Zakrzewska’s later decision to immigrate to the United States to study medicine probably reflected her desire to stand at the pinnacle of the medical hierarchy and not in the subordinate category retained for midwives. Once in the United States, she would even speak out against midwifery schools, insisting that women who wished to practice obstetrics should instead become physicians.∞∞ But while in Germany, Zakrzewska saw herself as a central player in Schmidt’s campaign to raise the status of the midwife. Coupling educational reform with legal protections, he instituted curricular changes designed to increase the knowledge base of midwives and battled successfully to prevent the elimination of midwives from the list of licensed medical personnel. Zakrzewska may have eventually rejected Schmidt’s commitment to midwifery, but her knowledge of the battles he fought and won taught her about the power both of the law and of claims to certain forms of knowledge in defining and protecting professional identity. ∞≤
Schmidt’s struggles to protect midwives is a story unto itself and must be dealt with only briefly here. ∞≥ Su≈ce it to say that they lasted approximately five years and harkened back to the dispute in which Zakrzewska’s mother had participated over swaddling women. Schmidt, who sided with the midwives, insisted that obstetricians refrain from using swaddling women as their assistants. In staking out this position, he was pitting himself against the Berlin Society of Obstetricians, which he had helped found and which wished to see the position of midwife abolished. Schmidt was not, it should be emphasized, trying to elevate the position of midwife to one even remotely on a par with that of physicians; still, he insisted that she had rights and responsibilities, which he was determined to protect. These rested upon a division of duties such that ‘‘the obstetrician is assigned chiefly to the irregular (unusual) cases, the midwives, on the other hand, chiefly to the regular (usual) cases.’’∞∂ No ruling, he insisted, ever described a situation in which a case was supposed to be assigned to swaddling women.
Schmidt eventually won this battle. In February 1852, as part of the government’s implementation of his plan for a total revamping of the medical hierarchy, it also forbade obstetricians from having a swaddling woman represent them at a delivery. Convinced, however, that physicians required assistants, the government agreed to increase the number of midwives in Berlin from fifty to
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one hundred. In the long run, the additional midwives were to come out of the Charité’s o≈cial training program, but in the short run, the government took the fifty most talented swaddling women and put them through a two-month course in the Charité. This instruction, as we will see, fell to Zakrzewska, who had by that time advanced to the position of head midwife. ∞∑
There is no direct evidence that Zakrzewska followed this battle in detail, but between her mother’s experiences trying to ban swaddling women, her close relationship with Schmidt, and her own role as instructor of the swaddling women in 1852, the general issues must have been familiar to her. For this reason, at least some aspects deserve attention. The first is the way each side used science to bolster its position. Carl Mayer, president of the Berlin Society of Obstetricians, insisted, for one, that only men had played a role in raising obstetrics to its current state as a medical science because only they ‘‘possess the scientific acuity and impartiality of the . . . senses.’’ What troubled Mayer was that by assigning all normal births to midwives, the state had created a situation in which the ‘‘material’’ (by which he meant the laboring women’s bodies) was
‘‘almost without exception lost to science.’’∞∏ Schmidt, in his rejoinder, turned to science as well, but he did so to distinguish not between physicians and midwives but between midwives and swaddling women. The former, he explained, were taught ‘‘small science [kleine Wissenschaft],’’ which helped them to recognize the boundary between natural and artificial assistance. ‘‘One calls this small science with its particular rules,’’ he emphasized, ‘‘ ‘ the art of midwifery’; the state does not yet recognize ‘ the art of swaddling.’ ’’∞π Thus both men used science rhetorically to justify the unequal distribution of power, but whereas Mayer wished to exclude women altogether from scientific activity, Schmidt claimed science for his midwives, albeit in a diminutive form. In this way, he too was inscribing gender distinctions: only physicians learned ‘‘big’’ science, and only men (by law) were physicians. Small wonder Zakrzewska would eventually speak out against midwifery schools in the United States. Her goal was to ensure that women received the same education as men, not that they be taught
‘‘small’’ science.∞∫
The other aspect of this battle that deserves attention is what it reveals about the power of the law and its role in shaping a professional identity. The 1852
legislation both raised the status of obstetrics by including it as one of the three examination areas for all physicians and strengthened the position of midwives by removing a formidable competitor. True, the government also grew more invested in impressing upon midwives their place as physicians’ assistants, but
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one need only think of the country that would later become Zakrzewska’s home to understand the significance of this legislation. The weakness of any licensing laws in the United States meant that when tensions mounted between midwives and physicians in the nineteenth century, American midwives had no recourse to state regulatory bodies that might have o√ered them some protection. Although not the only reason for their eventual decline, the lack of any e√ective legislative protection certainly contributed to the American midwife’s gradual disappearance from the birthing room.∞Ω
The midwives who benefited from the Prussian legislation formed an elite group. The decision to protect midwives had nothing to do with an appreciation of the knowledge of lay practitioners, who usually acquired their expertise through oral traditions and experience. The winners of this battle were midwives who attended a formal course of instruction at a state-run institution, followed by examinations that, if they passed, licensed them to handle normal births on their own and to assist physicians in the case of any abnormalities.
This was the group of midwives to which Zakrzewska belonged as long as she remained in Germany. One can only wonder whether much of her own sense of professionalism—which she would later carry with her to the United States and which would shape her views on women’s medical education, training, and behavior—might not have had its roots in this formally trained community of midwives.≤≠ Zakrzewska may have eventually turned her back on this community, but she had learned a valuable lesson about the role of the law, knowledge claims, and a common educational experience in shaping and solidifying a group’s identity.
. . .
Schmidt’s e√orts on behalf of midwives did not focus entirely on protecting their legal rights. He also set out to improve their knowledge base. For Schmidt, as we mentioned briefly, this meant greater attention to Wissenschaft, a di≈cult term to define but one that, by the 1840s, had come to refer to the pursuit of new knowledge through in-depth scholarly work. Schmidt’s choice of the term
‘‘ Wissenschaft ’’ must be seen as an intentional move on his part to link his own curricular reforms to the pedagogical revolution taking place in the German universities. Friedrich Wilhelm III’s decision to create a new Prussian university in Berlin in 1810 to ‘‘replace intellectually what [the state] has lost physically’’ to the French, coupled with Wilhelm von Humboldt’s emphasis on Wissenschaft, had fostered an educational environment that emphasized independence of thought and, perhaps even more important, independence of spirit. ≤∞ Schmidt
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did not, it should be emphasized, expect midwives to produce new knowledge (hence the qualifier ‘‘small’’), but he did seek to deepen their understanding of the theoretical underpinnings of their subject and to integrate this knowledge with t
heir practical skills.
It is possible to reconstruct in considerable detail the instruction Zakrzewska received from Schmidt during her years of study. Not only did his textbook form the basis of midwifery education throughout Prussia, but he submitted yearly reports to the government as well as publishing a lengthy article in the first issue of the Annalen des Charité-Krankenhauses in which he elaborated on both his pedagogical intentions and his style of teaching. As Schmidt made clear, one of his primary goals was to integrate both theory and practice in the training of midwives.≤≤
In promoting an intimate connection between theory and practice, Schmidt was echoing one of the rallying cries of physicians who were fighting for medical reform at midcentury. But where physicians were trying to counter an over-emphasis on ‘‘theory’’ in university education by insisting that students be required to attend both laboratory and clinical courses, Schmidt was trying to raise the status of the midwife by more fully developing her theoretical understanding of her field, albeit while linking it intimately to practical exercises. ≤≥ He
thus developed a program that combined lectures with both visual demonstra-tions and hands-on experience examining and attending women in labor.
Midwifery pupils attended lectures six days a week for one hour a day.
Schmidt followed the content of his textbook closely, beginning with the anatomy and physiology of the female pelvis and reproductive organs before moving on to pregnancy, birth, and confinement under normal conditions. Here he covered conception, the signs of pregnancy, the ways of noting when the time of delivery was approaching, the midwife’s responsibilities during the birthing process, the birth, and finally the care of mother and newborn in the first weeks following the birth. He then turned to abnormal conditions, discussing the problems that could arise from an irregular pelvis or reproductive organs, from the positions of the fetus, and from a premature or prolonged delivery. He followed this with a discussion of the accidents and illnesses that could occur during the birthing process, ending with a clear statement of the therapeutic measures midwives were permitted to provide and those that were strictly forbidden to them. ≤∂
Throughout this instruction Schmidt made extensive use of visual aids, including skeletons of both the female body and the newborn, wax forms, organs
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soaked in preservatives, manikins, dolls, and birthing chairs—in short, any aids that would help his students grasp more concretely the scientific underpinnings of midwifery. He even permitted at least some of his pupils to attend dissections of the mothers and infants who died during birth.≤∑
The core of Schmidt’s pedagogical program was, however, the coordination of these lectures with instruction in clinical practice. He organized the latter into two parts, which he named casuistic and systematic. The former he defined as the observation and management of the birth, and his goal was to ensure that each midwife received as much experience as possible. ≤∏ As he proudly wrote in his yearly reports to the government, he consistently exceeded the state-mandated requirement of two births for every midwife. In his clinic, each pupil had sole responsibility for at least four and often five births over the course of her training; she assisted in another eighteen cases, which included giving a full examination to the mother; and she observed as many as one hundred more deliveries. In the event of an abnormal delivery, Schmidt or one of the other physicians always took over, but the pupils were allowed to remain in the room.
This a√orded them the opportunity to observe the conditions under which forceps needed to be used or the fetus turned. One could well imagine Carl Mayer and other obstetricians worrying that midwives might as a result believe that they had learned enough to handle such di≈cult deliveries themselves. In fact, Schmidt did once permit a student to handle a breech birth on her own.
He was thus skating on thin ice. Still, he insisted that his goal was both to help midwives discern when it was necessary to send for a physician and to provide them with the skills to assist the obstetrician when he arrived.≤π
It bears mention that Schmidt may also have discussed with his midwives the need to take special precautions to avoid spreading puerperal fever (otherwise known as childbed fever). This postpartum septicemic infection posed one of the most serious threats to both European and American maternity wards before the introduction of antiseptic techniques in the last decades of the century.≤∫ Schmidt was well aware of the work of the physician Ignaz Semmelweis, who in the 1840s had attributed the high rates of puerperal fever at the Vienna General Hospital to the practice of leading medical students straight from the dissection room to the examination of parturient women. Schmidt, like most professors of midwifery at the time, did not subscribe fully to the notion that puerperal fever was being spread by the direct introduction of putrefying matter into the women’s bodies. He preferred the more commonly held view that ‘‘the hospital atmosphere of the maternity rooms’’ was principally responsible, but
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he considered the charge serious enough to warrant consideration. Of course, he would not have worried about his midwifery pupils spreading puerperal fever—even those who observed dissections were not performing them—but more than likely he would have discussed with them his reasons for recommending, even if he did not require, that his medical students take the precaution of washing their hands in a solution of chloric acid before examining the parturient women.≤Ω This may, in fact, explain why Zakrzewska instituted similar procedures when she opened her own hospital in 1862 and, as a result, had a comparatively low incidence of puerperal fever in her wards.≥≠
In addition to these ‘‘casuistic’’ lessons, which took place whenever a woman went into labor, Schmidt provided scheduled ‘‘systematic’’ clinical instruction.
This occurred at least twice a week for an hour at a time and focused on how to examine the parturient women. Here, Schmidt was most concerned with helping midwives to develop their sense of touch. They needed, he explained, to learn how ‘‘to have their eyes on the tips of their fingers. ’’≥∞ But other senses were also important, as was the use of instruments and techniques that could supplement the knowledge a midwife acquired through her own hands. Thus Schmidt introduced midwives both to the speculum, which relied on their sense of sight, and to the techniques of percussion and auscultation, which required a developed sense of sound. Throughout, moreover, he tried his best to develop his pupils’ powers of discernment by providing as many comparisons as possible, presenting, for example, women who were pregnant for the first time together with those who had given birth before, women who had pelvises of di√erent sizes, or those who had fetuses in di√erent positions. As Schmidt once explained, ‘‘Nothing is easier than to distinguish between a uterus descendens and a uterus ascendens when both are right next to one another.’’≥≤
Schmidt recognized that such comparisons were possible because the midwifery school was housed in a large urban hospital that could provide adequate clinical material. But the quantity of material was not the only advantage a hospital conferred. Although Schmidt never stated this explicitly, it was also evident that only in a large hospital would midwives have the opportunity to practice the various techniques that allowed them to perfect their skills.
Schmidt may have started his pupils on manikins, but he soon took them over to the station for syphilitics, where the women, mostly prostitutes, could raise few objections to having their bodies probed and prodded. During these visits, his pupils could practice how to percuss, use the speculum, insert catheters, apply leeches, and give injections.≥≥ For all of Schmidt’s insistence that he saw ‘‘some-
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thing more than a living phantom even in people who have sunk as low as they can go,’’ his conduct resembled that of most nineteenth-century hospital physicians who viewed their patients, almost all of whom came from the
poorest segments of society, as clinical material on which to practice their craft.≥∂
Zakrzewska would eventually develop a greater concern for the dignity of the poor and try her best to guard against the abuse of the patients who frequented her hospital. This sensitivity may very well have stemmed both from her experiences assisting her mother in practice and from her observations of the way poor women were frequently treated at the Charité. Zakrzewska never said as much; yet when she described her experiences at the hospital, she emphasized the respect she tried to show the prostitutes, refusing to treat them as totally lost souls. Still, Zakrzewska’s class upbringing comes through in a story she told about one of the prostitutes at the Charité, whom she engaged as a ‘‘servant’’ and to whom she ‘‘trusted every thing [ sic].’’≥∑ To Zakrzewska what was important was the trust she placed in a woman whom others dismissed as beyond redemption. That she showed her respect by placing this woman in a position of servitude remained fully unproblematic for her. Much like other middle-class reformers who were committed to building a just society, Zakrzewska frequently mixed compassion for those in need with a sense of her own superiority. ≥∏
The education in midwifery Zakrzewska received at the Charité was outstanding by any measure of the day. One need only consider that at that time most American medical students sought out clinical instruction, if they did so at all, on their own time. Few medical schools o√ered bedside training, let alone formal instruction in auscultation, percussion, or the use of the speculum.≥π
Perhaps even more impressive is the fact that Zakrzewska’s obstetric training, at least the practical end, di√ered little from what medical students at the University of Berlin were being taught. Schmidt, who was responsible for instructing both groups, saw no reason, in fact, to distinguish between the two in his detailed descriptions of his pedagogical methods, since he considered ‘‘the foundations of the one to repeat themselves, with the necessary changes, in that of the other.’’≥∫
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