Methods of Teaching Sjdrgei*^ 
BY 
JOHN S. BILLINGS, M.D., 
Surgeon United States Army. 
Reprinted from the Boston Medical and Surgical Jourttal 
of May j/, iBgp 
BOSTON: 
DAMRELL & UPHAM, Publishers, 
283 Washington Street. 
1894. S. J. PARKHILL & CO., PRINTERS 
BOSTON METHODS OF TEACHING SURGERY.I 
JOHN S. BILLINGS, M.D., SURGEON UNITED STATES ARMY. 
This paper has been prepared at the request of the 
Committee on Programme, to serve as an introduction 
to a discussion upon the best methods of teaching sur- 
gery, and is intended to ask questions rather than to 
answer them. We have to consider : (1) Who are to 
be taught ? (2) What is to be taught ? (3) How it is 
to be taught. 
Those who are to be taught include two classes : (1) 
The average medical student, who is presumably to 
become a general practitioner; (2) The men who 
wish to specially fit themselves for surgical work. 
There is a third class, namely, those who wish to learn 
only the least possible amount of surgery which will 
enable them to get the degree of M.D., but these we 
need not consider to-day. 
The surgical instruction to be given the average 
student depends on what he is required to know of 
anatomy and pathology before he begins his surgical 
studies, upon the amount of time which is allowed for 
surgical instruction, and upon the nature of the final 
examination which he must pass to obtain his degree, 
or license to practice. 
In any case it should include the diagnosis, and best 
method of treatment, of the injuries and surgical dis- 
eases which the general practitioner is most often called 
upon to treat, including recent wounds and their com- 
plications, erysipelas, abscess, ulcers, etc.; fractures 
and dislocations, injuries of blood-vessels, strangulated 
hernia, urethral stricture, retention of urine and its 
1 Paper read before the American Surgical Association at Wash- 
ington, Wednesday, May 30, 1894. 2 
consequences; obstruction of, or foreign bodies in, the 
air passages ; and also the selection and administration 
of anaesthetics, the details of aseptic and antiseptic 
methods, and of methods of performing the most usual 
amputations and ligations of blood-vessels. 
Let us suppose that the instruction is to be given in 
a three-years’ graded course; what other subjects be- 
sides those above mentioned ought to be fully treated 
of by the surgical teacher ? Under such circumstances 
is it worth while to go into the details of cerebral and 
abdominal surgery, of lithotomy and lithotrity, of ex- 
cisions of organs or of the jaws and joints, of plastic 
and orthopaedic surgery ? Is it not enough to tell the 
average student what can be done in these directions, 
and refer hinpu-tcr special courses or to current litera- 
ture for further information with regard to complicated 
and difficult operations requiring special instruments 
and apparatus ? Of course, it is to be practically dem- 
onstrated that the teacher is the proper person to whom 
cases of this kind should be sent. 
Deferring for a moment the consideration of the 
needs of the man who wishes to become a surgeon, we 
come to the question, “ How are these subjects to be 
taught?” There are five principal methods: (I) 
Didactic systematic lectures; (2) recitations: (3) 
demonstrations and practical instruction by means of 
manikins, dummies, cadavers, and operations on ani- 
mals, in the details of treatment of wounds, bandaging, 
dressings and operations; (4) theoretical clinical lect- 
ures, in which cases and operations are shown in an 
amphitheatre; (5) practical clinical instruction to 
small groups of students or ward classes, in which, as 
far as possible, each student has something to do in 
the diagnosis or treatment, or both. 
The modern tendency is to reduce the time given to 
systematic lectures. In discussing the wisdom of this, 3 
we must bear in mind the different organization of the 
teaching staff in different schools, the increasing num- 
ber of chairs or lectureships devoted to specialties, and 
the fact that the precise division of subjects among the 
instructors in a given school must depend to a consider- 
able extent on local conditions, on the character, tastes 
and teaching-powers of the different men who makeup 
the faculty, on the amount and character of the facilities 
for laboratory and clinical teaching present, etc. 
In the old-fashioned type of medical school, in which 
the whole instruction was given by seven or eight men, 
the professor of surgery taught what was called surgi- 
cal pathology, or the principles of surgery, gave con- 
siderable attention to surgical anatomy, and was the 
clinical as well as the systematic teacher. There was 
at least one advantage, namely, that the teaching was 
consistent and harmonious; the student was not much 
bewildered with the conflicting views of different pro- 
fessors. The professor of anatomy was in training for 
the chair of surgery and took very little interest in 
comparative anatomy or in embryology. There was 
no professor of pathology; and both the professor of 
surgery and of medicine lectured on inflammation, 
congestion, suppuration, etc., each from his own point 
of view. 
At present, in a large and popular medical school, 
there are from twenty to thirty teachers of various 
grades; there is a professor of pathology, of surgery, 
of clinical surgery, of surgical anatomy, of orthopaedic 
surgery, of genito-urinary surgery, etc., and the pro- 
fessor of gynaecology takes a large share of the abdomi- 
nal surgery. 
Now how can the subject of surgery be subdivided 
among all these teachers in such a way that the whole 
field shall be covered, without involving useless repeti- 
tions. embarrassing contradictions, and the expenditure 4 
of an undue amount of time and labor by the student, 
or of the production of heart-burnings in some of the 
teachers ? This is one of the most difficult problems 
in the organization of a large medical school which is 
to be really efficient and popular, and it is one to 
which no general and universal formula is applicable. 
Theoretically, each professor being a thoroughly 
wise, unselfish, good-tempered man, desiring only the 
best, interests of his pupils and of his school, and there 
being frequent consultations between them to secure 
harmony in their teachings, the desired result may be 
obtained. Practically, there are usually two or three 
strong men in the faculty who settle what shall be done, 
and the rest find it expedient to submit, although they 
may not agree. When there are no sufficiently strong 
men, and all the professors are not perfectly good and 
unselfish, there may be trouble. 
Let us consider details a little. A well organized 
medical school should have a professor of pathology 
and pathological anatomy, under whose direction a 
certain amount of laboratory instruction should be 
given comparatively simple for the average student, 
extended and elaborate for post-graduates. The 
greater part of his teaching for the average under- 
graduate student must be by lectures, with demonstra- 
tions. 
Given such a teacher, with the necessary facilities, 
why should the professor of surgery lecture on surgi- 
cal pathology or bacteriology to the average under- 
graduate ? The only really good reason I think of is, 
that he should be thoroughly familiar with the subject, 
and at times use experimental methods in devising im- 
provements in surgical practice, and that teaching the 
subject greatly helps him to obtain, classify and retain 
his knowledge. But his teaching on this subject would 
be most valuable to a special class of advanced stu- 5 
dents, or post-graduates who can devote themselves 
to it, and give the necessary time to that experimental 
work on animals which is absolutely essential to secure 
satisfactory results. 
At all events, 1 think we can agree that the rela- 
tions between the surgeon and the pathologist should 
be intimate and friendly, while each should be entirely 
independent of the other, and that the surgeon should 
go into details of practical application of principles in 
accordance with the more general teaching of the 
pathologist. 
As regards the teaching of surgical anatomy, and of 
operations on the cadaver, by a teacher distinct from, 
and entirely independent of, the professor of anatomy 
on the one hand and the professor of surgery on the 
other, I believe that there are widely different opinions 
as to its expediency. Such an independent chair, or 
demonstratorship, is usually provided to make a place 
for some particular man, and its utility must depend 
upon who this man is. 
While no general rule on this point can be laid 
down, might it not be best that attendance on such an 
independent course should be purely voluntary on the 
part of the class, and that it should be largely devoted 
to the instruction of those who wish to make a specialty 
of surgery ? It appears to me that more use should 
be made of living animals than is now done, in teach- 
ing the results and treatment of wounds, including de- 
tails of aseptics and antiseptics, and in special courses 
for advanced students who should be required to per- 
form operations under the guidance of the surgeon. 
The next question is as to the part which clinical 
surgery should play in a course of education leading to 
a medical degree. The great majority of students pre- 
fer clinical teaching and demonstrations to didactic 
lectures, and will go where this clinical teaching is 6 
most brilliant and varied ; and, so far as it goes, we 
must admit that this kind of teaching is generally the 
most useful to them, because they remember it better. 
How far is it possible to cover the field of diagnosis 
and treatment of injuries and surgical diseases by clin- 
ical teaching alone to the extent that is desirable for 
the average medical student? And how far is it de- 
sirable to vary and modify the didactic teaching so as 
to make it supplementary to the clinical teaching? 
Evidently the answers to these questions must de- 
pend in part upon the amount and variety of clinical 
material that is available, and hence must differ for 
different schools. As a rule, clinical material is not 
available to cover the entire field for any school, no 
matter how large its hospital and dispensaries hence 
there must be some systematic didactic teaching. Is it 
best that this should be a complete independent course 
covering the whole field, merely using for any particu- 
lar subject such cases as may happen on that day to 
be available, thus leaving the greater part of the clinical 
teaching to duplicate that which has been given in the 
systematic course ? This is, upon the whole, the 
easiest way, and in favor of it is urged that it is desir- 
able that the student should be told the same thing 
several times to ensure his remembering it. This is 
the argument which used to be used in tavor of the 
old plan of not having a graded course but compelling 
the students to listen to the same course of lectures in 
successive years. 
On the other hand, it can be seen that there would 
be certain advantages in deferring the systematic lect- 
ures until towards the end of the course, and then de- 
voting them mainly to subjects which had not been il- 
lustrated in previous clinical teaching; but to make 
this plan a success it would be necessary that the sys- 
tematic lecturer should either have given all the clinical 7 
instruction, or should be perfectly familiar with all 
that has been given. 
A possible modification of this plan would be to let 
two professors divide the field of work, each taking a 
certain class of diseases and injuries, giving clinical in- 
struction thereon and supplementing it with systematic 
teaching as above suggested, and then the two men 
exchanging fields of work each year. An objection to 
this is that a considerable part of clinical teaching is 
given in connection with patients who select their own 
surgeon, and who will not make such selection with 
reference to any curriculum. Undoubtedly the more 
clinical instruction of the right kind that can be given, 
the better for the students, and for the reputation and 
prosperity of the school. 
But this phrase “ clinical instruction of the right 
kind ” brings up a new set of questions. How much 
does it profit the student to witness, from the rear 
benches of an amphitheatre, such operations as the 
ligation of arteries, the extirpation of tumors, lithotomy 
or nephrectomy ? Undoubtedly the student is inter- 
ested and learns something, and he will go where he 
can see if not the operation itself, at least the heads 
of the persons who are busy about the patient; and 
it will not do to restrict his privileges much in this re- 
spect. At the same time, should not special opportu- 
nities be given to the few who are devoting themselves 
specially to surgery to see as much as possible of diffi- 
cult and unusual operations ? It appears to me that 
more than two hundred men cannot possibly obtain 
any special information from surgical clinics in an 
amphitheatre which they could not obtain equally well 
in a didactic lecture, and which could not be much 
better given with illustrations by means of lantern 
slides, than by using a patient as a means of demon- 
strating an operation. It is quite possible to show by 8 
means of lantern slides, as Dr. Kelly has proved, to 
several hundred men, every detail of an operation 
which can be seen by the immediate assistants of the 
operator. 
Now with regard to clinical teaching to comparatively 
small sections, or ward classes, the members of which 
are to be brought as much as possible into contact with 
the patient, and even to assist in the operation of dress- 
ing. There is no doubt as to the utility and popular- 
ity of this mode of teaching, but in this connection a 
word may be said with regard to the relations of hospi- 
tals and dispensaries to surgical teaching. 
While I believe that a hospital is not doing its full- 
est and best work if it is not increasing and diffusing 
knowledge, and that patients secure the best and most 
careful attention and treatment in teaching-hospitals, 
where the work of the staff is keenly scrutinized, yet 
it must be admitted that there is sometimes a danger 
that people will get the idea that in a teaching-hospital 
the interests of the patients are not as fully consulted 
as they should be, and will avoid that hospital as much 
as possible. This danger arises mainly from two 
things : first, the allowing students to have anything 
to do with the treatment, and especially with an oper- 
ation. The patient wants to be operated on by the 
most skilled man, that is, by the professor; and if he 
has a suspicion that after he is under the influence of 
an anaesthetic the professor may hand the knife to a 
student to make perhaps his first essay, he will avoid 
that place. All of us would do the same, and therefore 
in ward-class teaching a patient should never be de- 
ceived as to who is to perform the operation, for sooner 
or later the deception will be discovered and the news 
will spread. 
The second danger to the popularity of a teaching- 
hospital is that patients are not unfrequently made to 9 
wait until their cases can be used for clinical instruc- 
tion, sometimes for hours, sometimes for days. In 
most cases the patient knows when he is to be put off 
for this purpose, and after one experience of the kind 
he will go to another hospital the next time and advise 
his friends to do the same. 
It is well also that the clinical surgical teacher should 
remember that his ability to obtain abundant clinical 
material depends to a very considerable extent upon 
the manners and on the good-will of some of his assist- 
ants, the resident physician, the nurses, etc., who are 
often the first to see the patient as an applicant, and 
who have much to do with subsequent treatment. 
These assistants, residents, receiving-officers, case- 
takers and nurses, are not always possessed of the ex- 
quisite tact, kindly sympathy, and knowledge of human 
nature which it is to be presumed are invariably the 
characteristics of the clinical surgeon ; and it is a part 
of his business to instruct them and perfect their 
manners as much as possible. 
Recitations and quizzes are excellent methods of 
teaching for the majority of students, but are only 
well adapted to small classes or sections. At present 
they are, for the most part, conducted as a private 
enterprise by persons who may, or may not, be on the 
teaching staff. The question as to whether this mode 
of teaching should be made use of in the official course 
to a considerably greater extent than is now done is 
an interesting one and is commended for discussion. 
It appears to me more desirable that it should be ap- 
plied to the clinical teaching than to the didactic 
lectures, and one good result of this would be to dis- 
courage the reliance on quiz compends, which 1 think 
invariably do more harm than good. 
With regard to modes of lecturing, every man is, of 
course, a law unto himself; yet I will venture one or 10 
two suggestions. The teaching for a class of students 
should be definite, selective, and, to a considerable ex- 
tent, dogmatic; and critical historical discussions should 
be used very sparingly. 
What the student hears and sees daring the first 
half-hour of a lecture is what he will remember best, 
and will have the best notes of ; therefore, when there 
are several different ways of doing a thing, let the 
teacher describe first the method which he prefers, tak- 
ing all the time required to fully demonstrate it and 
impress it on the student. After that is done the other 
methods may be referred to and so much history and 
criticism given as time will permit. If the reasoning 
is given before the conclusions are stated, the student 
is apt to get confused, and to characterize the teacher 
as a “ wobbler.” 
If the lecturer will fix in his mind the half-dozen 
questions or so that he would ask to test the students’ 
knowledge of the subject upon which he is going to 
speak, and will then make it his main object to answer 
those questions clearly, definitely and fully, he can 
hardly fail to give a good lecture. 
In objecting to too much history in didactic or clini- 
cal lectures on surgery, 1 do not wish to be understood 
as underestimating the importance of giving historical 
instruction. I think that in every medical school a 
course of lectures on the history of medicine and sur- 
gery, combined with practical instruction in bibliographi- 
cal methods’, should be given; and if this is not done, 
then I would advise that the professor of surgery de- 
vote five or six lectures to the history and literature of 
his subject, which lectures will probably be most use- 
ful and interesting at the beginning of the last year of 
the student’s course. 
ft was stated at the beginning of this paper that be- 
sides the average medical students, the needs of the 11 
man who wishes to specially fit himself to be a surgeon 
should be considered. These relate to post-graduate 
work mainly, for a broad foundation of medical knowl- 
edge is requisite for the man who wishes to become a 
surgeon. The technique of operative surgery, impor- 
tant as it is, is secondary in importance to skill in diag- 
nosis, and to knowledge of therapeutical methods 
which do not involve the use of the knife. 
The man who intends to be a surgeon should not 
only make a special study of surgical anatomy, but 
should do a considerable amount of practical laboratory 
work in bacteriology, pathological histology and ex- 
perimental pathology and physiology. 
It is quite true that the majority of our leading sur- 
geons could not perhaps, by themselves, make a bacteri- 
ological diagnosis, or determine fine distinctions in 
new growths, and yet they do good work having 
these points settled for them by younger men trained 
in the new methods. But the surgeon of the future 
should himself be trained in these methods, even though 
he may employ others to carry them out. 
And in this connection I would remind you that 
bacteriology cannot be profitably studied for two or 
three days in a week, but that it needs at least three 
hours a day every day for three months for a man to 
learn how to begin readily to use its methods. In 
general, I think that all studies are best concentrated, 
and that the usual plan of dividing studies into an hour 
two days a week for this, and an hour three days a 
week for that, etc., is much more for the convenience 
of the professors than it is for the true interest of the 
students. 
As for operating technique, much of it can be learned 
on animals, but much of it requires also work on the 
cadaver, the repetition over and over again, until, as 
Billroth said, a man could do it when he was asleep. 12 
The most important of all is residence in a hospital, 
the working as assistant to a surgeon, the seeing and 
handling cases, and not merely looking at them from a 
distance. The number of men who are able and will- 
ing to carry out such a course of study as that indicated 
is limited, and the teacher of surgery cannot do very 
much for them except give them opportunities for see- 
ing his methods and results; but is it not possible to 
give them better opportunities than can be provided 
for a large class of undergraduates ? Should they not 
be required to repeatedly perform the many operations 
which can be advantageously performed on animals 
before they try these operations on man ? It seems to 
me that in the last year of a four-years’ course all 
students should be tested in this way ; but it must be 
admitted that, with the present curriculum, there is not 
time to spare for this purpose, especially where the 
graduating class is a large one. 
This leads to two final questions, which, though not 
directly connected with “ the best methods of teaching 
surgery,” have nevertheless, an important bearing on 
it. The first is; Are there not some subjects which 
occupy too much space in the undergraduate curricu- 
lum of our largest and best medical schools, such for 
example, as inorganic chemistry, and embryology ? 
Ought not the student to be required to know so much 
as is required of inorganic chemistry before he begins 
his medical course ? is it desirable to make embryology 
and general morphology a part of the curriculum for 
all medical students, as a basis for the study of anat- 
omy, or is it wiser to place these as elective studies 
in a post-graduate course, and to insist on more dissect- 
ing and a greater knowledge of practical anatomy than 
is now generally demanded ? In this connection your 
attention is invited to the widely different opinions as 
to the best methods of anatomical teaching as rep- 13 
resented by Professor Macalister for the morphologists, 
and Mr. T. Cooke for the old school, which have ap- 
peared in the Lancet and in the British Medical Journal 
during the past year. 
It appears to me that the teaching of anatomy should 
begin with a few lectures and demonstrations on gen- 
eral morphology, and that the first dissections should 
be made on cats and dogs until a good technique has 
been acquired, so that the supply of human cadavers, 
which is always insufficient, can be fully utilized to 
the best advantage. I also think that it is unwise to 
have the final examination in anatomy one or two 
years before the other final examinations ; the anatomy 
should be kept up throughout. 
My last question is : Would it not be good policy 
for a first-class popular medical school to limit the 
number of pupils which it will accept to its capacity 
to give them proper instruction in laboratory work, in 
practical anatomy, and in clinical medicine and sur- 
gery ? Of course, each faculty is prepared to assert 
that its own school now does this, and will disapprove 
of fixing any limit to the number of its pupils ; never- 
theless, it appears to me, as an outsider, that there are 
at least two or three medical schools in this country 
which would act wisely if they would fix a limit to the 
number of students which they would receive either 
in the first or in the third year, or in both, and enforce 
this limit by competitive examination or by higher fees, 
or by both. It would bring the best men to them, and 
would enable them to do thoroughly good work.  THE BOSTON 
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