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FNIVERSITY OF TORONTO. 
 
 REPORT OF THE 
 
 STAHDIHG GOllITTEE 
 
 ox THE 
 
 FACULTY OF MEDICINE 
 
 ON THE SUBJECT OF 
 
 HOSPITAL FACILITIES 
 
 1892. 
 
 ADOPTED BY THE SENATE, JUNE 3ud, 1892. 
 
 TORONTO: 
 ROWSELL & HUTCHISON, UNIVERSITY PRINTERS. 
 
 1892. 
 
1292. 
 
 The Select Comniittee on the Medical Faculty beg to report with reference to 
 Hospital Facilities as follows : — 
 
 1. Pursuant to the 34th paragraph of the Re;5ort on Re-organization, the subject 
 of obtaining, i*' possible, fnrtlier facilities in connection with Clinical work at the 
 Hospital was referred to us for further inquiry, negotiation and report. 
 
 2. We invited the opinions of the members of the Faculty, and obtained such 
 further information as we could ; and came to the conclusion that it is very important, 
 in the interests of Medical education, to obtain tliese facilities. 
 
 3. Cognate subjects were almost necessarily embraced in the inquiry, and upon the 
 more pressing of these we also reached conclusions. 
 
 4. We embodied our views in a Minute, which we communicated to the Board of 
 Trustees of the Toronto General Hospital on 30th May. 
 
 5. It appciirs to us important that the judgment of the Senate should be taken 
 upon the serious questions raised in this Minute, which accordingly we transmit as part 
 of this Report; and we recommend that it should be printed and distributed for 
 circulation, with a view to action by the Senate. 
 
 EDWARD BLAKE. 
 
IMINUTE OF THE SENATE COMMITTEE ON THE MEDICAL FACULTY 
 
 OF THE UNIVERSITY OF TORONTO ON THE SURJECT 
 
 OF HOSPITAL FACILITIES. 
 
 to 
 
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 ch 
 It, 
 
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 'or 
 
 1. Tlie Senate of the University of Toronto, in connection witli tho •(. -orguniziition of 
 its Mediciil Faculty, has referred the question of furtlier facilities for Clinical instruction 
 at the Toronto General Hospital for inquiry, negotiation and report to its Select Committee 
 on the I'^iculty of Mcdicini', composed of Tiie Honorable Edward Rlake, Chancellor of the 
 University; William Mulock, M.R, Vice-Chancellor ; Sir Daniel Wilson, President; The 
 Hononihle Chancellor Royd ; The Honorable Mr. Justice Falconbridge ; The Reverend 
 Principal Caven ; The Reverend Principal Sheraton; W. T. Aikins, M.D., Dean of the 
 Faculty; and N. W. Hoyles, Q.C. 
 
 2. The Committee has obtained tlio opinions of the members of the Faculty, and such 
 other information as was accessible, and has cjirefully considenid, in their ditlerent asjiects, 
 the various important questions involved ; and it now begs respectful ly to submit,, for the 
 consideration of the Board of Trustees of the Toronto General H<,s[)ital, the result of its 
 4leliberations, in the hope that the views advanced may receive their favourable consideration. 
 
 BEARING OF CLINICAL INSTRUCTION ON EFFICIENCY OF HOSPITAL. 
 
 3. The Committee has come to the Conclusion that the interests of the Hospital, the 
 welfare of the patients, the advancement of knowledge and the improvement of Medical 
 education will all be served by an increase in the facilities for Clinical instruction. 
 
 i. The most famous and most frequented Hospitals in the world are ju.st those where 
 the most Clinical teaching has been done, and the best use has been n.ade of the opportunities 
 ])resented. 
 
 Sound, thorough and extensive Clinical teaching gives a Hospital standing in the 
 profession, and reputation among the people, who realize that it is from the most thorough 
 and systematic investigation of their maladies ^hat they may expect the greatest benefits. 
 
 Such 'iivestigation is profitable to the patient as well as advantageous to the cause of 
 Medical science and instruction. 
 
 5. Patients recognize the value of attendance by Clinical instructors, who.se double 
 duty, as visiting I'hysicians or Suigeons and as Clii.ical teachers, imposes on them doubled 
 res|)onsihilitics for frequent and regular attendance, for great care, for thoroughness of 
 examination into each caso, and for repeated observation of its progress. Accordingly, 
 patients frequent Hospitals in which the.se elements are marked ; and, when in Hospital, 
 they j)refer to be placed under the care of Physicians or Surgeons who, being also (Jlinical 
 instructors in Medical Schools, are known to pay special attention to the.se points. 
 
 6. E.vperience shows that very generally the jiatient rather enjoys than objects to the 
 examinations. Of course rare exceptions may be found, both in the case of patients who 
 object and in the case of instructors whose manner may not be as wise or kind as it should 
 be ; but as a generally prevailing iiile no such difficulties exist, and the patient is found 
 willing and anxious to forward the examinations. An eminent member of the staff, who, 
 not being detailed for active duty, has recently had in the Hospital none but private pay 
 patients sent in by him.self, and has been obliged to depend on these as the subjects of his 
 l)edside lectures, re[)orts to the Couniiittee tliat, even in these cases, in which obviously 
 there was the greatest probability of difficulty, he has nut met with the slightest objection 
 on the pai't of anyone to becoming the subject of Clinical instruction. In the general 
 wai'ds he and otheis of the staff have repeatedly observed that the patients themselves take 
 pleasure and interest in the process, and objection has been raised but very rarely. 
 
 7. It is not suggested that any individual patient should be examined more frequently 
 than is proper, or that any plan should be adopted involving excessive examination ; on 
 the contrary, it is believed that the suggestions to lie made would greatly improve the 
 position and prospects of the patients ; because the reduced numbers in each class would 
 tend to obviate excitment on the part of the patient, and to diminish the number of indi- 
 vidual examinations on any one occasion ; while the other changes to lie proposed would 
 result in greater regularity and continuity of attendance on the part of a visiting Physician 
 or Surgeon ; and the whole effect would Ije to i)romote the general interests of the Hospital. 
 
BEARING OF CLINICAL IN.STUHCTION ON MEDICAL AND SURGICAL 
 
 KNOVVLEDGK AND TEACHING. 
 
 8. Looking at tho subject from tlie point of view of the udvaiuomcnt of Mediciil anil 
 Surgical science and education, it must be universally recognized that no greater boon lo^ 
 humanity can be conceived than such advancement ; and it siiould be an object dear to the 
 heart of every philanthropist to make all reasonable use of any opportunities available to 
 that end. 
 
 9. The Toronto General Hospital, a public institution endowed and maintained at a 
 large public charge, hikI served gratuitously by eminent practitioners, a place where nume- 
 rous patients thus receive, without payment, accommodation, remedies, treatment and 
 advice, affords tho great opportunity in this matter for the Province of Ontario ; and all 
 parties, patients included, should, and do, recognize the projjriety of utilizing this 
 opiwrtunity. 
 
 10. It is now generally conceded that Clinical teaching is perhaps tho most important 
 element in Medical education. 
 
 11. But adeqvuite Clinical teaching demands very frequent contact of the student witli 
 the jiatient, under the eye and ear of a trained instructor. Each sense nuist be trained to 
 the interrogation of the processes of natuie ; and also to the use of instruments of precision, 
 penetrating still further than can be accomplished by the unaided sense. The bedside is. 
 the School. The faculties must bo constantly exercised in the processenof observation and 
 education. The mystery in which the object is involved is great ; so great that the- 
 student must develop or acquire the jiower '' to track huggestion to her inmost cell." 
 
 12. Again, he must have the opportunity to study Pathology at the btd.side; thus 
 to watch the course and natural history of disease, and to recognize tho mode of cure ; 
 and so to become a Physician, a Physiol oyist of disease : and to kai n the means devised 
 by art and sanctioned by expeiience to deal with tho clifliculties which the case presents. 
 
 13. To achieve these ends we should aim at the creation of small and manageable 
 classes, at the same bedside, day after day, under competent supervision, slowly grinding 
 ilown the phenomena of aberrant physiology and disturbed function to a form assimilable 
 by the young observer. Later, when experience has begun to communicate its power, the 
 student may be taken more lapidly from case to case, reading them as he runs, by means 
 of his improved capacitj', per.spicuity and sagacity. Thus the slow action of observation, 
 memory, comparison and education will evolve a method of unconscious cerebration, too- 
 rapid for ajjjireciation and to subtle for analysis. 
 
 14. To accorap]if.h these desirable results numerous Clinical instructors are required ;. 
 since other things being equal, the snuiller the class the better the opportunities. Large 
 classes crowd around a bed, rendering effective instruction difficult for all, impossible for 
 some ; incommoding, obstructing and distracting one another ; and many, [lerhaps the 
 majority, never really seeing the case more than once. 
 
 COMPARATIVE FACILITIES. 
 
 15. It may be, indeed it has been suggested that the facilities at present given for- 
 Clinical instruction in the Toronto Hospital aie equal to those which exist elsewhere. But 
 this pro[)08ition will not stand the test of examination ; and examination is instructive,, 
 because it shows the system which is found most advisable, alike in the interest of 
 hospital, patient, and school, in the most famous and prosperous institutions in the world. 
 
 UNITED STATES. 
 
 16. For this purpose we may eliminate the great bulk of the Hospitals of the United 
 States, with the Clinical facilities in many of which our own, however inadequate, compare 
 favourably. It is not to the general methods of ihe States we should look. The general 
 course of Medical education there is one of two years ; and a three years' course exists only 
 in some, and a slowly increasing number of Colleges. So short a couise does not allow tlie: 
 
time necpHSfiiy for extensivf) Clinicivl work ; and great fucilitios consequently aro not 
 <leniaiicled and could not be nUlixcd. 
 
 17. But it is to bo observed that in somo o' tlie endowed Universities and Collogcs 
 ■of the States a wholly difftsrent condition obtains, sinro some students there have largely 
 increiiHed and most valuable opportunities by means of Hospital residence and postgradu- 
 ate work. 
 
 18. And probably in Pennsylvania, and certainly in Harvard Medical School, the 
 Clinical instruction is very much more etlicient than jjenerally prevails. 
 
 In Harviii-d School the teaching in Clinical Medicine and Surgery is given in the wards 
 ■of the M.issachusetts General Hospital, and of the Boston City Hospital, by numerous 
 Professors, Assistant and Associate Professors, Instructors and Assistants, ten of whom go 
 •<laily around the wards of the General Hospital with the students, bringing the latter into 
 direct contact with the patients, and giving good opi)ortunity for ac(uiiring practical 
 knowledge. 
 
 One-half of each year's class of students goes around the wards daily for two years, 
 <;ach student thus getting bedside instruction three times a wei^k for an eight, months' 
 session, making about 100 Clinics in each year in General Medicine and Surgery e.xclu8ive 
 of the specialties. 
 
 19. So far as the above Hospital staffs are concerned, they are composed from Harvard 
 Medical School Faculty as follows : — 
 
 
 No. OF Inpatients, 
 1890. 
 
 PlIVSICIANS. 
 
 SUROKONS. 
 
 
 Professors. 
 
 Assistants. 
 
 Professors. 
 
 Aagista&ts. 
 
 MASSACIinSETTS GENERAL 
 
 Boston City 
 
 3,381 
 6,853 
 
 3 
 2 
 
 1 3 
 
 (For OtU -patients.) 
 {■!) 
 
 2 1 
 
 3 
 
 (2) 
 
 
 
 Totals 
 
 5 
 
 3(?) 
 
 4 
 
 10 
 
 
 
 
 These staffs serve throughout the whole year. 
 
 20. It will be observed, therefore, that the principles of Assistants and of continuous 
 service, hereafter pressed, seem in this case to be applied. 
 
 GREAT BRITAIN. 
 
 21. Turning, however, to Great Britain, our facilities do not compare favourably with 
 those of any of the great Hospitals connected with Medical Schools. 
 
 22. It is believed that in all these, the organization differs materially from that in 
 Toronto. Omitting for the moment any questions connected with the House or Resident 
 staff or other subordinates, and confining ourselves to the visiting Physicians and 
 Surgeons, the general rule is to appoint on the visiting stafT not only Chiefs, but also 
 Assistants; and to keep on duty both Chiefs and Assistants for the whole year, with the 
 exception of the months of July and August, when the Chiefs are relieved. 
 
 23. The Assistants, besides taking independent charge of the outdoor patients, as 
 does the outdoor staff in Toronto, also take charge of the indoor patients during the 
 summer months, and also, with the consent and on the vesponsibility of the Chiefs, during 
 any occasional absences of the latter. They further with the like consent and responsibility, 
 attend the cases of such patients as they may send into the wards of the Chiefs, and 
 engage in Clinical instruction on some of the cases under the care of Chiefs. This system 
 ^ives to the patient the benefit of continuous attention by the same Physician, and of 
 
6 
 
 conipcttnit earo in ciiho of iihsenco ; wliihi it inoronHos the number of Clinical instnictors 
 and so affords more tl<orou<;li teacliin^^ to Hitiulier olnHsos, not merely witiiout detriment' 
 bnt to the advantajije of the j)ati»)nt, 
 
 24. The rp.sult of the yeno'iil system on the cliaracter of the r.taff is excidlont. 
 
 In the great London IIoHpitalH the Ci'ief goiicrally ri.scM to his higii grade by j'assii.ii 
 Hucccssfully through tlic! lower grades of s^uvico, for example, those of Clinical Tutor ai, I 
 AsHlstant. Ir. these grades he must prove himself worthy against numerous competitors, 
 by hard work, and by a long record as ,ui observer and investigator in Medical Hcience : 
 and he generally attains the suiiiiuit af'er the prime )f life, when his name has already 
 lM3come widely known wherever jMeilicai l{e^.earch is noted. Thus patients obtain the be.»t 
 and ripet^t skill and experience in the world ; while students must profit by the teaching 
 of men who have spent perhaps twenty oi thirty y(;ars in the various grades of Clinical 
 work, and have provcnl their right to their posts, as excellent teachers and reliable 
 investigators and observers. 
 
 COMPARATIVE TABLEH. 
 
 25. The following table shosvs the munber of inpatients and the number of chief 
 and of assistant Physicians and .Surgeons in several famous Hospitals in London, as 
 contrasted with the number in 'i'oroiito ; and it is to bo remembered that tJiese numbers 
 do by no means adequately represent the facts, because of the continuous attendance on 
 duty in London, as contrastcJ with the intermittent attendance prescribed in Toronto, 
 where the system is that each visiting niembci' of the staff goes on duty only every 
 alternate thres months. It will be seen that, taking into consideration this difference, 
 which practically halves, for comparative purposes, the Toronto figures, the comparison i» 
 decidedly unfavourable to Toronto. The table does not include those engaged in Obstet- 
 rical, Gyntecological and ocher special departments, in which respects the London Hospitals 
 have on the whole the ad vantage ; nor does it include the number put on the consulting 
 staff, who are for all practical purposes shelved, and are not to be taken into account : — 
 
 Hospital in 
 
 No. OK 
 
 Inpatiknts. 
 
 No. OF Physicians. 
 
 Total. 
 
 No. OF SUROEONS. 
 
 Total. 
 
 LoNnoN. 
 
 Chief. 
 
 Assiataut. 
 
 Chief. 
 
 Assiataut. 
 
 Guvs' 
 
 5.828 (in 1889). > 4 
 
 4 
 
 •2 
 1 
 
 4 
 3 
 4 
 4 
 2 
 
 8 
 7 
 11 
 8 
 6 
 8 
 8 
 6 . 
 
 4 
 5 
 (i 
 4 
 3 
 5 
 4 
 4 
 
 4 
 2 
 3 
 4 
 3 
 5 
 4 
 2 
 
 g 
 
 University College . 
 London Hospital . . 
 
 Middlesex 
 
 St. Mary's 
 
 St. Bartholomew's.. 
 
 St. Thomas' 
 
 St. George's 
 
 2,701 (in 1888).... 
 8,2G8(inl888).... 
 2,819 (in 1888).... 
 3,451 (in 1889).... 
 6,997 (in 1890).... 
 4,699 (in 1889).... 
 2,500 (about ?).... 
 
 5 
 10 
 4 
 3 
 4 
 4 
 4 
 
 7 
 » 
 8 
 (5 
 lO- 
 8 
 
 Toronto General , . 
 
 3,385 year ending 
 Sept. 30, 1891 
 (according to 
 Official report). 
 
 Or for comparative 
 purposes (each 
 servmg half time) 
 
 For half time. 
 Toronto Univ. 2 
 
 Trinity 2 
 
 Outside 2 
 
 Total. 
 - 6 
 
 < 
 
 3 
 
 For half time. 
 Toronto Univ. 2 
 
 Trinity 2 
 
 Unconnected 
 or outside. . 2 
 
 Total. 
 - 6 
 
 3 
 
 
 
 
 
2o. But oven iliHregnnling tho ward work of AHsistants altogotlior, and liiwinjj; rogani 
 to the fact ulrwidy Htatcd that tho nunihnr of Ohiofs in Toronto on duty in tho wiird.s at 
 any one tinio i" only hulf tho Htall' tlio coinparison as to th;) in(l'> ir stall" in Moilicinn and 
 Hurgory n diains unfavouralilo, as shown by tho following tal)ln of Ilospitaln, with a 
 Koinovi-hat aniilogoun number of ward |)ati(?nts : — 
 
 Hospital. 
 
 No. OF VVahu Patienth. 
 
 'I'oronto 
 
 Middlesex 2,810 . 
 
 University CoUego 2,701 
 
 St. Gf orgo's 2, oOO ? 
 
 St. Mary's i 3,4.''.J . 
 
 3,S0O (Comparative 
 ouch half time) 
 
 Average for four London Hospitals ' 71(1. . . 
 
 Average for University College Hospital 540 .. . 
 
 Average fcr Toronto (ieneral Hospital ! i ,100 . 
 
 SiTHOEONS. 
 
 3 
 4 
 
 r> 
 
 4 
 
 27. Although tho tables aheady given suflleiontly establish tho widcs application of 
 the principle of giving Assistant Physicians and Surgeons to tlio Chiefs, yet it may be well 
 to add tho further proof cont-vined in the following table, wliich, with those in the preced- 
 ing statement, is believed to represent all the great British Hospitals, having Medical 
 Schools attached. 
 
 Hospital. 
 
 P11Y.SICIANS. 
 
 Chief. 
 
 ^Edinburgh Royal Infirmary 
 Glasgow Royal Infirmary . , 
 Glasgow Weetern Infirmary 
 
 Charing Cross, Loiuion 
 
 King's College, London 
 
 Westminster , 
 
 Assistant. 
 
 SU KG EONS. 
 
 Chief. 
 
 Assistant. 
 
 28. It may be proper here to note the special circumstances in connection with the 
 London Hospital, in which the figures unexplained would convey an erroneous impression. 
 In the London Hospital no less than five of the ten Chief Physicians attend to the out- 
 patients as well as to ward work ; and one of the six Chief Surgeons is in the same posi- 
 tion ; so that the organization of this institution is exceptional ; half of the physicians and 
 one of tlie surgeons filling the double function of Chief and Assistant. 
 
 CONTINENT OF El ROPE. 
 
 29. Further illustrations may, it is believed, be oLLained from tlie great French and 
 German Hospitals. 
 
 30. For example, in the Paris Hospitals, which are under the control of the " Assist- 
 ance Publique," besides the Professors, Prosectors, Internes, ami Externes (the latter being 
 
8 
 
 "by aj.pointnieiits of at lea^t three years), there is an officer corresponding to the Engliuh 
 Assistant Physician or Surgeon, designated "Chef do Clinique," assigned to each Professor. 
 The " Chef de Clinique " does much Clinical teaching in the wards and elsewhere on the 
 cases of the Professor. 
 
 31. Again, in the Vienna Hospital, the Committee is informed that the Hospital 
 attendance and instruction is carried on by three classes : the Professor, the Privatdocenten 
 (appointed and paid by the University on the nomination of the Professor), and tirst, 
 second and third Assistants, appointed by the Professor. 
 
 Ward treatment and teaching, ae well as outpatient work, is done by all three. But 
 the main part is done by the latter two classes, under the direction of the Professor. 
 
 32. Agiiin, a case is reported to the Committee showing that in Strassburg the A.ssis- 
 tant gives Clinics on his Professor's patients in his wards. 
 
 ■ft 
 
 OPINIONS AS TO COMPA.E.ATIVF CONDITIONS. 
 
 33. It is stated that, when the graduates of Canadian Schools attempt competition in 
 tl"3 British Schools, they .".re found to compare favourably in Medical book work and the- 
 oretical knowledge ; but that when tested in practii .1 Clinical work, they fall behind men 
 far their inferiors iii the other branches. This is due to the superiority of the British 
 methods and facilities the application of which is suggested. 
 
 34. One of the Profesrors of the Faculty reports that having, after his course in 
 Tor»,.:to, spent a considerable time in London Hospitals, mainly at King's College, Middle- 
 sex, TJniveisity College, St. Bartholomew, London and Brompton Hospitals, and having 
 also spent a considerable time in Strassburg, he found that tLa facilities available in the 
 Toronto Hospital were far inferior to those f iijoyed by English and German students. 
 
 Though a total strangei-, without any introduction to a teacher, he was able to obtain 
 much more satisfactory instruction there than here ; and this not mainly because of the 
 superiority of the Clinicians, but beciuse of the better facilities and superior system which 
 have been described. Similar views have been expressed by other members. 
 
 35. It may be added that we understand our view that the present facilities are not 
 adequate, that they do not compare favourably with the British facilities, and that some 
 improvement in this direction should take place, to be concurred in generally, indeed all 
 but unanimously, by the members of the Faculty concerned in general Clinical teaching. 
 
 DEDUCTIONS. 
 
 3o. The fact would seem to be that, in the great and well regulated Hospitals to which 
 we should look for example, the general scheme of organization embraces a staff of Assis- 
 tant Piiysicians and Surgeons, in addition to the staff of Chief Physicians and Surgeons, 
 and that in many cases the number of Assistants is equal to that of Chiefs. 
 
 37. It would also seem to be the fact that in those Hospitals the term of duty of the 
 staff is continuous, with the exception of the summer months, durinj; which the Assistants 
 are in charge. In truth so far as we can learn the Toronto system of halt time is without 
 noted precedent. 
 
 38. It would also seem to be the fact Lliat the facilities thus obtained for clinical ward 
 teaching in frequent small classes are great, and far superior to those obtained in Toronto. 
 
 39. It is impossible to ovtsr-rate the importance of these facts, as furnishing strong 
 and convincing evidence of the best course as indicated by the light of experince. 
 
 40. It is submitted that the Toronto (general Hospital should no longer be an. excep- 
 tion to, but, on the contrary, should be organized in conformity to the general principles 
 thus established, with duo regard to any special conditions. 
 
ADVANTAGES TO PATIENT. 
 
 4!. The advHiitages to the patient are obvious. Tlie change would give to the 
 patient th<. continuous services of the Chief Physician or Surgeon to whom Jiis case hud 
 been assigned, sind would avoid the transfer of his case on the e::|jiration of the three 
 months' term of duty at present prescribed. 
 
 42. It would give the i)atient the further advantage of the services of a recognized 
 Assistant, working und<?r, and in conn^^ction with the Cliicf, che attendance of which 
 Assistant would be available in the occasional absence of, and also, on emergency oi nnder 
 special circumstimces, in conjunction with the Chief. For example, it would be the duty 
 of the Assistant Surgeon to assist the Chief at each operation. 
 
 43. Tlie patient would gain also ; because the system provides, as ali-eady shown, for 
 the continuous training of Assistants ready and competent to take the place of Cliiefs upon 
 their retirement. 
 
 44. A further gain would follow from the fact that, ^he term of duty being continuous, 
 the number of beds in charge of one Chief at one time, would of course be diminished, and 
 thus more time would be available than at ])resent for the discharge of the duty of the 
 visiting Physician or Surgeon, on occasions when an accumulation of serious cases requires 
 prolonged attention. 
 
 45. The Chiefs being responsible for the work and conduct of the Assistants, their 
 appointnien' need not entail serious added trouble to the Hospital authorities. Nor can 
 ^iny reasona: -i suggestion be made of injury to result to the patients from the adoption of 
 the plno 
 
 ADVANTAGES TO MEDICAL EDUCATION. 
 
 ■ 
 
 46. Turning to the advantages to Medical education, they would be very great. 
 
 47. The distinction as to the entire relief of Chiefs for a considerable period during 
 summer has less application here; and obviously the Clinical teaching and ward work of 
 the Assistants is required during the School Session. 
 
 48. The Assistants, as properly recognized ofBcials, would thus take throughout tli i 
 3 ear Clinical and Tutorial ward classes of small numbers ; dealing with the patients by 
 ■the permission and under the responsibility of the Chiefs. 
 
 49. The increased number of instructors would thus, without increasing the number 
 of examinations in any individual case, increase in a far greater degree the efficiency of 
 the instruction. 
 
 50. The Assistants would, in case of tlie unavoidable absence of the Chiefs, hold the 
 Chief's Clinics, thus insuring an uninterrupted course of study. 
 
 51. It has been further suggested that the Assistants might, to the advantage of all 
 interests, with the consent and under the responsibility of the Chiefs be given charge of 
 outpatients sent into the wards by themselves, and of a small number of beds; thus per- 
 fecting more rapjilly their training in every capacity, and enabling them to give Clinics on 
 their own patients, a matter very important, especially in Surgery. Tlii" coui-se is, it is 
 believed pursued in some of the great Hospitals. 
 
 52. The Assistants, who would in fact fill the place of the outdoor staff, would of 
 courac, take charge of the outdoor branch in all its departments as at present, assuming 
 in addition the suggested duties. 
 
 GENERAL RESULT. 
 
 53. The general result aimed at is that the University Chaira, whose subjects are 
 ■capable of Clinical illustration, should be represented on the Hospital Staff, and have each 
 a certain number of assigned beds ; that the representatives should hold their posts con- 
 tinuously through the year, and control the Medical or Siirgioal, a,8 .veil as the Tutorial 
 
10 
 
 work connected with the beds assigned to them ; that for each full or Chief Physician or 
 Surgeon on the visiting stafl' there shmild be an Assistiint, taking his independent part in 
 the dischaige of the outdoor work, Medical or Surgical and Tutorial ; and also, with the 
 consent and under the responsibility of the Cliief, assisting in the ward work in connection 
 with the Chiefs beds, giving Clinical instruction to limited classes, and fui^her discharging 
 the Chief's duties, Medical or Surgical and Tutorial, on occasions of unavoidable absence. 
 It is believed that thus there would be secured a greatly improved, continuous and uniform 
 system of attention to ])atients, as well as of instruction to students. The special circum- 
 stance that the Toronto General Hospital has a connection with two schools renders it 
 obviously convenient that the plan aJopted should be to allow an asssistant from each 
 school to each Chief in Medicine or Surgery from that School. 
 
 WORKING OF SCHEME. 
 
 54. The general subjects most pressingly requiring further Clinical facilities are those 
 of Medicine (includir^ Therai)eutics and Pharmacology) and Surgery (including Pathology); 
 and by the adoption of the proposed system of Chiefs and Assistants (the members of the 
 outdoor staff" filling the position of Assiiitants), these subjects can, so far as the question 
 of staff is concerned, be provided for without any serious or inconvenient change or 
 addition. 
 
 55. For example : the application of the proposals of the Committee as applied to the 
 University, assuming the reappointment of the present Hosi)ital staff, would result as 
 follows : — 
 
 MEDICINE. 
 
 Ward or Chief. Outdoor and Assistant. 
 
 Prof. Graham. Lecturer W. P. Caven. 
 
 Prof. McPhedran. Prof. J. M. McCallum. 
 
 SURGERY. 
 
 Ward or Chief. 
 Prof. Macfarlane. 
 Prof. Cameron. 
 
 Outdoor and Assistant. 
 
 Prof. Peters. 
 Prop. Primrose. 
 
 56. It will thus be observed that, with the adoption of the principle of Assistants, 
 the addition of a single officer to the University part of the outdoor and Assistant staff 
 is all that is required to carry out the scheme. 
 
 THEATRE LECTURES. 
 
 67. It is sometimes suggested tliat the theatre lectures on ])atients may be made 
 more frequent, and would prove an efficient substitute for the bedside teaching ; but it is 
 submitted that, however useful within their own important sphere such lectures may be, 
 and undoubtedly are, yet experience does not establish their efficacy as such substitute ; 
 but shows that the bedside teaching with small classes is the ])lan to which attention may- 
 be directed most profitably, and with results not otherwise attainable. 
 
 OUTPATIENT CLINICS. 
 
 58. It is also sometimes suggested that the additional development of instruction in 
 connection with the cases of the outpatients furnishes a means for avoiding furthei' 
 Clinical ward teaching ; but, though this teaching is in some aspects very valuable and 
 instructive, yet it cannot fill the void. 
 
 59. The outdoor Clinic is not the appropriate means of giving such instruction as 
 Clinical ward teaching affords, because, being open to all students of all schools, it is very 
 much crowded, quite too crowded for effective detailed instruction on many subjects of 
 
11 
 
 investigation ; because the numbers of patients are so great that expedition in treatment 
 is necessary, and detailed information cannot be fully given ; and because, each menibcf 
 seeing jmtients only one day in the week, a continuous course of instruction either by the 
 same instructor or on the same patient is impossible. 
 
 60. The suggestion has been made, with a view to limit ward teaching, that the 
 outdoor department might be systematically supplemented by means of patients bi ought 
 into the department from the wards. This has been tried but without encouraging 
 results. 
 
 61. The patient arranged for may be wanted at the time by the indoor Physician ; 
 or he may have become too ill to be taken out of the ward ; but worse than this, the 
 patient not having been under the immediate care of the Instructor, the chances are 
 against his being sufficiently familiar with the circumstances to warrant an attempt to 
 instruct ; and in fact this method has on past occasions done harm rather than good to 
 students. 
 
 QUESTIONS ARISING OUT OF THE RELATIONS TO THE HOSPITAL OF 
 
 DIFFERENT MEDICAL SCHOOLS, AND OF PRACTITIONERS 
 
 NOT ENGAGED IN TEACHING. 
 
 62. It is believed that as a rule the gieat British Hospitals to which reference has 
 been made are connected each nth a single medical school, and that their staff is composed 
 of members of the Faculty of that school. 
 
 63. The Toronto Hospital differs, in the resjject that it has in a sense relations with 
 more thatj one school, and that its staff is composed, net merely of members of the 
 Faculties of both schools, but also of practitioners not engaged in teaching. 
 
 64. These differences give rise to some considerations, which must be met, but which 
 do not, in the view of the Committee, interpose serious obstacles to the improvements it 
 suggests. 
 
 65. While it is obvious that the limitation of the Hospital staff to teachers would 
 enlarge, in respect to both teachers and subjects, the facilities for Clinical instruction, yet 
 the Committee has not thought it well at this time to suggest the adoption of any such 
 rule. It understands that the Trustees some years ago decided on the present plan in this 
 legard ; and its effort has been to devise a means for improving the Clinical facilities with 
 as little disturbance as possible of the existing arrangements. 
 
 66. As to the relations of the two schools to the Hospital, the Committee has been 
 informed that previous suggestions for an increase of the members of the staff connected 
 with the Faculty of Medicine of the University, and occasional visits to the Wards for the 
 purpose of Clinical instruction by members of the Faculty on the outpatient staff, have 
 been objected to by or on behalf of the Trinity College Medical School. 
 
 67. The Committee disclaims any desire to interfere in the slightest degree with the 
 jirocurement of full and adequate facilities for Medical teaching by that School ; and 
 expresses the earnest wish that the members of the Faculty of each Institution on the 
 Hospital staff should cordially co-operate for the advancement of the interests of the 
 Hospital and those of Medical Education. 
 
 68. But it cannot accede to the pretension that the needs of the Provincial Univer- 
 sity should be limited, and that the efficiency of the Medical education which the 
 University has undertaken should be impaired, by its Faculty being allowed only such 
 &cilities as it may suit Trinity Medical School to ask for itself. 
 
 6&. Whatever may have been the state of things in the past, the present conditions 
 are wholly opposed to the recognition of any such pretension. 
 
 70. There are now three Schools, the University Faculty, Trinity School, and the 
 Women's Medical College. It ia not pretended in theory, or admitted in practice, that 
 equal numbers should be given to each of the three. That woidd be at once regarded as 
 absurd. Indeed it is understood that the Women's College has no such relations with the 
 Hcmpital aa those of the other two Schools. 
 
12 
 
 71. A fair i)ropoition and equal facilities to each of the two Schools do by no means 
 imply equal numbers of Teachers for each. 
 
 72. And the conditions in several respects of Trinity School so differ from those now 
 obtaining with the TTniversity as to render it unjust in the extreme to permit the sug- 
 gested v'ews ot Trinity to prevail. 
 
 73. The numbers of students under the University Faculty have increased and are 
 still increasing, in spite of a rigorous observance by the University of certain limitations 
 which are understood to receive elsewhere a somewhat elastic interpretation. 
 
 7i. It hiis not been found possible to ascertain with exactness the numbers of 
 students in actual attendance in each year on the Medical course at Trii.ity. 
 
 75. An estimate has been made that for 1892-3 the number of Trinity students in the 
 third and fourth years ^when the Hospital Clinical teaching is taken) will be about 102 ; 
 and that the number in the same years for the University will be about 141. 
 
 76. The first and second year students, and the total number in actual attendance at 
 the University have been as follows : — 
 
 89/90 
 90/91 
 91/92 
 
 I.ST Year. 2nd Ykar. Total of Four Years, 
 
 66 
 81 
 
 85 
 
 66 
 60 
 75 
 
 258 
 263 
 283 
 
 77. It is believed that a proper investigation into the numbers of effective students, 
 as indicated by the numbers examined in each year of the course for the last three years, 
 and as shown by the Hospital records, would prove tha' on the score of numbers the 
 University has now passed Trinity, and requires further facilities in addition to those 
 required by Trinity. 
 
 78. It must be remembered that, since the essence of efficient Clinical teaching is a 
 small class, to limit a School with a larger body of students to the same number of teachei's 
 as a School witli a smaller body of students, is not to give equal facilities to each, but to 
 place the School with the larger number at a positive disadvantage ; in fact, it is to give 
 greater facilities to the smaller School. 
 
 79. But this, though important, is after all not the more important point. 
 
 80. The situation must also be considered in the interests of higher Medical educa- 
 tion, apart altogether from the relative number of students ; and, in this aspect, further 
 facilities are required, even if, for the sake of argument, it be (contrary to the fact) 
 assumed, that the numbeis are equal, or even that Trinity exceeds. 
 
 81. The numbers attending the Clinics under the present system are often more than 
 thirty. So large a class impairs and almost destroys the stimulus to care and exactness 
 on the part of the instructor, and often excludes the possibility of those features. The 
 results to the classes are, of course, lamentable. 
 
 82. The importance of small classes is recognized in the English Hospitals, where, 
 unless in the case of some instructor of exceptional merit, or under some exceptional con- 
 dition, the classes are seldom more than ten to twenty, or saj' an average of fifteen in 
 number. Twenty are too many ; and to secure good results the number should not exceed 
 twelve or fifteen. It is therefore important to pi-ovide for smaller classes than now obtain, 
 irrespective of the relative total numbers in each School. 
 
 83. Now, iu old days, both the Toronto School of Medicine and the Trinity School 
 were proprietary institutions, conducted largely on commercial principles, for the gain of their 
 proprietors. It naturally followed that the proprietors would be opposed to any avoidable 
 increase in Clinical facilities, involving a greater expenditure of time and money than 
 would be counterbalanced by the additional students' fees. They would naturally be 
 opposed to any avoidable increase in the charges, or to any diminution in the gains of their 
 venture ; and they would naturally endeavour, as far as possible, to limit the number of 
 instructors ; and, where increase became necessary, to accomplish it on the most economical 
 terms. 
 
13 
 
 84. It is understood tliat the chief proprietors of the Trinity School lately valued 
 their enterprise as worth an income of over $2,000 a year each ; and this income it woivld 
 naturally be their policy to maintain or increase as much, or at any rate tc diminisl- as 
 little as possible. 
 
 85. It is believed that a recent serions decrease in the number of Trinity students 
 has greatly changed the situation in this respect; and of course the diminution of num- 
 bers and lessening of receipts would strengthen the inducement of the pi-onrietors to oppose 
 tlie grant to the University of additional facilities less required by themselves, and increas- 
 ingly required by the University. 
 
 86. The considerations to which we have referred as formerly applying to both 
 Schools, were, as to one of them, in theory absolutely removed, and in practice largely 
 diminished, at the moment when the University of Toronto created its Faculty of Medicine ; 
 and, since the re-organization which has just been accomplished, tliey have been in practice 
 as well as in theory, substantially eliminated. 
 
 87. The Univer.sity authorities are now in a position to decide, independently, and in 
 the interests of Medical education alone, the number and grade of instructors, and the 
 division of the fees received. 
 
 88. They have made available in the departments of Biology, Chemistry and Physics 
 the unrivalled facilities of their Arts Department. 
 
 89. They have advanced to merited professorial rank a number of deserving instruc- 
 tors ; and they have divided the available fund strictly in jjroportion to the estimated 
 duty ; thus largely diminishing the emoluments formerly reaped by a few, and providing 
 a veiy scanty, but still a relatively just reward for the labour of all. 
 
 90. They have reserved to themselves the power of further increasing the number of 
 instructors as rapidly as the interests of Medical education require, and of apj)ropriating 
 the funds as may be necessary to provide for their remuneration. 
 
 91. Wliile this is the case with the University Faculty, Trinity School remains on its 
 old footing; and it is thus easy to understand the motives which would induce objection 
 on the part of Trinity School to the course pi'oposed by the University. 
 
 92. Trinity School wonlcl naturally object to the employment of additional instructors 
 by itself, now less wanted than before, in view of its lessened absolute and relative 
 numbers ; and further diminishing the gains of its propr-etors ; and it would equally 
 naturally object to the University being permitted the facilities for which it a.sks, under 
 the apprehension that the more efficient instruction which would thus be obtainable at the 
 University would attract the Medical student still more jiowerfully to the Provincial 
 Institution. 
 
 93. Equal facilities may perhaps as far as possible be allowed to both Schools, 
 irrespective of their difl'ering conditions ; but what is essential is that adequate facilities 
 should be allowed to each School ; and that the refusal of one to accept should not debar 
 the other from obtaining these adequate facilities. Nor should the educational necessities 
 of the Provincial Institution be measured, or its efforts to advance Medical education 
 hindered, by the necessities or personal interests or inclinations of the proprietors of 
 Trinity. 
 
 94. All reasonable facilities should be granted, particularly in regard to Clinical 
 ward work, with reference to the numbers which can be niost advantageously instructed ; 
 according to the resources of the staff of each School ; and to the extent which the staff 
 can adequately make available. 
 
 95. Considered on these principles the objections of Trinity ought not, as the 
 Committee submits, to prevail. 
 
 FURTHER SUGGESTIONS. 
 
 96. The Committee now ventures to submit, for the consideration of the Trustees, 
 some further suggestions which have been brought to its attention in the course of its 
 enquiry, and which seem so important as to render it a duty to bring them under the 
 notice of the Trustees. 
 
u 
 
 HOUSE PHYSICIANS AND SURGEONS. 
 
 97. Tho miniber of House Physicians and Surgeons, having reg«rcl to their ni ill tifarious 
 duties, including the Obstetrical Dei)iirtnient, appears inadequate to the proper discharge 
 of tlie functions of the Hospital ; and the interests of the Hospital and its patients would 
 be greatly advanced by a moderate increase in their number. 
 
 98. At present, a Chief may visit the Wards on several successive occasions, and, 
 finding the House Officer engaged with another visiting Physician, or discharging some 
 otiicr of ills many duties, may be unalle to leain the interim condition of his patients, or 
 give verbal instructions for changes in treatment or management. 
 
 99. Again, under the present system, and having regard to the existence of the two 
 Schools, it may happen that a House Officer may be trained in methods or opinions to which 
 his Chief is opposed, but which the latter may find it difficult to change in practice in his 
 own cases. 
 
 1 00. A 11 these difficulties would be remedied if to each Chief in M edicine and Surgery 
 were assigned a House Officer responsible to him for the well-being of the patients under 
 his care. 
 
 101. The very trifling expense of this addition to the Hospital staff would, it is 
 believed, be far more than recouped by the increased elliciency of the organization ; and, 
 in truth, it is submitted to be an almost necessary step. 
 
 102. The numbers of House Physicians and Surgeons, including the Obstetricians, in 
 some of the London Hospitals are as follows : 
 
 St. Mary's 'o 
 
 University College Is 
 
 St. Thomas' |3 & 2 Assistants = 5 ■ 
 
 Middlesex l6 
 
 I 
 
 Guy's 4 & 1 Assistant = 5 ' 
 
 i 
 St. Bartholomew's.. !3 
 
 House Sitroeo.ns. 
 
 Obstetricians. 
 
 Total. 
 
 a 
 
 4 
 
 16 
 
 6 
 
 12 
 
 26 
 12 
 
 4 & 1 Assistant = 5 
 
 2 
 
 6 
 
 2 
 
 14 
 
 4 & 2 Assistants = (i 
 
 2 
 
 13 
 
 10 
 
 
 13 
 
 103. It has been suggested that the House Staff might, on occasion, supervise such 
 matters as a physical diagnosis on the Medical side, and the dressing of wounds and 
 iractures on the Surgical side, in the presence of students. 
 
 104. The dressing might be done under the supervision and instruction of the House 
 Surgeon by dressers appointed l)y each Chief from amongst his pupils ; and analocrous 
 w'ork on the Medical side might be assigned to Clinical clerks, acting under the supervision 
 of the House Physician and appointed in like manner. 
 
 105. Under the further systemization involved in and rendered i)assible by these 
 arrangements a continuous interest in, responsibility for and attention to the cases could 
 be maintained on the part of all concerned with great general advantage. 
 
 106. It is believed that a system such as is suggested is in force with reference to 
 House Physicians and Surgeons in the case of the Montreal General Hospital. 
 
 107. The appointments of House Surgeons and Physicians are of great importance • 
 and it IS suggested that to insure good results it would be advantageous to obtain the 
 opinion ot the Faculty or of the authorities of each School as to the fitness of candidates 
 from the School before their selection, as is frequently done in Britain ; or that some 
 system of competition should be adopted, as is done at St. Mary's, University College and 
 Middlesex Hospitals. ' 
 
15 
 PATHOLOGY. 
 
 108. Patliology is so closely allied to Clinical work that they cannot proDerlv be 
 separated. r i j 
 
 I. 
 
 University Hcspital Labokatoky. 
 
 109. It is suggested that the Univeisity Patlioiogical staff should have control and 
 charge of this Uiboiatory, now approaching completion ; and that all e.xaniinations of 
 fluids, e.xcreta and pathological products should be carried on practically under th'j sujier- 
 vision of that staff. The reasons for this are too obvious to require extended statement. 
 Ihe etticient care of the patient and the complete investigation and studv of the case alike 
 reqnire this disposition of these jjroducts. 
 
 110. The opening of the Laboiatory is viewed with great pleasure, inasmuch aa it 
 will render possible, with regard to the .system and regularity of examinations, a great and 
 much needed improvement on the methods which have hitherto obtained ; and the interests 
 of the patients as well as the students will thus bo greatly promoted. 
 
 n. 
 
 Clinical Pathological Records. 
 
 1 1 1 . It is suggested that tne improved facilities for the examination and analysis of 
 the various fluids, excreta and i)athological products .should be, in the interest of the 
 patients, utilized, and that a .systematic record thereof should appear at the bedside daily, 
 or as often as is required for the information of the Chief. 
 
 III. 
 
 Autopsies. 
 
 112. The present arrangements with reference to autopsies appear unsatisfactorv. 
 A patient may succumb while under the care of a member of the University staff; but 
 the post-mortem examination may be made by a i lember of the other staff; and vice versa; 
 or it may be, and often is, not allowed to the pathologist of the staff, and afterwards made 
 by a house surgeon, without adequate notice. 
 
 113. It seems clear that the Pathologi»^ of each staff is the proper person to perform 
 the autopsy in all cases under charge of the Hospital Staff of that School ; thus rendering 
 possible the more complete final examination of a oa.se which has been the subject of obser- 
 vation by the student during the progress of disease ; the autopsy in which is of such great 
 importance to complete the demonstration ; and some of the products of which may be of 
 such great service for preservation and use in the Pathological Museum of the School. 
 
 114. To facilitate the attendance of students this autojjsy should take place at fixed 
 stated hours. 
 
 115. Much difficulty has been experienced by Clinicians and students from the want 
 of post-mortems so coiiducted, in cases in which these seemed to be important in order to 
 ascertain the cause of death, both in the interest of Medical Science, and with a view to 
 Medical education. 
 
 116. It is submitted that when, as is generally the case, the consent of friends can bo 
 obtained, post-mortems, in proper cases, to be reverently performed, without any disfigui-e- 
 nient, where the body is to be handed over to friends, should be encouraged rather than 
 discouraged. 
 
 1 17. It is indeed a rule in many Hospitals, that examination is to be made, if thought 
 necessary, by the Physician or Surgeon in charge ; and this is not found detrimental to any 
 interests. Such is assumed to be the law here ; though, if the Committee is rightly in 
 
16 
 
 formed, not invariiibly tlie practice. But it is believed that, apart from any such rule, the 
 consent of friends can fjenerally, by proper representations, be obtained, and tlius all 
 objection can be removed. 
 
 118. Tlie adoption of the system proposed as to autopsies would also allow of the 
 improvement of the Hospital Statistics by the addition of tlie Pathologist's report to the 
 Clinical record ; and it would improve the chance given to the attending Physician or 
 Surgeon for correcting his diagnosis, and increasing the stock of knowledge by the result 
 of the final examination. 
 
 CLINICAL AND HOSPITAL RECORDS. 
 
 119. It is suggested that complete contemporaneous records of all cases should be 
 kept, moie exactly than at present, by Clinical Clerks and Registrars, under the instruction 
 and guidance of the staff. 
 
 120. Registrars should be selected with great care, after consultation with the 
 respective Schools ; and the stuff should be responsible for some supervision of the work. 
 
 121. Permanent Hospital records properly kept are of the highest importance and of 
 the greatest interest. It is needless to dilate on the value of this system both from a 
 humanitarian and a scientific standpoint. It is in force in almost all Old World Hosjntals 
 connected with good Teaching Institutions ; and the reports are regularly published and 
 sold ; and are extensively subscribed for by the Alumni. 
 
 122. It is suggested that these records should be cai-efully and conscientiously made, 
 by the collaboration of the various officers referred to, from the highest to the lowest ; that 
 they should embrace statements of the main observations of importance, and of the cases 
 of interest to the profession, which have occurred ; and that they should be edited and 
 published yearly or half-yearly by a committee of the staff. So soon as their value is shown 
 a return v 11 be realized from their sale. 
 
 CONCLUSION. 
 
 123. Some other matters have been placed before the Committee, which seem to it 
 worthy of consideration, and which it may, on a future occasion, crave permission to sub- 
 mit to the attention of the trustees. 
 
 124. But these appear to be the more pressing points ; and the Committee, confining 
 itself to them for the present, closes by assuring the Trustees of its earnest desire to help 
 in any way in its power in the advancement of the Hospital ; and of its readiness to con- 
 fer with the Trustees on any points arising out of this Minute. 
 
 Adopted by the Committee and ordered to be transmitted to the Board of Trustees 
 of the Toronto General Hospital. 
 
 Registrar's Office, May 28th, 1892. 
 
 EDWARD BLAKE, 
 
 Acting Chairman.