POST-GRADUATE INSTRUCTION 
BY 
E. C. SEGUIN, M.D. 
CLINICAL PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM IN THE COLLEGE OF 
PHYSICIANS AND SURGEONS, NEW YORK., ETC. 
[Reprinted from the'‘Archives 6f Medicine, October, 1882] 
NEW YORK 
G. P. PUTNAM’S SONS 
27 & 29 West 230 Street 
1882 POST-GRADUATE INSTRUCTION. 
E. C. SEGUIN, M. D. 
A number of physicians of this city, mostly specialists, of con- 
spicuous disparity in reputation as men of science or as teachers, 
have formed themselves into a faculty of medicine, and pro- 
pose to organize a college for the purpose of teaching certain 
things, mostly matters which come within the limits of specialties, 
to graduates in medicine. So sanguine are these gentlemen of 
success, and so confident of the righteousness of their cause, that 
at least one of them has appended his new professional title to 
his name, on the title-page of a book before the college has 
been opened and before one lecture has been delivered. 
There is something captivating in the term post-graduate in- 
struction, or post-graduate course, and something imposing in 
post-graduate faculty ; and very naturally one interested in medi- 
cal education is at once led to inquire whether there is any need 
of post-graduate instruction as such (apart from that never-end- 
ing effort at self-instruction which intelligent and conscientious 
physicians make through their lives), and whether the proposed 
new faculty is indispensable for the purpose, or whether an even 
better course of advanced teaching for the senior medical stu- 
dent could not be organized in the colleges already existing, and 
graduates invited to follow this part of the curriculum. 
The first question, is there any need of post-graduate instruc- 
tion ? can, I regret to say, be answered only in the affirmative. 
Taking the men who are yearly sent out of our medical colleges 
Reprinted from the Archives of Medicine, VoI. viii, No. 2, October, 1882. 2 
POST-GRAD UA TE INSTR UCTION. 
with diplomas, we find that in spite of all they have acquired at 
the hands of their alma mater they are in need of more teach- 
ing, at least of more practical, educating teaching. A proof of 
this statement lies patent to all, in the fact that the very best men 
of these medical classes, those who have passed the most brilliant 
examinations and shown that they have crammed successfully, 
the very honor and prizemen of the schools, immediately compete 
for hospital appointments which will make them pupils again ; 
they will give themselves another and a better chance at self- 
improvement. This is a tacit acknowledgment of the incom- 
pleteness of their college education ; and if these well-crammed 
young men feel this way, and admit as much, what must be the 
condition of the rest of the hosts of graduates who, besides lack- 
ing practical education and training, are less well provided with 
memorized knowledge. They all need post-graduate instruction, 
and many of them will always need it and be glad to come for a 
few months to a large city to attempt to do what they ought to 
have done, or, more justly, ought to have been enabled and obliged 
by their alma mater to do before receiving a diploma. It is from 
this very numerous class of graduates of imperfect medical 
schools, who are men of all ages, of various degrees of practical 
success, but of one mind as to their need of better training, that 
the proposed post-graduate medical school is to be supplied with 
pupils or followers. 
At the present time each medical college in our great cities 
bears upon its matriculation lists the names of many such seekers 
after scientific improvement,—men who need training and special 
teaching. They find themselves lost in a crowd of youths who 
are struggling to learn enough by rote, through books and lectures, 
to pass examinations of greater or lesser severity. The gradu- 
ates find the lectures, as a rule, to be a mere rehash of what is in 
the books, made for the purposes of keeping up the time-honored 
plan of lecturing to large classes, and to give the student a sort of 
repetition of the various subjects. The impressions gathered 
through two senses, reading the matter by one’s self and receiv- 
ing it through the ear in an amphitheatre, are supposed to be more E. C. SEGUIN. 
3 
firmly fixed, better registered, and more definitely associated in 
the brain, than they would be if derived only through reading. 
That there is a degree of psychological truth in this no one will 
deny, but the crying evil of routine didactic teaching cannot be 
sustained on such a plea. Besides hearing lectures which are 
repetitions of chapters of books which he knows well enough, and 
therefore useless to him, the graduate finds no lectures given by 
the only men about the schools who could teach him something 
new and vital, viz.: the specialists. They are, as a rule, not al- 
lowed to lecture in the regular course of lectures, and are 
placed in charge of clinics. 
To these the graduate goes only to be disappointed and hindered 
in his work of self-improvement. He finds most clinics conducted 
without the least system, being merely an exhibition of cases as they 
happen to present themselves, with remarks by the professor. In 
many clinics, extraordinary cases of very little importance to the 
physician are made to play a great role, consuming time which 
should be devoted to the practical learning of methods of diagnosis 
and therapeutics, and to the systematic study of common diseases. 
Lastly, the graduate finds the front seats of lecture-rooms at the 
clinics crowded by junior students, who are there without appointed 
tasks, and who come to the clinics partly from curiosity to see dis- 
ease, and partly because they have a dim notion that they must 
get all the “ clinical experience ” they can, even in their first 
years. The machinery of most of our schools is as yet so inade- 
quate that there is no means of excluding the junior student from 
lectures and clinics which can do him no good, which use up time 
which should be devoted to a study of the fundamental branches, 
and where he occupies a seat which the undergraduate or gradu- 
ate has a moral right to. 
These difficulties dishearten the practitioner who has come to a 
medical centre, perhaps at much expense and inconvenience, to 
improve his scientific and practical knowledge. 
But some say to him : Why do you not take advantage of the 
numerous private classes which are organized during the winter 
session, either for cramming purposes, or to teach special subjects 4 
POST-GRADUATE INSTRUCTION. 
in a practical way ?_ This our practitioner does, but he finds it 
quite expensive, and also has to encounter another difficulty, sim- 
ilar to that which he found in the schools : the classes are or- 
ganized more for the teaching of undergraduates, by very ele- 
mentary methods ; he does learn something, but not as much as 
he hopes to, and not exactly what he needs. The proposed post- 
graduate school will say to the numerous graduates who return 
to New York for self-improvement: Come to us, gentlemen ; we 
offer a curriculum prepared specially for you ; you will not be 
elbowed by a crowd of raw students; we will give you every 
desired opportunity to study in a scientific and practical 
manner. 
It remains to be seen whether the proposed new school of 
medicine will succeed, by such an appeal, in attracting a re- 
spectable number of pupils. 
This brings us naturally to the consideration of the second 
proposition, whether a better course of advanced teaching than 
this new faculty offers, for senior students and for graduates, could 
not be organized in the already existing medical schools, as a part 
of their curriculum. 
The qualifications of the members of the new-born faculty, 
and the discouraging circumstances they will have to contend 
against, are negative points in the discussion of this question, 
which we do not care, and do not need, to take up. 
On the other hand, the advantages which the existing medi- 
cal colleges have for undertaking higher teaching are very 
great. 
Most of their professors, and nearly all of their assistants, are 
connected with hospital and dispensary services, and thus the 
colleges can command almost unlimited clinical opportunities. 
These means of teaching are now allowed to go to waste, chiefly 
because the faculties take no pains to bring these various services 
into a logical system. All the men connected with the school, 
and who have clinical services, teach as they please, several of 
them going over the same ground for the same unwieldy class of 
students. There is no attempt made to subordinate and correlate E. C. SEGUIN. 
5 
the various clinics in the college, in hospitals, and at dispensaries, 
to the plan of teaching at the college, and to certain series of 
didactic lectures. Indeed, it seems to be nobody’s business, and 
“ go-as-you-please ” appears to be the watchword among medical 
teachers. An enormous amount of clinical material is thus al- 
lowed to be ill-used or not used at all. 
It seems to us that, taking advantage of the disinterested desire 
to teach others which the talented young alumni of a medical 
school always manifest, and of their interested, though laudable 
desire to acquire a nominal connection with their alma mater, 
much good clinical teaching might be secured without any great 
pecuniary outlay ; only at the cost of careful planning of a scheme, 
and of energetic supervision of its execution. 
With each chair upon a practical branch (each elementary sci- 
entific branch, chemistry, anatomy, physiology, and materia media, 
should have its laboratory with competent teachers), quite a num- 
ber of younger men might be associated with some such title as 
clinical instructor or clinical professor, according to the profes- 
sional standing of the incumbent.. This title, desirable in itself, 
should convey with it to each appointee the various obligations to 
use his hospital or dispensary service mainly for the advantage of 
the school, to teach a number of months in each year to limited 
classes provided for him by the secretary of the faculty of his 
school ; to regulate his teaching in all reasonable ways (matters of 
scientific opinion excepted), according to the suggestions of the 
professor of his branch at the school, who would thus, besides de- 
livering lectures and giving clinical instruction himself, control and 
direct a large and highly efficient teaching force and a vast clinical 
material. By such means the senior student, or under-graduate, 
and the graduate in search of further teaching, could be registered 
and distributed in classes, to their great advantage. On the 
other hand, the school would have this reward, among others, 
that between these numerous junior teachers the liveliest rivalry 
would arise as to excellence in teaching and faithfulness in serving 
the school, and thus there would grow up a strong competing 
class of candidates for any vacant professorship. 6 
POST-GRAD UA TE INSTR UCTION. 
It may be said that these clinical teachers would demand emol- 
uments. We doubt it, partly because it is in the nature of young 
men (young physicians perhaps more especially) to labor for the 
sake of an honorable title, of a possible promotion to an assured 
position, and I place it last, but not least, disinterestedly for sci- 
ence’s sake. 
This relates to teaching of the practical branches at the bed- 
side, without the school principally. 
Now, what need the schools do to improve higher teaching 
within the college walls, and to offer a post-graduate curriculum 
better than that planned by the proposed school ? 
The thorough discussion of such a question would involve a 
consideration of the means of improving teaching for all grades 
of students ; a much too complicated theme. We must content 
ourselves with suggesting some simple changes in the present ar- 
rangement which would, in our opinion, fairly meet the wants of 
students about to graduate and of graduates seeking higher in- 
struction. 
In the first place it would be necessary to break through the 
present rule in most medical colleges, that only one lecture or 
clinic shall be offered to the class at one time. It is difficult to 
find polite terms in which to condemn this time-honored (Ameri- 
can) custom, so contrary does it seem to common-sense and to 
economy in the administration of a school. Here is a college 
building costing from forty to sixty thousand dollars, with a full 
staff of professors and assistants, with a class of three or four 
hundred students, and forsooth the whole of this machinery must 
result in but one form of teaching at anyone time, for a few hours 
a day. This is comparable to an attempt to irrigate a field from 
an ample reservoir, but the water must be made to flow through 
one little aperture ; the area of the field and its need of water on 
the one hand, and the abundant supply of water on the other 
hand, are made subject to a meagreness of distribution which is 
justified only by a senile custom. No doubt this practice had its 
rise in connection with the now antiquated notion that medicine 
was to be taught didactically, and the whole class obliged to hear E. C. SEGUIN. 
7 
the various lectures systematically. And, in the same way, the 
class was supposed to attend every clinic. By all this, wholesale 
superficial education was reduced to a system and made easy. 
The truth is that from three to six lectures, clinics, or private 
classes might be going on at the same time, during the same hour, 
if the building were appropriate, and if an official had the respon- 
sible duty of classifying students and distributing them in classes. 
As regards buildings : Our medical schools (in New York) have, 
as a rule, only two huge lecture-rooms or amphitheatres, and one 
dissecting-room. Even with this insufficient number of rooms, 
the present amount of teaching might be doubled. But in some 
schools more room might be had by devoting to a useful purpose 
rooms which are occupied by professors for a few minutes each 
day, merely as a convenience. Out of several professor’s rooms 
one or more small lecture-rooms might be arranged at small ex- 
pense. Besides, some of the schools could well afford to hire or 
purchase a private house near the school, alter it somewhat, and 
thus obtain two or three small lecture-rooms, and two or three 
laboratories. 
As regards the arrangement of studies and classes : A thorough 
system of graded study by divided classes may be desirable, but 
we are hardly ready for this. No one, however, can claim that 
the time has not arrived for a strict division of our large classes 
into junior and senior classes, and to these might be added a 
graduate class. These groupings should be formally made by 
registration in the books of the official in charge of the college 
work, and by means of tickets and door-keepers the separation 
should be practically enforced. 
By such means the junior students would be obliged to give 
all their time to the lectures and demonstrations upon anatomy, 
physiology, chemistry, and materia medica. They would also find 
time for special practical laboratory work in all of these branches, 
in the smaller teaching rooms of the school; and some of the more 
capable members of this class would find time to study also Ger- 
man or French, and perhaps medical physics and botany, branches 
which are almost necessary to a complete medical education. 8 
POS T- GRA DUA TE INS TR UC TION. 
As matters stand now, except in the case of the well-advised 
and seriously-minded few, junior students wander into clinics and 
hospitals, anxious to behold the horrors of disease, to experience 
the new sensations produced by the sight of a bloody operation, 
and, truth compels me to add, sometimes to gratify a lewd fancy 
by witnessing exposures of the human form. These young men 
have nothing to gain by going to clinics and visiting hospitals ; 
they waste their time, of which they have only too little to do 
justice to the noble sciences they need to study ; they take up 
room which the senior student or graduate should have. We are 
sure that many clinics are thus made to appear crowded and as- 
tonishingly successful; yet we hope and believe that the professors 
of such clinics would much rather teach a selected smaller class, 
free from the throng of curiosity and sensation seekers. The 
faculty of a medical school owes it to these misguided junior stu- 
dents, owes it to the seriously studious senior student, and more 
particularly to the earnest graduate who comes to the school 
seeking after higher instruction, to police the class, and by all 
the means in its power to restrict the junior class to its legitimate 
studies, and to keep it out of the rooms or hospitals where the 
practical branches are taught. 
The senior or undergraduate class, studying more particularly 
pathology, practical medicine, surgery, obstetrics and gynecology, 
and therapeutics (that ill-taught though crowning science), might 
continue to hear didactic lectures, since it is premature to ask 
the partial or complete omissions of these ; but the extensive 
clinical scheme proposed in the first part of this paper, should be 
employed as the chief means of education. The class could be 
subdivided into sections, and distributed in such a way as to allow 
each student an opportunity of practically studying disease in its 
various forms, of acquiring the arts of diagnosis and of treatment. 
It would be more especially for this purpose that the utility of 
numerous rooms for teaching would appear. Why, for example, 
should not, from 10 to n a.m., the junior class listen to a lecture, 
a demonstrative lecture let us hope, upon anatomy in one amphi- 
theatre, while the senior class is hearing a lecture upon a surgical E. C. SEGUIN. 
9 
topic, and a selected section or two are doing laboratory work of 
some sort ? Why in the afternoon should not sections of the senior 
class be at two or three hospitals attending bedside teaching or 
operations, and other sections busy in the same way in the college 
itself, or doing laboratory work ? 
The post-graduate class might well find opportunities for higher 
study in these small, well-officered clinics. This teaching, while 
not particularly scientific, would be practical, and would be better 
than any thing offered them in their student days. But much 
more might be done to meet the wants of the graduate class with- 
out interrupting the regular work of the school, with very little, if 
any, expense to the faculties, and we believe it might be done 
much better in the existing schools by their own teachers, than 
outside in a new special post-graduate school by a fortuitously 
conglomerated faculty. 
The graduate in search of more instruction wants above all to 
get the opinions and newest practical ideas of specialists—of 
specialists in study if not close specialists in practice. He also 
wants (perhaps needs it more than he wishes it) instruction in 
methods : the education of his eyes, ears, and hands to do, to exe- 
cute the things of science. He needs to be taught to manipulate 
all instruments, and to examine the human body thoroughly. He 
needs to learn practical therapeutics, including the use of elec 
tricity, hydrotherapy, massage, which are arts in themselves. 
The rooms which should be added to all our present medical 
schools could be utilized for the teaching of these practical 
specialties. Lectures, clinical or demonstrative ones we mean, upon 
these subjects might be going on at the very same time that the 
regular school lectures were being delivered and clinics held. 
Each school has affiliated with it a sufficient number of younger 
specialists, or quasi-specialists, who would gladly, with a nominal 
honorarium or even without any, give the instruction in such a 
post-graduate course. Every specialty could be represented by 
one professor and by several clinics in hospitals or dispensaries, 
and members of the graduate class assigned to these, in accord- 
ance with their needs and wishes, by the secretary or registrar of 10 
POST-GRADUATE INSTRUCTION. 
the school. The classes which would attend such very special 
lectures, lectures embodying the freshest and most applicable 
science of the day, might be small, but their members would be 
seriously studious or even enthusiastic. 
A post-graduate faculty organized in this way, from the 
younger men growing up around our medical schools, would do 
much to increase the reputation of their alma mater as a centre of 
learning, and would probably be stimulated to do much for medi- 
cal science by more original research than we have at present in 
America. Though perhaps lecturing at the same hour with the 
professors of the principal branches in the students’ department, 
there would be no rivalry or interference, if the students were 
classified and kept classified as above suggested. 
An objection to this plan of subdividing the classes, and having 
several lectures, clinics, or demonstrations going on at once, is 
that some members of the senior class need to go over part of the 
elementary branches before presenting themselves for their final 
examinations ; they should have an opportunity of attending the 
lectures upon these subjects, and in the scheme proposed they 
could not do this without missing some clinic or lecture upon a 
practical branch. The fallacy of this objection is obvious ;it is 
made by one who believes in the superior power of didactic lect- 
ures to instruct. The prestige of didactic lectures has been 
already much dimmed, and we may live to see them almost ban- 
ished from schools. The objection is invalid, because an intelli- 
gent member of the senior class can review his anatomy, 
physiology, etc., from text-books (having already studied these 
branches thoroughly and practically for a year or two). 
Another objection, more serious, is that a well-managed division 
of the class and the exercise of effectual control over the course 
of study followed by its members would throw a considerable 
additional labor and responsibility upon the faculty. True, but 
this would hold good of any serious scheme for improving medi- 
cal education. A part of the complicated badness of our present 
way of teaching students, has been the irresponsible ease with 
which a few men have done the business. A few faculty meetings E. C. SEGUIN'. 
in the year, an hour’s lecture three or four times a week, with one 
or two clinics each week (not prepared beforehand—mere off-hand 
conversations about cases), and a rather busy week at the time of 
the annual examinations,—these have constituted the labors of a 
professor in a medical school. One might say that it would not 
be very terrible to make an addition to these duties in the interest 
of the class, and of medical science, but the scheme does not call 
for this. It would, however, demand that the gentlemen compos- 
ing our medical faculties, with a deeper sense of the great respon- 
sibility they assume in attempting to educate three or four 
hundred young men, should carefully select one of themselves, 
or an outsider, a younger and less busy man than any of 
them, to co-ordinate the scheme of instruction. To do it well 
would tax the whole energy and time of a man having special 
executive ability. He might be termed secretary or registrar, 
and his duties would embrace keeping classified lists of the 
students, divided into junior and senior classes, and subdivided 
into sections for assignment to the various teachers connected 
with the school. He would have to see the students and teach- 
ers frequently, and secure such a rotation of these various 
sections as to give every student a full opportunity to study all 
branches of medicine. The numerous clinics affiliated with the 
school, held in hospitals and dispensaries throughout the city, 
should be, not under his control in any scientific sense, but 
guided and co-ordinated by him, in reference to their order of 
working. He could also keep a record of the various examina- 
tions passed by students of the three classes, junior, undergrad- 
uate, and graduate. 
Finally, graduates submitting to such a scheme of study, devot- 
ing several months to study under such favorable circumstances, 
would naturally expect a certificate of their attendance and at- 
tainments. The members of the special faculty might be em- 
powered to examine gentlemen desiring such certificates, and they 
could be issued by the medical school or by the university with 
which it might be affiliated. ARCHIVES OF MEDICINE FOR 1882, 
A 81-MONTHLY JOURNAL, 
Edited by Dr, E. C. Seguin, with the assistance of many prominent phy- 
sicians in this country and abroad, enters upon the fourth year of its existence. 
The Archives of Medicine will continue to be published every two 
months. 
Each number is handsomely printed in large octavo, form, on heavy paper, 
and contains from 104 to 112 pages. Whenever necessary, illustrations of various 
sorts will be freely inserted, as in the past. 
The Archives would make this special claim upon the medical profession, 
that it is made up solely of original matter, in the shape of Original Articles. 
Editorial Articles, Reviews, and records of Original Cases. 
Particular attention is given to the Review Department. Every effort is made 
to secure impartial reviewers ; they are asked by the Editor to praise or criticise 
without fear or favor, and they assume the responsibility of their statements by 
appending their initials to the reviews. 
Abstracts, proceedings of societies, etc., will be excluded in the future as in 
the past. Complete and responsible abstracts of the progress of medical science 
are now furnished in English, as well as in German and French, by periodicals 
specially devoted to this class of subjects ; and the Editor has every reason to 
believe that the medical profession is ready to support a journal exclusively de- 
voted to original communications and bona-fide reviews. 
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Germany.—Prof. Dr. W. Erb, of Leipzig. 
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