CHAPTER 9
Hopes Unfulfilled: Women Physicians and the Social Transformation of American Medicine
My experience ... has taught me that the day has not yet come for men to yield to us equal ground with them.
Dr. Caroline Purnell, 1918
 
 
By the end of the nineteenth century women physicians could congratulate themselves for a measure of achievement which offered ample opportunity for pride and satisfaction. “The woman physician has come,” wrote Dr. Mary Lobdell in the Woman’s Medical Journal in 1905, “and she has come to stay.” In numbers alone their ranks had increased by several thousand: in 1900 they comprised close to five percent of the profession, over seven thousand strong. Visionary women like Elizabeth Blackwell, Mary Putnam Jacobi, Ann Preston, Marie Zakrzewska, and Mary Harris Thompson could point proudly to the achievements of their own institutions. Even more heartening was the progress of medical coeducation. Several Midwestern and West Coast universities had begun accepting women students. By 1900, for example, the University of Michigan had already trained 394 women in its medical department. Crowning these achievements in 1893 was the opening of Johns Hopkins University Medical School as a coeducational institution. 1
Other developments, too, provided cause for optimism. The decline of sectarian medicine meant that 75 percent or more of women doctors were regular physicians by 1900. This move toward orthodoxy gave them more credibility as a group within a profession progressing rapidly toward standardization. During the last third of the nineteenth century, most state and local medical societies quietly admitted women without objection.2 Although the American Medical Association did not formally accept women until 1915, it indirectly recognized them when it received Dr. Sarah Hackett Stevenson as a state delegate from Illinois at the 1876 convention.
Women physicians had also made progress in securing admission to hospital clerkships, especially in New York, Philadelphia, and Chicago. Motivated sometimes by informal preference and sometimes by law, several states began to appoint them as clinicians or uperintendents at state asylums for the insane in which women were confined. In addition, a handful of women surgeons had demonstrated their proficiency in a specialty that was visibly gaining status within the profession as a whole. Finally, women doctors could proudly cite a growing list of publications in respected scientific and medical journals.3
By the 1890s they even had a journal of their own. In 1893 a group of women physicians from Toledo, Ohio, began the Worrcan’s Medical Journal, a periodical devoted to raising professional consciousness by publishing both scientific articles by and material about women physicians. The Journal viewed as its primary task the work of bringing the medical women of the country closer together. “Women physicians themselves, as a class,” declared the editor, Dr. Margaret Rockhill,
are not aware of the progress of other women physicians along lines but recently available to them as the work of women physicians because of the lack of numbers, has been so individual in character. The purpose of the Journal is to more widely spread the work of medical women, and to bring into closer relationship, the women physicians of different sections of the country. Only through the press can this result be obtained. Our columns are always open for contributions from regular women physicians. 4
In addition to the inroads they were making among the bastions of male privilege, women physicians began to heed cries from their own ranks to formalize their professional connections. In the decades between 1890 and 1920, women’s medical societies were founded in many states. Those in Boston and New York were particularly strong. In Philadelphia the alumnae association of the Woman’s Medical College of Pennsylvania took great satisfaction in its activity: in 1900 it boasted of 219 members. Because it had a policy of giving honorary memberships to distinguished female graduates of other schools, this association offered much more than mere parochial contact when it gathered for its annual two-day meeting in the late spring. Members read and criticized each other’s scientific papers, which were then published in the alumnae journal. They also shared case studies, debated such professional issues as fee splitting and specialization, and took positive steps to promote the interests of women in the profession.5 Women physicians believed organization to be an important aid to integration within the profession. In 1915 the trengthening.of their professional ties culminated with the founding of the American Medical Woman’s Association by a group of Chicago women 6
Yet despite the achievements of women doctors in the last third of the nineteenth century, more than one historian has pictured the next half-century as dark years for the progress of women in medicine, years in which nineteenth-century beachheads were surrendered and lost to the champions of male backlash and institutional discrimination. The statistics confirm such a view. Though coeducation seemed to hold out enormous promise in the 1890s, the ranks of women physicians did not continue to increase. In fact, the number of women medical students actually declined from 1,280 in 1902 to 992 in 1926 out of a total of 18,840. Female physicians lost ground both in percentages and in absolute numbers. Medicine, moreover, was the only profession in which the numbers of women declined absolutely. After peaking at 6 percent of the national total in 1910, the percentages steadily shrank, and only in 1950 did women physicians again reach 1910 levels. It was not until the 1970s that dramatic increases in the numbers of women in medical schools again occurred 7
There were several reasons for the declining numbers of medical women in the first half of the twentieth century, but the most important was the enormous alteration that came about in the structure and content of the medical-care delivery system. While professionalization in general narrowed women’s options in some fields while creating new career choices in “feminized” professions like nursing, librarianship, and social work, the overall effect of medical professionalization was to constrict women’s activity as physicians, and to confine their participation to particular specialties already implicitly agreed upon in the nineteenth century.
By 1900 the changes in American medicine that were begun in the previous two decades accelerated their pace, and in the next thirty years the modern profession emerged. This was a crucial time for women physicians, for they struggled for self-definition within a field that was rapidly restructuring itself and its social role. Two developments, one taking place within medicine itself, the other external and involving significant historical shifts within the organization of society at large, converged by 1900 to shape the contours of twentieth-century medical practice. The first was the emergence of modern, “scientific” medicine and bacteriology at the end of the nineteenth century. The second was the professionalization and bureaucratization of twentieth-century society, a phenomenon that many historians have identified as a major hallmark of modernization. The growth of modern medicine was continually interwoven with the structural changes within the profession, while both took place against the backdrop of broader shifts in the society at large. All of these changes limited women physicians’ options.
Although medical research flourished in France and Germany beginning in the 1830s, the American medical profession paid only nodding attention to these new developments because many of the earliest discoveries had limited application to actual practice. While pioneer researchers in France and later in Germany concentrated on differentiating diseases from each other, thus contributing to etiology and diagnosis, advances in therapeutics lagged behind, making “the inertia of traditional practice,” as Charles Rosenberg has observed, “powerful indeed.”8 Even when diagnosis stimulated the use and refinement of technical aids like the improved microscope, the stethoscope, the ophthalmoscope and the laryngoscope, the progress of medicine as a more exact science was slow, and older methods of treatment passed away only gradually.
Nevertheless, laboratory scientists eventually produced findings that would not only have wide applicability to treatment, but that would revolutionize concepts of disease. While cellular pathologists such as Virchow were moving toward a theory of disease localization by the 1850s, Pasteur, Koch, and other researchers concentrated their attention on the many microorganisms that had been discovered to exist in living matter. Pasteur’s work on fermentation in the 1860s and Koch’s experiments with the anthrax bacillus in the 1880s eventually led them to propose that certain bacteria were the primary causes of certain categories of illness. Soon their students and followers began isolating the specific microorganisms for several diseases, including tuberculosis, diphtheria, cholera, typhoid, and tetanus. The next step, particularly important in its implications for clinical medicine, came when two of Koch’s assistants, Emil von Behring and S. Kitasato, produced an antitoxin and used it successfully in 1891 to treat a child dying of diphtheria. In 1894 the era of specific immunotherapy was inaugurated when, after numerous experiments, researchers produced a diptheria antitoxin from horse serum which could inoculate successfully against the disease and be manufactured safely, cheaply, and in large quantities. The early discoveries of Pasteur also laid the foundation for surgical antisepsis and asepsis, and these techniques, combined with the discovery of anesthesia in 1846, prepared the way for the rise of gynecological and abdominal surgery in the 1880s.9
As Germany became the center for scientific medicine in the 1870s, some of the best-educated men and women physicians traveled abroad to study at its large clinics, excellent laboratories, and superior medical schools. It has been estimated that between 1870 and 1914, some fifteen thousand American practitioners spent time in Vienna or Berlin in some form of serious scientific study. Most men who studied abroad secured places on the medical faculties of Harvard, Yale, Johns Hopkins, and the University of Michigan when they returned to the United States.10 Women physicians interested in bacteriology, however, were rarely hired as medical faculty except at the Women’s Medical College of Pennsylvania.
With the opening of Johns Hopkins Medical School in 1892, German medical values placing emphasis on research in the basic sciences came to be implanted firmly in America. Both the medical school and the hospital so integrally connected with it were inspired by the German laboratory tradition, the “inductive” method of teaching biology, and a commitment to teaching science as a method of thinking and as an attitude of mind. The faculty at Hopkins hoped to create physicians with a generalized capacity to deal with medical problems scientifically. The great physiologist Franklin Mall, who was the most outspoken proponent of this philosophy, believed that students who had sought to assimilate information by drill must be encouraged instead to solve problems by developing their reasoning ability. A medical school, Mall believed, must carry on “perpetual warfare against drilling trades into inferior students” and ensure that the profession was filled “with learned men, and not tradesmen.”11
This new ideology of science was greeted with skepticism by some members of the American medical community, as recent historians have made clear. The conflict was not merely one between an educated elite and the average practitioner; it reflected a disagreement in values; a debate over what it was that the physician was supposed to do. The problem was particularly apparent in the first third of the nineteenth century when the Paris School’s studies in morbid anatomy contributed so little to therapeutics. One angry New York physician complained in 1836: “The French have departed too much from the method of Sydenham and Hippocrates to make themselves good practitioners. They are tearing down the temple of medicine to lay its foundations anew.... They lose more in Therapeutics than they gain by morbid anatomy. They are explaining how men die but not how to cure them.”
In the second half of the nineteenth century the debate only intensified, as many traditional practitioners, much like Elizabeth Blackwell, sensed in the new science what they felt to be a disdain for. the physician’s intuition and clinical good sense. The experimental researcher’s emphasis on exact numbers and empirical standards not only held out the promise that new ways of thinking would dramatically alter the physician’s treatment of disease, but also threatened to remove the physician from the bedside and replace- “art” with science, technology, and facts. “Out of the false pride of the laboratory, and the scorn with which the accurate man of science looks down upon medical indefiniteness,” complained the prominent neurologist S. Weir Mitchell in 1877, “has arisen the worse evil of therapeutic nihilism.” Like Mitchell, many physicians remained suspicious of laboratory science, and tensions between the ideals of the laboratory and the ideals of the bedside worked themselves out only haltingly. 12
The insistence at Hopkins on basic science, however, reflected the assumption that students learned habits of thinking in the laboratory that would prove beneficial whether they remained there, moved into the clinic, or performed in the operating theater. This approach stood in opposition to the opinions of many within the profession who preferred to see only a few elite medical schools training specialists and scientists, while the rest turned out modestly knowledgeable general practitioners who could minister to the less expensive and less elaborate needs of everyday health maintenance.
Nevertheless, the new ideology of science was powerful indeed, and William Welch, one of the great prime movers at Hopkins, rejected the accusation that the Hopkins model adapted itself only to the brilliant scholar. Welch stubbornly resisted the idea of a two-track system of medical education. “The practitioner,” he believed, “is all the better if he has acquired by example a precept, something of the scientific spirit and attitude of mind, and the clinician, who becomes an investigator and teacher, should become interested in patients and know how to diagnose and treat their diseases. ”13 It was Welch’s view of medical education that eventually prevailed.
Advances in bacteriological medicine not only affected medical education, but also catalyzed the metamorphosis of the hospital from a moralistic and caretaking institution for the urban poor to the primary locus of acute medical treatment for all classes. Urbanization and concomitant changes in family structure also had an important impact on the transformation of the hospital, while germ theory and asepsis, the professionalization of nursing, and the evolution of a whole range of diagnostic procedures, such as the x-ray, stimulated progress in surgery and other specific therapeutic regimens. As one historian has observed, germ theory narrowed the physician’s perception of his patients’ needs: now that diseases could be isolated and localized to some specific part of the body, the doctor no longer need be concerned with his patients’ social context. The hospital offered the kind of efficiency and technological sophistication that fit well with the narrow and technocratic medical practice that emerged at the end of the nine teenth century.14
Yet, changes in the locus of medical care, like the coming of scientific medicine itself, threatened the practitioner at the same time that it rationalized his or her practice and radically improved efficiency. The removal of the patient from his or her home increased the emotional distance between patient and physician, while reducing the actual time both spent together. The altered setting transformed not merely the patient’s experience but also the doctor’s. For many physicians it meant a radical redefinition of one’s professional self-image, a redefinition bound to create tension and anxiety.
Sensitive male physicians occasionally worried over the shifts in the locus and emotional ambience of medical treatment, but women physicians seem to have felt the transition more acutely. Their collective self-definition rested on their belief in their superiority over men in the “soft” and “nurturant” aspects of healing. Eliza Mosher, for example, a past president of the American Medical Women’s Association, lamented the passing of the “hu- , man” in medicine, regretted the loss of “the sympathetic relation which formerly existed between doctors and their patients,” and warned her colleagues to beware of “narrowing and concentrating their vision upon the purely physical to the exclusion of the psychic and human.”15
Other spokeswomen continued to believe that women physicians in particular must exert their influence in favor of preserving holistic approaches to treatment. The president of the Alumnae Association of the Woman’s Medical College of Pennsylvania spoke in defense of the general practitioner in 1901 even as she acknowledged that specialism was the wave of the future. Warning that the phrase “the healing art” should never be spoken of slightingly “as though it represented an old-fashioned idea,” she worried that “a training too exclusively for the laboratory fails by leaving out the human element.” “The mind that conceives of a human being as a mechanism simply and treats him as such,” continued Dr. Elizabeth Peck, “is sure to fail when confronted by the needs and problems of complex human nature.” Women, Peck believed, still gravitated to general practice because of their interest in family life, in children, and in “the best good of the community.” Though Peck admitted that perhaps even the majority of physicians would ultimately exhibit such social concern, she felt it “to be earlier developed in the medical woman than in her brother practitioner.”
Similarly, M. Esther Harding, a psychiatrist, spoke in 1930 for many women doctors when she wrote to Bertha Van Hoosen, a prominent female surgeon and the founder of the American Medical Women’s Association,
I have been struck recently more than once at the meetings of a Psychotherapeutic Society of which I am a member with a queer little difference between the attitude and approach of the men and the women ... to the subject under discussion.... Usually the men lead off with scientifically arranged data, followed by statistics and rather abstract theory. Then presently a women speaks up and nearly always her voice is raised to remind the group that after all the patient is a human being and not merely the subject of certain symptoms or mechanisms. And this I think is characteristic. We women are more nearly concerned with the human problem presented to us and relatively less absorbed with the collection and classification of scientific material. Let us who write about the intricacies of the human psyche, whether in its normal functioning or in its illnesses and conflicts, remember always that in any final analysis it is the human being that matters. Knowledge of disease and its detailed investigation are not ends in themselves, they are only means to an end, namely that the human being may grow and flourish.
In agreement with Harding, both Josephine Baker and Emily Dunning Barringer expressed concern that their profession was becoming “less human,” and decried the modern emphasis on “specialism.”16
Scientific medicine, then, challenged traditional holistic therapeutics, contributed to the modernization of the hospital, and catalyzed the reform of medical education. These developments, however, were all linked to significant changes in social organization that first became apparent at the end of the nineteenth century.
Most historians generally agree with Robert Wiebe that a major organizing theme for the years between 1877 and 1920 is the decline of “community” and the rise of “society.” In the late nineteenth century, the isolated, preurban “island” community, consisting of face-to-face primary group relationships, shared values, and relatively clear lines of authority, gave way to institutional centralization in nearly every aspect of life. Agriculture, industry, banking, and politics became increasingly nationalized and standardized. New bureaucratic means were devised for the modern implementation of old ethical values, and what emerged in the twentieth century was a society reordered by a reforming, rofessionalizing “new” middle class—an elite of technical and professional managers in business and government—a network of men and women who valued national communication through organized interest groups, and “continuity and regularity, functionality and rationalism, administration and management.”17
In response to these developments, issues of professionalization took the center stage as professional associations, state licensing agencies, and colleges and universities gradually emerged into their modern forms. Wiebe’s insights have been applied to the medical profession by a number of historians, and Wiebe himself saw the rofessionalization of medicine as the most important part of the emergence of the “new middle class” which he described. 18
For example, at the turn of the century, many physicians agreed that their economic and social position, as well as the collective status of the profession itself, warned of a crisis in medicine. The interests of various competing groups—medical societies, eastern scientific elites, midwestern general practitioners, licensing agencies, and the leading bloc of medical colleges—pointed to the necessity for consolidation and reform. Common aims included the raising of professional entrance standards, the standardization of medical-school curricula, the suppression of weak proprietary institutions, the control of various sects, and the overall reduction in the number of medical graduates. The educational goal of raising standards remained intertwined with the policy of drastically reducing the number of practitioners in a field believed to be already overcrowded.
The most immediate problem facing the reformers was the large number of inferior schools. Until the 1890s the field of medical education had been characterized by competition in an open market consisting primarily of proprietary schools that vied for students by keeping down both the cost and the quality of the education they offered. Though such a situation at first threatened only a minority of elite and college-trained physicians, whose sporadic efforts at reform had been generally unsuccessful, by the 1890s, the economic pattern of unregulated competition and growth typical of the last half of the nineteenth century proved problematic for society as a whole. Saturated markets and ruinous price wars, exhausted soil, miles of unprofitable railroad track—such conditions had led forward-looking businessmen to appeal to the government for the regulation of competition and production, and to trade associations and professional societies to promote consolidation and restore order. Here the medical profession was no different: too many practitioners‘meant fewer patients and lower incomes for the average doctor. As an editorial in the Journal of the American Medical Association observed in 1901, “The multiplication of doctor factories has gone far enough in this country. It is not a dignified comparison, that of the medical graduates to output of a machine shop, but the same principles of political economy apply in a measure to both. Over production in either has its bad effects, and we have not the recourse of foreign markets enjoyed by the ordinary manufacturer.” Thus rank and file physicians in the AMA favored reform much as railroad magnates looked to government for regulation: at long last it was decidedly in their self-interest to support such measures.19
The ideology of scientific medicine became a fitting rationale for such changes. Making medical training longer and more expensive certainly improved medical practice, but it also reduced the number of physicians in a competitive market. Fewer physicians meant predictable and more adequate incomes. As one historian suggested in his study of the rise of the discipline of biochemistry, in the unregulated market of the late nineteenth century, scientific medicine had remained the ideal of a small group of well-trained urban specialists. Indeed, its German-inspired intellectual program might well have endured as an isolated, minority style within the profession as a whole. “But in a market dominated by the new rules of regulated competition,” Robert Kohler points out, “ ‘scientific medicine’ was widely accepted as a means of improving physicians’ economic and cultural status, and of promoting social progress at the same time. Thus after two decades of indifference to scientific medicine, the profession rapidly accepted it as the basis for a reorganized medical training.” Indeed, no development illustrated more forcefully the ways in which science has held out to the medical profession entry into the realm of social and cultural power in the twentieth century. 20
Working through the combined efforts of the American Medical Association’s Council on Medical Education, organized in 1904, the publicity and the public pressure provided by the Journal of the American Medical Association, and the offices of several state licensing boards, the leaders of medical reform began the process of self-criticism. Yet, pressure from within was perhaps even less significant in the long run than pressure from without. It was in this period that large philanthropic foundations backed by Rockefeller and Carnegie wealth began to use their resources to force specific changes in medical education. From 1910 to 1930 the philanthropic foundations—which were able to provide an image of prestige and objectivity—donated over $300 million to medical education and research. Indeed, Rosemary Stevens has argued convincingly that these institutions were “the most vital outside force in effecting hanges in medical education after 1910."21
The most important event in this new alliance between scientific medicine and corporate power was the Carnegie Foundation’s publication in 1910 of Abraham Flexner’s meticulous study of contemporary medical education. The Flexner report made public what medical educators had known privately and had worked to correct for a decade: American medical schools labored under appalling inadequacies. Most schools accepted inferior students, provided meager or nonexistent training in laboratory science and clinical medicine, and overproduced doctors. Only the youthful Johns Hopkins Medical School totally escaped Flexner’s scathing criticism. According to Flexner’s study, medical schools needed to be placed under the control of universities; preliminary education requirements needed to be enforced; curricula needed to be lengthened ; and laboratory facilities needed to be improved. These changes would please both the foundations, which wanted higher standards, and the profession, which wanted less competition. Decreasing the number of doctors and consolidating medical schools reflected one important aspect of medical reform; affiliating surviving schools with hospitals and dispensaries reflected yet another. The hospital already had begun to house the complex technology that became the hallmark of modern medicine, and Flexner agreed with the leading spokesmen for scientific medicine who regarded the hospital as essential to the medical school curriculum.22
Flexner remained adamant on all his recommendations, and although his candid study did not launch the process of medical reform, which was already under way, it hastened the results. Between 1904 and 1915, some ninety-two schools merged with other institutions or closed their doors when confronted with higher state board requirements, poor clinical facilities, financial difficulties, or Flexner’s public criticism. By 1920 only 85 out of the 155 medical schools visited by Flexner remained in existence. The better schools improved their facilities through the generous help of the foundations; other were left to fend for themselves.
By 1920, then, the basic outlines of the reform in medical education had been firmly established. Schools formerly dependent on student fees shifted to reliance on university endowments and large donations from the foundations. Medical faculties that had previously controlled appointments and finances through their corporate authority relinquished these tasks and devoted more of their time to teaching. University administrators with easy access to the philanthropic foundations assumed the task of appointments and policy. The part-time physician-teacher began to be replaced by the professor-researcher, and the Hopkins ideal of a full-time medical school faculty gradually became the reality in many, though not all, institutions. These changes in turn brought others: research work and prominence in the discipline rather than clinical performance became the new “scientific” standard for faculty promotion and high status within the profession.
In addition, the place of medical education in the entire American educational system shifted ground: In the 1890s a medical degree had been roughly the equivalent of one or two years of college, by 1920 a division of labor between secondary, college, and graduate education had been effected and a medical degree from the better schools roughly equaled the achievement of a Ph.D., a university’s highest degree. Advanced courses in the biomedical sciences became a significant portion of every physician’s medical education. Gradually the triumph and institutionalization of scientific medicine took hold, first in a few elite medical schools in the East and then in institutions in the Midwest and West. Thus, for the first two decades of the twentieth century a reorganized American Medical Association using scientific medicine as a reigning ideology worked closely with the large-scale philanthropic foundations to effect the modern rofessionalization of medicine on a national scale.23
These structural changes within the medical profession affected women physicians in several ways. First there was the matter of medical education. Women physicians’ own commitment to separate schools was temporary. They continued to press for equal access to male institutions, and, as schools opened their doors to women, the dream of medical coeducation seemed within reach. Coupled with women’s increasing preference for the coeducational setting—itself in part a function of their strong commitment to high standards for women—was the seemingly inescapable cost of modern instruction. Schools wishing to maintain standards dictated by the Council on Medical Education needed the financial backing that only universities and their large endowments, state and government funds, or sizable contributions from philanthropic foundations could provide. For all of the women’s schools in existence at the turn of the century, mustering such resources proved an insurmountable barrier.
Between 1890 and 1918, women students clustered heavily in only seven states: New York, Pennsylvania, Massachusetts, Maryland, Illinois, Michigan, and California. While close to half of all regular physicians in the period between 1890 and 1918 graduated from schools located in these states, the ratio of women physicians was even higher—roughly two-thirds. In 1890, for example, 82 percent of female regulars were educated in these regions, and it was not until 1940 that their proportions from these states began more closely to approximate the figures for all students. (See TABLE 9-1.) Of further significance is the fact that prior to 1900, women were not merely clustered in these states, but were attending primarily women’s medical colleges. (See TABLE 9-2.) When we remember how women’s medical education in the nineteenth century took shape, this clustering is not remarkable. It was in these seven states that women made their greatest inroads prior to the 1890s. New York, Chicago, Philadelphia, and Baltimore all had flourishing women’s schools. Michigan and Maryland each boasted a quality coeducational institution. Boston, of course, had an early tradition of female medical education, while California instituted its medical education on a remarkably equalitarian basis.
While the absolute number of women medical students increased in the 1890s, their proportional percentages compared to men hovered between 4.8 and 5 percent for the decade. While some of the absolute increase took place in the seven states cited, the growth rate in these regions was surpassed by increases in other parts of the country, particularly in the Midwest, where coeducation was slowly catching on. The women’s colleges remained critical in this decade in educating women doctors: by 1899 they were still training nearly one-third of them. Yet the figures also reveal women’s enthusiasm for coeducation: while enrollments at the four major women’s medical colleges peaked around 1893, the number of students at these schools declined steadily for the rest of the decade. Though women’s enrollment continued to keep pace with men‘s, gains were being made primarily in coeducational institutions. Dean I. N. Danforth of the Woman’s Medical College of Chicago concluded that this was the case when he observed in 1898 that falling enrollments at the school resulted from the “fact that now nearly all Medical Schools not only admit women but make special provision for them.” Such developments, he warned, “must be taken into account in our future calculations.”24
 
TABLE 9-1 Women Regulars in Seven Key States, 1890-1918
Sources: Records of the Commission of Education for appropriate years.
004
Unfortunately, few women’s schools could enjoy the luxury of “future calculations,” because none of them were prepared to bear new financial burdens. The first to close its doors was the New York Infirmary. In 1897 the New York Infirmary’s medical college was a flourishing institution. Out of debt for the first time in its history, it boasted of a “considerable beginning of an endowment fund in our Treasury.” Of all of the women’s colleges, it might well have managed to connect itself in a few years with a university or a hospital while wielding considerable bargaining power. Then tragedy struck when the college building, with all its equipment, was destroyed by fire. Efforts were made to rebuild it, but the Board of Trustees quickly lost its dedication to the medical school when Cornell suddenly decided to admit women. It seemed a more suitable strategy now to build up the hospital—still an important postgraduate training center for women physicians—since opportunities for clinical positions were yet severely limited. Negotiations were completed with Cornell the following year, and in 1899 the remaining three classes at the New York Infirmary entered the university’s new medical school.
In her final address to the graduating class in 1899, Dean Emily Blackwell observed wistfully that the “modern medical school, with its broad and long course of study, its army of teachers of all grades, its costly laboratories for scientific training, its systematical clinical instruction and hospital classes, is an utterly different Institution from the small, comparatively inexpensive, college of thirty years ago.” Medical colleges, she continued, were beginning to “ally themselves with the universities, so as to secure the breadth of university culture, the guarantee of permanence, the prestige of a university degree.” Those small colleges “that have no connection with a university, or with a great hospital,” she explained, tended “to be absorbed or die out.”25
Women physicians in New York understood from the start that Cornell’s commitment to their education was equivocal. Although the school’s enrollment of women students, while erratic, remained high compared to many other elite schools—roughly 16 percentCornell refused from the first to appoint women physicians to its faculty. For Emily Blackwell and many others this policy was a bitter pill. Fifteen years after the New York Infirmary closed its doors, the dean of the Woman’s Medical College of Pennsylvania was still citing the situation at Cornell in her aggressive defense of the existence of a separate women’s school. “The closing of the Woman’s Medical College of the New York Infirmary ...” Clara Marshall wrote, “was the means of cutting short the teaching career of a number of able young women; yet in Cornell University Medical School, after fifteen years (with the exception of an appointment to a minor post in 1914) not a single medical woman holds a position on the teaching staff. "26
The fates of the other two leading women’s schools were variations of the same theme. The Woman’s Medical College of Baltimore, though given a respectable rating by Flexner’s report, could simply not maintain the high standards set by Hopkins on its small endowment. Its shrinking enrollments led it to close shortly before Flexner published his findings. In the Midwest, the Woman’s Medical College of Chicago, in a shrewd move, became part of Northwestern University in 1891. Its faculty believed that the school, which was rapidly upgrading its course of study, would especially benefit from access to the University’s “extensive physiological and pathological laboratories,” even as it retained its own institutional autonomy 27
On the part of Northwestern, the merger was one of several completed that year with a number of flourishing independent professional schools—including the Union College of Law, the University Dental College, the Illinois College of Pharmacy, and the Medical College of Chicago (a men’s school). By 1890 the woman’s college had erected a large new building, with two amphitheaters, each with a seating capacity of 150. It had built new laboratories and had made improvements on the old building for additional dispensary and laboratory use. “From a penniless and despised institution,” wrote historian Arthur Herbert Wilde in 1905, “the Woman’s Medical College had grown into a well-equipped institution with valuable property holdings, and its earnings provided for all incidental and running expenses and a fair dividend on the money expended.”28
In 1892 Henry Wade Rogers, president of Northwestern and a staunch friend of medical education for women, optimistically told his board that taking on the women’s school would be a likely financial proposition. “I am convinced that the interests of the University will be promoted by the action taken,” he concluded. “The Woman’s Medical College of Chicago had attained high reputation, possessed an excellent faculty, and attracted students from far and near.”29 And yet, despite the optimism of all involved, the next decade proved a fatal one for women’s medical education at Northwestern. The main problem was falling enrollments. Beginning in 1897, the number of freshmen in the entering class declined precipitously, until in 1899 their ranks had dropped from thirty-two in 1895 to a mere nine. It was first believed that the change from a three- to a four-year course was the cause, but faculty members soon realized that the real culprit was the lure of coeducation. By 1899 six medical schools in Chicago admitted women, and it became clear that for a new generation of female medical aspirants, the men’s schools had greater appeal, even when the woman’s college could boast of high standards and a prestigious faculty 30
By the end of the decade, the school desperately needed to update its laboratory facilities once again. But disappointing enrollments had created an operating deficit in 1897. Although the Woman’s Medical School was not the only one of Northwestern’s graduate schools to run a deficit, it became clear that the university would remain committed to women’s medical education only insofar as it was not a financial drain. Though there was some talk of sharing lab facilities and even merging with the men’s division, neither solution was deemed suitable by the Northwestern trustees. Finally, in a turn of bad luck, the Woman’s Medical abruptly lost a friend when President Rogers resigned in 1900. Two years later the trustees closed the women’s school, while simultaneously refusing to make the men’s division coeducational. Northwestern University Medical School remained closed to women students until 1926, when its faculty decided to set a female quota at four a year. Even at that time, however, the trustees were substantially influenced in their decision by a sizable donation for medical research from Mrs. Montgomery Ward, who had expressed shock and polite disapproval when she discovered that women were barred from the medical school. 31
Because the precarious financial position created by falling enrollments caused the closing of all but one of the women’s schools, it is difficult to speculate what their ultimate value would have been to women medical aspirants in the twentieth century. It is entirely possible that declining enrollments would have eventually tapered off to a respectable level. Though the Woman’s Medical College of Baltimore seemed to regain some of its numbers in 1908, the very year it closed its doors, it was always the smallest and poorest of the four schools, and it could not survive in so close proximity to Johns Hopkins, even when its student body increased from sixteen in 1905 to thirty in 1908. In Philadelphia, despite the fact that the Woman’s Medical College was virtually the only institution in the city to admit women until 1918, female enrollments steadily declined from 210 students in 1893 to between 90 and 120 in the 1920s. Thereafter, however, enrollments remained stable despite competition from the University of Pennsylvania, which began to accept women at the close of World War I.
The immediate impact of the closing of the women’s schools was a sharp decline in female enrollments nationwide, from 5 percent in 1899 to 3.5 percent in 1905 and 2.9 percent in 1910. It took women a little more than two decades to regain their numbers in coeducational medical colleges. Furthermore, the 5 percent figure for female medical students in 1890 represents something very different from the 5 percent figure in 1928. In 1890, women were concentrated in a few states and mainly in the women’s medical colleges. In 1928 they were more evenly distributed nationally and studying primarily .in coeducational schools. (See TABLE 9-3)
Certainly discrimination was at work here. Yet institutional discrimination was erratic, and women fared better in some places than in others. They experienced persistent difficulties in being admitted to Southern medical schools, and Midwest enrollments also remained small. But medical education for women in California, in contrast, was remarkably integrated from 1890 and on into the twentieth century. (See TABLE 9-4.) There was neither a women’s medical college nor the familiar clustering of women primarily in one or two schools. Indeed, the proportion of women students in California was roughly a consistent 10 ercentapproximately twice the national average.
It is difficult to find adequate explanations for the variations. In the fall of 1917, Dr. Joseph Erlanger, a faculty member at Washington University Medical School in St. Louis, became chairman of a committee appointed to investigate the possibility of admitting women. Erlanger’s first act was to poll by letter the opinions of the deans of sixty-eight Class A medical schools on the subject of coeducation. The responses he received—forty—five from schools that admitted women and eleven from schools that did not—pro—vide a fascinating look at the uneven and complex nature of institutional discrimination against women students.
 
TABLE 9-3 Regular Schools, Male-Female Enrollments, 1890-1928
Sources: Records of the Commissioner of Education 1892-1893, 1894-1895, 1904-1905. 1910-1911; JAMA “Educational Numbers,” 1913, 1918, 1923, 1928
005
 
TABLE 9-4 Women in California Medical Schools
Sources: Records of the Commissioner of Education 1892-1893, 1994-1895, 1904-1905, 1910-1911; JAMA “Educational numbers” 1913, 1918, 1923, 1928 32
006
Perhaps more revealing was the variety of responses from the schools that did admit women. Indiana and Yale, having accepted a few, lodged no specific complaints, but suggested that women had trouble meeting high admission standards. The correspondent from Yale editorialized that the “courses in science in the standard women’s colleges in this part of the world” had proved inferior.33 One puzzles at such a comment, considering the fact that Vassar, Bryn Mawr, and Smith had been sending large numbers of well-prepared women to Johns Hopkins for over two decades. Colorado, Howard, and Stanford accepted their women students matter-of-factly, although only Stanford’s female enrollments were significantly high. Most enthusiastic was Dr. W. S. Carter, dean of the University of Texas, who wrote that his school
has always been co-educational in all of its branches. We have not had a great number of women medical students at any one time but we usually have ten or twelve in the different classes each session. Probably the number has been somewhat greater by reason of the fact that Mr. Brackenridge, a member of the Board of Regents, has been deeply interested in getting women to take up the study of medicine and to giving every encouragement to worthy young women who are ambitious in this direction, he has provided a dormitory and a loan fund for women students in the School of Medicine.
Twenty years ago when I came here I must confess that I was somewhat prejudiced against coeducation for men and women in medical schools. However, after the experience of two decades, I am free to say that I am strongly in favor of this arrangement and believe it to be the very best that can be made. It is seldom that there is any inconvenience to the teaching staff in any way in the matter of giving practical instruction. It is only in genitourinary clinics for men that there is any difficulty and women can easily be excused from parts of that. The tremendous cost of medical education at the present time makes it highly desirable that women should have the privilege of attending medical schools in good standing in different parts of the country and should not be restricted to a limited number of schools for women exclusively. I believe also that the former arrangement, i.e. the coeducation of men and woman in medical schools is the best for the maintenance of high standards of efficiency.
From my own observations the great trouble in the past has been with women, as with men, that the preliminary education required for admission to medical schools has not been sufficient to prepare them for the study of medicine. I am confident from my own observations that most of the failures in this institution were due to that fact, both among the women and men.
I cannot see any valid objection to admitting women and men to all classes in medical schools. Objections that have been raised, and that have come to my attention, have been based upon theoretical considerations and not upon actual experience. There certainly is room for women in many branches of medicine, and I believe that all educational institutions should give them the same opportunity that is extended to men. It is gratifying to see that such institutions as Columbia University and the University of Pennsylvania, which in the past have been ultra conservative in this matter, have at last come to the admission of women to their medical schools. 34
Yet Dean Carter’s unqualified approval of women proved rare. More typical was the response of Dean Thomas McKee at the University of Buffalo, who wrote that the school had always admitted women. Confessing that he personally did not “regard coeducation in medicine with favor” and that his views were “shared by a majority of the faculty,” he nevertheless conceded the admission of women “to be part of the evolutionary development of the age” and thus kept his opinions to himself. So did the dean of the University of Pittsburgh, who felt that women should be trained at their own schools and complained that “we were compelled to open the doors of this school to women.”35
Union College, Marquette, Johns Hopkins, and Cornell all tolerated coeducation, but the deans of each school warned that female admissions should be limited, lest, in the words of M. Polk of Cornell, the school “would be overwhelmed by women applicants.” 36 The comments of J. Whitridge Williams, dean at Johns Hopkins, are particularly noteworthy. Boasting that Hopkins could “speak after twenty-five years experience in the matter,” he nevertheless cautioned that the proportion of women to men students should “not exceed one to four.” “I am convinced,” he continued, “that the training given in such schools [where female enrollments were limited] is quite as good as in those to which women are not admitted.” “On the other hand,” he concluded, “should the proportion of women greatly increase, I feel that the effect would be disastrous in that the school would gradually become feminized and men would desert it in favor of others in which there were fewer or no women.”37
Yet even those who were more enthusiastic about women revealed hidden biases. At the University of Pennsylvania, Dean Allen J. Smith wrote that the admission of women was proceeding smoothly; indeed “the influence of the women in the classes has been good.” Though some faculty “grumbled” that they could “not speak as freely to the mixed class,” the majority believed “we have done the proper thing.” “The girls are good hard students and as a class stand high,” he observed. Of course they were not as good as the best male students as a rule, “and, as you would expect, are better ‘book students’ than practical workers.” From Minnesota came a similar opinion from Dean E. P. Lyon that “women have a good effect upon men students and upon teachers.” Many of the faculty favored coeducation over separate schools for women and considered it a “manifest fact that women physicians from the women’s medical colleges were not only poorly trained by comparison but had such false notions and such sex limited points of view that they were much less effective in the profession.” He went on to conclude that he believed that “woman’s field in medicine is broadeniftg” and though they would not “for a long time” be equal to men in such fields as major surgery, “there can be no doubt as to their usefulness in the profession.”38
Finally, from Rush Medical College in Chicago came Dr. John M. Dodson’s observation that women had been “no trouble” from “the day of their admission to the present time.” Rush had been especially fortunate, the dean felt, “in the high type of women who had sought admission,” women, who “have been in every way a credit to themselves and to us.” The writer concluded his remarks with a curious paragraph which beautifully characterizes the unconscious prejudices of even women’s warmest supporters:
It will always be true, of course, that the number of women seeking to enter the medical profession will be small. A good many who do enter will be diverted into matrimony and homekeeping either before they finish or soon after graduation. That has happened to ten or twelve of our list of seventy, not counting several who were married before they entered Rush. I have noticed that no matter how superior these students may have been in their college work, nor how keen the interest of an instructor in their future development and accomplishments in medicine lies, they cannot but do otherwise than rejoice when matrimony claims them. For this reason, in my judgment, there cannot be the same interest and satisfaction in the education of women in medicine as one derives from the training of men. At the same time, as long as they are determined to enter the medical profession I feel that they ought to have the very best of opportunities. This I am sure they never could get in a school exclusively devoted to the teaching of women. Our own experience has shown that the instruction of the sexes is perfectly feasible and satisfactory.39
In discussing discrimination both institutional variation and regional differences must be factored into the equation. It is entirely possible that such differences may account for women physicians’ own contradictory perceptions of the barriers erected against them. When the Woman’s Medical College of Chicago closed, Rush Medical College and the University of Chicago showed a compensatory increase in female enrollments for several years thereafter. Consequently, female enrollments in Chicago maintained their pre-1902 levels. Such was not the case, however, in New York City, where Cornell was the only regular medical school open to women after 1899. While seventy women from the New York Infirmary entered the school in 1900, only a year later the female enrollment had dropped to twenty-one, and then to ten in 1903. Although Cornell was ostensibly committed to coeducation, it managed to reduce the number of women students in the entering classes by requiring that women take the first two years of the medical course in Ithaca, while men were free to take them either in Ithaca or in New York City. In Dean Polk’s letter to Joseph Erlanger in 1917, he admitted that the policy was deliberately intended to reduce the number of female students.40 It took almost fifteen years for women to regain a respectable showing at Cornell. And even in the 1930s and 1940s, their numbers, though greater than at other city schools admitting women, remained erratic.
The Erlanger letters merely flesh out the statistics: medical coeducation did not fulfill its promise in the first half of the twentieth century. Well through the 1950s there remained a handful of medical schools that stubbornly refused to admit women.41 More common were those which, in their reluctance to welcome women, grudgingly allowed them a few places each year in the freshman class—just enough, so the old joke went, to form a dissecting team. Even those schools with substantial female enrollments, such as Johns Hopkins, Cornell, Michigan, and Stanford, were not always able to provide congenial atmospheres for their women students. Discrimination in these schools, of course, remained subtle and often went by unnoticed. Yet the psychological strains of being a merely tolerated minority could often prove unbearable. Particularly difficult was the absence of female faculty role models who could provide support.
The closing of the women’s medical schools caused a crucial curtailment of the numbers of women in medicine. Still unaccounted for, however, is the proportionate decline of women in medical schools even before the women’s medical colleges shut their doors. Though the romance of women with coeducation contributed to the steady loss of some female students at these schools, it cannot explain why women’s applications to medical school did not increase and keep pace proportionately with men’s. Women’s perception of the existence of institutional discrimination was certainly a significant factor. Another was that women were forced to cope with coeducation and the upgrading of standards all at once. The increasing costs of a medical education certainly hurt women more than men. Outside of the seven states we have already discussed, one finds a gradual loss of women students over time—seven women at one school, twelve at another, as enrollments for both men and women at medical schools all over the country were being drastically reduced when schools merged or closed their doors. Since the total enrollment of women in these schools were already small, every loss was critical in terms of percentages. Thus, women fell victim disproportionately to the upgrading of standards, while discrimination in coeducational schoolsoccasionally subtle, at times overt, proved a bitter constant.
Though the relative role of the loss of the women’s medical colleges in these matters remains uncertain, one fact remains clear. When these schools closed, female medical educators lost autonomous control of institutions that, at least in the case of Chicago and New York, had been self-supporting and self-directed female communities. A loss of this kind cannot be minimized. Alice Weld Tallant, herself the product of a coeducational school, Johns Hopkins, and for many years professor of obstetrics and gynecology at the Woman’s Medical College of Pennsylvania, spoke in 1917 of the contrasts in her own experience. Although she had not noticed much overt discrimination while a student at Hopkins, she claimed that in retrospect the real difficulty was the poverty of female role models. “The point that has always seemed to me the strongest for a separate school,” she told her colleagues, “is that in the separate school for women, the women [sick student sees women teaching and women doing the clinical work, women operating, and so on. Until I took my internship I had never seen a woman operate, and I do not think those of you who have had your training in this school can realize what it means never to have seen a woman doing that which to you seems second nature, from your student days. It must be a very great incentive to the student to see what women can do; it is almost inevitable, if you never have seen a woman doing anything, to think she cannot do it quite as well as a man, no matter how strongly you feel in favor of women.” Similarly, the surgeon Dr. Clara Raven reminisced in a memorial to Dr. Bertha Van Hoosen on the importance of female role models to her own growth, especially because “my medical and premedical environment was dominated by the men. ,,42
And what of the sole surviving woman’s college, the Woman’s Medical College of Pennsylvania? No discussion of women’s medical education after 1900 can ignore its fate. While other women’s medical colleges quickly surrendered to rising costs and shrinking enrollments by closing their doors, the Woman’s Medical College of Pennsylvania limped along, a dissenter in the ranks. Dr. Caroline Purnell caught the emotional ambience of this effort when she reported as the alumnae’s representative on the Board of Corporators to the 43rd annual meeting of the school’s alumnae association in 1918. “Some years back,” she began,
there was quite an unsettled feeling in the minds of many of our graduates whether a small medical college should continue to exist. They were very much unsettled by the reports which were put out by the Carnegie Foundation regarding such radical changes and such high standards with such tremendous expense for every institution of medical learning. Many felt so overwhelmed by that report that they felt it not worth while to try to keep on our feet. At first I was so impressed. At that time I was a teacher in this institution. But finally I think I landed on my feet, and I think I landed on the right side.... I made up my mind, also, that there was need for the Woman’s Medical College of Pennsylvania; just as much need as for Bryn Mawr, Smith or Vassar. I think women of these United States have a right to say how they shall be educated, whether in women’s colleges or in coeducational institutions.... My experience upon committee has taught me that the day has not yet come for men to yield to us equal ground with them.... I think they need us, but they do not see it and therefore do not act. Therefore, I say that women should hold on to their institutions, medical colleges and hospitals. Women are capable of running these institutions. We have demonstrated that, and all we want is work.
Women had become “faint-hearted,” Dr. Purnell complained, plagued too often by “words of discouragement ... or criticism, or of doubt as to the need of our existence.” She concluded with a plea to her fellow alumnae to cast aside their fears, realize that the college is now “needed more than ever” by women, and plunge themselves into new fundraising efforts.
Such appeals were standard fare at the alumnae meetings of the Woman’s Medical. Despite chronic financial difficulties, and perhaps because of the peculiar slackness on the part of Philadelphia’s medical schools to admit women, faculty members and graduates remained decidedly skeptical of the benefits of medical coeducation. For them the struggle was simple: to remain financially afloat and maintain respectable educational standards. Lilian - Welsh, former president of the Alumnae Association, put it simply in 1912: “That this college stands for an idea,” she observed, “will not preserve it; these must be associated with abundant financial resources ”43
Woman’s Medical faced its first financial crisis, a crisis involving its constant efforts to provide proper and abundant clinical material as part of an upgraded teaching curriculum in 1903. No element was more vital to the school’s success, and no one understood the problem better than Dean Clara Marshall. Since 1861 the college had been closely connected with the Woman’s Hospital, founded by Dean Ann Preston precisely to serve the purposes of clinical education. For about two decades the hospital and college had been practically one institution, but after the new college building was erected in 1875, they gradually moved apart. Aiding in their disengagement was the fact that each institution had its own separate board of trustees. Although the college administration assumed that its own professors would be appointed to the clinical staff at the Woman’s Hospital, the college faculty had little direct control over hospital policy. Such a situation boded ill for the future.44
Besides its independent management, a second problem posed by the Woman’s Hospital was that it did not admit male patients. Thus, students received excellent training in obstetrics, gynecology, and pediatrics; but their knowledge of internal medicine came only from treating women and children. In 1904 the AMA’s Council on Medical Education instituted its rating system which required all accredited Class A medical colleges to be associated with a general hospital used for teaching purposes. In 1892 the college had established a small general hospital and dispensary.-the Amy S. Barton Dispensary—in Philadelphia’s downtown slums, which had provided additional teaching facilities to staff and students. But a decade later the Barton Dispensary was inadequate to meet new standards. Then, in 1903, the Board of Lady Managers of the Woman’s Hospital suddenly decided to limit the use of its wards as a teaching facility. In an abrupt move, it refused to appoint to the hospital staff the college faculty’s choice—Dr. Edith Cadwallader—as the replacement for Dr. Anna Broomall in the chair of obstetrics, To add insult to injury, not long afterward Dr. Ella B. Everitt, another faculty member, was denied the accustomed privilege of placing her postoperative patients on the hospital’s wards.
Correspondence and negotiations dragged on over the next year. But the lady managers were totally unsympathetic to the clinical needs of the college and fiercely jealous of their independence as an institution. In the end, a relationship of half a century could not be salvaged, and in 1904 ties between the college and the hospital were severed45
Almost immediately the college established a temporary hospital of its own by converting a small private house near the school. Next, Dean Marshall launched a campaign to raise funds for a modern structure which could provide the needed clinical material necessary to retain the school’s Class A rating. In 1907 the corner-stone of the new building was laid, and six years later—through the tireless fund-raising efforts of alumnae and dedicated supporters—the hospital was completed.
During the crisis over the new hospital two members of the college faculty, Frederick P. Henry and Ella B. Everitt, were asked to explore the possibility of affiliation with another medical school in Philadelphia. Financial problems pressed so acutely that the Board of Corporators felt “the time appears opportune ... for a comprehenseive statement of the facts bearing on this question.”46 This report was the first written statement by leaders of the college which formally investigated the benefits and liabilities of medical coeducation for all women. The results reaffirmed the importance of a woman’s school.
Arguing that there was a “reactive tendency against coeducation in certain universities and colleges where formerly both sexes were admitted,” the report gave as an example the closing of the Woman’s Medical College of Chicago. The committee explained that the motives that had hitherto induced private men’s colleges to admit women had been “largely pecuniary.” It was possible, they went on, “that a medical school might be found in this city to admit women students for a sufficient monetary consideration, but that they would be admitted out of regard for the medical education of women, is highly improbable.” The college did not have such funds in any event, Henry and Everitt pointed out, and, furthermore, it was doubtful whether such a course would improve women’s medical education in any substantial way.
And then came the suggestion that Woman’s Medical had more to offer women students than other schools. First, it afforded opportunities for personal and individual instruction—the luxury of smallness. Moreover, its course in obstetrics and diseases of women was “superior” to that of other schools, and “both are branches of prime importance to women physicians.” Noting that men enjoyed the choice between separate or coeducational medical schools, the committee wondered why women should not have the same flexibility? Finally, members asked, “What teaching positions are there for women in coeducational schools?” After surveying six medical schools—Tufts, the University of Michigan, Cornell, Johns Hopkins, Rush Medical College, and the University of Texas—the committee found that among 912 teachers, only 27 were female, and these all filled “subordinate positions.” “In view of the high valuation placed by men upon teaching opportunities, and the eagerness with which they are sought,” the report concluded, “this showing is very significant.” Raise an endowment to build a new hospital, not buy women’s way into a men’s school, urged the committee, and preserve the separate character of the Woman’s Medical College. 47
Though less elaborate than some others which would be produced in the future in various forms, this report stated a position that remained identified with the Woman’s Medical College of Pennsylvania for the next sixty years. Each time the school faced a financial crisis, similar arguments were mustered in support of preserving a separate college for women. For a core of stubborn women and their supporters, such reasoning remained convincing.
Of course large and small crises continued to plague the school. In 1904 the college applied for state aid for the first time, petitioning the legislature for $100,000 to help defray the costs of the new hospital. After a considerable delay, the Board of Public Charities awarded only $12,500 a year for two consecutive years. Although in the future the school’s state funding was increased slightly, it was never adequate.48
Another chronic problem was the need to upgrade the laboratories. Despite contrary trends in medical education, the college often toyed with the idea of becoming a first-rate teaching facility, while letting research lag behind. Soon after Sarah J. Morris joined the faculty in 1931 to do tuberculosis research, Dean Tracy asked her whether she thought there was a place for a “good teaching medical school, without adding the burden and expense of research.” Morris replied, of course, that the future of medicine was research and that Woman’s Medical dare not neglect it.49 The college did its best, but again relative poverty frustrated many plans for improvement.
Despite Abraham Flexner’s conclusion that the school’s laboratories were “simple, but intelligently equipped and conscientiously used,” and that there was “striking evidence of a genuine effort to do the best possible with limited resources,” improving the laboratories became a subject of alumnae concern for several years running.50 In 1911 Professor of Anatomy, Histology and Embryology Herbert H. Cushing put forward a four-part program to upgrade basic science teaching at the school, a program which included supporting full-time salaried instructors and graduate students engaged in full-time research. He explained that he had recently traveled to New York to see if he could induce Flexner to help him get Carnegie Foundation support for the project. Though “Mr. Flexner was courtesy itself,” Cushing reported, “he was also adamant.... He refused to do anything.... He said he could not in conscience ... because he did not believe in the separate medical education of women. He believed in coeducational medical colleges.”51
To compound the school’s difficulties, in 1912 and 1913 epresentatives from the Council on Medical Education made several site visits to reconfirm its class “A” rating. On 14 February 1913, Dr. N. P. Colwell, Secretary of the Council, wrote a long letter to the dean “showing the lines along which improvements could be made to the greatest advantage.” Speaking to the alumnae, Dean Marshall summed up Colwell’s suggestions with the observation, “The reply demonstrated what we already knew, that in order to keep in Class A, to say nothing of reaching Class A+, we need money and need it now.”52
More specifically, entrance requirements needed to be raised from the minimum of a high school diploma to two years of college, more full-time salaried professors needed to be added to the faculty, more clinical material needed to be secured, laboratory equipment needed updating, and, finally, “medical research has not been developed as largely as obtains in the majority of Class A colleges.” On this point Colwell editorialized that “one of the chief functions of the modern medical school is to add its quota to the world’s knowledge of medicine and by fulfilling this function it is also in better position to carry out the other two functions, namely, that of training medical students and of giving the best treatment to such patients as may come under its care.”53
In response, and as usual, the alumnae rallied around the dean. A campaign committee which was launched in 1911 increased its activity until it eventually collected $200,000 for the endowment fund. Most of the money came from female givers, who tended to give in much smaller amounts than their male counterparts. Indeed, the perpetual poverty of Woman’s Medical eloquently demonstrates the increasing inadequacy of female philanthropy to meet twentieth century needs. Clara Hammond-McGuigan reminded her fellow alumnae of just this fact in 1913 when she observed, “I think we will all have to bear in mind that the graduates of Princeton are in very different circumstances from our graduates. A great many of them are businessmen, making not thousands of dollars, but millions. You must therefore not expect as much from our graduates.”54
When Clara Marshall retired in 1917, Martha Tracy, a brilliant young physiological chemist who had worked with Mendel at Yale and had been since 1913 professor of physiological chemistry at the College, took her place. Tracy was a “modern” physician, welltrained in basic science and generally committed to expanding the school’s role in both clinical and pure research. But she, too, was fated to steer the school through several monetary crises, including one in 1935 which threatened to remove the college from the “acceptable” list prepared by the Council on Medical Education. 55
And yet, whatever its failings, the Woman’s Medical College of Pennsylvania did give Class A medical training to several generations of women physicians. Between 1920 and 1968, when it admitted men for the first time, the school graduated between 20 and 50 women a year—between one-third and one-fifth of all women graduates. It developed distinguished programs in preventive medicine, gynecology, and obstetrics. Most important, it offered women the opportunity to study in an atmosphere that was receptive to their needs, an atmosphere in which their role models could be other women, an atmosphere in which women, and not men, were the majority. Certainly for many women physicians, the college’s separatism remained suspect. But the institution’s history has yet to be thoroughly explored, while the benefits of separatism as a strategy of women professionals in the early twentieth century still needs careful evaluation.56
 
The difficulties of the Woman’s Medical College and the closing of the other women’s schools combined to have a negative effect on female enrollments in medical school after 1900. But it is also likely that middle-class women, for a variety of reasons, found it less desirable to study medicine. The impact of these shifting career choices also must be assessed.
For example, the late nineteenth-century scientific revolution in therapeutics disarmed the arguments that earlier women physicians had used in support of female medical education. Whereas the nineteenth-century physician approached a patient with a predisposition to physiological holism, twentieth-century therapeutics transformed the doctor into a specialist whose knowledge encompassed some specific symptom or some discrete portion of the patient’s body. Treatment understandably became fragmented; total patient “care” was increasingly dissociated from the specialist’s concerns as he busied himself with patient “cure.”57
Institutional developments in the early twentieth century reflected the gradual fragmentation in health care delivery. Public health nurses replaced the women interns who had defiantly entered the slums to teach the poor how to be well. In their effort to professionalize and claim nursing for women, self-conscious leaders in the field played an important part in shifting the so-called feminine and nurturing aspects of medical care from the doctor to the nurse. In 1913, while struggling to define an independent role for the tuberculosis nurse, Elizabeth Gregg, superintendent of nurses for the New York City Health Department, wrote:
Physicians have not the time, neither is it born in many [doctors] to devote themselves to the detail that requires the patient, painstaking effort of a woman; and this detail tends to reveal the very causes or the contributing factors of tuberculosis more than in any other disease ; so that the nurse, with her knowledge of home conditions and the family’s principles of living, and with her instinctive woman’s insight into the causes of trouble, is the physician’s right hand.58
As long as medical practice remained more a matter of “art” than “science,” women found themselves drawn to the work and armed with compelling reasons for claiming it as their own. In contrast, the organization and practice of medicine after 1900 moved from the intimacy of the home to the public arena and impersonal setting of the hospital. While it is certainly true that it became increasingly more difficult for a woman to be admitted to a first-rate school, it also seems possible to speculate that fewer woman were trying to do so.
What, then, were women doing who might otherwise have been applying to medical schools? Many chose nursing in these years. Between 1880 and 1900 the number of nurses increased from 15,601 to 120,000.59 Another category of health workers, “physicians and surgeons attendants,” showed an 86 percent increase in the census from 1910 to 1920. But because nursing generally attracted women from a different class background than that of women physicians, the declining number of women doctors after 1910 cannot be explained by the expansion of nursing alone. Statistics from these years indicate rather that social work and graduate school diverted some women’s interests from medicine.
The years between 1890 and 1918 reveal sharp increases in the number of women doing graduate work. The percentage of female graduate students rose from 10.2 of all graduate students in 1890 to 41.0 in 1918. In terms of absolute numbers, this change represented a twentyfold increase, while the number of men attending graduate school increased only fivefold. After 1910, the census data suggest that many of these women were using their degrees in the new helping professions. In that year women made up about 56 percent of the welfare workers; ten years later their absolute numbers had increased almost 200 percent. In 1910 women comprised 30 percent of the “keepers of charitable institutions”; by 1920 that percentage had increased to 38 percent. Again, the increase in actual numbers is impressive, from 2,250 in 1910 to 4,900 in 1920. Unfortunately, the census information cannot indicate what percentage of the total body of educated women were choosing welfare work and its allied fields. Nevertheless, one can hypothesize that there is a distinct connection between the rising numbers of women with advanced degrees and the sharp increase in the number of women professionals in these “feminized” occupations,. 60
The census data also suggest that other cultural factors were at work. The twentieth century has witnessed unmistakable shifts in the primacy of some essential nineteenth-century values. Most notable among those changes have been the altered expectations surrounding the home, women, and family life. A prominent feature of Victorian culture was the exaltation of motherhood through the cult of domesticity. The high status afforded motherhood followed logically from the conviction that mothers were the primary agents for the transmission of culture. Yet, despite feminists’ glorification of motherhood, they had expressed a particular personal disdain for the patriarchal Victorian family. In the nineteenth century, growing numbers of educated and professional women rejected marriage in favor of the pursuit of meaningful work. Opponents of higher education for women were fond of pointing out that college women married less frequently and had fewer children than did more ordinary women, and, indeed, statistics for the years between 1880 and 1920 support these claims.61
In the twentieth century, however, the image of woman-as-mother gradually gave way to the image of woman-as-mate. The social and economic changes in the decades before World War I created more positive attitudes toward pleasure, individual self-fulfillment, sexuality, and women’s work. 62 Possibly because of this altered climate, college-educated women and professional women did not continue to reject marriage with the vehemence that they had earlier. The proportion of professional women who married, for example, doubled from 12.2 percent in 1910 to 24.7 percent in 1930.63 Joyce Antler has convincingly argued that the early twentieth century produced a new kind of feminism, previously found only among a small minority of ninteenth-century women activists. These women chose not to shun marriage but to strive instead to “work out the large issues of feminism on an individual basis.” Only if we acknowledge the existence of this brand of feminism, which Antler labels “feminism-as-life-process,” can we “rescue from the lost generation of feminist endeavor after 1920 some of the women whose lives might properly be called ‘feminist.’ ”64
For these women the central issue was the need to balance professional, political, or other activities with marriage and family. In their own lives, they struggled to “work out that balance of interests between the private and public [in this case, between marriage and career] that would allow them to achieve the self-determination and autonomy that they posited as their highest goal.” Although more women physicians were married than other women professionals, this fact is not incompatible with the observation that it became increasingly more difficult for women who were doctors to manage both a career and family life in the high-powered world of twentieth-century medical practice. Women physicians in the twentieth century who did choose to do so were a small, exceptional, and highly motivated group, and it is quite likely that they were a different kind of woman from both their nineteenth-century counterparts and their twentieth-century sisters who chose less demanding careers. One interesting statistical confirmation of this fact is that nationally women were slightly underrepresented in Class B and C institutions, suggesting that women physicians were perhaps brighter and more motivated than many of their male colleagues. In the state of Illinois in 1913, for example, at a time when Northwestern, an A+ institution, was not even accepting women, over 51 percent of the women students were in A or A + schools, compared with only 48 percent of the men.65 (See table 9-5)
That these highly motivated women would continue to commit themselves to marriage was clear. The reminiscences of Bessie L. Moses about her days at Johns Hopkins and an encounter with Florence Sabin make this point particularly eloquently. Moses, who entered Hopkins in 1918, remembered Sabin as a “superb teacher and lecturer.” But for a role model, the young medical student decided to look elsewhere, explaining:
 
TABLE 9-5 Men and Women in Illinois Medical Schools, 1913
Source: JAMA “Educational Number” 1913.
007
My most personal association with Dr. Sabin occurred on the street car when we frequently rode over to the Medical School together. She got on the car after I did, and it was about at twenty minute ride from there to the Medical School. What she repeatedly tried to impress upon me was this idea—that no matter what happened in a woman’s personal life, she should never let it interfere with her medical career. I was a young medical student at the time, and I listened attentively to her advice. She had apparently sacrificed all of her personal social relationships for her work, and for her it had apparently been a completely satisfying life. My ideas were different. I felt, and still feel, that a woman in any profession should, of course, try to do her best and achieve her ambitions, but to me the woman comes first and the profession second.
Dr. Sabin was a great feminist and had experienced the difficult struggle which was common for all women in the medical field at that time. This, of course, colored her attitude. She cared nothing for dress or personal appearance. She seemed remote in her relationships and always appeared a little impatient, as though she were wasting time unless she was working. Dr. Sabin’s eminence in the field of science and medicine certainly proved that her philosophy of life for herself paid off.“66
Bessie Moses rejected Sabin’s exclusive commitment to her work, but she did not reject medicine. She married and practiced her profession with equal dedication to both. Indeed, she and many like her worked to ensure that marriage would not stand in the way of their careers. That effort alone, only partially successful, guaranteed that women physicians’ numbers would remain small. For in the final analysis, they would fall victim to the social dictates of a culture still characterized by extreme sex stereotyping. The vigorous, detached, almost godlike figure of the twentieth-century physician—a product of the triumph of scientific medicine—kept all but the most determined of them from challenging cultural barriers. In the first decades of the twentieth century, women doctors would continue to develop strategies to cope with these changes and would strive to ensure for themselves a place in the professional world of modern medicine. Such strategies often bore bitter fruit.