The Practical Teaching of Gynæcology.

901 of these " accidents" are preventable and should be preA better sense of responsibility in driving vented.

be said that the two

subjects of the medical curriculum which are most inadequately taught from the practical point motor-cars than has hitherto existed should be esta- of view at the present time are midwifery and gynaecology. It lies in the The legislation of last year is a complete Nor is the reason for this far to seek. blished. in the police-courts difficulties which surround the practical teaching of these failure. To follow the cases reported is to realise that the punishment for offences is in no way two subjects-difficulties which in this country at any deterrent, that too much stress is laid on the actual pace of rate very little attempt has been made to overcome. locomotion and too little on the exigencies of the roads in There is perhaps no subject in the whole range of the use, while no attempt has been made by local authorities to student’s career in which clinical teaching is of such enforce the provisions of the Act of 1903 which empowers importance, while the difficulties surrounding the proper " " carrying out of such teaching and the adequate excounty councils to limit speed within any areas or places which they may select, subject to the ratification by the amination of cases of pelvic disease are very considerable Local Government Board of their restrictions. We write not only on behalf of the general

indeed.

If the student

practice to enable public lung properly and such have to use the roads but also in the interests of motor-cars; systematically, how much more does he require practice medical men use them largely now and will use them more in the bimanual examination of the female pelvic organs? largely after the extremely satisfactory trials of small cars1 Yet from the very nature of the class of case it is often imposwhich the profession has been recently watching with much sible for a student, no matter how energetic he may be or interest. If the conduct of motorists is such as to create a how keenly he may seize the opportunities afforded him, to deep feeling against them which will be reflected in the become really expert in such examinations. The number actions of the county councils, limitations on the use of by- that can examine any one case is strictly limited and theIn our experience roads may be imposed which will be irksome to motorists in opportunities are correspondingly few. are loth to examine the but men often which will be peculiarly prejudicial to the use patients and require general, of horseless vehicles by the class of professional men who constant urging to make them seize all the opportunities need them most and who will unquestionably be valuable that are afforded them, nor is this frame of mind to becustomers to the automobile industry in the near future. wondered at. Many of the gynaecological out-patient There are a large number of excellent journals devoted to departments in our large general hospitals are flooded with motor-cars but it is to be regretted that they do not seem a number of cases of no value from the teaching point of to employ the influence which undoubtedly they possess to view and the time of the out-patient physician is only too train the neophytes of motoring in the important items of often taken up with such cases with the result that his, careful and considerate driving. One well-known manual, opportunity for teaching is markedly curtailed. It is a disheartening fact that there is no provision for which has reached a third edition, has a full-page illustration of "how to take a corner "-namely, on the wrong side any student who wishes to make a specialty of gynaecology of the road. It is true that the letterpress contains instruc- to pursue his studies in London. It is true that if he has the tions stating when the illustration should not apply but the time he can sometimes obtain a clinical assistantship at one picture is far more obvious than the letterpress and has of the special hospitals, but even there he is left more or less One of the best to his own devices, while of proper post-graduate teaching doubtless had regrettable results. periodicals contained in the spring of 1903 instructions, with an opportunity of carrying out a large number of pelvic’ with diagrams, for getting the shortest line of travel on a examinations there is no provision at all. Constantly winding road, which involves for the better maintenance have we had to advise a student wishing to obtain a special of equilibrium round curves the cutting of corners on the course of instruction in gynaecology to go abroad to one of wrong side of the road. Both tutors and pupils think but the foreign clinics. This is a condition of things which of the speed and learn only the lesson of safety at the should not exist in the largest city in the world. it is theAll this must be changed and then more to be deplored because the student sometimes in these expense of disaster. the motor-car will take its place as an unobjectionable, as circumstances must enter on his professional career without a sufficient amount of practical training to enable him to say well as a most useful, means of locomotion. with certainty whether the pelvic organs in any patient who

him to examine

are

The

Practical

Teaching Gynæcology.

of

THE

great strides which the art and science of gynaecology have made in the last few years have much increased its

importance

of the

subjects of the medical curriculum. knowledge required of the student is now

as one

The standard of much higher than it

and the examinations are correspondingly more difficult. Pari pa.ss2c with the development of the subject the teaching no doubt has improved but was

there is still much to be done in this direction.

It may well

1 An account of these trials was given in THE LANCET of Sept. 10th, p. 799, and they are referred to also in another column of our present number.

normal

or

a case

not.

requires

of heart

constant

or

disease

It must be confessed that the diffi-

culties in the way of ensuring that every student shall be as competent to examine the pelvic organs as he is to examine the chest are very great. That they are not insuperable in the case of a small number of candidates for an examination is shown by the fact that at the last London M.D. examination in obstetric medicine arrangements were actually made by which a practical examination in gynas-

cology was conducted satisfactorily. It will only be when the various examining bodies in this direction that

make

we shall see any marked the With increased improvement. tendency to treat so many of the diseases of women by operation the importance of accurate diagnosis becomes greater and greater. The a

move

902 fact that abdominal sections atthe present day carried out with such certainty and security to the

to attempt to avoid infection but’fortunately f risks be some may patient easily exaggerated. Indeed, is likely to cause the practitioner in the press and hurry of have maintained that the risks are so slight that it is work to lay less stress than he should upon the elucidation needless to attempt to prevent contagion. It is true that of all the minute physical signs of a case of obscure I some may live long and healthy lives without having abdominal disease. It is, of course, true that the detection adopted any precautions but the fact that contagion does of the minutest differences in the physical signs of any spread and in the most varied ways shows that if protection particular case is often of not the least importance in the can be obtained with a reasonable amount of trouble it is prognosis or treatment of the condition but at the same time worth the attempt. In some directions in which the risks of it affords the highest form of practical training both for the the transmission of disease are especially great much may be can

be

for

us

the

student and for the teacher, and its importance from the done by way of prophylaxis. There is one occupation which point of view of the education of the student cannot be over- undoubtedly is a fruitful channel of the dissemination of The great masters of clinical medicine con- disease and that is the hairdresser’s. The hands of the estimated. sidered no minute difference in the physical signs of any barber and the utensils which he employs come into very case too unimportant to be taken into account or to be intimate contact with the scalps and the faces of the persons we out. When examinations in on whom he operates, and should any disease be present the find, however, pointed gynaecology carried out without any practical test at all we chance of its spreading is very great indeed. In the ordinary operation of hair-cutting the scissors may cannot expect students to spend much time in the acquisition of knowledge which seems to be of no immediate value to convey disease but still more likely is disease to be spread them according to their often ill-judged notions of what is by the brushes and there is hardly anything more difficult to valuable in their training and what is not. It is indeed disinfect than a brush. Very slight observation of the ways only of recent years that it has been obligatory on the of most hairdressers will show that no attempt is made to student to take a clerkship in the gynaecological out- cleanse frequently the brushes employed. The rotating patient department or in the women’s wards. Let us hope brushes, which are extensively used, are probably even more that before long we shall find the various examining bodies successful in transferring micro-organisms than the handinsisting on some evidence that the candidates who present brushes, for the former are brought more forcibly and themselves for their diplomas have something more than a intimately in contact with the skin of the scalp. It is not unusual in cases of ringworm of the scalp for a scaly patch mere book knowledge of so important a subject, one in to remain after the reappearance of the hair ; in these cases, and which improper treatment can do so much mischief one in which the practical training of the medical student although the disease is apparently cured, the fungus is still of at the present time is more imperfect than in any present in large numbers. We have known of an instance of the other subjects in which he has to present himself for this condition in which a careful parent took a child to a hairdresser to have the hair"brushed

examination.

the scaliness. Who can estimate the of ringworm which may have resulted from that single case ? At the present time few dermatologists doubt the bacterial origin of seborrhoea capitis, though there order to

The MANY

Hygiene

of the Barber.

remove

number of

cases

possible channels of contagion and the spread enormously assisted by most of the may be less unanimity as to the micro-organism responsible facilities and conveniences of modern life. The gathering for the condition and the very great prevalence of the together of human beings in masses will always tend to disease is probably in part at least due to the brush of the promote the transference of germs from the diseased to the hairdresser, for it cannot be doubted that nearly every healthy. Everything used in common must teem with brush of almost every hairdresser in the whole country is bacteria, from the cab or the omnibus to the telephone or infected with it. The other branch of the hairdresser’s art is the speaking-tube. THACKERAY, in his " Book of Snobs," even more likely to lead to the transmission of disease, for laughed at the fastidiousness of some clubs where it was in shaving the skin is liable to be wounded and thus points considered necessary to wash silver coins before offering of entry are provided for micro-organisms. Even when no are

the

by machinery"in

of disease is

Those, however, who bear in mind the wound is made several diseases may be transferred. Some

them to members.

frequency with which coins by omnibus conductors and

are

held between the teeth

others while

forms of impetigo are perhaps the most common and other manifestations of the ordinary pyogenic organisms are also found. A form of ringworm is also not very rare on the

finding change weights to keep down the eyelids of the dead are not likely to level sarcasm at chin, always, or nearly always, due to the presence of the such a desirable hygienic practice as washing money. We trichophyton megalosporon ectothrix, and this is certainly do not in the least undervalue the very extensive increase in many instances contracted during the process of shaving. in primary education during recent years but it is impossible This disease, with the manifestations of the pyogenic cocci, to doubt that elementary schools have done much to spread constitutes what is popularly known as " barber’s itch " and scarlet fever, measles, and diphtheria, to say nothing the name indicates the popular attribution of the source of much less dangerous diseases such as ringworm and of the malady. The contagious variety of alopecia areata impetigo contagiosa. Convalescent homes and country of the chin is also doubtlessly spread by the operation of camps all tend to promote the extension of zymotic diseases shaving and at the last meeting of the International by crowding together many people. With so many channels Dermatological Congress in Paris a case was quoted in which. or

of

who have

contagion

seen

it

them used

might

as

appear

to

be

almost

hopeless

a

barber

naively remarked

that he had had many

examples