Up to the seventeenth century, pregnancy and childbirth was surrounded by ignorance, myth, and superstition. It was thought that labor pains were caused by the fetus clawing its way out of the womb and that fetal malformations were the result of a woman seeing or dreaming something bad during the pregnancy. Complications of labor were thought to be predetermined and astrologists were consulted for information about the birth and the child. Most births occurred at home with female relatives and friends providing emotional support and sometimes a midwife provided “expert” assistance although in some European cities poor women delivered in lying-in hospitals. The title “midwife” was generally self-professed and based on experience attending births, sometimes as an apprentice, although at different times and places midwives were licensed by the church [1, pp. 24–49].

Most women who went into labor gave birth to a live child but it wasn’t unusual for there to be serious complications and the mother or child or both would be badly injured or die. Occasionally when labor was very prolonged, a midwife would send for a surgeon but this always caused alarm because it meant that either mother or baby (or possibly both) if not already dead, soon would be. The surgeon had little to offer beyond destruction of the fetus and piecemeal delivery of its remains to possibly save the mother or a postmortem Cesarean section in a usually futile attempt to salvage a child. So bad was the reputation of surgeons in this context that the midwife and family would try almost anything to deliver the child and in turn this meant that surgeons had a very poor opinion of midwives [2, p. 17].

The first person known to have used an obstetric simulator for teaching was a Swede, Johan von Hoorn (1661–1726). Johan von Hoorn graduated from the University of Leiden in 1690 where he had studied childbirth and his doctoral thesis, De partu praeternaturali, proved the fetus had only a passive role in childbirth. Fortuitously this meant that in an obstetric simulator the fetus did not need to be animated. After further study in Oxford, London, and Paris he returned to his home city of Stockholm in 1690 but the Collegium Medicum, the Swedish Academy of Medicine took 2 years to recognize his foreign medical qualification [8]. In 1705 von Hoorn was one of the five physicians selected by the Collegium Medicum to give public lectures. The lecture was on childbirth and von Hoorn used a phantom with female genitalia and a fetus made of leather to demonstrate that the mother expelled the fetus [9]. He had already written a textbook for midwives and soon after the public demonstration he began using simulation for teaching midwives.

Georg Heinrich von Langsdorf (1774–1852) documented the early development of simulation in teaching midwifery and obstetrics in his doctoral thesis submitted to the Georgia Augusta Academy in 1797 [10]. The Gregoires began using simulation early in the eighteenth century and this was the foundation of the modern era of simulation in healthcare education. Whilst von Hoorn had used simulation in teaching before the Gregoires, it was an isolated event. In contrast, some of Gregoire’s pupils went on to teach using simulation and spread the technique first to Britain, Germany, and Italy and then across Europe and to the United States and beyond.

Philippe Hecquet declared that men should not be midwives in “De l’indecence aux homes d’accoucher les Femmes” published in 1708 [19] and in 1720 the board of the Hôtel–Dieu declared it was “indecent” for men to deliver babies [20, p. 236]. With the door to the “Salle d’accouchements” at the Hôtel–Dieu closed to them in the eighteenth century and male student accoucheurs made private arrangements to obtain clinical experience. For example, to “attend labors with Mons. Gregoire, the experience is eight livres to see him deliver a natural case, eighteen to see him turn and deliver by the feet, one guinea if he delivers by instruments and if a pupil delivers any unnatural case he pays two guineas” [21, p. 23].

James Houstoun MD graduated from Leyden University in 1714 and travelled to Paris with the principal aim of getting obstetric experience at the Hôtel–Dieu. Once there, he discovered that as male he would only be able to gain entry if he had an order from the King [22, p. 74]. Fortunately, Houston had a relative with aristocratic contacts who recommended him to Lord Perth living in France who had connections in court. Houston visited Lord Perth regularly for several months but it was 9 months until Lord Perth received the order Houston was waiting for by which time he had stopped visiting. Some more months passed before Houston received word that he had been given permission to undertake a clinical attachment at the Hôtel–Dieu and could collect the letter from his sponsor. Houston outlined his experience at the Hôtel–Dieu in his memoirs, The Works of James Houstoun MD, published in 1753.

I brought near three hundred Women to-bed in the time, and every one of the four Midwives in proportion: So that we had cases of all sorts; we assisted one another and had a Mistress Midwife who directed the whole; and, in very extraordinary cases, we called in the Master-Surgeon of the Hospital’s assistance. [22, p. 74]

Houston had to invest a considerable amount of time and effort to gain access to this experience of obstetrics.⁴ This was out of reach of most wanting to train as an accoucheur and another mode of training was required.

A chirurgien-accoucheur called Gregoire began offering private obstetric lessons in Paris at the beginning of the eighteenth century and his courses attracted students from across Europe. Gregoire’s son, often referred to as Gregoire the younger, also studied obstetrics and then also began to teach. Many noted obstetric teachers and practitioners were students of one of the Gregoires including the Scottish surgeon-anatomist Alexander Monro⁵ who was taught by Gregoire the elder [23] and William Smellie, another Scot [6, p. 23], and Jean-Georges Roederer who would later become established in Göttingen were taught by Gregoire the younger [20, p. 236].

It cost the equivalent of two guineas to attend a course of lectures delivered by Gregoire the younger [6]. Whilst the lectures were never published [24] there are some notes made by students who attended their courses and others from which we know how simulation was used to teach midwifery and obstetrics, i.e., the knowledge and skills required by accoucheurs. A description of Gregoire’s simulator was published in The London Medical Repository [25].

M. Gregoire was in the habit of explaining labours upon a machine fabricated of basket-work and covered with a painted cloth: through this machine, a real foetus, often in a state of putridity, was made to pass, in order to show the progress of labour.

William Smellie described the simulator and how it was used by Gregoire the younger in a Treatise on Midwifery,

…his machine was no other than a piece of basketwork, containing a real pelvis covered with black leather, upon which he could not clearly explain the difficulties that occur in turning children, proceeding from the contractions of the uterus, os internum, and os externum. And as for the forceps, he taught his pupils to introduce them at random, and pull with great force. [26, pp. 250–251]

The improvements on Gregoire’s simulator made by Smellie are described in the next section on “Obstetric Simulation in Britain.”

A short Comparative view of the Practice of Surgery in the French Hospitals by Harrison [11] published in 1750 contained another less than complimentary description of the simulator used by Gregoire younger,

It is compos’d of Basket-work cover’d with coarse Cloth; the pelvis is Human, covered with oil-skin; It has neither Uterus Externum nor Internum, nor any of the Contents of the Abdomen, the Want of which he [] substitutes with his Hands; in short, ‘tis so rude a Work that a common Pelvis stuck into a Whale, without any Embellishment would be as like Nature as the Machine which has been so admir’d; It has not any appearance of Ingenuity or Resemblence of Nature…one might work for an eternity on Gregoir’s (sic) basket and never know anything of the matter; for let a Part, however difficult, present itself in his Machine, you deliver it as easily as you would turn a cork in a Pail of Water.

The Paris-trained midwife Marguerite Angelique le Boursier du Coudray created the first national rural simulation-based training course for midwives in the second half of the nineteenth century. Her work and the obstetric simulator she developed for the course are detailed in the section on “Simulation in Midwifery.”

Mme du Coudray also taught surgeons but her visits were not universally appreciated. For example in April 1776 she visited Nantes to teach the master surgeon Jean-Baptiste Urbain Godebert (1730–1799) and his colleagues how to use the mannequin for demonstration and practice. The training was conducted over 15 days but one surgeon, Sieur Etienvrin, did not think it was necessary to attend. The course went so well the local administrators bought two machines, one for teaching and one to be the model for making replacement parts for those that wore out during use, and du Coudray was given a bonus [27, p. 9; 28, p. 198]. Five years later Godebert reported positively on midwives trained using simulation [29].

Jean-Louis Baudelocque was a surgeon-obstetrician trained by Solayre de Renhac, at the Charité Hospital in Paris. He is well known for his work on pelvimetry which gave rise to “Baudelocque’s diameter” used to predict difficult births and his books, Principes sur l’art des accouchemens first published in 1775 and L’art des accouchemens [30]. In the introduction to his book on the art of obstetrics Baudelocque recommended using a mannequin to demonstrate the process of childbirth and to practice obstetric procedures. In 1777 Baudelocque married Andree Voulier, whose family made obstetric mannequins [31]. An announcement in L’avantcoureur (The Front-runner), a weekly publication on innovation in science, technology, and the arts, from around this time (see Fig. 4.1) advertised obstetric “manequins” to practice manual delivery [32, p. 197].

Another obstetric simulator was invented by Mons. Adorne, a medical supplies merchant and mechanic from Strasbourg was advertised on July 21st 1781 in the “Mercure de France” [33] and again in August 1781 in the “Journal Encyclopedique” [24]. The body of the simulator was described as having a diaphragm and all the organs and major blood vessels of the abdomen and pelvis and a vagina and rectum. There was uterus in “the state of virginity” that could be replaced with one that had hidden ropes that could make the uterus appear to contract and deliver an artificial fetus. The fetus simulator had a body made of wood and springs were used to make the movements appear natural. The cost of one of these simulators was around 20–25 louis.⁶ The article noted that Adorne also repaired older mannequins and could make accessories for them [34].

The journalist and historian Louis-Marie Prudhomme (1752–1830) reported that Marie Marguerite Biheron (1719–1795) acquired the bodies of soldiers to develop skills in anatomical illustration [35]. Later she produced a series of very realistic anatomical models using wax under the direction of the surgeon Sauveur François Morand (1697–1773) [36]. When Sir John Pringle (1707–1782) saw some of her models he said to have exclaimed only the smell was missing [37, p. 455]. In April 1769, Jacob Jonas Björnståhl wrote to his friend Carl Linnaeus, the famous taxonomist that he had witnessed an anatomic miracle in the models made by Mademoiselle Biheron which were absolutely life-like and did not break. She kept their composition secret but Björnståhl thought they were made from wax with something added to it. He noted that the King of Denmark was one of her customers and that she sent her respects to Linnaeus [38].

To supplement her income from selling the models Biheron also exhibited them. In a flyer published in 1761 Biheron announced she would display “artificial anatomies,” that were better than anything made earlier, at her house from 13th May. One model was a truncated body that was covered with “a true skin,” the membranes and tissues were made in a way that tricked the eye into believing they were real and the lungs could be blown up. Nature, it was said, was copied with greatest precision.

In 1770 Biheron demonstrated a new model of the lower half of the body of a pregnant woman, referred to as a phantôme, to the Académie Royale des Sciences in Paris. This model had a bladder, intestines, rectum, etc. and a uterus containing a fetus and many of the parts moved in a co-ordinated manner such that over time the uterus contracted, the cervix to dilated and the fetus descended in the pelvis [39, p. 446]. When Sweden’s King Gustav III visited Paris in 1771 the Académie Royale des Sciences held a special meeting in his honor at which Biheron was invited to exhibit the model. Biheron taught in London as well as Paris and a collection of her models was acquired by Catherine the Great for an anatomy institute in St Petersburg. Her achievements were never recognized by the universally male medical establishment in France [36].

An obstetric simulator that had a uterus that contracted to deliver an artificial fetus was developed by Gustave Ozenne. It was first described in German journal in 1828 where it was noted that the horizontal and vertical contractions of the uterus, the perineum, vaginal area, and vulva were represented. The contractions could be felt by a hand placed on the body of the phantom. The author of the article concluded such a phantom was far more advanced than any others for students to practice obstetrics [46, p. 402]. Ozenne called it a Mannequin Tokomatique [47] and after six years of development, he exhibited it at a meeting of the Academie Royale de Science in May 1831 where a very complimentary report on the simulator was read by Étienne-Pierre-Félix Villeneuve [47, 48]. It had several notable features including progressive dilatation of the cervix, the contraction of the uterus as occurs naturally, the fetus was in a fluid-filled sac and could be put in any position, obstetric procedures such as use of forceps were made more realistic by the contracting uterus. Villeneuve thought it was a very sophisticated simulator and “…that this machine would be of utmost utility to the obstetric student.” Dubois sen. was concerned that “…it expels the fetus by the sinciput (brow), instead of first presenting by the occiput…” which could mislead students but he wrote “On the whole, all the obstetric teachers present concurred in the opinion that this ingenious piece of mechanism deserved to supersede all those in present use” [48].

One of those present at the meeting reported the obstetric machine of “singularly ingenious construction” invented by M. Ozenne was exhibited in the ante-chamber [49, p. 285]. The simulator worked “By means of air set in motion by bellows and pumps worked by handles, the contractions of the uterus, vagina, &c., determine the expulsion of a full-sized fetus” and “it presented it all the events of parturition with surprising fidelity” [49, p. 285]. This simulator was also reported in the United States in the New-York Medico-Chirurgical Bulletin in 1831 where it was called “A new Maunequin”⁸ [50, p. 200].

Villeuve’s report and a “memoire” by Ozenne in which he described why he made the simulator and how it should be used for teaching were published together as a book [48]. Ozenne claimed using the simulator would allow students to participate in many more births than would be possible in clinical attachments. The uterus in the simulator was made to contract by longitudinal and radial fibers and there was a mechanism through which the strength, rate, and rhythm of contractions could be controlled. The body of a recently deceased woman could be used to practice obstetrics and the body was sometimes referred to as a natural mannequin. Ozenne claimed that practice on a simulator in which the uterus contracted was an improvement on this because more scenarios could be presented, e.g. tumultuous contractions, and it was more realistic when practising internal version and fetal extraction using forceps [48]. Ozenne also suggested this simulator could be used to recreate particular births to study the outcome of alternative interventions.

An insight into simulator use in obstetric training in Paris around this time can be obtained from the writings of students. A column by an American medical student was published in the Boston Medical and Surgical Journal in 1833 [51, p. 317].

“I have just commenced a course of accouchements at Madame La Chapelle’s, spending one or two hours there every day after dinner. She gives us a short lecture; we then manoeuvre on the machine, and one or two women present themselves daily for examination, in different states of pregnancy. Accouchements happen from time to time, at which almost any one can be present by paying a couple of francs.” This student was most impressed by the teacher writing that “Madame La Chapelle is a most intelligent and extraordinary woman, about 25 years of age” [51].

A diary by an unknown medical student from Edinburgh University, of his time in Paris from 1834 to 1835 has also survived [52, p. 59]. The diarist recorded that after dinner on Tuesday 11th November 1834 at 7:00 he went to hear Madame La Chapelle’s introductory lecture on midwifery. This was a public lecture, i.e. free, but for those not enrolled on the course the practical “ toucher” (vaginal examination) teaching that followed needed to be paid for. The student was not that impressed by Madame La Chapelle and wrote “I was rather disappointed both in her appearance and her manner” but he still enrolled in her class. In subsequent lessons as well as the lecture and the “ toucher” there were sometimes “ maneuvres” where students had to identify the fetal presentation in a simulator and then practised turning and using forceps or the crotchet. He also attended lectures on midwifery and clinical teaching by several surgeons including François Joseph Victor Broussais, Gabriel Andral, and Alphonse Cèsar Robert. After Robert showed him how to use the vaginal speculum he wrote, “I had no idea, that the neck of the uterus could be seen so distinctly—this part is, since the introduction of the speculum, as much under the cognisance of the senses, as any part of the exterior of the body” [52, p. 60].

Little is actually known about the Madame Lachapelle who taught these two students. She was the only daughter of Marie Louise Dugès Lachapelle (1769–1821), who had worked with Baudelocque and was chief sage-femme at the new La Maternitè in Paris and grand-daughter of Marie Jonet Dugès who had been head midwife at Hôtel-Dieu [53, p. 98].

In the book by Bouvard et Pécuchet by Gustave Flaubert the main characters François Denys Bartholomée Bouvard and Juste Romain Cyrille Pécuchet had tried to study anatomy using an Auzoux manikin (see anatomy section). Sometime later, Pécuchet suggested they learn obstetrics using a manikin [54],

Stéphane Tarnier (1828–1897) succeeded Paul Dubois as chief surgeon at La Maternité in 1867. Whilst he was a trainee, Tarnier had studied mortality from puerperal fever and found it was 13 times higher in hospital than in the surrounding districts. When he became the head of surgery he introduced a series of infection control measures that resulted in mortality from puerperal fever at La Maternité falling from 93 per 1000 in 1870 to 23 per 1000 in 1880 and to just 7 per 1000 in 1890 [55]. Another legacy of his work is the routine use of incubators for “weaklings,” as preterm and low birth-weight babies were known, which he pioneered at La Maternité from 1880 [55]. There is an impressive monument to Tarnier on the Rue d’Assas in Paris near the Jardin des Grands Explorateurs (Garden of the Great Explorers).

When Pierre Budin (1846–1907) was working as an assistant to Tarnier, he recognized the need to avoid cold and starvation in newborns. He was an advocate of breastfeeding and maternal involvement in the care of preterm babies [56] and established postnatal care clinics where new mothers could receive education on infant well-being such as the importance of only using milk that had undergone the new process of “pasteurization.” Alphonse Pinard was another of Tarnier’s assistants who had a big impact on the care of mothers and babies [57]. Pinard had established a refuge for poor and destitute women who were pregnant and from this recognized the value of antenatal care generally. Pinard also introduced fetal heart auscultation as an indicator of well-being and invented a monaural stethoscope. Pinard also studied abdominal palpation of the fetus to determine its position in the uterus and described how this should be done in “A treatise on abdominal palpation as applied to obstetrics, and version by external manipulation” published in 1878 [57]. Together Tarnier, Budin, and Pinard had developed the model of obstetric care we use today.

In many of Europe’s cities in the second half of the nineteenth century, rickets was a common cause of pelvic deformation and obstructed labor. The combination of poor diet, long hours working inside, standing at machines and air pollution created “perfect storm” conditions for the development of the condition in young women [58, 59]. Caesarean section was still an unsafe procedure so when vaginal delivery wasn’t possible it was necessary to destroy the fetus to save the mother. Tarnier developed a teaching model of a pelvis in which the anteroposterior diameter could be adjusted to show how this impacted on childbirth (see Fig. 4.3).

In November 1877 an obstetric simulator that could reproduce the effect of rickets on the pelvis was demonstrated at a meeting of the Obstetrical Society of London. It was recorded in the proceedings of the meeting that “Dr. Fancourt Barnes described the model of Drs. Budin and Pinard” and later in the meeting he used it to demonstrate application of forceps on a fetal head [60]. This report provided no details of the model but fortunately a correspondent of the North Carolina Medical Journal was at the meeting and a description of the simulator and how it was intended to be used in teaching was subsequently published in that journal. Like Tarnier’s model, the A–P diameter of the pelvis in this mannequin was altered through moving the sacrum.

OBSTETRIC PHANTOMS.

Dr. Fancourt Barnes exhibited to the Obstetrical Society of London, a phantom made by Mathieu, which had lately come over from Paris. It was devised by Drs. Budin and Pinard, chiefly with a view of familiarizing students with the diagnosis of the fetal position by palpation through the abdominal walls. For this purpose a caoutchouc⁹ bag was provided, to represent the bag of membranes. In this a dead foetus was placed, water was poured in to the necessary amount, and the bag was tied up. The whole was then placed in the phantom, an apron of caoutchouc representing the anterior wall of the uterus was buttoned over it, and the part representing the abdominal walls was placed in situ. By this means a very fair imitation of the natural phenomena was provided. Another modification of this new form of phantom, was that the promontory of the sacrum could be moved forward by means of a screw, so as to represent different degrees of the pelvic contraction. Cephalotripsy, craniotomy, and embryotomy might then be performed with a much nearer approach to actual conditions than in common phantoms. Finally, one great advantage in having all the soft parts made of caoutchouc, was that they could be easily replaced when worn out. [61]

A month later, Tarnier demonstrated Budin and Pinard’s simulator at a meeting of the French Academy of Medicine in Paris [62]. The report of this meeting provided some additional information on the simulator and the first drawings of the “mannequin obstétricale” (see Figs. 4.4 and 4.5). Tarnier had shown how rectal examination could be performed on the mannequin and that a cadaver fetus could be placed in the uterus with some water to teach students how to ascertain fetal lie from abdominal palpation and perform external version.

In the United States, Jacob Trush “exhibited and described the obstetric manikin of Drs. Budin and Pinard, of Paris” at a meeting of the Obstetrical Society of Cincinnati in 1879 [63, p. 170–174]. He said the simulator had been developed 2 years earlier, was manufactured by Matthieu et fils and,

…in this manikin, the osseous framework is represented by wood; the abdominal walls, uterus, vagina, perineum, and external genitals by soft-rubber. This structure, then, suitably charged with a fetal cadaver and a few feet of intestine, is to impersonate the pregnant human female at term.

In Trush’s opinion external palpation to determine the presentation and position of the fetus was more difficult on the manikin than on a patient. However, if a student developed the required skills “in these artificial contrivances” then they would be mostly successful in arriving at the correct diagnosis in patients. Trush also noted that teaching internal digital examination depended on “the freshness and development of the fetal cadaver” and,

By means of such a cadaver, if recent and inclosed in the thin-rubber bag (furnished with the manikin), suitably filled with water to represent the liquor amnii, a very admirable imitation of the living fetus with its bag of water may be constructed, and the characteristics of the several presentations fairly studied and inculcated, and a degree of practical training secured which cannot fail to be useful in subsequent actual practice.

For operative practice, Trush observed that the rubber parts approximated the normal tension of the tissues and “by a special contrivance, the sacrum can be thrown forward, and thus the most frequent form of the contracted pelvis, the flat, represented.” The forceps “cannot be thrust into the pelvis in almost any haphazard way, as is the case with nearly all of the old-style manikins, but must be carefully inserted” and “the extraction will be difficult in proportion to the size of the child’s head.” Trush concluded that “This manikin, besides, is possessed of many other good qualities, altogether ‘too numerous to mention.’”

There was another description of the Budin–Pinard mannequin in L’année médicale, a publication covering advances in medical sciences, in 1879 which was very complimentary about the natural feel and function of the simulator [64, pp. 376–378]. Some illustrations of the Budin–Pinard mannequin were included in L’arsenal obstetricale, an appendix to Gustave-Joseph Witkowski’s “History of birth among all peoples” (Histoire des accouchements chez tous les peuples) published in 1887 [65] (See Fig. 4.6). These illustrations showed the mechanism to adjust the position of the sacrum had been changed and the shape of the rubber perineum had been modified (see Fig. 4.7).

L’embryotomie céphalique by Paul Bar, an accoucheur at L’hospital Tenon was published in 1889 [66, pp. 28–29]. Bar studied the requirement for destructive procedures using the Budin–Pinard mannequin and recognized that the obstruction simulated by adjusting the position of the sacral promontory was always an anterior–posterior narrowing in the midline whereas in patients the pelvis is often deformed asymmetrically. Bar described a simple modification to produce asymmetric deformations in the simulator.

There are many references to the Budin–Pinard simulator being used in the United Kingdom, Europe, and North America. For example, in “A System of Obstetric Medicine and Surgery,” “The student is recommended to follow the description of the positions of the presenting part, and track them through the pelvis, by help of a fetal skull and woman’s pelvis. It is better to do this by using a whole fetus. If he has access to Budin and Pinard’s phantom, the imitation of nature is almost perfect” [67, pp. 505–506]. In Rome, Felice la Torre used the Budin–Pinard in his obstetrics course at l’Ospedale S. Spirito at the end of the nineteenth century [68].

In North America, the Annual announcement of the College of Medicine and Surgery in Cincinnati OH for 1880–1881 included a note that the Faculty of the Obstetrical department “have imported direct from Paris the new rubber manikin of Profs. Budin and Pinard, a wonderful, life-like representation of all the parts involved in parturition” [69, p. 6]. The Budin–Pinard simulator was used at the University of Maryland in Baltimore after 1883 [70] and Montreal Maternity had one for use by students from McGill College [71, p. 246]. In the early twentieth century the obstetrics teaching of students at Georgetown University Hospital was “supplemented by an operative course on the Budin–Pinard manikin” [72, p. 111].

Pinard wrote the preface for “Fundamentals of Obstetrics” by Louis Herbert Farabeuf and Henri Varnier published in 1891. Pinard noted that the “mannequin artificielle” was used in a practical training on the main obstetric operations but that was “un simulacre impartfait” (an imperfect representation) and it was ten times better to practice on the bodies of dead women. However, whatever teaching material was used it was important for students to have expert guidance [73].

A review of the book in the British Medical Journal recommended that every teacher of obstetrics should read it [74]. Farabeuf and Varnier had conducted experiments on cadavers, which they referred to as the “mannequin naturel,” and the reviewer commented section of the work on forceps “seems to us to smack more of the laboratory than of the bedside.”

At the end of the nineteenth century J. Whitridge Williams, then associate professor of obstetrics at Johns Hopkins University Medical School, specifically recommended “the Budin–Pinard manikin” in a paper on “Teaching Obstetrics” presented at a meeting of the Association of American Medical Colleges (AAMC) [65, 75]. Around this time the company Charles H Ward of Rochester NY, manufacturers and importers of anatomical and physiological models sold two versions of the Budin–Pinard simulator. Ward’s Catalogue of Medical Instruments and Models compiled in 1902 [76] listed a Budin–Pinard simulator with movable sacrum for $200 and a “brevette” model that did not have a moveable sacrum was $150. These prices included tax but no fetus because it was deigned to be used with a cadaver fetus. In the 1915 catalogue of Kny-Scheerer, another US supplier of, the Budin–Pinard simulator was originally listed for $150¹⁰ including a fetus [77]. Several rubber parts for different teaching purposes were available and the rubber vagina and rectum cost USD$12.00 and a rubber uterus (Fig. 4.8) cost USD$9.60.

Plans for a mobile table specially designed for teaching using obstetric manikins were published in 1920 [78]. The table was shown being used with a Budin–Pinard simulator (see Fig. 4.9). The Budin–Pinard simulator also featured in several figures, for example Figs. 42, 43, 44, 45, 46, and 49 in the book Operative Obstetrics on the Manikin by Charles B Reed published in 1931 [79]. The Budin–Pinard simulator was still listed in the 1941 Kny-Scheerer catalogue, more than 60 years after it was first demonstrated [80].

Although widely used for such a long time the Budin–Pinard simulator is very rare. There is a Budin–Pinard simulator made by Tramond-Rouppert/Docteur Auzoux around 90 years ago in the Pelosi Medical Center in New Jersey (see Fig. 4.10). The rubber parts on this model have all but perished but this has revealed the mechanism to adjust the position of the sacrum. There is another Budin–Pinard simulator in the Musee Grenoblois des Sciences Medicales in Grenoble, France and more of the rubber parts of this simulator have survived. This model was used with some accessories to create the feel of intra-abdominal pathology (see Fig. 4.11a). Another Budin–Pinard simulator has recently been acquired by the Musée Flaubert et d’histoire de la médecine museum in Rouen (see Fig. 4.11b).

The Musée d’Histoire de la Médecine (History of Medicine Museum), housed in the historic Faculty of Medicine building of the Paris Descartes University, has a well-made obstetric mannequin of unknown origin. This simulator is made from carton (papier-mâché) covered by chamois leather and the abdomen and pelvis are lined with brown leather (see Fig. 4.12). The spinal column is represented by a ridge and the vulva contains springs that stretch to permit the passage of the artificial fetus (see Fig. 4.13). Marie-Veronique Clin, Curator of the museum, has suggested it was probably made by Auzoux. Another simulator of unknown origin was advertised in 1929 in the catalogue of Drapier et Fils (see Fig. 4.14) [81, p. 183].

The Gregoires pioneered the use of simulation to teach obstetrics in Paris in the first half of the eighteenth century and their work was adopted and extended across Europe. The French Revolution had a serious adverse impact on health professional education and, despite reforms introduced by Napoleon, in the nineteenth century other European cities such as Munich, Berlin, and particularly Vienna began to attract more students. Use of simulation in obstetric education expanded but this did not always improve outcome.

Pierre Spitzner travelled across Europe with a display of wax anatomical preparations. In the first half of the nineteenth century what was left of the collection was acquired by the medical school of the Paris Descartes University for in the Musée d’Anatomie Delmas-Orfila-Rouvière. One of the models shows a Caesarean section being performed in the nineteenth century (see Fig. 4.15). Like many wax models of anatomy dissection and surgical procedures there is no blood in the scene although the face shows more expression than is usual.

Until the Reformation in the first half of the sixteenth century, care of the poor and sick in England was provided by religious orders and included lying-in women and their infants. Dissolution of Monasteries was an important feature of the reforms instigated by Henry VIII but when responsibility for social welfare was transferred to the parishes there was no provision for women close to term or giving birth [82]. In 1723 an act passed by King George I allowed parishes to form a Union and share facilities. Large workhouses were established with wards for the sick and the largest were attached to workhouse infirmaries. Also, in the middle of the eighteenth century, several cities built voluntary or general hospitals but these, like the infirmaries, generally excluded women giving birth. The consequence of this was that almost all births were at home.

William Harvey (1578–1657), best known for his research on the circulation,¹¹ also practiced as a “man-midwife,” the term used to denote a physician or surgeon who had expertise in what we now call obstetrics [83]. Harvey was the first Englishman to write a text on midwifery and has been called “The Father of British Midwifery.” Harvey applied his knowledge of the circulation to obstetrics and discovered that pulsation of the umbilical artery came from the fetal heartbeat, not the mothers, so could be used to ascertain whether a newborn was alive [84, p. 570]. Harvey was also the first to describe the color change brought about by the newborn taking its first breaths. These two observations were very important, the former in determining whether the newborn could be baptized and the latter whether a child was stillborn or murdered after birth [83].

Percival Willughby was a man-midwife who practiced in Derby, England and was a friend of Harvey . Willughby audited 150 births he had been involved with and recognized that the fetus could engage in the pelvis in different positions and that some were associated with worse outcome than others and a few were very bad. In his book “Observations in Midwifery” Willughby wrote, “The situation of the infant in the womb is altogether uncertain variable and diverse…” and “For the better easing of laboring women and the saving of poor innocent infants’ lives … to know in what posture the child commeth, and how to alter unnatural and difficult births.” Willughby’s book was first published in the Netherlands in 1754 but was not published in English until 1863 by which time others had reached the same understanding of childbirth [85]. Observations like this were very important for women because the outcome of labor was no longer a matter of passive acceptance because someone with appropriate training could intervene purposefully and save the life of mother and child. Willughby explained in his book that when the head or feet present that should be a natural and straightforward delivery, “But when it commeth by the arme, back, or belly, buttocks, side, knees, or feet, these births they call unnaturall, and they have need of help” [86, p. 56].

The Chamberlen family held a monopoly on obstetric forceps for several generations but by the beginning of the eighteenth century, the secret had leaked out. In 1733 Edmund Chapmen was able to write in “A Treatise on the Improvement of Midwifery” that forceps were well known and in wide use [7, p. 33]. In the second edition of his book published in 1735 he included an illustration of his forceps and more on their use. In Paris, the Gregoires, father and son, used forceps very similar to those of the Chamberlens. Those used by Monsieur Dusee in Paris around the same time were to his own design, and these were described by Alexander Butter in Edinburgh [2, p. 33].

In the eighteenth century, Man-midwives fell into two camps, those that promoted almost routine use of forceps, and those that used them rarely. John Maubry, the first public lecturer on midwifery in Britain [87, p. 6] criticized frequent use of instrumental delivery in The Female Physician, or the whole Art of New Improved Midwifery published in 1724 [88]. Maubry recognized that midwifery training required more than classroom instruction and watching deliveries and the best courses included practical experience on patients. He explained this in an advertisement for his course on obstetrics,

But, because the theoretical part is not altogether sufficient for the full instruction of such as design to apply themselves, this way, the doctor proposes also to find them that enter as pupils proper subjects and sufficient opportunities for practical experience conformable to the laudable custom of France and other foreign parts. [82]

Maubry stopped lecturing around 1731 and in 1736 Edmund Chapman, author of a Treatise on Midwifery started advertising “that he would instruct young gentlemen in the art of midwifery, in Orange Street, Red Lion Square” [89].

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 [90]

No one in England had previously used a simulator so Manningham had to describe it in the advertisements. He also explained how practising on a simulator first caused fewer problems for patients. In the 1739, advert potential students were advised that men and women are instructed on different days [82]. The required text for male students was the Artis obstetricariæ compendium , a comprehensive text on obstetrics written by Manningham in Latin [91]. The text for female students was An Abstract of Midwifry [92], which was a shortened version of the Compendium with some extra additional material on teaching midwifery and the hospital. The full title of the book was An abstract of midwifry, for the use of the lying-in infirmary: which with due explanations by anatomical preparations, &c. the repeated Performances of all Kinds of Deliveries, on our great Machine, with the Ocular Demonstration of the Reason and Justness of the Rules to be observed in all genuine and true Labors, in the Lying-in Infirmary, on our Glass Machine, makes a complete method of teaching midwifry; by giving the Pupils the most exact Knowledge of the Art, and perfectly forming their Hands, at the same time, for the safe and ready practice of midwifry. There was the glass machine, used for demonstration and the great machine, used for skills training.

Manningham explained how the glass machine and the great machine were used in teaching midwifery in the preface to The Abstract.

Midwifry is the Work of the Hands and requires repeated practice to make the person ready for that Business; so here, by our Directions and your own careful Practise on the Machine, where every Case that can happen may be represented and repeated as often as we see necessary; you will have the greatest Opportunity of forming your Hands for Practice, and informing your Judgement at the same time, in the Manner and Method of operating in all genuine and true Labours; and our Glass Machine will most clearly convey and confirm our Directions and Rules, by giving you ocular Demonstration of the Reason and Justness of the Rules there laid down; and to be duly observ’d in performing Deliveries of every Kind. When, therefore, you are thus perfectly informed and habituated to the Manner of Touching or Handling of Women, and thoroughly experience’d, by repeated Deliveries of all kinds on our Machine, &c. you may be admitted to deliver in difficult Cases, under our Directions; and being so qualified, we secure our Women from all Injuries, which would happen from Pupils, attempting Deliveries, before they are fully inform’d: Now, by this Method of Instruction, join’d to your own Industry and Diligent Application, and Practice in the Lying-in Infirmary, we apprehend, you will most readily attain due Knowledge of the Art and Practice of Midwifry, and become Proficients, in a much shorter Time than by any other Method. [92]

Manningham explained in The Abstract that theory should precede practice and that simulation should precede clinical practice.

After these previous instructions, natural deliveries are often to be repeated on our great Machine, in order to form the pupils hands for Practice; and then they will be admitted to deliver natural labours, in the Lying-in Infirmary, under our directions. [92, preface]

Men and women students paid the same fee of ten guineas to attend the first part of the course on anatomy and theory of pregnancy and normal childbirth which was followed by demonstrations and simulation-based training. The men had to pay another five guineas after the first actual delivery and then another five guineas to attend the second part of the course which covered complications and difficult births.

After these further instructions, the repeated performance of praeternatural deliveries of all kinds, on our great machine, and demonstrating the reason and justness of the rules on the glass machine, will make the pupils hands ready for the business, and perfectly form their hands to practise in all difficult and praeternatural labours, and at the same time inform their judgements, in the manner and method of operating, in all genuine labours in the Lying-in Infirmary, till they are completely qualify’d for the safe and judicious practice of the art of Midwifry.

In a lecture “to students of physic” Sayer Rudd, said he had “been bless’d with an Opportunity of attending Sir RICHARD MANNINGHAM’S Lectures in Midwifery and Physic” and about the simulation he commented that, “The greater Machine is the most finish’d, in its way, that has, as yet, ever appeared, for conducting the different Kinds of Deliveries; while the Glass Machine gives ocular Proof of the Reason and Justness of the Rules to be observed in Operations on the Other; and, consequently, in Genuine Labors” [93].

Whilst the majority of Manningham’s work related to the education of healthcare professionals, he was an early advocate of patient education and empowerment. The notes on his single lecture for pregnant women, their husbands, etc. reveal he used a simulator to explain normal birth and the complications that could arise and how to use this knowledge to choose a knowledgeable midwife and when during labor it was necessary to send for the assistance of a man-midwife [94].

Queen Charlotte’s Hospital is the direct descendent of Manningham’s lying-in hospital. Dr Felix Macdonough took over the teaching and management of the hospital in 1752 [95] and it led a peripatetic existence in London for many years until it received Royal Patronage in 1809 and acquired it’s now famous name and reputation [82].

The surgeon-apothecary William Smellie (1697–1763) began practicing midwifery in London in 1739. Smellie had established a general practice in Lanark, Scotland in 1722 and it wasn’t unusual for him to be called by a midwife to assist delivery of a woman who had been in labor for a long time, sometimes days. To save the life of the mother Smellie “was often obliged to resort to instruments of a destructive kind” which he did not like doing [26]. In a Treatise of Midwifery, Smellie noted “In order to avoid this loss of children, which gave me great uneasiness, I procured a pair of French forceps, according to a draught published in the Medical Essays by Butter” [6, p. 20]. The forceps described by Alexander Butter’s article were designed by Dusee but when Smellie came to use them in a difficult birth he discovered “they were so long and ill-formed that I could not introduce them safely to take a proper hold” [96, case 281]. After this experience, around 1734, Smellie read Edmund Chapman’s “Treatise on Midwifery” [89] which described how forceps were used on many occasions to save children [89, p. 180] he started to make arrangements to go to London “in order to acquire more information on the subject.” The Encyclopedia Britanica of 1797 referred to Chapman as the second public teacher of midwifery in Britain [97].

A journey from Edinburgh to London was a significant undertaking in 1738 and Smellie must have been very disappointed when he reached the metropolis and “saw nothing was to be learned.” On the advice of a friend, Dr Stewart, Smellie went to Paris where he attended a course on obstetrics given by Gregoire the younger.¹² Smellie later wrote that he was very disappointed by Gregoire’s teaching and the simulator although he acknowledged that it might be useful to a young beginner.

Little satisfied with his manner of instructing, I considered that there was a possibility of forming machines, which should so exactly imitate real women and children as to exhibit to the learner all the difficulties that happen in midwifery; and such I actually contrived, and made by dint of uncommon labour and application. [96, pp. 250–251]

Smellie stayed in Paris for a few months and then returned to London where he established himself as a man-midwife and a teacher of midwifery for both male and female students in separate classes. Smellie began teaching midwifery in 1741. An advertisement he placed in the London Evening Post for one of his early courses announced, “On Monday, 14th June, will begin a course of lectures on the theory and practice of Midwifery at 11 am for women and 3 pm for men, by Mr Smellie at his house in the New Court, formerly the Key an Garter Tavern, over against St. Alban’s Street, Pall Mall” [98].

Smellie explained why he used simulation in his writings on requirements for training in midwifery, “In order to acquire a more perfect idea of the art, he ought to perform with his own hands upon proper machines, contrived to convey a just notion of all the difficulties to be met in every kind of labor; by which means, he will learn how to use the forceps and crotchets with more dexterity, be accustomed to the turning of children, and consequently be more capable of acquitting himself in troublesome cases, that may happen to him when he come to practise among women” [99, p. 441].

None of Smellie’s simulators have survived but several descriptions of them have been published. Some of the descriptions are quite general but claim the models were very realistic but a few were quite detailed. In one description Smellie was said to have “constructed machines upon the actual bones of the skeleton, covered with leather, and stuffed out so as to bear a much nearer resemblance to nature; and he covered the skeletons of fetuses in the same manner for the purpose of exhibiting parturition” [25].

An unknown student wrote Dr Smellie was

…an uncommon Genius in all sorts of mechanicks, which after having shewed itself in many other Improvements he manifested in the machines which he has contrived for teaching the Art of Midwifery. Machines which Dr. Desaguliers, who frequently visited him, allowed to be infinitely preferable to all that he had ever seen of the same kind, and which I (from having seen those that are used at Paris) will aver to be by far the best that were ever invented. They are composed of real Bones, mounted and covered with artificial Ligaments, Muscles and Cuticle, to give them the true Motion, Shape and Beauty of natural Bodies, and the contents of the abdomen are imitated with great Exactness. Besides his large machines (which are three in number) he has finished six artificial children with the same minute Proportion in all their Parts; so that with the apparatus he can perform and demonstrate all the different kinds of Delivery with more Deliberation, Perspicuity and Fulness than can be expected on real subjects. [6, p. 56; 100, p. 25].

Jean-Théophile Desaguliers (1683–1744), an expert in experimental philosophy, often visited Smellie and it is thought he contributed to the design of the simulators [101]. Petrus (Peter) Camper (1722–1789) was a Dutch physician who travelled to Paris and London to study surgery, anatomy and midwifery [102]. In London he was taught midwifery by William Smellie and he also contributed drawings to Smellie’s “A sett of anatomical tables, with explanations, and an abridgment, of the practice of midwifery” published in 1754. Camper wrote the following about Smellie’s obstetric simulators,

He [Smellie] demonstrates parturition in models of women of which the pelvis and spine of a well-modelled woman are the starting point. Both the abdominal and extra-abdominal parts have been made out of leather with such remarkable skill that not only is the structure as natural as possible but the necessary functions of parturition are performed by working models. For example, the contraction of both the internal and external os, the generation of waters in parturition and dilatation of the os uteri are so natural that hardly any difference is to be noticed between these and those in natural women. [100]

McClintock wrote that the machines made by Smellie had eclipsed those of his teacher [26] and after studying midwifery teaching in Paris and London, Harrison observed that the French phantom,

would probably have still kept its reputation had it not been for the surprising genius of Dr Smellie, whose machines are really curious: they are composed of real human bones, arm’d with fine smooth Leather and stuff’d with an agreeable soft substance. All the Parts seem very Natural both to Look and Touch; the Contents of the Abdomen are beautifully contriv’d, the Intestines look very natural as likewise the Kidneys, and large Vessels. The uterus externum and internum are made to contract and dilate according to the Difficulty intended for the Delivery. The Children for these Machines are likewise excellently contrived, they having all the Motions of the Joints. Their Craniums are so formed as to give way to any Force exerted, and are so Elastick that the pressure is no sooner taken off than they return to their natural Equalities [103]

Whilst Smellie’s simulators and his teaching were much admired he also had critics. William Douglas, another man-midwife, scorned the simulator in an open letter to Smellie on “the absurdity of his method of teaching and practising midwifry.” Douglas observed that Smellie’s courses on Midwifery “would not offer at anything more than shewing your Machine and Glass Matrix (which was invented by Mr. Aaron Lambe the auctioneer), thro which the nature of extracting or turning the Child might be shew’d” [104, 105]. If Douglas had read the syllabus of Smellie’s course he would have known that during the fifth lecture “Every pupil on a machine delivers a child coming in the natural way” [105] and students encountered breech and other presentations later in the course.

Douglas also asserted that “a Machine is used by most Masters to give an idea to their Pupils, in order to prepare them for operating upon the Natural Subject; the nearer to Nature their Apparatus is, the more preferable; every good Master should use a natural Fetus in his machine, as that is in some Measure Nature itself, and by it the Position of the Child, a very essential Part, is learnt. Instead of a Child you make use of little stuffed Babies, which have rather amused than instructed your Pupils in the natural members of a Child.”

Douglas had no evidence that simulation using a cadaver fetus was actually better than that provided using an artificial fetus. In fact, both Harrison and Maurice Onslow thought Smellie was right to replace the fetal cadaver with a fetal manikin.

The advantage Mr. Gregoir [sic] is said to have over Dr. Smellie is that of having real children. This at first appear’d to me a great advantage, but I find it not so; for the Coldness of the Child, the Flabbiness of the Parts, and the Skin coming off at the least Touch, makes the delivery much less natural than that of the leather children. [103, pp. 27–28]

M. Gregoire was in the habit of explaining labours upon a machine fabricated of basket-work and covered with painted cloth; through this machine, a real foetus, often in a state of putridity, was made to pass to show the progress of the labour. Smellie, improving upon this, constructed machines upon the actual bones of the skeleton, covered with leather, and stuffed out so as to bear a much nearer resemblance to nature; and he covered the skeletons of foetuses in the same manner for the purpose of exhibiting parturition. [25]

Elizabeth Nihell, a “professed midwife,” was another who was critical of Smellie’s teaching and gave an unfavorable account of simulation in A Treatise on the Art of Midwifery [106]. Nihell explained that Smellie’s simulator was,

a wooden statue, representing a woman with child, whose belly was of leather, in which a bladder full, perhaps, of small beer, represented the uterus. This bladder was stopped with a cork, to which was fastened a string of packthread to tap it, occasionally, and demonstrate in a palpable manner the flowing of the red-colored waters. In short, in the middle of the bladder was a wax-doll, to which were given various positions.

By this admirably ingenious piece of machinery, were formed and started up an innumerable and formidable swarm of men-midwives, spread over town and country [106, p. 51].

Smellie used simulation to prepare students for clinical experience but Nihell was either ignorant of this or, more likely, chose to ignore it. An extensive review of Nihell’s Treatise of Midwifery started, “We might have allowed this treatise to pass without any other lash than that of ridicule, had simple ignorance been its sole demerit: but there is such a mixture of presumption and malice incorporated with the whole, that is, requires a more severe chastisement” [107, pp. 198–197]. The review corrected several statements Nihell had made about Smellie and simulation and concluded that, “one would be tempted to believe it had been written by some person broke loose from Bedlam” and “of all the defective treatises on the art [of midwifery], this is the most deplorably deficient.” Book reviews today are quite tame.

When Smellie retired in 1758 he thought he had taught around 900 men but the number of women was unknown. In May 1758 there were notices in the London Evening Post and the Public Advertiser that John Harvie now had Smellie’s machines [108]. Harvie had married Smellie’s niece and been one of his pupils. A few years earlier Colin Mackenzie, Smellie’s senior pupil and assistant, had been expected to be the successor but he left in 1754 after the two had a disagreement over the conduct of a dissection. Harvie died in 1770 and his effects were catalogued for an auction which included Smellie’s machines.

A Catalogue of the Entire and Inestimable Apparatus for Lectures in Midwifery, Contrived with Consummate Judgment, and Executed with Infinite Labor, by the Late Ingenious Dr. William Smellie, Deceased: Consisting of a Variety of Anatomical Preparations, Illustrating the Theory of Midwifery, the Original Drawings by Rymsdyk, from which His Engravings Were Made, His Exquisite Artificial Machines, in Imitation of the Living Subjects, His Collection of Obstetrical Instruments, English and Foreign, Together with a Small Study of Medical Books, and Some Anatomical Prints : which Will be Sold by Auction at the House of the Late Dr. Harvie, in Wardour-Street, Soho, by Samuel Paterson, on Friday June the 29th, 1770, to Begin at Twelve O’clock : to be Viewed on Wednesday 27th, and to the Time of Sale : Catalogues May be Had (gratis) at Essex-House, in Essex-Street, in the Strand, and at the Late Dr. Harvie’s, in Wardour-Street, Aforesaid : Conditions of Sale as Usual [109]

Machines

103.

No. 1. A Machine contrived for explaining all natural and easy Labors, and likewise difficult Labors, where difficulties arise from the Circumstances of the Child

 

104.

No. 2. Another Machine of the same Constructions, but so contrives as to explain the Difficulties which happen in Labors, from the Narrowness of the Bones of the Mother. In this Machine, besides the under part of the Uterus, &c. are represented the Great Vessels on the Vertebrae of the Loins, with the […] Spermatics, and the Kidneys, all in the natural State

 

105.

No. 3. Another. This Machine is made with great Care, exhibiting not only the Uterus (which contracts and dilates) with all its Appendages, but all the different Bowels of the Abdomen

 

106.

No. 4. A new Machine finished (but not put together) by Dr. Smellie in the latter Part of his Life—The Uterus and its Appendages are so contrived as to be easily taken out and replaced by Lacing. This Machine, the Dr. intended to be the most perfect, and, at the same Time, the most simple

 

Artificial Uteri

107.

A large artificial uterus with an Hinge, with the artificial Secundines* of Twin for Explaining Cases of Twins

 

108.

A Glass Uterus protected by a Leather Covering, with one Window

 

109.

Ditto with several Windows

 

110.

A Leather Uterus with its Appendages

 

Artificial Fetus

111.

An artificial Child, pretty much used

 

112.

Another, more perfect

 

113.

Another, with the secundines

 

114.

Another, in which the Head separates from the Body, and the skull is opened to explain the Crotchet Cases

 

115.

Too smaller to explain Twin Cases

 

116.

A new Fetus, finely finished

 

117.

Ditto, the Head of which separates from the body

 

118.

An artificial Child’s Head, to explain the shattered State of that Part in Crotchet Cases

 

119.

Five Rings to explain the different States of the Os Uteri

 

(*Authors note. Secundine is an old term for the afterbirth or placenta)

Thomas Young, Professor of Midwifery in Edinburgh from 1756, used simulation in teaching obstetrics. Young acknowledged that a midwifery “machine” had been used by the Gregoires in Paris “but they had only a wicker woman & a dead child before it began to spoil” but that Smellie’s machines were a great improvement [126, pp. 251–292]. According to Young “the [midwifery] schools were never complete till Smyllies time, in which he did very much by inventing Machinery which is so necessary to all mechanical operations, and also by making his students practice all Cases before the delivered women.” In the outline of A Course of Lectures upon Midwifery Young explained that the manual part of midwifery would be “demonstrated upon machines made in the imitation of women and children” [127].

In Glasgow, James Muir advertised a private course of lectures on midwifery that included simulation in 1757 [126]. The first lectures on midwifery at the University of Glasgow were given by Thomas Hamilton in 1768. Hamilton asked the university to pay for teaching apparatus and the Senate minutes of 10th June 1768 recorded approval of a sum not to exceed £80 “to buy Machines for teaching midwifery as formerly proposed”. Later there was a note of “a figure of a woman being part of the Midwifery apparatus lately bought by the college.” In 1771 and 1789 there were items of expense in university records for safekeeping and repair of the midwifery machines. Thomas Hamilton had to resign in 1781 due to poor health and he was succeeded by his son William, who continued to use simulation in his teaching.

An industry supplying teaching materials to healthcare professional educators developed in the nineteenth century. Several advertisements by J Harnett addressed to lecturers, students, and all gentlemen connected with the medical profession was published in the Medical Times in 1841. Harnett offered to supply fetal skeletons of all ages (from 5 shillings) and a female pelvis with ligaments and fetal skull (from 10 shillings) from his osteological repository in Museum Street in London. Harnett also had for sale “A new and improved apparatus for practical midwifery” [128].

In 1900 Francis Rowland Humphreys demonstrated a simulator he had made for practising abdominal palpation for determining fetal position [135]. It was based on a female pelvis attached to a wooden base with a cover of twill sheeting representing the abdominal wall that was kept under tension by elastic cords. Bent cane rods at the upper and lower margins of the abdomen provided the required shape. A “dummy fetus” in the model was placed in the required position and stabilized by placing it on a pad. A second cover lined with cotton wool placed over the first “gave a close approximation to the abdominal wall of a stout person.” Humphreys recommended the beginning student’s first look at the way the artificial fetus was lying and then palpate it through the first cover and again through the second cover. Humpreys observed, “The absence of the human equation was a decided advantage in the early stages of acquiring the art of palpation.” He thought the dummy could also be modified for vaginal examination and it could be used for practising abdominal palpation in settings other than obstetrics.

“There can be no question that the actual patient in labour is the best mechanical teaching device” [137]

By the middle of the eighteenth century simulation had become a main-stream technique in obstetric teaching in Britain. Simulators were used to demonstrate processes and procedures to aid understanding, learning procedures on patients caused more complications, and this could be avoided by having students learn and practice on simulators, students practised managing unusual events and complications to be prepared for when they occurred in clinical practice, and new techniques and equipment were first tested on simulators. London in particular secured a reputation for excellence in obstetric teaching in the second half of the eighteenth century.

In the nineteenth century, Paris regained some of its earlier prestige and Berlin, Munich and particularly Vienna became magnet centers for those seeking the best training in obstetrics and diseases of women. In Britain in the late nineteenth and the first half of the twentieth century, medical education reform was directed at improving the standard of graduates. The changes focussed on the knowledge of practitioners and their exposure to the different clinical disciplines and less weight was given to practical training and competence. As the twentieth century progressed, the role of simulation in education and training regressed and there appear to have been several factors underlying this.

In 1932 the Section of Obstetrics and Gynaecology of the Royal Society of Medicine arranged a symposium to discuss the teaching of obstetrics [137]. The opening speaker, Eardley Holland gave an overview of medical education methods and stated,

I believe more use should be made of the phantom or dummy—which should be used with a pickled foetus, not with a doll. There should be a room containing dummies in which students could practice daily the well-known manoeuvres of normal and complicated breech extraction, the varieties of version, diagnosis and correction of presentation, and forceps delivery.

The second speaker, Louis Carnac Rivett said the dummy was used for demonstrations but there were “not sufficient stillborn infants to provide material to practice embryotomy on the dummy.” Ninian McI Falkiner spoke next and reported the use of phantoms and routine classes in operative midwifery are popular both with teachers and students. However, he felt it necessary to add the rider that “although such methods have a definite field of usefulness, they should be regarded as a preparatory adjunct to, rather than as a substitute for, the actual performance of various maneuvres.” This was immediately after he had said that without “manufacturing” forceps cases the supply of cases requiring intervention that could be used for teaching would not meet the demand. Gladys Hill had administered a questionnaire to students in London and reported that “Demonstrations with phantoms and models were valued by about two-thirds of those who replied.”

William G Mackay noted it was not possible for the student to obtain much real operative experience and in Glasgow a wooden phantom and a dead child were used. The students were taught the simple operations which every doctor should be capable of performing and were repeated frequently by the students so that they could “perform them without unnecessary manipulations.”

Charles D Read had spoken to “a representative body of senior students and newly qualified practitioners” to ascertain defects in obstetric teaching. One of the criticisms he recounted was “ Forceps application is taught almost entirely on the ‘dummy.’ Could not more practice at forceps application be obtained in the actual hospital deliveries?” Read also suggested that “a higher percentage of emergency cases should be admitted for teaching purposes” but did not suggest how this could be achieved.

During the meeting Chassar Moir stated that, “In every teaching school some attempt is made to give each student instruction on a dummy as to the method of applying forceps and of delivering the fetus when it presents by the breech.”

The value of the work is greatly increased by the use of a real foetus preserved in a manner which retains the natural flexibility. The foetus is lubricated with soft soap before use; and since the head and limbs can be delivered only when the joints are bent in the proper direction, errors of technique become at once apparent. The phantom pelvis preferred is the one supplied by the firm of Reiner in Vienna.

Most speakers considered there was insufficient time in the curriculum devoted to obstetrics and gynaecology and “insufficient material,” or number of women giving birth, for teaching interventions that might be required. No one who spoke seemed to recognize the value of integrating simulation in their teaching to achieve their goals [137].

Parkes was one who supported the use of “mechanical devices” in teaching midwifery and training the student in manual dexterity but said they were poor substitutes for actual experience.

With regard to the use of mechanical devices in teaching, I think that manipulation with the doll and phantom stands, in relation to midwifery, as operative work on the cadaver does to surgery. Both are useful methods for training the student in manual dexterity and could be more extensively employed than they are, but at best they are poor substitutes for actual experience. To summarize: Every effort should be made to increase the available clinical material, and to provide adequate supervision “on the spot,” to ensure that the lesson of each case is fully learned. In the routine course it is possible to produce a practitioner capable of dealing with the normal case. Increased post-graduate facilities are required for him to obtain personal experience in the abnormal. Teachers should endeavour to provide better training.

The President of the Section, Victor Bonney, asked those taking part in the discussion about the use of mechanical devices for teaching obstetrics and the responses indicated that in most of the London teaching hospitals these were reduced to a minimum, consisting of a pelvis, a fetal skull, and a fetal dummy. The President then stated, “There can be no question that the actual patient in labor is the best mechanical teaching device”! [137]

Many of those who used simulation in teaching obstetrics thought a preserved fetal cadaver, sometimes referred to as a “ pickled fetus” was much better than an artificial one. Improved clinical outcomes and changed social attitudes after the Second World War meant fetal manikins had to be used and they had to be purchased. Also, particularly in urban areas, more women went to a hospital when they went into labor and the range and frequency of deliveries and procedures that non-specialists managed decreased substantially. Teaching obstetric operations to the few trainees in obstetrics who needed those skills was quite a different proposition to teaching a whole class of medical students. It was easier, less expensive, and certainly more real to teach directly on the women and use of simulation in obstetrics declined.

At the beginning of the nineteenth century simulators were being used in obstetric and midwifery teaching across Italy including Rome, Florence,¹⁶ Naples, Parma, Modena, Catania, Cagliari, Pavia, Pistoia and more. Simulators were also used in high-stakes examinations in Italy around 200 years ago. When Zaffira Ferritti, a young woman who had been taught surgery by her father, sought a licence to practice early in the nineteenth century the Medical Faculty at the University Bologna was asked to assess her knowledge and skill. The archives of the university record that on first day in 1810 she had to perform specified operations on cadavers and obstetrical procedures on simulators [154].

When Napoleon was defeated, Austria replaced France as ruler of much of Italy. In regulations approved in 1839 obstetrics was included in medical training and it was mandated that the final examination would have verbal components and a practical component on an obstetric simulator and a cadaver in the anatomical theater [155, p. 137].

Regulations for the examinations in the medical course at the University of Rome were published in the Gazzetta ufficiale del regno d’italia in November 1875 [156]. The part of the practical examinations covering obstetrics and gynecology included an exercise on a simulator. Felix la Torre graduated from the University of Naples and then completed his studies in obstetrics and gynecology at the Charite in Paris where he worked with Budin. In 1889 he moved to Rome where he established a private school in obstetrics and taught to students at the Ospedale Santo Spirito (Hospital of St. Spirito) using the Budin–Pinard phantom described in the chapter discussing obstetric simulation in France, and cadavers [68]. The Ospedale Santo Spirito is now home of the Museo Storico Nazionale Dell’Arte Sanitaria (The National Museum of the History of Medicine). In a historical profile of the University of Turin published in the yearbook for 1899–1900 it was noted that from the 1880s medical students there had a short practical course on obstetric operations using a maternal simulator and they practised embryotomy on fetal cadavers [157, p. 60].

The Italians were early adopters of simulation for teaching obstetrics and midwifery. Nearly all the obstetric simulators have been lost but many collections of obstetric teaching models in Italy have survived, at least in part. Many early works were paid for by popes and later works were produced for the heads of Italian principalities who wanted to be seen to be supporting education and healthcare. The model makers in Florence and Bologna received commissions from across Italy. For example, after Giovanni Battista Manfredini of Bologna made several models for the University of Padua, the School of Obstetrics in Modena and for the University of Rome. Today, outside the major museums of Florence and Bologna the conditions in which many of the historical models are now exhibited are not ideal for their preservation. Some important works are not on public display and are stored in very poor conditions. Many models were badly damaged or destroyed during the Second World War and it will be a great shame if we lose more through indifference.

Gottfried Friedrich Mohr (1692–1774) produced the first obstetric simulator in Germany. According to Langsdorf [10], Mohr’s “Entbindungsmaschine” was originally made from a human pelvis with leather parts but later models were made of wood. Friedrich Börner included drawings of this simulator and component parts (see Fig. 4.34) in Die gebährende Frau samt ihrer Leibesfrucht in Lebensgrösse (The birthing woman and her fetus) published in 1752 [164]. Simulation became widely used in teaching obstetrics in Germany and Austria in the eighteenth century. Börner listed several centers using Mohr’s simulator, including Berlin, Munich, Vienna, etc. Heinrich Johann Nepomuk Crantz (1722–1799) also made several references to simulator use in Einleitung in eine wahre und gegründete Hebammenkunst [165] a book that was also translated into French and Italian.

In May 1784 the University of Vienna passed regulations to integrate obstetrics in surgical training. Raphael Johann Steidele (1737–1823), Professor of Theoretical Midwifery offered a course in obstetrics twice a year and students needed a certificate that they had attended the course diligently and been well behaved in order to sit the final surgical examination [166, p. 10]. Steidele used a simulator made from a round, red silk cushion attached with bands to a female pelvis and a large glass bottle big enough to take a full-term fetus that represented the uterus. He demonstrated obstetric procedures using a leather fetus simulator and he often asked questions to check that students understood his teaching [166, p. 10].

Steidele taught how to identify the fetal presentation and then how to intervene and manage the delivery [167, pp. 153–154], and whilst he used a simulator for demonstration he preferred the cadaver for practical training. In the foreword to a Treatise of Midwifery, published in 1803 Steidele wrote,

Exercise with corpses is the sole and safest way to train practical obstetricians. All machines mean nothing; there are many more apprentices that are more harmful than useful, because they get into the habit of certain types of treatment. [168, preface]

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