268 Sir J. Halliday Croom

X

THE TEEING OF THE STUDENT OF MEDICINE:

/Inquiry Conducted under the Auspices of the

Edinburgh Pathological Club.

/XLVIIL- ^ /

-THE TEACHING OF OBSTETRICS TO UNDER-

GRADUATES.

By Professor Sir J. HALLIDAY CROOM.

Obstetrics, like medicine and surgery, is both a science and an art, and in teaching the subject it must be realised that both are essential. Perhaps the tendency has been to minimise the importance of the

science and emphasise that of the art. Before approaching the actual subject of to-night's conference, one

or two questions naturally suggest themselves. Why, for example, has obstetrics only within recent years reached the position which unquestionably its importance demands'? Why. again, has the subject so long remained on a plane separate from medicine and surgery1? Why has it so long remained in the hands of inferior practitioners? longer than medicine 1 and lastly, Why was it left to women, and why in the hands of women did it make so little progress 1 In looking for an explanation it seems that in the final analysis that will be found in the fact that in human history childbirth has always been regarded as a normal process. There is ample proof to the contrary, but the idea was so deeply rooted in men's minds that its eradication has been a very slow though a certain process.

It is not for me to elaborate here the question that labour is no

longer a normal function, but I may just mention that 20,000 women die every year from direct or indirect effects of labour, and that we can form no idea of the late or postponed mortality of diseases acquired during pregnancy and the puerperium, and the immense amount of invalidism arising from childbed. i

Hundreds of thousands of women flock to hospital for repair of injuries and relief from effects of disease contracted during labour, and 50 per cent, of women bear marks of injury received during labour.

The teaching of midwifery has always held a prominent place in medical study in Edinburgh. I wish to look at the subject from a broad and general point of view, and suggest a practicable ideal in the teaching of midwifery, primarily an ideal in general and, secondarily only, as applicable to Edinburgh at the present time and under existing circumstances. I do not here, of course, refer to gynecology, because its birth, development, and maturity have practically taken place within the last generation. But I should like most emphatically to state that

The Teaching of Obstetrics 269

under no circumstances whatever should obstetrics and gynecology be divorced from one another. Gynecology ought ever to form an

integral part of the teaching of obstetrics, and they ought to be associated in a combined course. Every accomplished gynecologist must have a clinical knowledge of obstetrics.

In the first place, with regard to the length of the curriculum, it is impossible to attempt the teaching of obstetrics and gynecology in

anything less than a winter course, extending, say, from the beginning of October to the beginning of Mkrch, exclusive of the Christmas

recess. I have had ample experience of what is known as a three-

months' course, and there I found it impossible to overtake the two

subjects in that length of time, and consequently, for many years, I was in the habit of duplicating my lectures by lecturing in the morning on midwifery and twice or three times a week in the afternoon on

gynecology, which almost doubled the course, and extended it very

nearly to the length of a winter course. In the second place, I would like to point out that, in order to over-

take the subject of obstetrics, it can with great advantage be divided into two parts. Whether these parts need be continuous or not is a

matter of convenience. The first portion should be devoted entirely to

purely systematic lectures on the anatomy, physiology, and pathology of obstetrics. No one realises more than I do that the student of

to-day is over-lectured, but because systematic lecturing is overdone

that is not sufficient reason why it should be abolished. It should

only be relegated to its proper place, and that place in obstetrics is in the anatomy, physiology, and pathology of pregnancy. While a con-

siderable amount of surgery and medicine can be learned perhaps as well from books as by teaching, yet obstetrics is a subject which lends itself more to lucid and definite systematic teaching than any subject in the curriculum. Didactic teaching should be concretely illustrated. This may best be accomplished by means of models depicting accurately everything in obstetrics possible of reproduction. I need not enter

into details as to what these ought to be?obstetric anatomy, structural a changes of all kinds in the uterus from the beginning to the end of

pregnancy, attitudes, positions, presentations, mechanism of labour, and so on; and of recent years the adoption of opaque and lantern slides is essential for didactic teaching.

I by no means wish to over-emphasise the importance of didactic teaching. It is indispensable to the teaching of obstetrics as a science, and for the reasons I have just stated must precede and sometimes accompany the teaching of the practical and clinical side of the subject.

The great aim and object must be to avoid repetition as much as

possible, and while, of course, the subject of embryology forms no

integral part of obstetric teaching?being overtaken by a special teacher

in anatomy?yet it must be obvious that there must be a constant

270 Sir J. Halliday Croom

reference to this subject, in some form or another, daring the lectures. A saving might be accomplished both in anatomy ;md physiology, although there again it is necessary that the questions of anatomy and physiology, although taught in reference to obstetrics only, must be dealt with in a general way as well. It must be distinctly kept in mind that the student entering on obstetric study is entering on a

perfectly new field, and anatomy and physiology must be dealt with in a definite and concrete form as far as they are applicable to

obstetrics proper. In connection with this first half, tutorial teaching is of the utmost

value. The teaching of all microscopic work, microscopic demonstra- tions, and the study of the subject from this aspect, are best undertaken by a competent tutor or assistant. To this I attach very considerable

importance. The teaching of small sections in this way is of immense

advantage. The second part of the course should be devoted to obstetrics as

an art. By this I mean that the whole question of labour?normal, abnormal, tedious, instrumental, complex?should be undertaken by occasional lectures, demonstrations, and clinical instruction according to the discretion of the teacher. It is my opinion that clinical instruc- tion in the hospital should run concurrently with the second part of the course. I have tried both ways, and I am certain that it goes a

very considerable length in adding interest to the course if these two

parts are run at the same time. After the student has been thoroughly grounded in the preliminary part, he is quite competent to realise the minutise and importance of the clinical section. Systematic lectures, while forming an integral part of the course, would be supplemented by clinical teaching. While I consider the latter all-important, I am of the opinion, however, that, even in connection with the clinical

aspects of midwifery, much is to be gained by the student from lectures given from the clinical standpoint of the lecturer's experience.

It cannot be too strongly emphasised that while the student of

surgery and medicine sees his hospital cases daily, the student of

obstetrics on the other hand has no such advantage. What I claim g

for the student of obstetrics is that he should come in contact with the routine work of the hospital every day for a certain length of time. Compared to medicine and surgery, of course, the subject is relatively small, and therefore the shorter time will accomplish all that is

required. My opinion is that a month's clinical work at the hospital gives the

student all that he really requires to see. For example, he has first

of all an opportunity of examining pregnant women daily under the superintendence of a skilled teacher?a touch class. To this I attach

the greatest importance. He sees labours conducted in the hospital under competent management. He has an opportunity of seeing

The Teaching of Obstetrics 271

several times in the month all the commoner complications, such as the

application of forceps, conduct of abortions, eclampsia, premature labour, and so forth. These occur more or less every month. He has, further, an opportunity of seeing in the hospital the various conditions of the puerperium and the conditions of the infant. This I am perfectly certain, from a long experience of it, is essential for every student of obstetrics. He may, if he likes, extend his experience at his discretion, but a month's daily attendance ought to be the irreducible minimum, with the presence there daily of the same teacher if possible.

Furthermore, it must be distinctly kept in view that the function of a school of medicine is not to produce specialists, but general prac- titioners, and therefore it is of the utmost importance that men should be brought into daily contact as students with the work that they are to pursue in after-life.

My idea, therefore, is this: in order that a student may have an opportunity of studying midwifery systematically and clinically con- currently (because, after all, this is to my mind a very essential feature), some such method as this should be adopted. First of all, I think four months of obstetrics and one month of gynecology makes an absolutely complete course, but I do not think that less would cover the subject. I have no wish to lay down any hard-and-fast rule as to the number of lectures. All I desire to indicate is the relative time given to each of the three departments, namely, systematic teaching, practical and clinical teaching, and gynecology. Speaking, therefore, of obstetrics

pure and simple, if it were divided in this way, so that a man might have two months devoted entirely to systematic lectures and two months employed in lectures, demonstrations, and clinical instruction, this would accomplish all that is required. I can anticipate a criticism of this matter, because I can see that my point may be traversed by showing that only a limited number of students can be accommodated at the cliniques during the winter session ; that from fifteen to twenty can only be accommodated each month. That, of course, is a matter of arrangement. Obviously it is impossible to undertake all the students in small clinical classes during the session, but this difficulty can be overcome here, as it is elsewhere, by these cliniques being con- ducted by other members of the staff in succession.

The clinical teaching of midwifery to a class of students is, of

course, a development of these days of anaesthesia and asepsis. Before

the days of Simpson and Lister such teaching was attended by difficulties and grave risks to the patients. With anaesthesia and due

precautions regarding asepsis these difficulties and dangers are now fortunately removed. Hospitals were in those days dangerous institu- tions, and the clinical teaching was an impossibility.

A very excellent attempt was made to overcome the difficulty of

the students by the establishment of the Milne Murray Home. It was

272 Sir J. Halliday Croom

ideal in its conception, and could its object have been achieved, it

would have been a lasting memorial to the eminent physician after whom the home was called. It was found that during the working session, summer and winter, the students could not be prevailed upon to reside in the home for a month at a time, and the expense was con- siderable. It was therefore occupied by maternity students only during the recess. The home offered exceptional advantages to students, but its working as a practical method was surrounded by so many difficulties that it ultimately had to be abandoned.

So far as I understand, this conference refers to undergraduates only. As to the special teaching required for post-graduates and those who wish to specialise, that is a different matter altogether, and does not fall to be discussed at present.

Naturally, the teaching of the clinical and practical side of obstetrics can be accomplished satisfactorily only through the medium of a

suitably equipped and properly conducted hospital. Such hospitals should be teaching and research institutions in the fullest sense of the term, with obstetric material freely and constantly available, and the staff should consist of teachers only. For the proper utilisation of the

hospital material there ought to be a laboratory connected with the hospital where all the necessary investigations?pathological, chemical, and others?could be conducted under the charge of a qualified super- intendent. Until this is accomplished the work of the hospital cannot be properly pursued. Incidentally may I remark that this is the

clamant need of the hospital here. The reconstruction of the present one has been so often discussed and so often put aside that the hope of a new one, which is so very much needed before the department can ever hope to fulfil all its functions, must, I fear, be relegated to the somewhat distant future.

With regard to extern work a student has two options. Either he

can take the cliniques referred to and twelve cases (ten cases really, as two can, of course, be taken in the hospital), or the Medical Council

gives him the option of taking twenty cases anywhere he chooses. While believing that the extern attendance upon midwifery cases

is of less importance than the clinical instruction given in a hospital, at the same time it is a branch that must not be neglected. Ten cases

carefully demonstrated in hospital are worth fifty cases attended by the student without instruction. Yet I am of opinion that if these extern cases were managed as they ought to be, and carefully recorded, they would be of value in giving the men confidence and experience. My opinion is, further, that each man ought, when he attends these extern cases, be given a case-book in which to record the pulse and

temperature daily for ten days, with any remarks about the case that

may occur to him, such as the necessity for calling in assistance, and

any complication that may occur. As I have just said, the students

X The Teaching of Obstetrics 273

should be supplied with registers for the purpose, and these boolcs

should be handed in and carefully examined along with their other

certificates at the time of entering their names for the Final Examination. This system is carefully and thoroughly carried out by the Central Midwives Board for Nurses, and it is of equal if not of more importance that it should be carried out for the students. I am well aware, of

course, that irregularity may occur in this as in everything else. Case-

books can be made up to order at any time. But if a detailed record

of the cases was insisted on, it would impress on the student the

importance of this part of his work and with a little superintendence on the part of the hospital medical officers the accuracy of these reports could be easily verified from time to time.

So far as the extern work in the Edinburgh School is concerned, I have shown in evidence before a conjoint Board of the B,oyal Maternity Hospital and the Medical Faculty that there are ample cases in Edin-

burgh to supply material for the whole of the students were the work spread over the whole session, and I do not propose to go into the

figures again to-night, as they have no bearing upon the question. But I

would just like to say that from my point of view it is immaterial where a student gets his extern midwifery. It has long been a recognised habit among the students in Edinburgh that they should go somewhere

during the summer vacation by way of a holiday, say to Dublin, Bristol, or Liverpool, and have their extern cases there. I offer no objection to this whatever, nor can I see how in any way it is a disadvantage.

My opinion, however, has been traversed by the Dean of the Faculty of Medicine, who points out to me that it is a flaw in the curriculum

that students remain under the impression that they cannot get their proper number of extern cases in Edinburgh, and that fathers and guardians of these students often write to the Dean to express their disappointment that the complete course of midwifery is not

available in the city of Edinburgh. Now this is quite a mistake.

Edinburgh can supply the needs of all the students if only the work were properly systematised. But it must be obvious to anyone that

it is impracticable to expect students to attend extern midwifery during the period of their winter study or summer classes, and it must be, and

always will be, the case that men will take this irregular work during their vacation period. Any student can get the number of cases he

requires if he chooses to suit himself to the circumstances, but that would necessitate a certain number taking out their extern cases during the time they are attending other classes, and this they find interferes so much with their work that they prefer to go elsewhere during the vacation. Neither this hospital nor any other that I know of can

supply sufficient cases in three months for 150 to 170 students. There-

fore, so long as we can give those who desire to remain in Edinburgh a sufficient number of extern cases that is all that is required of us.

274 A. H. F. Barbour s

There is no reason why those who desire it and can afford it should not go to other centres for their education in this particular department if it best suits their convenience.

This is the common experience of every hospital in the kingdom, and the reason why the other hospitals are able to accommodate our students is because their own clientele of students is relatively so small. So long as we can offer to students who really wish to take their com- plete course here the adequate number of cases, no fault can be found with other men who have the means and who take their cases elsewhere. It seems to me we entirely amplify our bargain, and further, the Medical Council is quite contented with twenty cases attended anywhere the student chooses to take them.

To bring the matter to a conclusion, my ideal is that midwifery should be taught in two definite and distinct parts. First, the scientific part, which is overtaken by daily systematic lectures with the aid of tutorial demonstrations on models, diagrams, and microscopic work. Secondly, a practical and clinical part, which is conducted by occasional lectures, demonstrations, and clinical lectures in the class-room and in the hospital.

Concurrently with this second portion there should be daily instruction in the hospital. First of all, in touch work, which is of the utmost importance ; secondly, in normal labour ; thirdly, in the various abnormal conditions of labour and the puerperium, including instru- mental work with forceps ; fourthly, laboratory? work, where specimens are examined and chemical work done; and finally, for the sake of

experience/ind giving confidence, the students should attend a certain limited number of extern cases under the circumstances I have defined.

In/ftll suggestions for the advancement and effectiveness of the depjtfxment of obstetrics it must always be borne in mind qui vapiano, va/ano ; qui va sano va lontano.