COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64077640 R A982.B65 C49 Action of the truste RECAP Boston Actio: 93 of the n o^ton 3 petit Lon of hoi a t« atro— vft mfrftf) CAI Columbia (Brtfowsitp mtljeCttpofitaigork COLLEGE OF PHYSICIANS AND SURGEONS LIBRARY Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/actionoftrusteesOObost ACTION OF THE TRUSTEES 1 BOSTON CITY HOSPITAL UPON THE PETITIONS FOB THE INTRODUCTION OF HOMEOPATHIC TREATMENT, AND FOR THE ADMISSION OF MEDICAL STUDENTS TO SURGICAL OPERATIONS AND CLINICAL INSTRUCTION. BOSTON: ROCKWELL AND CHURCHILL, CITY PRINTERS, No. 39 ARCH STREET. 1886. Boston City Hospital, Boston, Oct. 7, 1886. To Charles G. "Wood and others, petitioners, ashing " that homoeopathic treatment may be furnished at the City Hos- pital for those who prefer it ": — I am instructed by the Trustees of the City Hospital to inform you that they have unanimously determined that it is inadvisable to grant your petition that homoeopathic treat- ment be provided in the City Hospital, as asked for. The Trustees have devoted much time and thought to the subject. They have recognized the fact that the petition has been supported by many and by deservedly influential citi- zens of Boston ; and they have arrived at their present con- clusion only after a careful hearing and consideration of the various statements and arguments of the petitioners and much further investigation. The Trustees have considered that their first duty in the administration of the Hospital is the proper care of the sick and injured who are put under their charge. So far as is consistent with such provision for the patients, they are re- sponsible to the City Government and to the citizens gener- ally for the economical expenditure of the large appropriation which the necessities of the Hospital each year demand. If the} 7 cause an increase in the running expenses of the Hos- pital, this increased expenditure must be met by diminishing the number of patients, and thereby rejecting deserving applicants ; or by lessening the expenses per patient, thereby cutting off some of the attention or comforts now deemed necessary ; or by obtaining from the City Government a larger yearly appropriation from the tax levy of the city. 4 Boston City Hospital. Experimental changes in treatment and administration, and the promotion of scientific knowledge, however desirable in themselves, must, in the belief of the Trustees, be held sub- ordinate to this regard for the welfare of patients and to the economical expenditure of the money appropriated to this end. The City Hospital of Boston having, from its inception under the present sj^stem of management, been attended with a remarkable success, and acquired a position among hos- pitals which is not surpassed in the country, it must be acknowledged that the present Trustees would not be justi- fied in making a radical change in its career, as called for, without satisfactory assurance that the change would result advantageously. The petitioners have asked for the introduction of homoeo- pathic treatment for a portion of the patients, — a change in the administration of the Hospital which must be accom- plished, if at all, in one of three ways : — I. By introducing another and independent body of physicians and surgeons, side by side with the present staff; or — II. By setting apart separate existing wards for a sepa- rate staff ; or — III. By building new wards for the homoeopathic treat- ment. The introduction of two, and, it must be confessed, some- what antagonistic or opposite methods of treatment into the same wards, bringing to adjacent beds physicians or sur- geons of different staffs, with different medicines and different diets, whose orders are to be executed by the same nurses, house officers, and other attendants, on different systems, would be attended with so apparent practical diffi- Homoeopathic Treatment. 5 culties that the petitioners themselves were hardly under- stood to favor such a change with the existing state of things, and this proposition may be dismissed as not practicable. II. The setting apart of certain existing wards for homoeo- pathic treatment, which was admitted as more desirable, and which was quite generally advocated by the petitioners, would undoubtedly in part reduce the practical difficulties, but would only lessen and not overcome them. The Hos- pital is a compact whole, with ward divisions, not now, in the opinion of the Trustees, sufficient in number to make so ex- tensive classifications as are desirable. Patients are assigned to the various wards according to their sex, age, and the nature of their complaints. Patients, nurses, and house officers must be transferred from one- ward to another, ac- cording to the exigencies of the cases and the service, and the whole is overlooked by single supervisors in different departments, all subordinate to a general superintendent, who is responsible to the Trustees. The successful and economical administration of an in- stitution with an average of three hundred and fifty patients and in all of five hundred and fifty people, almost literally under a single roof, depends largely upon the harmonious working of its different departments. If different methods of practice are introduced into different wards there must be constant confusion and trouble arising among house officers and nurses attempting sometimes to follow one system and sometimes another. Nurses and house officers, if possibly mentally qualified to pursue their duties under opposite methods and different masters, can hardly be expected to be neutral in their opinions, and perhaps prejudices, and just complaints would inevitably arise, and a harmonious admin- istration of details could not be expected. 6 Boston City Hospital. Could, however, such clashing of interests be avoided by introducing again into the Hospital two entirely different sets of house officers, nurses, and other subordinates correspond- ing to the different staffs, additional practical difficulties would then arise. House officers, being students who have completed courses at medical schools, come to the Hospital gratuitously for the knowledge and skill to be obtained from, the service in its various departments ; and its nurses are all pupils of the Training School, coming into the Hospital for a specified period to go out into the community trained to pursue their calling with patients of every class. Both the Hospital and its assistants materially gain by this method of service, which would be much interfered with, if not broken up, by confining one set of house officers and nurses to one limited class of wards and diseases, and the other set of house officers and nurses to another distinct class of wards and dis- eases. The different sets of house officers, nurses, and other attend- ants to be thus provided would materially increase the total number of employes ; the greater number of employes and the different systems of administration would require additional room, — crowded as is the Hospital already, — and there must follow either greater expenditures or an abridgment of the space or privileges now allotted to the patients. The suggested injustice done patients, in not allowing them to select by which method of practice they shall be treated, is certainly not overcome by arbitrarily assigning one sex, or age, or the victim of one kind of disease, to one practice or treatment, and the other sex, or another age, or a sufferer by a different disease, to the opposite treatment. Again, should the Trustees set specifically apart wards for the homoeopathic treatment of such patients as may prefer the system of homoeopathy, it is difficult to see how they could deny other patients and other petitioners when requesting wards to be assigned for other schools of medicine, embracing Homoeopathic Treatment. 7 considerable numbers of the citizens of Boston, and avoid multiplying the difficulties above set forth. Were the double sets of subordinates practicable the difficulty of treating two methods of practice fairly and impartially, and without impairing the harmony of admin- istration, would still be continued as long as a single superintendence continued. For a superintendent to be free from the charges of favoritism in the dual management would seem impossible, where two parties would be watch- ing their respective interests with emulation, if not with jealousy. The Trustees have, so far as they have been able, con- sulted with gentlemen acquainted with hospital manage- ment, and the general advice is against the mingling of dis- tinctly different methods of practice in the same institution. They have examined the systems of hospital administration in other cities, notably in the principal hospitals in New York and Philadelphia, they have addressed inquiries to all the principal hospitals of the country, and they find no such ex- periment successfully tried. Of nearly one hundred hospitals communicated with two only admit more than one method of practice. The general management of the institution which was the one hospital in this country cited by the petitioners as mingling two methods of practice is not believed to be so sat- isfactory as to add an argument in favor of the principle, or to commend itself to the Trustees of the City Hospital as an example. The Trustees have learned of but a single other considerable hospital where different methods of practice have been at all introduced, and in this the experiment, though but partially tried, seems far from satisfactory. The Trustees cannot therefore avoid the conclusion that the introduction of homoeopathic treatment, by setting apart separate existing wards for a homoeopathic staff, would lead to confusion and an impaired service, and would entail, unless 8 Boston City Hospital. the number of patients at present admitted were diminished, or the present privileges of patients were abridged, considerable additional yearly expense, for which the City Government would be called upon to make additional appropriations. In- deed, so specific and limited are appropriations made by the City Council, that it might be contended that the Trustees would not be justified in expending the appropriations granted year by year in conducting the Hospital upon methods radi- cally different from those adopted at the establishment of the Hospital and ever since followed. On the other hand, it cannot be said to be established that the welfare of the patients will be substantially increased by the changes required; while it is believed, and is acknowl- edged, we think, by the petitioners, that the advantages chiefly sought by them can be better secured otherwise ; that the secondary advantages resulting from the promotion of medical science, and from the experience to be gained from the treatment of patients by newer methods, can certainly best be secured by separate and independent buildings, alreadv erected or to be built. III. The practical difficulties enumerated, with others which might be added, and which must arise in either of the two solutions suggested, must, it is believed, make it regarded as conclusive that the desire of the petitioners can be fairly or satisfactorily gained only by new and separate buildings. This is a question beyond the province of the Trustees. The appropriations to the Hospital are made for specifically enumerated objects, — for supplies, for salaries and labor, for fuel, for medical supplies, for buildings and grounds ; if new buildings are to be erected, or extraordinary repairs are to be made, special appropriations are made for the purpose ; HOMCEOPATHIC TREATMENT. 9 and expenditures must be made, and can only be made, by the Trustees, according to these defined purposes. ISTew buildings can be obtained or erected and proper provision made for hoinceopathic treatment whenever the city, through its chosen government, shall say that it desires that homceopathic treatment shall be given to those of its citizens who prefer it. The Trustees cannot, therefore, but feel that upon further consideration the petitioners will be satisfied that the proper method of the introduction of homoeopathic hospital treat- ment by the city is through separate buildings under a distinct management ; that only in this way can results satisfactory to themselves be obtained, and that to this end the City Govern- ment, and not the Trustees of the City Hospital, are the body proper to determine how and when the city shall pro- vide treatment specially homceopathic to such of its citizens as shall desire that treatment, when compelled to seek assist- ance at a public institution. Very respectfully yours, HENEY H. SPEAGUE, Secretary. 10 Boston City Hospital. Boston City Hospital, Boston, Oct. 7, 1886. To William F. Warren, President of Boston University, and others, petitioners that the students of the Boston University School of Medicine may be allowed to visit the City Hospital for clinical purposes on the same terms and with the same privileges as the students of the Harvard Medical School; S. W. Harmon and others, petitioners that all clinical advantages and privileges of the Hospital may be made equally available to all students pursuing the study of medicine in Boston; and James White and others, petitioners that the Trustees allow all medical students and physicians to visit the Hospital for purposes of medical study and observation on equal terms and subject to the same conditions : — I am requested to comiiiiinicate to you the action of the Trustees of the City Hospital relative to the admission of medical students to the Hospital for purposes of instruction. The Trustees of the City Hospital have hitherto recognized the desirability of affording to students of medicine and sur- gery such opportunities for observation and instruction as might be properly granted without detriment to the main purposes of the Hospital. Rale No. 159 permits male medical practitioners and stu- dents to be admitted to the amphitheatre of the Hospital on operating days, under such restrictions as may be imposed by the Trustees. Under this rule, substantially all male appli- cants, so long as they have maintained proper order, have been admitted to the amphitheatre once a week, to witness the operations and listen to the clinical instruction given by the operating surgeon. It has been made a regulation that no operation should be performed upon a woman without the attendance of a female nurse, and that no operation upon women should be made in public when requiring an exposure of the genital organs. Admission of Medical Students. 11 Rule No. 158 provides that practitioners of medicine of one year's standing, on recommendation of the Visiting Staff, may, by vote of the Trustees, receive cards of admission to follow the practice of the Hospital for not more than one year. This is a rule passed long since, and, though continued upon the records, no action under it has been taken by the Trustees for many years. The Trustees, however, have tacitly allowed members of the Visiting Staff to invite such physicians, students, or others, as they might desire, to visit the wards of the Hos- pital with themselves, while making their daily rounds, and, on some occasions, patients have been taken from the wards into adjoining rooms, and their cases explained more at length by the attending physician or surgeon. Members of the Out-patient Staff have, also, by invitation, to a very limited extent, introduced students at their examinations of patients ; but this has generally been done for the purpose of obtaining some assistance from the students. Inasmuch as several members of the staff are also professors of the Harvard Medi- cal School, these gentlemen undoubtedly have chiefly invited students of that school to accompany them in their visits, but, by a tacit understanding, one of their visits each week has been attended by students generally. The students, on such occasions, have received valuable clinical instruction. No invitation or permission has otherwise been accorded by the Trustees to the students of the Harvard Medical School, or to others, though some tickets formerly printed for giving admission to the amphitheatre may have been improperly or inadvertently used for such purpose. The Trustees have formally recognized the practice, exercised by members of the staff, of inviting students to the wards, only so far as to provide that such visiting shall never be carried to the detriment of the patients or the injury of the Hospital; and they have at times informally restricted the privilege, as by instructing the superintendent to see that no patient ^° 12 Boston City Hospital. made the subject of instruction to his detriment or against his wish, and that students be not allowed to visit the wards in inconvenient numbers. The Trustees, while endeavoring to hold the members of the staff to a paramount duty to the Hospital of securing, by the best possible care, the welfare of the patients, — a service which is invariably performed gratuitously by the members of the staff, — have assumed that the instruction of students is in no wise a further duty on the part of the members of the staff to the Hospital, but that, in considera- tion of their valuable and gratuitous labors, it was proper to suffer such instruction to be given by them individually in such manner as they should desire, provided always that no injury should come to the patients or the Hospital. Several years ago, however, it was required, in accordance with the present Eule No. 159, that in case operations should be performed in the public amphitheatre, and clinical instruction be there given, all male students should, under proper regulations, be admitted. A due consideration of the petitions now before them has caused the Trustees not only to reexamine carefully the rules and practice now existing in the City Hospital as to medical and surgical instruction, but also to investigate and endeavor to ascertain accurately the position taken elsewhere in the matter of such instruction. The Trustees have, by personal investigation in New York and Philadelphia, and by letters of inquiry to other cities, as- certained, so far as possible, the practice of the leading hospi- tals in the country. Endeavor has been made to make the information accurate, and the inquiries have been answered in nearly all cases by the persons officially authorized to speak for their respective hospitals. The question of instruction to students has been consid- ered : — Admission of Medical Students. 13 1st. As to surgical operations and clinical instruction in the amphitheatre or other public room ; 2d. As to instruction in the wards or iu the out-patient rooms ; 3d. As to the admission of female students to the various privileges. As New York and Philadelphia are great centres of medical education, the information imparted to the Trus- tees at the leading hospitals in those cities is given in con- siderable detail, because the practices prevailing in those cities are not only in themselves important, but are also rep- resentative and explanatory of the statistics more generally given as to hospitals throughout the country. The practice in these hospitals, as told to the Trustees, is as follows : — New York. At the Bellevue Hospital, the city hospital of New York for acute and surgical cases, and the leading hospital of that city, if not of the country, in the regard of medical instruc- tion, all students, without distinction of sex or school of medicine, are admitted free to the operations and to such instruction as is given in the amphitheatre. The hospital is in four divisions, and the members of the Visiting Staff are appointed, three divisions respectively from the instructors of the three leading medical schools, and one division from the body of physicians not connected with either school, all the staff, however, being of the regular profession. Each division is allowed to give instruction in the amphitheatre, and not only surgical operations are performed there, and the cases lectured upon, but patients in the medical wards of the hospital are brought into the amphitheatre and made the subject of medical instruction. The attendance is very large, often from four hundred to five hundred students from various 14 Boston City Hospital. institutions, including an average attendance of perhaps six or eight female students. On the other hand, no instruction is recognized in the wards, and only as a matter of courtesy- are the various professors suffered, on their own invitation, to permit students to attend them in their hospital visits. This tacit permission is made use of by a part only of the profes- sors connected with the hospital, and while fifteen is the understood limit as to number, seldom, if ever, are more than twenty-five students at a time in attendance. The Out-patient department of Bellevue Hospital is lo- cated in the basement of the Bellevue Medical College, a private institution. In the Out-patient department no in- struction is afforded, except in a few instances by the attending physician to a small number of private pupils, seldom exceeding two or three. In the Charity Hospital, the other hospital supported by the city, which is for chronic cases exclusively, and re- mote in its situation, though similar rules apply, little in- struction is given, but patients, whose condition admits the removal, are tacitly allowed to be taken to the medical schools for the class instruction of the professors in charge of the various wards. The New York Hospital is the oldest in New York, and is a private institution corresponding to the Massachusetts Gen- eral Hospital. A by-law of the hospital provides as follows : — "In order to render the hospital, so far as may consist with the welfare of the patients, conducive to the advance- ment of medical science, the physicians and surgeons may provide among themselves adequate and regular practical instruction, by observations accompanying operations and prescriptions, by clinical lectures, or otherwise, to the students admitted to see the practice of the house. Due notice of the time and period of such instruction shall be Admission of Medical Students. 17 of recognized colleges, but not of " irregular schools." The number is limited to fifteen, and is chiefly of practitioners and third-year students. The wards are not opened to students. To the Out-patient department the attending physician or surgeon may invite two students at a time, for his assistance. The staff is all of the regular profession. The above are the leading New York hospitals, and embrace all which would seem to attract medical students in any con- siderable numbers. It is seen that general instruction, including surgical operations, open to all students, female as well as male, is given in the Bellevue and New York hospitals, and such general instruction is confined to the amphitheatre ; that in but a part only of the hospitals is clinical instruction allowed in the wards, or in the Out-patient departments, and in all cases where thus permitted the individual members of the staff are allowed, as a matter of courtesy, to instruct, in very limited numbers, such students as they themselves specially invite. Philadelphia. The Philadelphia Hospital (formerly called the Blockley) is the one general hospital maintained by the city of Phila- delphia, and is intimately connected with the almshouse, its patients being almost entirely of the pauper class. Its staff is wholly of the regular profession. Medical and surgical lectures are given in the amphitheatre, by such members of the staff as choose to instruct, the lectu- rers generally being professors of the medical colleges. These lectures are open to all students, and frequently there is a very large attendance. No students are admitted to the wards for clinical instruc- tion, but sometimes a surgeon or a physician has cases taken into rooms adjoining the wards for the clinical instruction of a small number of students invited by him. 18 Boston City Hospital. The Pennsylvania Hospital is a private hospital, the oldest in the country, and was originally instituted both for the treatment of the sick and the dissemination of medical knowl- edge. The rules specify that the members of the staff " shall, on the fourth and seventh days of each week, from ten to twelve o'clock, deliver clinical lectures to such students of medicine as may have acquired the right to attend," and that students can be admitted on the recommendation of the med- ical and surgical staff. Students are required to pay a small fee (three dollars to ten dollars each year) , and as a matter of fact no distinction is made as to sex or school of medicine. Women were admitted as above after a long controversy, and only after the resignation of several of the staff. There is much opposition among both members of the staff and gov- ernors to the admission of women to the clinics, and con- siderable feeling against all clinics. One hundred and sixty tickets were thus issued last year. No students or clinical instruction are permitted in the wards of the hospital. Students to the number of two or three at a time are sometimes invited by the attending physi- cian or surgeon to the Out-patient department. The Hospital of the University of Pennsylvania is a large hospital, maintained in connection with the University School pf Medicine, and is used for the instruction of its students. General clinical instruction is given in the amphitheatre only, and no women or homoeopathists are admitted ; and in fact no one but students of the University are supposed to attend. Patients in the hospital are freely used in the am- phitheatre for both medical and surgical instruction, and the Out-patient department is also drawn upon for interesting cases. Students, if taken to the wards, are limited to two days in a week and to parties of six. The Jefferson College Hospital is closely connected with the Jefferson College of Medicine, and admits students sub- stantially on the same terms as the hospital of the University. Admission of Medical Students. 19 At the Episcopal Hospital no clinics or students are per- mitted in the wards of the hospital, except that a student is occasionally invited to attend a member of the staff on his routine visit. The Women's Hospital is intimately connected with the Women's College, and admits students of the Women's Col- lege to clinics in its wards, but only six at a time, and such as are specially appointed. Instruction to students is given in the amphitheatre, and patients are taken from the wards for clinical purposes. Homoeopathic female students are, however, not admitted to these privileges. The Hahnemann Medical College (homoeopathic) admits to clinics only male homoeopathic students, female homoeo- pathic students having been expressly refused. The situation in Philadelphia seems to be that all students, without discrimination, are distinctly admitted to instruction in the amphitheatre at the Philadelphia Hospital only, but as a matter of fact all students, on payment of the fee, are suf- fered to attend the instruction in the amphitheatre also at the Pennsylvania Hospital. Homoeopathic male students are further admitted to the Hahnemann Hospital, and female regular students are ad- mitted to the Women's Hospital ; otherwise women and homoeopaths are substantially debarred from clinical in- struction at the Hospitals. There is no general admission to the wards of any hospital or to Out-patient examinations ; in a part only of the hos- pitals are any ward and Out-patient clinics allowed, and in these only in very limited numbers, and at the option and in- vitation of individual members of the visiting staff. There are other smaller hospitals in Philadelphia, but these, as in New York, would attract few students for clinical in- struction. 20 Boston City Hospital. The following rule has been adopted by the Trustees of the Massachusetts General Hospital : — " Physicians and Surgeons of regular standing may visit the Hospital on making themselves known to the Visiting Physicians or Surgeons, or to the Resident Physician ; but they are not to examine the patients, or make any observa- tions upon their treatment, or attend operations except with the permission of one of the Visiting Physicians or Surgeons. " Students of medicine may be admitted to view the clini- cal practice of the Hospital by the written permission of one of the Visiting Physicians or Surgeons, or of the Resi- dent Physician ; but female students, if admitted, shall be placed in classes separate from male students, and shall attend the clinical practice of the female wards exclusively." Since the adoption of the rule the Surgical Staff have voted that female students shall not be allowed to be present at the operations in the amphitheatre. It is, however, the prac- tice to admit male students without any restriction to the operations in the amphitheatre, no tickets for the purpose being required. The Visiting Physicians and Surgeons who are connected with the Harvard Medical School are allowed to take with them in their visits to the wards such students as they desire ; and members of the Out-patient Staff are also allowed to invite medical students to their examinations ; no further limitations have been imposed, but the invitations of the staff are substantially limited to the students of the Har- vard Medical School, with which most of its members are connected. The question of instruction at this hospital seems to be left at the option of the staff. Written inquiries, showing the points upon which the in- formation was sought, were addressed to all those hospitals in Admission of Medical Students. 21 the country, so far as their names could be ascertained, which would seem likely to afford instruction to students. The answers received embrace all the important hospitals, except perhaps one or two in remoter cities. The whole number of hospitals from which the statistics have been received is ninety-one. 1 Of these, twenty-seven hospitals located in the larger cities, — Albany, N.Y. ; Au- gusta, Ga. ; Ann Arbor, Mich. ; Baltimore, Md. ; Brooklyn, N.Y. ; Buffalo, N.Y. ; Chicago, 111. ; Cincinnati, O. ; Cleve- land, O. ; Denver, Col. ; Indianapolis, Ind. ; Kansas City, Mo. ; Louisville, Ky. ; New Orleans, La. ; New York, N.Y. ; Philadelphia, Penn. ; Quincy, 111. ; San Francisco, Cal. ; St. Louis, Mo. ; St. Joseph, Mo. ; Washington, D.C. ; Worcester, Mass., — are maintained in whole or in part by the city or the State, and therefore more especially resemble in their conditions the Boston City Hospital. In the follow- ing statistics these are termed public hospitals. The information from all the hospitals, including those of New York and Philadelphia, is summarized as follows : — 1st. As to instruction in the amphitheatre or other public room : — No. of hospitals which admit students to surgical opera- tions : — Male students without restrictions . . .30 " " on invitation of the staff . . 20 " " of specified colleges . . .16 " " on payment of a fee Female students only . . . — 7fi No. of hospitals which do not admit students to surgical operations . . . . . . 15 Total number of hospitals . . . . 91 1 The names of all the hospitals from which information has been received are given in the appendix. 22 Boston City Hospital. No. of public hospitals which admit students to surgical operations : — Male students without restrictions " " on invitation of the staff " " of specified colleges " " on payment of a fee Female students only 12 4 5 4 1 26 No. of public hospitals which do not admit students to surgical operations ..... 1 Total number of public hospitals ... 27 Sixty of the whole number of hospitals permit medical as well as surgical instruction in the amphitheatre or other public room. 2d. As to instruction in the wards : — No. of hospitals which admit students to wards : — Male students without restrictions . . .7 . " " on invitation of the staff . . 38 " " of specified colleges . . .14 Female students only . . . . .2 - 61 No. of hospitals which do not admit students to wards ........ 30 Total number of hospitals . . . . 91 No. of public hospitals which admit students to wards : — Male students without restrictions ... 1 " " on invitation of the staff . . 18 " " of specified colleges ... 3 — 22 Admission of Medical Students. 23 No. of public hospitals which do not admit students to wards ........ o Total number of public hospitals ... 27 In nine at least of the public hospitals the number of students admitted at a time is by rule limited to a few. 3d. As to the admission of female students the same as male students: — No. of hospitals which admit female students to surgical operations ...... 46 No. of hospitals which do not admit female students to surgical operations ..... 25 No. of hospitals which have no rule upon the sub- ject, and to which no female students have applied for admission ....... 5 Total number of hospitals which admit students to surgical operations ..... 76 No. of public hospitals which admit female students to surgical operations ..... 18 No. of public hospitals which do not admit female students to surgical operations .... 6 No. of public hospitals which have no rule upon the subject, and to which no female students have ap- plied for admission ...... 2 Total number of public hospitals which admit students to surgical operations ... 26 No. of hospitals which admit female students to wards : — On invitation of the staff . . . . .22 Of specified colleges ..... 5 Without restriction ...... 6 — 33 24 Boston City Hospital. No. of hospitals which do not admit female students to wards ........ 23 No. of hospitals which have no regulation upon the subject, and to which no female students have ap- plied for admission ...... 5 Total number of hospitals which admit students to wards ....... 61 No. of public hospitals which admit female students to wards : — On invitation of the staff . . . . .12 Of specified colleges ..... 1 Without restriction ...... — 13 No. of public hospitals which do not admit female students to wards ...... 12 No. of public hospitals which have no regulation upon the subject, and to which no female students have applied for admission .... 1 Total number of public hospitals which admit female students to wards .... 26 In all the public hospitals, except two, the staff is com- posed of regular physicians, and of these two, one has both regular and homoeopathic members, and the other has no Visiting Staff proper, but a head or superintendent (regular), assisted more or less by members of " all the schools, regular, irregular, and defective." Of all the hospitals answering the inquiries, five were homoeopathic, the remainder were regular. The present Trustees believe it their duty to continue to make the proper care and treatment of the sick and injured the main and controlling purpose of the Hospital, and to Admission of Medical Students. 25 continue to permit medical instruction and observation in the Hospital only as incidental, and only so far as such instruction and observation can be afforded without detriment to the main purpose. While, as the Hospital is a city institution, they cannot invite students of one school and debar those of another, they cannot assume to require of the Hospital staff, in addition to the duty of a careful attention to the patients, the giving of gratuitous instruction to medical students. Were they to impose the duty of free medical instruction upon the staff, the Trustees might properly be called upon to say further that the instruction should not be confined to one school of practice, but made to extend to the different schools in vogue in the city. Being desirous, however, that the Hospital should afford to the citizens of Boston generally all incidental advantages in the way of medical knowledge which it is in the power of the Hospital to bestow, consistent with the welfare of the patients, the Trustees will gladly continue to offer the large amphitheatre to the staff not only for surgical operations or instruction, but will willingly extend these facilities to the medical department, requiring that in every case of introduc- ing patients for instruction, the physician or surgeon in charge shall pronounce that the patient can undergo such examina- tion and treatment without injury, and that the patient him- self and the superintendent shall consent to the same. This instruction in the amphitheatre has hitherto, as has been said, been open to all male students of medicine. The Trustees are now asked to extend the privilege of the amphi- theatre to female students. The propriety of women prac- tising as physicians or surgeons, and their comparative ability and fitness to pursue this profession, are not questions for the Trustees to consider in the official management of the Hospital ; they must recognize the fact that women are be- coming practitioners in all the schools of medicine ; that they are admitted to the Massachusetts Medical and other 26 Boston City Hospital. State societies, and are recognized as such practitioners by the community at large ; and that they are admitted in com- mon with male students to other leading hospitals of the country. The Trustees therefore feel that there is no suffi- cient reason why women should not be admitted to the public instruction in the amphitheatre on the same terms as men, except as to certain operations from which a reasonable sense or regard for propriety may exclude them. They have therefore determined that operations and in- struction in the amphitheatre shall be open, upon reasonable regulations, to all students of medicine, of one year's stand- ing, of duly incorporated colleges, with the proviso that the attending surgeon or physician may on any occasion reserve such cases as he deems improper for consideration in the presence of students of both sexes to the end of the lecture, and before proceeding with them require the withdrawal of all male or female students, as the case may be. Such extension of the privileges of the Hospital in the direc- tion indicated, if accepted by the staff, will, in the opinion of the Trustees, much increase its possible usefulness in the broader field of medical science and knowledge. The medi- cal instruction which may thus be incidentally imparted by the members of the staff, who are of acknowledged eminence in their respective departments, will undoubtedly attract students from other institutions than those to which they are themselves attached, and of other schools of practice than those to which they themselves belong, but it will at the same time thus help to make this city more a centre for medical study and research, and help make the practice of its physicians, of whatever school they follow, more enlight- ened and beneficent. The staff, in thus adding to the general benefit conferred by the Hospital upon the community at large, would certainly not lessen the fame and prosperity of the particular institution especially receiving the benefit of their valuable medical knowledge and experience. Admission of Medical Students. 27 Clinical instruction in the wards must, from due regard to the many patients in various stages of disease, be limited, and conducted, if at all, with great care and circumspection. It would be manifestly detrimental to make it general, as in the amphitheatre ; and in no great hospital in the country, even including those hospitals where medical instruction would seem paramount to the care of the patient, are the wards so opened to all comers. On the other hand, to suifer members of the Visiting Staff specially to invite students or other phy- sicians to accompany them in limited numbers on the Hos- pital visits — always subject to careful restrictions — would seem a proper return and courtesy which the Hospital can make to the staff for their arduous and gratuitous services. To compel them to make their daily visits free lectures to such medical students as might choose to attend, would, on the other hand, seems to impose an ungracious and uncalled burden upon the physician, and inflict a positive injury upon the patient, and to be contrary to the usage of every large hospital, so far as can be ascertained, in the country. In accordance with the foregoing conclusions, the Trus- tees have unanimously adopted the following rules, in place of those formerly existing upon the subject : — Eepeal Rules 158-159-160, and substitute therefor the following, — No. 158. Members of the Surgical Visiting Staff may, on regularly appointed days, perform operations in the amphithea- tre, and members of both the Medical and Surgical Visiting Staff may likewise give instruction there in their respective departments; and for the purposes of instruction they shall, subject to such restrictions as the Trustees may deem neces- sary, have the privilege of introducing patients, provided that in every case the attending surgeon or physician shall 28 Boston City Hospital. certify in writing that the patient may undergo such exami- nation and treatment without detriment, and that the Super- intendent and the patient consent thereto. Due notice of the nature of such operations or instruction shall, so far as prac- ticable, be posted in the Lodge. No. 159. When the amphitheatre is so opened for opera- tions and instruction, physicians having received a degree of doctor of medicine, and students, of one year's standing, of any duly incorporated college or school of medicine or sur- gery, may be admitted in such numbers and on such regula- tions as the Trustees may from time to time determine. Whenever the operating surgeon or the physician shall deem a case improper for consideration, in the presence of students of both sexes, he may reserve such case for the close of his operation or lecture, and require the withdrawal of all male or female students, as the case may be. No female patient shall be taken into the amphitheatre without the attendance of a nurse (female), and no operation upon a female patient requiring the exposure of the genital organs shall be per- formed in the presence of male visiting students. No. 160. Physicians and medical students accompanying, on his invitation, a member of the staff in his hospital visitor examinations shall be limited to such numbers, not exceeding twenty, and shall conform to such regulations as the Trustees may from time to time determine, and shall further observe all such requests as to order and propriety as the attending physician or surgeon, or the Superintendent, may make. No. 160 A. The persons mentioned in the preceding rules shall be admitted only at the regular hours of operations, lectures, or visiting. Such persons shall, when required, show to the lodge-keeper cards of admission or of in- vitation issued in accordance with the above rules ; and all cards or invitations so issued may at any time be revoked or suspended by the Trustees. All such tickets shall be for- feited if transferred to or used by persons other than those Admission or Medical Students. 29 to whom they are issued. The Superintendent may compel the withdrawal of any person who violates the regulations of the Trustees or good order, or refuses to conform to the re- quirements of the physician or surgeon in attendance, and he shall report all such violations, and all breaches of the rules, to the Trustees. HENEY H. SPRAGUE, Secretary. APPENDIX. List of Hospitals from which Information has been Received. Albany Hospital and County Hospital, of Albany, N.Y. ; City Hospital and Freedinen's Hospital, of Augusta, Ga. ; Michigan State University Hospital, of Ann Arbor, Mich. ; Bay View Hos- pital, City Hospital, Hospital of the Good Samaritan, Maryland Woman's Hospital, Maryland University Hospital, Mt. Hope Retreat, Presbyterian Eye, Ear, and Throat Charity Hospital, and St. Agnes Hospital, of Baltimore, Md. ; Brooklyn Eye and Ear Hospital, and Long Island College Hospital, of Brooklyn, N.Y. ; Buffalo General Hospital, Buffalo Hospital of the Sisters of Char- ity, and St. Francis Asylum, of Buffalo, N.Y. ; Mary Fletcher Hospital, of Burlington, Vt. ; Carney Hospital, Children's Hospi- tal, Mass. General Hospital, Mass. Homoeopathic Hospital, and New England Hospital for Women and Children, of Boston, Mass. ; Augustana Hospital, Bennett Hospital, Cook County Hos- pital, Hahnemann Hospital, Mercy Hospital, Michael Reese Hos- pital, Presbyterian Hospital, St. Joseph's Hospital, St. Luke's Free Hospital, Women's Hospital, and United States Marine Hospital, of Chicago, 111. ; Cincinnati Hospital, Hospital of the Protestant Episcopal Church, Good Samaritan Hospital, Jewish Hospital, Ohio Hospital for Women and Children, St. Mary's Hospital, and St. Joseph's Private Lying-in Hospital, of Cin- cinnati, O. ; Charity Hospital and Cleveland City Hospital, of Cleveland, O. ; Arapahoe County Hospital, of Denver, Col. ; St. Mary's Hospital, of Detroit, Mich. ; Hartford Hospital, of Hartford, Conn. ; City Hospital, of Indianapolis, Ind. ; Mercy Hospital, of Iowa City, la. ; City Hospital and Sisters' Hospital, of Kansas City, Mo. ; Chy Hospital, of Louisville, Ky. ; Minnesota College Hospital, of Minneapolis, Minn. ; New Haven Hospital, of New Haven, Conn. ; Charity Hospital, of New Or- 32 Boston City Hospital. leans, La. ; Bellevue Hospital, Charity Hospital, Manhattan Eye and Ear Hospital, Mt. Sinai Hospital, New York Hospital, Pres- byterian Hospital, Roosevelt Hospital, St. Luke's Hospital, and Woman's Hospital, of New York, N.Y. ; Episcopal Hospital, Hos- pital of the University of Pennsylvania, Pennsylvania Hospital, Philadelphia Hospital, Philadelphia Hospital for Skin Diseases, Wills' Hospital, Women's Hospital and Women's Homoeopathic Hospital, of Philadelphia, Pa. ; Blessing Hospital and St. Mary's Hospital, of Quincy, 111. ; City and County Hospital, German Hospital, St. Luke's Hospital, and St. Mary's Hospital, of San Francisco, Cal. ; House of the Good Shepherd, of Syracuse, N.Y. ; Alexian Brothers Hospital, City Hospital, St. John's Hos- pital, and St. Louis Hospital, of St. Louis, Mo. ; City Hospital, of St. Joseph, Mo. ; St. Vincent Hospital, of Toledo, O. ; Colum- bia Hospital for Women and Lying-in Asylum, Eye and Ear Infirmary, Freedman's Hospital, Garfield Memorial Hospital, National Homoeopathic Hospital, and Providence Hospital, of Washington, D.C. ; City Hospital, of Worcester, Mass. Admission of Medical Students. 15 given, and, when announced, shall be punctually observed." (Chap. X., 10.) A limited list is kept of physicians and surgeons and of students, about seventy or eighty in number, all belonging to the regular profession, to whom the invitations to the instruction in the amphitheatre are regularly sent by postal cards containing lists of the operations. Practically, how- ever, no tickets being required for admission, all students appearing are suffered to attend. Few homoeopathic stu- dents attend, and the question of their admission has not been formally raised ; but it was said that they would not be admitted if the point of their homoeopathy were mooted. Woman students do attend in small numbers, frequently from one to six out of an attendance of two hundred, but it is understood that they present themselves before such attending surgeons as do not object to their presence, and do not attend when the attending surgeon does object to their admission, the staff of the hospital being divided in their opinion upon the subject. Instruction in the amphitheatre is almost entirely confined to the surgeons, one physician only giving such instruction, and that irregularly and to a small number of the students of the college with which he is connected as a professor. No students at all are allowed in the wards or in the Out- patient department, and medical instruction is accordingly confined to the amphitheatre. The Presbyterian Hospital is a large hospital, supported principally by the Presbyterian churches. In general no students are admitted to the wards, but if a member of the Visiting Staff should desire to take two or three students on his visit he would be expected to obtain special permission from the superintendent. A very limited number of students is sometimes invited by the attending surgeon to the operating room, but no gen- 16 Boston City Hospital. eral instruction is afforded, even by members of the staff who are instructors in the medical colleges to their own stu- dents. It was said that no homoeopathic students would be admitted to this hospital. Several years since women were admitted to operations by one surgeon ; but the practice quickly stopped from disfavor. The St. Luke's Hospital permits no instruction to stu- dents either in the wards or at the operations, the govern- ment of the hospital being opposed to clinics and affording no opportunity for them. A few physicians, and, perhaps, occasional students, may be invited to special operations. On one occasion only has a female physician been invited by an attending surgeon to an operation, and the affair created much opposition from other members of the staff and from the government. At the Roosevelt Hospital no general clinical instruction is given. Occasionally students are specially invited into the wards by the attending physician, but the practice is rare. Invitations are extended upon operating days to a small list of persons, principally physicians, made up by the staff and the superintendent. One of the Out-patient Staff, a relative of the founder, did institute a private course of clinics, using patients from the hospital, and to those female medical stu- dents were admitted. The action of the physician met with disfavor from other members of the staff, and from members of the governing board, and his course has not been repeated. At the Mt. Sinai Hospital, maintained by the Hebrews, but admitting patients of all sects and nationalities, no in- struction is given either in the operating room or in the wards, and a request for the admission of students was re- fused by the managers. Possibly a member of the staff may invite to his visit a student, male or female, but the action is not supposed to be known by the authorities. The Woman's Hospital admits to the operations in the amphitheatre physicians and surgeons, both male and female, COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28M 1 40) m too RA982.E65 C49 Boston. City hospital.