WOMAN’S NATURE AND WOMEN DOCTORS

12 May

The ‘‘Woman Question’’ was the theme of endless books by nineteenth- century physicians, scientists, and philosophers. Using so-called scientific arguments to rationalize and legitimate traditional social and economic patterns, doctors portrayed themselves as scientists with special know- ledge of female physiology. American physicians argued that women were condemned to weakness and sickness, because female physiology, including the menstrual cycle, was inherently pathological. In the 1870s, doctors increasingly focused on the threat that education posed to the health of girls and women. Woman’s whole being, especially her central nervous system, was said to be controlled by her uterus and ovaries. Brainwork during puberty, especially in a coeducational setting, there- fore, would interfere with the development of the female reproductive system. The best-known proponent of this rationale was Edward H. Clarke (1820–1877), author of an influential book entitled Sex in Education: or, a Fair Chance for the Girls (1874). In addition to his large private practice in Boston, Clarke was a Harvard professor and a leader in the battle to prevent the admission of female students to Harvard. Clarke subscribed to the prevailing idea that the human body was a closed system with a limited ‘‘energy bank.’’ In other words, the body was a battlefield where all organs fought for a share of limited energy resources.

The struggle between the brain and the female reproductive system was particularly dangerous. ‘‘Nature has reserved the catamenial week for the process of ovulation,’’ Clarke insisted (quite incorrectly), ‘‘and for the development and perfection of the reproductive system.’’ Total mental and physical rest during the menstrual period was essential for the proper development of the female reproductive system. According to Clarke, women who graduated from college, if they survived the ordeal at all, were doomed to become sterile, sickly inva- lids, subject to amenorrhea, dysmenorrhea, leucorrhoea, chronic and acute ovaritis, prolapsus uteri, anemia, constipation, headaches, hys- teria, neuralgia, and other horrors. The ‘‘intellectual force’’ expended by girls studying Latin or mathematics destroyed significant numbers of brain cells in addition to decreasing fertility. Educated women who escaped sterility would face dangerous pregnancies and deliveries because they had smaller pelvises and their babies had bigger brains. They would be unable to nurse their own babies, because they had ‘‘neither the organs nor nourishment requisite.’’ As evidence, Clarke pre- sented the sad case of the flat-chested Miss D., who entered Vassar at 14. By the time she graduated, she was the victim of dysmenorrhea, hysteria, nervousness, headaches, chronic invalidism, and constipation. Another unfortunate student died soon after graduation; the postmortem revealed a worn-out brain. Even Martha Carey Thomas (1857–1935), founder and president of Bryn Mawr College, remembered being terrified when she read such warnings as a girl. Tests of the Clarke hypothesis demonstrated that college women were as healthy as other women and studies of motor and mental skills found no special effects associated with the menstrual cycle. Critics of the Clarke hypothesis argued that doctors who shared his beliefs were simply prejudiced and influenced by the fact that the women they saw as patients were indeed sickly. Female doctors argued that girls were often sickly because of bad diet, lack of fresh air, tight corsets, restric- tive clothing, and the lack of education and exercise. Some skeptics argued that, because of the great oversupply of doctors, practitioners were eager to find chronic, but nonfatal ‘‘female complaints’’ among delicate upper-class women. Servants, factory workers, and other poor women did not seem to need a week of rest during their menses. Mary Putnam Jacobi (1842–1906), an eminent physician and medi- cal writer, explicitly asserted that women were diagnosed as perpetual invalids because doctors saw them as lucrative patients. Her book The Question of Rest for Women During Menstruation, which was written to answer the question ‘‘Do women require mental and bodily rest dur- ing menstruation, and to what extent?,’’ won the Boylston Prize from Harvard University in 1876. Jacobi’s work demonstrated that education and professional work did not damage women’s health. Indeed, edu- cated women were healthier than any other group of women. Certainly, many women were not as healthy as they could be, but the true remedy for them was more education, not less. Sickly women were most likely the victims of alcoholic fathers, husbands with venereal diseases, and ‘‘bad social arrangements,’’ but hysteria and other debilitating ‘‘nervous diseases’’ supported doctors like Clarke quite well, because they were ‘‘never fatal, impossible to cure, but always in need of medical atten- tion.’’ Jacobi, one of the founders of the Women’s Medical Association of New York City, was an active crusader for women’s access to medical education. Jacobi graduated from the Female Medical College of Pennsylvania in 1864. She spent a year as an intern in the New England Hospital.

To improve her medical training she went to Paris and was the first woman admitted to the Paris School of Medicine. She graduated in 1871 with high honors. Representatives of many colleges studied Clarke’s claims and argued that their women students were very healthy. The Resident Physician at Vassar College insisted that no one who knew how wrong Clarke was about Vassar could trust the rest of his book. No evidence of Clarke’s unfortunate ‘‘Miss D.’’ could be found at Vassar, an outstanding school that did not accept 14-year-old girls. Julia Ward Howe (1819–1910), American feminist and author of the ‘‘Battle Hymn of the Republic’’ (1862), published a collection of critical responses entitled A Reply to Dr. E. H. Clarke’s ‘‘Sex in Education.’’ After carefully reviewing Sex in Education, Howe concluded that it was not a work of science, literature, philosophy, or a treatise on health, but simply a polemic against education for women. Contrary to Clarke’s ominous predictions, women were not becoming sick and sterile just because some wished to enter Harvard College. Clarke’s warnings about the dangers of education during female development had no more validity than ancient ‘‘old wives’ tales’’ that attributed female complaints to wet feet, silk stockings, horseback riding, dancing, or winter parties. The true remedy for female disabilities was more education, not less, especially education about physiology. While Clarke generalized from his own observations of sick women, he failed to note that women did not become sick until after graduation when they stopped studying and succumbed to intellectual starvation. Clarke was not alone in his campaign against female education. Horatio Storer (1869–1872), a Boston gynecologist and publisher of the Journal of the Gynaecological Society of Boston, also used the ‘‘menstrual difficulties’’ argument. Another American gynecologist advised girls to ‘‘spend the year before and two years after puberty at rest.’’ Each menstrual period, he added, should be endured in ‘‘the recumbent position.’’ American neurologist S. Weir Mitchell (1829– 1914) asserted that excessive brainwork before a girl was fully mature would damage her ‘‘future womanly usefulness’’ and turn her into an invalid.

The well-known American psychologist G. Stanley Hall (1844–1924) agreed that excessive mental stimulation was a danger to girls and women. Girls should, therefore, attend special schools that accommodated the female cycle of disability. When the American Medical Association (AMA) debated admit- ting female physicians, the arguments offered in the 1870s included the assertion that women could never become physicians because they lacked rational judgment, that physiological evidence proved that the brain size of females was insufficient for medical education, and that their judgment varied daily ‘‘according to the time of the month.’’ In the great debate about the ‘‘woman question’’ in Great Britain, editorials in the Lancet proclaimed that women were too encumbered by ‘‘physical disqualifications’’ to become physicians, although they could serve as nurses and midwives for the poor. Many doctors agreed with the doctrines proposed by Edward H. Clarke in Sex and Education, but a few argued in favor of accepting women as professional collea- gues. One doctor complained that if the AMA would not recognize female physicians, he would be unable to consult with the ‘‘most highly educated’’ women physicians, even though he was free to consult ‘‘with the most ignorant masculine ass in the medical profession.’’ Women did not necessarily turn to medical men like Dr. Clarke for their special ‘‘female complaints.’’ Indeed, most people relied on domes- tic medicine, folk remedies, and patent medicines rather than physi- cians. Nursing the sick was part of ‘‘woman’s natural sphere.’’ However, some women were able to turn female modesty and the womanly art of healing into flourishing businesses.

The most famous example was Lydia E. Pinkham (1819–1883) and her Vegetable Compound, an herbal remedy supposedly effective for dozens of female complaints related to the reproductive organs and functions, but not excluding headache and fatigue. The success of the Vegetable Compound reflected widespread dissatisfaction with orthodox medicine, especially among women, and the genius for marketing and advertising displayed by the Pinkham family. Pinkham’s ‘‘female weakness cure’’ was a forty proof herbal tonic containing life root, unicorn root, black cohosh, pleurisy root, and fenugreek seeds. Thousand of letters from satisfied customers supported her belief that the Vegetable Compound was more effective and certainly less dangerous than the medicines pre- scribed by doctors. Pinkham’s Compound was still popular in the 1940s when modern ‘‘miracle drugs’’ displaced Lydia Pinkham’s herbal elixir. During the nineteenth century, many medical practitioners had earned the title ‘‘doctor’’ by apprenticeships or a few months of dreary lectures at a medical school—orthodox or sectarian—with dubious cre- dentials. In this context, it is important to remember that although Elizabeth Blackwell is often called the first woman doctor, this is not strictly true. Other women had practiced medicine before Blackwell, but she was a pioneer in opening the orthodox medical profession to women. Throughout history, female practitioners were typically described as midwives and herbalists even if their training and their work was essentially the same as that of male practitioners. Harriot Hunt (1805–1875), for example, practiced medicine in Boston for about 40 years, after completing a medical apprenticeship. At the time, only a minority of medical practitioners had graduated from a medical col- lege. Nevertheless, in her autobiography, Hunt described being shunned by the male medical establishment as if she had some terrible disease.

In her autobiography Elizabeth Blackwell (1821–1910) said that she decided to become a doctor because of a friend who died of a painful disease of a ‘‘delicate nature’’—probably uterine cancer. Confid- ing that her ‘‘worst sufferings’’ were caused by having to be treated by a male physician, this woman suggested that Blackwell become a doctor. Overcoming her initial disgust at the thought of studying anatomy, physiology, and all the afflictions of the human body, Blackwell decided that becoming a doctor was a necessary moral crusade. In 1847, when Blackwell began to apply to medical schools, none of the regular schools admitted women. Eventually, she was accepted by Geneva Medical College, New York, a mediocre, but orthodox medical school. In January of 1849, Blackwell was awarded her diploma and the title Doctor of Medicine. To gain clinical experience in surgery and obstetrics, Blackwell went to Europe. An eye infection, contracted while caring for a patient at La Maternite´ in Paris, almost destroyed her career. Treatment of the infection included cauterization of the eyelids, application of leeches to the temples, cold compresses, ointment of belladonna, footbaths, mustard plasters, and a diet limited to broth. With the sight in one eye permanently destroyed, Blackwell gave up the idea of specializing in surgery. While in England, Blackwell met Florence Nightingale and became aware of the importance of sanitation and proper hospital administration. In 1859, Elizabeth Blackwell became the first woman listed in the Medical Register of the United Kingdom. Blackwell gave several lectures on medical education for women and helped establish the London School of Medicine for Women, the first medical school for women in Great Britain. Hopeful that opportunities for medical women were improving, Blackwell returned to America. Her sister Emily Blackwell (1826–1910), who had graduated from Cleveland Medical College in 1854, studied obstetrics with James Young Simpson (1811–1879), Professor of Midwifery at Edinburgh and one of Scotland’s leading surgeons and obstetricians.

In 1857, the Blackwells and Marie Zakrzewska (1829–1902) established a dispensary and a hospital to serve the poor. The Woman’s Medical College of the New York Infirmary for Women and Children provided instruction and clinical experience for female stu- dents until 1899. Zakrzewska, originally a professor of midwifery at the Berlin School for Midwives, immigrated to America and earned a medi- cal degree from the Cleveland Medical College. After working with the Blackwells, she moved to Boston and established the New England Hospital for Women and Children. When Elizabeth Blackwell assessed the progress of women in medi- cine in 1869, she was entirely optimistic about the future. Blackwell asserted that, at least in the northern states, ‘‘the free and equal entrance of women into the profession of medicine’’ had been achieved. Twentieth- century women, who venerated Blackwell as a role model, had to admit that she was obviously better at being a pioneer than a prophet. Similarly, although Blackwell served as an inspiration to generations of American girls, her life was often presented as the inevitable long, lonely struggle that a woman would have to wage if she chose a professional life instead of marriage and family. A closer study of the pioneering generation of female physicians reveals a broad range of personal and professional rela- tionships. Many little known nineteenth-century women physicians mar- ried, raised children, and practiced medicine. Excluded from full participation in the medical community, other female physicians found their niche in public health, the settlement house movement, well-baby clinics, industrial hygiene, and laboratory medicine. In 1859, while visiting her sister in London, Elizabeth Garrett (1836–1917) met Elizabeth Blackwell at one of her lectures on ‘‘Medi- cine as a Profession for Ladies.’’ Blackwell’s example stimulated Garrett’s determination to become a physician. When one doctor asked Garrett why she wanted to be a doctor instead of a nurse, she retorted: ‘‘Because I prefer to earn a thousand rather than twenty pounds a year!’’ The logic of her answer won the complete and total support of her father, Newson Garrett, a prosperous businessman.

No British medical schools were open to women and the Medical Register had been closed to women with foreign degrees after Blackwell secured a place on the list. Friends suggested that Garret work as a nurse at Middlesex Hospital for six months to test her endurance and dedication before attempting to study medicine. After a three-month probationary period, Garrett abandoned the pretense of being a nurse and simply assumed the role of a medical student, making rounds in the wards, working in the dispensary, helping with emergency patients, attending lectures, and taking examinations. Although Garrett received a Certificate of Honor in each of the subjects covered by her lecture courses, she was not allowed to become an official student. Her applica- tions were rejected by Oxford, Cambridge, and the University of London, which according to its charter provided education for ‘‘all classes and denominations without distinction whatsoever.’’ She was told that women were neither a class nor a denomination. Determined to secure a qualifying diploma in order to have her name on the Medical Register, Garret decided to obtain the degree of Licentiate of the Society of Apothecaries (L.S.A.). The L.S.A. was not as prestigious as the M.D., but holders of the license granted by the Apothecaries’ Hall could become accredited physicians. To qualify, an applicant had to serve a five-year apprenticeship under a qualified doc- tor, take lecture courses with recognized university tutors, and pass the qualifying examination. The Hall of Apothecaries was certainly not an advocate of equal opportunity for women, but its charter stated that it would examine ‘‘all persons’’ who had satisfied the regulations. Accord- ing to legal opinions obtained by Mr. Garrett, ‘‘persons’’ included women. In 1865, Garrett finally forced the Society of Apothecaries to accept her credentials and administer the qualifying examination. One year later, Garrett’s name was enrolled in the Medical Register.

The Society of Apothecaries immediately changed its charter to require graduation from an accredited medical school as a prerequisite for the L.S.A. degree. Of course, all such school excluded women. For another 12 years, no women’s names were added to the Medical Register. In 1866, Garrett opened the St. Mary’s Dispensary for Women in London. Six years later, the dispensary became the New Hospital for Women and Children. (When Elizabeth Garrett Anderson died, the hos- pital was renamed the Elizabeth Garrett Anderson Hospital.) In 1869, Garret met her future husband, James George Skelton Anderson, who was serving as a member of the board of directors of the Shadwell Hospital for Children. Despite marriage and the birth of three children, Garrett Anderson continued to practice medicine. Moreover, she earned the degree of M.D. from the University of Paris, successfully passing examinations and defending a thesis on ‘‘Migraine.’’ Garrett Anderson and other women doctors established the London Medical College for Women. As dean and professor, Anderson opposed the idea that women planning work as missionaries should come to the school and acquire a little medical knowledge. Medicine, she believed was a pro- fession and not a charity. Moreover, she thought that the willingness of women to sacrifice themselves was too easily exploited. During World War I, Garrett Anderson’s daughter Dr. Louisa Garrett Anderson (1873–1943) served as organizer of the women’s hospital corps and chief surgeon of the military hospital at Endell Street. Some women doctors carved out unique careers by entering fields closely allied with social reform movements that were of little interest to established male practitioners. Alice Hamilton (1869–1970), American pioneer of industrial hygiene, decided to study medicine because she considered it the only profession open to women that would allow her to support herself while doing useful and independent work. When she received her M.D. in 1893 from the medical department of the University of Michigan, she was one of 13 women in a class of 47. Hamilton interned at the Northwestern Hospital for Women and Children in Minneapolis and the New England Hospital for Women and Children in Boston.

More interested in research than private prac- tice, Hamilton studied bacteriology and pathology at the Universities of Leipzig and Munich, the Pasteur Institute in Paris, and the Johns Hopkins School of Medicine. While teaching pathology at the Woman’s Medical School of Northwestern University, Hamilton became a resident of Hull House, the settlement house founded by American social reformer Jane Addams (1860–1935). When the Woman’s Medical School closed in 1902, Hamilton joined the new Memorial Institute for Infectious Diseases. Hamilton’s studies of typhoid fever in Chicago called attention to the role of the fly in transmitting germs, the relationship between disease and sanitation, and the need for public health reforms. Through her experiences at Hull House, Hamilton realized that many workers became incurable invalids because of exposure to poisonous substances in factories, foundries, and steel mills. Although industrial medicine was already an established discipline in Europe, in the United States occupational diseases were essentially ignored. Medical men, she discovered, seemed to consider the study of occupational disease somewhat ‘‘tainted with Socialism or with female sentimentality for the poor.’’ As managing director of the Illinois Commission on Occupational Diseases, Hamilton combined field studies of industrial poisons, such as lead, with laboratory research. As a result of her survey, Illinois passed a workmen’s compensation law requiring safety measures in factories and medical examinations of workers. In 1911, Hamilton became an unpaid special investigator for the United States Bureau of Labor. When Hamilton began her studies of industrial diseases, doctors and employers argued that industrial poisoning could be prevented by hav- ing workers keep their hands clean. Hamilton tried to convince them that ‘‘a lead worker eats only three times and day and even then he does not wash his hands in his soup or coffee, but he breathes sixteen times a minute and when there is lead in the air, he will get it no matter how often he scrubs his nails.’’ Having established the dangers of lead dust, Hamilton went on to investigate the hazards of arsenic, mercury, organic solvents, radium, and many other toxic materials, especially in the rubber industry and munitions plants. Hamilton wrote that she was often successful in negotiating with factory owners, because she was pragmatic, persistent, and ‘‘fair but not too fair.’’ After World War I, interest in industrial hygiene increased, but because the field was new and still somewhat suspect, it was of limited interest to medical men. Hamilton readily admitted that she became assistant professor of industrial medicine at the Harvard Medical School, because she was the only candidate available.

Harvard attached three stipulations to her appointment as the university’s first female pro- fessor. She was not to enter the Harvard Faculty Club, march in the commencement procession, or claim her quota of football tickets. In 1935, Hamilton retired from Harvard with the title of Assistant Professor Emeritus of Industrial Medicine. Throughout her life, Hamil- ton was an advocate of protective legislation, child labor laws, pacifism, birth control, and other social reforms. She was 101 when she died of a stroke at her home. In the United States, 19 female medical schools were established between 1850 and 1895. The schools that survived until the end of the century were the Boston Female Medical College (New England Female Medical College), Woman’s Medical College (Kansas City, Missouri), Woman’s Medical College of the New York Infirmary for Women and Children, Women’s Hospital Medical College of Chicago, the New York Free Medical College for Women, Woman’s Medical College of Baltimore, the Woman’s Medical College of Pennsylvania, and the New York Woman’s Medical College and Hospital for Women. Only the last three schools were still open in 1909. The others closed or merged with coeducational schools. The Woman’s Medical College of Pennsylvania was initially staffed by male physicians who supported medical education for women. By the 1890s, the Woman’s Medical College was staffed by both women and men. Generally, the professors of obstetrics and of gynecology and the dean of the school were women. After first admitting male students in 1969, the school became the Medical College of Pennsylvania. In 1899, when Cornell University admitted women as medical students, the Blackwells closed the Woman’s Medical College of the New York Infirmary. Many leaders of the campaign for opening the medical profession to women saw coeducational schools as proof that separate women’s schools were no longer needed. After the struggle to gain admission to American medical schools, the 1890s seemed to represent a ‘‘golden age’’ for women physicians.

The Blackwells believed that the doors to all medical schools were opening to women. Unfortu- nately, it did not take long for the doors to slam shut once again. During the first half of the twentieth century, the number of ‘‘places’’ allotted to female medical students was so small that it was difficult for girls to believe that women had ever constituted a significant fraction of medical students. Some nineteenth-century sectarian schools were more accessible to women than orthodox medical schools, but most of those schools disap- peared by the turn of the century. A few survived by abandoning the philosophy of their founders or merging with orthodox institutions. The College of Medical Evangelists, for example, was founded by Ellen G. White to promote the Adventist health message and protect the mod- esty of female patients by including female teachers and students. Four of the first 10 students were female. The Adventist College of Medical Evangelists in Loma Linda, California, began as a hydropathic school, although White expected the college to attain full accreditation. As White’s influence diminished, the college’s leaders were able to change the balance between religious doctrine and the medical sciences. White’s goal of training women to serve women patients was quickly aban- doned, along with the ‘‘modesty doctrine’’ that had rationalized the role of women as students and teachers. By the 1920s, the Adventist school had transformed itself into an orthodox medical school and abandoned its commitment to the education of women physicians. A century after Blackwell optimistically declared that the battle for women’s access to medical education was all but won, Congressional hearings provided ample evidence of what women had long known: American medical schools discriminated against women. Some school administrators, however, argued that a five percent quota of ‘‘women’s places’’ was actually more than sufficient. In 1970, the Women’s Equity Action League (WEAL) filed a class action complaint against all medi- cal schools in the United States, alleging abuses in admission and chal- lenging the quota system. From 1905 to 1955, about four to five percent of medical students were female. In 1969, women made up nine percent of medical students. In 1971, in response to the lawsuit filed by the WEAL, the U.S. Public Health Service announced that medical schools accepting federal funds could not discriminate against women in admissions or salaries. By 1975, the number of female medical students had tripled.

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