(1)
Flinders University of South Australia School of Medicine, Adelaide, SA, Australia
The recorded history of simulation in health professional education stretches over 1500 years and around the world and in that time simulators and the professionals who used them have had many names. For most of this time medicine was at best ineffective, surgery was turned to as a last resort and there was little use of simulation. The Enlightenment that started in France in the middle of the seventeenth century and spread widely over the next hundred and fifty years challenged established doctrines, including the prevailing system of medicine. Using careful observation and experiment physicians and surgeons began to develop effective therapeutic measures from interventions during labor that could save the life of the fetus and the mother and vaccination could prevent smallpox.
The demand for knowledge of new medical proced ures overwhelmed the traditional apprentice-based training system and gave rise to courses in which simulation was introduced to help students learn the practical skills and when to use them. When such courses were first advertised in the early eighteenth century the pioneers of simulation-based training needed to explain this innovation to prospective students. Manningham’s advertisement for a course on midwifery in the London Evening Post in 1740 included an explanation that students taking this course would learn on “a contrivance made on the bones or skeleton of a woman, with an artificial matrix [womb]” [1]. Later in the advertisement this simulator was referred as “the machine”. The advertisement also explained why and how simulation was important in obstetrics education. Manningham identified that harm can come from having inexperienced practitioners attend patients and that students on his course would learn how to deliver a baby on the simulator before attending a real labor. A simulator would also be used to show what could go wrong and how such problems were best managed and then practice these interventions on a simulator.
From page 4 of the London Evening Post, Tuesday, April 12, 1740
“From the lying-in infirmary in Jermyn Street, St James. On Monday the 5th of May, at five in the evening, will begin lectures in midwifery; wherein the whole theory and practice of the art of midwifery will be fully explain’d and taught, …”
“Also the performance of deliveries of all kinds, with the utmost decency and dexterity, by means of a contrivance made on the bones or skeleton of a woman, with an artificial matrix; whereby all the inconveniences which might otherwise happen to women from pupils practising too early on real objects will be entirely prevented and each pupil become in a great measure proficient in his business before he attempts a real delivery. On this machine will also be showed the natural situation of the child and matrix and all the various preternatural situations of each and the safest and most effective methods of rectifying all these difficulties, and perfecting the delivery; and a further illustration of the best and proficient methods of performing difficult deliveries with all possible ease and safety, a small glass matrix is contriv’d (in which is enclosed an artificial child) to be fix’d on ivory frames, imitating the various shapes of the bones forming the pelvis, in that every position the matrix or child can any way take and the hindrance either may meet from the said bones and the easiest and most effectual ways of performing all difficult deliveries, (as is taught on the great machine) together with the realms of the rules, will hereby in a most instructive manner be beautifully and clearly represented to the eye.”
Sir Richard Manningham [1]
The Rise of the Machines
Machines that imitate nature have always been a source of fascination and have a long history. The philosopher Lao Tzŭ (b. 604 BCE) described an automaton made by the “artificer” Yen Shi that could walk, sing, gesture, and wink. The individual parts were made from wood, leather, and glue and painted and inside the body were “all the internal organs complete—liver, gall, heart, lungs, spleen, kidneys, stomach, and intestines—and over these, again, muscles and bones and limbs with their joints, skin and teeth and hair, all of them artificial” [2, pp. 90–92].
Several automata made by mechanicians in the sixteenth and seventeenth century have survived and show remarkable ingenuity in their construction. The modern era of machines in healthcare education began around three hundred years ago and the terms associated with their use in this context evolved as the meaning of terms changed and new ones were invented. The term simulation, derived from the Latin simulare, meaning to pretend or imitate, has a short history of use in healthcare professional education.
Machine was a term much used for a simulator in the eighteenth century. Some authors have misunderstood this use of machine in simulation and unfairly derided the pioneers of simulation that used it. William Smellie and Madame du Coudray did not use the term to suggest women were baby factories or birth could be managed like an industrial process. In the eighteenth century any device that had been made for an activity or action was a machine and it did not have connotations of engineering and manufacturing. For example, early in the eighteenth century Pierre Armand a surgeon in Paris invented a “nouvelle machine” for extracting the head of a fetus that had been separated from the body and was still in the uterus. Amand’s machine was a net with attached cords that was inserted by hand and passed up over the head which could then be pulled out [3, pp. 243–249]. The umbrella is another example of an eighteenth century machine [4, pp. 123–124].
“If you walk with an umbrella, and meet a similar machine, lower yours in time, lest you either break it, or get entangled with the other.”
Advice on walking London’s streets from The London Adviser and Guide by the Revd. Dr. Trusler (1790) [4]
An issue in this book was how to refer the health professionals who used simulation. Until the seventeenth century a midwife was a woman who was more or less experienced in comforting a woman giving birth but often knew very little about the process. The first surgeons or physicians such as William Harvey who acquired additional skills to intervene in childbirth were also called midwives. Professional midwives learnt their craft through a lengthy apprenticeship but the demand for training for the new discipline that would become obstetrics created a need for a different education model . The training courses that began to appear in the eighteenth century led to increased numbers of these practitioners and the term man-midwife was introduced to better explain their role in childbirth. This differentiation was important in justifying their fee which was more than that of a midwife. Some adopted the more fashionable title of accoucheur that originated in France. In France midwives were called sages-femme an in Germany they were called Hebamme or Geburtshelfer. Widespread use of the terms obstetrics and obstetrician developed in the nineteenth century and the word for obstetrics German started as Geburtshülfliche and later became Geburtshilfliche. A challenge in narrating the development of simulation has been the way boundaries changed in Europe in the last three hundred years particularly those associated with what is now Germany. The biggest problem has been with names used for simulators, which have changed a lot over the years in all languages.
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