The process of formation of medical education in the Voronezh province and its impact on the stuff problem in the region in the second half of the XIX – early XX century

Samedova Natella Elnurovna Postgraduate student of the Department of Russian History of the Peoples' Friendship University of Russia 10/2 Miklukho-Maklaya str., Moscow, 117198, Russia samedova.natella@yandex.ru

In Russia, the issue of providing the country's population with access to high-quality medical care, which requires the availability of qualified medical workers, has always been relevant. The study of the process of development of medical professional education, which is the main "supplier" of medical personnel, on the example of a specific region allows us to study in more detail some of the problems that affected the well–being of Russian society in the second half of the XIX - early XX century, to determine their causes and historical consequences. In the second half of the 19th century, medical professional education was just beginning to take shape in the Voronezh province, so the region's healthcare faced a number of problems. The issues of the development of outpatient treatment, the availability of highly specialized professionals in medicine, the shortage of medical institutions and qualified personnel, and the need to create specialized educational institutions for their training were gradually resolved. However, to a greater extent, their vector of development began to change decisively after the "Great Reforms" carried out by Emperor Alexander II.

A significant historical contribution to the solution of the medical issue was made by the provincial zemstvo and county forms of public government. The condition of the provincial zemstvo hospital was optimized, obstetric and paramedic schools were opened, medical congresses were organized, sanitary and hygienic knowledge was disseminated, and the constant fight against epidemics was carried out. According to the historian and founder of budget statistics F. A. Shcherbina, the positive role of the zemstvo was to create its own special forms of public medicine with equipped hospitals and medical centers, with medical service professionals, who were the foundation for the further evolution of medical business ^{[19, p. 630]}.

The purpose of the article is to determine the importance of professional medical educational institutions of the Voronezh province for the health care system of the region. Realizing that the problems of healthcare in the province are more extensive and require separate scientific research, we set ourselves the task of considering the role of the personnel issue in the medicine of the Voronezh province and its solution by Voronezh medical education.

A complete picture of the foundation and functioning of the first medical institutions, obstetric and paramedic schools, in imperial Russia is presented in the works of domestic historians Ya. A. Chistovich ^{[18, p. 1034]}, V. A. Rybasov ^{[15, p. 49-50]}. The study by N. A. Mitsuk and A.V. Belova ^{[11, pp. 270-285]} analyzed the history of the obstetric profession among women and the gender role of midwives in the history of medicine in Russia. An important place in the historiography of the research topic is occupied by the works of the prominent historian of medicine I. P. Furmenko ^{[16, p. 256]}, in which he pays attention to the state of health care in the Voronezh province in the post-reform period, the stages of formation and functioning of medical institutions, the activities of individuals who influenced the promotion of medical knowledge in the region. N. M. Shchetinina's works made a significant contribution to the study of the activities of public and private charitable organizations of the Voronezh province, especially the Red Cross ^{[20, p. 238]}. The fundamental work of B. N. Mironov is devoted to the study of the standard of living of the Russian population in the period under review ^{[10, p. 848]}. Y. V. Pylnev's monograph ^{[14, p. 728]} gives an idea of the number of professional medical schools in the Voronezh region and their place in the system of public education in the region.

Having considered a certain layer of scientific works created by scientists of the pre-revolutionary, Soviet and post-Soviet periods, it can be argued that the study of the history of vocational education, including medical education, and the state of health care does not stand still. However, the issue of the development of professional medical education in the context of its impact on the personnel "hunger" in the healthcare sector of the Voronezh region is not sufficiently studied and leads to the need to continue scientific research.

The study used clerical documents submitted to the State Archive of the Voronezh Region (hereinafter – GAVO), periodical materials, including the journal "Medical Conversation". General information on the number of medical institutions and special educational institutions, medical centers and medical personnel of the province, statistical data on the spread of morbidity in the population of the province and the degree of provision of patients with the number of beds in medical centers are contained in Commemorative books and Reviews of the Voronezh province. These sources help to understand the relationship and interdependence between the training of medical personnel in the region and the state of healthcare in the Voronezh province.

The population of the Voronezh province grew steadily during the 19th century: in 1860, the population of the province was 1,943,682 people, in 1885 – 2 532 843 a person, and in 1895 – 2,715,706 ^{[12, p. 22]}. There has been some progress in the development of science and medicine. The standard of living of the population of post-reform Russia, according to a study by historian B. N. Mironov, increased and was associated with the intensive economic growth of the state, an increase in literacy and life expectancy of the population of the empire. And yet, constant epidemics of various types and patterns of occurrence, alternating and/or coexisting in parallel with each other, affected the general health of the population of the province and the life expectancy of people. For the entire period of the XIX century and the beginning of the XX century. Voronezh province has faced a variety of epidemics, not only in terms of symptoms, but also in terms of the level of damage caused to the region: diphtheria, scurvy, scarlet fever, typhus, cholera, smallpox and dysentery. The urgent need for qualified medical personnel became the important reason why educational institutions of medical orientation began to open in the Voronezh province.

The Voronezh Zemstvo Paramedic School, which was opened and established in 1870, opens a page in the history of medical educational institutions of the Voronezh province of the post-reform period. It is worth noting that the idea of creating such a school originated earlier, namely in 1865 and belonged to the Nizhnedevitsky Zemstvo. However, the decision to organize the school had to be approved from above, so the educational institution was opened only five years later and largely thanks to the generous donation of funds by the provincial leader of the nobility, I. I. Shidlovsky ^{[8, p. 52]}.

The school had its own charter, which clearly stated the purpose of its organization and the model of student training, expected learning outcomes and training programs for each subject. The course of study at this educational institution was designed for three years. The school had three classes, each of which had to have 12 students. Another class was created later, in 1873, in order for students to have not only theoretical knowledge, but also practical skills and abilities necessary for them in their professional activities. Since the fourth year, the pupils of the school were obliged to attend to the sick, perform medical autopsies of corpses, and participate in the creation of pharmacological agents. The academic year lasted ten months: from September to June. In the month of May, the session period was already beginning, and examination tests were conducted to move to the next grade. Most of the students successfully passed them, as can be seen from the archival data of students' academic performance ^{[7, l. 18]}.

Among the subjects taught at the paramedic school were both general disciplines such as Russian, history, arithmetic, and special subjects aimed at mastering medical knowledge by students: surgery, pharmacy, hygiene, therapy, anatomy. The noble vowels of the Voronezh province (I. I. Shidlovsky, D. D. Ryabinin, etc.) were able to organize a library for the school ^{[14, p. 421]}.

At the end of their studies, the students of the school had to take final exams in absolutely all the subjects they studied. With positive results, the student received a certificate of graduation with the rank of a paramedic, as well as a paramedic's kit for the duration of service and a set of textbooks according to which the training took place. In the position of a paramedic, it was necessary, in accordance with the Charter of the zemsky paramedic school, to work for 4.5 years.

Every year of study, as statistics show, the number of students at the school grew. So, if in 1871 there were 15 of them ^{[2, l. 31]}, in 1885 – 52, then by 1886 their number had grown to 63 people ^{[8, p. 53]}.

In addition to the Zemsky paramedic school, in the 1970s, another medical educational institution, the obstetric school, functioned in the Voronezh province. It is clear from the name of the school that its purpose was to train obstetric and gynecological personnel. The school provided Voronezh province with about 15 full-time pupils and 11 free students. Both general and highly specialized medical disciplines were taught at the school. Its maintenance cost the Zemstvo three times less than the maintenance of the paramedic school and amounted to 3,374 rubles per year. To enter the school, it was necessary to submit an application, which looked something like this:

"Daughters of the deceased lieutenant

Anna Korotkova

THE PETITION

Wishing to study midwifery at the obstetric school of the Provincial Zemstvo, I humbly ask you to enroll me as a candidate for admission to this school. I am enclosing my father's full service record.

April 20, 1876. Anna Korotkova.

I have a residence on Bolshaya Chernavskaya Street near the Chernavsky Bridge in the Vladimirova house" ^{[5, l. 15]}.

In the late 1970s, the opinion was formed in the zemstvo that the obstetric school did not bring the benefit to the people that it was supposed to bring. There was even a question about the need to close this educational institution: "The Voronezh County Zemstvo Assembly, by resolution on October 12, in accordance with the conclusion of the county council, recognized that the said school, as it turned out not to bring the desired benefit from experience, should simply be closed ..." ^{[4, l. 32]}. This situation was due to the fact that the school could not issue diplomas to its pupils and they, in turn, were deprived of the right to practice freely. To get a diploma, students had to "go to universities to pass exams for the title of midwives, giving the right to practice freely" ^{[6, L. 1]}. In 1876, only 8 out of 15 pupils decided to take exams, but additional funding was needed to send them to the university city. In 1877, a proposal was put forward to transform the midwifery school into a school of midwives-paramedics. "The provincial council speaks positively in favor of introducing the education of midwives-paramedics in the obstetric school" ^{[4, l. 43]} and in 1878 this proposal was adopted. Already at the end of the XIX century, we can talk about the existence of two paramedic schools in the Voronezh province – male and female. In the women's paramedic school, there is unification in the educational program and the number of subjects studied is equalized in accordance with the canons of the zemstvo men's paramedic school. After graduation, the pupils received a certificate of assignment of the title of midwives-paramedics.

It is worth noting that there were no educational institutions of higher medical education in the province during the period under review. The doctors who carried out their practical activities in the Voronezh province came from other regions of the Russian Empire. For example, the senior doctor of the Voronezh Provincial Zemstvo Hospital (1870-1898), K. V. Fedyaevsky, was originally from Tambov and was a graduate of the medical faculty of Moscow University.

Despite the development of education in the region and a certain increase in qualified specialists in the field of medicine, the existing medical professional educational institutions did not fully cover the existing health care needs on personnel issues. There was a shortage of specialized medical care in the Voronezh Province during the period under review. From the statistical information in the Commemorative Book of the Voronezh province, we see that the population of the region in 1885 was 2,532,843 people ^{[13, pp. 308-309]}, while there were only 170 specialists (doctors, paramedics, midwives, midwives) for the entire province. Of these, approximately 70-100 specialists were graduated annually from medical educational institutions of the Voronezh province. However, some students of paramedic schools left the province after completing their studies, without even starting medical practice. So the "medical reserve" of personnel became even smaller. The problem of the quantitative shortage of medical personnel was solved through the dissemination of sanitary and hygienic knowledge among the entire population, the redistribution of medical personnel in the province during epidemics and their involvement from other regions of the country.

To combat various epidemics and infectious diseases that claimed people's lives, medical workers of the province, for example, Dr. V. E. Vonsovich, as well as a number of public figures, noted the importance of educational and explanatory work among the population, obtaining sanitary and hygienic knowledge. It was about holding folk readings, school explanatory talks, and publishing information on this issue in print media. So, since 1887, the journal "Medical Conversation" began to be published in Voronezh in order to popularize medical education. The noble vowel I. T. Alisov insisted that such measures would bear more fruit in the fight against the terrible phenomena of epidemics than an increase in the number of medical sites.

During periods of epidemics and the spread of various infectious diseases, institutes of county sanitary doctors were organized to assist the victims, paramedics were sent to counties where their help was most urgently needed: "A certificate was given to the permanent epidemic paramedic of the provincial zemstvo, Vasily Ilyich Mosin, that he was sent to help the zemstvo doctor of the Rossoshansky district, Ostrogozhsky district to combat the epidemic of typhus in Maryevskaya volost ..." ^{[3, l. 77]}. Zemstvo medical congresses were convened in the province to exchange practical experience and knowledge. As noted by the noble vowel I. T. Alisov, with each new epidemic, the number of cases of people seeking medical help increased (in 1885, 37,963 people were treated). This created the need to open new inter-county medical centers and attract medical personnel from other regions of the state, as evidenced by information from the statement of midwife E. S. Mitrofanova: "Wishing to enter the service of the Voronezh Provincial Zemstvo at the opening inter-county medical center at Liski station, I have the honor to humbly ask the Voronezh City Council, if it agrees to my proposal, notify me..." ^{[3, l. 64]}. The costs of opening these points were taken from the budget of the Voronezh Zemstvo. So, about 100 and even more thousand rubles were spent on the elimination of the cholera epidemic at the beginning of the XX century, which was the largest amount at that time ^{[9, p. 60]}.

The private initiative of individuals also took part in solving the problem of healthcare in the Voronezh province. Of the noble vowels, the surname of I. A. Lisanevich, chairman of the provincial council, is especially known for the fact that he was more zealous, active and understanding about the medical business and was engaged in the improvement of hospitals in the region. In 1886, he put forward a proposal to open a hospital and an asylum for the insane in the province ^{[17, p. 318]}. Another vowel, T. I. Rubashevsky, presented the Bobrovsky Zemstvo with a building for the construction of a hospital. It should also be noted that an important role in maintaining the life support and public health of the population of the province was played by charitable organizations of the Voronezh province such as the Nikolaev Community of Sisters of Mercy, the Red Cross Society, the Medical Society, the Department of Guardianship of Empress Maria Alexandrovna for the Blind and a number of others, which by the end of the XIX century there were about 47 organizations ^{[1, L. 52-53]}.

Thus, despite a certain shortage of qualified medical personnel in the Voronezh province in the second half of the XIX – early XX centuries, the state of health care in the province gradually improved. This became possible thanks to the development of medical professional education, the activities of individuals and charitable organizations, educational and explanatory work on sanitary and hygienic issues, which was carried out by prominent public figures, doctors, teachers among the entire population. By the beginning of the First World War, there were 223 hospitals and paramedic stations in the Voronezh province and 278 doctors were practicing medicine. The average standard of living of the population grew not only in a particular Voronezh province, but also throughout the Russian Empire: at the beginning of the XX century. it was 33 years old, that is, 3-5 years more than in the middle of the XIX century.