THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
WHEN the Department of Med icine and Surgery was established in 1850, two outstanding scientific men were members of its faculty — Silas Hamilton Douglass* (A.M. hon. Vermont '47) and Abram Sager (Rensselaer Polytechnic Institute '31, M.D. Castleton Medical College '35, A.M. hon. Michigan '52). With the aid of Regent Zina Pitcher, one of the most widely known physicians in the state, they had organized the department. In 1851, his last year as Regent, Pitcher was appointed Emeritus Professor of the Institutes of Medicine and Obstetrics. The position was purely honorary, however, and his appointment to it was apparently the University's only record of any special interest he may have had in the teaching of obstetrics.
Sager was appointed Professor of the Theory and Practice of Medicine in January, 1848, with the understanding that he would also teach pharmacy and medical jurisprudence. By his own choice, in 1854, he was transferred to be Professor of Obstetrics and Physiology. Although there were discrepancies between the titles and duties of the other four medical professors, Sager's title corresponded with his teaching responsibilities.
Jonathan Adams Allen (Middlebury '45, M.D. Castleton Medical College '46), who had previously taught physiology, left the University in 1854, and Alonzo Benjamin Palmer (M.D. College of Physicians and Surgeons [N.Y.] '39, A.M. hon. Nashville '55, LL.D. Michigan '81) was appointed Professor of Materia Medica and of the Diseases of Women and Children.
While in charge of the teaching of gynecology, Palmer was closely associated with Zina Pitcher in efforts to improve medical education. From 1854 to 1858 Palmer was an editor of the Peninsular Journal of Medicine, of which, during about one-half of that time, Pitcher was the chief editor; and in the summers of 1857 and 1858 Palmer gave clinical lectures and bedside demonstrations before the University's clinical classes in Detroit, which also were under Pitcher's direction. In these classes a few normal and abnormal obstetrical cases were presented. Both men advocated the inclusion of adequate hospital training in the work required for the medical degree, but unlike Pitcher, Palmer at that time favored a plan — advanced by Professor Moses Gunn and emphatically rejected by the Regents in 1858-to move the entire Medical Department to Detroit.
In 1860, when Palmer was placed in charge of the instruction in medicine and pathology, Sager was relieved of his work in physiology and resumed the teaching of women's and children's diseases. The six-year period which then ended was the only time in the history of the school when gynecology and obstetrics were not taught in the same department.
One student has said that Sager, in lecturing, was inclined to become absorbed in general biology rather to the neglect of obstetrics, but from all accounts he was a conscientious, if not an eloquent, lecturer. By 1871-72 throughout the six-month session he was giving Page 859eight lectures a week, including those in obstetrics, gynecology, and pediatrics.*
Though a little clinical instruction in medicine and surgery was regularly provided throughout Sager's period of service, first by means of free clinics before the students and later in the wards of the Hospital, clinical obstetrics in the University was practically nonexistent, and gynecology also was taught largely by means of lecture and recitation. Ordinarily, neither Sager nor his successor performed more than the most minor operations; major surgery in this field, such as the removal of ovarian cysts, was the province of the professor of surgery. For nearly forty years medical students at the University of Michigan were graduated without having been required to witness a case of labor or a childbirth. Some ambitious and wide-awake students witnessed a few cases in the practice of their preceptors, but such instances were exceptional, for women naturally disliked having the students present, and it is to be doubted that even these students learned much about practical obstetrics, for at that period obstetrical manipulations were conducted under the sheet.
The Hospital was opened in 1869. The financial principle on which it was established, namely, that it should be wholly self-supporting, explains why the obstetrical material did not increase much for another twenty years, for, no matter how small the charge — and at first it included only food and medicines — women would not pay to be delivered by medical students, and the Michigan state laws authorizing the use of public moneys for the maintenance and transportation of those unable to pay had not yet been enacted.
In fact, it was just as well in the days before antisepsis that the University could do so little work in clinical obstetrics, for at least one-half of the women confined in hospitals, such as Bellevue in New York City, died of puerperal sepsis. Although Semmelweiss in 1847 had proved conclusively that childbirth fever was transmitted by the contaminated hands of medical students, the medical profession as a whole either was ignorant of the fact or denied its truth. Scientific information spread slowly between 1850 and 1890.
In Sager's time surgery at the University was performed under great difficulties. In those days neglect of ordinary cleanliness before and during operations was not recognized as the cause of the many postoperative fatalities, but because of the risk, major operations were avoided whenever possible. After 1869 some operations were performed at the Hospital "upon patients that could not be brought before the class" in the presence of a few specially interested students (R.P., 1870-76, p. 207). Many of the surgical patients were carried across the campus to an upper lecture room of the Medical Building and were operated on while lying on a table upon which, perhaps the hour before, the professor of anatomy had demonstrated on a cadaver.
It was under such circumstances that Sager performed a Caesarean section on a rachitic dwarf — one of the first, if not the first, of such operations in Michigan (Univ. Mich. Med. Journ., 2 : 385-93). It is not to be wondered at that the patient died of peritonitis soon after the operation. Sager's description of the operation, in which he was assisted by Professor Corydon L. Ford and George E. Frothingham, Demonstrator of Anatomy, is of particular interest. Because he thought it his duty, this modest little man, who probably had had very little experience as a surgeon, performed an Page 860operation almost without parallel in this section of the country. Thirteen years earlier such a procedure was advocated by Sänger. The uterine wound was sutured to avoid spill from the interior of the uterus and subsequent infection. Dr. Sager secured the pelvis and gave exact measurements to show why birth through the natural passages was impossible. The report of the case is impressive for its demonstration of the scientific mind of that period.
Sager's teaching career ended in 1873. At that time he obtained a leave of absence because of ill-health, and in his place Dr. Edward S. Dunster was appointed Lecturer in Obstetrics and Diseases of Women and Children. In March of the following year, Sager resigned his chair and was made Professor Emeritus, but, at the request of the faculty, he retained the deanship, which he had held since 1868. The admiration with which his colleagues and the University officials regarded him was expressed in the following resolutions adopted by the Regents in March, 1874:
Resolved, That we hold Prof. Sager in the highest esteem, not only for the symmetry of his character and purity of his life, but also for the eminent services which he has rendered to this University during a period of thirty-two years.
Resolved, That the great success attending the Medical Department has been largely due to his loyalty, industry, wisdom and scholarship.
(R.P., 1870-76, p. 334.)
Sager resigned the deanship in 1875 as a protest against the University policy of requiring certain of the "regular" medical professors to receive students of the new Homeopathic Medical College into their courses. He died in Ann Arbor, August 6, 1877.
Edward Swift Dunster (Harvard '56, A.M. ibid. '59, M.D. New York College of Medicine and Surgery '59, M.D. hon. Dartmouth '81), a direct descendant of Henry Dunster, the first president of Harvard College, was appointed Professor of Obstetrics and Diseases of Women and Children in 1874. He had served through the Civil War and until 1868 as assistant surgeon in the United States Army. From 1868 to 1871 he had been professor of obstetrics and of the diseases of women and children in the University of Vermont and also editor of the New York Medical Journal, and from 1869 to 1874 he served on the faculty of the Long Island College Hospital as lecturer on the subjects of obstetrics and the diseases of women and children. In 1871 he became professor of obstetrics at Dartmouth College and continued to lecture there during the summer months until his death. Holding chairs in two separate institutions at once, as he did from 1869 to 1871 and again in 1873-74, was a practice typical of the times, made possible by short annual sessions and an almost total lack of clinical teaching.
Dunster was in many ways a brilliant man and was acknowledged to be the most logical, eloquent, and interesting lecturer that the Department of Medicine and Surgery had ever had. To quote the words of his pupil, assistant, and successor, James Nelson Martin (Hillsdale '80, Ph.M. ibid. '83, Michigan '83m):
Last but facile princeps in the lecture room or editor's chair, was our scholarly Dunster. It is no disparagement to the others of that faculty to say that he was the most brilliant lecturer and writer among them all. Everyone enjoys a logical presentation of the subject, and no one left Doctor Dunster's classroom or read his articles, without a clear conception of the subject under discussion. Listening to him gave pleasure like that derived from the study of a fine painting. His language was almost perfect, his diction polished, and his argument clear and convincing … His students love to remember him in the lecture room.
(Physician and Surgeon, 27 : 152-53.)
Page 861For nearly three years the Regents had been considering plans for a large hospital, to be donated by the state and operated by the University. Such an institution, it was suggested, might have been (1) entirely an alms hospital for county patients, or (2) a treatment center where victims of diseases which were hard to treat might receive effective care, whether they were public patients or not, or (3) an alms hospital for the invalid poor which would also serve as a special treatment center for the general public (R.P., 1870-76, cf. pp. 189 and 202). Gynecological surgery was mentioned in particular in this connection, though with the indirectness customary in references to such matters at that time, as a specialty greatly needing attention and development for the relief of unnecessary suffering among all economic classes. The Regents' "committee on state hospitals" went so far as to report that very few doctors in Michigan or near-by states had the requisite skills and the costly apparatus needed for the proper treatment of certain difficult cases; moreover, that at no hospital west of the eastern seaboard could such treatment be secured; and that, in consequence, even the well-to-do delayed proper care because of the inconvenience involved, while the poor usually went without treatment altogether. Because it seemed inexpedient at the time to ask the state for such a large sum as would have been required for such a hospital as was desired, that project was temporarily abandoned in December, 1872.
In 1875-76 the original campus Hospital was remodeled, and a long annex at the rear of it, designed on the pavilion plan, was erected. This sixty-bed Hospital, mostly new, was financed largely by the state and was called a state hospital; it differed from the state hospital envisioned in the early seventies, however, not only in size, but also in other important respects, as the state made no legal provision for the transportation and living expenses of public patients.
A clinical lecture room, originally specified to be included in the new Hospital (R.P., 1870-76, p. 435), was built only after additional state funds were granted in 1879, but a lengthened course, which was intended to include much more clinical work than had been given, was introduced as an option in 1876, and by 1880 all beginning students were required to take the new three-year course, and the school year had been lengthened to nine months.
Dunster's work in the long curriculum was concentrated in the senior year. In 1881 his theoretical work in obstetrics, consisting of a one-semester course of sixty lectures, was offered both semesters of the second year. His lecture course in the diseases of women and children, consisting of forty-five lectures, also given in both semesters, remained in the third year, and the seniors also met in the amphitheater twice a week throughout the year for his course called Clinical Gynecology and Diseases of Children.
The better facilities of the Pavilion Hospital, opened in 1876, gave an impetus to the clinical work in surgery, medicine, and ophthalmology, but had practically no effect on clinical work in obstetrics, and even in gynecology the cases were pitifully meager — three in 1877, seventeen in 1878, and eleven in 1879. In spite of this, when the titles of the heads of the other clinical departments were changed in 1880, to signalize the improvement in clinical instruction expected as a result of the acquisition of the Hospital amphitheater, Dunster's title was altered to Professor of Obstetrics and of the Diseases of Women and Children and of Clinical Gynecology. The lack of any reference to clinical obstetrics in his new title was significant. In presenting a request for an obstetrical Page 862manikin in 1879 — apparently the first one purchased in nearly thirty years of obstetrical teaching at the University — he had stated that the need of it was particularly urgent in obstetrics, because, "from our position, we are unable to have clinics" (R.P., 1876-80, p. 391).
An obstetrical clinic might have been maintained just as the physics and chemistry laboratories were maintained, or the practice of sending welfare cases at local or state expense might have been stimulated by legislation. The first law under which public patients were sent to the University Hospital was a children's hospitalization law, requested by the officials of the State Public School at Coldwater in 1878 and passed by the legislature in 1881. In his annual reports for both of those years, President Angell suggested that a similar law for adult inmates of the county almshouses be passed. It was not readily perceived, however, that the enactment and observance of special laws might be necessary to guarantee the admission of a sufficient number and variety of cases for instruction, and his suggestion met with no response (see Hospital, p. 975).
In February, 1888, a senior petition for a lying-in ward was received by the medical faculty and was referred to Dunster. He died in Ann Arbor on May 3, 1888, without having made any formal report on the subject, but the establishment of a small obstetrical ward within the Hospital and the launching of a vigorous local campaign, in that same year, for a separate maternity hospital appear to have been results of his efforts.
One mark of the students' affection and respect for Dunster was a petition from the seniors, soon after his death, requesting the faculty to devise a way of affixing his signature to their diplomas. The faculty responded by asking the steward to have it electrotyped.
Immediately after the death of Dunster, his assistant, Dr. James Nelson Martin, was placed in temporary charge of the chair of obstetrics and diseases of women and children, in accordance with a recommendation of the medical faculty. The Regents took their time in making a more permanent appointment. In December, 1888, they appointed Martin Acting Professor of Obstetrics and Diseases of Women and Children. He was reappointed in 1889. The faculty recommended in 1890 that he be appointed Professor of Obstetrics and Diseases of Women, but the Board renewed his acting professorship of all three subjects for a single year. He was finally appointed Professor of Obstetrics and Diseases of Women in March, 1891 (R.P., 1886-91, p. 487), and thus pediatrics, previously always associated with gynecology, was formally removed from the department. A course in the diseases of children had been organized in 1889 and was continued through 1892. The transfer of instruction in that subject may have taken place about 1890, when Walter Shield Christopher (M.D. Medical College of Ohio [Cinn.] '83), a distinguished pediatrician, was in charge of the Department of the Theory and Practice of Medicine. For some years after 1892 pediatrics was taught in connection with internal medicine. In the present century, until the establishment in 1921 of a separate Department of Pediatrics and Infectious Diseases, it was given increasing attention as a specialty within the Department of Internal Medicine. In the summer of 1888, Judge Harriman, E. B. Pond, A. W. Hamilton, and Otto Eberbach, a committee representing the citizens of Ann Arbor, came before the Board of Regents to discuss the possibility of establishing a local maternity hospital (R.P., 1886-91, p. 239), and in the yearly Announcement published soon afterward (Med. Ann., 1888-89, p. 21) it was stated that local citizens had "initiated Page 863measures looking to the erection at an early day of a well equipped lying-in hospital," to be conducted by the faculty and to be utilized for clinical instruction. In October of that year, President Angell stated that it was most desirable to have a lying-in hospital (R.P., 1886-91, p. 269). Then this particular project was dropped; it was never mentioned in the University Calendar nor in subsequent issues of the Announcement.
From the official records the reason for discontinuing the campaign is clear, even though there was no published explanation. The University was being severely criticized for the inadequacy of its hospital plant as a whole, and an organized effort was being made to have the clinical teaching done in Detroit. Ann Arbor would probably not have had a University Hospital at all, if quick action had not been taken to provide a new main building and better equipment. This was the basic clinical need, and the one with which the President was primarily concerned, even when he mentioned the special need of an obstetrical hospital. Moreover, the chance of obtaining enough money for an entirely new hospital plant depended chiefly on the size of the conditional pledge which the Regents could obtain from the townspeople before the state was asked for help. A citizens' committee estimated in December, 1888, that $25,000 might be raised for the purpose in Ann Arbor (R.P., 1886-91, p. 291), and fortified by this tentative promise the University obtained, under an act approved the following summer, a state gift of $50,000 for the new hospital plant. To enlarge the city's contribution and thus ensure the construction of new main buildings for the University and Homeopathic hospitals, the citizens interested in founding a special maternity hospital undoubtedly agreed to postpone their own plans.
Before the fall of 1888, without awaiting the outcome of the campaign for a separate maternity hospital, the faculty established a small "lying-in ward," inside the old campus Hospital; and there, according to the Announcement of 1888-89, each senior was expected to attend several confinement cases — "when available" — as the corrected explanation read during the next two years, for practically no patients came. Adopting a practice which had proved successful under similar circumstances in the Homeopathic Hospital, the faculty of the Department of Medicine and Surgery therefore obtained a Regents' order authorizing the Hospital superintendent to find obstetrical patients who would consent to be used for instruction if the University paid their maintenance costs. For this purpose the Medical Department was granted a University subsidy of $200 in each of the three years 1888, 1889, and 1890.
The first state law authorizing the care and treatment of indigent adult patients in the University and Homeopathic hospitals and the payment of their transportation and maintenance costs from public* funds (Public Acts, No. 246, 1889) contained the provision:
Whenever obstetrical wards are established in said hospitals, the said [county] superintendents [of the poor] may make special contracts with the regents for the care and treatment of such obstetrical cases as are a public charge in their respective counties.
As the small obstetrical wards in the two campus hospitals were already in existence, what the writers of this part of the law had in mind was evidently the establishment of much more ample accommodations for obstetrical patients, Page 864such as the University would have had if the plan of 1888 for a special maternity hospital had materialized. Many patients were sent to the Hospital every year under other provisions of Act No. 246 of 1889, until a new hospitalization law (No. 267) for adults was enacted in 1915, but for some reason, even after separate buildings for maternity patients were occupied in 1906 and in 1908, the above-quoted section governing obstetrical cases was almost wholly inoperative.
With the exception of the course of sixty lectures in obstetrics, taken twice in the intermediate year of the curriculum, all of the work in the department under Dunster between 1881 and 1888 had been concentrated in the third, or senior, year. In the fall of 1888, after Martin was placed in temporary charge, a two-semester lecture course in gynecology and obstetrics was begun. Originally, it was taken in the second year and was repeated in the third, but in 1889-90 it was scheduled only for seniors. A separate, one-semester course in children's diseases, for second-year students, was begun in February, 1890.
When the four-year curriculum went into effect, in 1890-91, the clinical work in gynecology, as well as that in obstetrics, was taken only by seniors, but the general lecture course in these subjects, requiring two hours a week in the first semester and four hours a week in the second, was scheduled for both juniors and seniors. Diseases of Children, a first-semester course meeting two hours a week, was also taken twice. In 1892, after this separate course in children's diseases was discontinued, the junior-senior lecture course, Obstetrics and Gynecology, was scheduled for three hours a week throughout the year, and juniors as well as seniors came to the biweekly gynecological clinics. In the same year special junior drill courses in the clinical subjects, with daily meetings for several weeks, were introduced. In the demonstration course in obstetrics and gynecology, the juniors were shown, by means of manikins and models,* what to do in the various presentations and in emergencies that might occur in obstetrical practice (Med. Ann., 1893-94, pp. 21-22).
According to a statement appearing in the Announcement of 1894-95 (p. 29) and in the following years, every senior had an opportunity to attend one or more obstetrical cases, since pregnant women were admitted several weeks before delivery and were kept for several weeks afterward, and each patient was assigned to a group of a few students, who were expected to make a study of her case throughout her stay at the Hospital. Through 1898, however, only eleven or twelve confinement cases a year were available. The difficulties of obtaining even these few is indicated by the fact that in 1897-98 the Board of Regents found it expedient to grant another subsidy ($100) to "each of the hospitals … for the purpose of maintaining obstetrical cases" (R.P., 1896-1901, p. 115).
Most of the work in this department of diseases of women and obstetrics is done before sections of the class, that they may come in closer contact with the patients and observe more closely the pathological changes that have taken place, while the same are being considered. Also that they may observe more closely each step in the examination and treatment of the cases, and especially each step in the operation, and thus discover the cause of the trouble and the methods of relieving the same.
(Ann. Rept. Univ. Hosp., 1893-94, p. 18; Ann. Rept. Univ. Hosp., 1896-97, p. 25.)
Page 865According to an article in the Physician and Surgeon (11 : 415-18), there had been only ten obstetrical patients in the Hospital in 1888 and 1889 and not more than seventy gynecological patients, representing about ninety examples of gynecological disorders — for often, in this branch of medicine, several such conditions are present at once, and the number of cases, therefore, usually exceeds the number of patients. In 1892-93, however, there were about five hundred gynecological cases; in 1893-94, approximately eight hundred; and throughout the remainder of Martin's administration, six hundred to eight hundred a year. After the completion of the new Catherine Street Hospital late in 1891, there had been an increase in the number of cases in gynecology, as in nearly every other clinical branch of medicine excepting obstetrics, and the work of Martin's department had been further augmented in the early nineties (Hosp. Rept., 1892-93, p. 15) by the transfer from the Department of Surgery of all surgery on the female pelvic organs. This was a great step forward, as far as the work in both obstetrics and gynecology was concerned, for previously there had been no opportunity for those who taught female pelvic and abdominal surgery to increase their knowledge of the subject. Martin was handicapped in his surgical work, however, for even the new Hospital was poorly constructed and was septic. The surgical ward was large and overcrowded, and students had free access to it. A Hospital rule in force since 1876 forbade the admission of patients known to have contagious diseases, but occasionally a patient contracted such a disease on the way to the Hospital or even after being admitted. Unfortunately, there was no separate building for these separate emergency cases until 1898-99, and con tagious-disease epidemics were common. Whenever such a disease as diphtheria, scarlet fever, or smallpox was discovered in a ward, the ward had to be quarantined and surgical work discontinued, or the lives of patients would have been seriously endangered.
The Announcement published a short time before October, 1894, contained the statement: "In the coming session … the seniors and juniors will have no didactic lectures in common, separate courses being given to each class." The lectures on obstetrics were then concentrated in the junior year, and the theoretical work in gynecology was given in the senior year. In 1894 the courses were further compressed, the theoretical work in obstetrics being given only for secondsemester juniors and the general lectures in gynecology being given only for firstsemester seniors. Throughout the early period juniors and seniors attended at least some of the clinical demonstrations in gynecology together, but the methods course preparatory to actual case work continued to be given in the junior year.
In 1894-95 each student was required to devote 382 hours to obstetrics and gynecology, in addition to the indefinite time needed for attending cases in the lying-in room (Med. Ann., 1894-95, p. 32); 192 hours were spent at classroom lectures, 128 hours at "clinical lectures," 32 hours in recitations, and 30 hours in studying methods of diagnosis and the use of instruments. The required work remained essentially the same until 1900, except for the addition of a few hours for the study of diagnosis and of the use of instruments. In 1900-1901, Martin's general lecture courses, including recitations, required only sixty-four hours in the junior year and sixty-four hours in the senior year; the junior methods course, conducted by his assistant, required thirty-six hours; and the clinical work in gynecology, again scheduled for seniors only, required 180 hours in all. Page 866The afternoon gynecological clinics were held, as before; in addition, since 1899, there had been several short morning clinics each week in gynecology.
Word came in the spring of 1898 that the University might receive, "subject to certain charges," the bulk of the estate of Dr. Elizabeth H. Bates, of Port Chester, New York, for a professorship to be "known and called the Bates Professorship of the Diseases of Women and Children," provided the University admitted women to its Medical Department and gave them the same educational advantages as it gave male students. President Angell estimated that the legacy would yield at least $100,000. Within two years, however, the Bates property in the University's possession was worth more than $133,000, and by 1940 the principal derived from it was valued at $137,000.
President Angell wrote:
It does not appear that our benefactor ever visited the University. So far as we can learn, she was moved to remember us in this generous manner by the fact that this University was one of the first to offer medical education to women. She wished to testify her appreciation of the service thus rendered to her sex, and to enlarge our facilities for medical education.
(R.P., 1896-1901, p. 312.)
The Regents voted in May, 1898, to accept the gift and comply with the conditions laid down; in June they established the new professorship and gave the medical faculty the task of suggesting a suitable person to hold it. The old custom of combining the teaching of gynecology with that of children's diseases had still been widespread when the Bates will had been drawn up in 1890, but even then this custom had been falling into obsolescence at the University, and by 1898 the medical faculty apparently had no intention of permanently re-establishing it. The report of the faculty's views on the best disposition of the gift was made to the Regents orally, but the following statement in the Announcement for 1898-99 (p. 6) throws some light on faculty opinion:
In accordance with another provision of the will it is proposed that the title of Elizabeth H. Bates Professor of Diseases of Women and Children be given to Dr. James N. Martin. (The didactic and clinical work in connection with children's diseases will be in charge of the chair of Theory and Practice of Medicine, as heretofore.) It is also proposed that the income from the bequest be allowed to accumulate, and that when a sufficient fund has been acquired a ward be built for sick children, as a memorial of the donor.
During the summer the Board's main concern in connection with the bequest was a legal struggle for the property, certain relatives of Dr. Bates having contested her will. By November, 1898, a court decision affirming the validity of the will had been rendered; still, the Bates chair remained unoccupied throughout the session of 1898-99. Finally, at the Regents' meeting of September, 1899, "the Chair of Obstetrics and Diseases of Women, in the Department of Medicine and Surgery was abolished, and James N. Martin (Hillsdale '80, Ph.M. hon. ibid. '83, Michigan '83m) was appointed to the chair of the Bates Professorship of the Diseases of Women and Children at a salary of $2,000" (R.P., 1896-1901, p. 415). The Board's intentions with respect to the teaching were made clear a month later, when the following resolutions were adopted:
Resolved, That the duties of Dr. Martin, Professor of the Bates chair, Diseases of Women and Children, remain the same as before, with the addition of Diseases of Women.
Resolved, That the instruction in and the treatment of diseases of children be done by Dr. Dock, Professor of Theory and Practice.
(R.P., 1896-1901, p. 433.)
Page 867Thus, in spite of the apparent implications of Martin's new title, both the association of obstetrics and gynecology were continued — nor has the actual teaching of pediatrics ever been assigned to the occupant of the Bates chair. One of these resolutions brings to light a fact not mentioned elsewhere, namely, that at some previous time — possibly only a year or two before — Martin had delegated the instruction in gynecology to an assistant, concentrating his own efforts on the work in obstetrics, and that he again taught both subjects in 1899.
It was reasonable to establish the Bates chair to fulfill the terms of the bequest, but it was wholly unnecessary to exclude the word "obstetrics" from the title of the chief professorship of the department. Ever since the beginning of medical instruction at the University in 1850, obstetrics, internal medicine, and surgery had been treated as major subjects of equal importance. The occupant of the new chair was expected to be primarily an obstetrician, and this fact should have been indicated by some such official title as the one finally adopted in 1923, which was "professor of obstetrics and gynecology and Bates professor of the diseases of women and children." The actualities of the situation were recognized in the period 1899-1923, however, by the use of the unofficial title, "Bates professor of obstetrics and diseases of women," in the faculty list of the Announcement, though elsewhere in the University publications "Bates professor of the diseases of women and children" was the title ordinarily used.
The nominal "abolition" of the chair of obstetrics and gynecology was not the only strange result of accepting the Bates bequest. The amount set aside for the professor's salary was only about one-third of the income of the bequest. As has been noted, the faculty originally endorsed a plan of saving as much as possible of this income for a building fund for a children's ward. Eventually, in December, 1901, the Regents adopted a motion to make the projected Palmer Ward a children's ward, thus ending the possibility that any of the Bates money would be used for that purpose. Before this happened, however, and while Martin still held the Bates professorship, the Regents established a policy of meeting the regular expenses of the Department of Obstetrics and Gynecology, not by the customary appropriations from the general University fund, but instead, by revenue from the Bates fund. This policy was made effective with the adoption of a resolution that, after October 1, 1900, "the expense of maintaining the Chair of the Bates Professorship of the diseases of women and children be paid from the Bates fund" (R.P., 1896-1901, p. 602).
The obvious reason for the bequest was the donor's desire to enlarge the facilities for medical education, especially for women, in a university that had early admitted women to its medical school, and the greatest deficiency in the Medical Department and in the University Hospital when the bequest was received was the lack of adequate clinical instruction in obstetrics. Had this resolution not been passed the greater part of the Bates income might have been saved for the building and equipping of a maternity hospital as soon as the idea of a Bates ward for children was given up, or — though this was perhaps too much to expect in those days — it might have been used to finance a broad, intensive program of research. A small hospital laboratory equipped with apparatus for the investigation of gynecological and obstetrical cases had been set up in 1897-98, and the Regents in 1901 did appropriate $500 of the Bates income for additional equipment for this laboratory, but under the plan adopted in 1900, and Page 868with the growth of the department and of its cost of operation, the possibility of obtaining continuous support for research or for other special projects from this source steadily declined. The result of the new policy was, therefore, that the department did not actually benefit from the money. In fact, within a few years the gift became more of a handicap than a benefit, for, while the other clinical departments expanded and were granted successively larger budgets, the Department of Obstetrics and Gynecology was retarded because the Regents refused to appropriate anything for it except the income from the Bates fund. As the principal professorship of the Department of Obstetrics and Gynecology was named in honor of Dr. Bates, her bequest should have been devoted to ways of increasing the efficiency of that department. In justice to the Regents it may be stated that they acted in good faith and thought that under the provisions of the will no action except the one which they took was feasible. It would seem that a donor should specify more definitely the purpose of a bequest and yet give the governing board the greatest possible freedom in its administration.
Martin was aided continuously after the summer of 1888 by James Gifford Lynds ('88m), who was promoted in 1892 from an assistantship to the position of Demonstrator of Obstetrics and Diseases of Women. During the year 1897-98 he was Acting Professor of Gynecology. Other assistants, each of whom served under Martin for a briefer period, were Casper K. Lahuis ('96m), Dr. Clara A. O. Dedrick, and John J. Mersen (Hope '95, A.M. ibid. '98, Michigan '99m).
Neither Martin nor Lynds had any national affiliations. Their work was confined to the state. One of the reasons, probably, for Martin's breakdown in health was his custom of operating in private houses in towns in the neighborhood of Ann Arbor, and then riding through the night in order to keep his University obligations the next day. In 1895 he was granted a leave of absence on account of blood poisoning contracted from operating on a septic case. Another year's leave of absence in 1897-98 was also granted because of ill-health. In 1900, a year before his resignation, he manifested distinct signs of mental instability and these symptoms grew worse until the time of his death in 1913. Lynds resigned with Martin, in February, 1901, and on October 1 of that year Reuben Peterson (Harvard '85, M.D. ibid. '89, Sc.D. hon. Michigan '36) became Bates Professor of the Diseases of Women and Children.
Peterson was born in Boston in 1862. After graduating from Harvard University and interning in three Boston hospitals, he came to Grand Rapids, Michigan, in 1890 and established a general practice. Because of his hospital training and inclinations, Peterson, even when engaged in general practice, devoted more and more of his attention to obstetrics and gynecology and in 1897 was elected to membership in the American Gynecological Society. In 1898 he went to the Chicago Post-Graduate Medical School as a professor of gynecology, and a year later he accepted an assistant professorship of obstetrics and gynecology at Rush Medical College.
In the early and middle nineties, instruction in gynecological diagnosis and treatment, as well as in obstetrics, had been given to small groups of students at Michigan. The effort to increase the individualization of instruction was perhaps relinquished to some extent after Martin's illness in 1897; at any rate, as late as 1900, patients were operated on before large classes, while the students sat on hard benches during long, prescribed hours and watched, seeing little and Page 869understanding less of what was done. Clinical teaching in this manner had been an almost universal custom throughout the country in the last decade of the nineteenth century.
Peterson's first task on assuming his duties at Michigan was to increase the effectiveness of the gynecological teaching by having the technique of pelvic and abdominal diagnosis and treatment of diseases peculiar to women taught to small groups of students. At the gynecological clinic, held twice a week, emphasis was laid on differential diagnosis, demonstration of specimens, and the progress and after-treatment of patients operated on at previous clinics. There were frequent ward walks and demonstrations of postoperated patients.
Peterson's second task was to build an obstetrical clinic. Because the town was small this was no easy task, and the University authorities at that time were either opposed to, or at least unsympathetic to, the idea of making the expenditures necessary for such a clinic. It should be borne in mind that until thirteen years before Peterson's appointment, practically nothing had been done to furnish obstetrical material, and that the steady but meager supply throughout most of the period had been obtained with great difficulty. The establishment of a separate detention ward, though not ending the hazard of contagion, was no doubt partly accountable for the fact that by 1900-1901 the number of pregnancy cases observed and treated had been increased to thirty (Hosp. Rept., p. 36). Despite the difficulty of obtaining clinical material for teaching obstetrics, within the next few years the department was sometimes embarrassed by the lack of enough beds for obstetrical patients applying for admission.
As a matter of fact, the time spent in waiting for an adequate supply of obstetrical material was not wasted, however, for it was found possible to teach the principles of the mechanism of labor, at little expense, by means of the manikins with which the department was then abundantly supplied. The students, meeting in small groups, were thoroughly drilled in this way, so that even those who had had no experience in actual deliveries might have some practical knowledge of scientific obstetrics before entering medical practice. Students from Michigan interning at outside hospitals sometimes discovered that they were better grounded in the fundamental principles of normal and abnormal obstetrics than were fellow interns who had delivered, in hospitals or in outpatient services, six or more women. This method of teaching has been retained as one of the principal features of obstetrical instruction at the University.
During Peterson's first years at the University, although there were no instructors in the department, there were three or four assistants at a time, each of whom remained about two years. One of these men, Wales Melvin Signor ('05m), was advanced to an instructorship in 1906. He as well as each of the next two appointees to this position held it for only a year, but after 1909 the average tenure was lengthened. By 1917 it was customary for an instructor to remain three or four years, and the number of instructorships had been increased to four.
A co-operative interdepartmental arrangement was made in 1902, whereby one assistant appointed to the staff of the Department of Obstetrics and Gynecology was responsible for the clinical laboratory work of the department and also taught gynecological pathology in the Department of Pathology. Ralph Luther Morse ('02m) was the Assistant in Obstetrics and Diseases of Women, in charge of laboratory work from 1902 until 1904, when he was succeeded by Page 870Samuel Reese Haythorn ('04m). Frank Clarence Witter ('06m) did the same work from 1906 until 1908, first as assistant and later as demonstrator; he was then promoted to a regular instructorship in obstetrics and gynecology, and the laboratory work was assigned to Neal Naramore Wood ('08m). In his second year on the staff, Wood was both Instructor in Obstetrics and Gynecology and Demonstrator of Obstetrics, in charge of laboratory work, but in 1910 the second half of his title was dropped and the interdepartmental staff arrangement was discontinued.
In 1902-3 the obstetrical ward was still so small that only about thirty patients received treatment. The policy of granting free maintenance during the last month of pregnancy, as well as after delivery, resulted in its being almost always full, for physicians throughout the state were glad to send certain patients who could not have afforded to come under a less liberal plan.
Eugene S. Gilmore, Superintendent of the University Hospital from 1900 until 1908, did his best to secure an increase in the obstetrical material. The new Hospital addition, Palmer Ward, had been intended primarily for children, but when it was opened, in 1903, Gilmore and Dr. George Dock, head of the department in which pediatrics was then taught, consented to the temporary use of a part of it as an obstetrical ward. When this change was made, the number of obstetrical beds was more than doubled.
The kindness of Dr. Dock in approving this arrangement was greatly appreciated, but Dr. Peterson felt that his patients were there only on sufferance. Consequently, in November, 1903, Peterson persuaded the medical faculty to make a formal request to the Regents to "rent a separate house near the hospital for the use of obstetrical cases," both in order that these cases might receive proper care and in order that Palmer Ward might be utilized to better advantage (R.P., 1901-6, p. 295); but the Regents took no action on this faculty request.
A curious incident in the continual struggle to secure more obstetrical patients should be recorded here. In those days there was little hope of obtaining anything for a department without the approval of James H. Wade, Secretary of the University and watchdog of the University treasury. Peterson, therefore, went to him with a plea that obstetrical patients be admitted free of charge. Wade was astounded and said that such a request was ridiculous, because it was sufficient that every student witnessed one delivery in the hospital amphitheater.
During Wade's illness in 1905, Peterson appealed to Regent Charles DeWitt Lawton, chairman of the medical committee of the Board, and obtained authorization to admit "certain obstetrical patients to the hospital free of cost, to remain three months" (R.P., 1901-6, p. 501). This action was taken in February. In May, as soon as Wade had recovered from his illness, he persuaded the Regents to limit the number of free obstetrical beds to three.
A frame building intended to be made into a contagious-disease ward, the Penny house, was moved from North University Avenue in 1905 to a site close to the small building then used for contagious cases, at the rear of the Medical Ward.* An alternative plan of erecting a separate, modern contagious-disease hospital was under consideration at the time, however, and as the Penny house was still empty in October, 1905, it was Page 871remodeled to serve as an obstetrical ward, at a cost of $335. Despite this decision the uncertainty continued, and the building stood unoccupied throughout the winter and early spring, but finally, in May, 1906, after its use as a detention ward had once more been seriously considered, the Regents again ordered that it be made into a maternity ward. They authorized purchases of furniture and other equipment to the amount of $1,300, this sum to be taken, if possible, from income from the Bates fund, and also authorized the employment of four additional nurses for the ward, but ruled that there should not be more than ten obstetrical cases in the hospital at a time.
Both before and after the establishment of the pediatrics clinic, it was felt that the care of the normal infant should be a part of obstetrical teaching. The students were, therefore, instructed in infant feeding throughout the six weeks during which many of the babies were retained in the clinic before being placed in institutions. Abnormal infants were referred to or transferred to the Department of Pediatrics. In 1907-8 a quarantine of the surgical wards resulting from an epidemic of scarlet fever halted the admission of new patients to the obstetrical and gynecological service. Such quarantines and the lack of an adequate number of beds had created a long waiting list, and many prospective patients had had to be turned away. Yet, in the five years, 1903-8, there had been an increase of nearly 100 per cent in the number of patients treated each year, and the increase in obstetrical work had been proportionate to the growth of the department's clinical work as a whole.
Another frame house intended as a ward for contagious diseases was moved to a site a little to the west of the Maternity Ward in 1908, but remained empty while city and University officials again discussed the possibility of building a modern contagious disease hospital. Peterson suggested that this second house be used instead as an addition to the obstetrical clinic and outlined a plan whereby the department might obtain a larger proportion of obstetrical patients in the earlier stages of pregnancy.
These suggestions were approved by the Regents, and at last the department came into possession of an obstetrical clinic worthy of the name. The newly acquired building was made into a residence for waiting patients and was called the Maternity Cottage; and the former Maternity Ward was changed into a Maternity Hospital, for patients in labor and for post partum patients. At this time the main room of the Maternity Hospital was equipped for small demonstration classes in obstetrics.
In the Maternity Cottage eighteen to twenty patients were always available for demonstrations of the various fetal presentations, normal and abnormal. These presentations were also being demonstrated by the use of manikins. In all, the department had about thirty obstetrical beds and more teaching material than was furnished by the type of teaching clinic in which there were more deliveries but few waiting patients. Success in maintaining this necessary teaching material lay in the fact that the patients were charged only while waiting, and this nominal sum, $2.50 a week, they could pay by performing certain duties for the hospital, such as the preparation of bandages and the repairing of linens, during the waiting period.
One hundred and one deliveries were reported for the year ended June, 1910. The list contained an unusually large proportion of abnormalities, which were utilized for purposes of instruction. In the next few years the department continued to grow, in spite of serious handicaps.
Page 872It should be borne in mind that since 1850, although obstetrics and gynecology had been emphasized as major subjects and taught on a par with medicine and surgery, during the first forty years almost nothing had been done to develop the clinical work of the department. Very little more had been accomplished in the nineties. Since 1900, however, the two small buildings had been secured and more liberal rules had been established, whereby, through reduced rates, obstetrical material was obtained.
Seen in this perspective, the situation of the department in the years which followed 1908 might appear to have been favorable. Actually, however, conditions were so unsatisfactory that, from the modern point of view, it seems hardly possible that they could have been endured. Both wooden structures were firetraps, and it had been intended that they be used for obstetrical cases only until suitable quarters could be secured. The proximity of the small detention ward to the Maternity Hospital constituted a serious threat to the welfare of post partum patients. Surgical patients in the gynecological service were still endangered by the septic condition of the main Hospital, which in addition to having been poorly designed had not been properly kept in repair. The situation was somewhat improved by the opening of two new buildings in the decade 1901-11 (Palmer Ward and the Eye, Ear, Nose, and Throat Ward), because this additional space provided some relief from congestion in the surgical wards.
An attempt was made in 1913 to establish an outpatient obstetrical service for poor patients referred by physicians or charitable societies, but for several reasons — principally because of the small size of the town — the effort proved a failure and was abandoned.
In June, 1914, the much-needed Contagious Disease Hospital, given by the city of Ann Arbor, was made ready for occupancy. With the new unit in operation, maternity patients with doubtful or pronounced contagious diseases could be cared for satisfactorily. The installation of this ward benefited every department of the Hospital, because it prevented epidemics and quarantines, and for the Department of Obstetrics in particular, it provided relief by doing away with the need for the two-room contagious shack, which had long menaced the welfare of obstetrical patients. Plant alterations involving a new annoyance were made, however, in the same year: the track of a trolley line for carrying coal from the Michigan Central Railroad to the new heating plant on Washington Street was laid between the Maternity Hospital and the Maternity Cottage. This greatly increased the difficulty of transporting patients in labor from one building to the other — not to mention the noise of the loaded coal trains, running between the buildings at night with clanging bells.
Peterson was Medical Director of the University Hospital and executive officer of its medical committee from 1913 until 1920, and, in addition to his arduous hospital executive duties, carried on his administrative duties in the Department of Obstetrics and Gynecology.
In 1915 Peterson was able to secure legislation whereby the benefits of Act No. 274 of 1913 for sick or crippled children were duplicated for adults, in Act No. 267. By these acts children and adults needing hospital care, but unable to pay their maintenance and travel costs, could be sent to the University Hospital by order of the county probate judges. By a provision of the adult act, pregnant women were included. Had it been possible to have the hospital expenses of adults paid out of the general state fund, as were those of the children, there would soon have been plenty of obstetrical material, but the fact that Page 873these expenses were charged to the counties acted as a deterrent, since the county supervisors were held accountable for expenses and it was cheaper to have unmarried mothers without funds confined in unsanitary county farms. Despite this handicap, many obstetrical patients, married and unmarried, were sent to the University Hospital under the provisions of Act No. 267 of 1915.
J. B. Draper, Superintendent of the University Hospital since 1908, was accidentally killed in 1915, and the policy of the administration, which had been that of building up the obstetrical clinic by charging little or nothing for maternity service was changed.
A chance was seen to increase the hospital receipts from state patients sent by the judges of probate under Act No. 267 of 1915. Gradually, the charge for such patients was raised, with the result that the counties naturally declined to refer them to the Hospital.
The report of the business officer of the Hospital for the year 1921-22 included the following statement, which shows the failure to grasp the fundamental difference between obtaining obstetrical teaching material and obtaining material for teaching the other clinical subjects: "We might also mention the fact that if the hospital had been allowed to charge regular rates for services in the Maternity Department our receipts would have been increased by from $20,000 to $25,000" (Hosp. Rept., 1921-22, p. 19).
These figures were based upon the supposition that the same number of patients would have been admitted to the service. This was an absurdity since, as a rule, unmarried pregnant women had no money, and state patients could have been cared for at less expense.
Dr. Peterson was called into service in World War I in November, 1917, and served until January, 1919, in the Medical Corps of the United States Army. Fortunately, so far as the teaching of obstetrics and gynecology was concerned, he was stationed in Michigan and could supervise the work of the department. He also remained as medical director of the University Hospital.
When the United States entered the war, the obstetrical and gynecological staff consisted only of the head of the department and four instructors. Two of these men, Frederic Morris Loomis ('09, '12m) and Rudolph Artilles Bartholomew ('08, '12m), left permanently within the next fifteen months, and John Wesley Sherrick ('12, '15m) was absent on leave for two years. The only instructor to remain was Leslie Lee Bottsford (Williams '09, Michigan '14m), who, in 1919, received the first appointment to an assistant professorship to be made in the department. Bottsford left the position in 1920 and was succeeded by Sherrick, who left in 1922, and the position was held during the next year by Roland Spuhler Cron ('16, '17m). There was no assistant professor from 1923 until Norman Fritz Miller ('23, '20m) was advanced to the position in 1925, nor for two years after Miller left in 1926.
More time was given to gynecology than to the obstetrics division of the department, because of the exceptional increase in the number of such cases admitted and requiring operative treatment. Although the counties hesitated and often refused to send pregnant women to the clinic, they could not refuse to send those cases requiring the services of a specialist. Thus the gynecological beds from 1901 on were in great demand. Because of the amount of time consumed by the staff in nonoperative and operative care, the question often arose as to whether or not it would be wise to limit the number of gynecological cases, yet such restrictions were never adopted.
Page 874The department became, in its special field, a postgraduate school where men were thoroughly trained before entering private practice. It now seems axiomatic that staff members should be given every possible opportunity for advancement in clinical knowledge and skill; yet such was not the custom as late as 1901, when men spent years as part-time assistants, picking up what crumbs of knowledge they could but having few or no opportunities to perfect their surgical technique. Furthermore, any change was bitterly opposed by the heads of clinics, trained differently, who thought everything should center in them.
It was stated in the Announcement in 1913 that the two frame buildings were being used only "temporarily," for obstetrical patients. Inadequate and dangerous as these old buildings were, however, during the next twelve years they continued to be the only quarters available for active and waiting maternity patients.
In 1925, before the completion of the new Hospital, the Eye, Ear, Nose, and Throat Ward, a brick building erected in 1910, was remodeled at a cost of more than $20,000, into an eighty-two-bed obstetrical hospital well adapted for the care of waiting and active maternity patients. The work in clinical obstetrics has been carried on since 1925 in this brick building, renamed the Maternity Hospital.
With the transfer of obstetrical patients from the two antiquated wooden buildings to this brick structure, and with the provision for gynecological patients in the new Hospital, a new era began. Gone were the old days when entire wards were quarantined for weeks because of outbreaks of contagious disease. No longer did the surgeons have to contend with serious infections which could be ascribed only to unsanitary hospital conditions.
Between 1919 and 1927 the departmental staff was increased from five to seven, exclusive of interns and assistants below the rank of instructor. James Mortimer Pierce ('23m), who was appointed Instructor in 1925, was made Assistant Professor of Obstetrics and Gynecology in 1928, and in 1930 he became the first member of the staff of the department to be advanced to an associate professorship. Those instructors who remained during the twenties for a period of three years were: Theodore Wright Adams ('18, '20m), 1921-24; William Henry Rumpf (Minnesota '20, B.Med. ibid. '21, M.D. ibid. '22), 1923-26; Lawrence Edward McCaffrey (M.D. McGill '21, C.M. ibid. '21), 1924-27; Harold Arthur Furlong ('22, '24m) and James Valentine Campbell ('24m), 1926-29; L. Grant Baldwin ('25m) and Harold Smith Morgan ('25m), 1927-30. Lewis Ernest Daniels ('11, M.D. Harvard '20) was an instructor in the department from 1922 until 1925 and returned in 1930.
In December, 1930, after thirty years of service Dr. Peterson resigned his position as head of the Department of Obstetrics and Gynecology. He was succeeded by Dr. Norman F. Miller, one of his former assistants, who some years before had gone to the University of Iowa to become associated with Dr. Everett D. Plass, head of the Department of Obstetrics and Gynecology there.
In the nine years which followed Miller's return to the University in 1931, the staff usually consisted of eight or nine faculty members, in addition to the interns, most of whom remained as instructors for two or three years after completing the internship. By 1937 it was customary to designate a man "intern" in the first year of his internship, "assistant resident" in the second, and "resident" in the third.
Associate Professor James M. Pierce left the department in October, 1931, Page 875and in the same year Dr. Daniels and Norman Rudolph Kretzschmar ('24, '26m, M.S. '31), instructors, were made assistant professors. Glenn Allan Carmichael ('28m) served as an instructor for three years before leaving the department, as did Woodburn Kenneth Lamb (Alma '26, '30m), David Charles Kimball (27, '30m), and Sprague Heman Gardiner ('30, '34m, M.S. '39). James T. Bradbury (Montana State College '28, Sc.D. Michigan '33) was selected to fill a special research assistantship in the department in 1933. He was transferred to an instructorship in 1938, and a year later the research position was filled by the appointment of Lore Sophie Marx (Ph.D. Heidelberg '28).
Carl Parker Huber ('24, A.M. '25, '28m) served as an instructor from 1930 until 1936, and for three years of that time, 1932-35, was Reuben Peterson Instructor and Fellow in Obstetrics and Gynecology. Kretzschmar* was promoted to an associate professorship in 1938, and Clair Edwin Folsome (Albion '25, Michigan '33m, M.S. ibid. '38), after four years as an instructor, was appointed Lecturer in Obstetrics and Gynecology in 1939.
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