The Practice of Practical Education: Male Students and Female Apprentices in the Lying-in Hospital of Göttingen University, 1792–1815

It is generally agreed that, in most European countries, practical education became increasingly important for future physicians and surgeons during the course of the eighteenth century. Recent studies have shown that, around 1800, clinical teaching took place in a variety of contexts: hospitals with inpatients, polyclinics or outpatient dispensaries, consultation hours for poor people, private tutoring by, or a kind of apprenticeship with, an experienced practitioner.¹ While these organizational forms have become fairly clear in several countries, much less is known about what “practical” training actually meant. Did it mainly consist of “studying written case histories”,² or following “clinical lectures” in the classroom where the teacher brought in patients and explained their diseases? Did students attend the hospital rounds of professors and hospital physicians, or did they “walk the wards” on their own? To what extent were medical students allowed to question patients, and physically examine them? Were they given responsibility for patients under the supervision of a professor or an experienced physician? If so, how many patients did they examine or treat during their education? It is true that we know the regulations of some medical schools at specific points in time, but we have much less knowledge about how these rules were implemented. The few surviving memoirs, diaries and travel accounts make clear that there may have been a considerable gap between norms and practice. A major constraining factor was of course the number of students per patient, and per teacher.

Detailed archival and printed sources from the lying-in hospital of Göttingen University allow a deeper insight into the practice of clinical teaching during the late eighteenth and early nineteenth centuries. In this period, when midwifery was being transformed into a branch of medical science, access to practical experience was of particular importance. Males, physicians or surgeons, could compete successfully with female midwives only if they acquired practical skills in addition to the superior theoretical knowledge which they claimed. Midwives, on the other hand, had free access to practice and were usually trained by an informal apprenticeship with an older midwife. But, according to many medical men, they were ignorant because they lacked any theoretical knowledge.³ In Germany, where medical education continued to be centred mainly on universities,⁴ the lying-in hospitals attached to them were of crucial importance for the rise of man-midwifery. The maternity hospital of Göttingen University, founded in 1751, played a pioneer role.⁵ The University, a foundation of the Enlightenment, had tried to include bedside teaching from its beginnings in the 1730s because its medical faculty was aware that this was a prime factor in attracting students. The maternity school of 1751, however, was its first clinical institution; a general infirmary was opened only in 1781.⁶ In the early days, under the directorship of Professor Johann Georg Roederer (1726–63), the lying-in service consisted of just two rooms in a hospital which mainly housed elderly persons, and the number of deliveries was usually less than 30 per year. In the 1780s, the University persuaded the government to have the old building pulled down and replaced by a spacious new structure, earmarked exclusively for the maternity hospital. On the first floor, there were seven chambers for a total of fourteen patients, the delivery room, the teaching hall, and the hospital midwife's accommodation. The second floor housed the director and his family; while the manager and his family, the servant and the midwife apprentices lived on the ground floor. The new house opened in 1791, and in 1792, a new professor of obstetrics and hospital director was called to Göttingen. Friedrich Benjamin Osiander (1759–1822), trained in Tübingen, Strasbourg and Kassel, held office until his death. In the new building, the annual number of deliveries rose to between 70 and 100.

Osiander was outspoken about the hospital's order of priorities: “The lying-in hospital at Göttingen aims, above all, to train skilful obstetricians … secondly, to train midwives … and finally, to provide a safe shelter for poor pregnant women, married or not, during the period of childbirth …”.⁷

To what extent were students and midwives attracted by this offer?

The Lying-in Hospital: An Attraction for Medical Students

The University of Göttingen of the Electorate of Hanover was not only the most recent foundation (1734/37) among German universities—rivalling Halle (in Prussia, founded in 1694) as the most modern⁸—but it was also among the largest. During the eighteenth century, it was one of the top four in terms of student numbers, together with Halle, Jena and Leipzig, and for some years in the early nineteenth century it even became the largest of them all.⁹ In the 1790s, the total number of students at Göttingen averaged over 700, and in 1815 it was more than 800.¹⁰ The medical faculty, too, was among the most important in Germany in terms of numbers of students (more than 100 in the 1790s: see Table 1, col. 1), MD degrees awarded (a total of almost 200 in the decade 1790–99), and full professors (eight in 1796).¹¹ Like the other faculties, it was able to attract many young men from “abroad”, i.e. from other German states, as well as from foreign countries including Russia, Switzerland and England.¹²

Table 1.

Number of students at the medical faculty of Göttingen University, number of students and of midwives using the lying-in hospital, 1792–1801 and 1815

Semester	Number of students at the medical faculty		Number of users of the lying-in hospital
	Total number	out of whom newly matriculated	Medical students		Midwives
			Total number1	Repeaters	First/second quarters2
	(1)	(2)	(3)	(4)	(5)
WS 1792/93	110	35	21	–*	–/4
SS 1793	114	23	36	8	2/–
WS 1793/94	116	29	24	6	1/–
SS 1794	108	25	18	–	–/–
WS 1794/95	103	22	27	7	–/–
SS 1795	102	26	30	10	–/–
WS 1795/96	114	25	40	17	–/2
SS 1796	118	28	49	13	2/–
WS 1796/97	105	26	47	–	5/6
SS 1797	114	26	39	–	2/0
WS 1797/98	110	32	41	–	2/2
SS 1798	110	28	31	–	–/–
WS 1798/99	113	28	41	–	4/4
SS 1799	103	30	47	–	4/4
WS 1799/1800	104	20	28	17	3/3
SS 1800	106	26	48	15	8/1
WS 1800/01	100	25	35	20	1/–
Subtotal	1,850	454	602
WS 1814/15	145	–	65	–
SS 1815	136	–	60	–	163
W 1815/16	146	–	61	–
Subtotal	427		186

^*Dashes indicate that these numbers are not available.

¹The source gives the number of students per quarter (three-month period). In most cases, the number was the same for both quarters, or given for only one of the two quarters. For the three semesters where the numbers for the two quarters differed by one, the table gives the higher figure. For the two semesters where the numbers of the two quarters differed by two, and for one semester, where the numbers of the two quarters differed by four, the table gives the average.

²The courses for midwives usually lasted three months. Since we do not know the exact dates in most years, it is difficult to tell to what extent the same midwives are counted as using the lying-in hospital, in two subsequent quarters. Cf. note 103 of the text.

³The source gives a total of 16 midwives for the whole of 1815.

Sources:

Col. 1: Norbert Kamp (ed.), 250 Jahre Georg-August-Universität Göttingen: Studentenzahlen 1734/37–1987, Göttingen, Goltze [c.1987], p. 29; Hartmut Titze et al., Wachstum und Differenzierung der deutschen Universitäten 1830–1945, Göttingen, Vandenhoeck & Ruprecht, 1995, p. 232.

Col. 2: My own calculation, based on: Götz von Selle (ed.), Die Matrikel der Georg-August-Universität zu Göttingen 1734–1837, Hildesheim, Lax, 1937, pp. 338–412. I have counted those enrolled 1 March to 31 August as newly matriculated for the summer semester (SS, 1 April–30 September), and those enrolled 1 September–28 (29) February for the winter semester (WS, 1 October–31 March).

Cols. 3 and 5: AUFK Gö, O 3: Friedrich Benjamin Osiander, ‘Sammlung der vierteljährigen Übersichten der Königlichen Entbindungsanstalt zu Göttingen’, 1785–1800; for 1815: Friedrich Benjamin Osiander, Übersicht über die Ereignisse in der Entbindungslehranstalt im Jahr 1815, Göttingen, Huth, 1816, pp. 14–15.

Col. 4: AUFK Gö, W 29: Ankündigung von Lehrveranstaltungen, 1790–1797, fols. 8–9, 16–17, 23–24, 27–28; Friedrich Benjamin Osiander, Kurze Übersicht der Vorfälle in dem Königl. Entbindungshospital auf der Georg-Augustus-Universität zu Göttingen vom 1. Octob. 1794 bis 23. März 1795 […], Göttingen, (no date, no publisher given), p. [1]; idem, Kurze Übersicht der Vorfälle in dem Königl. Entbindungshospital auf der Georg-Augustus-Universität zu Göttingen vom 1. April bis 31.[sic] September 1795 […], Göttingen, (no date, no publisher given), p. [1]; AUFK Gö, A 1: Tagebuch, vol. 4, 1795–1797, fols. [364]–[365]; Friedrich Benjamin Osiander, Annalen der Entbindungs-Lehranstalt auf der Universität zu Göttingen vom Jahr 1800, 2 vols. in 4 parts, Göttingen, Dieterich, 1800–1804, vol. 1, part 1, pp. 164–6, vol. 1, part 2, pp. 91–5, vol. 2, part 2, pp. 320–1.

Out of this large number of medical students, how many were interested in the relatively new speciality of obstetrics? As Table 1 (cols. 1 and 3) shows, during each semester in the 1790s an average of one-third (32.5 per cent) of all the medical students “used” the lying-in hospital, and in 1815 close to half (43.6 per cent). This figure is surprisingly high, but can in part be explained by the fact that around 1800 in Germany students tended to stay for only about two years at a specific university.¹³ Some moved from one university to another, but many appear to have studied for only a relatively short time, since there were no established curricula, and few final exams or formal requirements for graduation in terms of expert knowledge. This was true of the medical faculty of Göttingen, as well,¹⁴ and there, too, students spent an average of four semesters in the 1790s (Table 1: ratio between col. 1 and col. 2). Those who received an MD from Göttingen University in the last decade of the eighteenth century had spent there on average less than a year and a half.¹⁵

For some semesters, Osiander's list of students specified how many attended his course for the first time and how many were repeaters (Table 1, col. 4). The proportion of the latter amounted to more than a third of the total number of participants in those semesters (113 out of 317, i.e. 35.6 per cent). Therefore, the total of 602 students (col. 3), when corrected for repeaters, probably implies about 387 individuals. Thus the overwhelming majority of the students enrolled at the medical faculty did in fact use the lying-in hospital: 387 out of 454 (col. 2), that is 85 per cent.¹⁶

As this figure shows, Osiander had good reason to argue that his lying-in hospital was a major asset of the University's medical faculty and helped considerably to attract both German and foreign students.¹⁷ The fact that attendance at his course was so high is particularly remarkable, since in many German states there were no formal requirements of this kind, neither for graduation, nor for admission by public authorities as a practitioner.¹⁸ It appears that the faculty relied on the students' own interest in a good education as the best way to achieve success in practice.

For how long did the students participate in the courses at the maternity hospital? Osiander reported that, during nine semesters between summer 1793 and winter 1800/01, out of a total of 313 students, 200 attended for the first time, 90 for the second, 15 for the third, 5 for the fourth, and 3 for even the fifth time. On this basis, the estimate is that the majority (55 per cent) of the students attended his course for only one semester, but more than a third (37.5 per cent) for two semesters, 5 per cent for three semesters, and 2.5 per cent for four or even five semesters.¹⁹

These figures show that the medical faculty of Göttingen attracted high numbers of students partly because of the importance of the lying-in hospital. Almost all the medical students enrolled in Göttingen made use of it, although a majority for only one semester. There was a minority of medical students, however, who were eager to get a more extensive training in midwifery.

As for the training of female midwives, the figures clearly seem to show that this was much less important than the education of male students (Table 1, col. 5). Usually between two and six women participated in the course, that is about one-tenth of the number of medical students. The course for midwives lasted three months, generally from May to July, and from December to February.²⁰ As early as 1752, just six months after the lying-in hospital opened, the government of Hanover had ordered that towns should not accept any new midwives unless they had been taught at the maternity hospital and examined by the professor of obstetrics.²¹ This would have created a strong incentive for women to attend the course, in particular if towns followed the advice of the government and paid the cost of their midwives' stay at Göttingen. It appears, however, that it took a long while before this ordinance was fully implemented in all towns, and even longer before rural communities followed suit.²²

“A Complete Course on the Theoretical and Practical Parts of Midwifery”

“Every semester a complete course on the theoretical and practical parts of midwifery is held”, Professor Osiander told the medical reading public.²³ What this meant becomes clearer by his remark that he based his course on Stein's textbook.²⁴ Georg Wilhelm Stein (senior), whom Osiander revered as his teacher,²⁵ divided his manual into two parts Theoretische Anleitung zur Geburtshülfe (Theoretical Guide to Midwifery), and Practische Anleitung zur Geburtshülfe (Practical Guide to Midwifery), both explicitly designed as lecture textbooks.²⁶ The first “theoretical” volume had chapters on the female genitals, pregnancy, the “fruit” or “embryo”, and childbirth, in particular “natural childbirth”.²⁷ The second “practical” volume dealt with “contranatural and difficult cases”, and had chapters on “manual” and “instrumental operations”.²⁸ Later, Osiander used his own Grundriss der Entbindungskunst zum Leitfaden bei seinen Vorlesungen (Outline of the Art of Accouchement), published in 1802,²⁹ for he believed that the development of the discipline during the previous decade made a more up-to-date manual necessary.³⁰ This text was also in two volumes, the first treating pregnancy and childbirth, and the second, delivery and instruments.³¹ The second “practical” part explained “what an accoucheur should and should not do in contranatural cases and in such cases of childbirth which require artificial assistance”.³² It is no coincidence that Osiander, like most of his colleagues, in Germany at least, thought that artificial assistance in childbirth was reserved for the male sex, while female midwives should, in principle, be limited to assisting in “natural” deliveries. This was in line with a dichotomous notion of gender in which male and female were bound up with the polarities of culture and nature, activity and passivity, reason and emotion.³³ All this implies that the “theoretical” part of midwifery dealing with “natural” childbirth basically concerned the type of cases which medical doctors were willing to leave to female midwives, while the “practical” part treated those complicated cases where male physicians or surgeons thought that their own intervention was required.³⁴

There were, however, further reasons why Osiander called his course practical as well as theoretical. He held “practical exercises”, in addition to the lecture course. Students appear to have been even more keenly interested in the former than in the latter. In the summer of 1796, the only semester for which a list for both the “collegium theoreticum” and the “practical exercises” is preserved, 36 students participated in the lectures, but 49 in the practical part. All those who took Osiander's course for the first time, attended both; those who were repeaters participated in the practical exercises only.³⁵ Not surprisingly, Osiander advertised this aspect of his course by emphasizing the demonstrations and exercises with a manikin or “phantom”, a female pelvis covered by leather. Compared to mere lectures and even to pictures, this form of practise was considered to be a major improvement, and it was an important element in the courses taught by “the King's midwife”, Madame du Coudray, to midwives, surgeons and physicians in many parts of France from 1759 to 1783, as well as in the lessons given by William Smellie and other British men-midwives to male students since mid-century.³⁶ Like his teacher Stein,³⁷ Osiander was well aware of this practical turn in obstetric teaching, and during his first term in Göttingen he bought, at the hospital's expense, a phantom designed by a colleague in Jena.³⁸ The next semester, he lectured on Mondays, Tuesdays, Thursdays and Fridays from 9 a.m. to 10 a.m., and set aside Wednesdays and Saturdays for practising with the dummy. Later he used the entire final month of each semester for exercises with the phantom.³⁹ He insisted that no more than four students per hour could practice on it. Therefore, in addition to the lessons which Osiander taught himself, he let groups of students exercise on their own, supervised by one who was more experienced than the rest. Even so, the time available for each student was quite limited. This is made plain in an announcement, handwritten by Osiander in late August 1793, and posted in the hospital at the end of his lecture course. He notified his students that the exercises with the phantom would continue during the first half of September, four days a week from 9.00 to 10.00 in the morning. He distributed the 31 students who remained out of the 36 who had attended his classes during the summer term into groups of four and assigned a day to each group.⁴⁰ This meant that each student had just fifteen minutes' practice during the two-week period.

With the phantom, Osiander taught two things: first, the semiotics of foetal positions, i.e. how to discover the position of the unborn in the uterus by touching it with one or several fingers through the vagina, and, second, how to intervene in difficult cases. In particular, he demonstrated, and let his students practise, how to deliver a child presenting the feet, to turn a child in the uterus, and to use the forceps and the vectis.⁴¹ According to his peculiar approach, he refused to teach embryotomy, and insisted that, in almost all cases, a living child could be delivered with the forceps.⁴² Following Stein, Osiander endeavoured to make the exercise on the phantom as realistic as possible. They both preferred to use corpses of stillborn babies, preserved in alcohol, rather than artificial dolls. Osiander considered this to be the only effective way of training palpation,⁴³ and there was always a supply of dead babies in the hospital.

Above all, the hospital made living patients available for teaching purposes. The students were thus trained in palpation not only on the phantom, but also on the pregnant women in the clinic. They learnt how to perform both external and internal manual examinations, and in this way determine the state of the pregnancy and the position of the foetus. A man touching a woman's genitals and womb clearly transgressed a strong shame taboo, and that was not easily allowed in private practise.⁴⁴ The women in the hospital, however, who were mostly unmarried servants,⁴⁵ had free board, lodging and treatment during their stay, and had to accept being used for this purpose. To be sure, midwives had practised manual examinations of pregnant women for a long time. For male obstetricians, however, it was a recent development, crucial for their efforts to build a knowledge of their own, independent of that of the women concerned.⁴⁶ For this reason, teaching medical students how to examine pregnant women “according to the rules of the art” was an important part of the practical course.⁴⁷

Like that of the medical students, the training of female midwives was theoretical as well as practical, although with significant differences in the content of the theoretical knowledge taught and in what was exercised on the phantom. Thus, in an announcement of the courses for the summer semester of 1796, posted in the maternity hospital, Osiander spoke of the “Collegium theoreticum” on the “science of obstetrics” for the male students, as opposed to the “lessons in the art of midwifery” for the female apprentices.⁴⁸ The medical students were supposed to know Latin. As for the midwife apprentices, Osiander would have liked them all to be able to read and even write, but he was unable to insist on this because he had no control over which women came to his course.⁴⁹ They were either elected by the married women in their community, or picked by local officers.⁵⁰ In fact, many of them did not even speak high German, but only low German, the language of the North, including the Electorate of Hanover. During his first years in Göttingen, this appears to have been a problem for Osiander, since he was from Württemberg, in the southwest.

Like the lectures for medical students, the lessons for midwife apprentices were based on a textbook by Georg Wilhelm Stein, the Hebammen-Catechismus (Catechism for Midwives). Consisting of only about 100 pages, this was more elementary and shorter than the students' textbook, and was written in the form of questions and answers, which Enlightenment authors thought especially appropriate for teaching ordinary people.⁵¹ Osiander would ask the most literate apprentice to read out a paragraph from the textbook. He would then question the women to ascertain whether all had properly understood the meaning, and he endeavoured to imprint the matter firmly in their memory by using terms from their dialect, giving examples, and showing drawings, copper engravings and preparations from his collections.⁵²

The professor insisted that the “midwives' art” is to the “science of obstetrics” as a part is to the whole. This is evident in the way “contranatural” deliveries were treated. Whereas in the textbook for medical students most of the second volume was devoted to this topic, in the reader for midwives only one chapter out of sixteen dealt with such deliveries, and the information given was strictly limited to what a midwife was required know about the subject.⁵³ On the other hand, the latter book had a chapter on the female body in general, in addition to one on female genitals, several chapters on how to treat newborn babies and women after birth, including common diseases of both, and a section on religious customs in different religions, Protestant and Catholic baptism as well as Jewish circumcision. All this was missing in the text for medical students. Also in terms of practical skills, the apprentices were taught to administer clysters, insert catheters, perform phlebotomies and put on bandages,⁵⁴ and they were trained in nursing. At least part of this was probably taught by the hospital midwife, who was in charge of these tasks in the wards.⁵⁵

With the dummy, the female apprentices were shown, and practised, how to determine the position of the foetus, and to deliver a child presenting by the feet or the breech. For emergencies, they were even supposed to learn how to turn a foetus in the uterus.⁵⁶ They were taught to do these operations manually,⁵⁷ but never how to use instruments. The forceps, in particular, were for Osiander, as for most obstetricians, the exclusive privilege of male accoucheurs.⁵⁸ In the physical examination of patients, midwives learnt the same skills as male students.

Osiander appears to have felt uneasy about male and female pupils being present in the same building at the same time.⁵⁹ Once, on the day that he started the course for midwives, he posted a handwritten message to the medical students, explaining changes in the schedule for practices with the phantom and examinations of patients. At the end he admonished the young men: “I have already told these women [i.e. the apprentices] to behave in the most decent and polite way towards you, gentlemen. I also hope that you, thanks to your good manners, will behave most decently towards them.”⁶⁰ In many ways, the professor drew as clear a line as possible between the “gentlemen”-students and the “women”-midwives. Whereas he spoke directly to the apprentices, he addressed the disciples in writing, often sending them messages in Latin, for example, invitations to attend a post mortem or the circumcision of a newborn Jewish boy. Even the “order and statutes” of the hospital, in so far as they concerned the “most noble and honourable students of the healing art”, were composed in Latin by Osiander.⁶¹ The courses for both groups took place in the same building, probably in the same room, the “teaching hall” (Lehr-Saal), but at different times. In the summer of 1796, the lecture course on “the science of obstetrics” was scheduled on Mondays to Fridays from 9 a.m. to 10 a.m., and the “lessons in the art of midwifery” from 10 a.m. to 11 a.m. on the same days.⁶² In 1800, he taught the midwives' class from 11.00 to 12.00,⁶³ possibly in order to avoid contact between the two groups. The exercises in examining patients were on different days for the two sexes, in some years on Wednesdays for male students, and on Saturdays for female apprentices.⁶⁴

When it came to using patients as teaching material, it is evident that the two groups competed with each other for a relatively scarce resource. In the summer semester, there were always fewer women in the hospital than in the winter, since, being single, many of them simply required shelter during the difficult period before and after childbirth.⁶⁵ In spring 1793, the hospital housed on average only two or three pregnant patients at a time.⁶⁶ Therefore, on 12 June 1793, Osiander felt obliged to write a long letter to the gentlemen, his students, in order to resolve “a misunderstanding that seems to prevail regarding the examination of the pregnant women”. He stated that the frequency with which each student could practise physical examinations depended, first, on the number of pregnant patients in the hospital, and, second, on the number of “gentlemen” and “midwives” using the teaching institution. He explained at length that “a pregnant woman cannot be expected to let herself be examined more than twice a week”, each time by no more than three, or at most four persons. More frequent examinations would not be “advantageous” either to her or her “fruit”, or to the attendance of the hospital. Most patients abhorred being examined, and there were even rumours that the relatively numerous contranatural deliveries in the clinic were caused by the many physical examinations—which was not, of course, the case. For this reason, Osiander divided his students into two groups and gave each of them a number. Those in the first group would examine the pregnant women on Wednesdays, those in the second, on Saturdays. Each week, however, only three from each class would be allowed to examine, in the order of their numbers, and each day only half of the patients would be there for them. The other half would be examined by the midwife apprentices. In this way, each of the 36 medical students present in the 1793 summer semester (Table 1, col. 3) had an equal chance to practise physical examination of the pregnant women. But while there were so few patients, only six per week were allowed to do this, and it took six weeks before all had had their turn. As a consolation, Osiander stressed that, as soon as the midwives' course finished at the end of July, more women would be available for the medical students.⁶⁷

In his letter to the “gentlemen”, the professor did not conceal the fact that only two midwives participated in the summer 1793 course. What seems to be a fair compromise between the categories of medical students on the one hand, and apprentices on the other, amounted to a very uneven distribution of opportunities for examining pregnant women, if calculated per person. The two midwife apprentices would have weekly, or even twice weekly, practices, whereas for each medical student the opportunity arose only once in six weeks. To be sure, the apprentices stayed for only three months, and the students could use the time between the semesters and courses. Nevertheless, the majority of students, that is those who took the course in obstetrics just once, probably examined real women in the hospital only twice or at most four times during the whole of their training at Göttingen.

It appears that for practice on the phantom there was also equality between medical students and midwives, considered as groups. Due to the much greater number of students, however, each of them had far fewer opportunities to exercise with the dummy. As for the theoretical part of the course, the number of hours taught was equal for both categories. Although the midwives' class was much smaller, so that they could easily ask, or be asked, questions, Osiander made it clear that he could teach much less to the women, who were not accustomed to learning in the classroom. “It is easy, says the proverb, to preach to learned persons, but converting pagans demands the talents of an apostle.”⁶⁸

The midwives' course, which lasted for three months, as in many other German places during this period,⁶⁹ was obviously short by comparison with the course of one or even two years for the elite of French midwives in the big maternity hospital of Port-Royal, Paris.⁷⁰ Nevertheless, compared with the great majority of Göttingen medical students, who studied obstetrics for only one or two semesters, the female apprentices had much better opportunities to acquire practical skills. This is true not only in terms of the minor everyday chores which, living in the house day and night, they shared with the hospital midwife as a matter of course, but also of exercises on the phantom and examinations of real women. This is a rather surprising finding, since Osiander never ceased to emphasize that his maternity hospital was a university institution, and that its foremost goal was to educate skilful doctors as men-midwives.

What about the most crucial occasion the hospital could offer for practising midwifery, attending childbirth?

“To Derive as much Benefit for Teaching as Possible from the Births”

Professor Osiander was proud of his unfailing presence in the clinic: “At every delivery, whether in the day or at night, I am present from beginning to end, unless prevented by illness, a visit to a village or other urgent business.”⁷¹ The birth protocols in the medical diaries, handwritten by the director, confirm this.⁷² Implicitly, Osiander compared his institution with the huge maternity hospitals, such as those in Vienna or Paris, which had more than a thousand births per year, most of which were, however, attended by midwives and midwife apprentices, not the medical director.⁷³ “[T]hroughout, it is my intention to derive as much benefit for teaching as possible from the births which occur here. If one does this, one hundred births can be more instructive than thousands in another lying-in hospital.”⁷⁴

In his publications, Osiander described how he organized this core of practical teaching. When a woman had gone into labour and her orificium uteri was open four fingers wide, the students, whose lodgings were scattered through the town, were called in by the hospital's servant. Then the parturient woman was led from her bed to the delivery room and placed on the birth stool. The students assembled in the adjacent room, as did the apprentice midwives, who lived in the hospital during their course. Osiander called some of the advanced students into the delivery room and had them examine the woman. They reported their findings on the position of the child and the state of the birthing process. Then, the professor explained the situation to the whole audience in the adjacent room. Using the dummy and an artificial head of a baby, he showed the position of the child, pointed out any impediments to the birth and indications for intervention, and demonstrated the course of action he had chosen. He strove to make the logical sequence from diagnosis to action and success as transparent to the learners in the delivery room as it appeared in his handwritten and published case histories.⁷⁵ If Osiander had decided to “leave the birth to nature”, he asked one of the apprentice midwives to assist. If he opted for “artificial” help, he called upon one of the advanced students. Now the entire audience entered the delivery room. They found the upper half of the parturient's body hidden by a green curtain, so that “her shame was spared, as much as the circumstances allow”. “Up to her genitals”, she was naked “so that all the audience could observe the procedure”. The hospital's midwife stood at her side and “instructed her how to push skilfully during contractions”. The professor sat next to the student or apprentice whom he had invited to attend. He directed the “business”, and took over himself as soon as the attendant experienced difficulties or made an error.⁷⁶

As this description makes clear, there were several levels at which pupils participated in the deliveries: watching, examining, helping in a natural birth, assisting in an artificial delivery. The higher the level, the fewer the number of those who had access to it.

From his second semester in Göttingen, Osiander divided his students into two groups, at least when there were more than thirty, so that only half of them were present at each birth, except in especially complicated cases, when all were summoned.⁷⁷ The students appear to have kept a careful eye on getting their fair chance of observing deliveries. In December 1797, the professor received an anonymous letter complaining that in some cases not all the students had been called when births took place. Taking this charge seriously, he replied in an open letter that, in spite of all his efforts, it was inevitable that sometimes a delivery came to a natural end, or had to be terminated for urgent reasons, before all the gentlemen whom he had summoned arrived. He reminded his students that his ultimate aim was to make all of them, without any exception, profit from the deliveries in the hospital. He explained that, precisely for this reason, he had tried, in the current semester, to have all the students called to each birth, instead of just half or even a third of them. But since some, who did not know what they could reasonably demand, were dissatisfied, he found it necessary to return to the former order, dividing the students into two classes, which would be summoned to deliveries alternately.⁷⁸ It is evident that, even in a relatively small town like Göttingen,⁷⁹ it took a considerable time for the hospital's servant to call at all the different houses where the students (41 in the winter of 1797/98) lived. On the other hand, this may have made it easier for Osiander to manipulate the order and eventually to exclude some students if there were too many. For the midwife apprentices, Osiander did not deem it necessary to divide them into two classes, because there were usually only between two and six, so all could watch every delivery.

While some births progressed too quickly, many lasted for long hours, even after the students had arrived at the hospital. In such a case, they tended to enter the delivery room early in order to get the best places in front of the parturient woman. The professor told the students repeatedly to wait in the hall until the last phase of labour, when he called them in. Not only would it be useless for them to stand for hours in the small “cell”, but their gazing at the patient for a long time and talking to each other would frighten and torment her. Moreover, it could disturb Osiander while he wrote the birth protocol into the hospital diary, although in principle he loved having useful conversations with his students while the patient was in labour.⁸⁰ He appealed to their good manners: “Honourable and diligent students will on their own initiative refrain from smoking tobacco in this building, passing the time by playing cards, causing quarrels or tumults, bringing dogs, and entering the rooms of pregnant women.”⁸¹ As a positive alternative, in December 1794 he started to build up a collection of obstetric books to be stored in the hall next to the delivery room, where they could be read by his keen students during the hours of waiting.⁸²

With regard to the second level of participation, i.e. physical examinations during the birthing process, Osiander makes no explicit mention of apprentices being invited to do these, but does speak of students in this context, even “several” at a time.⁸³ Presumably no more than three or four of them were admitted to a parturient woman, as in the case of pregnant patients, since examining a woman in labour involved the risks of untimely disruption of the amniotic sac or of causing a swelling on the head or other parts of the child.⁸⁴ In any case, the professor ordered the students to enter the delivery room for the physical examination one by one. The reason he gave was not consideration for the woman, but that the subsequent gentleman should not hear the findings of the previous one.⁸⁵

Actually assisting or intervening in a delivery was the highlight of practical education, usually reserved for one student or apprentice per case, rarely to more than two. The scarcest and the most crucial of the opportunities which the hospital could offer was carefully regulated. “[T]he gentleman whose turn it is” was “always called first”, and “is obliged to stay not only to the end of the birth, but until the delivered woman is led to her bed”. Students were left in no doubt that this was an occasion not to be missed; they would have to wait a long time for another. “If the gentleman whose turn it is voluntarily transfers the delivery to somebody else, he is nevertheless considered to have attended it himself.”⁸⁶ By posting in the hospital the list of students, numbered and divided into classes, the professor allowed them, at least in principle, to check that such opportunities were distributed in an impartial way. On the list for the 1793 summer semester, which appears to have been put up after the “misunderstanding” of 12 June, he explicitly stated: “The gentlemen take care of the births in the order noted here.”⁸⁷ In his letter of 12 June, however, he had made a proviso in favour of the female apprentices: “from St John's day [24 June] to the end of July, the two midwives will alternate with the gentlemen in attending the births occurring in the hospital”, or at least the “natural” ones. He assured the students: “Nevertheless, each time one of the gentlemen's groups will be summoned.”⁸⁸

Thus, Osiander, as hospital director, claimed to establish a just and transparent order, balancing the chances for practical experience, both between students and midwives as groups, and between individuals within each category, especially among students.

To what extent did he in practice observe the regime he had proclaimed? Since he used to note the name of the birth attendant in the diary, and in some years in the calendar where he briefly registered the deliveries, it is possible to examine this question.⁸⁹ In several semesters, including the summer of 1793, he even tallied the list of students with the deliveries attended by the respective gentlemen. In April and May 1793, no midwife is recorded as birth attendant. Among the students, the deliveries were distributed very unevenly, which may have been an additional reason for the discontent or “misunderstanding” that Osiander tried to resolve by his letter of 12 June and by dividing the students into two classes. Out of the eleven births occurring between 1 April, which can be considered as the beginning of the summer semester, and 11 June, the day before Osiander's letter, Johann Dietrich Hensing from Kurland, one of the Baltic provinces of the Russian empire, took care of no less than three deliveries, on 3, 14 and 18 April.⁹⁰ Dr Johann Ludwig Eberhard Orth from Heilbronn, a Free Imperial City in southwest Germany, attended two deliveries on 5 April and 1 June.⁹¹ Six other students were in charge of one birth each.⁹² Did things become more equal once the professor had announced a transparent order on 12 June? The next birth, on 16 June, was attended by Frau Spangenbergin, one of the two midwife apprentices, despite Osiander's having told his students that the women would not perform deliveries before St John's day. But the first student of the second class, Joseph Jacob Gumprecht, son of a Jewish family in Göttingen, assisted the same delivery, incidentally of twins.⁹³ Contrary to what the professor had announced, the following birth, on 6 July, was also assisted by a midwife, Frau Gottgardin, although Osiander himself intervened as well. Then, two days later, it was a student's turn, but not the one next on the list. Instead it was Gumprecht again. The attendants in the next four cases matched the order set out in June: on 10 July, one of the gentlemen had his first opportunity, and Frau Spangenbergin assisted once more; on 14 July another student was called upon; on 18 July Frau Gottgardin helped alone; and on 20 July, Osiander did a forceps operation, assisted by yet another student. Then, on 27 July, the last delivery of the month was performed by the professor alone.

At the end of their three-month course, therefore, each of the two midwife apprentices had attended two births. Out of the 36 students, however, during the six months of the summer semester (April–September), 20 had not been in charge of any delivery. Twelve had taken care of one birth each, three of two, and one (Hensing) of four births. The order in which the students attended the deliveries does not correspond at all to the numbers on Osiander's list. There was not even a regular alternation between the two classes of 18 students. From the first class, 11 students attended fifteen births, whereas from the second, 5 students took care of only seven births.

In the winter semester of 1793/94, there were, as usual, more births than in the summer, so the chances for gaining practical experience were better. Out of 27 students, only 8 were not in charge of any delivery. Thirteen attended one birth each, three took care of two, and one of three births. Two students, however, took care of six and eight deliveries respectively. One of them was Gumprecht, who took his MD degree in December. As in the summer of 1793, the order in which the students were called did not follow a consistent pattern, and there was a great imbalance between the two classes. From the first, 10 students attended twenty-six times, whereas from the second class, 6 gentlemen attended once each.⁹⁴ Only one apprentice, Frau Heiderin, took part in the midwives course during the last quarter of 1793 (Table 1, col. 5). She was in charge of two births on 3 and 13 December.⁹⁵

Why did Osiander deviate so far from the order which he himself had drawn up? In the Latin “order and statutes”, which he composed in about 1795, he announced a major exception to a strictly numerical order of students attending deliveries: “In assisting in childbirth, priority is given to those students who have already attended my lecture course.”⁹⁶ Does this proviso explain the deviations from the order in the lists? In some of these documents, the students who took the course for the second or even third time are marked. In fact, all those who attended more than two deliveries per semester were repeaters.⁹⁷ On the other hand, 18 out of 45 repeaters, that is 40 per cent, were not allowed to take care of any births. It is clear from this that Osiander distributed such opportunities among his students much less fairly or systematically than he tried to make them believe.

There may, however, be an explanation why some students had more opportunities than others for gaining practical experience with deliveries. In some of the lists of students (though not in those posted in the hospital) there was a separate section of those who took a “privatissimum” with Osiander.⁹⁸ These were private lessons and exercises attended by very small groups or only one gentleman, for which the professor charged a high honorarium. To be sure, even Osiander's normal theoretical and practical course in midwifery was “private” and cost each student ten taler per semester, as was usual at Göttingen University in this period, and five taler for repeaters, although poor students were admitted free.⁹⁹ The privatissima, however, were much more expensive and exclusive. They added a market element to the educational system of state universities in Germany.¹⁰⁰ In most cases, such private courses with Osiander lasted for three months, and were taken by students who were also in the normal class, often by repeaters. Sometimes, young doctors from outside Göttingen had a privatissimum for a few weeks only, or even just a few hours, if they were passing through. It appears that hands-on practice was the main component of these private lessons. Occasionally, Osiander explicitly stated that the privatissimum provided experience in obstetric interventions. Of course, the phantom was used in this context, but experience of real deliveries was even more crucial. The lists of participants in Osiander's privatissima for five semesters between the winters of 1797/98 and 1800/01 still exist, and, in spite of some gaps in the birth records, it can be seen that each of the 22 participants was in charge of at least one delivery. Half of them are even mentioned as birth attendants several times during the period of their privatissimum. During all their time at Göttingen University, out of these 22 students, only 5 took care of just one delivery, 7 were in charge of two, 5 of three, and 2 of four. One attended five births, another nine, and a third student eleven. On average, therefore, each of the privatissimum students took care of three births. Clearly a private course with Osiander greatly enhanced a student's chances of assisting at a delivery in the hospital (see Table 2). In fact, in 1801 complaints were made to the Hanover government that Osiander gave too few opportunities for gaining hands-on experience in his normal “private” lectures, and thus students were compelled to enrol in a privatissimum with him. The professor was admonished and told to ensure that all his students received equal opportunities for such practical exercises and to avoid anything that could be interpreted as pressure on them to take a privatissimum.¹⁰¹

Table 2(a).

Male students and female apprentices, by number of deliveries attended¹ at the lying-in hospital of Göttingen University, 1793–1814

Number of deliveries attended	Male students			Female apprentices
	Number	% of those who attended at least 1 delivery	Estimated % of all male students	Number	% of those who attended at least 1 delivery	Estimated % of all female apprentices
	(1)	(2)	(3)	(4)	(5)	(6)
0			34.42			11.13
1	229	52.8	34.6	42	35.0	31.1
2	105	24.2	15.9	25	20.8	18.5
3	42	9.7	6.3	18	15.0	13.3
4	23	5.3	3.5	12	10.0	8.9
5	16	3.7	2.4	8	6.7	5.9
6 and over	19	4.4	2.9	15	12.5	11.1
Total of those who attended at least 1 delivery	434			120

What chance, then, did ordinary students have of being actively involved in a delivery? By comparing the lists of students with the names of birth attendants in the hospital diaries and calendars for periods when the records do not have major gaps, we can estimate how many of those who enrolled in Osiander's course never took part in any delivery at the hospital. For seven semesters between the summer of 1793 and winter of 1800/01, there were 209 students. Out of these, 72 (34.4 per cent) were never mentioned in the birth protocols.¹⁰² Therefore, the estimate is that a third of Osiander's students never had any hands-on experience in a delivery.

A similar calculation can be done for the midwife apprentices. For five courses between the winters of 1796/97 and 1800/01, there are lists, either handwritten or published by Osiander, containing a total of 23 names.¹⁰³ For six more quarters between 1793 and 1797, we have the number of apprentices (Table 1, col. 5) and the records of deliveries with the names of the birth attendants without major gaps. There is, thus, detailed evidence of a total of 36 apprentices, of whom only four (11.1 per cent) are never mentioned as birth attendants. These four took part in the spring course of 1800, which had eight participants. So the proportion of learners who were never in charge of any delivery was three times higher among Osiander's male students than among his female apprentices, one in three, as compared to one in nine.

Of the 434 students who did act as birth attendants in the University hospital, more than half took care of only one delivery (Table 2a, col. 2). Less than a quarter were in charge twice, just one out of ten, three times, and one out of twenty, four times. In this respect, too, female midwife apprentices had better access to practice (Table 2a, col. 5). Just over one-third of those who were actively involved in hospital deliveries were given only one such opportunity, and one out of five attended two births. Fifteen per cent assisted in three cases, 10 per cent in four, and 12.5 per cent in more than five.

If those who were never actively involved in a birth during their time at the hospital are taken into account (Table 2a, cols. 3 and 6), it is evident that more than two-thirds of the medical students attended no more than one delivery. Less than one-sixth took care of two, and even fewer were those involved in three or more births. Out of the female apprentices, however, almost 60 per cent assisted with at least two births, over 25 per cent with four or more births.

Among the medical students actively involved in deliveries, the average number of births attended per student was two, but for the midwife apprentices it was three. Taking into account those who were never actively involved, the average is 1.4 for male students, and 2.6 for female apprentices (Table 2b). This shows that in order to have training conditions comparable to those of the midwives—i.e. small groups and ample access to practise, in particular attendance at deliveries—the students were obliged to pay for a privatissimum; but only a small minority could afford such classes.

Table 2(b).

Average number of deliveries attended by male students and female apprentices

	Male students	Female apprentices
Average of those who attended at least 1 delivery	2.1	3.0
Estimated average of all (incl. those who did not attend a delivery)	1.4	2.6

¹Attending a delivery is defined here (and in the text) as being mentioned in the hospital diaries or calendars, which normally means being actively involved, either “assisting” the parturient woman or doing an operation, not merely looking on. Occasional visitors, students of law, etc. are excluded, although they are sometimes mentioned by name in the sources used.

This table may have a small bias, underestimating the number of deliveries attended by students. Midwife apprentices usually stayed for only three months at the hospital, whereas a considerable minority of the students stayed for more than one term. For this reason, more students than apprentices included in this table may have attended an additional birth during the periods when there are gaps between the different sources. If such a bias exists, it slightly exaggerates the difference between students and midwives.

²The estimated percentage of male students who did not attend a delivery is based on a total of 209 students in nominative lists for seven semesters between summer 1793 and winter 1800/01. See text and note 102 for details.

³The estimated percentage of female apprentices who did not attend a delivery is based on a total of 36 apprentices mentioned either in nominative lists or in statistical reports for eleven courses between 1793 and winter 1800/01. See text and note 103 for details.

Sources: AUFK Gö, A 1–8 (Tagebücher, vol. 4, 6–7, 10–14); I 1–3 (Kalender 1793, 1794, 1798).

Given Osiander's insistence that the training of male medical practitioners was the main purpose of the University's lying-in hospital, these figures come as a surprise. They are a significant indicator of the extent to which students and apprentices assisted at deliveries, but of course they do not tell the whole story about practical education. Equally important is the content of the training.

In this regard, we do know that students and midwives were not trained in exactly the same hands-on skills during deliveries. As in the theoretical part of the course and in the exercises with the phantom, the emphasis for female apprentices was on assisting “natural” births. When a midwife was the only attendant mentioned in the medical case book, the Latin summary, placed in the margin of each protocol, usually read : “Partus naturalis. Assist[it] Fr[au] Meissnerin”, “Natural birth, Mrs Meissnerin assisted”, or, with slightly more detail: “Partus praematurus naturae viribus finitus. Assist[it] Fr[au] Hillin”, “Premature birth, finished by the forces of nature. Mrs Hillin assisted”.¹⁰⁴ How exactly the apprentice assisted, is hardly ever specified. Osiander considered the midwife's task as routine, not worth a mention in his diary. If both a female and a male attendant are noted in a protocol, the Latin summary most commonly reports that the student performed an operation (op[era]t[ionem] fec[it]), and the apprentice assisted. While the former's operation is described precisely in the German transcript, the latter's help is generally veiled in silence. The few exceptions to this illustrate the distribution of tasks between midwife and medical student, and sometimes also between professor and student: “Since the head would not advance, I had Mr Schlemm apply the forceps, who finished the birth (of the head) by 8 tractions. Mrs. Kling[en]b[ergin] received the child.”¹⁰⁵ Another responsibility for the midwife, in the case of a forceps operation, was supporting the perineum. “The labour pains were violent, and the head had advanced a great deal, but finally came to a halt. Therefore, I had Mr Werner apply the forceps and move the head by several tractions until it began to come through. Then we left it to nature, but the head did not advance any further. Instead, it receded again and again, because of narrow genitals. Therefore I applied the forceps once more, while the midwife Hübnerin was sitting in front [of the patient] and supporting [the perineum] …”.¹⁰⁶

In general, there are few references in Osiander's diary to the apprentices doing anything apart from waiting and receiving the child, but occasionally there is a passing mention of their performing other tasks. For example, in one case, Mrs “Seidin dilated the mouth of the uterus” before a student applied the forceps.¹⁰⁷ In some other cases, an apprentice seems to have unwrapped the umbilical cord from the child's neck, probably after the head, but before the body, had come through.¹⁰⁸

Using the phantom, Osiander taught midwives how to deliver a child presenting by the feet or the breech, and apparently even how to turn a foetus in the uterus,¹⁰⁹ but the medical case books contain hardly any indications that he allowed them to practise these manoeuvres during real births. On Sunday, 20 September 1812, however, the apprentice Frau Sievertin alone helped in the birth of a girl presenting by the breech. Osiander explicitly noted in the hospital diary that she “freed” the arms and “pulled out the head”. But he added that he was absent at the time. Similarly, in the late evening of 9 March 1814, “a premature girl … presenting by the breech” was born “quickly and easily … without any help”, apparently more quickly than expected, for the patient was not even led to the birth stool in the delivery room, but gave birth in her chamber. Here too, only an apprentice, Frau Klapprothin, is noted as assisting, and the protocol seems to imply that Osiander did not come down in time from his apartment on the second floor of the hospital.¹¹⁰ He frequently committed cases where the child presented the head in a “perverse” way, such as face presentations, to the midwife apprentices,¹¹¹ but breech and foot presentations, and certainly versions, were normally dealt with by the professor himself or by medical students. Thus, in a twin birth on 8 January 1800, the first child, presenting the head, was delivered by the apprentice Frau Hakfeldin; however, the second child, presenting the feet, was delivered by Osiander and Mr van den Bosch, a student from The Hague (Netherlands). As usual, the midwife's actions are not specified, while those of the student and the professor are recorded: “At 10 [p. m.] the mouth of the uterus was completely open. At 10.15 [p.m.] birth of the first child. The second child presented the feet. At 11.15 [p.m.], I had Mr van d[en] Bosch grip the feet, but I ruptured the amniotic sac myself. Mr v[an] d[en] B[osch] pulled out the child up to the shoulder, freed the arms, I pulled out the head.”¹¹²

Regarding the medical students, the teaching concern most visible in Osiander's case books was to show them how to use the forceps, for he was firmly convinced that a forceps operation, performed skilfully, was the best assistance in most protracted and difficult births. Although leading English obstetricians had opposed this view since the mid-eighteenth century, and even French accoucheurs were beginning to give it up, Osiander proudly declared in print that he hardly ever let a lingering or painful delivery, “whether caused by the umbilical cord wrapped around the foetus, or by a first degree of obstruction, slip by without the forceps being applied, either by myself in front of the students, or by a student who is already well-practised on the phantom”. This was not an overstatement. In the thirty years for which he directed the maternity hospital of Göttingen, the forceps were used in 40 per cent of all deliveries.¹¹³

Osiander had several ways of training students in use of the instrument. In some deliveries, he first “demonstrated how to apply the forceps, took them out again, let” the student “apply them again” and make tractions.¹¹⁴ In other cases, the professor had the student introduce the first blade of the forceps, and applied the second one himself. “Thereby”, he explained in a protocol, “one saw how much depended on the skill with which the forceps were held and directed”.¹¹⁵ On other occasions, Osiander took over only after his disciple's attempts failed. In a “slow and painful birth” on 30 December 1806, “the parturient woman became tired and asked for help.¹¹⁶ Therefore, I had D[r] Daeubler apply the forceps, introduced the second blade, however, myself, because he could not introduce it.” Similarly, on the very next day, Mr von Walther, a student from Livonia, one of the Baltic Provinces of the Russian empire, was only partially successful in a “birth that was slow because of inertia of the uterus”: “… the forceps are applied. I introduce the second blade myself, because Mr v[on] W[alther] missed the bend and could not apply it. Then he finished the operation happily with 23 tractions.” In another protracted delivery, “I had Mr Hiller apply the forceps. He introduced only the first blade successfully, the second, however, buckled. Hence I took over, did some standing tractions, and had D[r] Hiller do the remaining larger number [of tractions]. About 18 standing and 25 sitting [tractions] were necessary to pull out the head.”¹¹⁷

The aim was to apply the forceps quickly and painlessly.¹¹⁸ But sometimes the professor was very patient with his students, letting them try again and again. As usual, he did not record the woman's reactions to this treatment. “Since at midnight the head had not yet advanced further, I had the forceps applied, but Mr Block was unable to introduce them. Therefore, I applied them first, pulled down the head with about 20 standing tractions, let Mr Block try to apply the forceps, but again it did not work. Therefore I applied them for the second time, pulled the head down even more. At last, the third time, Mr Block succeeded, he did about 12 tractions, sitting.”¹¹⁹ In another case, Osiander let several students try to introduce the forceps, and only the third one managed to do so.¹²⁰

Applying the forceps was not the only difficulty. How to perform the tractions correctly also had to be learnt by trial and error. “Mr Österle applied the forceps, did some tractions, but since he bent them upwards too early, the forceps slipped away.” Osiander took over and showed how to do the operation correctly.¹²¹ In another case, the student applied the forceps and did about fifty tractions, “but once, when he lifted [the forceps] too much, they threatened to slip away”. Osiander let him apply the instrument again, and only later took over and finished the operation.¹²² In yet another birth, the professor had Mr Kübler apply the forceps, but realized that “the case was too difficult for a beginner”. In fact, it was the first, and incidentally the only, birth attended by this student. Thus, Osiander “took over the operation myself, and finished the delivery with many firm, strong, and, because of the narrow outer genitals, careful pulls.”¹²³

Often, Osiander and one or several students alternated and cooperated in a delivery. In a difficult birth during the night of 11/12 June 1801, the professor “dilated the mouth of the uterus with my dilatator, applied the forceps … took out the forceps again, had Mr Albrecht apply [them]. But since at first he did not manage to do this, I had Mr Reuß apply [them], who introduced them after some attempts. Now Mr Albr[echt] did tractions. Since the forceps deviated a little too far, he took them out again, applied them well this time, and finished the birth with 47 tractions.”¹²⁴ During the night of 20/21 July 1807, a patient was in labour who in 1804 had already been delivered by a long forceps operation in the Göttingen hospital because she had a very narrow pelvis. The professor “predicted to my students that we had to be prepared for a difficult delivery, and announced what we would do now”. He performed the most complicated tasks himself, but sought to delegate to the student as much as possible. “I had Mr Steiner break the amniotic sac with his fingers”. Then “the position of the head was examined. The occiput stood above the left acetabulum. Mr Steiner was supposed to pull it down and apply the forceps. He did not succeed in introducing the second blade, however, because of the high position of the head. Therefore, I took over applying them, and then had him do standing tractions. We alternated in this, but the head would not go down into the pelvis.” Now Osiander tried to find a better way to apply the forceps, but in vain, “partially because of the narrow pelvis, partially because the woman in labour did not help by any effort on her part”.¹²⁵ At last, during a heavy contraction, Osiander managed to pull down the occiput, apparently with his hand. He applied the forceps again, did tractions standing and sitting, “had the mouth of the uterus pushed upwards”, and after many more efforts—“according to several persons present a total of 103 tractions had to be done”—at last he could move the head down. “Now I had Mr Steiner finish the birth, who in fact artfully completed pulling out the head and the body.”¹²⁶ In the protocol of a birth, on 25 August 1808, which was “very difficult because of the narrow pelvis and the large head”, Osiander admitted to having called on the help of a student, whereas normally he was the one who guided, and if necessary helped, his students. In this case, he first vainly tried to lead the occiput down into the pelvis with his hand, then did a podalic version. When he pulled the feet forcefully, the head did not follow. At last, he got the child into a position where he could apply the forceps, did “about 60 [tractions], and Mr Hering probably did 20 to 30, but still the head did not move. At last Mr Borchers volunteered, who according to his fellow students was the strongest of them. I accepted, but admonished him to be very careful. With only the second traction, however, he pulled the head out of the genitals, with a jerk. The perineum was partially ripped open, bled a lot, and fits of fainting followed.” The child was dead. The next day, Osiander found that the fissure in the perineum went right down to the anus, and sewed it up. He reported that the wound had healed completely by the time the woman left the hospital on 28 September, and that he had shown this to his students.¹²⁷

As this case shows, there were risks involved, especially when inexperienced students did a forceps operation. Several times, the perineum was lacerated.¹²⁸ For precisely this reason, the professor sometimes took over and did the last tractions himself.¹²⁹ Another risk implied in forceps operations was that the child could be moved into a worse position when the instrument was introduced into the uterus.¹³⁰ If this happened, it was usually, according to the protocol, the fault of an inexperienced student. In other cases, such as the difficult deliveries of 11/12 June 1801 and 20/21 July 1807, the forceps left “an impression in the skin in the middle of the forehead” of the baby, or even “an impression” which “seemed deep” at first, and after several days still appeared as a “red strip”.¹³¹ On another occasion, an os occipitale was incised, and, on still another, an impression of the forceps in the skin that had hardly been visible right after birth, developed into two holes in the scalp after three days, which became deeper and deeper. Both children died within twelve days. In a different case, the protocol seems to suggest that the asphyxia and death of the child were, at least in part, caused by a student who did forceps tractions in the wrong way.¹³²

Apart from questions of life and death, it is not surprising that many students did not do really well when they first tried out on a living patient what they had previously practised on the dummy. The effective use of forceps could be learnt only by extensive practice, guided by an experienced practitioner.¹³³ It should be borne in mind, however, that more than half of those students who were allowed to attend a delivery took care of only one birth during their time at the Göttingen hospital. This is also true for several of the students who, according to the protocols cited, were not really successful in their first practical endeavours: Walther, Kübler, Albrecht, Steiner and Borchers never had another chance in Göttingen, and Block, who did attend a second delivery later, then introduced only the first blade of the forceps, while the professor applied the second and pulled the child out.¹³⁴

Foot and breech presentations do not seem to have been a major focus in Osiander's practical teaching. He took care of many of them himself, or committed them to his son Johann Friedrich (1787–1855), who first studied with him, later became his assistant, and was then made a professor of medicine in Göttingen, too.¹³⁵ Once, he let a newly arrived privatissimum student pull out a child presenting the right foot, which was easy in this particular case, although the left leg was extended along the child's body in the womb.¹³⁶ Osiander tended to turn breech presentations so the feet presented,¹³⁷ and if he did not do this operation entirely by himself, he assigned only partial tasks to his students. Thus, on 18 July 1802, he carried out a podalic version and then had Dr Näff complete the birth by pulling the feet, although it was difficult to make the head pass.¹³⁸ In another breech presentation, on 8 April 1813, the professor “got the feet down, and had Mr Plagge pull them. However, I myself undertook to free the shoulders. For, since the shoulders were broad and the arms crossed, this was too difficult for a beginner.” In fact, this was the first delivery attended by Martin Wilhelm Plagge, although he had been a student at Göttingen for two years. Osiander's protocol did not specify who slipped the umbilical cord, which passed between the two legs, over one foot. But it was he who applied the forceps in order to get the head out quickly. The Latin summary said accurately: “Professor Osiander did the operation, Mr Plagge helped.”¹³⁹

Most versions were done by Osiander or by his son, or by them both. But Osiander seems to have been particularly eager for his students to watch this type of delivery, for he frequently mentions in his case book that he started the operation only when the students had arrived.¹⁴⁰ In the evening of 3 November 1814, he diagnosed a transverse presentation, but did not begin the manoeuvre of turning the child until “almost all the spectators, about 60”, out of 65 had assembled. The complicated operation started with dilating the os uteri and breaking the amniotic sac, it included putting loops around the feet and pulling them down, and ended with applying the forceps for extracting the head. Evidently, the professor enjoyed the students admiring his virtuosity, and he added in the end of the protocol: “In a few minutes, the whole operation was finished” at 11 p.m., despite the fact that “the mother behaved very impatiently”.¹⁴¹ This was the usual scenario for versions: the professor, centre stage, often with his son, and the students as spectators. If, however, one or several of them were assigned an active role, this was for limited tasks only,¹⁴² for example, Dr Näff in 1802 and Mr Plagge in 1813. Unlike forceps operations, versions were hardly ever performed by students. But one such case was given to Dr Joseph Friedrich Österle on Sunday, 17 May 1801. He had already attended four births in Göttingen, including two forceps operations, and in at least one of them he had done “very well”. This time, the professor had diagnosed an elbow presentation. He had Österle dilate the mouth of the uterus and push the arms and the head upwards, so that the feet came down. The student tried unsuccessfully to attach the loop. Only then did Osiander intervene, introducing his hand into the womb and pulling the feet down. Then he let Österle finish the version, which he did very well until the head became visible, and the professor pulled it out. In this case, he had entrusted most of the operation to the student, as he often did if the forceps were to be applied, and helped out himself when the learner could not manage.¹⁴³ A similar exception was the hand or foot presentation—Osiander was not sure which of the two—on 4 April 1804. There Osiander had Mr Dreyer do the whole operation, including turning the child, since he “was already well trained in the version, privatissime”, on the phantom. Moreover, he had taken care of three deliveries before, one of them a forceps operation. The professor stated that the student did the operation “very cautiously and slowly” and did not “cause any special pain” to the patient, although she “behaved in a very unruly way and screamed a lot at the beginning”.¹⁴⁴

Since Osiander committed versions to medical students in only exceptional cases, it is less surprising that he did not allow midwife apprentices to practise them on real patients, although in principle he wanted them to learn this operation, in case of emergencies.¹⁴⁵ The difference between what he taught students on the one hand and apprentices on the other is much clearer with regard to his favourite operation, the forceps. It was a major focus in training students, but taboo for midwives. There was only one exception confirming the rule of this dichotomy: a woman who, under Osiander's direction, intervened with the forceps in all three deliveries that she took care of. She was Fräulein Charlotte Heiland, also named von Siebold. On 24 August 1812, in a “natural birth” the professor had her “apply the forceps just for a trial, and take them out again”. In the protocol, he added a remarkably positive comment: “She applied them quite well, although she had had only a few lessons before.” A month later, she introduced the forceps and “happily” pulled out the head with about six tractions. On 12 October 1812, when the professor was absent, his son had Fräulein von Siebold apply the forceps and finish the birth with twelve to sixteen tractions. On both occasions, her performance was assessed as “quite good” or “skilful”. Osiander did record why he allowed this woman to use his favourite instrument: she was not a midwife apprentice, but “a student of the obstetric art”. The reason she was admitted by the professors of the Göttingen medical faculty, including Osiander, to both their normal “private” and their “privatissima” lessons, even though she was not formally matriculated, was without doubt because, through her stepfather, she was part of the famous Siebold dynasty of medical doctors and professors.¹⁴⁶

Training Obstetricians and Midwives

In several ways, the archival sources on practical education at the maternity hospital of Göttingen confirm Osiander's words that its first priority was the training of skilful obstetricians, and that the training of midwives was of only secondary importance. The number of medical students using the hospital by attending the professor's theoretical and practical course was much larger than that of female apprentices. Therefore, among all those who are mentioned as birth attendants in the hospital diaries or calendars, 78 per cent were male and only 22 per cent female. Moreover, the skills which the professor of obstetrics considered superior were reserved for medical students. This is true of “artificial help” in general, and the use of the forceps in particular.

If, however, we turn from this aggregate level to the experience of individual students and apprentices, the balance is less clear. Many medical students attended Osiander's lectures for only one semester, exercised a couple of times on the phantom, practised a few physical examinations, and watched a small number of births. One-third of his students never took part in any delivery in the hospital. Most of those who did were in charge of just one birth, and only a small minority, 5 per cent of all students, attended more than four deliveries. In this respect, midwife apprentices were clearly privileged. Since their number was much smaller, they did more exercises with the phantom, examined patients every week and took care of more births. Possibly, Osiander thought that, because of their limited theoretical capacities, more extensive practical experience in the hospital was required, if the traditional bad habits of uninstructed matrons, to which they were exposed in their local communities, were to be overcome by his lessons.¹⁴⁷ Medical students, on the other hand, were supposed to be much more accustomed to learning by means of books and words, not by practical experience.

As regards the great emphasis that Osiander put on expertise in the use of the forceps, his reasoning may have been that physicians and surgeons were called more frequently to emergencies than to normal births.¹⁴⁸ It is questionable, however, whether effective use of this instrument could be learnt by seeing it used by the professor, exercising a couple of times on the phantom, and trying it out once or twice on a real patient. There is indirect evidence that Osiander himself had doubts, for in his case book he occasionally noted with surprise that a student had introduced the forceps well, although he had practised for only a limited time.¹⁴⁹ And in his textbook, Osiander stressed that use of the forceps had to be learnt thoroughly: you “should familiarize yourself meticulously with … the skilful application of the forceps and acquire the required degree of dexterity, before you start to practise midwifery on your own”; otherwise, you “may be exposed to the humiliating reproach that, in the hand of an ignorant and clumsy person, the forceps are like a sharp knife in that of a child”.¹⁵⁰

There is no doubt that a maternity hospital like the one at the University of Göttingen allowed more practical training than had previously been possible, and Osiander proudly told the Hanover government in 1801: “Perhaps, no professor before me has ever insisted to such a degree on giving students of obstetrics so much practical experience as well as a thorough theoretical education.”¹⁵¹ All the same, the great majority of medical students probably had much to learn on the job, after their years at university. Osiander hoped to build the foundation for such a continuing education by the enlightened principles expounded in his lectures and demonstrated in the obstetric activity of his hospital. Discussing in his textbook “the right way of learning the obstetric art”, he actively promoted the model he practised in Göttingen: first oral and written instruction was required, then practical instruction had to follow, and finally the student needed to “try the art himself” at a maternity hospital, “under the guidance of the teacher”. Although humility was not one of his most noticeable traits, Osiander added that a man will become a “master of the art” only by exercising on his own in private practise, and by continued lifelong study.¹⁵²

The hospital at Göttingen offered the students no more than an initial opportunity at trying the art themselves. Hands-on practical experience with deliveries was a scarce resource, and only a small amount could be allocated to each. In spite of that, governments, professors and students were convinced that such experience made a crucial difference in forming capable physicians. Whether students had more opportunities in this area in big hospitals, such as those in Vienna or in Dublin, remains to be explored. No male students were allowed in the huge lying-in hospital of Port-Royal until the late nineteenth century, and it may well be that in other places, too, most deliveries were attended by midwives, not doctors or students, during the late eighteenth and early nineteenth centuries.¹⁵³