w W539L- 184-6 mi M ■ Hi. j*> H9 ■ ■ 53 *b "W J- # ^.Ocu-v;.- *vjii* jty*?* ^$JS^%frM LAST DATE yT X A LECTURE PRACTICAL EDUCATION IN AND ON % bourse of Instruction at th.e flf. 8. hospital. DELIVERED AT THE HOSPITAL, NOV. 3, 1846. BY / JOHN WATSON, M.D., ONE OF THE SUROfiONS OP THAT INSTITUTION. JL6,?A/f,' NEW YORK: I. & H. G. LANGLEY, 8 ASTOR HOUSE. 1846. 8287 VV33?L |%4fc A LECTUEE ON PRACTICAL EDUCATION IN MEDICINE, iBntlemen : The Physicians and Surgeons of this Hospital, as most of you are aware, have for years past devoted much time and attention to the business of Instruction. Ever since the first organization of our associated courses of teaching here, it has been usual to commence, at each season, with an Introduc- tory Address. In conformity with this custom, and at the request of my colleagues, it becomes my duty on the present occasion to bid you welcome, and to preface our coming winter course of clinical instruction with a few general remarks. The subject assigned to me for the present discourse, though not of my own choosing, is perhaps the most appropriate that could have been selected for the occasion. I have been called upon to address you on the subject of Practical Education ; and in connection with this, to speak of the New York Hospital as a clinical school. The task imposed upon me I have heartily accepted, doubting only my ability to execute it properly, and regretting that a theme so worthy of serious consideration, has not been assigned to some one more capa- ble than myself of presenting it to you in a lucid and impressive manner. But, gentlemen, I have first to bid you welcome. And I am at a loss how to perform this portion of my duty more becomingly, than by stat- ing, in a few words, the fare we have in readiness for you. The physicians and surgeons of large hospitals, whether specially ap- pointed for the purpose or not, rest in some measure under two obliga- tions to their fellow practitioners. In the first place, they are expected to employ the means at their disposal for extending the bounds of medi- cal knowledge, by recording and communicating the result of their ex- perience. In the second place, they are looked up to as the proper teachers of all the practical details of the profession. 4 Watson on Practical Education in Medicine. These duties, it is true, so far as we are here concerned, are as yet merely implied. Nevertheless, these implied duties, and particularly > that of teaching, are every day becoming more imperative. For it is only by hospital and bedside instruction that students can ever expect to become qualified for entering upon the practice of the healing art, either with credit to themselves, or with safety to their patients. Aware of these reasonable expectations on the part of the profession, and impressed with the paramount advantages which the liberal and en- lightened Governors of this Institution have placed at our disposal, my colleagues and myself have spared no pains to render it available, by furnishing the students with every facility for acquiring a practical knowledge of the nature and treatment of disease. In pursuance of this object, the wards of the Hospital are visited at stated hours ; and during these daily visits the students have access to all the cases excepting only such as are likely to be injured by fatiguing examinations and inquiries. Clinical remarks are daily made in the wards ; and for fuller expositions of important cases, each student, on inquiry, can have access to the Hospital Case Books. Several series of Clinical Lectures on the details of hospital service are every year deli- vered in this Theatre, illustrating in this way most of the important points of pathology and therapeutics. The students are kept informed of the results of our numerous con- sultations, and now and then admitted to attend them. The indica- tions and modes of proceeding in our surgical operations are explained to them. They have the use of our valuable library, rich in every de- partment of medical lore. . Among not the least of their privileges, they are furnished with opportunities for prosecuting the study of pathological anatomy, by the inspection of our pathological cabinet, and by attending post mortem examinations. And finally, several of the phy- sicians and surgeons on duty here are in the habit, at seasons in which the colleges are not in session, of delivering every year associated courses of lectures on most of the specialties of medicine and surgery, and of illustrating these lectures by models, drawings, and pathological preparations, as well as by frequent reference to cases under treatment in the wards. Such, gentlemen, is the fare we have to offer you, and to such we bid you welcome. In reflecting on the subject of practical education, it has occurred to me, that what we are apt to consider one of the greatest blessings of the present age—the general diffusion of knowledge—is not quite so great a blessing as it might be. For acquiring, as well as for imparting know- ledge, we trust too much in books. Hence, though men are at present better read than formerly, it is questionable whether they are in the same proportion better educated. Learning and education are by no means synonymous terms. By education is meant the development of the faculties, mental and physi- cal, for exertion, for endurance, for observation, reflection, investiga- tion, discovery and invention. By learning, is meant the acquisition of such knowledge as others have already been acquainted with. The difference between the two is immense, and should never be forgotten by those who are engaged in the business of instruction. Watson on Practical Education in Medicine. 5 In the modes and degrees of learning, too, there are very essential dis- tinctions. To learn to know, is one thing—too often thought the all- sufficient business of the learner. To learn to do, is a much more im- portant, a much more difficult matter. This is the learning which books cannot teach. This is practical learning, and it is different, both in es- sence and degree, from the speculative knowledge obtained from the mere opinions or words of other men. Abstract teaching cannot impart to us the knowledge of things. The utmost it can do, is to help us to imagine how perchance things may be. It is, therefore, to be commended to our attention, only when the things of which it treats are beyond our reach ; or as the simple friend that sup- plies us with notes of introduction to those facts with which we are desirous of becoming intimately acquainted. He who trusts to books, or to the opinions of others, for all that he knows, is as the blind man, who, by hearsay, has been taught to dis- course most learnedly about the light of heaven, a thing with which he is nevertheless hopelessly unacquainted. Learned words, and conven- tional expressions, too often mask the most confused perceptions. To the youth who is about to prepare himself for a profession, there are certain studies, which, in view of the shortness of human life, he may entirely overlook. There are others, which, for the same reason, demand of him nothing more than a speculative acquaintance. There are again others, having a greater claim upon his attention ; yet not so essential as to demand of him more than a superficial practical know- ledge. But those studies which are to prepare him for the business of his profession, and by which his course through life is to be character- ized for good or bad, it would be worse than folly to pursue, only so far as they are to be learnt through books, or the teachings of others. In regard to our own profession, it has been often and justly observed, that the student, in order to be fully prepared for it, has to acquire a much more extensive and varied stock of knowledge, than for any other pursuit. The acquisition of languages, the study of the exact sciences, of natural philosophy, of mental philosophy, of natural history in all its departments, and above all, the study of man, of man intellectual, moral and physical, of man in his social relations, man in his propensities, his passions, his habits and his follies, all of these have to precede, or to accompany the study of the various branches of medicine strictly so called. And then these branches, how numerous, how diversified, how ex- acting of time and labor! Anatomy, the first of these, if followed through all its ramifications, descriptive, general, topographical, com- parative, microscopic, philosophical, &c, is in itself the study of a life- time • and when pursued only so far as to subserve the purposes of an accomplished practitioner, demanding a vast amount of application. Physiology, too, that offset of anatomy, well worthy of all the attention that has ever been bestowed upon it, is to be acquired only by the most patient and diligent application. And after this, and closely associated with it, comes Pathology, marking with cautious eye the multifarious irregularities of vital action, and the innumerable agencies that give rise to these ; the resisting and self-adjusting forces of the living frame; the yielding of the body beneath the burthen of disease or age ; and the traces of disorder and dissolution, as detected in the several organs after death. Such is the study of Pa- 2 6 Watson on Practical Education in Medicine. thology, a study sufficiently attractive, and sufficiently extensive, for the whole of your future years, and for acquiring even the elements of which, the years assigned to your course of preparatory studies are scarcely sufficient. And now comes the most essential of all, the study of Therapeutics, the modus medendi. In pursuit of this, you have not only to familiarize yourselves with the various agencies that directly or indirectly influence the living body in enabling it to resist or overcome disease ; you must also obtain an intimate knowledge of the times and circumstances under which these agents are most likely to operate with injury or advantage. In a word, you must learn not only how to bring into requisition the materia medica and armamenta chirurgica, but the whole of the details of medicine and surgery. Numerous and diversified indeed are these branches of medical edu- cation ! And though some of them are not to be so thoroughly pursued as others, it is still well to remember, that none of them are to be studied merely in the abstract. Into all of them you should be practically in- itiated, and with some of them you must be profoundly imbued. For, be it remembered, that medicine, strict medicine, is not so much an ab- stract science, as it is the application of certain general principles to practical details. And singular as it may seem, few circumstances have tended more directly to retard the progress of medical knowledge, than premature attempts on the part of writers and teachers to give to it a strictly scientific cast. It was by such attempts, in ancient times, that the study of medicine was transferred from the temples of Esculapius, those early hospitals in which Hippocrates and his ancestors had acquired their knowledge of it, to the scholastic halls of Athens and Alexandria. It was by such at- tempts that, in the middle ages, the student withdrawn from the camp, the hospital, and the bedside, was immured in cloisters, or confined within the walls of Monastic Universities. It is this same effort that, in modern times; has mystified and confused the profession with a host of dreamy speculations under the specious name of systems of medical phi- losophy. And it is this same effort that, up to the present day, has aid- ed the aspirant to while away his years of preparation in lecture-rooms, and in the study of books and opinions, instead of employing some por- tion of this time in the observation of facts, the exercise of his own faculties, and the development of his own resources. The practice of medicine is an art, as strictly and as literally such, as the art of building, of printing, or of metal working ; and the more our systems of education are made to conform to this view of the matter, provided the principles of this art are not in the meanwhile neglected, the better they will subserve the purposes of the profession. The joiner, the shipwright, and the smith, initiate their youth into the magic uses of the saw, the hammer, and the file ; and they would laugh at the philosopher who should attempt to convince them that these youths, by studying the principle of mechanics, of the wheel-axle, of the lever, the screw, or the inclined plane, as taught in books and lecture-rooms, might be saved from the disagreeable necessity of plying their bones and muscles in the work-shop. Like those engaged in the study of other pursuits, the student of me- dicine must be taught to exert his own powers; and before entering upon the responsible duties of his profession, he should be made to give Watson on Practical Education in Medicine. 7 evidence of practical acquirement. For, without this, his principles will serve him to but sorry purpose at the bed-side. They may impart to him the semblance of knowledge ; they may serve him in discourse ; they may enable him to pass, even with some eclat, through the ordeal of a green-room examination. But unsupported and unenlivened by personal observation and experience, they must gradually escape him; or, in the long run, serve only to mislead him by the flattering, though false, conviction of being really master of all that he remembers. In the year 1831, after devoting more than three years to preparatory studies, I entered upon my duties as one of the Junior Dressers of this Hospital, and in a day or two after my appointment, 1 was requested to take charge of a patient who had been seized with an obstinate vom- iting. As yet unacquainted with practical details, I stood for some minutes at the bedside, revolving upon the remedy most likely to be of service in the case. While I was thus employed in thinking, one of my associates, whom I had no reason to look upon as my superior, sud- denly entered the ward, and directed the nurse to apply a mustard plas- ter over the pit of the patient's stomach. I saw at once the propriety of the measure. I was struck with the promptitude of the prescriber. My self-esteem was, for a time, humbled ; but the lesson, I believe, has not been lost upon me. A couple of youths, fresh from their studies, were directed here, many years ago, to apply cupping-glasses to the temples of a negro woman. The cups were at first applied moderately heated; but not adhering, they were held over the lamp until nearly roasting hot, and then applied anew. Still they would not stick. The process was again and again repeated, all to no purpose. The poor woman roared, and the poor lads labored, until the Superintendent of the Hospital, attracted by the noise, at length relieved her from her tormentors,—archly observing to them as he entered the ward, that " they had better practise on each other until they had learned how." Not long since, as is my frequent custom, I requested some of the young men accompanying me through the wards, to examine and report upon the nature of an inflammatory swelling. The first that came for- ward was, as I afterwards ascertained, one who had just passed the or- deal of his examination. He could detect nothing peculiar in the case. The second was a student of scarcely a year's standing, who had pre- viously examined similar cases. He pronounced the swelling to be an abscess already in need of the lancet. I allowed him to apply this, and to the no small mortification of the other, he gave exit to a large collec- tion of purulent matter. The practice of our profession is made up of details like these, and a knowledge of these details, be assured, is never to be reached through lectures, or deduced from abstract principles. The physician or sur- geon worthy of the name, is such, only so far as he is able to turn to advantage those innumerable and ever changing little circumstances of daily experience which language cannot teach. The senses of the stu- dent, as well as his intellectual faculties, require to be thoroughly and systematically indoctrinated. The study of principles may give employ- ment to the mind, either in the closet or the class-room ; but the hospi- tal, and the bed-side, are the schools for the senses. I had almost said the only schools:—there are others I remember to have heard an anatomical lecture, many years ago, at 8 Watson on Practical Education in Medicine. the University of Glasgow. It was just after the period of the Burlc excitement. The learned professor, in want of what is now fashionably called Materiel, was attempting to demonstrate the muscles of the hu- man body, by means of wires drawn across the skeleton. The students of Scotland, in those days, saw but little of anatomy, and knew less of the use of the scalpel. The interruption there was but temporary. We, too, have had our Doctors' Mob. But as yet, our teachers have never been reduced to this whimsical expedient of the wires. Our stu- dents, however, for all the practical anatomy they are called upon to know, might as well have Burks among them always. A practical knowledge of anatomy should not be merely recommended. The business of Medical Education has, I admit, within the past few years, been materially improved. But I may venture to affirm that it is destined, in this country, to undergo still more important alterations for the better, before it meets the full and reasonable demands of this jeal- ous, exacting and enlightened age. The course of education in our well appointed colleges—and espe- cially in the rival schools of this city (rivals be it ever hoped only in their ability for usefulness)—is every year becoming more and more ele- vated. The time, I trust, will soon come when these useful institutions may rise above the obstacles that still prevent them from placing their curriculum of study on a level with that of the most reputable schools of Europe. And let it not be said (for the charge is a libel on the people of this nation) that we are not prepared for such a system. Are our people less intelligent than those of other nations ? Are they less abundantly supplied with the conveniences, the comforts, or even the luxuries of life 1 Are they less disposed to patronize talent and acquirement ? I speak not of the residents of our larget cities, I speak of our people as a na- tion. Gentlemen, the medical institution which first comes up to the reasonable demands of the profession in this respect, and possessing the facilities, requires of its graduates practical acquirements equal to those at present enjoined upon the students of European schools, will find its interest in the measure. We hear, in all quarters, loud and la'menta- ble outcries against the reign of quackery and imposture. But the rifest and rankest quackery of this land, is the quackery of half-educated gradu- ates in medicine. But I have said that the standard of medical education has of late years been rapidly advancing here. Let us inquire in what respect; and see what remains to be effected. Numbers and noise indicate nothing but commotion. Let us look for the indications of progress. In the first place, then, our youth, prior to commencing their profes- sional studies, are better instructed in the elements of general know- ledge than formerly. Although not required to have obtained a classical education, the great mass of them at present are more or less acquainted with the classics. Those resident in this city, are nearly all graduates in letters. Judging from those that I have had charge of as private pupils, for the last ten years, I should say that nine-tenths of them had received a liberal elementary education. This fact, of itself, speaks much in favor of fixing upon an elevated standard of preliminary acquirement; and of excluding from the ma- triculation-book all applicants whose habits of life, or whose want of pre- liminary education, is such as to disqualify them from engaging in the profession. Watson on Practical Education in Medicine. 9 In the second place, as evidence of progress for the better, although the regularly prescribed time for public teaching is still confined to four months ; yet by extra and accessory courses, the annual term of public teaching in this city has, in effect, been extended of late years to be- tween seven and eight months. And during the recess, the opportunities for practical improvement are, in some respects, greater than during the winter term. With a lengthened regular term, and with fewer public lectures daily, the students from a distance who have not the means of passing all their time in the city, would have some few hours every day to devote to the Hospital, the Dissecting Room, the Laboratory, the Cabinets of Materia Medica, of Pathological and Comparative Anatomy, and of Natural His- tory,—not to speak of necessary time for meals, and no less necessary time for recreation— Neque semper arcum j Tendit Apollo. In the next place, as evidence of progress, the branches of medical education that have always been considered essential, are at present taught more efficiently than formerly. As to anatomy, it is true, dissections have as yet never been enjoined. But the students, in this respect, are in advance of the requirements of the schools. The public dissecting-rooms are tolerably well occupied; and private dissecting-rooms have been well supported. The principal improvements in reference to anatomy are, the rise of private schools for dissection, the practical spirit of most of the students, and the greater attention now paid to surgical anatomy. The subject of Materia Medica, as far as it can be taught by lectures and class-room demonstrations, is at present well managed. The student, however, might, with advantage, be called upon to familiarize himself still farther with medicines, by frequent inspection of the articles in their various forms and stages of preparation. He should be somewhat fur- ther instructed in practical botany, and be able to point out our indige- nous medicinal plants. In a word, he should be so taught as to be at no loss, whether in the field, the pharmacy, or the warehouse, to select such articles as he may be in need of. 1 put it to my fellow-practition- ers : Who of them can do this 1 Or who, when asked by some anxious mother to examine the medicine of his own prescribing, has not often had occasion to cross himself, and exclaim, " God help me, I am igno- rant of all this !" Our courses of chemistry are sufficiently full and admirably illustrat- ed ; and of late much attention has been paid to the analysis of organic substances. The practitioner of the present day, in view of the multi- tude of other investigations that have a more direct claim upon his atten- tion, is not usually required to be a proficient in chemical manipulations. But even in this branch, what is learnt should be learnt in a practical manner. The pupil, with test-glass in hand, should know how to ma- nipulate for himself. This mode of teaching has begun, and should be- come more general. No part of medicine has been taught with greater zeal in this city than midwifery. It is the fault of the student if he is not a proficient in this before receiving his degree. Midwifery with us is, indeed, one of the foremost branches of the profession. And while that superci- 10 Watson on Practical Education in Medicine. " lious body, the College of Surgeons of London, has been refusing to hold communion with obstetricians, the hero of the vectis on this side of the water has been marching in the foremost ranks of professional preferment. Two hundred years ago—and there was no such thing as an obstetri- cian ! Those ancient matrons, the midwives, even until long within that period, had it all to themselves! But now, throughout the length and breadth of this land, I know of no such thing as a reputable mid- wife. Obstetrics, as a distinct branch of our profession, was unknown until Louis XIV., the great patron of this as of other of the fine arts, first brought it into vogue, by commending it to the ladies of his court. And not long ere this, a certain Dr. Veit of the city of Hamburg, was actu- ally brought to the stake, and roasted alive, like any other pagan, for having, under the disguise of quoif and petticoats, simply attended the mysteries of the lying-in service, and assisted in the cry of—Age,Lucina! Imagine, for a moment, this illustrious martyr in the cause of midwifery still before you. What a subject for the chisel or the pencil! How worthy of embodiment by some able hand among the distinguished members of our American Art-Union ! We have seen the walls of college-halls illuminated in fresco or in oil, with Democritus at his ana- tomical investigations, Hippocrates rejecting the bribes of the Persians, Socrates in the act of swallowing his hemlock-draught; and we might fancy, for the same purpose, Seneca submissively invoking death, by opening his own veins; Desgenettes spurning the orders of Napoleon with the heroic reply that his office was to save life, not to take it; or Larrey, transferred in safety from shoulder to shoulder over the falling bridge of Berezina, by a grateful soldiery, amid the horrors of surrounding slaughter. But, gentlemen, there is not one of all these noble themes so worthy of selection for adorning the halls of our colleges, as the history of this martyr of Hamburg. We have indeed but very few martyrs for gracing the annals of medi- cine. So far as I can at this moment call to mind, I know of not another. For, Servetus had been dabbling in theology, and was burnt on that ac- count, rather than for his alleged discovery of the circulation of the blood. Let us then cherish the memory of this unfortunate German. And should the saucy fellows of the College of Surgeons ever again turn up their noses, or attempt to twit our worthy obstetricians, may the lat- ter hold up to them this glorious example of devotion to their cause, and exultingly demand of them anything to compare with it. Truly, midwifery is a great subject, and in high consideration here. And yet even here all are not aware of this. I have heard of Americans leaving their own schools, for the sole purpose of investigating some of the specialities of this department on the other side of the Atlantic. This, by way of episode. Let us now return to our inquiry. Last in order come the principles of Medicine and of Surgery. In these two great departments of medical education, our colleges are fully up to all the improTements of the day; and in connection with the usual teach- ing of principles, they have made a strenuous, and in the sight of many a successful effort to introduce practical teaching also. For this latter pur- pose a series of dispensary services has been instituted, which has added much to their popularity, and has, no doubt, in some respects, increased their efficiency for useful instruction. Watson on Practical Education in Medicine. 11 The introduction of dispensary services constitutes the latest feature in the character of the medical schools of this country. And as these dispensaries have for a year or two past been the subject of much gene- ral remark, I beg leave to say a word or two in regard to them before proceeding further. By clinical teaching, or simply clinique, is properly meant, practical teaching, in connection with observation at the bed-side. Instruction of this sort, says M. Raige Delorme, having for its object the detection and recognition of disease, the tracing of prognoses, and the considerations of treatment; and having for its text actual disease, as witnessed in indi- vidual examples ; can only well have place at the bed-side. It might be superfluous, says he, to point out in detail the re- quisite and necessary conditions for a proper clinique. They may be summed up as follows : 1st. A sufficient number of cases for teaching, and for study ; which should be so brought forward as not to dissipate the attention of the student; and so studied, examined, and discussed, as to be thoroughly understood. 2d. Convenient apartments for examining and treating patients. 3d. Special apartments for holding conferences, for consultations, and for surgical operations. 4th. A room for prosecuting post-mortem inspections, and all the means proper for facilitating anatomico-pathological research. The study of medicine and surgery by such me«, observes this excel- lent writer, should constitute the completion of every medical educa- tion. For, says he, it is at the bed-side of the patient that the pupil is enabled to search for the proof of the theories, and where he begins to apply the general rules, which have been imparted to him elsewhere. Deprived of clinical instruction, other learning the most solid and extensive, will only serve to demonstrate to him the difficulties of an art, which, like all others, is only to be acquired by the study of exam- ples. Now, I need not say, gentlemen, that these requests, and these aims, are not and cannot be fulfilled by dispensary exhibitions. Still, to dis- pensary service, when confined to the management of such affections as legitimately belong to it, there is no direct objection. The student may in this way be made familiar with much that is of interest to him. He should be cautious, however, not to place his main reliance for the practical study of disease, upon the opportunities he may chance to enjoy in this way. College Dispensaries should never be held up as sufficient to supply the place of Hospitals. And if thus held up, I most sincerely believe, in common with many of your professors, and with the great body of practitioners here and elsewhere, that they must do much indirect mischief to the cause of sound practical instruction, by withdrawing the student from the only places in which such instruction can be properly imparted. . , Yhe college cliniques, as they are now called, were first started in a neighboring city, where hospital privileges had been so much restricted as to be of little service to the winter students. As an expedient for supplying this deficiency, they were unquestionably acceptable, on the same principle that half a loaf is better than no bread. They were at first called by their true name ; but this attracting little notice, was soon altered. The example thus set, and the title then assumed, were copied 12 Watson on Practical Education in Medicine. by the schools of other places. In the country institutions, these dis- pensaries have been of real service ; and in conducting them, these schools have placed themselves fully on a level with those of the larger cities. It is somewhat remarkable, however, that, in this city, where hospital privileges are ample and almost unlimited, these exhibitions soon became so popular, as, for a time, to have entirely supplanted clinical instruction. There were probably between six and seven hundred medical students in this city during the last winter. I was on duty in the second surgical department of this hospital, during the greater part of that time, and strange to say, it was a rare thing to see the face of a single student in any of my wards during the whole of my attendance. I shall not attempt to notice the several unsatisfactory reasons that have been assigned for this state of things, reasons which scarcely serve to shield the only true and sufficient one. The clinique epidemic of the colleges, as my friend Dr. Bell has happily expressed it, was last winter at its height. The students, one and all, were affected by it, and the Hospitals were forsaken. It is to be presumed that, ere this, the disease has materially abated. Such, I am told, is the fact in Philadelphia, where it first broke out. The University of Pennsylvania, and some of the other schools there, have already abandoned their dispensaries, and are now supplying their second course students with Hospital Tickets, at their own expense. And if hospital attendance there is beyond measure superior to their misnamed cliniques, what are we to think of the facilities for practical instruction enjoyed by students within the walls of the New York Hospital! Gentlemen, if I know my own mind, I have no disposition to draw invidious comparisons; or to speak of the relative advantages of rival cities or of rival institutions. I should rejoice to see a well endowed hospital connected with each of our flourishing and useful colleges, in which the students might have ample instruction in the practice of the profession, from their own teachers. But until such hospitals can be provided, it is both interest and policy on the part of these schools, as well as on the part of the students, to turn to as much account as possible the clinical teachings of this Hospital. This has never yet been done. I fear the disposition to do it has not always been sufficiently manifested. I have heard it announced amidst an assembled multitude of young men from every quarter of the United States, that the New York Hospital is badly managed; and that the students of this city are, or rather were, to have access to a much bet- ter institution. The time may come for the fulfilment of this promise. But, in the meanwhile, we may have an opportunity of saying a few words in our own defence. We will begin this, with a summary view of the rise and progress of clinical teaching. In early times, when the practice of medicine constituted a portion of the mysteries of heathen mythology, it was doubtless taught, as other callings still are, by examples. In the circuit of the private preceptor, and in the wards of infirmaries, it has ever since, to some extent, been taught in the same way. But in Universities and other scholastic institutions, from their origin, soon after the decline of Arabic learning, until towards the commencement of the present century, practical education in medicine appears to have been entirely overlooked. Watson on Practical Education in Medicine. 13 The attention of the profession in regard to this important business, was awakened by slow and almost imperceptible degrees. At the present time it is somewhat difficult to fix upon the individual to whom the honor of originating it shall be definitively awarded. In several of s the great schools of Europe, much attention had been given to clinical instruction prior to the commencement of the present century. But as I an essential part ,of education, it is among the innovations of the present * age,—and in this country, as yet, it is only beginning to receive that degree of attention to which it is justly entitled. Although some earlier attempts at this mode of teaching may have been made at Padua, at Utrecht, and elsewhere ; yet to Francis de le , B^e, better known under the name of Sylvius, who filled the chair of Practical Medicine in the University of Leyden, from 1658 to 1672, we are probably indebted for the first well marked effort at combining clinical with theoretical instruction. But the celebrated Boerhaave, who afterwards occupied the same chair in that University, in the early part of the last century, gave to this mode of teaching the impetus which has continued to influence it for the better ever since. The example of the great school of Holland was followed, about the } middle of the last century, by the University of Edinburgh ; where the name of Cullen is associated with the earliest attempt at clinical teaching in Great Britain. At the University of Vienna, about the same time, the same system was introduced by Van-Swieten, De Haen, and Stall. It was not fully adopted at the school of Medicine at Paris, until the period of its re-organization in 1795 ; when under the charge of Corvisart, Pinel, and Desault, it became an essential portion of medi- cal education. And there it has ever since been cultivated with unpa- ralleled ardor and success, by a galaxy of brilliant men ; who, mainly through the influence of their practical teaching in the hospitals, have raised the school with which they are connected to be by far the great- est of the present age. At London and Dublin the introduction of this mode of teaching ap- , pears to have been of later date. Sir Astley Cooper, in commencing his , career, was unacquainted with it, and began to lecture on Surgery, as he himself had probably been taught by Hunter and others, without the ac- companiment of practical illustrations. He was not, however, long in \ discovering the signs of the times. And to the force of his bright ex- ample at Guy's and St. Thomas's, more perhaps than to that of any other individual, the people of Great Britain and Ireland owe the re-; markable revolution that has already been effected there in the whole system of medical education. At this moment there is scarcely a hospital of any magnitude or im- portance in England or Ireland, that has not associated with it a well- organized medical school. In these institutions clinical teaching con- stitutes, as it should ever do, the most essential portion of medical education. The schools there are no longer independent establishments. They have become appendages to the hospitals. The founders of the earliest schools in America had mostly received their professional education at Edinburgh. The organization of our own schools was accordingly much after the pattern of that once renowned and still popular institution. Among the first efforts on the part of the projectors of the medical de- partment of the Edinburgh University, was one for establishing an In- 14 Watson on Practical Education in Medicine. firmary. In consequence of their exertions the Royal Infirmary of that city was founded in 1738, and was soon afterwards in a condition for the reception of patients. Here Cullen, prior to 1756, the year of his appoint- ment to the chair of Medicine in the University, had already begun his clinical lectures, attracting to his wards young men from every part of the civilized world, and building up a school to be for many years the first in magnitude, as it was first in the talents of its teachers. As at Edinburgh, so in this country, and particularly in this city—one of the first efforts on the part of the projectors of the medical school con- nected with King's, or, as it is now called, Columbia College, was for establishing the New York Hospital. In the year 1769, through the exertions of Dr. Bajrd, Middleton, and Jones, professors in our first school of medicine, aided by some of the most public-spirited of their fellow citizens, a subscription for this object was undertaken. The Society of the New York Hospital was organized and chartered, in 1771; and in 1773, was laid the foundation of the building which we are at this moment occupying. But interrupted by a conflagration, and by the subsequent events of the Revolution, this house was not in a condition for the reception of patients until the 3d of January, 1791. Ever since that period the Governors of the Hospital have been enlarging its accommodations, and extending its sphere of use- fulness, in pace with their pecuniary resources, and the increasing ne- cessities of this growing city. It is not my purpose on the present occasion to trace the general movements of practical education beyond our own borders. I have not again to speak of it except so far as it has been connected with this Hospital. Here, and up to the opening of the college dispensaries, here only, have the students of medicine in this city been taught to look for it. The Society whose charitable purposes have been so admirably carried out in establishing this Hospital, and which, through a Board of twenty-six Governors, has still the ultimate control of it, is composed of some of the most influential, enlightened, and benevolent of our fellow citizens. The Board of Governors have the immediate charge of all that relates to the Hospital proper, as well as to the Lunatic Asylum at Blooming- dale, which is a part of the same institution. They have the appoint- ment of all the officers, medical as well as others. They have the management of the finances, and the care of the property. And through their several committees, they supervise the reception and discharge of patients, the internal economy of the several departments, and the com- fort and accommodation of the inmates. In a word, they exercise the most watchful and scrutinising supervision over all that concerns the prosperity of the Institution, and the purposes for which it was originally founded. The funds of the Hospital are derived in part from a State annuity, in part from the general government of the United States for the board of a hundred seamen, and in small part from pay patients. The Governors, the attending Physicians and Surgeons, and their assistants, receive no remuneration either directly or indirectly for their services. And with the exception of a few salaries to the superintendent, clerk, nurses, and servants, the whole of the moneys accruing to the institution, are ap- propriated to the support and maintenance of the sick. Watson on Practical Education in Medicine. 15 The three principal Buildings of the Hospital proper, can at present accommodate about 390 patients. The average number for the year past has not fallen far short of 300. The forms of disease under treatment are as multifarious as the characters and habits of our heterogeneous populace, collected as they are from all quarters, and almost every nation of the globe. The cases are for the most part acute and severe. The only diseases expressly excluded, and for which accommodation is elsewhere provided, are the contagious and eruptive fevers. The institution is under the professional care of four physicians and six surgeons, who arrange their respective terms of attendance so as to have one physician and two surgeons continually on duty. The patients are grouped into three services or divisions ; one Medical and two Sur- gical Divisions. The Medical Division, including rather more than one third of all the patients, occupies the whole of the new or North House, and two wards in the north wing of the central or Main Building. The First Surgical Division occupies all the wards of the Main Building excepting two in the north wing. The Second Surgical Division occupies the whole of the south, or as it was formerly called, the Marine House. To each of these Divisions are attached a House Physician, or House Surgeon, and two Assistants. These junior officers receive their ap- pointment at the nomination of the Attending Physicians and Surgeons, to whom they are directly responsible. They serve by gradation, for three years. During the first year, in the capacity of Junior Assistant, they accompany the Attending Physician or Surgeon in his daily visits, they attend to cupping, leeching, the administering of baths, and the ap- plication of galvanism ; they have their share in dressing and bandaging ; and they transcribe into the case-book the history of every case in their respective divisions. During the second year, in the capacity of Senior Assistant, besides attending to a portion of their former duties, they draw up the minutes of all the cases, they perform venesections, they make the autopsic examinations, and they visit patients throughout the town who apply for admission, with the view of determining whether such applicants are proper objects for the charity of the hospital. The Senior Assistant must be a graduate in medicine, he is occasionally called upon to perform the duties of the Resident in the absence of the latter. During the third year, in the capacity of House Surgeon or House Phy- sician, they reside in the Hospital, and are only allowed to be absent by express permission. They have now to carry into effect the directions of the Attending Physician or Surgeon, to supervise the registry of cases, to keep a record of all the admissions and discharges ; to visit the wards of their respective divisions at least every morning and evening. They are present at all consultations, and are allowed to prescribe for emer- gent cases, and for others, at the discretion of the Attending Physician or Surgeon, to whom they are always responsible. By this well ordered and most thorough training, the young men who pass through these gradations of duty, are at once prepared to take high rank as accomplished and experienced physicians. I need not speak of the Attending Physicians and Surgeons individu- ally. With most of these the students, during the coming winter, will have abundant opportunity of becoming more or less acquainted. Associated with the Hospital, we have also a consulting Physician, and two Consulting Surgeons. These appointments are honorary ; and 16 Watson on Practical Education in Medicine. are given in acknowledgment of the former valuable and long continued services of those who held them. And here, fondly would I dwell for a few moments, did time permit, to recount the labors and triumphs of these honored gentlemen, now among the fathers of the profession. But their deeds are already known, not soon to be forgotten. Long may they continue to enjoy their well- earned, and far-spread reputation. " Urit enim fulgore suo, qui praegravat artes Infra se positas: extinctus amabitur idem." There are also other names connected with the history of this Hos- pital, no less worthy of the passing tribute ; and among them, some, for ever associated with the history of medical sciences. The youth who now hears of them perhaps for the first time, may have in future years sufficient reason for remembering the names of Bard, of Middleton, of John Jones, of Elihu H. Smith, of Edward Miller, of Watts, of Mitchell, and of Hosack, among our former physicians ; or of Richard Bayley, Borrowe, S' aman, Kissam,and Post, among our former Surgeons. The odor of these names is still fresh among us. Here may it survive, to > be transmitted, with increase of admiration, to our successors ! I i* We now come to the business of Hospital Instruction. The main object of the founders of this Hospital was, doubtless, the commendable one of relieving the suffering and afflicted. But the mode of its origin, the character of the institution after which it was modelled, and the custom of its medical officers from the commencement, leave no room to doubt, that foremost among the incidental benefits expected from it, was the means of affording practical education in medicine and Surgery. Under this conviction it has ever been the practice of the Physicians and Surgeons on duty here to allow the students to accompany them through the wards, to explain the cases, and to give brief and unstudied, though practical, and highly useful expositions of disease, at the bed-side. This long continued custom has been attended with many beneficial results. And there are at this moment practitioners in every part of the Union, who can look back upon the familiar and unceremonious lessons thus listened to, with the liveliest recollections ; and with the full conviction of having derived greater benefit from them, than from all the abstract discourses on the theory of medicine they have ever heard. These useful and informal bed-side discourses, gentlemen, are still continued. They will occupy much of your attention here throughout the coming winter. The time may come when you will have reason to remember them with as much satisfaction, as do now those who are your seniors and your instructors. In order more fully to benefit the students of this city, as well as for the advantage of the profession generally, an effort was made, about four years after the opening of the Hospital, to establish a Medical Library in connection with it. The funds derived from the sale of hospital tick- ets to the students were appropriated to this purpose. The library, from its commencement in 1796, has been supported almost exclusively in this way. At present it contains nearly six thousand volumes of the choicest and most costly works of medical literature, both ancient and modern ; and it is continually increasing. To the student the privilege of using and consulting these works, in connection with his practical studies here, can Watson on Practical Education in Medicine. 17 never be too highly estimated. It may be well to know that there is not a hospital either in France, Great Britain, Ireland, and so far as I know, in any other part of Europe, that contains a library fit to be com- pared with ours. Prior to 1811, I am not aware that any attempt had ever been made to introduce here a course of teaching, more complete than that of which I have already spoken. About this period Dr. Edward Miller, in asso- ciation with Dr. Seaman, attempted to institute a system of clinical lecturing in the Hospital Theatre ; Dr. Miller, with this view, commen- cing on Clinical Medicine, and Dr. Seaman, on Clinical Surgery. But the death of Dr. Miller, which occurred in 1812, arrested this commend- able undertaking. Several of the attendants here, in their connection with the colleges, have at different times since the first opening of the Hospital, enjoyed the nominal office of Clinical Professors. But their mode of instruction here has always been the same as that of their colleagues. The students have never been required to attend them, or indeed to attend to Hospital teaching at all. As a means, however, of inducing them to seek for prac- tical instruction, the custom was introduced of granting to each hospital student at the end of the winter session, an engraved certificate signed by each of the Attending Physicians and Surgeons. This custom was followed up for many years ; and tended, as much as any other circum- stance, to increase the sale of hospital tickets. These certificates were adorned with a copper-plate engraving of the Hospital Buildings. They may still be occasionally seen, framed and suspended in the office of city, as well as country practitioners, exhibit- ing the names of Hammersley, Hosack, Mitchell, Post, Cock, Mott, Ste- vens, and others, as vouchers for the practical acquirements of the posses- sor. The custom of calling for these testimonials has, within a few years past, been entirely neglected. Why, I know not. The students are as much entitled to them now, as they ever were. And the opportunities which they now enjoy here, should give them a far better right to make use of them. , From 1812, up to the period at which I first became acquainted with j this Institution, I am not aware of any further attempt to extend the sphere of teaching here. In the year 1827,1 remember to have heard a series of three lectures in the Theatre, from the late Dr. Watts, on the subject of Hemorrhages. With the exception of these, I can refer to no others delivered here, until Dr. Stevens, about the year 1837 or '3S, began to give an occasional practical discourse. These lectures he pur- sued, at intervals, up to the period of his resignation in 1839. They were received with marked satisfaction. Most of those who heard them can now look back to his discourses " On the Treatment of Patients im- mediately after the Receipt of Severe Injuries," " On Lithotomy," " On Ulcers," "On Hemorrhoidal Affections," "On Venereal Diseases," " On the Extirpation of Tumors," and a few other topics, as the harbin- gers of a brighter era. After what has now been stated, it may ill become me to speak of more recent improvements. I may, however, be permitted to say, that soon after my appointment here, 1 had the honor of submitting to my colleagues a series of propositions, recommending, among other things, the formation of a pathological cabinet; the erection of a convenient building for post-mortem examinations, to which students might have 18 Watson on Practical Education in Medicine. access; and a regular mode of registry for all the hospital cases. These propositions were warmly accepted and seconded by my colleagues. They were, in due time, submitted to the Board of Governors; and be- fore the end of the year they were successfully carried into effect. In the spring of 1840, that following my appointment, I commenced a special course of Lectures on Surgical Pathology, illustrating most of them by hospital cases. These were soon followed by other special courses from my colleagues; and by a more thorough system of Clinical Lecturing in the Theatre. These distinct courses have since resulted in our associated and extensive Spring Lectures ; which are given every season, immediately after the close of the college sessions. To sum up, then, we have only to repeat the bill of fare with which we first set out. Until recently, the privileges of the student in attend- ance here, were, 1st, the opportunity of visiting the wards, of examin- ing the cases for themselves, and of listening to the practical remarks of the attending Physician and Surgeon. 2d, the use of the library. 3d, the opportunity of witnessing surgical operations in the Theatre. In connection with these, they have now the privilege of consulting our Hospital case books. They have access to our Pathological Cabinet, a collection of the greatest value to the student. They have, in the next place, convenient rooms, well supplied with all the appyfrtenances proper for post-mortem examinations. The hour for making which, throughout the year, being regularly at 11 o'clock, allows to all who are so dis- posed, the opportunity of witnessing them. Furthermore, they have now, full expositions of all severe or difficult surgical operations. They have, every year, Clinical Lectures, in course, on Medicine and Sur- gery. And lastly, they have access to our Associated Lectures on Seve- ral of the important Specialties of Medicine and Surgery ; among which may be specified, Topographical and Morbid Anatomy, Dressing and Bandaging, Ophthalmic and Aural Surgery, Surgical Pathology, Thoracic Affections, Diseases of the Nervous System, with practical teaching in Chemical Analysis. And for these privileges, which in any of the schools of Great Britain would cost them more than two hundred dollars a year, privileges which they could not enjoy in any single hospital in ; Paris,—and which neither love nor money could purchase for them elsewhere in this country, they are called upon to pay—I almost blush to name it, the amount of eight dollars annually! Gentlemen, the means of practical instruction at present at our dis- posal are all brought into requisition. Our system is nearly complete. By extending our Spring Lectures; by employing our Apothecary's De- partment for teaching the materia medica and pharmacy, and our open grounds for a botanic garden ; by distributing external patients among the students, and establishing dissecting rooms somewhere in the neighbor- hood ; a course of education might be made more thorough here, than in any other institution in America. These remaining resources may, per- haps, some day be brought within our reach. In the meantime, gentle- men, you cannot do better than turn what is already provided for you, to someuseful account. You may, in other countries, find larger hospitals; but none present- ing a greater variety of acute and important diseases. You may find in other hospitals, abler teachers ; but none so willing as we have been to give you our time and services for nothing. You may find, in some few other institutions, greater opportunities for autopsic examinations ; Watson on Practical Education in Medicine. 19 you may find, in the cabinets of foreign societies, more valuable patho- logical collections; you may, in other cities, even find larger libraries than ours. But look for all of these together in.any other hospital either at home or abroad,—-and you will look for them in vain. I say it with- out fear of contradiction, you will not find a single hospital to compare with this,—not one that contains within itself so many advantages for both theoretical and practical study as this New York Hospital. A word or two more in conclusion.—During the coming winter, it will be well for every medical student here, but more particularly for such as are not prepared to remain in town after the close of the college session, to visit the hospital daily. Let nothing prevent you from attend- ing at the hour set apart for the purpose. Come not merely with your ears open, as students often do. Come not to gaze about the wards with idle curiosity. But rather, come like philosophers, with all your faculties awake, for examining, comparing, judging, and thinking for yourselves; and working, too, for yourselves, at every opportunity. Pick out your own cases, and study these, and note these for your- selves. Do not attempt to listen to all that is said with the view of re- membering it:—but listen well to what is said of the cases on your own list, and see if it be true. Attempt not too much. Do not fall into the puerile fondness of hunting after strange sights, rare diseases, and great cases. The dressing of an ulcer, the setting of a bone, the treatment of a pleurisy, pneumonia, or fever,—these, and such as these, should be your study here. Striking cases you may look at; but the business that should fix your attention, is that which best prepares you for the daily business of the profession. Finally, avoid that morbid appetite for surgical operations, so long magnified and so much over-rated. Surgery is a good thing, a,useful, an excellent thing in its way; but too much of it is a great evil. And the sooner you find out this for yourselves, the better for your patients. I \v&v y\ ^- % (_ vr