HIGHER MEDICAL EDUCATION IN 
NEW YORK 
I. 
ORGANIZATION OF TIIE MEDICAL STAFF OF HOSPITALS 
BY- 
E. C. SEGUIN, M. D. 
[Reprinted from the ARCHnw w M KDICKW., April, 1881] 
NF.W YORK 
G. P. PUTNAM'S SONS' 
27 & 29 West 230 Street 
1881 HIGHER MEDICAL EDUCATION IN NEW 
YORK. 
The last twenty years have witnessed a steady and usually jn. 
telligent improvement in the curriculum and requirements for 
graduation of the various medical schools in New York. A num- 
ber of devices, short of a radical reform, have been resorted to, 
in order to insure a better education to the numerous youths 
who, often after no proper preparation, wish to become physi- 
cians. Some of these proposed reforms are more or less illusory in 
their nature, and read well in prospectuses, but others are of un- 
questionable sincerity and value, such as the lengthening of the 
regular term of lectures, the opening of laboratories, and the en- 
forcement of more rigid examinations. The offer of substantial 
prizes to the members of the graduating class who shall come out 
best of two competitive examinations, if not theoretically correct, 
seems a beneficial stimulus. Besides these efforts on the part 
of the various schools, the enterprise of a number of well-trained 
physicians offers to students (and to graduates) quite varied 
opportunities for private practical instruction. Among these we 
cannot, however, include the so-called “ quizz-classes,” whose 
influence must be deemed pernicious. 
In the midst of these indications of a somewhat reluctant 
though encouraging progress in elementary medical instruction, 
we fail to perceive any attempt at serious post-graduate education, 
and, practically, many of the great advantages which a metropolis 
offers for the pursuit of the higher medical studies and for orig- 
Reprinted from the Archives of Medicine, Vol, v, No. 2, April, 1881. 2 
E. C. SEGUIN. 
inal investigation are not utilized in New York. Young Ameri- 
can physicians who can afford the expense must go to European 
cities to find that thorough clinical and experimental instruction 
which is necessary to the extension of their training. 
We certainly have hospitals and dispensaries and colleges 
enough to give a field for post-graduate study. We have, taking 
the city as a whole, probably as many cases of the rarer forms of 
disease, medical, surgical and special, as are necessary to illus- 
trate such study, and we believe that there are enough men well 
qualified to direct higher medical studies. 
With the material and the teachers, why is it that so little is 
done in this great city for the advancement of scientific medi- 
cine ? Why must a costly European tour be necessary (apart 
from its nominal advantage) to the completion of a medical 
education ? 
The reasons are numerous, but one fundamental reason stands 
out so prominently as to deserve elaborate consideration. Were 
the defects we are about to enumerate to be remedied, New York 
would soon acquire preeminence as a scientific medical centre, 
instead of being , chiefly known, as it now is, as a place where so 
many hundred young doctors are manufactured every year. 
This chief obstacle to progress is, we firmly believe, the bad 
organization of the medical staffs of our hospitals. 
i. The personnel of the hospital staffs is most unequal and het- 
erogeneous. The lower grades of internes are, as a rule, filled 
by unusually intelligent and well-qualified recent graduates who 
have passed a competitive examination, which for some hospitals 
is very severe. The higher grades, those of visiting physicians 
and surgeons, the places of the men who are to have the responsi- 
bility of the treatment of patients, and who are supposed to train 
the internes, are filled without any examination or other test of 
capacity. Through political, or social, or collegiate influences 
the directing authorities of hospitals select these visiting phy- 
sicians and surgeons. It thus happens that some competent men 
are appointed, as well as many others who are both incompetent 
and ignorant. HIGHER MEDICAL EDUCA TION IN NEW YORK. 
3 
Thus it happens that in a hospital ward, the well-prepared 
junior medical men must go around under the nominal direction 
of a visiting physician or surgeon who is intellectually their in- 
ferior, and who, perhaps, knows much less of medicine. This re- 
lation, which has been known to exist in our hospitals, is hardly a 
favorable one for hospital discipline, or for the education of the 
junior staff, and as visiting physicians and surgeons are on duty 
from two to four months at a time, it follows that the internes are 
witness to the most varying exhibitions of knowledge and capacity, 
and they must employ a portion of their time in criticising or con- 
temptuously discussing the conduct and qualifications of those 
who should be their teachers. 
Besides, the number of visiting physicians and surgeons is too 
large, and that of internes is too small in proportion to the num- 
ber of patients. 
The following table is constructed from data obtained from the 
Medical Register for 1880. It embraces only the chief institu- 
tions : 
Hospitals. 
No. of Beds. 
Attending 
Staff. 
Proportion. 
Resident 
Staff. 
Charity .... 
1,000 
27 
i:37 
8 
Bellevue 
800 
26 
1:30 
8 
Presbyterian . . 
100 
10 
1 10 
2 
St. Luke 
200 
8 
1:26 
2 
New York . 
150 
9 
1:16 
2 
St. Vincent . . . 
250 
6 
1:40 
1 
St. Francis . . . 
200 
6 
i:33 
2 
German .... 
90 
10 
1:9 
1 
Mt. Sinai . . . 
160 
7 
1:23 
2 
Roosevelt 
180 
7 
1:26 
2 
Nursery and Child’s 
Woman’s 
32 
4 
1:8 
1 
127 
6 
1:2i 
2 
Each resident staff is usually made up of three internes, viz.: 
a house physician or surgeon, and two assistants ; in some hos- 
pitals only one assistant. The duties of the house physician or sur- 
geon are very responsible and onerous, and the proper perform- 
ance of them becomes difficult when he has more than fifty beds 
under his supervision, and, in my opinion, impossible with more 
than one hundred beds. He is supposed to know all about each 4 
E. C. SEGUIN. 
patient, making the morning visit to all the wards, prescribing for 
the patients under the supervision of the visiting physician, and 
directing his assistants in the performance of their duties. 
Histories of all the patients are kept, or are supposed to be kept, 
and this alone is a great work when the number of patients ex- 
ceeds fifty. The numerous exact medical observations and elab- 
orate surgical dressings which are now necessary to successful 
practice are nearly all to be done by the resident staff, and con- 
sume much of their time. 
As things now are I believe that our hospital case-books would 
hardly stand a critical examination ; fragmentary, unscientific 
notes of cases too often taking the place of what should be an ac- 
curate account of a case. The responsibility for this defect, a 
very serious one, as it interferes with the use of hospital records 
for study and publication, is to be shared by the visiting and the 
resident staffs : the former not taking sufficient pains in dictating 
notes and reading over the case-books, and also because their 
short terms of service limits their observation of many cases ; the 
latter being overburdened with various duties, and not sufficiently 
guided by the visiting physicians. Recently an eminent physician 
told me that he had had quite a number of cases of a certain rare 
disease in his various terms of service at a certain hospital, and 
he intended incorporating them into an article. A few weeks 
later he told me that the histories of these valuable cases were 
nearly worthless and he would not dare make them public. This 
I believe to be a frequent experience, and to be one reason why 
our hospitals produce so little in the way of original research. 
The number of visiting medical officers is much too large; on the 
average, according to the above table, one to twenty-six patients. 
Partly for the sake of making a larger “service” for visiting phy- 
sicians and surgeons, the European practice of having certain 
wards assigned to each physician for years has been abandoned, 
and the custom of quickly rotating duty substituted. Thus, in 
Bellevue or Charity Hospital, a visiting physician is on duty for 
two or three months, and thus has charge of about one hundred 
patients. HIGHER MEDICAL EDUCATION IN NEW YORK. 
5 
The Woman’s Hospital and St. Francis Hospital are the only 
ones, to my knowledge, where the physicians have their respec- 
tive divisions, and serve the year around. 
Another evil way of seeking to correct the drawbacks of short 
services is by having a service in more than one hospital. Several 
physicians in New York rejoice in the privileges of three hospital 
appointments. 
It is this plan of short services which has, we believe, done the 
most to lower the utility of our hospitals, both from a scientific 
and a humanitarian standpoint, and it is a prominent obstacle to 
higher medical education. 
Let us consider some of the ways in which this plan operates 
injuriously. 
It is unsatisfactory to the physician himself. He goes 
on duty and must become acquainted with the resident staff 
attached to his division or wards ; that is, to know them in a per- 
sonal and a scientific manner. It may take him a week or two to 
find out whether the young gentlemen of the staff are reliable and 
willing to be guided by him. He may find that, however well-in- 
tentioned at the beginning of their connection with the hospital, 
they have been demoralized, rendered careless, skeptical, or even 
rude, by the incompetency or carelessness of the preceding vis- 
iting physician. It is then necessary for him to learn more or less 
about all the patients in the wards assigned him, numbering from 
sixty to one hundred, and this is by no means an easy task. 
When the time has come for him to abandon his service he 
begins to understand his cases. It is not merely his advice which 
is sought, but he is supposed to actually direct and be responsi- 
ble for the treatment of each case. Some of the cases in the 
wards are acute and may run their course during his term of 
service, two or three months ; but many others are chronic, and 
some of these are of the highest interest. In my experience 
chronic cases are often neglected and allowed to become incur- 
able in wards which are subject to this rule of short services, 
partly because the visiting physician naturally prefers to devote 
his attention and give time to cases which he can watch through 6 
E. C. SEGUIN'. 
the whole of their evolution. There are many cases of disease 
which are curable only by six, or eight, or twelve months of 
systematic treatment persistently directed by one mind; but 
with a change of physicians every two months what can one 
hope to accomplish in such cases ? 
How can a physician who enjoys the privilege of a hospital 
service for two months once or twice a year, ever hope to utilize 
his hospital experience ? How can he accumulate numbers of 
well-made observations upon certain diseases, upon certain thera- 
peutic procedures, or how can he ever hope to demcfastate his in- 
terest and success in special lines of practice ? Can our surgeons 
ever hope to rival their European confrlres in the matter of num- 
bers of operations ? A discouraging no is the only possible answer 
to these queries, and perhaps it is the appreciation of the really 
small value of their services which renders many visiting phy- 
sicians and surgeons so careless and superficial in their hospital 
work. 
Monumental works, like Trousseau’s Clinical Medicine, Murchi- 
son on Fevers, Andral’s Clinical Medicine, Charcot on Diseases 
of the Nervous System, would have never been possible with 
other than continuous hospital attendance and study. 
The influence of the visiting staff upon the internes is weak- 
ened or perverted by our system. Even in our deficient organi- 
zation the house physician or surgeon and his assistants are sup- 
posed to be men who have entered the hospital for the purpose of 
further study, to obtain the practical education which colleges do 
not give ; they are pupils. Yet, not only are these young men 
left, as a rule, to pick up knowledge for themselves, are not 
trained by any one mind, but they are often led into the delusion 
that they are not pupils. This demoralization is brought about 
by the presence of incompetent or careless men on the visiting 
staff. The internes quickly perceive the ignorance or lack of 
skill and success of their visiting physician, and after a few visits 
entertain, or even openly show contempt for him ; the house phy- 
sician is obliged, or thinks he is obliged, to assume a sort of 
charge of cases, and not very rarely the visit degenerates into a HIGHER MEDICAL EDUCATION IN NEW YORK. 
7 
formality or a farce. Other visiting physicians and surgeons, per- 
fectly competent, come to the hospital, go to the house physi- 
cian’s room, engage in pleasant chat, and ask : “ Anything special 
to-day, doctor ? ” or, “ Any new case to-day, doctor ? ” Then fol- 
lows a short visit to the ward, a walk around, a word said to one 
or two patients, and the farce is done. If there is nothing “spe- 
cial,” or nothing “ new,” the visit is occasionally wholly omitted. 
In consequence, some resident staff vote the physician or surgeon 
a mighty nice fellow who does not interfere, and go on untaught, 
seeking experience for themselves. 
It may be said that such neglect of duty is not the rule ; per- 
haps it is not; but admitting that each hospital has one such 
visiting physician or surgeon, the demoralizing effect is produced 
upon the resident staff : the notions of contempt for their pro- 
fessional superiors and of their own relative capacity to “ run the 
wards ” enter their minds, and are difficult to eradicate. From 
conversations with conscientious and able visiting physicians, 
I know that to take a service after the young men attached to it 
have got into this morbid mental state is a discouraging ex- 
perience. The thorough visits, the complete examinations' of 
patients, the requests that minute observations be made, etc., 
seem to the demoralized resident staff like tyranny and fussiness ; 
they have forgotten that the patients professionally belong to the 
visiting physician, and that they themselves are in the hospital to 
be taught and trained. 
Under the European plan of continuous attendance, a young 
man who enters a hospital has the prospect of serving through 
various grades under one physician, of being constantly watched 
and advised by him, of becoming moulded by his methods, of 
being afterward known as his pupil, and, if worthy, of being 
helped by him in scientific and practical matters after leaving 
the hospital. Can any of the many able young men who leave 
our hospitals say in after life : “ I was a pupil of so-and-so ; he 
trained me, and I have assisted him in his researches ! ” They 
can only claim that they witnessed the various ways of a number 
of visiting physicians, some able and careful, others able and 8 
E. C. SEGUIN. 
careless, others still incompetent or even ignorant ; that they 
“ picked up ” many valuable notions, and neglected many fine op- 
portunities for clinical and therapeutical study. They look back 
with pleasure to their relations with some of their visiting staff, 
and with mingled contempt and resentment at their subjection to 
others. 
With our system of short services how can a higher medical 
education be attempted ? A physician from a distant place, or 
a recent graduate of one of our schools, would like to become 
the pupil of Dr. A , who is so well known in connection with, 
we will say, the study of fevers, or for his skill in auscultation 
and percussion. He would like to watch his cases and methods, 
and really learn something of the subject. He finds that Dr. 
A is attached to a certain hospital, and further, that he has 
charge of two or more wards of that institution for two months 
only—a period allowing of the complete observation of only a 
few cases ; he finds that this gentleman’s wards contain numerous 
cases of diseases in which neither Dr. A himself nor the 
visitor is interested, and that the class of diseases he came to ob- 
serve is represented by a few cases. Can he carry out his plan ? 
Is he not, if he can afford it, driven to go to Vienna, or Berlin, or 
Paris, even though he may feel convinced that Dr. A is an 
able man and fully as good a teacher as the German or French 
professor he will have to find ? But this foreign physician con- 
trols a service year after year, and, by a sort of natural selection, 
cases which he understands best have accumulated in his service, 
and he can at almost any time offer a rich store of instruction to 
pupils. 
This criticism is true, we believe, of the present state of all our 
hospitals, except perhaps those for diseases of women and for 
diseases of the eye and ear. We might amplify the criticism, but 
perhaps, put in the above brief form, it is fully comprehensible, 
and we believe its validity will be admitted. 
Lastly, by no means least, the system of short medical services, 
two months or even four, is very unjust and unfavorable to many 
patients in our hospitals. As stated before, many chronic or semi- HIGHER MEDICAL EDUCA TION IN NEW YORK. 
9 
chronic cases cannot receive that continuous and persevering 
treatment which alone can save them from incurability. Each 
new visiting physician or surgeon must go over such cases, take 
time to understand them, and then, probably, he will try another 
treatment for a few weeks. Or else, for the length of one physi- 
cian’s term of service, the care of these cases will be left wholly in 
the hands of the resident staff, because the visiting physician or 
surgeon is interested only in acute cases, or cases requiring opera- 
tion. I believe that the controlling authorities of our hospitals 
would be shocked if they knew the number of cases which under- 
go this “ treatment ” in their institutions, and also if they realized 
how many curable or ameliorable cases are refused admittance 
because they come under the somewhat arbitrary classification 
of chronic or incurable affections—terms which are wrongly held 
to be nearly synonymous, especially by hospital physicians. 
Another way in which patients in hospitals are aggrieved is this. 
They have a certain moral right to ask to be under a given phy- 
sician’s care, provided there be room for them in his ward, and 
the discipline of the hospital be not injured by complying with 
their request. This right is more evidently possessed by paying 
patients. If Dr. B, for example, has earned a reputation for skill 
in the treatment of diseases of the digestive apparatus, a dyspeptic 
wretch who applies at Dr. B’s. hospital should, if he desire it, be 
given the benefit of that supposed skill. With our present system 
this dyspeptic, if he wishes to be under Dr. B’s. care, must wait 
until Dr. B “ goes on duty,” and then may be treated by him for 
two or three months, when another physician, who, perhaps, is far 
from skilled in the treatment of dyspepsia, and takes no in- 
terest in such cases, assumes charge of the ward. What can be 
the result of such an experience, but relapse of the disease or 
failure to completely cure it ? Some years ago it was within my 
personal knowledge that uterine cases were neglected and left 
wholly in the hands of the house physician by-some of the visit- 
ing physicians of a hospital in this city. The rules of the hospital 
allowed of the reception of these cases and their location in the 
wards of a physician who knew little about them, and who looked 10 
E. C. SEGUIN. 
upon the manipulations necessary to their diagnosis and cure with 
feelings of mingled dread and repugnance. 
As I have pointed out in another place,* there-is an inevitable, 
semi-conscious tendency to the cultivation of specialties in medi- 
cine, and nearly all of the men from among whom hospital phy- 
sicians are or should be chosen, are quasi-specialists, i. e., they 
have studied with care and feel an interest—a real scientific in- 
terest--in a limited number of diseases, and in proportion as they 
increase their knowledge and skill in this special direction, they 
become less competent to deal successfully with other diseases. 
The system of short changing services forces all patients to submit 
to a succession of variously qualified physicians, and obliges a phy- 
sician to try to treat all sorts of diseases, or tempts him into 
neglecting many of the patients placed under his care. The sys- 
tem does not recognize the fact, the hard and undeniable fact, 
that all intelligent and scientific physicians are quasi-specialists, 
and must be. In the present development of medical science 
there is no alternative ; a physician must be a quasi-specialist, or 
possess a universal knowledge of a superficial, mostly booky kind, 
a knowledge wholly insufficient to ensure intelligent or successful 
practice. 
In this city the height of absurdity in the way of appointing 
physicians to services for which they have no liking, was reached 
when a well-known specialist was placed in charge of a service 
in a hospital devoted to a specialty altogether different from the 
one in which he excelled ; but every hospital at the present time 
is witness to a minor degree of the same injustice to patients. 
In a subsequent article means of correcting these evils will be 
discussed. E. C. Seguin. 
By an unfortunate lapsus calami, the author is made to condemn “ quizz- 
classes,” The term should be “cram-quizzes.” The author entertains, on the 
contrary, a favorable opinion of those quizz-classes which limit their recitations 
to the regular curriculum of a medical school, and which sincerely aim to perfect 
the student in his knowledge of what is being taught him there. Examination 
classes whose purpose is to prepare men to pass a severe examination by a sys- 
tematized process of “cramming,” is the kind of quizz-class which, the author 
thinks, exerts pernicious effects. 
* The cultivation of specialties in or Mkokine, vol. iv, 
p. 280. ARCHIVES OF MEDICINE FOR 1881, 
A BI-MONTHLY JOURNAL, 
Edited by Dr. E. C. Seguin, with the assistance of ma«y prominent physicians in this 
country and abroad, enters upon the third year of its existence. 
The Archives of Medicine will continue to be published every two months. 
Each number is handsomely printed in large octavo form on heavy paper, and contains from 
104 to 112 pages. The articles are illustrated by means of lithographs or wood-cuts wherever 
necessary. 
It is intended to devote the whole of each number to original matter, consisting of original 
communications or editorial articles, reviews of books, and a record of important cases. 
The Abstract Department has already been omitted in two numbers. The principal reason 
for this change is that the editor believes that the profession are ready to support a journal devoted 
to original communications and bona fide reviews. 
Especial attention is given to the review department, and while every pains is taken to secure 
the services of unprejudiced reviewers, they are to criticise or praise without fear or favor 
and to assume the responsibility of their statements by appending their initials to the reviews. 
The following Editorial Articles have appeared during the year 1880 : Mr. Lister’s Antiseptic 
Method, by Dr. Lewis A. Stimson ; Our Asylums as seen by a Competent Foreign Visitor, by 
Dr. von den Steinen ; Observations on the Insane Asylums of California and Nevada, by 
Dr. R. W. Birdsall ; The Right of the Insane to Liberty, by the Editor. 
Among the Origitial Articles may be mentioned the extensive papers by Dr. N. M. 
Shaffer, On the Hysterical Element in Orthopaedic Surgery ; by Dr. Mary Putnam Jacobi, 
On the Use of the Cold Pack, followed by Massage, in the Treatment of Anaemia; and Dr. 
Amidon’s Prize Essay on the Temperature of the Head. 
London.—Drs. J. Hughlings J ackson, J. Burdon-Sanderson, and Sydney Ringer. 
Paris.—Profs. J. M. Charcot, J. Marey, and A. Ollivier. 
Germany.—Prof. Dr. W. Erb, of Leipzig. 
Philadelphia.—Profs. D. Hayes Agnew, M.D., J. M. Da Costa, M.D., William Goodell, M.D., Roberts Bar- 
tholow, M.D., S. W. Gross, M.D., and Drs. Thos. G. Morton, E. O. Sharespeare, and J. C. Wilson. 
Boston.—Drs. James R. Chadwick, Charles P. Putnam, James J. Putnam, and Samuel R. Webber. 
Baltimore,—Prof E. T. Miles, M.D., Dr. I. E. Atkinson. 
Hartford, Conn.—Dr. Samuel B. St. John, Dr. M. D. Mann. 
Albany, N. V.—Prof. Samuel B. Ward, M.D. 
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