadelphia
              Hospital, Blockley.
OCTOBER lOth, 1856.
PHILADELPHIA
W  K,
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    KING & BAIRD, PRINTERS, No. 9 SANSOM STREET.   |j

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INTRODUCTORY  LECTURE
Cliitial  Course
PHILADELPHIA  HOSPITAL,
FOR THE WINTER OF 1855-6.
    3DR-  ROBERT  IK.  SIMHTH,

Chief Resident Physician and President of the Medical Board of the Philadelphia
               Hospital, Blockley.
OCTOBER lOth, 1856.
            PHILADELPHIA:

KING & BAIRD, PRINTERS, No. 9 SANSOM STREET.

                   1855. 
I 
CORRESPONDENCE.
                                  West Philadelphia, Oct. 15th, 1855.
Dr. Robt. K. Smith.
     Dear Sir :
   At a Meeting of the  Guardians of  the  Poor this afternoon, the  fol-
lowing Extract from the Minutes of the Medical Board of the Philadel-
phia Hospital was presented:

                                       Philadelphia, Oct. 10th, 1855.
   At a Special Meeting of the Medical Board of the Philadelphia Hos-
pital, on  motion of Dr.  Caspar Morris, the following Resolution was
unanimously adopted.

   Resolved, That we have listened with great satisfaction to the highly
interesting and appropriate Lecture of Dr. Robt. K. Smith, introductory
to the Clinical Course of instruction, and respectfully recommend to  the
Board of  Guardians, the publication of the same, for  distribution among
the Medical Classes of our City.
                                                J. L. Ludlow,
                                        Secretary of Medical Board.

  The Communication  was referred  to  the Hospital Committee, with
authority to publish.  You will therefore please furnish the manuscript.
                       Very respectfully, yours,
                                            Jas. N. Marks,
                                     Chairman Hospital Committee. 
4
                                      Philadelphia, Oct. 10$, 1855.
To the Board op Guardians, &c.
    Gentlemen :
  By order of the Medical Board, and with great personal gratification,
I have the honor to transmit to you the following Resolution of the Board,
passed at a Special Meeting, held October 10th,  1855, at the Hospital.
                 Respectfully, your Obedient Servant,
                                             J.  L. Ludlow,
                                       Secretary of Medical Board.
  Resolved, That we have listened with great satisfaction  to the highly
interesting and appropriate Lecture of Dr. R. K. Smith, introductory to
the Clinical course of instruction,  and respectfully recommend to the
Board of Guardians the publication of the same, for distribution among
the Medical Class of our city.
                                            J. L. Ludlow,
                                     Secretary of Medical Board.
Guardians' Room, No. 36

                                Philadelphia, October 15th, 1855.
North Seventh Street
.}
  At a Stated Meeting of the Board of Guardians, held this day, the fol-
lowing, among other proceedings, were had, viz.:
  Resolved,  That the Communication from  the  Medical Board of the
Philadelphia Hospital, be  referred to the  Hospital  Committee,  with
authority to have the Lecture of Dr. R. K. Smith,  President of the
Medical Board, printed for distribution, as recommended in said  commu-
nication.
                                            S. Snyder Leidy,
                                                        Secretary.
                             Philadelphia  Hospital,  Oct. 16$, 1855.
Dear Sir :
  In transmitting to you the manuscript of my Lecture for  publication,
permit me to say, that the flattering  testimonial of the Medical Board,
and the complimentary action of the Guardians of the  Poor, in respond-
ing so promptly to their recommendation, demands a ready compliance
with your request.
  These evidences of good-will on  the  part  of those with whom I am
officially connected, I shall ever remember with pleasure, and hope  that
nothing may occur to  mar or disturb those friendly relations to which, in
some degree, I may be indebted for this gratifying mark of your appro-
bation.
                        Very truly, Your  friend,
  m   t   -vt  u      -,-,                          Robt. K. Smith.
  To  Jas. N. Marks, Esq.,
          Chairman Hospital Committee. 
INTRODUCTORY LECTURE.
  Gentlemen :—
  I offer you a cordial greeting; and in the  name of  the
Managers and Board of Instruction, welcome you to the Wards
and the Lecture Room of the Philadelphia Hospital.
  The custom which prevails at the commencement of  every
course of instruction—indeed I may say of every lecture—of
receiving the lecturer with noisy demonstrations of  applause ;
I feel, in this place, constrained to  condemn.  Need I say to
you, gentlemen, that the sick, tho suffering, and  excitable sur-
round you ?  That the patients of the clinic, and the insane ;
those whose ears are painfully acute, and who are tremblingly
aliVe  to every thing that disturbs the  order and monotony of
their  lives, are within  the sound of my voice ?  And need I
tell you more  than this  to  induce you to withhold, in this
place, every boisterous evidence of your approval or condem-
nation ?
  We are now entering upon a  course of instruction which has
for its object, not  only the preparation of the student for the
honors of the doctorate, but also his fitness for the performance
of the arduous and responsible duties of his future professional
career.   That student  whose ambition  is limited to the attain-
ment of his  degree, and  who  does not earnestly desire,  and
labour to perfect himself in those qualifications which must en-
sure  success and usefulness  in his profession, may no  doubt
realize his anticipations, without the opportunities that are now
offered to you.   But depend upon it, gentlemen, the man who 
6
 does not avail himself of these advantages, must, in the earlier
 years of his practice, want  that  clearness of discrimination ;
 that confidence in his own judgment; and that firmness of pur-
 pose ; which  such instruction, and such  experience, alone  can
 give.
   The teaching of the schools and of the bed-side, go hand-in-
 hand, and are equally indispensable in  forming the thoroughly
 practical  physician.    The  schools  confer  a knowledge of  the
 history, description, and classification of disease in all its forms.
 There the material is furnished, and the foundation laid, upon
 which the whole structure of your professional ability must
 rest.  It matters not how much may have been your practical
 advantages, or how large your experience; without  the train-
 ing  of the schools; the acquisition of the rudimental branches
 of the science; the theories  and  doctrines of the profession ;
 and the discipline, which must prepare your minds for a proper
 exercise of judgment, and  appreciation  of all  the various rela-
 tions  and phenomena which  exist in  the  derangements  of
 disease;  I say without this basis, your practice must be em-
 pirical, and success  an  accident.   On  the other hand,  where
 clinical instruction has been neglected; the mind may be stored
 with the  rich treasures of  medical literature; the memory
 strengthened  by its  constant exercise  in grasping the  almost
 numberless truths which are daily presented; and when the
 day  of trial comes,  by  unwearied diligence,  the  persevering
 student may even attain the most brilliant prizes  in the honors
 that await him, yet without the experience which is only to be
 obtained at the bed-side of the patient,  he must realize in the
 stern realities  of the  sick room, that  he is in  theory a physi-
 cian, but in practice a bungler.
   Rational and empirical physicians have existed from the earli-
 est days of medicine.  By the combination  of theory and experi-
 ence, and by applying them in the investigation of every medical
 fact, the  rational physician has succeeded in securing for the
 science that high and  honorable position it now so proudly occu-
pies : while at the same time, the empiric has pursued his onward 
7
course of experience, unaided by the ground-work of a medical
education ; unable to found correct reasoning upon his collected
facts ; incapable of deducing from them fixed principles for his
guidance, and so totally powerless to employ this experience in
the augmentation of either usefulness or knowledge, that the
name has become a by-word and reproach to the profession.
   It is to  make you  safe  and efficient practitioners, that the
teaching of the schools and the hospitals are united.   In the
practice of this hospital it is our object to give you the most
ample opportunities for observation.  We expect to be able to
show you,  during the  present  course, nearly  every  form  of
disease you may be called upon to attend.   Those cases which
are of most frequent occurrence, and are consequently of most
importance to you—in a practical point of view—will be most
frequently  presented ; we intend to exhibit to you the various
changes that take place in the same cases, that you may be able
to trace step by step their vicissitudes, whether they result in
death or recovery, and enable you to decide upon the usefulness
of the agents employed, from your own experience.
   In  this way, it is our object to pursue a rational course of
instruction.  You are not to expect at every succeeding visit
here, to see an entire change in the programme of performance,
in order either to amuse or astonish you.  Ours is  a plain and
practical school of  experience, where there are no  jealousies,
and no rivalry ; except that rivalry which seeks the elevation
of the science of  medicine, and that jealous care of the suffer-
ing, that tends to the alleviation  of human misery.
   It  may, however, be argued, that the Clinics established by
many of the colleges, anticipate  for the student every advan-
tage  and opportunity the Hospital presents;  and that every
argument  in favor  of hospital attendance  applies with  equal
force to  the clinical  lectures  of  our city schools.   This  argu-
ment, so far as the dazzling operations in surgery which may
take place in this amphitheatre, are concerned, may be a valid
one ;  and I am not unwilling to admit that all such operations,
whether they be performed in your presence, here or elsewhere, 
8
are equally meritorious.  But, gentlemen, let me assure you,
that whilst there is in the system of Hospital teaching, nothing
else, that the most  zealous friend of the College Clinic can seize
upon as an apology for this fungous growth upon the legitimate
province of such institutions; there is at the same time nothing
else in the  College Clinic, that is not deserving of the severest
reprobation.   You are to  remember, that the  schools offer you
the Clinic, as a substitute  for the  Hospital: you  are  called
upon to consider whether  they are coincident in point of prac-
cal advantages.   You are  to  investigate  the pretensions of
these school exhibitions, with a view to their utility;  and you
are to decide whether these " Glorious Operations,"  with the
attendant display that surrounds them; this grand feature and
ultimatum which is to give eclat and attractiveness to the insti-
tution ; and which almost bewilder you  in contemplating the
danger, temerity, and skill involved in their performance ;  can
by any possible contingency, afford you the knowledge  which
the plain every day duties of your profession must necessarily
demand.  I do not  say, gentlemen, that  these capital opera-
tions in surgery are unimportant  or unnecessary;  they are
neither the one nor  the other;  and you should as well  be in-
structed  in them,  as in every thing else appertaining to your
profession; but I  do say, that such clinics can never be suc-
cessfully substituted for the  practical  teaching of the wards of
the Hospital.
  Have you never reflected, that such cases will be to you,
in the beginning  of practice, " like angel's visits;"  and that
some stern  necessity, or sudden emergency, only, could induce
you to attempt their treatment.  Have you not discovered that
it is the common and daily cases of the acute  form of disease
that you will most frequently be  called upon to see, and that
with you, it is  only in the  Hospital that this kind of experience
can be best obtained ?   And have you never observed, that in
the clinics  of the  schools, the transitory cases presented, are
such, as are generally unusual in appearance, and chronic in
their character ?   How then can you in justice to yourselves, 
9
and  the  profession you  have  chosen, rest satisfied with this
defective and miserable substitute.
  I have thus far, confined myself, to the Hospitals, as an im-
portant element in practical medical education; and it may not
be improper in this connection, for me to say something, of the
one over which I have the honor to preside.
  The Philadelphia Hospital  and  Lunatic Asylum  have an
average  population of about nine hundred, and contain  about
one thousand beds for the reception of patients.  The number
of patients now occupying beds in the institution is eight hundred
and  eighty.   The Hospital proper in the men's department, is
divided into the surgical; black and white venereal; black and
white medical; drunkards ; and eye  wards.   In  the  women's
we have the black and white surgical; black and white medical;
black and white  obstetrical; drunkards; and venereal wards.
There is  also the children's department;  comprising the nursery
and  children's Asylum; where diseases incident to infancy and
childhood, receive attention.  In addition to these is the Lunatic
Asylum ;  where the insane sick are treated; and beyond the en-
closure, is the Small Pox  Hospital.  Belonging to the institution,
is a  library of rare and valuable medical works, many of  which
are no where else to be found in  this country.  It is  to  be re-
gretted, that, in an institution like this, so  rich in  material, no
pathological museum has been established; and I am  at a loss
to account for this oversight on the  part of its former medical
officers, unless  it be upon the supposition—which I am free to
confess is a selfish one—that in the insecurity of the  position,
they might be deprived of enjoying  the fruits of their labors.
It is my  purpose, however, with the assistance of my colleagues,
and  the generosity of the Board of Guardians, to commence its
foundation; and I firmly believe, that with  the  facilities  at
command, in a very few  years, such a cabinet would be unsur-
passed by any  other in the Union.   There is, notwithstanding
this  absence, no  scarcity of pathological  specimens, from the
recent subject; and the board looking to your special  improve-
ment, will avail themselves of everything in this department 
10
that will afford you a useful lesson.  You must perceive, gentle-
men, that in the constitution of the present medical board the
interests of no particular school have  been consulted.   And I
would have you bear in mind that  this Hospital cannot  be
made an instrument for  the  advancement  of  any one  institu-
tion above another.  Students will meet  here  on terms of the
most perfect equality, and they will be  entitled to the same
consideration  and  advantages,  whether they come from  the
oldest or youngest  school in the country.  My colleagues  in
the clinical board, have been selected by the managers  with
a view to the best  interests of this Hospital, and  the cause of
medical education.   They are known to most of you, as gentle-
men distinguished in their  respective  departments of the  pro-
fession, and entitled to your  confidence and respect.   The
terms of  service, and the  hours for lectures,  have been  so
arranged, as to secure efficient teachers, and  not disturb  the
ordinary routine of other studies.  Besides the usual clinics, it
has been decided by the board, that a series of  lectures shall
be  delivered upon  disorders of the  mind,  in order  that  the
subject of insanity may be brought before you in a more prac-
tical light.  There is no question, gentlemen,  but that  mental
diseases, are in this country, rapidly on the increase.  The
number of cases to be met with in private  practice; the accu-
mulation of public institutions, for the reception of such cases ;
and the well filled wards  of this asylum,  loudly attest this
alarming  truth.  Few opportunities  are presented, under the
present system of education, for you to become acquainted with
this class  of diseases ; the  importance of which, you will most
certainly  realize in the prosecution of your  profession.  We
propose, for the first time in this country, to show you, prac-
tically, all the different varieties of  mental aberration.  Not
only to investigate the phenomena of insanity, but to illustrate
the subject  from the wards  around you.   We  trust, that by
these means, you may become acquainted with  the diversified
aspects of this  alarming malady; and that  an impulse will be
given to a more careful and studious examination, and rational 
11
treatment of such cases.   There is near us another institution,
devoted to the insane, which you would do well to visit.  I refer
to the Lunatic Department  of the  Pennsylvania Hospital.   Its
plan and arrangements, and the rational principles upon which
this class of patients are  there  treated will  afford you an in-
structive lesson.  The views and suggestions of its experienced
superintendent, are worthy  of your serious  consideration, and
you ought by no means to allow the opportunity for making  a
personal visit  to pass, without embracing it.
   The diseases of children, the department of obstetrics, and
the sexual diseases of women;  have also a place in the clinic
of this hospital.   A portion  of your time will therefore be occu-
pied with these branches of study,  and every facility compatible
with a proper regard, to female delicacy, and the necessities of
such cases; will be  afforded  you for their investigation.
   From what  has been already said in this  description of the
institution, and the  arrangments  made for  your  benefit, you
will be able to  decide, upon  the  comparative advantages we
offer; and to understand what it is you are  to expect from us,
in the relations we  sustain to each other, as  teacher and pupil.
   And, gentlemen, you are  to remember, that there is also on
your part,  a duty to be performed.
   The profession to  which  you have  devoted yourselves, de-
mands the exertion of the highest faculties you  possess.   To
excel  in it, every hour must  be diligently employed, and every
opportunity improved.  You who are already familiar with its
elementary departments ;  who have, in the schools and dissect-
ing room, acquired  a knowledge of anatomy and  physiology ;
who understand the healthy organization and functions of the
body, are prepared to appreciate  the diseased, to follow the
surgeon's knife, and to  read  in  the  dimmed eye the pallid
cheek, the disturbed pulse, the unsteady hand, and the rattling
lung,  a living  lecture.
  Disease may exist, and continue  to undermine the health, yet
show  to  the inexperienced  observer,  no  outward  sign.  But
when  the man  of experience  examines the pulse and the tongue ; 
12
the condition of the skin; the expression of the face and the
eye ;  the posture of the body; the respiratory sounds; and  a
variety of other circumstances affecting the hidden malady; he
sees by these unfailing  lights every point and position  he is
required to assail.   To do this, gentlemen, you will be required
to examine with  the most  careful scrutiny, every probability
that may be suggested as likely to control or modify the usual
progress of disease.  You must fix upon the  memory, by the
most  watchful  attention, every principle developed  in the
theory, the practice, and pathology of the  science.   In the
hospital and dead house, this vigilance is  especially desirable.
It is there that  the lessons of the schools are to be applied, and
a comparison made, of  the  doctrines and precepts you have
been taught, with the facts as  they exist.   Without this vigi-
lance, the labours of the teacher for your improvement, will be
of little value.   To  realize  the full benefit of his instruction,
there must be on your part, earnestness of observation, economy
of time, indefatigable industry, and  a systematic arrangement
of studies.
  The intelligent application of  the principles of medicine, is
not the mere administration of  certain remedies to  different
disordered conditions of the system, which may be easily ascer-
tained, and which pursue in  analogous diseases, the same un-
varying course.  Were this  the case, a preparation for the
duties  of the physician would be a comparatively easy  task.
The human  body obeys natural laws, and  is not often subject
to abrupt  transitions.   Disease is  induced  by unsuspected
causes;  and  often exists  entirely  unobserved, until  some
palpable result demands a  remedy.   Every deviation  from
health is a condition of disease ; which may be aggravated,
modified, mitigated or removed, according to the circumstances
by which it is surrounded.  These varying conditions and cir-
cumstances  may require your  interposition ;  and it is of the
utmost importance  that clear discrimination, and  intelligent
reasoning,  should direct every professional  act.   The  chief
end in view, in  your visits here, should be to attain this ability. 
13
If you carelessly stroll through the wards, for the gratification
of an idle curiosity; if you indifferently follow your teacher to
the bed-side, with  a disposition simply to perform an  irksome
but compulsory duty; if you listen to the elucidation of the
cases that are brought before you, with languishing attention ;
and suffer your minds  to be diverted from the practical points
which  these  cases exhibit; you may rest assured, that these
unimproved opportunities, and mis-spent  time, will be to you
in after life, an unceasing source of regret.  No student can be
called to  the bed-side, and have an exhibition of all the posi-
tive, tangible points of  the case  clearly  demonstrated to his
fixed attention, without an awakened interest; and no student
can leave  that  bed-side, whose disposition has been teachable,
and who has exercised his powers of observation, without profit.
It is well, then, to impress upon you the importance of these
visits, and the necessity for a methodical and carefully  digested
arrangement of all the facts subjected  to your scrutiny.  The
impressions left upon the mind must be something more than a
mere unarranged  and confused mass  of incidents, that have
served to amuse and  while away an hour, or  your  hospital
experience will be  productive  of no  permanent  good; and
when you desire to apply it, of no practical value.  When you
come into practice, you will meet with cases that  are described
in no text books ;  you will be called upon to administer aid in
emergencies, for which the lecture-room has not prepared you;
and  amid the thousands  of human ills, you must  necessarily
find complications and difficulties to be  encountered, that  no
system of teaching,  and  no human foresight, could anticipate.
It is then, that a ready adaptation of  the knowledge you have
acquired will be called into play; and the exercise  of plain,
practical  good sense,  fortified by study  and experience, and
quickened by the vigilant  employment of your  faculties, will
relieve you in every  embarrassing position.
  Gentlemen, you may talk learnedly of  the  science of medi-
cine; you maybe familiar with all its most gifted authors; you
may see in the phenomena of the diseases subjected  to your 
                            14

care, clear and beautiful  illustrations which confirm some fa-
vorite theory; and when death comes to your patient, you may
be able to select and prepare from the disease, which you have
watched  in  its uninterrupted course, rare and valuable speci-
mens  of morbid anatomy;  but remember, gentlemen, that in
all this, there is more of  the naturalist than physician.  The
first care of the physician is  to interrupt and arrest this morbid
action;  to give back  to his  patient  that which has been lost;
and to employ whatever real science he may possess, not simply
in verifying  his own peculiar views, in  tracing  the order of
symptoms he has been taught to expect, or in the pursuit of an
abstruse  philosophical inquiry for his own benefit, but to restore
to health  and usefulness, a fellow being.   Another point in this
connection, to which I would especially direct your attention, is
the propriety of impressing  indellibly upon the  memory,  the
symptoms and phenomena which  are the  usual characteristics
of  disease.   Look well to every condition that exhibits an
indication of the peculiar morbid action ;  examine carefully all
the ordinary and prominent features  of the case that esta-
blish a diagnosis, and study with  interest every evidence upon
which a rational opinion of its character, progress, and  proba-
ble termination may be founded.   The more common the dis-
ease, the  more careful should be the scrutiny; and although
you should not permit those extraordinary traits, to  be found
in many cases, to escape your observation, you should be care-
ful in investigating them, not to  lose sight of such as are of
more  importance.   Avoid every specialty in the classification
of  symptoms that would tend to  limit the various diseases to
any one  set of organs  or functions ; but examine  the  whole
from  a stand point that will include every derangement, and
every morbid action that is  developed.
   Gentlemen, your pursuits and opportunities in  an institution
like this—a receptacle for every  disease incident to the indi-
gent and depraved population of a great city—must necessarily
render you  familiar with many of the most  humiliating  and
revolting phases of human life.   Do not permit these exhibi- 
15
tions of debasement to diminish the  respect you owe to your
fellow men or yourselves, to extinguish your feelings of com-
miseration for the unfortunate, or to dry up those fountains of
sympathy which  should ever flow towards those, who  by the
reverses and  vicissitudes of  fortune, are subjected to your care
and compassion.
  The instruction which they furnish  is not simply the amount
of scientific information to be acquired, but practical lessons of
morality, of far greater value.
  Some of you, gentlemen,  are probably for the first time, ex-
posed to the allurements and temptations which a large  city so
freely presents.   Remember that these living monitors warn
you of danger;  they witness that the fruits of  unlawful plea-
sure and  vicious habits,  are poverty and disease; and they
serve as beacon  lights to guide you  in the paths of virtue, to
future usefulness and peace.
  Remember that parental  affections, and earnest friendly so-
licitude are  hopefully clustering around you.  Do  not disap-
point the fond hearts that so ardently yearn for your prosperity
and  happiness.   Do not  betray the confidence that is reposed
in you ; but  by faithfulness in the performance  of duty, devo-
tion to study, and uniform  good conduct, enable your friends
to realize, that  the sacrifices, the  anxiety, and care  for your
welfare, have been  abundantly rewarded.
i