# A History of the Medical Department of the University of Pennsylvania/Chapter XVI

CHAPTER XVI.
CLINICAL INSTRUCTION.
It has been shown that clinical instruction was inaugurated in the Pennsylvania Hospital in 1766, by Dr. Bond, in connection with the establishment of the medical lectures of the College, At the time of the organization of the Medical Department, five of the physicians of the Hospital were Trustees of the College, and, well aware of the advantages of clinical teaching, they regarded the association of the two institutions as of the highest consequence to the success of the enterprise of establishing systematic medical teaching in the city of Philadelphia. Anterior to 1800, eight of the professors engaged in conducting courses of lectures on the several branches of medicine taught in the College or University had successively been elected physicians or surgeons of the Hospital. The instruction in this institution has been continued under the direction of medical professors, or of the physicians attached to it, to the present time, and has always been regarded as one of the privileges of students visiting Philadelphia.
As far as we have been able to ascertain, the mode of conducting the instruction in the Pennsylvania Hospital in early times was at the bed-side of the patient; the physician, in making his stated rounds of the wards, selecting such cases as he deemed most interesting or instructive, and especially dwelling upon their nature and treatment. For a large class this plan of procedure was attended with its disadvantages; the confusion of a crowded apartment; the possibility of only a ​limited number of students approaching the patient; the manifest danger of injury to those seriously ill who were the subject of remarks, or in close proximity at the time of their delivery; and the inability on the part of the teacher to discuss and illustrate particular diseases in detail for want of classification, were reasons for the abandonment of this method, and of substituting for it that of presenting the proper subjects of disease before the class in the amphitheatre, which had been arranged for this purpose, and more especially for the peform-ance of surgical operations in public.
To Dr. Benjamin H. Coates is the credit due of putting this method of demonstrating and of lecturing into operation in the Pennsylvania Hospital. He introduced it about the year 1834, and continued it afterwards during his connection with the institution. Dr. Wood, who succeeded to the winter term, as senior physician, on the resignation of Dr. Coates, in 1841, pursued the same method, in which he was joined by the surgeon, Dr. Randolph. It has been continued ever since, and has been extended during the terms of service, throughout the year, of all the medical attendants.
To another establishment must attention be directed as having conduced to the important purpose of training the younger members of the profession for their duties, and of affording facilities for instruction in clinical medicine. The Philadelphia Almshouse went into operation before the erection of the Pennsylvania Hospital, and the first physicians, of whose appointment to minister to the relief of its inmates we have a record, were Drs. Thomas Bond and Cadwalader Evans.
It is stated by Dr. Agnew, in his lecture on the Medical History of the Almshouse, that we may claim for that Institution the establishment of the first obstetrical clinic. “Students of good character were allowed to attend cases of labor, and the various stages of the process were explained to them by Drs. ​Bond and Evans, under whose personal directions these instructions were conducted as early as 1770, and, in all probability, much earlier, as may be inferred from the phraseology of the minutes touching this subject.
“In 1772 a proposition was made to the managers to extend the usefulness of the house by the admission of students, and an increase in the number of medical attendants. This proposition included an offer of gratuitous service, the institution being only at the expense of purchasing the medicines required for the sick” In March, 1774, an addition to the medical corps was effected by the election of Dr. Adam Kuhn, Dr. Benjamin Rush, Dr. Samuel Duffield (one of the first graduates of the College), Dr. Gerardus Clarkson, and Dr. Thomas Parke.
It must not be supposed that a uniform course of clinical instruction has been conducted in the Almshouse from the period alluded to. On the contrary, it appears from the records that the instruction was fitful and irregular, depending on a variety of circumstances, and much upon the opinions controlling the management with respect to its expediency, and hence we find that from time to time the admission of students was suspended.
When, after the evacuation of Philadelphia by the British, who had forcibly occupied the buildings of the Almshouse, affairs assumed a more settled condition, the desire for clinical instruction was rekindled. “In November, 1778, the subject was revived by the students present in the city. They presented a formal application to the physicians of the Almshouse for permission to witness the practice of the institution. Drs. Rogers and Leib waited on the Board of Managers in their behalf, and presented the importance of such a measure with much earnestness.” The application was at first refused, and then granted, but either from hostility on the part of the direction, or from other causes, it was of little avail.
In 1788, Dr. Samuel P. Griffitts and Dr. Caspar Wistar became physicians to the House, and, in 1789, Dr. William Shippen, Jr., was elected. At this time the proposition for ​facilities of clinical teaching was renewed, but was not received with favor, and, in a short time afterwards, all of the physicians resigned.
In 1795 Dr. Cummings again brought this vexed question to the notice of the managers, but “the proposition was promptly rejected upon the ground of such publicity being calculated to do harm to the sick.”
In 1797 Dr. John Church and Thomas C. James were chosen medical officers. These gentlemen were subsequently associated in teaching Midwifery. “In 1803 Drs. James and Church proposed to attend the Lying-in Ward, on condition they should be allowed to have one private pupil present at each case of labor. The application was granted, and much valuable instruction was communicated in this responsible department of medicine.” “The same year, on the 23d of March, Dr. Caldwell was allowed to introduce and instruct twenty, and afterwards forty students, during his stated visits to the medical wards, on the condition of his becoming responsible for their good deportment.”
“In November, 1805, through the efforts of Drs. James and Church, the Managers conceded the privilege to deliver clinical lectures to a class of students twice a week in the ‘Green,’ or ‘Dead House,’ during the winter season. Shortly after, Dr. Barton was permitted to give instruction to his class on the days of his regular attendance at the House. Every successive year now removed more and more the prejudices which had so long operated against the admission of medical students. The Managers were seized with an active desire to promote and foster a system which contributed so largely toward laying a solid foundation of medical usefulness.”
“Until October 25, 1805, no fee was demanded from those attending the instruction of the Institution, but, at the above date, a ticket was directed to be issued, signed by the ​President and Secretary of the Board of Guardians, at the price of eight dollars—two purchasing a perpetual privilege. The office pupils of the medical officers were free to attend without charge. In November, 1807, Dr. James was delivering lectures still in the Green Boom, and there the physicians continued to give clinical instruction until 1811, when the surgeons connected with the Almshouse asked for more suitable apartments in which operations could be performed, and thus remove from the ward a source of mischief to the other sick. To correct this evil, the Board had the building called the ‘Dye and Wash-House,’ carried up an additional story, fitted up as a lecture-room, with two adjoining wards capable of holding each twenty or thirty patients; and here were next delivered clinical lectures.”
“During 1813 the Managers, anxious to advance the reputation and popularity of the house, were induced to tender to every student taking its ticket the privilege of attending a case of labor; and to give the proposal greater publicity, it was by their authority announced in the public papers. This scheme of indiscriminate admission to the ward of the lying-in department brought out a minority protest.”
It appears that, by a rule of the house, a physician or surgeon holding a position of a similar kind in the Pennsylvania Hospital was not eligible to office in it. To this reference was made in the same report, and the wisdom was urged of selecting the “very best talent wherever found, and especially the propriety of seeking as many lecturers from the Medical School as possible.” The views thus presented were received with favor, the discriminating rule was rescinded, and a cordial ​understanding entered into with the Hospital. On the part of the University, the spirit exhibited by the Board of Guardians was reciprocated, and on Nov. 15, 1815, the following modification of the rules was enacted by the Faculty, with the sanction of the Trustees:—
“Resolved, that so much of the Bye-Laws as requires the students of medicine to attend the Pennsylvania Hospital, during one session at least, be altered by inserting after the word Hospital, the words, ‘or the City Almshouse.’”
In 1822 we find three of the Professors of the University in connection with the clinic of the Almshouse, having as their associates some of the most prominent members of the profession, among whom was Dr. Jackson. It appears that upon the reorganization, at this period, of the Board of Physicians and Surgeons of that institution, the system was introduced of delivering the clinical lectures regularly on Wednesdays and Saturdays in the lecture-room. To this the patients could be conveniently taken, either from the adjacent wards, or, when proper, from those at a distance. Systematic instruction in clinical medicine in the institution, indeed, dates from that period.
The importance of the Clinical School of the Almshouse to the interests of medicine, and the appreciation on the part of the students of the practical knowledge afforded by it, may be inferred from the fact that in ten years, between 1815 and 1825, eleven thousand one hundred and sixty dollars, in the form of fees of admission, had been received by the institution.
​In 1826 the Faculty applied to the Board of Trustees of the University for authority to employ an assistant to the Professor of Practice in the delivery of his clinical lectures, on the ground that the duties of the Chair were too onerous for a single individual. Whereupon it was resolved, “That the Professor of the Institutes and the Practice of Medicine have permission to employ an assistant in the performance of his duties at the Almshouse, in giving clinical lectures there during the present course, and no longer.”
In 1827, Dr. Jackson was chosen the Assistant to the Professor of Practice, Institutes, and Clinical Medicine, and from that time took an active part in conducting the clinics of the winter season, as well as in performing the duties devolving upon him during his own especial term. In 1832, Dr. Chapman resigned his position as Physician of the Almshouse.
The Legislature having passed the necessary law to enable the Board of Guardians of the Poor to erect new buildings for the accommodation of the indigent, this was carried into effect in 1830, and the Hospital Department, the first portion of the pile of buildings, afterwards completed on the west bank of the Schuylkill River, was in sufficient readiness upon the first visitation of the cholera, in 1832, to receive patients. The locality selected was at the time outside of the limits of the city, and in the district which was called Blockley; hence the title that was soon acquired of Blockley Hospital. Since the act of consolidation, as it has been technically called, by which the districts were united under the city government, the name of Philadelphia Hospital has been used to designate the establishment.
After the removal west of the Schuylkill, the numbers of the students attending the clinical lectures fell off. In 1834 measures were taken to secure their attendance and render it easy. Negotiations were entered into between the University and the Board of Guardians, and at a meeting of the Medical Faculty, held October 29th, it was ​“Resolved, That if the Guardians of the Poor will make arrangements to transport twice a week, for the four months directly ensuing, two hundred and twenty students to and from the Alms House to a convenient site in the city; should the number of students be less than that number, the Medical Faculty will pay to the Board the sum of three dollars upon each case of the deficiency.”
The proposition was accepted by the Board, and the students were conveyed in omnibuses.
In 1838, Dr. William Gerhard was appointed an Assistant to Dr. Jackson. The services of Dr. Gerhard were so highly appreciated by the class attending the clinic of the Blockley Hospital in the winter of 1840 as to lead to a series of resolutions expressive of approbation.
In 1840 Dr. Gibson withdrew from the service of the Hospital, and was followed, in 1845, by Drs. Jackson and Horner.
In 1841, the system of Dispensary Clinics was adopted by the University. The first that was instituted under its auspices was conducted by Dr. Gerhard and Dr. William P. Johnston, in the building of the Medical Institute, in Locust Street above Eleventh. It was there carried on until the commencement of the course of 1843, when it was transferred to the University building, under the immediate superintendence of the professors, with the assistance of those gentlemen. From that time to the present this mode of practical instruction has constituted a part of the regular course of medical teaching conducted by the University.
​In connection with the clinical service two rooms within the building were appropriated for the accommodation of patients requiring operations, who could not be immediately removed. By this arrangement the same attention, nursing, and care can be bestowed upon the subjects of capital operations as in a hospital.
With a view of completing the plan for clinical instruction, so as to give to it the greatest efficiency compatible with the progress of medical education, on October 4, 1845, it was
“Resolved, by the Faculty that a surgeon connected with the Pennsylvania Hospital, and whose duties there were performed during the session of the University, be requested to officiate as Clinical Lecturer on Surgery.”
This led to the creation of the Chair of Clinical Surgery in the University by the Trustees, and the appointment by the Board, in 1847, of Dr. Jacob Randolph to perform the duties of the office in the Hospital.
In 1848 Dr. Randolph died, and Dr. George W. Norris, who had delivered the course of clinical lectures under the auspices of the University during Dr. Randolph’s illness, was elected his successor in the professorship. Dr. Norris continued to perform his duties as Clinical Professor until 1857, when, upon being elected a Trustee of the University, he resigned.
The instruction in the Pennsylvania Hospital having now been fully organized, with regular lectures delivered throughout the year by the physicians and surgeons in attendance, and a similar system introduced into the Philadelphia Hospital, the office of Clinical Professor to the University has been abolished. Students have now the advantages afforded in the way of instruction by both these Institutions, which have occupied so important a position in connection with medical teaching; and also those afforded by the clinics in the University building.
The establishment of numerous hospitals of late years, both of a general character or devoted to special diseases, has greatly ​increased the sources of medical information, and opened a more extensive field for the cultivation of medical science to the young and zealous aspirants whose talents and energies are each year called into requisition to minister to the maladies of the inmates of these charitable institutions.
The hospitals of Philadelphia, besides the two large ones mentioned, are the Wills Hospital, for diseases of the eye and ear; St. Joseph’s Hospital, the Episcopal Hospital, the Preston Retreat for Lying-in Women, the Children’s Hospital, Howard Hospital, and some others lately organized.
* ↑ See Appendix G.
* ↑ Dr. Caldwell, in his Autobiography, states that “Dr. Rush prescribed and lectured to his pupils in the Pennsylvania Hospital twice every week during the season of the medical school, which extended from the beginning of November to the close of February. This was in 1796-97. ” p. 264.
* ↑ Lecture on the Medical History of the Philadelphia Almshouse; delivered at the opening of the Clinical Lectures, October 15, 1862, by Dr. D. Hayes Agnew, M. D. Published by request of the Board of Guardians. To this interesting and full account of that institution we are indebted for much of the information herein presented, where the Almshouse is alluded to.
* ↑ It is to be understood that this clinic was in a public institution. The private clinic of Dr. Shippen has been referred to in a previous chapter.
* ↑ Dr. Caldwell, in alluding to this in his autobiography, states: “The first course of clinical lectures in the Philadelphia Almshouse was delivered by myself, not long after the commencement of the present century, the precise year not being remembered (1803). I was then a member of the Faculty of that Institution, and continued my lectures annually for several years, until deprived of my appointment in it on political grounds.” p. 264.
* ↑ The Almshouse building was located on the square bounded by Spruce and Pine and Tenth and Eleventh Streets. Across the centre of the lot, from east to west, was the addition made which served for the purposes specified. It made the south side of a quadrilateral; the main building facing on Spruce Street, and on the sides extending back to the new erection. In the centre was a hollow square, consisting of spacious courtyards on the sides, and a small garden between them. To the south of the entire building, as thus arranged, between it and Pine Street, was a vegetable garden. At one time the small garden was used by Dr. Wm. P. C. Barton for botanical purposes. In its centre was a summer-house that had been carried in the Federal Procession.
* ↑ In 1822 the Board of Physicians and Surgeons consisted of Drs. Chapman, Gibson, Horner, Jackson, Joseph Klapp, J. K. Mitchell, Richard Harlan, J. V. O. Lawrence, and John Rhea Barton. Dr. Lawrence died that year, and was succeeded by Dr. Hugh L. Hodge.
* ↑ Report of the Clerk of the Almshouse to the Dean of the University— Minutes of the Faculty, May 14, 1823. This would give an average of 139 students annually. In 1830 the number was 185, and in 1834 it was 220. The pupils of both Schools, the University and Jefferson Medical College, were then in attendance. In 1835, Dr. Joseph Pan coast and Dr. Robley Dunglison, were members of the Medical Board of the Almshouse. It is to be recollected that the medical students in the city were divided between the two hospitals.
* ↑ The duties performed by Dr. Chapman were daily lectures in the University upon the Practice of Medicine, and two lectures additional a week in the Almshouse. He consequently lectured twice in succession on two days of the week.
* ↑ Minutes, Dec. 5, 1826.
* ↑ For an account of the changes which subsequently occurred, and the policy pursued, we must refer to the pages of Dr. Agnew’s Lecture; it is sufficient here to remark, that, after a trial of various schemes for the management of the institution, with the appointment of a chief resident physician, and, in 1855, of special lecturers on medicine and surgery, there was a return, in 1859, to the original plan of a Board of Physicians and Surgeons, upon whom devolved the care of the sick as well as the instruction of pupils. Attendance has been made free to all medical students, who, aided by the facilities of attendance afforded by the street cars, now freely avail themselves of the excellent clinical teaching conducted in the establishment. See Appendix G. for list of the Professors who have served in the Almshouse.
* ↑ This method of clinical instruction was first adopted on the organization of the Jefferson Medical College, in 1824, at its building in Prune Street. The history of that School has been written by Dr. J. F. Gayley.
* ↑ Dr. Randolph had previously accepted the invitation of the Faculty to deliver the lectures on Clinical Surgery.
* ↑ An interesting Memoir of Dr. Jacob Randolph was read before the College of Physicians of Philadelphia by Dr. George W. Norris.