HIGHER MEDICAL EDUCATION IN 
NEW YORK 
11. 
REORGANIZATION OF THE MEDICAL STAFF OF HOSPITALS, 
BY 
E. C. SEGUIN, M. D. 
[Reprinted from the Archives of Medicine, June, 1881] 
NEWYORK 
G. P. PUTNAM’S SONS 
27 & 29 West 23D Street 
1881 HIGHER MEDICAL EDUCATION IN 
NEWYORK. 
11. 
In the editorial article which appeared in the April number of 
the Archives, an attempt was made to show that the present 
medical organization of our general hospitals was unfavorable to 
their inmates, was not calculated to favor the cultivation of 
medical science, and was not such as to afford instruction of a 
higher kind to the internes and to physicians who chose to 
follow the hospital service. 
The chief evils in the medical organization of our hospitals 
were stated to be the comparatively small number of resident 
pupils or internes, the excessive number and unequal capacity of 
attending or visiting medical officers, and, above all, the short 
periods during which they are on duty. 
It is always more easy to criticise and condemn than to build 
up, and I am not as sure of the value of the remedies which I 
shall propose, as I was of the unsatisfactory nature of the system 
I portrayed. 
i. The attending or visiting medical staff should be made 
smaller in all hospitals. That this proposition is not premature 
is shown by the fact that the governors of the New York 
Hospital, and the managers of the Roosevelt Hospital, have 
resolved to allow the number of physicians and surgeons in their 
institutions to fall, by natural means, to four of each class. 
Reprinted from the Archives of Medicine, Yol. v, No. 3, June, 1881. 2 
E. C. SEGUIN'. 
In general terms, the visiting staff might be so reduced as to 
allot between thirty and forty beds to each physician or surgeon. 
Upon the basis of thirty beds to each service, the following 
would be the number of visiting medical officers in each of our 
large hospitals, given in approximate figures : 
Hospital. 
Beds. 
Visiting Staff. 
Charity ....... 
1,000 
33 
Bellevue ...... 
800 
26 
Presbyterian ...... 
St. Luke’s ...... 
100 
3 
200 
6 
New York ...... 
150 
5 
St. Vincent’s ..... 
250 
8 
St. Francis’ ...... 
200 
6 
German ...... 
9° 
3 
Mt. Sinai ...... 
160 
5 
Roosevelt ...... 
180 
I omit from this table the Woman’s Hospital and the Nursery 
and Child’s Hospital, because they are, in all essential par- 
ticulars, special hospitals. 
The larger hospitals, as Bellevue and Charity, might well be 
organized on the basis of one physician to sixty beds, giving the 
former a staff of thirteen, the latter one of sixteen. 
On the other hand, the smaller hospitals, as the German, 
might need a larger staff, say of four or five members. 
2. These physicians and surgeons should be elected by the 
authorities of the hospitals, solely with respect to their pro- 
fessional excellence and reputation, and in such a way as to 
secure for the hospital the services of men able to carry out 
quasi-special work. For example, if two surgeons were to be 
selected, one should be a good general surgeon and the other one 
versed in genito-urinary surgery, syphilis, and dermatology. If 
three or four physicians were to be chosen, one should excel in 
pulmonary and cardiac diseases, another in visceral and consti- 
tutional affections generally, another in diseases of women, and, 
lastly, one should be expert in nervous diseases. 
This brings us to the consideration of the appointment of 
specialists to hospitals. In the first place, in the present state of HIGHER MEDICAL EDUCATION IN NEW YORK. 
3 
hospital organization in New York, no general hospital needs the 
services of an oculist or aurist, except as consulting surgeon, be- 
cause there are well-appointed institutions for the reception of 
eye and ear cases. I am not in favor of the appointment of 
specialists, or quasi-specialists, to duty as specialists, i. e., with 
any title indicating what branch of medicine they prefer. I 
would favor the appointment only of visiting physicians and 
surgeons, leaving it partly to the medical staff to arrange their 
services to suit their tastes. The separation of cases in the 
hospital should, it seems to me, be allowed to take place by 
a process somewhat like natural selection. For example ; 
Dr. A. being well known as an expert in digestive disorders, 
cases of this class might be allowed to go into his service, with- 
out there being any arbitrary, absolute rule about it. Dr. A.’s 
advice might, for example, be also sought by a patient with nervous 
disease, and there need not be any red-tape rule to prevent this. 
People applying at the hospital would learn in time the peculiar 
fitness of the various physicians ; in case of doubt, members of 
the resident staff might be entrusted with a preliminary classi- 
fication of the applicants. 
It may be objected that the managers of hospitals would be 
greatly embarrassed in choosing men in the way suggested; 
i. e., to select men who were eminent, or, what is perhaps better, 
who bid fair to become eminent in certain departments (not to 
use the word specialties') of medicine and surgery. This does 
not seem to me a valid objection, because it is well known that 
such a selection is constantly being made by people as intelli- 
gent, or even less intelligent, than are managers of hospitals, for 
the purpose of obtaining advice and treatment for themselves. 
It is becoming a more and more popular idea, or a better under- 
stood idea, that all physicians are not equally excellent in all 
departments of medicine ; and by the help of common report, 
or by a few inquiries, an educated man goes quite accurately to 
the proper physician or surgeon, specialist or quasi-specialist, 
for advice. The same common-sense which prevents a woman 
with uterine disease from consulting a specialist for pulmonary 4 
E. C. SEGUIN. 
diseases or for nervous diseases, which leads a man with stricture 
to seek the help of one of a comparatively small circle of sur- 
geons, would enable the authorities of a hospital, with the 
advice of their medical staff, to pick out the men who would be 
well calculated to develop and bring to a high degree of effi- 
ciency the various services of the hospital. 
The question as to how the selection should be made, whether, 
as now, upon the recommendation of the medical board and by 
election by the managers, or by universal competition with a rigid 
public examination, is a very important one, and one which pre- 
sents strong points on its various aspects. 
The advantages of the competitive plan are well known. By 
it men are secured simply on the basis of excellence in passing 
through a series of tests ; more self-possessed and clear-headed 
men, men qualified to become good teachers, are likely to be the 
successful candidates. The frequent personal bias of managers, 
and even of physicians, in the choice of a new member of the 
staff, is thus avoided. 
On the other hand, competitive examinations present some im- 
portant objectionable features. By them the standard of excel- 
lence is made to consist in answering questions well. Now, it is 
an universally admitted fact, that men who have learned the most, 
whose memories are best, are not by any means always the men 
who possess the sound judgment, the courage, and, above all, the 
originality which are needed to make a successful practitioner and 
teacher. This is borne out by the almost complete scientific 
sterility and professional mediocrity of naval and army medical 
staffs, which are filled up under a competitive examination of a 
high order of thoroughness. Still, by making the examination 
consist largely of practical tests, this objection might to a certain 
extent be remedied. 
Selection in the way which now obtains in our hospitals pre- 
sents advantages and disadvantages. Against it may be urged 
the undeniable fact that managers are sometimes led to a choice 
by extra-professional considerations, such as social influence, 
questions of race, religion, etc. On the other hand, if the medical HIGHER MEDICAL EDUCA TION IN NEW YORK. 
5 
board were instructed to present two candidates for the vacant 
place, in order of merit, without “ influence ” from the managers, 
it is quite probable that a good man would be elected, i. <?., a man 
peculiarly fitted to take charge of the kind of cases composing the 
service which needed a new head. 
On the whole, in the present state of medical education in New 
York, I am in favor of the latter way of selecting visiting physi- 
cians and surgeons, providing the spirit of the regulations be ad- 
hered to. 
3. The visiting physicians and surgeons selected as above sug- 
gested, with reference to their special qualifications to take charge 
of wards containing certain classes of disease, should be assigned 
to continuous duty in the same service, and required to make daily 
visits at a fixed hour. 
The thirty or fifty beds referred to supra as constituting 
a “ service ” would afford ample scope, if not filled up with 
incurable cases, for the display of the greatest interest in ob- 
servation and skill in treatment by the visiting physician, and, 
would afford the internes enough material for instruction. No 
physician or surgeon, I may venture to assert, who intends to do 
justice to his hospital patients, giving each sufferer plenty of time, 
and to thoroughly understand all his cases ; who could and would 
build up an experience out of his hospital work ; or who designs 
to become a clinical teacher in certain directions, will consider a 
service of thirty or fifty beds as too small. Having been a per- 
sonal witness to the neglect or insufficient care of one hundred 
patients by visiting physicians in general hospitals, and having 
had charge myself of services varying from twenty-five to one 
hundred beds, I can state quite positively that a permanent ser- 
vice of from thirty to fifty beds is fully large enough to meet the 
chief end and purpose of hospital organization, viz., the cure or 
relief of the largest number of patients. 
Of the greatest importance is continuity of service, year after 
year, until a good reason obtains for changing to another ser- 
vice or to another hospital. By having a continuous service, the 
physician or surgeon secures numerous advantages : 6 
E. C. SEGUIN. 
He has ample time to study his cases, and learning all about 
new patients is a comparatively easy task. 
He can train and educate his staff of internes in accordance with 
his own conceptions of medical practice, and he can have a routine 
or traditional way of doing things established, and transmitted 
through the successive members of the house staff. 
He is enabled to systematize certain methods of treatment, 
more especially for subacute and chronic cases, treatment which 
may extend over periods of weeks or months, and secure their 
execution by internes and nurses in an exact manner, year 
after year in the same way, to the great advantage of patients. 
He can at all times have a certain number of cases illustrating 
those diseases which he understands best, and about which he is 
capable of teaching students and practitioners. 
He can collect numbers of well-recorded histories of cases with 
cure or with post-mortem examinations, and make these the 
basis of articles or books which shall be instructive to the pro- 
fession, and thus indirectly profitable to the multitude of sick 
persons elsewhere. 
The only objection which I have ever heard addressed against 
a continuous service, is the fact that it would interfere somewhat 
with private practice, and would cause the physician a loss of per- 
haps several hundred dollars a year. But it seems to me that a 
hospital physician who, from philanthropic and scientific motives, 
does not value his public service more than he does the adding of 
two or three visits a day to his receipts is not worthy of his posi- 
tion ; and I know the profession well enough to think that 
managers of hospitals would have no trouble in finding candidates 
who would look upon the matter in a proper light. Having a 
hospital service is a high honor ; it gives an opportunity for doing 
some good in an immediate humanitarian way, and in a less di- 
rect scientific manner ; and a physician should be glad to give from 
one to three hours a day for this privilege. If there be any men 
who want hospital services for the nominal honor the post affords 
—to allow them to write a title after their names, to enable them to 
occupy positions in medical schools, or to attract private patients, HIGHER MEDICAL EDUCA TION IN NEW YORK. 
7 
—if there be a few such men, they will, of course, object to serving 
poor patients daily, and will naturally champion the present evil 
system of short services. 
By a continuous service, I mean a service extending over the 
whole year, except the time when the physician needs to go away 
for rest—a period of from two to six weeks. 
The way of providing a temporary visiting medical officer for 
this period is a matter of more importance than it is now thought 
to be, and several plans might be suggested. 
The present plan of a colleague being left in charge of the ab- 
sentee’s service, in addition to his own, during the summer months 
is bad enough with the present arrangement of hospital service, 
and would be even worse under the plan which I suggest : a 
physician cannot reasonably be expected to do double duty in a 
thorough manner in New York during the heated term, and in 
the re-organized hospital each physican or surgeon would be 
a quasi-specialist, not actively interested in his colleague’s 
branches. 
The plan of having assistant visiting physicians and surgeons I 
can condemn, having been an assistant visiting 
physician myself for a few months. The real use of such assist- 
ants is to save the physician a few hours’ time occasionally, by 
making the visit for him. He, the assistant physician, knows 
little about the cases in the service, he has no standing in the 
estimation of the patients and of the internes, and his visits 
are simply ceremonial. Except in hospitals having out-door 
departments which can be wholly given over to assistant visiting 
physicians and surgeons, I am quite positive that making such 
appointments creates a needless complication, and opens a door to 
neglect of duty by the visiting medical officers. 
The best plan would, it seems to me, be that the physician who 
intends absenting himself should nominate an acting visiting 
physician to the medical board and board of managers. This 
would probably ensure the selection of a competent man, of one 
interested in the same branches of medicine as the attending 
physician making the nomination. Besides, such acting visiting 8 
E. C. SEGUIN. 
physicians or surgeons would naturally, in the course of time, 
become desirable candidates for filling vacancies. 
It is almost needless to add that with a continuous service in 
one general hospital there would be no desire to hold a similar 
position in another hospital. Still, there might be no objection to 
a physician holding appointments in one special and in one 
general hospital. 
The question of a salary or honorarium for visiting physicians 
and surgeons is an important one. In Europe—on the Continent 
at least—hospital physicians are paid a modest sum yearly. This 
establishes more firmly the contract between the managers of the 
hospital and the medical staff; and in some cases would aid in 
securing the services of good men. An objection to a salary is, 
that it would tend to place the physician in the position of an 
and destroy the satisfaction of doing some charitable 
work. 
4. The re-arrangement of hospitals into smaller services, with 
their visiting physicians and surgeons on duty all the year round, 
would necessitate a corresponding change in the resident staff or 
internes. This change would consist in the creation of a separate 
resident staff for each service of the hospital. To do this a much 
larger number of young men would have to be appointed each 
year, and increased accommodations for their residence and board 
would have to be provided for, entailing a considerable additional 
expense on the hospital. Supposing that, as at present, each staff 
should consist of three members, a resident physician (or surgeon) 
and two assistants, the following table would represent the personnel 
of our general hospitals. A column is added to show the number 
of internes if only the house or resident physician (or surgeon) 
and one assistant were appointed, or allowed to live in the 
hospital : 
To counterbalance the greater cost of so considerable an in- 
crease in the house staff, what advantages would accrue from the 
change ? Great advantages, I believe. 
a. Direct advantages : making possible and successful the plan 
of continuous service of visiting physicians or surgeons; the HIGHER MEDICAL EDUCATION IN NEW YORK. 
9 
thorough cultivation of such service ; the making and writing out 
of complete observations ; the doing of minute and exact thera- 
peutic applications ; the saving of time which the young men 
could employ in study ; and, lastly, the health and even lives 
of promising young men, now endangered by overwork in hospi- 
tals, would be made more secure. 
Hospital. 
Beds. 
Visiting 
Staff. 
Resident 
Staff (3). 
Resident 
Staff (2). 
Bellevue .... 
800 
13 
39 
26 
Charity .... 
1,000 
16 
48 
32 
Presbyterian.... 
100 
3 
9 
6 
St. Luke’s 
209 
6 
18 
12 
New York .... 
ISO 
5 
15 
IO 
St. Vincent’s 
250 
8 
24 
l6 
St. Francis’ .... 
200 
6 
x8 
12 
German .... 
90 
4 
12 
8 
Mt. Sinai .... 
160 
5 
15 
xo 
Roosevelt .... 
180 
6 
18 
12 
Total 
2,139 
72 
216 
I44 
b. Indirect advantages : There is often something dangerously 
narrow and near-sighted in the administration of charities. For 
example, material relief or medical service is given to applicants 
without any inquiry as to whether they are proper subjects for 
charitable assistance, and without attention to the pauperizing 
tendency of such recklessly-extended assistance. So, it seems to 
me, is the way in which the governing bodies of general hospitals 
are apt to look at the institutions under their charge. They 
fancy that their hospital is created and maintained for the relief 
of suffering people in their immediate vicinity and nothing more. 
If that function be well performed, the managers are satisfied, and 
they seem to have no conception of a hospital as a centre whence 
a far-reaching beneficence may radiate. To cure three hundred 
sick annually is a good deed, but is not the completion of the 
education of young medical men likewise a worthy object ? These 
men leave the hospital to settle in private practice in the country 
or city, and what they observed and learned while in hospital is 
the means of relieving and curing multitudes of sick in the course 10 
E. C. SEGUIN. 
of years. Every one in the community is or should be personally 
interested in the thorough training of young physicians, partly from 
philanthropic motives, but also from selfish motives, since every 
one at some time or other comes under a physician’s care either 
at home or while away from the physician of his choice, and there 
is thus created a personal interest in the general excellence of the 
medical profession. Now, if the general hospitals of New York 
could employ a much larger number of young men as internes, 
and each year send out ten times as many hospital graduates, how 
immense would be the advantages conferred upon different sec- 
tions of the country. The function of the hospital to cure and 
relieve the sick would thus be extended to such proportions that 
its local good work, that of curing say three hundred sick people 
annually, would be dwarfed by the indirect good resulting from 
the practical education and training which the institution had 
afforded to a succession of internes. 
In the table on p. 299 I have inserted a last column, giving the 
number of internes who would have to reside in the hospitals, but 
even this might be reduced a good deal, as in many services both 
assistants might sleep out of the hospital. 
There would be, of course, many difficulties in the way of re- 
organizing hospitals in the direction which experience in Europe 
has shown to be practicable and eminently useful, and which I have 
endeavored to sketch in this paper. Encouraged by the words of 
encouragement which the preceding critical article (see Archives 
for April, p. 177) brought me from eminent physicians, I venture 
to throw out the present sketch of an improved hospital service in 
New York. The following is a summary of the principles upon 
which the changes ought to be made : 
1. The creation of small services, each consisting of from 25 
to 60 beds, according to the size of the hospital. 
2. Each service to be under the continuous care of one visiting 
physician or surgeon for a period to be fixed by regulation, say 
ten or twenty years. 
3. The selection of the visiting physicians and surgeons upon 
the basis of personal and professional merit, and also upon their HIGHER MEDICAL EDUCATION IN NEW YORK. 
11 
special qualifications for taking charge of services intended to re- 
ceive certain classes of diseases. This would establish the hos- 
pital work upon the same basis as the higher class of private 
practice, viz., upon the principle of the cultivation of specialties, 
or of departments of medicine. 
4. The creation of a much larger staff of internes, first for the 
purpose of securing better attendance upon the patients of the 
hospital, and also for the (no less meritorious) object of educating 
a greater number of physicians previous to their settling in private 
practice. 
E. C. SEGUIN. ARCHIVES OF MEDICINE FOR 1881, 
A 81-MONTHLY JOURNAL, 
Edited by Dr. E. C. Seguin, with the assistance of many prominent physicians in this 
country and abroad, enters upon the third year of its existence. 
Each number is handsomely printed in large octavo form on heavy paper, and contains from 
104 to 112 pages. The anicles are illustrated by means of lithographs or wood-cuts wherever 
necessary. , 
It is intended to devote the whole of each number to original matter, consisting of original 
communications or editorial articles, reviews of books, and a record of important cases. 
The Abstract Department has already been omitted in two numbers. The principal reason 
for this change is that the editor believes that the profession are ready to support a journal devoted 
to original communications and bona fide reviews. 
Especial attention is given to the review department, and while every pains is taken to secure 
the services of unprejudiced reviewers, they are asked to criticise or praise without fear or favor 
and to assume the responsibility of their statements by appending their initials to the reviews. 
The following Editorial Articles have appeared during the year 1880 : Mr. Lister’s Antiseptic 
Method, by Dr. Lewis A. Stimson ; Our Asylums as seen by a Competent Foreign Visitor, by 
Dr. von den Steinen ; Observations on the Insane Asylums of California and Nevada, by 
Dr. R. W. Birdsall ; The Right of the Insane to Liberty, by the Editor. 
Among the Original Articles may be mentioned the extensive papers by Dr. N. M. 
Shaffer, On the Hysterical Element in Orthopaedic Surgery ; by Dr. Mary Putnam Jacobi, 
On the Use of the Cold Pack, followed by Massage, in the Treatment of Anaemia; and Dr. 
Amidon’s Prize Essay on the Temperature of the Head. 
The Archives of Medicine will continue to be published every two months. 
COLLABORATORS. 
London.—Drs. J. Hughlings Jackson, J. Burdon-Sandkrson, and Sydney Ringer. 
Paris.—Profs. J. M. Charcot, J. Marey, and A. Ollivier. 
Germany.—Prof. Dr. W. Erb, of Leipzig. 
Philadelphia.—Profs. D. Haves Agnew, M.D., J. M. Da Costa, M.D., William Goodell, M.D., Roberts Bar- 
tholow, M.D., S. W. Gross, M.D., and Drs. Thos. G. Morton, E. O. Sharespeare, and J. C. Wilson. 
Boston.—Drs. James R. Chadwick, Charles P. Putnam, James J. Putnam, and Webber 
Baltimore,—Prof. E. T. Miles, M.D., Dr. I. E. Atkinson. 
Hartford, Conn.—Dr. Samuel B. St. John, Dr. M. D. Mann. \ 
Albany, N. V.—Prof. Samuel B. Ward, M.D. / ' J 
Prof. C. R. Agnew, M.D., Prof. Fordyce Barker, M.D., Prof. Francis Delafield, M.D., Prof. W. D, 
Draper, M.D., Prof. Austin Flint, Sr., M.D., Prof. William A. Hammond, M.D., Prof. A. Jacobi, M.D., 
Prof. Mary Putnam Jacobi, M.D., Prof. E. G. Janeway, M.D., Prof. E. L. Keyes, M.D., Prof. Alfred L. 
Loomis, M.D., Prof. F. N. Otis, M.D., Prof. M. A. Fallen, M.D., Prof. Thos R. Pooley, M.D., Prof. D. B. 
St. J. Roosa, M.D., Prof. H. B. Sands M.D., Prof. A. J. C. Skene, M.D , Prof. R. W. Taylor, M.D., Prof. 
T. Gaillard Thomas, M.D., Prof. W. H. Van Buren, M.D., Dr. R. W. Amidon, Dr. Wm. T. Bull, A. Floyd 
Delafield, A.8., Dr. H. J. Garrigues, Dr. V. P. Gibney, Dr. L. Carter Gray, Dr. E. Gruening, Dr. C. 
Heitzmann, Dr. F. P. Kinnicutt, Dr. Jas. R. Teaming, Dr. C. C. Lee, Dr. P. F. Munde, Dr. J. C. Perry, 
Dr. N. M. Shaffrr, Dr. J. C. Shaw, Dr. J. Marion Sims, Dr. A. H. Smith, Dr. E. C. Spitzka, Dr. L. A. 
Stimson, Dr. Clinton Wagner, Dr. Robert Watts, Dr. David Webster, Dr. R. F. Weir, Dr. T. A. Mcßride, 
and others. 
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