Even worse, doctors took the management of childbirth out of women’s hands, drawing into professional auspices a process that had been hitherto defined as natural, and limiting women’s right to handle—with other women—a traditionally female event. The result was the increased incidence of mechanical intervention, which actually endangered the lives of those who might otherwise have done better under the more cautious supervision of a midwife content to “wait on nature.” Male doctors allegedly resorted to forceps out of impatience, thereby increasing the possibility of infection and tearing, while remaining stubbornly unresponsive to growing evidence that the obstetrician himself often spread puerperal fever because of improper sanitary precautions.²

While male physicians have been criticized, women doctors have been depicted as leaders in a struggle against the medical oppression of their sex. Indeed, a few scholars have argued that women physicians founded a “woman’s medical movement” to combat erroneous and self-fulfilling concepts of female health that pictured women as innately weak and sickly. They have assumed, for example, that women were more sensitive to the natural birthing process, that they were less likely than men to hurry a patient through labor by resorting to forceps or drugs, and that they remained eager to minimize the risks of infection. Outraged at the ravages of puerperal fever, female practitioners seemed to some historians more willing to entertain the idea that the physician might be a source of infection.

Others have claimed that women physicians universally and consistently shunned heroic dosing and were much more reluctant than their male colleagues to use the physician’s arsenal for questionable diagnoses. Women physicians are credited with the organized rebellion against the medical wisdom that held females to be prisoners of their reproductive systems, and are described as seeking to redefine female health and disease in a manner more commensurate with autonomy and independence. “The women doctors who began to appear on the American scene in the 1850s,” wrote Ann Douglas in 1974, “saw women’s diseases as a result of submission, and promoted independence from masculine domination, whether professional or sexual, as their cure for feminine ailments.” Though such intentions might have led them to unscientific conclusions on occasion, women doctors could be excused, Douglas observed, because “these women bypassed science in large part because they had a goal quite distinct from its advancement : namely, the advancement of their sex.”³

No historian of women physicians can fail to address the important issues—issues of crucial significance to our understanding of the relationship between nineteenth-century culture and nineteenth-century medicine-raised by these scholars. In addition, the motivations and purposes attributed to women physicians---especially the assumption that they were rebellious reformers rather than authentic medical professionals-invite further investigation, especially in the light of our comparison of the differing approaches of leading women physicians like Mary Putnam Jacobi and Elizabeth Blackwell to the problem of women in medicine. This chapter, then, will speak to two important questions that underlie the historical debate. The first is whether, how, and in what ways either medical theory or practice was used as an instrument of power over women. The second asks if women physicians were aware of the use of medicine for conservative cultural ends and, if so, how they coped with this perception without jeopardizing their role as medical professionals.

An answer to the first question about medical theory must begin with the acknowledgment that many, though not all, male physicians in the nineteenth century played a central and conservative role in the debate over woman’s nature. Especially in the latter half of the century, when ministerial authority declined and increasing secularization enshrined science as a new touchstone for truth, physicians, who wrote much of the prescriptive literature regarding health, sexuality, and gender roles, gave voice to traditional definitions of femininity which limited women’s social role to domesticity. We have already examined most of the objections to an expanded role for women raised by these doctors, for their suppositions were used as well to oppose the entrance of women into the medical profession. After the Civil War, the spiritual arguments developed in the antebellum period gave way to more rigid biological sanctions promoting an increasingly inflexible conception of woman’s nature and capacity.

Indeed, the last third of the nineteenth century was an era of extreme somaticism in which physiological explanations for character, class, race, and gender traits became accepted as a matter of course. The optimistic environmentalism of the antebellum period gave way to the social Darwinism of Herbert Spencer and William Graham Sumner.⁴ According to Spencer, the human body was a closed energy system in which any abnormal demands made on one part would inevitably deplete the healthy development of some other part. This theory was often applied to men, particularly when physicians discussed sexuality, but historians have discovered an even greater willingness among medical thinkers to appeal to variations of the closed energy theory when discussing women. It formed, for example, the basis for the contention of E. H. Clarke and his medical disciples that the mental strain of a college education would have dire effects on the natural development of women’s reproductive organs.⁵

Historians have carefully investigated and exposed the medical and biological views regarding women that saw them both as prisoners and products of their reproductive systems. The modern reader may find nineteenth-century medical theories at best peculiar, but such theories could also be blatantly oppressive. To many physicians woman’s diseases—indeed woman herself—were defined primarily by her uterus. It was, wrote one commentator in 1870 “as if the Almighty, in creating the female sex, had taken the uterus and built up a woman around it.” Most female complaints, argued another, “will be found, on due investigation, to be in reality no disease at all, but merely the sympathetic reaction or the symptoms of one disease, namely a disease of the womb.” As late as 1900 the president of the American Gynecological Society could state about female health:

There was nothing particularly novel about the idea that woman’s capacity was limited by and connected to her reproductive organs. Indeed, the theory was as old as antiquity, and it was the Greeks who coined the term “hysteria,” meaning “wandering womb.” But in the latter half of the nineteenth century, the social need to muster indisputable justification for keeping women in the home became particularly urgent, and historians have rightly seen a connection between social needs and doctors’ medical theories, even if a few scholars have tended to overstate the case.⁷

What caused this growing tension and social anxiety in the latter half of the nineteenth century? The ideology of separate spheres had provided a measure of emotional sustenance to men and women who needed to come to terms with change. On the simplest level it explained and justified visible changes in individual’s lives, offering to them a social explanation for economic alterations which threatened traditional assumptions about how they were supposed to behave. Industrialization separated home and work. Just as it was characterized by differentiation and specialization, so, too, the identification of home and work with contrasting women’s and men’s spheres linked changes taking place in the economic realm with more specialized conceptions of gender roles and called it progress. Herbert Spencer himself believed the divergence of male and female roles to be the inevitable result of higher civilization.

But as we have seen in chapters 2 and 3, however comforting was the sexual division of labor, the new domesticity also endowed woman’s role with social and political meaning by invoking her central obligation to regenerate family life and social morality. The result was that women threatened to achieve new forms of power and influence in the nineteenth century, first in the family and then in the public sphere. Mothers gained more power over child-rearing and implicitly over the rearing of sons; wives asserted the right to control their own bodies in matters of sex and reproduction and thus presumably gained a degree of power over husbands. Female moral reformers and temperance advocates occasionally wielded the power of public exposure over men.⁸ Meanwhile industrial expansion tempted farm girls to leave their families for work in the factory. Middle-class women participated in health reform, abolitionism, and benevolent work of all kinds. By the middle of the nineteenth century women were taking over the teaching profession. Some demanded the right to higher education and a few asserted their intention to practice medicine and law. The closer some women’s activities came to blurring the lines between the home and the world-even if it was often done in the name of a higher domesticity—the more anxious were conservative social commentators to reassert the boundaries between men’s and women’s spheres.

With the growing American respect for science, doctors found themselves the spokespersons for the affirmation of traditional cultural verities. Many of them relished the opportunity to wield such authority and were particularly assiduous in giving attention to problems regarding women’s role. Physicians like S. Weir Mitchell, J. Marion Sims, E. H. Clarke, Augustus K. Gardner, and C. W. Meigs have come under particular attack in the last decade for their denigration of women only superficially veiled by medical theory. And yet the pronouncements of these conservative male physicians regarding female nature tell us less about male physicians in general-or even about the conspiratorial hostility toward women of particular individuals—than about the cultural component of scientific assumptions and the power that those who are recognized interpreters of scientific theory began to exert in the social realm.

Scientific discovery and scientific explanation, Tristam Englehardt has so cogently argued, always depend on the researcher’s prior evaluation of reality. In the nineteenth century evaluations of female health were informed not by empirical evidence tested carefully in the laboratory, but by cultural assumptions that had a particular non-medical use in ordering social and power relationships. “Moral values influence the search for goals in nature and direct attention,” Englehardt writes, “to what will be considered natural, normal and non-deviant.” Englehardt’s observations concerning the “disease of masturbation” in the nineteenth century can easily be applied to physicians’ pronouncements regarding women’s health:

Although it is possible to argue convincingly, as many historians have, that women unreasonably bore the brunt of the late nineteenth-century emphasis on somatic justifications for social roles, they were not the only group to experience this form of social constriction. Blacks, immigrants, and the poor were also subjected to scientific labeling when the aim was to define broadly the accepted cultural parameters of the normal. Furthermore, the control of sexuality that was one goal of medical practice subjected men as well as women to intrusive therapeutical treatments which tortured their bodies and troubled their souls. The unfortunate young man who was treated with doses of quinine, strychnine, calomel, and podophyllin, and whose penis and scrotum were on alternate days given such strong quantities of faradic and galvanic shock that he fainted after the meatus was cut in order to tolerate an even larger sized electric sound—all because he was plagued by seminal emissions “accompanied by lascivious dreams” assumed to be induced by early masturbation—believed, as surely as did his doctor, that he had a serious disease. Though doctors did not use medical theory to control men’s activity in the public world, they did use science to control male sexuality as well as female, believing that they did so in the interests of general cultural stability.¹⁰

Indeed, we are witnessing in all these examples of the social usage of diagnosis and treatment the beginnings of what Christopher Lasch has labeled the “medicalization of society.” In the period after 1900 the helping professions gained increasing leave to intrude on the family in various ways, disseminating the principles of efficiency of function, expertise, and science, and rationalizing emotional life. Educators, psychiatrists, social workers, penologists, and public-health advocates would all increasingly use the metaphor of a sick society in order to best define their own newly developed social role: as agents of a more scientific, more humane, and more rationalized social order. Doctors, too, would participate in these changes, while their medical theorizing reflected the gradual equation of deviance not with crime or sin, but with illness.¹¹

Women physicians, by virtue of their being professionals, could not help but be influenced by the growing use of the medical profession as an instrument of social control. They, too, naturally turned to science to buttress their cultural theory. It is important that we keep this in mind as we address the second question raised at the beginning of this chapter. How aware were women physicians of the use of medical practice for conservative cultural definitions of woman’s role, and how did they cope with their perceptions while continuing to maintain their self-respect as qualified medical professionals? Did they indeed offer a coherent critique of male medical procedure, either in theory or in practice, as some historians have claimed? ¹²

To begin with, many women physicians seem to have expected their medical practice to differ in a number of important ways from that of their male teachers and colleagues. Since they based their arguments in favor of women’s role in medicine on their difference from men, it is hardly surprising that such would have been the case. Nor did the assumption that women and children would be their primary constituency trouble them, because they sincerely believed that women usually were more effective than men in treating women Ella Ridgeway wrote in her 1873 thesis at the Woman’s Medical College of Pennsylvania that women had been called upon to “supply a deficiency” in medicine “in regard to the diseases of women.” There were many questions about the subject that “no doubt” have arisen in the “mind of every woman student which are not answered either by our professors or the books. One of these is why do women generally suffer so much more from ill health than men?” Anna Longshore-Potts also displayed pique at her male colleagues when she wrote that their opinions about women were “cut and dried” and if women had pursued medicine earlier, “today women would have had more healthy bodies.” A generation later, Rosalie Slaughter Morton agreed that even wellintentioned male physicians misdiagnosed women. “Diagnoses made by men often indicated,” she wrote, “they they either did not, or could not, fully understand the diseases classified as those of women. Their analyses lacked clarity through insufficent differentiation from male disorders.” Consequently, Mary E. Bates chided those few women physicians who “have cherished the ambition to be consulted solely because of medical attainment,” preaching the doctrine “that there should be ‘no sex in medicine.’ ” “So long as there are men and women patients there will be sex in medical problems,” she warned, and women needed women physicians to understand their ailments best. ¹³

In addition, women physicians readily acknowledge that they practiced a more nurturing, milder, and a more holistic brand of therapeutics. Sarah Adamson Dolley urged her students to meet patients “as something more than a static entity or dynamic quantity whose muscles, nerves, and joints are not simply a bundle of levers, pulleys and hinges, but are the instruments of that mysterious something which we call life.” Similarly, Dean Clara Marshall emphasized this point to her graduating classes in Philadelphia. Study people as well as diseases, she warned. “A distinguished physician has said ‘there are no diseases, only patients,’ ” she told a group of students in 1879, “and you will often reach patients and cure them too, by a scientific use of your humanity.” Susan Dimock, the brilliant young surgeon at the New England Hospital, frequently commented that if she were asked “to do without sympathy or medicine, I should say do without medicine.” “A woman physician sees life without its mask,” observed the surgeon Rosalie Slaughter Morton. “[She] gets closer to the inner thought of other women in understanding the many domestic and social factors in illness ... because her mother heart has scientific facts to support intuition and sympathy.”¹⁴

So pervasive was the belief that women had more patience and insight, that even the greater physician Oliver Wendell Holmes, Sr., admitted to a suspicion that male physicians all too often resorted to drugs when empathy was all that was in order. “I have often wished,” he mused,

Implicit in such sentiments, of course, was a critique not unlike Elizabeth Blackwells, of the male style. Men were presumably neglectful of important but subtle aspects of medical practice and could not be expected to change because such deficiencies were a reflection of both the strengths and weaknesses of the male character. Not inherently altruistic like women, men lacked the “spirit of self-sacrifice” and thus could not do as well with children because they had “neither enough love or patience.” Male physicians were apt to reject the insane “pitilessly,” whereas women took the time to communicate with them. The interests of men lay in pure science, not in its sympathetic application. In obstetrics, argued Effa Davis, this meant that it had always been “the mechanical side” that had “appealed to men from the beginning.” Preparing the patient for childbirth through instruction and advice has been less “alluring.” Indeed, male physicians’ most serious deficiency was found to be in the area of prevention. ¹⁶

Evidence to support these assumptions about male and female differences is intriguing but inconclusive. The Philadelphia physician Arthur Ames Bliss offered some indirect verification for the “male” medical style when he noted in his memoirs about his early days at Blockley that:

In contrast, Harriet Belcher reported her own internship at the New England Hospital as a “ceaseless round of care, work, and anxiety.” “The Maternity is the saddest of places to me,” she told a friend. “Most of the women are unmarried, and except for the respectability of the thing, by far the greater number had better not be—the Husbands being brutal wretches who abuse them in every way.” Proud of the efforts of the hospital’s lady managers to help such unfortunate women find work and a home, Belcher concluded, “I have always been interested in such work ... and I am very glad, as you may imagine, to take any part in it.”¹⁸

As far as criticizing actual practice is concerned, many of the, published case studies of women physicians are specifically concerned with alternative therapies to “scientifically applied therapeutics.” In 1884 Dr. Sarah R. Munro argued that women physicians were better at curing dysmenorrhea in young girls first because “they will not be contented with giving morphia month by month as the main remedy,” and, second, because they would put greater emphasis on preventive hygiene. Three years later Lena V. Ingraham reminded her listeners at the Woman’s Medical College of Pennsylvania in a paper on “Preventive Medicine” that drugs, pledgets of cotton, and pessaries should not be resorted to in cases of prolapsed or retroverted uterus until proper attention had been paid to healthful dress. Finally, Dr. Bertha R. Lewis spoke in a paper on correcting spinal curvature, of her sense of male doctors’ reluctance to use exercise therapy as a cure. “It is so much easier to put on a stiff brace,” she observed. “I think the few men physicians who do approve of giving exercises for lateral curvature, are unwilling or unable to find time to give the necessary personal supervision,” she concluded. ¹⁹

It is clear from their published work that women physicians admired a therapeutic style that reflected sensitivity to the patient’s feelings. In remembering her mentors at the New England Hospital at the end of the nineteenth century, Dr. Alice Bigelow emphasized Dr. Sarah Bond’s gentle speech. “I never heard it harsh.... Her patients adored her, and she went through the old medical building like sunshine.” Likewise, Dr. Elsie Brown was a woman full of “kindliness.” Attending a seminar on gynecological surgery, Mary E. Bates was particularly offended by the fact that the speakers “limited their attacks to the offending ... uterus,” while “practically ignoring the patient.” Harriet Belcher believed that women even handled dissection differently in their medical schools. In a letter in 1875, she noted her own surprise at finding dissection less difficult to endure than she had expected. “I find that when the spirit of scientific research and inquiry is roused, you soon lose sight of all the rest,” she explained. Nevertheless, she concluded, “from what I hear of it in other colleges I have no doubt that a dissection as managed by women is a very different matter from one under the charge of male attendants. Every possible precaution is taken to spare the sense and feelings of those engaged in it.”²⁰

A fascinating first-hand description of one highly respected woman physician’s empathic style has been left to us by the feminist writer Charlotte Perkins Gilman. Gilman’s account is particularly noteworthy, because in 1885, soon after the birth of her daughter, she experienced a nervous breakdown and was for a short time placed under the care of S. Weir Mitchell, the eminent Philadelphia neurologist who was renowned for his treatment of hysteria. Though Mitchell’s paternalistic “rest cure”—placing the patient in an isolated room under the care of a nurse for complete bed rest and total inactivity—worked with scores of women in the late nineteenth century, he failed miserably with independent-minded individuals like Gilman whose very lives stood as indictments of Victorian traditionalism. Gilman’s meeting with Mitchell was so unsatisfactory that she wrote a brilliantly critical caricature of him and the “rest cure” in her gripping short story “The Yellow Wall-Paper. ,²¹

Unable to find complete relief for her ill health, Gilman suffered from nervousness the rest of her life. She was helped in 1902, however, by the treatment of Mary Putnam Jacobi, and left the following account of their relationship:

Besides the question of variations in style, there was also the contention that women physicians used drugs differently. Many argued that women physicians would reject heroic dosing and that some women doctors actually preferred milder therapies. Certainly this may have been partially true. In a letter to Elizabeth Blackwell, for example, Marie Zakrzewska confessed her dislike for drugs, admitting that her “whole success in practice” was based upon viewing medicines as “secondary,” often using drugs as placebos. “I have the reputation among my large clientele, men, women & children as giving hardly any medicine but teaching people how to keep well without it ... I can assure you,” she concluded, “it is far harder, requiring more strength, and more endurance & more patience to practise Hygiene then [sic] what is called medicine.”²³

Yet we cannot generalize about women physicians and heroic therapy. Scores of male physicians rejected harsh dosing, while one also occasionally finds a woman practicing heroic medicine. The casebooks of Anna Manning Comfort, a homeopathic physician, reveal that she sometimes bled patients with leeches. Bleeding, leeching, and other drugs were often recommended therapies in the gynecological and obstetrical theses at the Woman’s Medical College of Pennsylvania. These essays refer again and again to standard therapies described in medical texts that both the female authors and their male student counterparts were reading. In 1889 Mary Putnam Jacobi herself reported a case in which she used leeches applied to the cervix to restore the flow of menstruation to a woman suffering for over three months from amenhorrea. And as we shall see below, my own comparative study of the management of obstetrical cases at a female-run and a mate-run Boston hospital revealed only minor variations in the use of heroic medicines, but an unexpected divergence in the frequency of drug prescription.²⁴

It is also important to remember that patients themselves often demanded heroic treatment as proof of the physician’s skill. Charles Rosenberg has observed that therapeutics played a central role in the doctor-patient interaction, and often the severity of the drug administered demonstrated to the patient and his family that something was indeed being done.²⁵ In fact, doctors who were skeptical of heroic dosing often complained that public expectations worked against change: a physician who failed to bleed in some cases was subject to criticism. That women physicians were not immune to such pressure is illustrated by the following passage from a letter of Elizabeth Blackwell’s to her sister Emily:

Similarly Marie Zakrzewska, writing to Elizabeth Blackwell in 1891, noted that women came to the New England Hospital begging for operations “on the slightest cause.” Married women “between 28 and 40 years” come in asking for ovariotomies “because causing [sic] dismenorrhea & children were not desired.” When surgeons were thus tempted, she mused, “do you wonder ... [that they] go the whole length of disregard for Nature?” Zakrzewska felt that “material comfort, indulgence in luxurious living, dislike to work & of self abnegation are the motives which prompt women to seek operations.” “Yes,” she observed bitterly, “they rather die, then bring up a family of children and work & practice self denials.”²⁷

When discussing their conservative attitudes toward dosing, women physicians usually connected their willingness to use milder therapies to their greater emphasis on prevention over cure. Marie Zakrzewska, remember, justified her use of placebos by her willingness to teach “people how to keep well.” Similarly, Sarah Adamson Dolley expressed such sentiments in a letter to a cousin written while she was still in medical school. “Heroic treatment,” she argued, was a “necessary evil” with which people could do without “if they learned to live properly.” Indeed, we have seen that many women physicians took their role as teachers of hygiene extremely seriously. Scores of them gave lectures on physiology and health from the midnineteenth and into the twentieth century. Others taught hygiene in the newly established women’s colleges. Still others published books and pamphlets to combat mass ignorance and the prevalence of disease.²⁸

Abudant evidence also exists to suggest that the hospitals that women physicians founded in the latter half of the nineteenth century gave particular attention to the doctor’s teaching role. The New York Infirmary, for example, established the office of “sanitary visitor” in 1867. This position was usually filled by a young medical graduate wishing to gain further,clinical experience. The work entailed going into the homes of the poor, checking on ventilation, cleanliness, diet, and general hygiene, and giving families advice on how to keep themselves healthy.²⁹

In Cleveland and Philadelphia, the Woman’s Hospitals sent interns into patients’ homes. Physicians, revealed the Cleveland Hospital’s Annual Report of 1882, did not confine their work “entirely to curing the sick,” but also offered “instruction ... in the laws of health” and in “the care and diet of children.” Similarly, the Mary Harris Thompson Hospital in Chicago had female physicians as medical visitors who did “many things for their improvement besides administering medicines for a present illness” when they went “into the homes of the poor. ³⁰

Let us now turn to the prevailing theories of female health in the nineteenth century, and ask how and in what ways women physicians offered an alternative to the traditional definition of woman as weak, emotional, sickly, and hysterical, governed without mercy by the vagaries of her reproductive organs, and liable to permanent physiological damage if she imprudently exposed herself to the dubious rewards of higher education.

In 1891, on the eve of the opening of Johns Hopkins Medical School, M. Carey Thomas praised the woman physician as the individual who could best guide young girls through school and college life. First, she observed, a woman doctor would be less ready than a man to preserve physical health “at the expense of intellectual development”; indeed, she would be more skeptical even that such a thing could be done. She would never “prescribe sheer idleness as a remedy ... for the indispositions of girls” hungry to learn. But most important, believed Thomas, the woman physician would have an infinitely better “conception of the ideal or normal life of women, and will understand and know how to remove or diminish the difficulties in the way of its realization.”³¹ M. Carey Thomas knew what she was about. However much women physicians differed on the details of female health, they were drawn together by the conviction that women had a right to good health, that their own role should facilitate that right, and that better health among their contemporaries and future generations of women was indeed possible. Some of them were extremely cautious about the physiological crises of puberty, childbirth, and menopause, and occasionally their prescriptions for behavior appear in retrospect strikingly similar to those of conservative men. Yet the female doctor who believed it was woman’s fate to suffer indefinitely because of her physiology was a rare exception. Most would have agreed with Anita Tyng, who declared in 1880 in a paper on “Dysmenorrhea” delivered to the alumnae of the Woman’s Medical College of Pennsylvania, “I do not believe that we are born to suffer, or born sick and malformed simply because we are born women.”

At that meeting, Tyng called for a concerted effort by women physicians to investigate the subject of female health:

In the 1880s women physicians took up Tyng’s mandate. They monitored the health of college girls and began to publish works contradicting the Clarke thesis. Most of these studies demonstrated that higher education not only did not adversely affect women’s health, but made a positive contribution to good health by teaching “a proper appreciation of physiological laws.”³³

Yet it is also a mistake to claim too much innovation for the woman doctor. Especially after 1880, the majority of female physicians were committed professionals who shared a common medical education with their male counterparts, and who grew up influenced by the same social environment. Thus, it is possible to find plenty of “conservative” medical opinions among them on the subject of women’s role, puberty and menopause, marriage and motherhood.

Like their male counterparts, for example, a number of women physicians, some of them strongly identified .with social feminism and suffrage, revered motherhood in sentimental Victorian fashion. Though male physicians have been accused of veremphasizing woman’s reproductive role in order to cement her more firmly in the home, it is hard to find much difference in the pronouncements of many women doctors on the subject. I have uncovered no woman doctor who directly challenged woman’s primary role as mother, and many who devoted much attention to seeking ways to improve it. Eliza Mosher believed it “economic in the highest degree” to preserve female health because it was a great “loss to the State” when “through ill health or physical disability, women are unable to bear and properly rear children.” As dean of women at the University of Michigan, Mosher enjoyed teaching home economics more than any other course because she had a chance to preach scientific motherhood. Like Mosher, Dr. Josephine Whetmore considered maternity the central event in a woman’s life. She hoped women would prepare for it by “clean living from the cradle.”³⁴

Another defender of scientific motherhood was Dr. Mary Wood-Allen, a well-known social-purity lecturer. Though married and a mother herself, Wood-Allen thought it generally undesirable for a woman to work outside the home if a “husband’s income is sufficient to maintain the home in comfort.” “Motherhood is a profession most exacting in its demands,” Wood-Allen wrote, “and the strength, thought, courage and patience of the wife are fully occupied in caring for the needs of the family.” Dr. Josephine Griffith Davis believed that “every true wife who loves her husband is willing, nay anxious, to bear children to him”; and Dr. Helen S. Childs asserted that the best thing about a college education for women is that it made them better mothers. College women were quite as willing as non-college women to become mothers, she argued, “because the inclination toward motherhood is instinctiv.”³⁵

All women physicians worried about the idleness and dissipation which had been brought by modern life to the lives of potential mothers. Conservative women physicians like Wood-Allen sought a solution in “professionalizing” motherhood by making it more scientific. While she discouraged work outside the home, other women doctors were bolder: Rachel Brooks Gleason urged husbands to “help their wives and daughters to some encouraging, ennobling work. Infirmities, both imaginary and real, would be lessened.” Sarah Hackett Stevenson believed that “successful occupation” was “the cure for many, many sins” and that making women self-supporting would be a boon to “domestic life.” She estimated that half the female population was sick from “ennui.” “If Satan had a mission on earth,” she wrote, “it is in finding employment for unemployed women. He starts them on a career of self-contemplation ... they revolve from day to day around themselves ... a sort of ... disintegration of character takes place.”³⁶ And yet few women doctors seemed willing to explore the logical contradiction between the idea of “scientific motherhood” and women’s venturing out into the real world of work. One is never sure whether they are recommending paid work or volunteer activity, while practical solutions are generally left unexamined.

Furthermore, the importance of preserving women for healthy motherhood led many women physicians to be extremely cautious about a too casual or neglectful approach to women’s biological milestones. Elizabeth L. Martin, adviser and medical examiner to women at the University of Pittsburgh, warned her colleagues that any training for woman “which in any way handicaps her for what should be her highest and happiest function—that of wifehood and motherhood” would be a wrong to society. Admitting that “brilliancy of intellect is often associated with an instability of the nervous system which makes parenthood undesirable for some of these women,” Martin nevertheless believed that careful supervision by the woman physician could counteract such dangers. ³⁷

Margaret E. Colby, president of the Iowa Society of Medical Women in 1902, similarly viewed puberty as a dangerous time. “For a year or two ...” she pressed, “we as physicians, should urge the necessity of fewer studies, or shorter study hours, sandwiched with manual training, in economics and out-door and indoor gymnastics, instruction in regard to the physical changes, their significance and values.” Writing in the Woman’s Medical Journal, another woman physician disapproved of competitive sports for girls, arguing that it “overworked ... [the] heart.” Mary Wood-Allen advised the avoidance of long walks, bicycling, dancing, and all physical exertion, while Anna Manning Comfort felt careful physiological instruction by mothers would ease pubescent girls onto the right track.³⁸

Some women physicians subscribed to the maternal-impression theory—the idea that a pregnant mother’s experience could affect a fetus—and many believed in the inheritance of acquired characteristics. Such beliefs led to the prescription of carefully chosen activity during gestation and the cultivation by women of lofty character traits. “Sometimes,” wrote Mary Wenck, “a mother may force an ugly disposition on a child by her own discontented and unhappy mind during the carrying period.” She urged fellow obstetricians to teach mothers the fearful effects of “mental disquietude.” ³⁹ Such an approach certainly could help to confine pregnant women to their sphere, and to encourage them to feel guilt if they felt dissatisfied with their inactivity.

Most female physicians expressed shock at the prevalence of abortion among middle-class women. “Nothing was so surprising to me during my first year of practice,” remembered Eliza Mosher, “as the assurance with which women came to my office and asked for illegal operations. That’s what they thought women doctors were for.”⁴⁰ Yet women physicians not surprisingly displayed a particular sensitivity to women’s right to control both the timing and the purpose of the sexual act. They agreed on this point, whether their attitudes toward sexuality were liberal or conservative, and whether or not they condoned family limitation. Compelling wives in sexual relations was an “outrage” to both mother and “unborn” child. “If woman has an inalienable right in this world,” declared Sarah Hackett Stevenson, it is the right to become a mother “in accordance with her own desires.” This conviction appeared repeatedly in the literature women doctors wrote for the lay public, although some male physicians held it as well.

Women physicians also tended to argue for a more positive interpretation of the menopause. Though they admitted that “dangers do attend the menopause,” the careful supervision by a physician could avert most suffering and women “would be prepared to enjoy a healthy and useful post-climacteric period of life.”⁴¹

One area of medical practice that seems to have drawn much critical attention from women physicians was gynecological surgery. Elizabeth Blackwell was not the only woman physician to complain about the increase in ovariotomy in the last third of the nineteenth century, others did as well. In a fit of pique in 1894, Mary A. Spink responded to a physician who had ridiculed women doctors with the accusation that plenty of irresponsible men practiced poor medicine:

In addition, several women doctors pioneered in the growing professional criticism of the theory of reflex irritation which stressed uterine disease as a cause of insanity in women. In a paper published in 1894, Anne H. McFarland welcomed the modern tendency to play down the connection between the female reproductive system and mental illness. Calista V. Luther, in a talk on the participation of women physicians in work among the insane, praised the pioneer activities of Margaret Cleaves in the 1880s, though she admitted that Cleaves believed in the theory of reflex irritation. “I differ from her in respect to uterine diseases being a potent factor in the insanities of women,” Luther explained, “yet her opinion and the authorities are worthy of our respectful attention.” Luther closed with the remark that, if Cleaves were writing in 1900, she believed the older woman would lay much less stress on the causal nature of uterine disease.⁴³

And yet women doctors themselves occasionally performed sexual surgery, although one gets the impression they were extremely cautious about it. Anita Tyng, Mary A. Dixon-Jones, and Elizabeth Keller all published several case studies of “Battey’s Operation” —the removal of normal ovaries to cure a variety of gynecological and psychological complaints—and Anita Newcomb McGee advocated ovariotomy for all “degraded or low-class or poor women who will submit to it, to prevent multiplication of the race from its dregs.”⁴⁴

Furthermore, women physicians were for the most part absolutely delighted with their achievements in the operating room. Many believed surgery “particularly appropriate for a woman.” Their hospital reports and case studies published in the journals proudly boasted of the number of “capital operations” performed each year. Lilian Welsh, a graduate of the Woman’s Medical College of Pennsylvania, retrospectively summarized the attitudes of many when she recalled that “in those early days of gynecological surgery, women physicians, as a rule, were very ambitious to enter the field. "⁴⁵

It is also clear that by the 1890s a more conservative approach to ovariotomy was making headway among male physicians. In a letter to Elizabeth Blackwell written in 1896, Dr. Mary Augusta Scott, a surgical assistant to the gynecologist Howard Kelly at Johns Hopkins, reported the attempts by Kelly and several other male physicians—including the president of the AMA—to put a stop to abusive gynecological surgery. In that year Kelly published an article in the Journal of the American Medical Association in which he observed, “Conservatism ... is undoubtedly the progressive spirit in gynecology: exsective and amputative gynecology has gone to its extreme limits, and the more thoughtful surgeons ... have already sounded the keynote of the new advance.” Similarly, I. N. Love accused the profession of going “mad in the direction of gynecological tinkering” after “the J. Marion Sims epoch,” and praised the fact that “the surgical pendulum is swinging well in the opposite direction.”⁴⁶

It is hard not to conclude that, although women physicians had a greater awareness and sensitivity to women’s issues than men, their overall medical opinions tended to reflect professional and scientific trends and their divergences among themselves often appeared to be similar to those of male doctors. Just as men lacked unanimity on many medical isues, women physicians also differed significantly with each other. As females struggling to strike a balance between science, professionalism, and their own womanhood, they were bound to develop individual solutions to the problems of female health. The historian is hard pressed, therefore, to uncover a uniform approach among these women on how to treat, diagnose, or prevent illness. Women internalized many “male” values, just as men were sometimes advocates of “female” positions.

An excellent example of such diversity may be drawn from the obstetrical literature. The persistent reader of medical journals appearing in the last third of the nineteenth century will likely discover that a debate raged among obstetricians over whether childbirth was a natural event requiring the obstetrician to “wait on nature” or a pathological crisis demanding active and vigorous intervention. Prominent male physicians can be found on both sides of the issue. The debate crystallized in the pages of the American Journal of Obstetrics and Diseases of Women and Children for 1888, where William T. Byford, teacher in Rush Medical College and president of the Chicago Gynecological Society, and A. F. A. King, president of the Washington, D.C., Obstetrical and Gynecological Society, warmly contested “The Physiological Argument in Obstetric Studies and Practice.” King’s article had a familiar ring. Though childbirth perhaps should be natural, “in the present age, and among civilized communities,” he wrote, a case of natural labor can only be “hypothetical.” The bad habits of modern life had exacted their toll on parturient women. Byford, on the other hand, scorned King’s distorted picture of American womanhood. The doctor’s patients were not representative: “Let the author look elsewhere than in Washington and in large cities and he will find plenty of healthy women in physiological labor—he might indeed have found plenty in Washington.” Byford’s positive approach to female health led him to decry passionately the “meddlesome practices” of some of his colleagues. ⁴⁷

If we examine the theses on childbirth at the Woman’s Medical College of Pennsylvania, we discover that they, too, reflected the thinking of the medical profession at large. In the early decades, from the 1850s to the 1870s, the theme was deference to nature, limited interference, and patience in delivery ⁴⁸By the end of the century, however, when doctors began to worry that excessive civilization had complicated delivery for middle-class women, the women’s theses reflected this change. Pregnancy, wrote Phoebe Oliver in 1869, though a physiological condition, “has the peculiarity of being in some susceptible constitutions, pathological.” She recommended moderate interference, including some drugging, rather than “waiting on nature,” especially when there were spasms. Other students noted the dire effects of advancing civilization on the ability of women to give birth easily.⁴⁹ Lucy R. Weaver believed that the way in which the physical system changes during pregnancy “may easily become pathological, for it borders so closely on disease.” Mary Jordan Finley chided old-fashioned obstetricians reluctant to use forceps. She warned that much serious damage could be prevented by the “timely” use of both forceps and ergot to ease pain, secure the child, and conserve the strength of the mother. “A timid or incompetent practitioner,” she complained, “sits by the patient waiting for nature to accomplish the delivery until the life has been crushed out of some point in the soft tissues.” The result: vesico-vaginal fistula, a hole in the uterine or vaginal wall caused not by the forceps, but by the hesitation of the physician to use them. ⁵⁰

Articles on childbirth in the Woman’s Medical Journal, established in 1893, also reflected prevailing wisdom. While old-timers such as Marie Zakrzewska reminded young practitioners that childbirth was “the most natural process in a woman’s life” and decried “meddlesome interference,” other women physicians shared the attitude of Agnes Eichelberger. Childbirth might be a physiological function, she conceded, but “from the moment of conception to the end of the lying-in state, our patient is in danger and it is our duty to protect her. ”⁵¹

Eliza Root recommended wide experience in the use of forceps in teaching obstetrics because of the frequency of faulty development of the reproductive system caused by modern civilization. Other women doctors were actually innovative with certain surgical procedures. Anna E. Broomall, who ran the obstetrical service at the Woman’s Hospital of the Woman’s Medical College of Pennsylvania, was one of the first surgeons of either sex to recommend episiotomy as a safe and justifiable procedure. When she presented her findings to the Philadelphia Obstetrical Society in 1878, she was criticized by the men for too much interference and for needlessly exposing the patient to septic poisoning. ⁵²

I do not believe these differences were primarily generational, although medical trends were important. It is helpful to point out that both the “natural” and the “medicalized” view of childbirth could be and in fact were used to justify both feminist and antifeminist positions. It is not surprising to learn that Dr. Byford and Dr. King’s attitudes toward childbirth dovetail with other opinions they held on the subject of women. Byford was a strong supporter of women in medicine, and helped establish the Woman’s Medical College in Chicago. In contrast, King opposed the admission of women to medical school, and was instrumental in seeing to it that his own institution, Columbian University, closed its doors to them in the 1890s.⁵³

As for the question of childbirth, the issue was often who should be in control; male physicians who preferred interference may have done so in order to assert medical control over parturition. Women in the nineteenth century who advocated certain types of interference, however, often did so on the grounds that such interference could be liberating for patients—either from pain itself or from male incompetence. The Twilight Sleep movement in the early part of the twentieth century presents an excellent case in point. In this instance women physicians and other feminists campaigning for woman’s relief from birth pain through the use of scapolomine-morphine pressured obstetricians into administering a technique of anesthesia that at the turn of the century had been rejected by male doctors as unreliable and unsafe. In contrast, antifeminist physicians often used intervention as a means of asserting professional control over the birth process and keeping women in their places. ⁵⁴ .

A study of the medical literature has revealed that gender played a small but not necessarily insignificant part in the approach of men and women physicians to treatment. Professional trends and shifts of opinion influenced women physicians’ thinking on medical issues just as such change affected their male colleagues. Yet, unlike men, women expected to take an especial interest in female health and this interest often led them to reject the most extreme positions on woman’s innate physiological infirmity. Although this meant that their differences with the majority of male practitioners would be extremely subtle, and that their opinion would usually conform to those of the more liberal wing of the profession, gender mattered, though it mattered in only obscure ways ⁵⁵

The actual clinical records can help to strengthen these conclusions. Nineteenth-century Boston offers a unique opportunity for the study of the treatment of women. Many hospital records have been preserved and are still available. Boston also boasted one of the first hospitals for women and children staffed by women physicians. Until it began to lose its appeal in the late 1890s, the New England Hospital, founded by Marie Zakrzewska in 1862, was a showplace for quality medical care in the latter third of the nineteenth century. Ambitious women doctors longed to receive clinical training there, and its teaching program, compared to others at the time, was rigorous and demanding. Standards reflected the very highest of the day. Fortunately, medical, surgical, and obstetrical records for this institution are virtually intact, and if used along with comparable records for the Massachusetts General Hospital and the Boston Lying-In-both teaching facilities for Harvard Medical School—some interesting comparisons can be made.

My objective was to determine whether women in childbirth were likely to receive treatment from women physicians different from that given by men and to test statistically whether childbearing women received better care from female physicians. A systematic sequential sample was drawn from maternity cases at the female-run New England Hospital for the period 1873-1899 and Harvard’s Boston Lying-in for the period 1887-1899.⁵⁶ Three broad areas of medical treatment and outcome were recorded: the incidence of complications among patients, the use of drugs, and the use of physical intervention techniques, particularly forceps. Any significant differences between hospitals in these areas could be attributed to the sex of the physicians involved if inherent differences in patient population and other non-gender-related institutional differences could be statistically controlled. ^a

For this study, this qualification was important. Nineteenth-century hospitals were institutions of the urban poor, who were by no means a homogeneous group. Nor did nineteenth-century institutions always perceive all poor people as the same. This distinction in perception was reflected in the development of two different types of hospitals. On the one hand stood the free municipal hospital, a medical almshouse which represented a refuge of last resort for the chronically ill and indigent. The private or “voluntary” hospital, in contrast, ministered to a paying clientele or to the “industrious and worthy” poor who filled its endowed beds. ⁵⁷ Though Boston Lying-In and New England Hospital were both voluntary institutions, evidence reveals that there were important differences in their clienteles.

Records and annual reports indicate that the “worthiness” of patients was an appreciably more significant factor in New England Hospital’s admissions policy than at Boston Lying-In’s. New England Hospital patients generally paid at least a nominal fee for the medical services they received to ensure that they would not be “pauperized” by the experience. At Boston Lying-In, only 23 percent were paying patients. Like the male-run Boston Lying-In, the female-run New England Hospital normally refused obstetric service to unwed mothers bearing their second illegitimate child. Unlike Boston Lying-In, however, the ratio of single mothers to married mothers at New England Hospital declined throughout the time period studied. One of the hospital’s senior physicians, Emma Call, optimistically referred to this trend when she noted that after the hospital moved to suburban Roxbury in 1871, “the class of patients was ... a much better one, and we have never had any number of the most undesirable cases, which inevitably gravitate to an institution located in the midst of a dense population.”⁵⁸ These factors, as well as comments on the physicians’ charts and in the hospital’s annual reports intimate that physicians at the New England Hospital showed a greater interest than the male physicians at the Lying-In in the patient amenable to moral reform and in creating a Christian atmosphere for erring women. Male physicians viewed their hospital role from a narrower perspective.

Clearly discernible here is a conflict between old and new concepts of rofessionalism. In the middle of the nineteenth century, doctors of both sexes believed in the medically curative powers of morality and natural living—a belief that technocratic male physicians increasingly abandoned after 1880. Male doctors apparently surrendered their concern with morality more quickly than did women, and one suspects that female physicians’ traditionalism in this instance had much to do with their investment in Victorian culture’s identification of women as the moral guardians of society.

The socioeconomic difference in patient populations suggests that in both hospitals patients were poor, but Boston’s Lying-In’s women were poorer. One infers from this that New England Hospital patients may have had an advantage, however slight, in their general medical condition. Ironically, women physicians attracted a somewhat different type of patient, with somewhat different medical and social problems, and this in turn affected the type of medicine women doctors practiced.

Another noticeable difference between the institutions was the sheer amount of information given on the hospital’s patient charts. New England’s records are consistently more complete. In addition to an account of actual treatment, they provided a greater amount of information regarding patients’ medical background (general physical condition, number of prior miscarriages, etc.) and a more detailed indication of social status.

This meticulous record keeping reveals the self-conscious professionalism typical of women physicians, but it also indicates a “leveling” process at work in the Boston Lying-In. The women doctors at New England Hospital made an attempt to know who they were treating and distinguished, at least in their records, between various levels of poverty. The lack of similar distinctions at Boston Lying-In implies that poor women treated in an often overcrowded teaching facility may very well have represented a single category to the male physicians. Interestingly enough, case records were scrupulously complete when male Boston Lying-In physicians presided at the home deliveries of middle-class women.⁵⁹

One’s impression is that male physicians at the Boston Lying-In lumped the poor together. Additional support for such a conclusion lies in the fact that the maternal recuperative period at the hospital was a standard two weeks with very little variation. The Lying-In’s annual reports express regret that overcrowding made this policy necessary. However unavoidable, it stands in marked contrast to New England Hospital practice. New England Hospital patients remained under care for from four days to three months and were, on the average, under medical supervision over one week longer than their Boston Lying-In counterparts, even during the identical time period (1887-1899). Perhaps this variation can be attributed to a greater sensitivity to individual physical considerations coupled with the availability of space. But the evidence also suggests social considerations. Single mothers normally remained under medical care longer, perhaps because they had nowhere else to go, or because the women doctors of New England Hospital felt such patients required more of the hospital’s meliorative moral influence. Bits and pieces of evidence suggest that to women physicians the medical variables were measured equally with their patients’ social situations when determining length of stay. This factor alone implies a very different subjective experience for each group of patients.

What about differences in actual medical treatment? The statistics revealed no significant divergence between the two hospitals regarding infant mortality or maternal outcome, particularly when the patient’s general state of health was taken into account. More intriguing, however, were contrasting modes of care offered patients after delivery, particularly regarding prescriptions for relief. Here strong patterns of difference emerged.

By the 1870s heroic medicine was on the decline. Physicians conscious of changing medical trends generally avoided large doses of painful and life-threatening therapies. Nevertheless, drugs were often deemed necessary. One expected that drugs would be given in direct proportion to the severity of the complaint, and that women physicians, who had often decried heroic procedures, would be more conservative in their prescriptions. The hospital records revealed precisely the opposite pattern.

Nearly two-thirds of all Boston Lying-In patients received no medication whatever from their physicians, and the statistical correlations revealed that the use of drugs was strongly predicated on the occurrence and severity of complications. At the New England Hospital, every patient was given some form of medication by the women doctors, usually in the range of what was classified as mild to strong pharmaceuticals. Moreover, the prescription of drugs at the New England Hospital did not correlate decisively with any discernible medical factors, meaning that drug prescriptions for postdelivery women were simply standard procedure among women physicians. In short, the male Boston Lying-In physicians followed an objective model: drug prescription was dependent on the physical symptoms. Women physicians dispensed medication or supportive therapy for’ less codifiable and nonphysical reasons. Everyone received at least “beef tea,” and more often a mild pharmaceutical ⁶⁰

While it may be that most of the Boston Lying-In patients were protected from needless medication, it is also possible that they were virtually ignored after delivery. The scanty medical charts certainly suggest this to be the case. The New England Hospital’s medication policy implies an alternative ethos concerning the needs of postdelivery women, and the greater prescription of medication by women doctors may be the objective indicator of more patient-doctor contact. If this speculation is correct, then the female physicians were again exhibiting a concept of professionalism that deemed supportive therapy as important to the patient as purely technical concerns.

Another factor under consideration was the relative use of intervention techniques, particularly forceps. This subject is easily the most controversial since it is one of the main issues on which recent historians have based their case that male physicians were arrogantly insensitive to the needs of maternity patients. The use of forceps has become symbolic of the definition of childbirth as a doctor-controlled medical crisis. Hypothetically, women physicians, because they were women, were more sympathetic to the concept of childbirth as a natural process and hence should have been less prone to resort to instrumental interference in delivery ⁶¹

Examined over the entire period, the data revealed no dramatic difference in the relative willingness of doctors at either hospital to resort to intervention techniques. In addition, medical criteria for forceps use were similar at both hospitals. The labors of those women involved in forceps deliveries were significantly longer than the average, probably because most were bearing their first child. Moreover, these women tended to receive stronger medication in the recuperative period. Finally, the use of forceps increased gradually at both hospitals in the last decade of the nineteenth century. This fact suggests that once sepsis could be controlled forceps deliveries became more likely.⁶²

On the issue of puerperal fever, several historians have charged male physicians with negligence in correcting their role in transmitting the dreaded disease. It is true that Boston Lying-In had more difficulty controlling puerperal infection than did New England Hospital. Before the introduction of successful antiseptic techniques there in 1885, the hospital had been forced to close three times because of epidemics, in contrast to only once at New England Hospital. More lives were lost at the male-run hospital. One researcher claimed that Boston Lying-In’s comparatively poorer record in preventing sepsis stemmed from the staff’s stubborn reluctance to accept the nurses’ and physicians’ role as possible sources of infection, whereas women physicians at New England Hospital were more willing “to view themselves as fallible.”⁶³ Careful investigation of those charges through an examination of the annual reports of the two hospitals strongly suggests that their divergent records on the fever may not have been related directly to the sex of the physicians in charge at all, but rather to complex and idiosyncratic difficulties having more to do with hospital architecture and finances, the personalities and experience of the respective resident physicians, and blind lucky⁶⁴

As far as the mechanics of obstetric practice are concerned, the hospital studies reveal that the complication rates and frequency of forceps use within each institution indicate a rough parity between the therapeutics of male and female physicians. Drug prescription, in fact, represented the only discernible difference between the two hospitals that can be directly attributed to the sex of the physicians.

Physicians’ social assumptions also influenced their medical practice, and it seems to be the case that male and female physicians’ attitudes toward their role may well have been diverging. As men embraced a more “modern,” technocratic approach to their patients, women physicians continued to cling to traditional holistic orientations. Thus New England Hospital sought a different type of patient from the Boston Lying-In: the “worthy poor.” Its annual reports consistently emphasized the women’s concern with the hospital’s Christian atmosphere. That the obstetric care at the two hospitals was therapeutically similar suggests that the impact of such attitudes on patients remained indirect.

Letters, diaries, written literature, and hospital records have served to illuminate the differences between nineteenth-century male and female physicians in their approach to medical care. We see a picture certainly more penetrating than that revealed by what women physicians said and wrote about themselves. The therapeutic similarities remind us that women physicians were not only women, but physicians as well. As physicians, they operated under the dictates of their profession: they viewed themselves as full-fledged health professionals, they read the same journals as the men, and they subscribed to theories that they believed represented the collective wisdom of their group.

Nevertheless, the gender of the physician mattered in more subtle ways. Some, perhaps most, parturient women were comforted by the attendance of a professional physician of their own sex. Certainly women physicians never forgot that they were women, and it is clear that their interests within medicine as well as their affective behavior while caring for patients were influenced by that fact. Probably women physicians exhibited a different orientation toward patient care. Thus men and women doctors acted alike in most therapeutic situations, but for very different reasons and with meanings both different to themselves and to their patients. The hospital records’ offer a valuable insight into this complex and as yet dimly understood relationship between attitudes and therapeutic behavior, suggesting that the polarized perspective with which historians have hitherto approached the subject of medical treatment for women must be modified.