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THE TEACHING OF ANATOMY
155 But real-life disability must be conceded: a grumbling appendix the same thing as grumbling schizophrenia. Nor could one ignore the real social problems of immigrant minorities (e.g., of the Irish in London), which often contributed more than their share of pathological reactions-firstly because of discrimination against them by the majority, which produced reactive disturbances of all kinds; secondly, because such groups tended to contain an excess of psychologically vulnerable and psychopathic people; and, thirdly, because any rapid social change was potentially disruptive. Exclusion of immigrants particularly likely to induce hostility seemed legitimate. Legislation obliging firms to employ a proportion of disabled people had eased some of the problems of this group, and legislation against other forms of discrimination was overdue. But the problem was one of prevention as well as of cure, and Dr. Fox warned that television films were spreading a new and distorted view of the " white man’s world " among emerging peoples. The tendency to overvalue intelligence tests, too, was producing " first-class and second-class citizens " from as early as 8 years of age. " Regarding the authoritarian personality ", Dr. Fox believed that, as with psychopathy, authoritarian traits were universally distributed to varying degree. The more abnormal forms of authoritarianism could be little influenced-indeed attempts to do so often raised the resistances still higher. Prejudices here had a protective value. The problem was one of prevention, and any action programme must hope that favourable changes in the mass would more than contain the disordered few. It seemed likely that race feeling existed quite apart from high scorers on the Californian F (Fascism) scale, but these people could become foci of violence in tense situations. Society could rightly take strong measures against those who threatened the social order by stirring up inter-race trouble. Research into the origins of morbid attitudes might be usefully and economically incorporated into the various longitudinal studies designed to shed light on the origins of other forms of social and psychological disorders. Discussing the development of cognitive and affective attitudes in children, Dr. HENRY TAJFEL (Oxford) noted three main theoretical trends: " general motivational theory " in which prejudice might be related to inherent fear of the strange and to inevitable frustrations during the process of socialisation; the attempt to trace prejudice through special personality structures, such as the scale of authoritarianism; and theories related to direct parental and peer group influence. Dr. Tajfel was clear that a multiplicity of influences were at work and indicated some ways in which children first recognised differences between things, then identified them for what they were, and finally put values upon them in a single concrete manner. Study of concept formation in arithmetic was revolutionising mathematics teaching in the U.S.A., and physics textbooks, too, were being rewritten. It seemed likely that more knowledge of the evolution of crucial social concepts (so far neglected) could be applied in nursery and primary schools. Dr. Tajfel looked forward to the day when a new subject, " People around you," might take its place in the curriculum. The importance of influencing the teaching of teachers was frequently noted in subsequent discussions, though it had proved very hard to get teachers to accept or impart this kind of information. Apart from the priorities of educational action, perhaps
Medical Education
was not
three
important general conclusions emerged:
(1) Real differences-perhaps inherent ones-exist between groups and the aim is to modify attitudes towards these differences. (2) Anti-discrimination legislation need not and should not wait upon education programmes, and should run ahead of public opinion. Desegregation of housing estates in the U.S.A., for example, though strenuously resisted at first, was shown to lead to more tolerant attitudes towards Negroes. (3) What public figures said and did was important-the example set by the Queen, for instance, when she recently visited a leper colony in Nigeria.
THE TEACHING OF ANATOMY IN the year 1901, when I began to dissect the human body and to study its structure, anatomy was considered, by many students, as the dullest and most difficult of all the subjects of the medical curriculum. It was hard to learn, easy to forget, and full of detail the relationship of which to our future work as doctors was not obvious to us; and the second professional examination, which included anatomy, was the pons asinoruna of medicine and dreaded by most of us. It should have sprung to life in " physiology, which may be defined as anatomy in action ". It did not really do so. The departments were separate, independent, and uncoordinated-for example, I was taught the physiology of the heart before I knew its anatomy. By the time we students reached the wards and the study of clinical medicine and surgery-the real goal of these two basic studies-they had been largely forgotten, lost. and their freshness and interest had been This defect in the teaching of anatomy, which I find exists in the teaching of 1961 just as it did sixty years ago, was not the fault of our teachers. They were masters of their subject, keen on teaching us, personally interested in our success. The fault lay in the system. It can be, and it seems to me ought to be, put right in 1962. Let me explain how I think it can be done. The essential defect in the teaching of anatomy is that the student has to learn an immense number of separate facts, without pegs in his memory to hang them on and without any clear idea of how any single fact is to be of use in the practice of his profession. These facts should be linked up with those of physiology and of clinical medicine. Take, for example, Wilson’s disease. This disease was first identified by Kinnier Wilson in 1911. In 1913,I took an adolescent girl to a consultant, who informed me that she was suffering from degeneration of the lenticular nuclei at the base of the brain (as Wilson’s disease was then called). I knew this girl well, and when, less than a year later, this consultant presented me with a girl of the same age for diagnosis, I at once made the correct diagnosis of this disease, the whole appearance and actions being characteristic. Years later it was discovered that Wilson’s disease was due to a defect in the metabolism of copper, which metal was deposited in the lenticular nuclei and in the liver and eventually caused these
partly
degenerate and so brought about the patient’s death. What a fine opportunity for a film, to link up dramatically the normal anatomy, the physiological defect, the clinical picture. If described by, say, a clinical tutor in general terms, it could hardly fail to excite the student’s vivid interest. It would be shown to him while he was dissecting the brain, and surely he could hardly forget about the lenticular nuclei. organs to
This principle could be applied to many diseases and all the organs of the body. It would solve the vexed question of how much of the special subjects, anatomy and physiology, should be taught to the average student. The answer is-as much as is necessary to enable him to understand his clinical work. The construction of these films, all over the great sphere of disease, would call for enormous skill and knowledge. But it would be worth while. The teachers of anatomy and physiology would find their students keen and eager, and the clinical teachers would find their students had a wonderful background of knowledge on which they could build. I met recently an attractive lad of eighteen. He had just finished at a great English public school and was to
156 to enter a Scottish university. I asked him if he going to study medicine. He told me that he was not clever enough for that. I wondered. Might it be that it was not the student was not clever enough, but that his teachers were not clever enough to take advantage of modern advances and make their entrancing science easy
about was
to
learn and
to
understand ? PETER MCEWAN.
LEARNING ANATOMY BY INVENTION IN the mass of criticism on medical education in recent years, the main one has fallen on the excessive use of memory to pile up for a time facts for examinations with no or little stimulation of the thinking and inquiring mental processes necessary for future adaptability and
flexibility. Anatomy has been most blamed as a mentally deadening study, which it certainly was when, in Scotland (whence come most of the professors and textbooks), I was first plunged into osteology, the memorisation of bare bones with their bumps (tubercles) and their hollows (fossae) to which muscles and tendons (unseen then) were said to be attached. With such uncoordinated facts I crammed by memory and won a stupid prize because I could say whether one of the eight little bones in the wrist was or left. I can’t remember even its name now, but I do recall the slightly vulgar students’ mnemonic (not in Gray) which helped us to name rather uselessly (except for examinations) the eight wrist bones. When I came down to London to take the primary I found most of the questions more practical, but to be asked to identify a baby’s shrivelled uterus (bee-sized) in a spirit bottle did not strike me as an intelligent use of the brain nor a useful index of anatomical knowledge for a future surgeon. Since then I have thought of a less stultifying way of learning anatomy, and as I shall never be a professor or teacher to inculcate it by demonstration I shall outline it here as if I were:
right
(1) First, with a strung-up skeleton I would name the bones and demonstrate the movements of the joints, flexion, extension, pronation, &c; no invention about this but merely the hard broad facts of the skeleton without any details. Next, on a lean and muscular student I would demonstrate the tensing and use of the muscles involved in a few joint movements of flexing and extending, say, the knee or elbow, and perhaps explain how they are named. (2) Then I would set the class, by inspection and palpation of themselves and their fellow students, to study the muscles, their origin and insertions, used in various movements, and so to invent myology for themselves. They would compare their different inventions under the guiding eye of the teacher and so perhaps arrive as a class at an agreed invented myology for which the teacher might help them to invent names. Then they would by dissection and/or by illustrated textbooks (Gray would do) see what Nature had produced and the names that man had given to the results of natural evolution of the muscular system. This I think would not only stimulate the imagination but probably imprint the necessary facts more easily on memory than many hours of the present weary swotting. (3) Then neurology and angiology could be studied, though less easily, in the same sort of way, after a brief but necessary course
of
embryology had shown
ments carry structures.
the
nerves
and vessels
how the
out to
developing segsupply the peripheral
And so, as far as possible, in every system let the student make his own discoveries and then compare these with the facts of Nature. I hope this is enough to make mv
main idea clear
to
teachers and students.
R. D.
LAWRENCE.
In
England
Now
A Running Commentary by Peripatetic Correspondents " THE patient, aged 33, married 10 years, gave birth to 2 living children followed by 2 abortions and 2 stillbirths, both rhesus affected. Her blood-group is Rh-negative cde/cde, and her husband’s Rh-positive cDE/CDe. Last year she became pregnant again. At 35 weeks her blood showed an antibody titre of 1/800, at 37 weeks 1/1200. It was decided to induce labour by csesarean section. The mother made a good recovery and the child thrived despite prematurity." The dry, precise voice of the lecturer continued: " This case must be called a failure, because to our surprise the baby’s cord blood showed the child to be Rh-negative, cde/cde. This, of course, could not happen with a rhesus-positive father who was homozygous. We checked for technical errors,but found none. We have to admit the genotyping is based on probabilities and not on certainties, and one possibility is that the father had been wrongly typed." My thoughts wandered to another possibility and a patient with a similar history. Sally K. has reddish hair, a bit untidy, a freckled face and a good figure. She is fond of her family, works hard, feeds them well, and keeps the place fairly clean. Every now and then she gets an urge to have a baby. Some women are like that. It is a primitive urge not understood by men. It has little or nothing to do with the urge for sexual intercourse, which is quite well understood by both men and women. This urge to have a baby is satisfied by pregnancy, labour, and the handling and care of a live child. A dead one or a miscarriage will not do. The begetting is not important. The important thing is to deliver yourself of a living baby. Sally is no fool. She realises that her husband (not his fault) cannot give her one. In a way she was lucky. She picked a man -it must have been pure chance-who was Rh-negative like herself. But instead of a decent normal labour and a child big enough to handle from birth, she had a cassarean section and a premature baby. She had not reckoned on the marvels of modern obstetrics. It was rumoured that our hospital group’s funds were benefiting unexpectedly from the closure of an outlying sanatorium. I got in quickly with a request for an automatic processing unit (for some S7000). It proved to be the winner, for none of the competing demands could mop up the windfall so effectively within the remaining weeks of the financial year. I was away during the actual installation, but returned a day early to see the inauguration. At 10 A.M. I asked how many films were ready for reporting. Given the answer less than half-a-dozen, I decided that as I was still really on holiday I
would go out for an hour to attend to little matters in the town (such as the replenishment of my depleted bank account). At 11 A.M. I returned and was horrified to find an enormous tottering pile of films, and the machine still oozing them out before my eyes, all dry and ready. The pile grew almost as fast as I could get through it. The unit cost around E7000, and I did not have to say " please " twice. But I am putting in a request for about £ 300-worth of equipment to enable us to provide an abdominal aortography service for the hospitals in the city. I look forward to a long-drawn-out running battle before we get it. There is more to reading in bed than just keeping warm. Every doctor will have smiled to himself during the weeks of fascinating correspondence in the top people’s newspaper. It would seem that the peak of human ingenuity must have been reached in bizarre designs for thermal efficiency in our night attire: the uttermost limit of technological skill brought to bear on creating a tolerable microclimate for us to snatch a glimpse of the written word before next day’s radio and television start again. But the problem does not end with the physiology of the body’s heat-regulating mechanism. Simple delicacy has prompted me to transfer these matters to a medical journal: clinical interest is better kept on a professional plane.
Medical Education
was not
three
important general conclusions emerged:
(1) Real differences-perhaps inherent ones-exist between groups and the aim is to modify attitudes towards these differences. (2) Anti-discrimination legislation need not and should not wait upon education programmes, and should run ahead of public opinion. Desegregation of housing estates in the U.S.A., for example, though strenuously resisted at first, was shown to lead to more tolerant attitudes towards Negroes. (3) What public figures said and did was important-the example set by the Queen, for instance, when she recently visited a leper colony in Nigeria.
THE TEACHING OF ANATOMY IN the year 1901, when I began to dissect the human body and to study its structure, anatomy was considered, by many students, as the dullest and most difficult of all the subjects of the medical curriculum. It was hard to learn, easy to forget, and full of detail the relationship of which to our future work as doctors was not obvious to us; and the second professional examination, which included anatomy, was the pons asinoruna of medicine and dreaded by most of us. It should have sprung to life in " physiology, which may be defined as anatomy in action ". It did not really do so. The departments were separate, independent, and uncoordinated-for example, I was taught the physiology of the heart before I knew its anatomy. By the time we students reached the wards and the study of clinical medicine and surgery-the real goal of these two basic studies-they had been largely forgotten, lost. and their freshness and interest had been This defect in the teaching of anatomy, which I find exists in the teaching of 1961 just as it did sixty years ago, was not the fault of our teachers. They were masters of their subject, keen on teaching us, personally interested in our success. The fault lay in the system. It can be, and it seems to me ought to be, put right in 1962. Let me explain how I think it can be done. The essential defect in the teaching of anatomy is that the student has to learn an immense number of separate facts, without pegs in his memory to hang them on and without any clear idea of how any single fact is to be of use in the practice of his profession. These facts should be linked up with those of physiology and of clinical medicine. Take, for example, Wilson’s disease. This disease was first identified by Kinnier Wilson in 1911. In 1913,I took an adolescent girl to a consultant, who informed me that she was suffering from degeneration of the lenticular nuclei at the base of the brain (as Wilson’s disease was then called). I knew this girl well, and when, less than a year later, this consultant presented me with a girl of the same age for diagnosis, I at once made the correct diagnosis of this disease, the whole appearance and actions being characteristic. Years later it was discovered that Wilson’s disease was due to a defect in the metabolism of copper, which metal was deposited in the lenticular nuclei and in the liver and eventually caused these
partly
degenerate and so brought about the patient’s death. What a fine opportunity for a film, to link up dramatically the normal anatomy, the physiological defect, the clinical picture. If described by, say, a clinical tutor in general terms, it could hardly fail to excite the student’s vivid interest. It would be shown to him while he was dissecting the brain, and surely he could hardly forget about the lenticular nuclei. organs to
This principle could be applied to many diseases and all the organs of the body. It would solve the vexed question of how much of the special subjects, anatomy and physiology, should be taught to the average student. The answer is-as much as is necessary to enable him to understand his clinical work. The construction of these films, all over the great sphere of disease, would call for enormous skill and knowledge. But it would be worth while. The teachers of anatomy and physiology would find their students keen and eager, and the clinical teachers would find their students had a wonderful background of knowledge on which they could build. I met recently an attractive lad of eighteen. He had just finished at a great English public school and was to
156 to enter a Scottish university. I asked him if he going to study medicine. He told me that he was not clever enough for that. I wondered. Might it be that it was not the student was not clever enough, but that his teachers were not clever enough to take advantage of modern advances and make their entrancing science easy
about was
to
learn and
to
understand ? PETER MCEWAN.
LEARNING ANATOMY BY INVENTION IN the mass of criticism on medical education in recent years, the main one has fallen on the excessive use of memory to pile up for a time facts for examinations with no or little stimulation of the thinking and inquiring mental processes necessary for future adaptability and
flexibility. Anatomy has been most blamed as a mentally deadening study, which it certainly was when, in Scotland (whence come most of the professors and textbooks), I was first plunged into osteology, the memorisation of bare bones with their bumps (tubercles) and their hollows (fossae) to which muscles and tendons (unseen then) were said to be attached. With such uncoordinated facts I crammed by memory and won a stupid prize because I could say whether one of the eight little bones in the wrist was or left. I can’t remember even its name now, but I do recall the slightly vulgar students’ mnemonic (not in Gray) which helped us to name rather uselessly (except for examinations) the eight wrist bones. When I came down to London to take the primary I found most of the questions more practical, but to be asked to identify a baby’s shrivelled uterus (bee-sized) in a spirit bottle did not strike me as an intelligent use of the brain nor a useful index of anatomical knowledge for a future surgeon. Since then I have thought of a less stultifying way of learning anatomy, and as I shall never be a professor or teacher to inculcate it by demonstration I shall outline it here as if I were:
right
(1) First, with a strung-up skeleton I would name the bones and demonstrate the movements of the joints, flexion, extension, pronation, &c; no invention about this but merely the hard broad facts of the skeleton without any details. Next, on a lean and muscular student I would demonstrate the tensing and use of the muscles involved in a few joint movements of flexing and extending, say, the knee or elbow, and perhaps explain how they are named. (2) Then I would set the class, by inspection and palpation of themselves and their fellow students, to study the muscles, their origin and insertions, used in various movements, and so to invent myology for themselves. They would compare their different inventions under the guiding eye of the teacher and so perhaps arrive as a class at an agreed invented myology for which the teacher might help them to invent names. Then they would by dissection and/or by illustrated textbooks (Gray would do) see what Nature had produced and the names that man had given to the results of natural evolution of the muscular system. This I think would not only stimulate the imagination but probably imprint the necessary facts more easily on memory than many hours of the present weary swotting. (3) Then neurology and angiology could be studied, though less easily, in the same sort of way, after a brief but necessary course
of
embryology had shown
ments carry structures.
the
nerves
and vessels
how the
out to
developing segsupply the peripheral
And so, as far as possible, in every system let the student make his own discoveries and then compare these with the facts of Nature. I hope this is enough to make mv
main idea clear
to
teachers and students.
R. D.
LAWRENCE.
In
England
Now
A Running Commentary by Peripatetic Correspondents " THE patient, aged 33, married 10 years, gave birth to 2 living children followed by 2 abortions and 2 stillbirths, both rhesus affected. Her blood-group is Rh-negative cde/cde, and her husband’s Rh-positive cDE/CDe. Last year she became pregnant again. At 35 weeks her blood showed an antibody titre of 1/800, at 37 weeks 1/1200. It was decided to induce labour by csesarean section. The mother made a good recovery and the child thrived despite prematurity." The dry, precise voice of the lecturer continued: " This case must be called a failure, because to our surprise the baby’s cord blood showed the child to be Rh-negative, cde/cde. This, of course, could not happen with a rhesus-positive father who was homozygous. We checked for technical errors,but found none. We have to admit the genotyping is based on probabilities and not on certainties, and one possibility is that the father had been wrongly typed." My thoughts wandered to another possibility and a patient with a similar history. Sally K. has reddish hair, a bit untidy, a freckled face and a good figure. She is fond of her family, works hard, feeds them well, and keeps the place fairly clean. Every now and then she gets an urge to have a baby. Some women are like that. It is a primitive urge not understood by men. It has little or nothing to do with the urge for sexual intercourse, which is quite well understood by both men and women. This urge to have a baby is satisfied by pregnancy, labour, and the handling and care of a live child. A dead one or a miscarriage will not do. The begetting is not important. The important thing is to deliver yourself of a living baby. Sally is no fool. She realises that her husband (not his fault) cannot give her one. In a way she was lucky. She picked a man -it must have been pure chance-who was Rh-negative like herself. But instead of a decent normal labour and a child big enough to handle from birth, she had a cassarean section and a premature baby. She had not reckoned on the marvels of modern obstetrics. It was rumoured that our hospital group’s funds were benefiting unexpectedly from the closure of an outlying sanatorium. I got in quickly with a request for an automatic processing unit (for some S7000). It proved to be the winner, for none of the competing demands could mop up the windfall so effectively within the remaining weeks of the financial year. I was away during the actual installation, but returned a day early to see the inauguration. At 10 A.M. I asked how many films were ready for reporting. Given the answer less than half-a-dozen, I decided that as I was still really on holiday I
would go out for an hour to attend to little matters in the town (such as the replenishment of my depleted bank account). At 11 A.M. I returned and was horrified to find an enormous tottering pile of films, and the machine still oozing them out before my eyes, all dry and ready. The pile grew almost as fast as I could get through it. The unit cost around E7000, and I did not have to say " please " twice. But I am putting in a request for about £ 300-worth of equipment to enable us to provide an abdominal aortography service for the hospitals in the city. I look forward to a long-drawn-out running battle before we get it. There is more to reading in bed than just keeping warm. Every doctor will have smiled to himself during the weeks of fascinating correspondence in the top people’s newspaper. It would seem that the peak of human ingenuity must have been reached in bizarre designs for thermal efficiency in our night attire: the uttermost limit of technological skill brought to bear on creating a tolerable microclimate for us to snatch a glimpse of the written word before next day’s radio and television start again. But the problem does not end with the physiology of the body’s heat-regulating mechanism. Simple delicacy has prompted me to transfer these matters to a medical journal: clinical interest is better kept on a professional plane.