Meryl S. Justin
The entrance of women into American medical practice during the mid-nineteenth century was a direct outgrowth of the social reform movements that characterized the period. Two trends were discernable in the first ten years: the scattered admissions of women to co-educational medical schools and the establishment of institutions for the medical education women exclusively. Both of these required women to overcome numerous obstacles in a struggle for recognition and acceptance.
Medical practice in the mid-1800’s was at a low ebb in America. Medical schools of dubious quality proliferated with the westward expansion. Sectarian medical movements such as homeopathy and eclecticism1 flourished; harsh therapeutics drove many disaffected patients from the "regular" professionals to these irregular practitioners.
The term irregular as applied to medical practitioners during the 19th and early 20th century generally referred to those physicians who did not hold a license granted by a state Board of Examiners, who did not belong to a state or local medical society, or who had not graduated from a recognized medical school. An irregular practitioner, as described in the By-Laws of 1932 of the Massachusetts Medical Society was
A person who is engaged in the practice of medicine or surgery in this commonwealth, not being a fellow or licensate of this society, nor a Doctor of Medicine of Harvard University, shall be deemed by the fellows of this society an irregular practitioner, likewise anyone who has been expelled from this society, or who after being permitted to resign his fellowship has been denied his privileges…2
In the by-laws of 1874, there appears an addition providing
That he does not profess to cure diseases by, nor intend to practice spiritualism, homeopathy, allopathy, Thompsonianism [an herbal healing technique—ed.], eclecticism or any other irregular or exclusive system, generally recognized as such by the profession or declared so by the society. 3
Medical accreditation throughout the 19th century varied from state to state. In general, medical licensing requirements were passed in most states between 1790 and 1820. These placed the power of licensure in a Board of Examiners, closely allied to the state medical society. During the Jacksonian era, however, most states’ licensing laws were repealed. The medical societies continued to grant licenses, which were not honorary, rather than legal admission to the practice of medicine. It was not until the latter part of the 19th century that licensing laws were readopted in most states.
The American Medical Association was formed in 1846 to raise the standard of medical practice and education, and to suppress the growth of the irregular medical movement. The low state of practice in America was unquestionably a factor favoring the entrance of women into the profession.4 Samuel Gregory, in support of his program to end male midwifery, said
That physicians are often ignorant, often indelicate will not surprise us, when we consider how easy it is to get a medical diploma, and how often the students of medicine are notorious for idleness and dissipation. Certainly it would be very desirable to have women education regularly to practice in this [obstetrics] and similar departments of medicine.5
Interest in personal hygiene, diet and sanitation characterized another reform movement which was influential in encouraging the entrance of women into medical practice. Elizabeth Blackwell, the first graduate of an American medical school noted the mutual interactions among ladies’ physiological societies, popular lectures to lay female audiences, and the first female physicians:
The attention of a considerable number of women has been turned to medicine, the first use they have made of it has been to establish a class of lectures on physiology and hygiene for women…the lectures are generally as crude and unsatisfactory as the education out of which they have sprung; but the impulse [shows] the instinctive perception of women…how directly [these issues] bear upon the interests of women…As teachers, then, to diffuse among women the physiological and sanitary knowledge that they need we find the first work for women.6
The growing feminist movement of the 1840’s7 was, of course, another source of support. Entry of women into professional positions and broader educational opportunities ranked with suffrage as a primary goal of the feminist program.
Yet, Samuel Gregory was not a feminist; he frequently expressed disapproval of female suffrage. It was not from feminist quarters that he received the strongest support for his program. In opposition to the trend of liberalism spreading throughout American society in this period, stood a stolid, 19th century morality. Excessive delicacy, cultivated in American women, caused them to abhor the idea of gynecological examination by a male physician. Because they would not place confidence in the physician, women frequently did not receive treatment for serious medical problems. Although many physicians deplored the situation, others held it to be evidence of the high moral tone of their generation:
The custom of confining medical and sanitary knowledge to male physicians, thereby obliging females to consult them in those conditions and circumstances which, of all others in their whole existence, women would choose to be relieved from the intervention of men, appears to the author to be a violent outrage against female delicacy and pernicious in its influence on the social and moral welfare of society.8
Gregory’s campaign won support form the matrons of Boston, and financial backing from several prominent physicians. His agitation resulted in the establishment of the Boston Female Medical College in 1848. Renamed the New England Female Medical College, this school for midwives was expanded in 1850 to include a full medical curriculum, and began to grant medical degrees to women. Reaction by the Boston medical establishment was swift and condemnatory. Members of this group charged that women had insufficient stamina to deal with the tension of medical practice. In response to this charge, Gregory asserted, "Suppose physicians were as ignorant upon this subject as females now are; they would then be easily alarmed and incapable of rendering efficient and in case of emergency…the fact of being one of the stronger sex does not render one competent."9
In Philadelphia problems similar to those in Boston surfaced. The Women’s Medical College of Pennsylvania was chartered in March, 1850, and graduated its first class of eight physicians in 1852. The medical establishment of the city reacted unequivocally. They took advantage of the fact that three of the school’s founders were sectarian practitioners of eclectic medicine and declared the new institution irregular.10
While practicing in New York, Elizabeth Blackwell found it impossible to obtain a position in a public hospital or dispensary. With the help of her sister Dr. Emily Blackwell and Dr. Marie Zaskrewska, both recent graduates of coeducational institutions, Blackwell in 1863 founded the New York Infirmary for Women and children. It was the first hospital of this type in the country. In 1865, the three women founded a medical college in association with the infirmary. Here Blackwell was able to emphasize clinical medical training. The school had the first chair of hygiene in the country, and it was filled by Blackwell herself. The last of the major women’s institutions established during this period was the Chicago Women’s Hospital and College, which was founded in 1865 by Dr. Mary Thompson, an 1863 graduate of the New England Female Medical College.
Not all women were educated in sex-segregated schools. Several of the leaders in founding the women’s medical schools , Blackwell and others , received their training in regular (male) medical colleges. Women were admitted to these schools as "exceptions: for several years. Before 1847, however, any woman seeking medical training was forced to go abroad to Europe where the University of Zurich and University of Berlin allowed women to study the medical curriculum, although they were not granted a degree. Blackwell, the first woman to receive her medical education in an American chartered school 11 was accepted to the Geneva Medical College in upstate New York, after being rejected from several prestigious American medical schools. Perhaps the only reason for this single acceptance was the attitude of her fellow students. The Dean of Geneva, not wishing to be personally responsible for offending Miss Blackwell’s sponsor, a noted Philadelphia physician, brought the matter of her admission before the student body:
A meeting was…called for the evening and a more uproarious scene can scarcely be imagined. Fulsome speeches were made…the whole class voted ‘aye’…a faint nay was heard in the corner of the room…and screams of ‘cuff him’, ‘crack his skull’. A young man was dragged to the platform screaming ‘Aye, aye I vote aye’."12
Reaction to Blackwell’s presence is described by the Boston Medical and Surgical Journal, which later became the voice of opposition to the education of female physicians:
"Miss Blackwell, made her appearance in the lecture room about two weeks ago. She is a pretty little specimen of the feminine gender…She comes into class with a great deal of composure takes off her bonnet and puts it under the seat (exposing a fine phrenology), takes notes constantly and maintains throughout an unchanged countenance. The effect on the class has been good, and a great decorum is preserved when she is present."13
Blackwell’s presence at Geneva set no precedent; in the year following her graduation, Elizabeth’s sister Emily was denied admission to the school. Emily spent a year at respected Rush Medical College in Chicago, which refused to admit her for the second term. She was graduated in 1853 from Cleveland Medical College (Western Reserve), which had graduated Dr. Nancy Talbot Clark a year earlier. A lack of opportunity for clinical education in the United States forced the Blackwells and other women graduates of the male medical schools to travel abroad. This expense probably discouraged many women from entering medical careers.
In 1870, the University of Michigan medical School at Ann Arbor became co-educational. A precedent was set, and other chartered medical schools also began to admit small numbers of women. One school received an endowment conditional upon the equal access of male and female students. 14 The Johns Hopkins Medical School, established in 1898, owed its existence to a sizable endowment by Mary Garrett and M. Carey Thomas. Johns Hopkins medical School was founded to provide a model for American medical education. The admission of women to the school lent prestige to the movement for co-education.
Harvard University entered the controversy over co-education in 1851. Harriot K. Hunt, an irregular practitioner, requested permission to attend lectures at the medical school, but not in pursuit of a degree (in order to avoid conflict with the University by-laws). Permission was granted after considerable debate. A body of students protested:
"Resolved, that no woman of true delicacy would be willing in the presence of men to enter to the discussion of the subjects that necessarily come under the consideration of students of medicine."
"Resolved, that we are not opposed to allowing woman her rights, but do protest against her appearing in places where her presence is calculated to destroy our respect for the modesty and delicacy of her sex." 15
Hunt did not remain in class, and in 1874 a request for merger by the failing New England Female Medical College met official silence from the University.
The question of co-education was reopened in 1878. Marion Hovey, acting as executor of her father’s will was prepared to grant a $10,000 endowment on the condition that women be accepted into the medical school. A joint committee of the Corporation and Board of Trustees prepared a report on the advisability of coeducation (1879). The majority report:
"That there exists an increasing demand for the employment of women physicians, specially in the treatment of their own sex and children…Nor must it be forgotten that recent experiences, in army hospitals and in camps have shown that the [nursing] service of women, already so valuable would be worth still more [with] some knowledge of surgery and medicine…" 16
The report concluded that admission of women to the medical school would be desirable if a sizable ($200,000) endowment were provided, and if separate labs and recitation sections could be provided for the two sexes. The minority report dissented:
"…there is reason to believe that such an association [co-education] in medical studies… would not be looked upon with favor by the better class of male students and would not tend to increase the mutual respect, which it is desirable on all accounts to maintain between the sexes." 17
The minority report concluded by expressing support for female medical education, in principle, as long as it was not under Harvard’s aegis. The minority report was adopted by the Faculty and Board of Trustees; Hovey’s offer was rejected. A further inquiry from trustees of the New York Infirmary, offering $50,00 to establish a women’s medical department at Harvard, met similar treatment. In fact, the Harvard Medical School remained until 1945 one of the last six all male American medical schools.
The issue of coeducation caused debate even within the ranks of the women’s medical education movement. Advocates of separate facilities, such as Francis White of the Pennsylvania Women’s Medical School, 18 cites the outstanding performance of her school’s graduates in the competitive examinations of the state certifying boards. White praised the high academic standards of the women’s schools. In addition the alumni provided financial support and helped secure clinical training positions for new graduates. This, she stated, provided the most extensive possible education for medical women.
The other view, held by Blackwell and others, was expressed in an article by her colleague in the New York Infirmary.
So far as our personal knowledge goes, the majority of women students would prefer not to receive all their instruction in mixed classes, but they want the best, and they know that women’s colleges, though deserving great praise for what they have done, cannot, in the nature of things, offer the advantages of institutions which have for years had the best talent of the country at their command. 19
When Cornell Medical School admitted women students, Blackwell closed the New York Infirmary College, she claimed that it had served its purpose. By 1900, eleven of the nineteen institutions originally serving women had closed. In 1910 only two remained, one being a homeopathic school. 20
Nevertheless, advocates of coeducation were reserved about mixed classes in certain subjects. An 1878 questionnaire from the Massachusetts Medical Society revealed that among 320 doctors (in 570 respondents) who favored the coeducation of the Harvard Medical School, only 127 felt all subjects should be taught in common. 21
The nature of the medical education varied among the early women’s medical schools. The New England Female medical College required a "good English Education" and "a thesis on some medical subject." 22 Six professorships were maintained in the theory and practice of medicine, materiamedica/chemistry/therapeutics, anatomy, principle and practice of surgery and medical jurisprudence, obstetrics and diseases of women and children, and physiology/hygiene. During the years that it granted the medical degree, classes ran for 17 weeks, 30 hours per week of instruction. Three years attendance was required, with a preceptorialship under a physician supervision in the college’s last two years of training. 23 Few dissections were performed because embalming was not yet done, and it was illegal to obtain cadavers. Frequently, French 160-part Auzomanikins and obstetric manikins were used for anatomy instructors. On the other hand, the Pennsylvania Women’s Medical College was one of the first medical schools in the country to require physiology lab of every student.
New York Infirmary College had entrance examinations for admission ten years before these were required by law. Blackwell’s school emphasized clinical observation, public health and hygiene. The 2 ½ year training period was followed by an assistanceship, making housecalls and in the informary.24 The anatomy classroom in the New York Infirmary was described by a popular magazine:
The study of medicine is not an unmingled pleasure, and dissecting room is no bed of roses. More especially is medicine disgusting to those accustomed to softness… There is, however, no flowerly path to medicine. Disgust and horror open with the first pages of Grey’s Anatomy. That the enthusiastic women who are engaged in studying medicine…will be seen with interest. [there are] six tables, and on each there was a cadaver, with the students surrounding… The lady student is dissecting a leg. The outer muscles have been laid bare, and the arteries, nerves and veins brought to view in their proper locality." 25
The primary barriers in obtaining a truly complete medical education was not, however, the struggle with Gray’s Anatomy; it was the struggle to obtain clinical training and internships. Since the medical traditionalists could not prevent the classroom training of female students, they tried to prevent them from receiving their license to practice. They denied them the opportunity to observe in clinics and dispensaries and to train as interns in public hospitals. In 1864 the Boston City Hospital denied students of the New England Female Medical College access to the wards for clinical training. Likewise, the Philadelphia Public Hospitals barred attendance of Pennsylvania Women’s Medical College students at its clinical lectures. This prompted an angry reply from Dean Ann Preston:
We maintain in common with medical men, that science is impersonal, and the high aim of relief to suffering humanity sanctifies all duties, and we hold it derogatory to the profession of medicine the assertion that the physician that has risen to the high level of his high calling need be embarrassed in treating general diseases by the presence of earnest students. 26
Thus, clinical training had to be provided within a feminine context. Once again the interest of charity and social welfare groups coincided with the women’s medical education movement:
We need a maternity hospital for the instruction of students…but it is not the less true that such an institution is necessary for the sake of that portion of the poor who are unprovided for…but what can the best physician do when the surrounding circumstances are so hostile that these pull the patients two steps back for every one he manages to get forward? Dark, badly ventilated rooms, indigestible food, box-like sleeping places and ignorant attendants are hard to contend with…for all the poor, and for children especially a good hospital is necessary. 27
In this respect, the New England Hospital for Women and Children was founded as a teaching facility for The New England School. It had 12 in-patient beds and a dispensary. Meanwhile, Elizabeth Blackwell’s New York Infirmary had only 10 beds. Its physicians frequently performed their rounds and then repaired to the kitchen to prepare patients meals. The extended hours were worthwhile for Blackwell. They made the Infirmary an attraction for women all over the country who wished to obtain a clinical education. Its goals were set forth in a 188 page pamphlet:
First , to afford an opportunity for the medical treatment of women and children by women physicians.
Second , to give clinical instruction to women medical students.
Third , to train nurses, under female supervision.
In accordance with these aims, the resident and attending physicians and interns have, with few exceptions been women, the consulting staff alone including men. 28
In its first year, 3700 patients were treated in the Infirmary’s first building at 64 Bleecker Street. After initial hostility from the community was overcome, the hospital enjoyed great popularity among the poor and immigrant populations. Possibly because European immigrant women were accustomed to the attention of midwives, they found it easy to accept the women doctors.
Nevertheless, as late as 1925 Dr. Bertha Van Hoosen, a Chicago M.D. would notes,
In the nineties, it was the usual thing for the medical student to look upon a year spent as an intern as a sort of luxury…the ability to get an internship marked the great divergence in the sexes…the admittance of women to hospital internships has been a slow but steady gain…there are 127 hospitals [of 525, which offered internships] reported to accept women applicants on the same terms as men. 29
Another obstacle faced by the female physician was the consistent refusal of the medical societies to grant membership women. An "over-production of physicians 30 and competition from the sectarian schools has caused great anxiety among practitioners about new sources of competition. Moreover, occupations containing a high proportion of women, such as teaching, had low status and tended to provide commensurately low salaries. Resistance to female practitioners arose, to a great extent, not from innate social prejudice, but from economic considerations.
Meanwhile, anxious to widen their influence, the irregular sects had welcomed women into their schools and societies, and a number of irregular female medical schools were established during the period. When, in 1874, the New England female Medical College could not get Harvard to accept its merger offer, the college approached the newly opened homeopathic Boston University medical School.
The [sudden merger was made with] the college in the school of medicine of Boston University, which [was] under exclusive control of homeopaths. While this act may have involved no betrayal of trust in the legal sense, it certainly was an indefensible breach of trust toward those who had contributed funds to enable women to obtain a medical education in accordance with the tenants of the regular school. 31
The defection of the New England School was a blow to the legitimacy of the women’s medical colleges, and to the struggle to gain acceptance by the medical societies.
The medical societies consistently pursued a course of non-recognition for female practitioners. Although the women’s medical schools were irregular without the state medical societies; approval, these societies still felt threatened:
They persist in the declaration that they are regulars to the letter, and the only boon they ask of the organized fraternity of physicians is to be recognized…The serious inroads made by female physicians in the obstetrical business, one of the essential branches of income to a majority of well-established practitioners, makes it natural enough to inquire what course is it best to pursue? All the female medical colleges have charters from the same sources from which our own emanate…and the law is no respecter of persons. 32
As late as 1859, male physicians who so much as held consultation with female physicians, as well as those who taught in women’s medical schools, were ejected from the Philadelphia Medical Society. 33
The medical societies based another of their arguments on the inherent biological inferiority of women. A dialogue in the medical journal and popular press speaks for itself:
The proposition that women, as a sex are not fit to practice medicine—that their weak physical organization renders then unfit for such duties and exposures—that their physiological condition during a portion of every month disqualifies them from such grave responsibilities, is too nearly self evident to require argument. 34
An article in the popular press of the period states the opposite view:
It is quite plain that his [a male physician’s] objection is to the fact that women may be employed in a respectable, lucrative employment, one in which she is a competitor in skill and scientific attainments. His difficulty is on behalf of his own monopoly, not with the health of women. 35
Admission of women to the medical societies eventually opened, as more and more female doctors established successful practices. By 1880 there were 2432 female doctors in America, and by 1900 there were 7387. 36 The first medical society openings in California in 1853 were followed by those in Kansas and Michigan. These provide a clue to the demography of acceptance for female practitioners. The western states, which desperately needed physicians, attempted to lure female practitioners by providing an attractive work situation. In the east, where practice was far more competitive, recognition of female practitioners was slow.
In New York, women were admitted to the state medical society in 1877. In Massachusetts the question first arose in 1872 with reference to the application of Dr. Susan Dimmock, a graduate of New England Female Medical College and the University of Zurich Medical School. Her application was denied. Ten years later Dr. James Chadwick published a report which cited contributions of the first generation of New York Infirmary school graduates. This was used by advocates of women’s medical education of obtain access to the Massachusetts Medical Society. Women were officially admitted to this body in 1874. The Pennsylvania society, however, did not relent in its adamant refusal to recognize female physicians until 1915, when the American Medical Association admitted its first female members. 37
In 1910 the Flexner report of medical education indicated that
Women have no apparent a function in certain specialties and seemingly so assured of a place in general medicine under some obvious limitations that the struggle for wider educational opportunities for the sex were destined to early success. 38
Flexner advocated co-education, in the medical schools rather than the strengthening of sex segregated facilities:
The benefits would be shared by men without loss to women students, but…if separate medical schools and hospitals are not be developed for women, intern privileges must be granted to women graduates on the same terms as men. 39
Although Flexner expressed strong reservation about the medical education of women in American, he did advocate its continuation. With the growth of the number of female physicians, educational opportunities and recognition were continually expanding. The trend was anticipated by Dr. Mary Putnam Jacobi in a prophetic article of 1882:
When we shall be rid of the injustice, of the unfairness, the monstrous pretensions of the arrogant argument with which the subject of the admission of women to medicine has hitherto been so largely treated; when the mass of women students can obtain the same education and women physicians the same facilities that men do, a sound theoretical conclusion on the fitness of women to medical practice may then be reached, if required. But by that time the practical conclusion will probably have established itself, and people will cease to interest themselves in dissertations on the true theory of un fait accompli. 40