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(2) The ridiculous regulations of the various examining boards, and the neglect of the body appointed to supervise them, the General Medical Council.
First let us consider the regulations as regards medical studies. Having been present at a debate at this Society on medical education held sometime last year, I know that most of you agree that you are overburdened with the earlier science subjects and are left with too little time for the clinical subjects. In fact there is a great struggle to fit in the work to be done in the last two years, with the result that midwifery takes a very back seat. This, I take it, is due to the fact that it is very inadequately represented on the Medical Council, and on the various university faculties and examining boards. For, apparently, it is human nature that every man should think his own subject of paramount importance, and so it happens that just as we of the practice side of medicine think that the chemists and botanists take up more than their share of the student's time, so in turn do we of the obstetric branch think that our colleagues of medicine and surgery do not allow midwifery its proper place in the last two years of study. Whether this is right or wrong, the time given to midwifery is by no means proportionate to its prominent place in the work of general practice. Here I would remind you that these remarks apply strictly to midwifery, and do not include gynecology; that subject gets its full share of the student's attention. The great error is that the regulations allow the student to take the midwifery examination at the end of his fourth year instead at the end of his fifth, and to anyone who knows the medical student, this means that when he can he will always do So. The Conjoint Board, as I hope to prove to you later, is the arch offender in this respect.
What ought the student to have done before he undertakes his midwifery cases? Under our present conditions we will take it for granted that he has been to a course of lectures on the subject and has had some instruction, a condition by no means always fulfilled.
Without question he ought to have done his dressing; of that there can be no doubt, for until a man has been thoroughly drilled in the methods of surgical cleanliness in the wards and in the operating theatre, he ought never to be allowed into the lying-in He is not safe. For those of you who are going into general practice, I consider the chief thing that you acquire while you are helping your surgeon at all sorts of operations that you are not very likely to do yourself, to be the preliminary training for your future mid-wifery practice in the form of a sound technique on strict Listerian principles. For this most essential part of the practical midwifery training, the student is almost entirely dependant on the surgeon.
To the majority of you the details of the operations will be nothing after you have been in practice ten years, but one fondly hopes that the methods of surgical cleanliness as drilled into you in the surgical wards will never be lost and one knows that you will find the most frequent occasion of applying them to be in your every-day midwifery work.
I think that it will be generally acknowledged that it is more difficult to apply strict surgical methods to midwifery than to the ordinary surgical operative procedures. The hands have to be used for so many purposes for which strict asepsis does not provide that there is greater difficulty in maintaining a proper technique. For instance, the hand has to be used to control the uterus during the management of the third stage of labour when at any time internal manipulation may be required and so on. On these grounds it is most important that practical midwifery be learnt and habits acquired after the student has had a thorough training in surgical methods. If this is not the case the work will be done badly and slovenly habits acquired. In order to illustrate what happens in our district, may I quote an experience of my own on one occasion recently when I came to an operative midwifery case? I found the three O.C.'s on duty all present and anxious to assist. I asked the clerk whose case it was, if he had done his dressing, but found that he was then engaged in doing his O.P. clerking and had done no surgery, so I asked for the one most experienced in surgical methods to assist me, and had to be satisfied with a man who had actually got as far as beginning his O.P. dressing. I went home afterwards saddened with the thought that the District did not have the advantage of that drilling in aseptic technique, which your President has done so much to develop.
It is perhaps not quite so essential that the clerking ought to have been done, but it is certainly very much to the advantage of the student if it has been. It is the time when he learns observation and examination and acquires a knowledge of the ordinary ailments which may be met with in the course of his work, both in mothers and babies. Some instruction is necessary before the student can acquire any degree of proficiency in abdominal palpation, and he ought not to be left to make his maiden efforts in a Lambeth slum without supervision. Happily most men have done some portion of their medical work before coming on as O.C. But this ought not to be left to chance, it ought to be one of the regulations of the General Medical Council that no midwifery cases are to be counted until the student has been fully signed up for his medical and surgical work. The necessity for this may be illustrated by two incidents that happened at the Conjoint Board
midwifery examination; the first of them I heard direct from the examiner to whom it happened. The candidate was asked what he knew of the fevers which might occur in the puerperium and after thinking for a moment, replied apologetically that he had not yet done his fevers, but hoped to do so soon. In the second case a candidate objected to a question because on the albuminuria of pregnancy that he had not yet done his clerking, and it was therefore quite unreasonable to expect him to answer a question involving a knowledge of urine testing.
Before considering how an improvement in our training is to be brought about, let us for a moment glance at the Continental methods.
I do not know anything of the methods in France, though I remember that the Obstetricians who were over here a year ago at the time of the visit of the French medical men to this country were as scornful of our methods of instruction as their natural politeness would permit them to be.
I have, however, seen a little of the work in the German and Swiss Universities, and certainly it is done in a way very different from ours. Midwifery is taught exactly like other subjects, i.c. in Hospital. At each University there is a Frauenklinik under the charge of the Professor or Director, who has several experienced assistants under him. Both obstetrical and gynæcological cases are taken in, and the students are thoroughly drilled in the work under the immediate supervision of the distinguished teachers of the klinik. To show how thoroughly this training is done, a number of women are taken into the hospital in the later stages of pregnancy, and are given free board and lodging for some weeks or months in order that they may be used as material to teach abdominal and other methods of examination to the students. I very much doubt if our Lambeth patients would appreciate this form of hospital charity, especially as these women also do as much of the scrubbing and cleaning of the hospital as their condition will allow, in order to make sure that they really earn their keep. No only are the students thoroughly grounded in the theory and practice of obstetrics, but when it comes to examination, they are examined clinically. About a year ago I spent a few days attending Prof. von Rosthorn's klinik at Heidelberg, and accompanied the Professor while he was examining a man for his state examination. The unfortunate candidate spent the whole of a happy week in undergoing his examination in obstetrics and gynæcology alone, and on the morning when I was present he had a very bad time because the case of labour he had to conduct was not satisfactorily reported; as far as I could make out he had not managed the third stage to the satisfaction of the examiner,
and had not made a proper investigation of the placenta after delivery. However, I do not know that I envy the Germans their method of examination, but I do envy them their systematic teaching in the practice of midwifery.
No doubt there is something to be said for the time-honoured method of the practice being learnt in an out-door maternity district as prevails in this country; it is exactly what the man has to do when he goes into practice, and he has a certain amount of responsibility which is good for him, and tends to make him more selfreliant. But before he commences to attend cases in the district he ought to be instructed clinically in the aseptic management of child birth and child bed, in the mechanism and management of labour, and in the indications for interference. If he had had this preparatory instruction then I think our methods would be better than the German. Our lying-in hospitals in London and, except in Dublin, those also of the provincial towns have been used for the teaching of midwives rather than of students. With the Midwives' Act of 1902 now in force, the medical profession ought to be even more strictly trained in this work than before, for the well trained midwife will know a great deal more than the old gamps, though she may chatter just as much, and will be in a much better position to recognise what is required of a medical man when he is called in. Nowadays many of these women are trained for three months in a hospital where they see a good deal of work, and must personally deliver twenty cases, and no B.B.A's are allowed to count. At present these well trained midwives are in so hopeless a minority that their influence will not be felt for many years to come, but it only a matter of time for this to make itself evident. Remember that after 1911 no woman will be allowed to practice as a midwife "habitually and for gain," unless she is on the register, and that from now onwards, she must have three or four months of practical training, and pass an examination at the end of it. I am strongly of opinion that this Act has made it incumbent on the medical profession to set their own house in order in regard to midwifery training. It is enacted that in all cases of abnormal labour the midwife must advise that the help of a doctor be obtained, and no doubt where there are well trained women of this class they will know enough to discover very quickly which doctor in their district is most helpful to them, and this means that he will no doubt get most of their work and will have the chance of acquiring an experience and a local reputation which will be most valuable to him; the immediate financial results will probably not be much, but the experience and interest obtained through the cases will be ample compensation.
The question of the improvement of our midwifery training is one that has exercised the minds of all those engaged in teaching the subject for many years past. I have already quoted from an address by Sir William Sinclair, of Manchester on this matter, and the President of the Obstetrical Society discussed the same problem in his inaugural address this year. I shall, therefore, be in good company if I mention a few things which would bring about a great change for the better, even though it means some repetition of what I have already said.
The first and simplest change, and the one that would be attended with the least dislocation of the existing arrangements, is that the examination in midwifery should be taken with or after the surgery and medicine examinations at the end of the fifth year. Secondly, that no student should be allowed to do his maternity cases until he has completed his dressing and clerking. Thirdly, that every student should have a period of in-patient instruction in clinical obstetrics before attending his cases in the out-patient department. Regulations of this kind would revolutionise the training of the student, and would turn out to be an enormous blessing to all who are embarking on family practice. No doubt many of you have heard that this Hospital has for some time been considering the question of opening a lying-in ward for the better instruction of our men, and I hope that we may be the first large hospital in London to do so, and thus be the first to wipe out the reproaches of our French and German confrères. As a matter of fact this will only be going back to a state of affairs that was common enough in former times. Many of the great hospitals of the country had lying-in wards, but the ravages of puerperal and hospital fevers made the close association of surgical and obstetric patients in the same building inadvisable; now we have reached a time when those terrors have lost their meaning, and there is no reason why the old association should not be resumed. Another great advantage in such a ward will be that it will give opportunity for a certain number of men to obtain some experience of the minor operative procedures in the way of low forceps, inductions, washing out the uterine cavity and so on.
No doubt it will have struck many of you that at this hospital we might lessen the deficiencies of the present system on the lines I have already suggested, by refusing to take on men in the district before they had completed their in-patient medical and surgical work. I think that there is no question that we would do it to-morrow, Conjoint Board or no Conjoint Board, if it were not for the insuperable difficulty of keeping the district going during the interval in which the change was being effected. Difficult as it is to arrange the scheme of work in a different way to that laid down by the