RELATION OF HOSPITALS 
TO 
MEDICAL EDUCATION. 
WITHIN GrTOIST THE 
RELATION OF HOSPITALS TO 
MEDICAL EDUCATION. 
BY 
CHARLES FRANCIS WITHINGTON, M.D. 
“S-itb jjlablg foolbt Ije lertte aub glablg Like.” 
BOSTON 
CUPPLES, UPHAM & COMPANY 
Cljc ©lb Conur fiookslort 
283 Washington Street 
iBB6 Copyright 1886. 
C. F. WITHINGTON. 
All Rights Reserved. 
At the Annual Meeting for 1886, of the Boylston Medical Committee, appointed by the 
President and Fellows of Harvard University, it was voted that a prize of Two Hundred 
Dollars be awarded to Charles F. AVithingtok, M.D., of Boston, Massachusetts, for a 
dissertation on “ The Relation of Hospitals to Medical Education.” 
By an order adopted in 1826, the Secretary was directed to publish annually the following 
votes; 
Ist. That the Board do not consider themselves as approving the doctrines contained in 
any of the dissertations to which premiums may be adjudged. 
2d. That in case of publication of a successful dissertation, the author be considered as 
bound to print the above vote in connection therewith. CONTENTS. 
PAGE 
Introduction vi 
Measures not distinctly contemplated by the founder of 
a trust may become necessary to the truest fulfil- 
ment of the spirit of the trust. Thus, Medical 
Education an implied function of the Hospital . 
I. The Peculiar Obligation oe Hospitals in Regard 
to Medical Education ' 7-14 
Resting on 
1. The Possession of Clinical Material . . . 7-9 
The right so to use it 8 
2. Various Appliances 9. 10 
Post-Mortem 9 
Surgical, etc. 10 
3. Records of Cases ....... 10-12 
Histories 10 
Charts 11 
4. Qualifications of Hospital Staff .... 13 
Post-Mortem 12 
5. Control of Conditions 13, 14 
11. The Possible Conflict between the Interests of 
Medical Science and those of the Patient, and 
the Latter's Indefeasible Rights .... 14-22 
1. Subjection to Experiments 15-17 
2. Over-frequent Physical Examinations . . . 17, 18 
8. Protection from Exposure 18-20 
4. Parturient Women 20, 21 
5. Post-Mortem Examinations . . . . • 21, 23 IV 
CONTENTS, 
111. Factors Increasing the Educational Value of 
Hospitals 22-47 
PAGE 
1. Their Use for the Clinical Instruction of Students 23-26 
2. Resident Physicians or House Students . . 26-29 
3. Training Schools for Nurses 29-36 
4. The Appointment and Tenure of Hospital Physi- 
cians 36-39 
5. Hospital Workshops . . . . . 40, 41 
6. Therapeutic Investigations 41, 42 
7. Uniformity and Completeness of Records . . 43, 44 
8. Hospital Reports 45, 46 
9. A Salaried Pathologist 46-47 INTRODUCTION. 
It is a frequent experience in the history of public trusts that 
lapse of time and change of circumstances make necessary for the 
administration of those trusts, in the fullest requirements of their 
spirit, extensions and modifications of method which were not 
contemplated in the provisions for their foundation, and whose 
possibility, even, never occurred to their founders. The necessity 
for such changes in administrative policy is recognized by every 
court of law. Indeed, there are few endowed institutions, at 
once of long standing and of active usefulness, which are carried 
on precisely as their originators supposed they would be. Pos- 
sibly, it is to be hoped, probably, these founders, were they now 
upon the stage of action and possessed of all the facts in the case, 
would, in the exercise of the same judgment and generosity 
which characterized their lives, endorse and approve the action 
made necessary by changed conditions. There is, then, incum- 
bent upon all intelligent and conscientious administrators of en- 
dowed institutions a strong moral obligation to adapt their policy 
not solely to the specific end nominated in the trust, but to every 
allied interest which a far-sighted mind can see to be capable of 
furthering that end. 
The primary intention of the founders of the world’s great 
hospitals, from the middle ages down to modern times, has been 
the relief during times of sickness of those who are unable prop- 
erly to provide for themselves. It may be admitted that even at 
the present day this is the motive which calls forth by far the 
greater part of the contributions made for hospital purposes. 
Yet to the men who are charged with the expenditure of hospital 
funds, alike whether those funds are derived from a monastic 
foundation of the middle ages or are the contributions of a “ Hos- 
pital Sunday ” in the present year, there is an obligation to favor 
whatever policy will directly or indirectly increase the efficiency 
of the institution for the relief of the sick poor. Nay more, in VI 
INTRODUCTION. 
as much as the hospital is designed not for the welfare of one 
generation alone but of many, and as any useful discovery made 
in one such institution is at once available for all its fellows, no 
management has a right to limit its endeavors strictly to the 
patients who for the time being are under its own roof. The 
sick poor, to whom its mission is, are the sick poor of every 
country and of all time. 
The reason that the present inmates of St. Thomas’ and St. 
Bartholomew’s hospitals are more benefited than their predeces- 
sors in the same institutions, under monkish supervision, is 
simply that medical science has in these intervening centuries 
made discoveries, the best, indeed, the whole of which are to-day 
enjoyed by every hospital patient the world over. The surgical 
achievements which have brought relief to so many suiferers in the 
hospitals during the last decade have been made possible by such 
events as the induction of anaesthesia by ether in the amphithe- 
atre of the Massachusetts General Hospital, and the study and 
practice of asepsis in the hospitals of Glasgow and of Vienna. Is 
it not then obvious that the welfare of hospital patients in future 
time, nearer or more remote, depends in the highest degree upon 
the contributions which can be made to medical science ? And 
is it not clear that every hospital has a relation through interest 
as well as through duty with the cause of medical education? 
At this point the objection may be raised by the lay supporters 
of hospitals that while the advancement of medical education is 
doubtless for the advantage of all men, including hospital benefi- 
ciaries, yet that there is no special obligation resting upon hos- 
pitals more than upon the general medical profession to contribute 
to such advancement, and secondly that to a certain extent the 
use of a hospital for purposes of medical education is in conflict 
with the comfort and well-being of the individuals under treat- 
ment; in other words, that hospital managers will prejudice the 
interest of their present patients by allowing them to be used for 
the purpose of advancing medical science, however useful such 
augmented medical science may be for future sufferers. To 
O *■' 
these two objections it will be our first duty to reply, and we 
will take them up in the order indicated. THE PECULIAR OBLIGATION OF HOSPITALS IN 
REGARD TO MEDICAL EDUCATION. 
It is a generally admitted ethical principle that responsibility 
is proportioned to opportunity. If, then, it can be shown that 
hospitals possess certain facilities for the advancement of medical 
science that are not enjoyed elsewhere, and if those facilities 
have relation to important elements in medical education, it 
will follow that hospitals are under a peculiar obligation to 
second this work. 
1. The Possession of Clinical Material is a practical 
monopoly in the hands of hospitals and dispensaries. It needs 
no argument to show that for the medical education of the indi- 
vidual clinical instruction is a sine qua non. The didactic in- 
struction of the schools might very well be replaced by the pri- 
vate use of text-books, but the practical study of and familiarity 
with disease as it exists in the sick-bed, can be replaced by no- 
thing. But the hope of future progress in the science of medi- 
cine rests upon the information gained and the acuteness devel- 
oped by individual students and practitioners. Therefore med- 
ical science, with all its possibilities for the relief of the sick, 
rests upon clinical study as its corner stone. 
In former days the great majority of students in medicine 
derived what clinical opportunities they possessed from 
accompanying the practitioners with whom they studied in their 
daily rounds. In simple communities and wherever the personal 
influence of the family physician was great, a certain portion of 
patients would consent to receive one such person as the attendant 
might choose to bring, though it is perhaps doubtful whether, 
had methods of physical examination been as extended and 
thorough then as now, even this privilege would have been 8 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
granted. It would be very difficult at the present day to obtain 
the consent of well-to-do persons, who pay for their medical 
attendance, to allow themselves to be used for purposes of 
clinical instruction, and even if those practitioners who are 
competent to teach, could each take one student with him 
in his daily rounds, the amount of material thus available 
when distributed among all the students would give each but a 
small number of cases, covering but a narrow range of subjects. 
On the other hand, the hospitals, both general and special, 
have the material, in large amount, and brought together so 
that no time is lost in passing from one case to the next. 
The student who has the freedom of a moderately large hos- 
pital will see more important cases than he could if he were 
able to follow the practice of twenty average physicians. For 
the ordinary practitioner has much of his time taken up daily 
with cases of minor illness varying from slight indisposition to 
imaginary maladies, few of which find their way into the hospitals. 
Besides the ordinary and average cases of disease, with which 
the student cannot be made too familiar, many extraordinary 
and rare maladies are to be found in hospitals, being attracted 
either by the unusual facilities for treatment or for the sake 
of a more perfect diagnosis. 
Assuming, then, the existence of a large and varied amount 
of clinical material in a hospital, we now come to consider the 
right to use this for purposes of instruction. When a patient 
is paying the cost of his treatment either in his own home or in 
a private room of a hospital, we concede his right to say 
whether or no his malady shall be made the occasion of instruc- 
tion to others. From free patients, however, we claim that the 
hospital management, which, be it always remembered, should 
act not in the interest of the hospital alone, but of the public, 
and not only of that portion of the public which for the time 
being is in its wards, but of the larger public which in the 
future shall come under its benefaction, has a right to re- 
quire such a quid pro quo as can be rendered without detriment 
to the patients. This principle, as applied to the pecuniary 
liability of patients, according to their ability, is recognized and THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
9 
enforced in many of our large “free” hospitals, and the man 
who has money enough to pay a half or a quarter of the expense 
of maintenance is required to pay it in the interest of future 
beneficiaries for whom the hospital can thereby do so much 
more. If this be legitimate, it is equally so to require in the 
same interest from all free patients, in consideration of the ben- 
efits they are receiving, such compensation as they have it in 
their power to make, to wit., the opportunity for clinical in- 
struction. The only limitation to this requirement is the im- 
portant one to be alluded to later, that the facilities for instruc- 
tion which are employed shall not be prejudicial to the recovery 
•or other welfare of the individuals. 
Nor does this requirement, with the proviso last referred to, 
work any hardship to hospital patients as a class. To those 
who are reasonable, it seems a small price to pay for the advan- 
tages they enjoy. Like other small requirements, taxes, for in- 
stance, it might be irksome if there were a consciousness that it 
was unjustly imposed, but to those who accept its rightfulness, 
it is not onerous. The experience of the writer is that it is rare 
for hospital patients to object to being used in this way as a 
means of instruction. Indeed not a few of them appear to 
enjoy the attention which they thus attract. 
The considerations above advanced have reference chiefly to 
the education of medical students, an end of importance for the 
future of medical science, but, perhaps, less immediately and 
strictly so than some of those now to be mentioned. 
2. Various Appliances more or less unattainable, except 
for hospitals, are peculiarly useful for observing and col- 
lating facts of scientific value. Foremost among these we 
may mention those found in the autopsy room. The value of 
post-mortem studies does not need argument in such a paper 
as this. It may be said, however, that pathological investiga- 
tions, in order to be of the most practical use, require to be 
closely associated with clinical studies. Every practitioner, 
however he may desire to examine macroscopically and mic- 
roscopically those diseased organs whose depraved functions 10 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
have required his attention at the bed-side, realizes the practi- 
cal difficulties in the way of making a satisfactory autopsy in a 
private house. Much of this difficulty, no doubt, is due to his 
lack of facility, through infrequent practice, in the technique of 
autopsies and (shall we add ?) in the interpretation of post-mortem 
appearances. Still, there is a great advantage in a well equipped 
autopsy room. A well-lighted and warmed room, a table of con- 
venient height, abundance of running water (with no sense of 
anxiety for carpets, sheets and mattresses), balances for weigh- 
ing the organs, and dishes for containing them, a microscope 
table at hand, with, of course, a complete set of post-mortem 
instruments, all these are to be found in most of our well- 
appointed hospitals, and cannot be had outside such institutions. 
With these aids the investigator is much less likely to overlook 
any important point than without them, and when we add the 
expert pathologist that most hospitals possess, the chance for 
useful results from an autopsy are vastly increased. 
Abundant surgical appliances are within the reach of most 
hospitals and their completeness enables surgeons to perform 
operations which they would hesitate to undertake elsewhere* 
The manifold details necessary to full Listerism or the aseptic 
method practiced among the German surgeons could hardly 
have been carried out without the facilities which a hospital 
grants. Surgical science has made its most rapid strides in hos- 
pitals, and this because of the perfection of appliances and the 
trained assistants that have made possible the boldest of opera- 
tions. The raised tiers of seats in the operating room—the 
amphitheatre enable an operation to be witnessed in every de- 
tail by a hundred pairs of eyes. The patient is none the worse 
for it, the surgeon is not incommoded, yet, by this simple ar- 
rangement, for which a hospital alone gives an opportunity, a 
hundred men receive instruction from an operation which other- 
wise would have no educational value except to the surgeon and 
his immediate assistants. 
3. Records of Cases can be kept in a hospital with a 
completeness possible nowhere else. The system of house-pupils- THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
11 
or resident physicians, now everywhere in vogue, provides a 
corps of clinical clerks able under proper supervision to keep a 
full record of all essential facts in every case of sickness treated. 
As to what these records should comprise, we shall have some 
thing to say at the proper place. Suffice it 1o sa}T here that a 
continuous series of good records is of inestimable value to one 
who is studying any form of disease. The frequency with which 
any one symptom occurs, the time at which it makes its 
appearance, its relation to age and sex, its prognostic value, 
these and countless other facts of importance can be deter- 
mined only by a comparison of a largo number of authentic 
records, and such records can only be kept in a hospital. In 
private practice a physician lacks the time for complete records. 
In a case which promises to be of interest he jots down certain 
notes, but it is not always possible to tell, at the outset, what are 
going to be the interesting cases. Moreover, for such purposes 
as the “ collective investigation” of disease the ordinary every 
day cases are of more importance than rare forms, and here the 
lack of fulness of most private notes prevents the drawing of de- 
ductions even from the range of one’s personal experience, 
limited as that is. In some few instances the circulars prepared 
by collective investigation committees in England and this 
country have suggested a uniform system for recording cases 
which has enabled the comparatively few practitioners who have 
had at once the leisure and the ability to comply with it, to 
collate their own cases with each other and with those of their 
contemporaries. But, except under some such system, there 
is little basis for comparative deductions founded on properly 
recorded observations of individual practitioners. 
A species of record which is peculiarly adapted to a well- 
appointed hospital is the chart of temperature, pulse and 
respiration. Where there are trained nurses, this record is easily 
kept by them. The advantage of such a record is seen not 
only in cases where there is a marked deviation from the norm, 
but also in cases, like some of the forms of mental disease, 
where the deviation of temperature is not palpable to the 
touch, and where nothing but an accurate thermometric record 12 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
reveals the state of things. The record may be made if 
desired oftener than twice daily, and may show, as in cases of 
insolation, or when the uterus is being irrigated internally in 
puerperal septicaemia, the relation of the temperature to the 
therapeutic means employed. In private practice it is not 
possible to obtain such records, except when a trained nurse is 
in charge, for the physician’s visits are neither frequent nor long- 
enough to enable him to take more of such observations than 
are necessary for the practical conduct of the case. But the 
proportion of private patients who are able to afford the service 
of a trained nurse is not large, and it is among those who are 
unable to have such attendance that cases are most likely to 
occur where a stated record of temperature, pulse and respiration 
would be most useful from a scientific point of view. 
Autopsical records, where fulness and accuracy are so im- 
portant, deserve a word of mention in this connection. The 
private practitioner when lie records an autopsy, is likely to note 
only such points as seem to have a bearing on the cause of death. 
Frequently but one, and that the most obvious morbid condition 
is recorded. But the hospital record, supposing an autopsy 
to be made, will show all that is seen, whether its bearing 
upon the cause of death be understood by the observer or not. 
Cases are not wanting where such complete post-mortem records 
have waited years, even centuries, for their interpretation.* 
Even though a condition noted has no relation with the cause 
of death it may prove of value to some future investigator who 
shall search the records for some wholly different purpose. 
For instance, in an autopsy of a case of pneumonia it may be 
recorded that there were old uterine adhesions. This, and 
other like notes in other autopsies, may prove of value to a 
man who is seeking to learn the frequency of pelvic iuflam- 
* King James I. is said to have died of an ague. The physicians who 
made the necropsy recorded certain appearances, hypertrophy of the heart 
and atrophy of the kidneys, which although not understood by their 
observers, convey to us the probability that the king had Bright’s Disease. 
Similar information has been transmitted unwittingly regarding other 
noted persons. . THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
13 
raations. Yet such a note 'would rarely be found outside of 
hospital records. 
4. The Qualifications of the Hospital Staff constitute 
an element in the educational capacity of the institution 
without which all the facilities previously mentioned would 
be of no avail. Fortunately as yet the methods of “practical 
politics ” have had little part in the composition of the visiting 
staffs of our principal hospitals, and it is true in the main that 
such positions are held by men who have the ability and the 
disposition to use the opportunities of their place with a view 
to the enlargement of the general store of medical knowledge. 
o o o 
In not a few instances these men hold chairs of instruction in 
medical schools and are thus able to utilize their material directly 
for the teaching of students. Even when not engaged directly 
in teaching, they are, as a rule, very hospitable in extending 
the privilege of a visit through the wards to younger men. 
For the harder work of unravelling obscure cases and for col- 
lating the results of their own and others’ observations many of 
them possess a marked aptitude. 
Where a body of men is thus working together in harmony 
much good can come from the opportunity of conference and 
consultation, which, however useful it may be in private prac- 
tice, is necessarily a matter of some formality and expense, 
but which, in the hospital wards, becomes natural and easy. 
Whenever, as in the larger hospitals, the work is divided 
among specialists, of diagnosis is promoted by calling 
in perhaps several expert opinions upon different organs in- 
volved by a common disease. In an obscure nervous affection, 
for instance, light may be shed by the aurist, the ophthal- 
mologist and the gynaecologist, to the advantage both of 
diagnosis and of treatment. 
O 
5. The Control of Conditions is much more perfect 
in a hospital then in private practice. Not to mention the 
difficulties that arise in the latter case from lack of proper nurs- 
ing, injudicious friends may by neglect of instructions imperil 
the success of the most carefully considered treatment. It is 14 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
under strict hospital discipline that the physician can be surest 
that his orders are being exactly carried out. Again, in private 
practice, the physician is often obliged to modify the treat- 
ment he would prefer in deference to the wishes or prejudices 
of the friends. Medicines are objected to from their unpalatable- 
ness or even from a mere whim. Perhaps oftener medicines 
are clamored for when the physician considers them unnecessary. 
When the patient is removed to the hospital it is only he, and 
no longer his friends, who requires treatment by the physician. 
If the case be a mild typhoid fever and the attendant believes 
no drugs to be indicated he can study the natural history of the 
disease by allowing it to run through its phases uncomplicated 
even by such placebos as he otherwise might feel obliged to 
administer. When the patient himself retains his conscious- 
ness something may have to be done to satisfy his craving for 
medication, even in a hospital. But in the absence of a copy 
of the prescription he never need know the simplicity of the 
means that are adopted for this end. 
THE POSSIBLE CONFLICT BETWEEN THE IN- 
TERESTS OF MEDICAL SCIENCE AND THOSE OF 
THE INDIVIDUAL PATIENT, AND THE LATTER’S 
INDEFEASIBLE RIGHTS. 
While it is true, as has been already said, that in many 
respects there is an identity of interest between practitioner and 
patient in the advancement of medical science, and while any 
gains so made are for the benefit of the whole race, it may 
nevertheless be admitted that these advantages are not equally 
distributed among all persons, and that it is occasionally 
at the expense of the individual that truths of the greatest 
general utility have been learned. A surgeon’s first opera- THE RELATION OE HOSPITALS TO MEDICAL EDUCATION. 
15 
tion of ovariotomy, for instance, is not so skilfully performed 
as his one hundredth, yet through the former he gains a facility 
in the operation which enhances his subsequent capacity to save 
life. Yet somebody must be his first patient. So in the develop- 
ment and establishment of any new method of surgical proce- 
dure ; the later subjects profit from experiences obtained at the 
expense of the earlier subjects. If it be an injustice that the 
individual should sometimes suffer for the welfare of the race, 
it is one that is not confined to the development of medical 
science, but exists throughout the constitution of things. 
Everywhere it is true of Nature, in the words of Tennyson, 
“ So careful of the type she seems 
So careless of the single life.” 
In the matter under consideration it is the clear duty of those 
who are charged with the administration of charitable trusts to 
adjudicate between what are at times the conflicting claims of 
medical science and of individual welfare so that neither inter- 
est may receive more than the least possible detriment. In the 
older countries of Europe especially, where the life and happi- 
ness of the so-called lower classes are perhaps held more cheaply 
than with us, enthusiastic devotees of science are very apt to 
encroach upon the rights of the individual patient in a manner 
which cannot be justified. In this country we are less likely 
to fall into this error than those living under monarchical insti- 
tutions, but even with us it may be well to draw up, as it were, 
a Bill of Rights which shall secure patients against any injustice 
from the votaries of science. The occupants of hospital wards 
are something more than merely so much clinical material 
during their lives and so much pathological material after their 
death. 
1. Subjection to Experiments. The first matter to 
be referred to, namely the extent to which a patient may right- 
fully be made the subject of experimentation, is one in which 
it is impossible to draw a definite line. On the one hand, 
every practitioner must admit that the treatment which ho 16 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
adopts in every case that comes under his charge is to a certain 
extent experimental. That is to say, the result of the treat- 
ment is a matter of greater or less probability, but never of 
certainty. Whatever course is decided upon, an alternative 
has usually presented itself, and in the event, whether favorable 
or otherwise, the question usually suggests itself, “ what would 
have happened if I had followed the alternative course? ” 
Again, a physician reads a plausible account of a new method of 
treatment for some disease in which his own previous experi- 
ence has been unfavorable. He decides that the next case that 
presents itself shall be treated in accordance with the new 
method. This is purely an experiment, yet it may be perfectly 
legitimate, and is equally so whether the patient comes to him 
in private or in hospital practice. To go a step further; it 
may devolve upon the physician to test for himself and for the 
good of science some mew and hitherto untried remedy in a 
certain disease. There is here the puzzling ethical fact that he 
would be unwilling, Avere the patient one of his own family, 
to subject him to the risk of the proposed novelty. Yet if 
what is known of the physiological action of the drug makes 
its employment reasonable, it may be proper for him in the 
interests of medical science to establish its usefulness or the 
reverse. This can only be done by making trial of it in 
appropriate cases. The individuals upon whom that trial 
chances to fall are then exactly in the position of those alluded 
to a moment ago, whose lot was cast in the early days of 
ovariotomy. Like the men who have lived in times of politi- 
cal crisis and turmoil, their environment was their misfortune. 
Kespousibilities were devolved upon them whose discharge was 
of greater profit to their posterity than to themselves. Hospital 
patients, then, cannot complain if they have to bear a part in 
the solution of the medical problems of the day, in so far, at 
least, as a similar obligation rests upon the sick who are out- 
side of such institutions. 
They have, however, a right to immunity from experiments 
merely as such, and outside of therapeutic application. This 
right is one that is especially liable to violation by enthusiastic 17 
THE RELATION OP HOSPITALS TO MEDICAL EDUCATION. 
investigators. Its violation may, on the one hand, involve no 
pain, discomfort or other harm, as when anthropometrical 
observations are sought, a collection of sphygmographic trac- 
ings is desired, or the facts regarding the normal condition of 
O O O 
the reflexes are wished for. If the investigator were to ask 
these things as a favor, few, if any, of the patients would refuse 
him ; and if as a matter of convenience he takes them as a 
right, no harm is done. On the other hand, however, there 
are experiments, pure and simple, which do involve harm and 
pain to their subjects. Within a year or two, two prominent 
English therapeutists who were studying the action of nitrite 
of sodium, administered the drug to a large number of hospital 
patients in doses designed to show its physiological action. 
The vaso-motor symptoms produced were uncomfortable and 
in some cases, to the subjects at least, alarming. To perfect 
the demonstration the administrations were repeated again and 
again in the same and in new subjects. The whole affair was 
an egregious usurpation. There was no pretense that the drug 
was given for any therapeutic purpose. If the experimenters 
wished to investigate the physiological action of the drug they 
should have called for volunteers; they had no right to make 
any man the unwilling victim of suclran experiment. 
A temptation kindred to the above is the recommendation 
of hopeless surgical operations. When the patient demands 
such an operation the surgeon should set the chances fairly 
before him and if it is still insisted upon, he is then justified 
in undertaking an operation which gives but small chances 
of success. But he has no right to take advantage of the 
patient’s extremity to recommend a procedure which can have 
no other advantage than to enhance the operator’s reputation 
for boldness. 
2. Overfrequent Physical Examinations sometimes 
work an injustice to hospital patients. It is in acute diseases 
that they are especially likely to be made. In a pneumonia, 
for instance, there is great interest in following the various 
stages in the evolution of the disease. The area of consolida- 18 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
tion and the character of the rales undergo such marked 
changes in a few hours that repeated and prolonged physical 
examinations of the chest are sometimes made, when nothing 
can be added thereby either to the diagnosis or to the indica- 
tions for treatment. The development of the crepitant and 
subcrepitant rale and of the crepitans redux is particularly inter- 
esting to demonstrate to students, yet the frequent uncovering 
of the chest and the exhaustion incident to being auscultated 
and percussed by a class of students cannot fail to be prejudi- 
cial to the patient. Physicians would defend their private 
patients against such injurious influences; they should be 
equally solicitous for hospital patients. It is not rarely that 
we see an expression of weariness come over the face of the 
patient who is in the hands of the too ardent and precise diag- 
nostician. Its occurrence should always be the signal for a 
prompt suspension of the exploration. “Do not probe the 
wound too curiously ” is a maxim which should never be for- 
gotten either in surgery or in medicine. 
Sufferers from more chronic maladies, on the other hand, 
can generally support examinations frequent enough for pre- 
cision of diagnosis as well as for clinical demonstration. 
When the exact amount of a pleuritic effusion or the precise 
size of a hypertrophied heart can be learned without comprom- 
ising the patient’s safety, it is our duty to learn them, for 
then there is no conflict between the interests of science 
and of the individual. 
The utilization of the opportunity for physical examina- 
tion of patients to secure facility in the manipulation 
of various instruments of diagnosis, provided the operation 
be not itself dangerous and the physician exercises careful 
oversight that it does not become injurious through the 
maladroitness of the operator, is not an injustice to the 
patient. But the writer confesses to a sentiment of indignation 
upon seeing a class of students invited each to pass a uterine 
sound upon the occupant of a gynaecological table. 
3. Protection from Exrosure is a right of every THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
19 
female hospital patient, which deserves special emphasis. Low- 
ness in the social or even in the moral scale is no excuse for 
a disregard of what are or should be the patient’s sentiments 
of modesty. Formal gynaecological examinations, which might 
be expected to be the severest ordeal to womanly delicacy, 
have been so guarded in the practice of the most eminent 
practitioners of this specialty, by the preparation of the patient 
through the attention of the female nurse, as to occasion really 
almost no exposure. These precautions ought always to be, as 
in most cases they already are, enforced. It is perhaps in the 
examinations, other than gynaecological, that carelessness in this 
regard is oftenest met. Thoracic and abdominal inspection 
should not be practiced in cases of young women or indeed of 
women of any age without the attendance of a female nurse 
whose duty it should be to arrange the clothing so as to leave 
the portion desired to be examined accessible to the physician, 
and to cover and protect such portions of the body as have 
already been sufficiently examined. Cases are not uncommon 
in which it comes to the knowledge of the physician that the 
greatest objection entertained by women to a hospital is the 
unnecessary exposure to which they have been subjected. The 
exposure is doubtless due merely to carelessness on the part of 
the physician, but it is a carelessness which in private practice 
would lose him his patient, and against which gentlemanliness 
should be as efficient a preventive as pecuniary interest could 
be. In the venereal wards of the Vienna Hospital the entrance 
of the professor and his students is the signal for the turning 
down of the coverlets of all the beds and the exposure of the 
entire bodies of the patients to the view of each other as well 
as to that of the students. Such wholesale exposure would 
probably be tolerated nowhere in our own country, but some 
men coming home fresh from the usages of continental cities 
show too much of the influence of their recent associations. 
Of course a venereal patient must expect examination of the 
seat of his malady and even the use of his case for clinical 
instruction or any other proper means of scientific advance- 
ment. But he has not forfeited his right to a decent privacy, 20 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
and would have a just cause for complaint if his naked body 
were made a gazing stock to nurse and fellow-patients. 
Now the essential injury involved in an exposure, or viola- 
tion of privacy, depends entirely upon a revelation of personal 
identity. When the personality is hidden there is no shame 
on exposure. A nude figure in an art gallery would bring no 
sense of shame to its subject provided his identity were con- 
cealed. So a photograph to illustrate a pathological condition 
of any portion of the body is no great injury to one’s modesty 
provided the face is hidden so that the personal identity is 
concealed. In all gynaecological examinations and operations 
which are used for clinical instruction the face of the subject 
should be covered. The personality being hidden, the sense of 
exposure is lost. 
Again, there is no violation of modesty when there is no 
consciousness of exposure. An operation may be performed 
upon a woman before a whole amphitheatre of students and 
provided she is unconscious at the time of her surroundings and 
never learns subsequently of the circumstances, there has been 
no violation Of her modesty. The operating room of a hospi- 
tal should therefore be absolutely a terra incognita to every 
patient. None should ever be permitted to see its interior. 
Etherization should be performed in another room, the patient 
should be taken to the operating room only when unconscious 
(the face being, if practicable, concealed so as to avoid the 
possibility of subsequent recognition by any spectator) and 
should be removed again at once after the operation to a receiv- 
ing room. If this be done in all cases the hospital public will 
be ignorant of the nature of the operating room and patients 
may be kept forever oblivious of the fact that spectators were 
present at the time of the operation. In the absence of this 
knowledge no person can complain of any injury to modesty. 
There has been so such injury. 
4. Parturient Women have a claim in addition to that 
last referred to, a right none the less imperative because the 
women themselves are in most cases ignorant of it. We refer THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
21 
to protection against the transfer of contagion, of which the 
danger is somewhat enhanced by the use of the cases for pur- 
poses of clinical instruction unless special precautions be 
taken. In this matter the hospitals of Germany are more 
advanced than many of our own. A general hospital has no 
right to receive puerperal cases into its miscellaneous, surgical, 
or even medical wards. Where no isolated or special lying-in 
ward is provided it is an act of humanity in all but most 
extreme cares of destitution or emergency to refuse admission 
to puerperal cases. This seems a hardship to many women 
who think that shelter is all that they require, and the urgency 
of their application sometimes doubtless influences zealous 
teachers to avail themselves of the opportunity this affords for 
scientific observation or instruction. 
Given a suitable ward for such cases, no student or practi- 
tioner, who comes directly from the autopsy or dissecting 
room, or from immediate attendance upon any surgical case 
where suppuration is present, or upon puerperal fever, should 
be allowed to make a digital examination of the parturient 
women. Persons in attendance upon scarlet fever or diphtheria 
should also be excluded unless they have made a complete 
change of clothing and taken an antiseptic bath. Others may 
be allowed to make digital examinations in order to study the 
course of the labor and to acquire facility in diagnosticating 
foetal positions, but in every case a thorough ablution in some 
disinfectant solution and an abundant use of the nail brush 
should be required prior to such examinations. With these 
precautions “touch courses” are conducted in many of the 
large lying-in hospitals of Europe and in some in our own 
country without prejudice to the safety of the patients. With- 
out them, such courses entail the utmost risk to all who are 
made their subjects. 
5. Post-mortem Examinations should never be insisted 
upon against the expressed wish of the subject during life 
or of his nearest friends after his death, unless, indeed, the 
latter opposition is countervailed by an express permission THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
obtained in writing from the subject himself. In many states 
and countries this protection is secured by law, but in all cases 
justice requires it. One great dread in the minds of a portion 
of the public in entering a hospital is that of being dissected 
should they die. However we may regard this as a sign of 
mental weakness, we have no moral right to disregard it. It is 
well known that considerations of sentiment have more effect 
with the majority of persons than considerations of philosophy. 
Each man’s strongest desires and fears are of great moment to 
himself, however trivial they may appear to others. The usage 
of the best administered hospitals enables the reply to be 
made to any anxious patient who ma}? ask the question, that no 
autopsy is ever made except on a written permission of the 
patient himself or of his nearest relations. 
Nor does this rule work the injury to science that might at 
first appear. When properly approached and assured that no 
visible disfigurement of their friends’ remains will be made, a 
very large number of people even in the most ignorant classes 
accede to such a request. The fact that they are consulted 
propitiates them and inclines them to grant that when asked as 
a favor which would excite their bitterest resentment if taken 
as if a right. Of course it will occasionally happen that an 
autopsy will be refused in just the case where it wTas most 
earnestly desired. But if our tables of recorded cases with 
autopsies are less complete than those of German observers, it 
is better that it should be so than that any one in receipt of 
hospital charity should be subjected to what is, from his point 
of view, a great wrong. 
FACTORS INCREASING THE EDUCATIONAL 
VALUE OF HOSPITALS. 
Having thus far considered the obligation of hospitals to the 
furtherance of medical education and the safeguards which THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
23 
should be observed in order that the fulfillment of this obliga- 
O 
tion may not conflict with the interest of the individual 
patient, we now turn to a discussion of those means whereby 
medical education, through the instrumentality of hospitals, 
can be most effectively aided. With a consideration of these 
points the remainder of this paper will be occupied. 
1. The Use of Hospitals for the Clinical Instruction 
or Students. 
There are two functions of the university, both of which are 
sought to be filled by most of our institutions of higher edu- 
cation, whether liberal or professional. But as we shall pres- 
ently show, while both are of importance, they are very 
unequal in the demand which they make either upon the time 
or the endeavor of teachers and taught. Moreover it is not 
necessary that these functions should be united in every educa- 
tional institution. The older and more fully equipped univer- 
sities provide a corps of professors consisting often of men 
who have attained great eminence in their special lines of study, 
whose duty it is tp impart instruction, to give direction to the 
student’s line of investigation, and finally to determine by 
suitable examinations his fitness to receive a diploma indicating 
either his general intellectual attainments or his fitness for the 
practice of some particular profession. In proportion as the 
students have attained intellectual maturity the amount of actual 
instruction given them often grows less and less, till their uni- 
versity residence simply amounts to such an environment either 
of libraries or of laboratories as makes it easy for them to carry 
on in whatever way they may prefer whatever researches they 
wish. Now it is a frequent experience that men who have 
made for themselves a distinguished reputation in science or 
literature are by no means the most successful teachers of the 
subject which they themselves have so fully mastered. Many 
a student learns more from the adjunct professors, the instruct- 
ors and the tutors in our colleges, men who are nearer his own 
age and can better appreciate his peculiar difficulties, than from 24 
THE RELATION OP HOSPITALS TO MEDICAL EDUCATION. 
the professors, despite the possibly greater attainments of the 
latter. So in the department of medicine the clinical assistants 
and the privat Docenten are often in a position to give instruc- 
tion which has a greater practical value than that of celebrated 
incumbents of the professional chairs. 
The “teaching universities” are then the ones which have 
the widest field. Every young man must spend years in order 
to acquire the rudiments of his profession and he may find it 
convenient and useful to pursue his studies in many places and 
under many teachers. He must for a certain time, for the sake 
of obtaining an approval and certificate of his methods of study 
and his degree of profit thereby, connect himself with some 
institution which in addition to teaching functions has authority 
to examine candidates and issue diplomas. But before, and 
indeed after that time he may avail himself of extra-mural 
teaching as well as intra-mural. There is no reason why “ free 
trade ” should not obtain in the matter of teaching as well as in 
the distribution of other valuable commodities. Let any one, 
we say, who has the opportunity and the ability for imparting 
instruction, do so. The quality of the wrares which he brings 
to market should be the only factor in his success. Men know 
as a rule what they want, and will not spend much time or 
money upon teachers that have not something valuable to offer. 
It is this principle which has led to the formation and 
successful career of the several polyclinics and post-graduate 
schools which have recently grown up in the large cities of our 
country. These institutions are but simply organized associa- 
tions of private teachers of medicine. The members of the 
associations are men who possess from hospital or dispensary 
positions clinical material which they believe themselves able 
to utilize to the benefit of students and practitioners of medi- 
cine. If they are mistaken in their estimate of their ability 
their course will not flourish long, even should their association 
with other successful teachers give them pupils for a time. A 
polyclinic is to medical teachers merely Tvhat a broker’s board 
or a stock exchange is to its members, a means of better en- 
abling each man to find customers for what he has to dispose of. THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
25 
For such private medical instruction, whether given by single 
individuals or by men united for convenience into polyclinic 
associations, all hospitals, whether large or small, are adapted. 
Many of the older and more prominent hospitals are 
connected more or less intimately with some medical school, 
and of course for every such school it is of great importance 
that a hospital be available to its students. But there is need 
of many more hospitals in the community than of diploma- 
granting medical schools. Of the former there are far too few 
and of the latter already far too many.* The mistake has been 
made too often of thinking that every new hospital which is 
built must have connected with it a school of medicine, 
authorized to issue diplomas. In many cases it has happened 
that the quality of instruction offered has not been sufficiently 
attractive to secure students unless the additional bait were 
presented of a diploma in medicine. Hence the lamentably 
low value of so many medical diplomas. If a proper limit 
were set by our state legislatures to the number of institutions 
chartered to issue diplomas, the value of these certificates 
would be increased, and at the same time the quality of the in- 
struction offered by the attending staff of the various hospitals, 
no longer able to give diplomas and hence depending for their 
success as teachers upon the value of the commodity offered, 
would be improved. There are indeed some manifest ad- 
vantages in separating the diploma-granting from the teaching 
function, even as regards the university itself. This question, 
however, lies outside our present subject. 
In the old-time custom of a practitioner taking a student into 
his office and to ride about with him, there were certain 
advantages which were lost in the era of medical schools which 
was brought in by advances in the science of medicine. As has 
been shown in the earlier portion of this paper, the former 
method of instruction in its details is no longer feasible. But 
* The number of colleges authorized to grant diplomas in medicine, in 
the United States and Canada, was for the year 1885, according to the 
report of the Illinois State Board of Health, one hundred and twenty- 
eight. 26 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
its great benefits to the student, derived from personal associa- 
tion with a master’s mind, and observation of the manner in 
which that single mind attacks the various problems of a 
general practitioner’s work,—these benefits may all be retained, 
with the added advantages of an increased range of clinical 
subjects, by any student who can place himself under the 
tuition of a good hospital physician. Into a well-rounded medi- 
cal education many other elements must enter, laboratory work, 
didactic instruction on the theory of Physic, familiarity with 
different views on the controverted points of pathology and 
treatment, but for a certain portion of his professional curri- 
culum a young man can hardly do better than to bring himself 
in contact with a medical personality and study individual 
methods, in the treatment of disease. For this purpose no field 
can be so fruitful as a hospital ward under the direction of a 
man who is wise in action and clear in explanation. 
2. Resident Physicians or House Students. 
There has been a very commendable disposition on the part 
of the large hospitals of late years to increase the number of 
their resident house officers. In the Pennsylvania Hospital, 
for example, forty to fifty years ago there were but two resident 
physicians, who served for two years, and each alternately took 
charge for six months of about two hundred insane cases, the 
male and female medical wards, the obstetrical wards, where 
each case of labor was attended in turn by each resident; and 
the male and female surgical wards, where there were frequently 
eighty beds to be dressed each day. In other large hospitals 
there was a similar inadequacy in the number of the resident 
staff. The increase which has been made in late years has 
benefited not only the large number of young men who have 
been educated to the study and care of disease, but has 
enabled the work to be done more thoroughly and has thereby 
conduced to the comfort and welfare of patients and the popu- 
larity of the hospital. At present the large hospitals of this 
country are tolerably well supplied with resident physicians, THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
27 
but in some cases the smaller ones have not as yet provided for 
such officers. We believe there is no hospital but would find it 
profitable from a purely administrative and economical point of 
view to appoint such an officer at the expense of his board and 
lodging. In many cases, no doubt, even should the manage- 
ment feel itself unable to offer the consideration of board, 
a suitable man could be found. 
The question suggests itself at this point as to the equity of 
a hospital’s requiring from young men who seek positions a 
honorarium in consideration of the instruction to be gained by 
such residence. The desirability of a house-service is so great 
that many young men are willing to pay roundly for the 
appointment in some special hospitals. Is it proper, then, for 
the management to neglect to avail itself of this possible addi- 
tion to its income? In cases where the institution is suffering 
from insufficiency of funds to carry on its work, or where the 
duties are not so onerous as to occupy all the incumbent’s time, 
or again where the opportunities for gaining experience and 
instruction are especially great and out of proportion to the 
amount of service required, it seems entirely just that the 
hospital management should add to its resources in the way 
indicated. 
As to the advantage to the young medical man of a position 
which enables him to study various cases of disease from 
constant daily personal observation through their successive 
phases of development, to make diagnoses under the correction 
of experienced clinicians, and to learn to respond to calls of 
emergency, nothing need here be said. Such experiences are 
simply invaluable. On the other hand, in the economy of time 
which by intelligent watchfulness he may make for his visitant, 
in the fulness and carefulness of the records which he keeps of 
the cases, and in the immediate relief which his attentions may 
give to suffering patients, he fully compensates the hospital for 
the slight expense of his maintenance. The laborer is worthy 
of his hire. 
There is every reason in the interest both of the hospital and 
of the student why these prizes should be awarded strictly on 28 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
the basis of professional excellence. No other means, we 
believe, is on the whole so adequate to the determination of 
the question of fitness as the competitive examination. While 
this method may occasionally work an injustice, it is less likely 
to do so than any other. Appointments by favor of the visit- 
ing staff or of the hospital management, by which men of less 
ability are given precedence over those of more, are at once 
discouraging to meritorious students and prejudicial to the 
welfare of the hospital, which receives a poorer quality of 
service than it might otherwise command. Besides, the class 
to which it is to look for its future visiting physicians, is not 
thus composed of the best material attainable. 
Wherever practicable, the special character of the house 
officer’s service should be elective,—priority of choice being 
given on the basis of excellence in the competitive examina- 
tion. In this way each man is more likely to secure the kind 
of service in which he is especially interested, where he will be 
likely both to give and to receive the greatest possible amount 
of benefit. In the general hospitals, which are sought presum- 
ably by men who intend to engage in general practice, it is 
desirable that there should be alternation of service, which 
while giving a preponderance to a particular branch, will yet 
afford some experience in others. Thus men may be eight 
months in surgical wards and four in medical, or vice versa, or 
a man who elects to be a surgical interne may be required in 
hospitals where there is an out-patient department, to serve a 
period as medical externe. 
In the interest of patient, hospital and house officer alike, it 
is desirable that too much responsibility be not placed upon the 
latter. The proper conception of his function is the carrying 
out in detail of a line of treatment of which the general policy 
is laid out by his visitant. In this manner the dread of the 
patient (not always ill founded) of inexperienced and youthful 
practitioners is removed. But above all, it is of incalculably 
greater advantage to the house officer to study the operations 
of maturer judgments than to flounder about in the empiricism 
of his own immaturity. During the latter part of his service, THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
29 
however, his responsibilities may be increased, following the 
discretion of the visitant, but the latter, who still retains the 
actual responsibility for the management of his patients, 
should always carefully revise any work that may have been 
done in his absence, and make any criticism that may be called 
for. In the surgical wards the visitant, if able to spare the 
necessary time, may permit his house physician, late in the 
latter’s service, to perform certain operations, always under his 
own direction or supervision. Thus if any emergency arises, 
the more youthful operator will possess the moral if not the 
manual support of a senior, and the patient will receive no 
detriment. 
The term of a house physician’s tenure should not as a rule 
exceed eighteen months as a maximum. First, because the 
fatigue resulting from any longer service will prevent his 
receiving much advantage from it or his really discharging his 
full duties to the hospital; and secondly because a longer incum- 
bency will encroach upon the rights of other men who should 
share in the privileges of such posititons. 
3. Training Schools for Nurses. 
The last two points considered have had reference to the 
preparation of young medical men, through the educational 
influences of hospitals, for the practice of their profession. But, 
as we shall see, this function, important as it is, by no means 
exhausts the educational capacity of the hospital. The most 
useful handmaid of medicine is nursing. In many cases, 
notably in the acute fevers, the labor of the nurse is 
undoubtedly more important than that of the physician. For 
the reduction of medicine from a science to an art good nurs- 
ing is absolutely indispensable. For the education of a class 
of persons fit to carry on this important work, hospitals offer 
peculiar advantages. Prior to the year 1860 when Florence 
Nightingale established at St. Thomas’ Hospital, London, the 
first training school for nurses, there had been no instru- 
O 7 
mentality outside of certain religious orders for systematic 30 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
and thorough instruction in nursing. This work, alike in 
hospitals and in private families, was clone by persons usually 
of a low grade of intelligence, who possessed no farther train- 
ing for their duties than a certain manual dexterity gained by 
more or less practice in the care of the sick. In 1873, three 
training schools were organized nearly simultaneously in this 
country, one at New Haven, Conn., one at Bellevue Hospital, 
New York, and a third at the Massachusetts General Hospital, 
Boston. We have now, perhaps, a score, connected with well- 
established hospitals in various cities of the United States. It 
is the general testimony of older hospital physicians, who 
have had experience of both systems, that the character of the 
nursing in their wards is vastly better where training schools 
exist than under the former method. This redounds directly 
of course to the advantage of the patients both inside and out- 
side of hospitals. In many instances it diminishes the length 
of residence in a hospital and thereby enables a greater number 
of persons to be treated in a year. In private practice enor- 
mous relief is afforded the practitioner who no longer is obliged 
to attend personally to pass a catheter, make a hypodermic 
injection or renew a surgical dressing. Much time thus saved 
from the drudgery of his profession can be devoted to 
scientific improvement. Again, various symptoms or other 
phsenomena of disease which might not be evident at the time 
of the daily visit, are noted and recorded by the intelligent 
trained nurse in her daily bulletin, and thus are utilized for 
purposes of diagnosis or as contributions to the knowledge of 
the natural history of the disease. 
There is no reason why every large hospital, and many 
smaller ones, should not adopt the system which is working so 
admirably in the institutions which have inaugurated it. Cer- 
tainly in every town of thirty thousand to forty thousand 
inhabitants there should be a source of supply of competent 
educated nurses for the inhabitants and for persons in the 
adjacent country. To the hospitals themselves this would 
involve little, if any additional expense. The cost of mainte- 
nance of the nurses is increased only as women of higher 31 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
social grade require a little more privacy in their domiciliary 
accommodations than those who are less refined. But on the 
other hand, as apprentices to a craft, they are willing to work 
for a less compensation than women who are gaining no 
instruction. Of course, when a building is provided for the 
sole use of the student-nurses a considerable outlay is required. 
But even then the vacating of rooms whicli would otherwise 
be taken up by the nurses, increases the accommodations 
available for the sick,— accommodations which can be made 
to bring in a direct pecuniary return. The money received 
from paying patients, who are usually ready to take such 
rooms, will pay the expense of the nurses’ dormitory. In 
general, there is no question but that an equal outlay of money 
will secure as good nursing service to a hospital under a 
training-school system as the same money would purchase 
in the labor market. 
Properly speaking, there is need of a greater number of 
nurses in the community than of doctors. For a given case of 
serious illness requires the undivided attention of at least one 
nursing attendant for a period of time during which the 
attending physician is able to care for a large number of 
patients. From motives both of affection and of economy 
the work of nursing is now done in the majority of cases 
by the relatives and friends of the patient. But with each 
succeeding year the former of these motives is becoming less 
strong in influencing friends to take the personal care of their 
sick. The sentiment is growing that in grave cases of disease, 
trained capacity is a more efficient help than untrained affection. 
The high wages earned by thoroughly trained nurses and the 
constant call for their services show that in this matter as yet 
the supply is not equal to the demand. 
But the very fact that trained nurses are at present able to 
command so high a price, is for persons in moderate circum- 
stances a great obstacle to their employment. The women of 
a household must often attend their sick relatives, or an out- 
sider, at best of the grade of an upper servant and command- 
ing only a corresponding price, must be called in. For such 32 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
attendants, premising that they have tact, gentleness and fair 
judgment, something else is necessary that they may do well for 
the patients under their charge. That something else, namely, 
facility in doing easily and quietly certain simple things, such 
as bathing, changing clothing of the person and of the bed, 
assisting at the calls of nature, preparing and administering 
food, drink and medicine, giving injections, making poultices 
and dressings, moving painful or injured limbs,— these and 
many other accomplishments are within the capacity of any 
woman of ordinary intelligence, but they are not innate. They 
can be properly learned only by seeing them done. 
Here is a large and as yet unoccupied field of usefulness for 
the hospital. In addition to those women who can give the 
time and study necessary to a full training as professional 
nurses and who will receive diplomas at the completion of 
their term of study, why should not the hospital give private 
instruction to any woman who wishes to learn something of 
nursing? For the latter there would be no examination and no 
certificate, simply instruction. On payment of a moderate fee, 
sufficient to reimburse the management for its extra trouble, 
mothers who wished to learn to take care of their children 
in illness, girls whose natural bent inclined them to assist their 
families in the sick room rather than in the kitchen, 
“ untrained ” nurses and domestics of good intelligence whose 
tastes make the work of the sick room more agreeable than 
that of the nursery or the laundry, or again young women of 
the higher walks of life, might enroll their names in small 
classes of three or four each, not to become “professional 
nurses” but to receive training in some of the fundamental 
principles of giving comfort to the sick. On certain days of 
the week at a fixed hour these women visit a ward, and are 
placed under the guidance of an intelligent nurse who shall 
demonstrate the proper mode of performing such duties as have 
been indicated, and make any necessary explanations in answer 
to questions. Either the hours of the instruction may be 
altered from day to day, so as to bring the various branches of 
work in their natural course under the observation of the THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
33 
pupils, or the requisite changes may be made in the routine of 
ward work. If the classes were made as small as two, the 
pupils could themselves do the work under direction of their 
instructor. Of course this occupies some of a nurse’s time, but 
the hospital could receive sufficient pecuniary compensation for 
that, and the impartment of the instruction, which would 
naturally fall to the lot of the more advanced members of the 
training school, would have, as such work always does, an 
excellent effect upon those students themselves. Finally the 
lay-pupils, as we may call them, might be admitted on payment 
of a small sum to hear the didactic lectures which are usually 
provided for the training-school. 
We believe that in our large cities there are a considerable 
number of women who would gladly avail themselves of the 
opportunity of learning something of the care of the sick, but 
for whom such knowledge is generally unattainable except 
through the medium of a hospital. 
To return for a few moments to the training-school proper. 
There are two different systems upon which these institutions 
are managed. According to the one, a number of persons 
interested in the establishment of a training-school, organize, 
obtain a charter and select a superintendent. They then enter 
into a contract with the management of some hospital, agreeing, 
on their part, to supply the nursing for some or all of the 
wards ; the hospital, on the other hand, agreeing to furnish as 
compensation for the work done a money payment, or main- 
tenance of nurses, or both. According to the other method, 
the hospital management itself, for the sake of securing 
good nursing for its wards and of supplying the community 
with well-trained nurses, undertakes the same work, but of 
course there is no contract between two parties, and the one 
executive head of the hospital administers also the training 
school. The former method has the advantage of being 
applicable where hosiptal authorities lack either the authority 
or the disposition to organize and maintain such an institution, 
but from self-interest are willing to avail themselves of its 
advantages in an increased efficiency of the nursing force. It 34 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
has the disadvantage of substituting two boards for one, with 
increased chance thereby of friction and disagreement. This 
method has worked admirably in some instances, when there 
was a hearty co-operation and close sympathy between the two 
parties concerned. On the other hand it has produced most 
disastrous results, as in the quarrel a few years since at Guy’s 
Hospital where there was a conflict between the nursing force 
and the medical staff. Independent training-school managers 
may in their zeal for the education of their pupils, make such 
a distribution of the latter, that the hospital administration 
shall suffer. The balance of advantage to all interests, there- 
fore, seems to be with the method which makes the training 
school a department of the hospital and under its administra- 
tive control. Then the medical staff at whose immediate 
disposal this most important instrument lies, can in case of 
failure or incompetency look, as in all other cases of difficulty, 
to the one executive head to have the matter righted. 
O 
The general similarity in the minutke of the management of 
the various training schools in this country and the high degree 
of success which they are achieving makes extended comment 
on these methods superfluous. One or two points, however, 
bearing closely upon their efficiency deserve mention. There 
is, so far as the writer knows, no training school for the supply 
of male nurses. Men who serve the public in this capacity 
have usually picked up their knowledge as orderlies and ward- 
tenders and without the careful supervision and instruction 
attainable by the other sex. While for obvious reasons the 
instruction given in a school for the education of both men 
and women would much of it have to be duplicated, it seems 
as if some of the large hospitals were in a position to organize 
such instruction. The chief obstacle to its success is likely to 
be lack of men willing to devote the necessary time to the 
course, on account of the many channels for earning a liveli- 
hood open to young men. Still there is no doubt that there is 
a call for trained male nurses. 
A similar work, much needed but long neglected, namely 
the training of nurses for the insane has, it is a pleasure to THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
35 
say, very recently been taken up by two hospitals in this 
country. A school for this purpose, connected with the 
McLean Asylum, at Somerville, Mass., graduated, six women 
March 1, 1886, and a similar one at the Buffalo State Asylum 
in New York, graduated seven women April 20th. These are, 
so far as known, the first schools of the kind. The former is 
wholly independent of the Massachusetts Training School, 
which is established in the General Hospital, a co-ordinate 
branch with the McLean Asylum of one common corporation. 
The aim in this case has not been to educate nurses who 
should be “ specialists in insanity,” but, after giving a thorough 
training in all those general branches which are essential to the 
o o 
nurse’s art, to give the pupils in addition particular instruction 
in the care of nervous and mental diseases. Such nurses will 
no doubt be appreciated by that portion of the public which is 
obliged for longer or shorter times to retain insane relatives in 
O O 
their own homes. It is suggested that where such independent 
schools are not yet feasible, an arrangement might advantage- 
ously be made with general hospitals whereby the latter could 
for a season send their pupils to such institutions, precisely as 
they now do in some cases to maternity hospitals. 
Into the question of the character and extent of the 
theoretical instruction that shall be given to nurses during their 
course of training in hospitals, our subject does not call upon 
us to enter. That some knowledge of anatomy and physiology 
is desirable will hardly be denied. As to what constitutes a 
proper amount there would be much diversity of opinion. 
The objection sometimes raised against officious nurses that 
they “ know too much,” is hardly valid. One cannot have 
too much knowledge provided it is modestly held and does not 
lead to usurpation of functions properly belonging to others. 
On the practical side, a professional nurse should be trained 
first and thoroughly in the matters already mentioned as among 
the elementary branches of nursing. In addition to these she 
should be instructed in the principles of ventilation and 
hygiene of the sick room; the disinfection of the secreta and 
excreta of the body, of clothing, furniture etc., and the general 36 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
principles of the destruction of spores and micro-organisms ; 
the administration of medicines by mouth, rectum, lungs and 
skin, and of nutrient and evacuant enemata; the vaginal 
douche; hot air and hot water baths and wet packs: the 
immediate treatment of poisoning and other emergencies ; the 
control of haemorrhage ; the treatment of syncope and shock; 
the observation and record of pulse, temperature and respira- 
tion ; the administration (under medical supervision) of 
anaesthetics; the preparation of patients for operations and the 
after-treatment; the application of surgical dressings; the 
care of the tracheotomy-tube; the use of the female catheter; 
massage; the care of the dead. And, finally, the special 
requirements for the care of various classes of diseases, as 
fevers, diseases of the skin, of the eye, of the ear, of the nervous 
system, of the chest; surgical cases, operations and fractures; 
labor, with the management of obstetric emergencies; the care 
of the new-born and the management of sick children, including 
orthopaedic cases. 
4. The Appointment and Tenure of Hospital 
Physicians. 
It is obvious that very much of the usefulness of a hospital 
both for the present needs of the sick and for the advance- 
ment of medical science depends upon the securing of the 
best professional skill available for its visiting staff. It is a 
fortunate circumstance that for various reasons a hospital is 
able to command if it will, the highest professional talent of 
its vicinity. When anything less than this is secured it is 
from blundering in the selection, not from the refusal of the 
best men to serve. When we say the “ best men ”we do not 
necessarily mean the most famous. For in medicine as in 
every other pursuit a man attains his maximum of ability 
before he reaches his maximum of reputation ; the latter being 
consequent and therefore subsequent to the former. The 
“ best man ” for a hospital appointment, may even especially 
if he is to begin at the foot of the ladder in an out-patient THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
37 
service, —be not the one of the highest absolute achieve- 
ment in the professional community, but he who having most 
thoroughly performed what he has had to do gives thereby best 
promise of intelligent and painstaking service during his 
hospital connection. An inducement, effective no doubt in 
many cases, to the acceptance of hospital service is a chari- 
table willingness to be of service to humanity. But waiving 
this, and confining ourselves to the argument from exchange 
of equivalents, which has weight with all men, we see that at 
the beginning of one’s hospital service the burden of obligation 
is upon his side. He receives what is most valuable to him, a 
field of study upon which to employ that leisure that his pro- 
fessional duties still allow him, an opportunity to increase his 
diagnostic acumen and technical facility in surgical and other 
operations. He also receives the prestige which naturally and 
properly attaches to a hospital appointment. In return for 
these advantages he gives his skill, his presence in many cases 
whether summoned by day or by night, and much of his time, 
a commodity less valuable to him than it will subsequently 
become. 
In process of time, the balance of obligation shifts its side. 
His reputation reaches a point where it confers greater tclat 
upon the hospital than the latter does upon him. His skill is 
increased: his time has a larger money value. Yet both are 
given freely as in the beginning. Every large hospital has 
such men upon its stall,— men who continue in their connection 
long after they have more than repaid all the personal 
advantages they have received from it. 
How then shall the hospital secure such servants for its 
immediate, and through their contributions to medical service, 
for its remote advantage? At the outset we make the obvious 
but no less important reply that politics and personal favor 
should have no part whatever in the selection. In municipal 
hospitals the former factor is most likely to exert an influence, 
and the latter must be guarded against everywhere. Lay 
trustees and overseers are entirely incapable of forming a 
reliable opinion as to the best man for a hospital position. A 38 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
wise selection can be made only by professional men. These 
men should be either the visiting or the consulting staff or a 
committee of the same appointed as an examining board. The 
principles of the reformed civil service should guide the selec- 
tion. No one denies that the methods of examination 
employed by the army and navy boards secure a most admir- 
able set of men for the medical officers in their respective 
branches. Why should not the same methods give equally 
good results in civil hospitals? Civil-service methods might 
require some modification to adapt them to the case in hand 
but a suitable critical examination to determine the fitness of 
candidates in the theoretical and practical knowledge of their 
profession would, in the opinion of the writer, constitute a most 
admirable basis upon which to rest the succession of decisions 
which shall lead up to the final selection. Such a criterion 
would effectually prevent the unfit appointments which 
occasionally creep into some of our best hospitals. A compe- 
titive examination, however, does not reveal all the qualities of 
the successful physician, and from among the names of those 
successful in this examination the one or two should be 
selected who possess in the highest degree the tact, the judg- 
ment and the other qualities which give the best promise for 
the professional future of their possessor. Finally, as so much 
in the last resort depends upon the personal equation, and as a 
feeling of mental liking and esteem adds so much to the power 
of a co-operating body, an alternative choice might be 
referred to the nominating body from which to select the 
appointee. The final nomination of the professional staff 
should receive the formal confirmation of the governing body 
in almost every conceivable case. 
A reform much needed in many of our metropolitan hospitals 
is an increase in the number of the visiting staff. In many 
instances the number of physicians is so small that each 
individual has a term of service so lono; that it becomes irk- 
some before it is finished, or else that the number of patients to 
be seen daily is so large as to interfere with their receiving 
individually as much attention as they should. A service, on 39 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
the one hand, should cover not less than three months consecu- 
tively, because many of the longer cases cannot otherwise be 
followed out to their conclusion under the same charge to which 
they were at first assigned, and frequent changes of the 
service interfere alike with the interests of the patient and the 
interest of the physician. But, on the other hand, the 
demands of hospital service if continued longer than this 
period are likely to involve such physical and mental fatigue as to 
impair its value. The evils of too large a number of patients are 
especially seen in out-patient clinics, where the practitioner 
having but a few moments for each patient is prone to fall into 
a perfunctory, routine method of treatment. The reason that 
out-patient clinics are not more abundantly utilized for 
collated observations is doubtless their too great numerical 
size which involves the waste of much material of possible 
educational value. Of course out-patient clinics present 
many cases of small professional interest, but the tendency 
which perhaps exists to slight such services is well guarded 
against by the habit now so general in hospitals of making 
such positions stepping-stones to the more responsible and 
attractive in-door services. 
Finally, hospital appointments should be held by none but 
those who are willing to give attention to the duties. When a 
man, by reason of age or of private engagements, professional 
or otherwise, reaches a point where he cannot or will not give 
the attention necessary for an adequate observation and care of 
his cases, he should be politely but firmly requested by the 
hospital management to resign his place. An honorary position 
upon the consulting staff, or in very exceptional cases an ap- 
pointment emeritus with two or three beds at his disposal, 
which he may fill with cases of his own if he desires, should 
content such a person. Substituting, except in cases of dis- 
ability from sickness or other temporary cause, should not be 
permitted. If a man has not time to make his daily visits, 
or if he is a habitual absentee for the summer, leaving his 
place to be filled by another, he has no right to retain his 
position. Let the one who actually does the work receive the 40 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
credit of it, and his work will be much more satisfactory to 
himself and to all others concerned. In no position is 
“ deadheadism ” more out of place than upon a hospital staff. 
5. Hospital Workshops. 
In hospitals where orthopaedic and general surgical diseases 
are treated, various appliances are necessary which, in order to 
meet most fully the requirements for their use, should be 
designed and made expressly for each individual case. The 
day has gone by when such apparatus is bought at wholesale 
for the prospective spinal and hip cases of the year. Two 
courses are now open to the progressive hospital, one to order 
from the instrument maker, who comes and makes his measure- 
ments in each instance, the best apparatus which he can devise 
to meet the requirement of the cases—a method which is as 
unscientific as it would be for the physician to describe symp- 
toms to an apothecary and leave the latter to select an appropri- 
ate remedy. The other method is to establish and fit up the 
hospital workshop, with soft and hard woods and carpenters’ 
tools, with iron and steel rods, flat and cylindrical, sheet iron 
and tin, wire, steel and copper rivets, cold chisels, pliers, shears, 
files, hammers, vises and anvils; with sole-leather, rubber, 
gutta-percha and plaster;—in a word, with every material used 
in making the ordinary forms of surgical apparatus and with 
the tools necessary for working the same. Here should be one 
or two workmen who may during a portion of their time per- 
form other labor for the hospital. All apparatus required in the 
hospital, with the exception of some standard articles like 
crutches and also perhaps some hernial trusses, should be made 
in this workshop under the direction of the surgeons, accom- 
panied usually by working drawings. The advantage thus given 
to a branch of surgical technics, hitherto much neglected, is 
very great. In many cases the surgeon and house-officers in 
their efforts at realizing some desideratum for a given case will 
be materially aided by familiarizing themselves with the use of 
tools; and such a workshop may become a place of instruction THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
41 
second in value to no other laboratory in which the student of 
medicine works. The successful orthopaedist must be some- 
thing of a mechanician, and unless some such shop is provided 
(which can be done in connection with the hospital where the 
apparatus is to be used) this part of his training is neglected. 
Every invention, on the other hand, and every discovery to 
which he is led, becomes at once, unrestricted by caveat or 
copyright, the property of his suffering fellow men. What 
need of further argument for the wisdom of an instrumentality 
which inures in so great degree to the benefit at once of 
o o 
present and prospective inmates of the hospital ? 
Yet, valuable as is such a department, it can be established 
at very small expense. The experiment has actually proved 
a financial success. It has been tried in the Children’s Hospital 
and in a partial degree in the City Hospital of Boston. It is 
working admirably in the New York Orthopaedic Dispensary, 
and in the University Hospital of Philadelphia, where a shop in 
a building erected for the purpose and supplied with steam 
power, has been established at a cost of about two thousand 
dollars. Although only the actual cost of production of appa- 
ratus is charged to patient s, and to those only who are able to pay 
for it, the shop is now nearly self-sustaining. Meantime appa- 
ratus is produced, always after drawings by the surgeons and 
under their supervision, accurately adapted to each case and 
developing in the surgeons an inventive skill and a manual dex- 
terity which conveys the highest promise . for the future of 
orthopaedics. 
6. Therapeutic Investigations. 
The question of how far the hospital patient may rightfully 
be made the subject of experimental therapeutics has been con- 
sidered above in the chapter upon the rights of patients. It 
remains in this connection to mention the most useful methods 
of collecting and comparing the results of drug treatment. 
Such results, to be of value, must represent a considerable 
number of observations, and the observations should, as far as 42 
THE RELATION OP HOSPITALS TO MEDICAL EDUCATION. 
possible, be made under similar circumstances of diet, tempera- 
ture, nursing and other collateral factors in treatment. Such 
similarity of circumstances can best be secured in the wards of 
a single hospital or of different hospitals in the same locality 
and having the same policy of management. In some of the 
occasional conferences that hospital physicians should hold, it 
may be decided to try the effect in appropriate cases of a cer- 
tain line of treatment. Some of the many “ new remedies” 
that are constantly being brought to professional notice may be 
considered worthy a trial, and as the manufacturers publish in 
their copious “ reports” only favorable cases, we must look to 
hospital tests for an impartial publication of the cons as well 
as the pros. It is agreed, for instance, among a number of 
physicians that they will try the effect for a certain length of 
time of antipyrin upon all cases of constantly elevated tempera- 
ture coming within their care, whatever the disease. The 
doses and times of administration are to be accurately recorded, 
and thermometric observations are to be made before and at 
certain agreed intervals after the dose. The amount and the 
length of the refrigeration are thus determined in a large 
series of cases. The effects upon the circulatory and respira- 
tory systems are also noted, together with any modification in 
the subsequent natural history of the disease. Any abnormal 
effects produced upon the digestive, the urinary, or the cutane- 
ous systems, and any peculiarities in the mental or nervous 
state are observed. In this way, by the contributions of the 
different observers, the favorable, the unfavorable, and the 
negative effects of the drug can be fairly estimated, and con- 
clusions of real value can be drawn. 
In like manner the effects of hydrotherapy in the continued 
fevers, the relative value of the various antiseptics in obstetrical 
or surgical practice, and many other important questions can 
be studied. No compulsion, of course, is to be exercised upon 
any physician to make him an unwilling participant in such 
experiments. Each man, being responsible to his own judg- 
ment and conscience for the treatment of his cases, must 
decide whether a proposed therapeutic policy has enough 43 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
reasonableness and plausibility to make it justifiable, and if be 
decides against participating in a proposed experiment his 
results will still afford a basis of comparison with those of his 
less conservative associates. 
7, Uniformity and Completeness of Records. 
This subject follows naturally upon the one last considered, 
for to the comparison of therapeutic or of any other data com- 
plete records are essential. Who that has ever had occasion 
to look through series of notes in the investigation of any 
class of diseases, has not been annoyed to find the record 
occasionally silent on points of the greatest significance? or 
has not been obliged to search through pages of manuscript for 
implied information that might have been explicitly given in a 
word in the proper logical connection of the narrative ? The 
discipline of a hospital makes it possible to secure for long 
series of years records which shall be nearly uniform in both 
subject matter and arrangement. It is not necessary for our 
purpose to add one to the various schedules for case-taking that 
have been proposed, all more or less logical and complete. 
The principal thing is that each hospital adopt through an 
appropriate committee a scheme of records (which may indeed 
to advantage be uniform with that of other neighboring 
hospitals) and that that scheme when adopted be rigidly carried 
out under the special supervision of some person appointed for 
that purpose. The English plan of having a Registrar has been 
adopted in one or two instances in this country and seems well 
adapted to its purpose. Whatever schedule is selected should 
be based upon substantially the following outline : 
The patient’s age, sex, color, social condition, nativity, 
length of residence in the locality, present and previous occu- 
pations. Signature (when possible) as an index to intelli- 
gence and nervous state. Heredity. Personal habits, in 
regard to beverages and narcotics. Venereal history. In 
women, menstrual history, number and character of labors; 44 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
miscarriages and causes therefor. Previous diseases, and 
general state of health. Present illness, rational symptoms, 
first in the patient’s own words and secondly in answer to 
questions ; the inquiries as to the different organs being made 
in a prescribed order. Physical examination, in the same 
order. Temperature, pulse and respiration. The name of 
the physician should be appended in the margin, as well as 
that of the recorder. Any subsequent change in the attendant 
should be noted, A chart of temperature should be kept until 
discontinued by the physician. Wherever the chart shows any 
rise of temperature it should be preserved as a portion of the 
record of the case. The report of the original and of any 
subsequent physical examination should be accompanied by 
the name of the examiner. The daily record should be made 
at the dictation or at least under the supervision of the visiting 
physician. All operations should be described in full, at the 
dictation of the operator or of his principal assistant, with 
particulars as to the duration, the use of the anaesthetic, the 
material employed for ligatures, the number of deep sutures, 
the use of antiseptics during the operation, the character of 
the dressings, and the patient’s state after the operation. The 
name of the operator should always be given. 
Photography is susceptible of a much wider application in 
clinical records than it has yet received. The house physician 
or perhaps the hospital chemist can by the aid of dry plates 
without great expense secure graphic representations of many 
diseased states. Tumors in situ and even after removal; 
deformities, congenital and acquired; joint affections, with 
the apparatus employed for their treatment, and the appear- 
ances after such treatment; the indications for and the results 
of plastic operations. Medical diseases also, ascites, 
aneurismal tumors, leucocythiemia, these and many other 
maladies can be described more briefly and sometimes more 
completely by the camera than by the pen. Perhaps in 
nervous diseases an application of the instantaneous method of 
photography may give as graphic a picture of the knee jerk 
phenomenon or of a spastic gait, as a common photograph does THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
of the appearances in muscular atrophy. Photomicrography 
will also find a very useful field in recording the histological 
work of the hospital. 
8. Hospital Reports. 
It has long been the custom with most of our municipal and 
charity hospitals to publish for the information of those who 
furnish them their means, stated reports upon the administra- 
tive side of their work. Aldermen and voters as well as 
charitable contributors like to know how many patients have 
been treated during the year, from what diseases they suffered 
and how many got well. The outlay necessary for printing 
such a report is therefore considered a legitimate expense of 
the hospital. Yet such reports have a very transient value. 
The significant statistics could be easily comprised in a half 
column of the daily press. On the other hand, an occasional 
medical report summing up the valuable results of the volumes 
of the hospital records and bringing their conclusions before 
the medical world would be of great value. The worthy 
example in this matter set by such hospitals as Guy’s and 
St. Bartholomew’s, the London and St. George’s, has never, so 
far as the writer is aware, been followed to any extent in this 
country, though the Boston City Hospital has issued at inter- 
vals of five or six years three series of medical and surgical 
reports prepared by the members of the staff. If it is urged 
against such reports that many of the valuable results of hospi- 
tal practice are already made public in the form of papers read 
by individual hospital physicians before the various medical 
societies, it is to be answered that while such papers contain 
isolated cases of interest and sometimes generalizations from 
series of cases occurring in one man’s service, they almost 
never embody the entire hospital data for a series of years ; 
which data are likely to lie buried in the manuscript volumes, 
until such a publication as a general medical report brings 
them to the light. That magnificent compilation, the Medical 46 
THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
and Surgical History of the War of the Rebellion, bears the 
same relation to the work of the army surgeons that the report 
of which we have been speaking bears to the daily work of the 
civil hospitals. And if a wise interpretation of the functions 
of a government department authorized the publication of the 
former work, an equally wise interpretation of a hospital trust 
would justify the expense involved in giving a permanent 
expression and a wide diffusion to knowledge which is to be of 
value in the treatment of all future hospital patients. 
9. A Salaried Pathologist. 
In the earlier portion of this paper, under the general 
subject of hospital appliances, reference was made to the facili- 
ties for pathological investigation which are now fortunately 
enjoyed by many of our leading hospitals. Mention was also 
made of the expert pathologist whose services are so generally 
called upon to give interpretation to the post-mortem findings. 
It remains to add in the present connection as one of the 
desiderata for the highest educational usefulness of the hospi- 
tal, the appropriation of a sum of money to pay for such 
services. The position of a pathologist, unlike that of attend- 
ant physician, does not carry with it its own compensation. 
The person who holds the position is not usually in the line of 
hospital promotion. So far from its increasing his practice and 
thereby his income, it is a serious interference with practice 
not only by reason of the large amount of time which it 
claims, but because the character of the work makes it unsafe 
for it to be combined with obstetrical or surgical work. Path- 
ology is a pure science, having no application to bread- 
winning, except from the precarious chances of a summons as 
a medico-legal expert, or, in one or two of the states, of 
appointment as a medical examiner. Unless a man can teach 
(and medical teaching is not profitable) or has an independent 
income, he cannot look forward to pathology as a life-work any 
more than he could to botany or zoology. Yet even in the 
temporary way in which a young man now is able to devote THE RELATION OF HOSPITALS TO MEDICAL EDUCATION. 
47 
himself to this work, he gives a service to the hospital for 
which he never receives any compensation, and for that expert 
service there is just as much reason that the hospital should 
pay, as for the not more valuable service of the chemist who 
prepares its prescriptions. A payment of a few hundred 
dollars a year would discharge the indebtedness of the hospital, 
and in performing that act of common justice, it would secure 
a longer continuance of those services, growing more valuable 
each year, than could otherwise be possible. In the larger 
cities one man might serve as pathologist to several hospitals, 
and, being thus assured of a livelihood, could devote his life 
to that science. Under such supervision each hospital could 
organize a pathological museum where the students of records 
and the compilers of reports might in many cases find pre- 
served the pathological specimens illustrating the subjects of 
their investigations. The sharing of a pathologist’s services 
between several hospitals would enhance rather than diminish 
their value, while the undivided and continuous character of 
those services would secure to each institution that received 
them, a constant skilled oversight of all the branches of patho- 
logical work, which would be of incalculable advantage to the 
visiting staff and through them to their successors in an 
indefinite series.