ADDRESS IN GYNECOLOGY. How Gynecology is Taught. BY ELY VAN DE WARKER, M.D., OF SYRACUSE, N. Y. Being the Address of the Chairman of the Section on Obstetrics at the Thirty-ninth Annual Meeting of the American Medical Associa- tion, May, 1888. Reprinted from the “Journal of the American Medical Association,” August n, 1888. CHICAGO : Printed at the Office of the Association. 1888. ADDRESS IN GYNECOLOGY. How Gynecology is Taught. BY ELY VAN DE WARKER, M.D., OF SYRACUSE, N. Y. Being the Address of the Chairman of the Section on Obstetrics at the Thirty-ninth Annual Meeting of the American Medical Associa- tion, May, 1888. Reprinted from the “Journal of the American Medical Association,” August n, 1888. CHICAGO : Printed at the Office of the Association. 1888. ADDRESS IN GYNECOLOGY. HOW GYNECOLOGY IS TAUGHT. The Victorian period furnishes no more marked example of the evolution of a great science and a technical art, than the growth of gynecology during a single generation. The Imperial Dic- tionary says that gynecology is the doctrine of the nature and diseases of women. Brief as is this definition it includes a field too extensive with too many elements of medical and surgical complexity to be defined as a specialty. Every province of Medicine is placed under tribute. Ethics, dialectics, casuistry and sociology con- tribute to the solution of mental, moral, social, and physical problems in a field where priest and logician claim an equal right with the medical man. The depths to which gynecic surgery may penetrate have not yet been sounded, while opera- tions so desperate that the surgeon is sustained only by his training and the courage of his con- victions, are simple matters of routine. Surely this cannot be called a specialty. I would define it as general medicine and surgery brought as near perfection as the age permits ; and gives direction by certain mental qualities in the med- ical man himself. This brings us to speak of the man and the large element of personal equation that shapes him 4 for his work and in the direction of which he has a certain natural drift, for which he is fitted only by gradually maturing in his calling. How else can he be prepared with the large measure of sympathy and the boundless patience that he must expend in the routine of his daily life; how else can he make himself at one with a moral nature that stands in the order of vital events at the opposite pole of spiritual life to his own? He must be possessed of some innate qualities of truth and consistency in order to deal with a being specially created by God to understand and interpret him. His inner life must be free from guile, and his outer life lived cleanly, that he may gain the confidence of one to whom all good- ness, and beauty and truth are sexual traits of mind. He must have a sturdy and manly moral nature that will give repose to those about him, that can lead at all times, and that can govern when he must. Such is, I believe, the thing called gynecology, and measurably approaching this standard must be the gynecologist. When we take into con- sideration the fact that this is the growth of but a single generation, the conclusion that gyne- cology has outgrown the system of medical edu- cation as it exists to-day is evident, and further, that it is not the outcome of any existing method of medical training, but the product of the period, and has simply kept pace with the march of events in the intellectual evolution of the age. We can account for the gynecologist in no other way. No college has educated him, no poly- clinic has turned out the finished product, but the history of civilization has shown that surely out of human needs has grown the supply of every want. Heretofore he has been an accident, but the necessity having created him, the supply can 5 no longer be left to chance, he must be educated to meet the want. Here we touch the real difficulty of the ques- tion. Has medical education in any existing system perfected itself to meet the needs of the civilization of which it is a part ? We may say of any of the special sciences, outside of medi- cine, that in some centre of learning each may be followed to the ultimate borders of its progress, and what is of equal value, one may there cross the borders, and add to the material facts of his chosen field, but leaving out the pure sciences as they exist in their special forms, we find the ap- plied sciences taught to meet the demand that called them into existence. Steam has created the mechanical engineer, and has perfected schools to educate him. Electricity has produced the electrical engineer and technical schools are able to turn out the finished expert. Scientific warfare has created special schools where the most advanced forms can be practically taught. The same thoroughness of technical education applied to medicine seems to carry the student away from its simple practice to that of the se- cluded laboratory, or in the direction of the great specialty of the future,—State Medicine, as we can already see it in the government laboratories of Europe. Each step in advance as it has as- sumed a form made necessary by the demand of social evolution has enlarged the bounds of prac- tical education, that of the work-shop, the labora- tory and the instrument of precision. There is not an exception to this law anywhere in the line of march of material progress. This is not a national matter, but is cosmo- politan in its breadth; but as America is the country in which the most finished forms of the gynecologist has been produced let us turn to our 6 own standard of medical education, and to our best methods as they exist to-day, and question what are the chances of meeting the requirements of the future? You must remember, that I and my contemporaries in the profession passed through our medical training with scarcely a suspicion that such a thing as gynecology ex- isted. The teacher to whom we looked for in- struction in this department held the chair of Obstetrics and the Diseases of Women and Chil- dren, and he was expected to do all of this in the short space of sixteen weeks. Why the function of this one man was limited by subjects that he never taught, and that it was impossible for him to teach, was one of the mysteries of the system. Such was the fact, not only in my college, but all over the land, and what is yet more to the point, in not a few instances, it is a fact to-day. I have been able, by means of some publica- tions of the Illinois State Board of Health, to ex- amine into the teaching methods of our medical colleges. And here let me say, that I know there are a number of distinguished teachers before me, and no one will more willingly accord to them than I the merit that they have so honorably won. It must be understood, then, that I say without disrespect, but also without fear, that the medical teaching of to-day does not as perfectly reflect the actual state of medicine, or as completely meet its needs, as that of twenty-five or thirty years ago. At the time of which I speak, gyne- cology was obstetrics. There was no separating them, and, indeed, no need; for all that was known of gynecology was practiced through a narrow tube called a speculum, and its surgery varied from the potassa fusa of Simpson to the antiphlogistic touches of Meigs. Now let us see how this important subject, that involves so large 7 a part of the life-work of every medical man, is disposed of in American medical schools. I have selected only those that are accepted by the Illi- nois Board of Health; nor have I drawn the line at medical sectarianism, for every woman, no mat- ter what may be the particular “pathy” of her medical attendant, has a right to expect that her sexual ills are safe in his hands. I have here a list of 109 medical colleges, so-called, and 56 of them have the diseases of .women taught by the Professor of Obstetrics, and 14 of them still re- taining under this head the diseases of children. There may be other means of teaching gynecic medicine, but if so no mention is made of the fact in the list of teachers. In 82 there are either professors, lecturers or instructors of gynecology, and as such are given a place in the faculty. In 10 no mention is made of the subject of women’s diseases at all. That is, the professor of obstet- rics is such only, and no mention is made of his occupying the double chair of the first group. So far as these schools give us any knowledge of their methods, the subject of gynecology has no place in their curriculum. One school that stands by itself in my tabulation mentions that 44 lec- tures are given upon gynecology. This part of my table gives us 66 colleges out of 109 in which the diseases of women is either taught by the Pro- fessor of Obstetrics, or is not taught at all. This is the old method of work, and like the ma- jority of things that are old has the*merit of being respectable to say the least. According to my way of thinking worse remains to be told, worse in the sense that if the new method, the graded system, does not give us something better it implies fail- ure and defeat, and thus the cause of medical edu- cation is set back another generation. Now I do not believe that any one will dispute me when I 8 assert that the so-called graded system came from the practicing body of the profession and not from the teaching branch. I have watched and studied this change from its inception and think that I know something about it from the non-teaching side of the question. Years of agitation in this Association, in State and local societies were needed before any practical shape was given to reform, and even then nothing was gained from the teaching branch of the profession. Reform emanated directly from the practicing ranks. The change was not grafted upon an old school, but was given form in a new school with its faculty recruited from the rank and- file. This was the college at Syracuse, and the graded method of study forms the sole basis of instruction. The establishment of this school marked the period that was ripe for reform. Fifteen years have passed since, and in this interval but thirteen colleges are organized upon a required basis of graded study. In all other instances it is recommended, but not required. The advocates of this reform can find no cause of offense if we stop to critically examine the measure of good that has been the outcome of the method. And first, I may say for the great mass of the profession, that the new departure was well re- ceived. They were pleased to know that the growing demand for higher medical culture was met in a fair spirit, and while a few schools con- formed to the demand, it was looked upon as a beginning reformation. Courage and faith in the real depth of the reform spirit in the mass of the profession was needed on the part of those who embarked in the new system. The commercial enterprise of the majority of the schools was ar- rayed against it, and disaster was continually pre- dicted for the new movement. So active was the 9 reform spirit that several schools began their char- tered existence with the graded system as a part of their organic law, and that without which would have had little reason to exist, but flourished in spite of, or by reason of, a state of nearly open warfare. These few words tell the history of the movement, for here the matter ended. The in- ertia of the commercial spirit rests upon it, and the old and new have struck hands in a sort of unholy alliance. Not to my knowledge has there been any addition to the ranks of the new schools. Among 109 institutions 13 have the graded plan of study as a required curriculum. President Andrew D. White, before the Yale College Alumni, reviews in a most caustic address, the defects of our educational, social and intellec- tual life. All the deficiencies that an American of cosmopolitan culture would be ashamed of, he attributed to a broad undercurrent of retarding influence that he called mercantilism. He did not refer to American medical education as an in- stance of this overpowering trade spirit, but it asserts its presence as powerfully in the profes- sional training school as in the academy or in the senate. Upon this theory we may explain what happened to the young and promising reform party. It found itself circumscribed as with a rampart by this mercantilism and barely held its place. It did not advance. It is to-day what it was in the beginning, and has become as indiffer- ent to the progressive spirit of the age as the old order of things that it endeavored to replace. There was a fatal mistake made at the very begin- ning of the reform in regarding it as established, instead of being merely a trial of the new order of things upon its merits—an experiment capable of being extended and improved. At the the time the change in medical education found a few prac- 10 tical adherents, educational methods were receiv- ing great attention, and old ideas were giving place to new upon every side. The reform in medical teaching differed from that in other fields of edu- cation in moving at once to some radical changes, and then becoming as fixed in its new direction as it was in the old, while in the latter the subjects as well as the methods of education are debated as earnestly to-day as when the movement began. Matters are yet in a state of evolution, and step by step the questions are being solved. Another singular difference also exists, as I shall show. The new medical curriculum has taken up meth- ods of teaching that advanced educationalists have abandoned ; thus, while the text-book is becoming less an instrument of higher education, it has more or less ursurped the place of the didactic lecture in the graded medical school. The result to my mind is serious, and is becoming evident in the fact that reform medical education is taking up the very methods that progressive education is abandoning for demonstration and the didactic lecture. It is a total misconception of the pur- pose of a text-book to place it before the student as a substitute for the magnetic personality of the living teacher. Now a medical man may be de- fined as one trained to observe natural phenomena in a certain special field, and he must be trained to observe as accurately the phases of disease as the operation of that uncertain factor called a remedy. I assert, and no one who has been a thorough and original student will contradict me, that the text-book was never written and never so carefully studied, as would transform the untrained man into the accurate observer; but I will go further, and say that just in proportion as he masters his text-book will he narrow his mental horizon and blunt his observing faculties. If it 11 is the purpose of medical education to simply fit a man to pass an examination, a series of memor- ized facts acquired under the drill of a simple coach—for to that function have many professors degenerated—is as good an education, if not even better, than any other, but while being thus edu- cated the student has been exercising one of the lowest faculties of his intellect, leaving higher and more useful faculties untrained. The dangers of this method do not end here. I say flatly that the text-book cannot educate, but it has entered into branches from which it ought to have been excluded, if the object to be gained was education. For instance, Anatomy and Materia Medica in the new medical curriculum have by nearly common consent been surrendered to text-book teaching. What ought to be a series of object lectures, each fact being materialized and studied in its exact and natural relation, is reduced to a useless mem- orizing of a mass of disjointed facts that no amount of after training will place at the call of the man in after life when text-books are forgot- ten. What ought to be entirely laboratory work and lecture demonstration, is taught exclusively in the recitation room. If you remonstrate with an advocate of this method he will point with pride to the high aver- age of the man’s term examination, as though tech- nical education could be represented, like interest, at so much per cent. The teaching of anatomy was crude enough under the old method in the majority of the schools, but it is incomparably worse in those in which the text-book has gained the ascendant. It is extraordinary that small country schools that aspired to take a high rank as thorough teaching bodies did not see the ad- vantage that would result to them of excluding the elementary sciences entirely from the recita- 12 tion room and making them the subjects of labor- atory work. So far for the student. But I believe that the effect upon the teacher is equally bad. A medical teacher, of all men given to that calling, ought to be a man growing continually deeper in his knowledge, wider in his range of mental vision, and riper and more complete in his method of work. He reaches these progressive levels of de- velopment by study and experience in his real specialty, that of teaching. Conceive of the ef- fect upon any ordinary man of sitting before a class of young men, with his book upon his knee, and hearing a mechanical recitation, while he in- dustriously marks his men as they repeat more or less accurately the pages of the author then in the ascendant upon the subject-matter of the profes- sor’s topic. Can he develop ? Will his character round out in the fullness of time into the perfect teacher who inspires enthusiasm, clarifies the un- derstandings of his students, and contributes his share toward developing that most complete em- bodiment of the education of the age, the scientific observer ? What retards the growth of the graded system ? why is it recommended instead of required in 96 out of 109 colleges? The reason is, I believe, mainly due to the fact that practical educators recognize the insuperable difficulties of joining a system of graded study to a three years course of the numerous subjects that enter into a medical education. In some schools anatomy consumes two years, the freshmen of the second year taking it up where the freshmen of the year before left it off. The same was true of physiology, and yet in this same year clinical medicine and surgery, with therapeutics, had of necessity to be taken up. I know of no school where the elementary sciences were cleanly finished up in the freshman 13 year under the graded system. This is not the place, nor have I the time to give all the reasons necessary to prove my position that the old didac- tic three years course of study must be abandoned in favor of a four years course of study, in order to perfect a system of graded medical training. Nor has the demand of the profession been satis- fied by this imperfect attempt at reform. The growth of the polyclinic, the development of which has been a phenomenal outgrowth of the attempted reform in medical education, is one of the best evidences that the working body of the profession is in search of something better in the way of technical training than is afforded by the medical college. Their existence as teaching bodies independent of the regular schools still further complicates the question, and will in the future add further difficulties in the way of the adjustment of the conflict that exists between the just demands of the body of the profession and what we are compelled to regard as the mercan- tilism of the schools. Under this so-called graded system gynecology has fared more poorly than under the old method. In one school dermatology is given a full chair, while gynecology is in charge of an instructor, at the end of everything. Three of the schools have the subject assigned to the second year, while the ten remaining have given it to the third year. It appears as much out of place in one as in the other, if we are to find a place for it among the following third year studies as advertised by one school, namely: Therapeutics, practice, surgery, clinics, obstetrics, pediatrics, gynecology, forensic medicine, ophthalmology, hygiene. This school gravely states in its advertisement that ‘ ‘ steady growth and not distension is the result ’ ’ of the graded system. 14 Now, under these circumstances, how is gyn- ecology taught? It is simply not taught. The graduate leaves his alma mater with his mind like virgin soil so far as this great branch is concerned. In forming an estimate of what a medical college can do we must take into consideration our own personal bias. We of this Section insist that medical education should tend to make a student a safe and efficient obstetrician and gynecologist, while the ophthalmologist makes the same demand for his Section, and the neurologist for his. Now we must admit that it is not the purpose, nor is it possible, for medical schools to turn out the fin- ished expert in the practical subdivisions. In this sense we must regard the school as a primary department in medicine. It sows the seed, and each one reaps a harvest according to his needs, or the quality of his manhood. If in all the spe- cial fields, in which a practical knowledge implies brain culture with manual training, the medical teacher will teach correctly, consuming the time, brief of necessity, that the student can devote to the branch, grounding him in practical education with sound viva voce object teaching, and not text- book recitation with a view to passing an examin- ation, the man may be safely left to himself in the field of practice. Teach him to observe and how to examine, and knowledge and expertness will come to him. The man who travels through a strange country with a map and compass does not find depicted ever}- declivity and vale and devious winding of his route. His map gives a series of suggestions, his compass points the way, the land- scape is new and strange, yet with trained facul- ties of observation he safely pursues his way. We are living to-day under a new dispensation in the matter of teaching gynecology, and that is the influence diffused among us by the womens’ 15 hospitals. Starting from the germ planted by our great master Sims in the Woman’s Hospital of the State of New York, scarce a city of the land but has its hospital, great or small, public or private, where some faithful master, surrounded by a little band of followers, works and teaches. Each be- comes a nucleus from which radiate widely di- verging influences, the result of which may be seen in nearly every hamlet of the land. But a few years have witnessed this influence at work among us, and but a few years bear the token ot the new art itself, yet the numbers who have re- ceived their inspiration and teaching from this source may be numbered by thousands. Those who were under the personal influence of Sims realize the full meaning of this. Being in touch with this man has sent a thrill of enthusiasm down far-reaching channels of medical life that has not yet ceased to vibrate. To us the man is a memory, in a few years he will become a tradition, and will pass into the history ot a great people and of a beneficent art, while his influence over the think- ing and doing of those who come after him in his beloved art is ever growing wider and deeper. Sims was a man of the working ranks. He was the apostle of the general practitioner, he leavened the mass, he diffused through it his superabundant individuality like a subtle essence. To his teach- ing, his example, and his enthusiasm we owe the position we occupy among the nations as gyne- cologists. - CM:.: TirtAI m W YuRK Hospital for Women, . bi > k., SYRACUSE, N. Y. Dr. ELY VAN DE WAKKEE, Surgeon in Charge. Miss Dr. F. A. ADAMS, Assistant Physician. MIss J U LI EXT E GO D PRE Y, Matron.