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SHALL WOMEN PRACTICE MEDICINE? by Mary Putnam Jacobi
The North American Review 134 (1882) 52-75.
THE continually renewed discussion, on the part of society, concerning the sphere, capacities, rights, functions, duties, and allowable occupations of women may well seem, from some points of view, rather ridiculous. We may justly ask why women require so much more discussion and preachment than men; and may even decide that the argument is largely superfluous, and the sermon often impertinent.
Further consideration, however, discloses several grounds of justification for this social habit, from which, in any case, it is quite impossible to escape. In the first place, women, as the most malleable part of the social organism, are destined to receive the first, and also the most lasting, impress of prevailing social opinions. They transmit -- the phrase is becoming classical -- the organized experience of the race. The least change in such experience affects them especially, and hence they must bear the special brunt of the criticism upon it.
In regard to the particular subject we propose briefly to consider, social opinion is of very real importance. Success in a professional career necessarily depends, to a large extent, on the taste of the community. There must be a readiness to consult women physicians; a willingness to educate them; a sufficiently wide-spread desire on their part to be so educated. If the social prejudice be very strong, no young woman will dare express the wish to study medicine. Should the vagrant fancy arise, it will be promptly checked, as something eminently improper, -- like going on the stage, or dancing on the tight-rope at a circus. That considerable numbers of women do now study medicine and support themselves by its practice, is itself a proof that the prejudice of thirty years ago has somewhat abated. Women are admitted, in America, to the State universities of Michigan and of California, and sustain, moreover, three separate schools: one in Philadelphia, one in New York, one -- the youngest -- in Chicago. In Europe, they study at the universities of Paris, Zurich, Berne, Upsala, Leyden; have a separate school at St. Petersburg, and are admitted to examinations for degrees at the University of London, and also at Dublin. They are members of various medical societies, contribute to various medical journals, conduct hospitals, perform surgical operations, build up practice, and in other ways seem to conduct themselves and to be treated like other members of the medical profession.
Yet discussion still continues, and although the once continuous opposition has become intermittent, its crises are perhaps rendered more noticeable on that very account. The centennial meeting of the Massachusetts Medical Society was agitated by a renewal of the controversy concerning the admission of women physicians. Their cause found vigorous champions, but was defeated, when an equally vigorous opposition supported the majesty of precedent, by the tactics of parliamentary maneuvering. The siege at the gates of Harvard, destined to be as memorable, we believe, as that formerly laid against Thebes, is still maintained. The echoes of the fierce battle waged in the University of London have scarcely died away; a few years ago, the Society of German Naturalists, meeting at Berlin, voted to "purge itself of the presence of women"; and only last summer, public attention was called to the formal exclusion of women from the International Medical Congress, at its first meeting held in England. The measure, it is said, was taken in obedience to the wishes of the Queen, and certainly to those of the court physician, Sir William Jenner.
All innovations excite opposition. But it is difficult to account for the peculiar bitterness of the opposition which has been manifested to the admission of women to medicine, when it is remembered that this admission is no innovation at all. Women practiced freely in medicine so long as the practice of medicine was free, and entrance upon it was decided merely by natural taste for dealing with the sick and ministering to their infirmities. When, however, instruction in medicine began to be systematized, when universities took charge of it, and legal standards of qualification were established, women were excluded, because, at the time, no one thought of them as either able or willing to submit to the new conditions imposed. The monastic discipline out of which universities had emerged still molded their etiquette sufficiently to render them inaccessible to women. The women themselves do not appear to have thought of presenting themselves as candidates for a university education. Thus, in the onward current of progress, the women physicians of the Middle Ages, or, in France at least, of all the centuries preceding the Revolution, were dropped on the bank. Women are now merely endeavoring to reënter the stream, by adapting themselves, whenever they are allowed to do so, to the changed conditions of things.
In this effort, the most serious obstacles to be encountered are not always the most real ones. In this, as in everything that women do, the question of capacity is often outranked by the question of taste. Whether woman, with all her organic imperfections on her head, can be theoretically supposed capable of the study and practice of medicine; whether, which is quite a different question, there actually exist any number of women whose capacity in this direction has been fairly tested and demonstrated, -- these are interesting subjects of inquiry. But the most completely affirmative answer to such inquiry might still leave unsettled a question of much more importance for that large class of people whose convictions and actions are under the permanent domination of their tastes. These ask not, "Is she capable?" but, "Is this fearfully capable person nice?" Will she upset our ideal of womanhood, and maidenhood, and the social relations of the sexes? Can a woman physician be lovable; can she marry; can she have children; will she take care of them? If she cannot, what is she? "Qu'est ce qu'une femme," said a French journalist in this connection, "qui n'est ni épouse ni mère?" "God," declared a Boston physician, well versed in the counsels of Providence, "never intended women to practice medicine." Hence the inference that piety, if nothing else, demanded the exclusion of women from the Massachusetts Medical Society.
It is from the peculiarity of the conditions involved, that the handful of women now engaged in the practice of medicine may be considered in any way to affect or endanger existing arrangements or social ideals. Thousands of women, from manifold causes quite extraneous to medicine, remain celibates all their lives; yet no one reproaches them for refusing the duties of wife and mother. Thousands of women earn their living by non-domestic labor; one profession, that of public teaching, practically thrown open to women only during the last half-century, is already thronged by them. Yet no one feels that the foundations of society are therefore liable to be overthrown. What is it in the profession of medicine which excites, at present, such different feeling and such bitter prejudice?
There are several things. In the first place, the profession of medicine has always been subjected to popular misconceptions, and the odium due to these is necessarily shared by the women who aspire to be physicians. Again, by a social fiction, it is assumed that the usual employments now sought by women are to be filled by them only while waiting for marriage, or as a resource in widowhood or desertion. Even such professional work as teaching is expected to be laid aside after a few years, and there is much, at least in the primary grades of teaching, to make such interruption rather desirable. But the profession of medicine must be chosen deliberately, and not at hap-hazard; from a strong and genuine taste, and not from the mere pressure of economic necessity; it must be seriously prepared for in youth; must be entered upon at the age at which at present many women marry; does not yield its best returns until full maturity has been reached; must be adopted, therefore, if at all, for a life-time. Hence is required either an accidental celibacy or a deliberate renunciation of marriage for the sake of medicine, such as is not dreamed of in regard to any other work; or else such an adjustment of domestic claims as shall render them and the practice of medicine by married women mutually compatible.
But further, apart from the special odium attaching to medical knowledge, the assumption of capacity on the part of women for any knowledge which leads to first-class responsibilities offends the average social ideal. Again: The idea of mental training as a means of developing force is rather new to the world in any aspect. It is practically almost unthought of in regard to women, who are habitually estimated by the measure of their native, untrained capacities. This is seen to be inadequate for the responsibilities of medical practice.
To consider a little in detail the foregoing topics. The assertion that medicine and physicians are permanently and profoundly misunderstood by the public may not at once be accepted. Yet, it is certain that, despite the familiarity of his presence and appearance, the laity know less about the doctor than about any one else with whom they have to do. They cannot understand why he wants to dissect, or to "vivisect," or to make post-mortem examinations; why he stickles for a punctilious etiquette; why he is fascinated by repulsive objects; why he can find fathomless mysteries in the commonplace miseries which they have to endure; and how, by any process of reasoning, the recondite connection between these mysteries can be detected and made clear. The handling of familiar things in an unfamiliar way is a process inevitably bewildering to the uninitiated spectator. There is something uncanny about it. Moreover, the human body has ever been esteemed sacred. From the Egyptian embalmer down, those who have dared to intrude upon its mysteries have been branded as profane. When, from the pressure of evident necessity, the profanity has been tolerated, the toleration has only half-repressed a shuddering horror at the sacrilege. The violent popular excitement recently aroused in fox-hunting England against physiological experiments -- with such effect that they have been practically forbidden by legislation -- recalls the still more violent agitations in the last century against "body snatching," and the legislative repressions of anatomical studies. Mr. Tennyson, in one of his latest poems, draws a caricature of the most humane of professions in the person of a "red-bearded" student from "the hellish schools of France." In 1794, Mrs. Shelley, in her romance of "Frankenstein," stigmatized the sublime search after the origins of life as "dabbling in the filthy secrets of the grave." The same sentiment really animates the modern poet-laureate and the wife of the elder poet; although in recent times exquisite experiments have somewhat redeemed the theme of the spontaneous generation of life from the realm of "filthiness," and the "anti-vivisection" prejudice drapes itself in the pretext of philanthropy. But at bottom the feeling is identical. Life is a mystery; the attempt to penetrate mysteries is a sacrilege; and terror of the awful, unknown consequences of sacrilege is quite sufficient to overpower the reasonable apprehension about intrusting the care of sick bodies to persons who have been forbidden to learn anything about them.
Now, the introduction of women into a sphere regarded as at once dirty, horrid, and irreverent certainly shocks many of the "finest sensibilities of our nature." The feminine university founded by Tennyson's lovely Princess had, among all its schools, "not one anatomic." She could not bear
"-- to ape
The monstrous male, who carves the living hound";
and only in the spirit of the sublimest self-sacrifice could she, fearing casualty, be induced,
" -- through many a weary month,
To learn the craft of healing."
The poet does not seem to doubt her capacity for mastering this wearisome business, but evidently feels that the Princess would have been alienated from poetic sympathies had she found the task other than repulsive -- had she delighted and gloried in it, as a real physician must do. In this estimate, he strikes the keynote of average popular sentiment.
That the study of the mechanism of the human body is not mere dirty work, but one of the most sublime occupations; that mysteries are not sacred, but embarrassing masses of ignorance destined to be dispelled; that the sensuous disgust attendant on anatomical and physiological research can be, and is, completely consumed in the divine flame of an idea; that human life is more precious and more deserving of reverence than any of the accidents, physical or social, by which it is environed -- these convictions have been steadily pressed against the inert minds of the unreasoning multitude, until they have at last secured for themselves toleration, if not acceptance. The odium attaching to the study of medicine by women must be overcome by similar means. The charge of "unsexing themselves" by the acquisition of the particular kind of knowledge required in medicine is, after all, less formidable than that of "dehumanizing themselves," which, in one form or another, has so often been brought against men for the same thing. With those whose beliefs are not a matter of reason but of habit, the mere repetition of a fact until it become habitual is sufficient to insure acquiescence. This circumstance goes far to compensate the inconvenience of the prejudice engendered by the mere fact of unfamiliarity.
Touching closely upon the universal prejudice which is primitively rooted in the terror of sacrilege, comes another, which, at the present day, is held almost exclusively in regard to women. It is often said that the work of practicing medicine is necessarily so coarse and disagreeable, that none but coarse and disagreeable people are naturally fitted for it; or, if others engage in it, they must inevitably deteriorate to an inferior personal and social level.
Now, the people who advance these statements have often themselves been sick -- have had, therefore, frequent personal intercourse with physicians. It is, therefore, pertinent to inquire whether these delicate ones have always found their own physicians to have been rough-shod brutes, or whether they consider that the task of ministering to their infirmities in any way necessitates coarseness and harshness? The tacit answer to this inquiry is, we believe, that refined people would never do anything so eccentric as to consult a woman physician. She must perforce "go about among all sorts of people," pick up her practice where she can, and the process of "going about" is often alluded to as if it implied carrying a revolver, or seeking the escort of a policeman.
Of all the social bewilderments with which this question is befogged, this is, perhaps, at once the most ridiculous and the most exasperating. It is impossible to imagine a sphere in human life, with the exception, perhaps, of the artistic, in which delicacy -- mental, moral, and even physical -- is more essential than in that of the physician. The preservation of decorum, the maintenance of suitable reserves, the just balance of rights, the quick perception of feelings, all these are the natural correlatives of the deft physical touch, of the intellectual subtlety, which should, and which does, characterize a true physician. What is there in all this incompatible with the classical, not to say conventional, ideal of feminine character?
There is another consideration more excusably overlooked. It is impossible to be a physician on the basis of personal sympathies alone. If the interest in the disease be not habitually greater than the interest in the patient, the patient will not profit, but suffer. He may gain a nurse, but he loses a physician. Now disease, even more than death, tends to level distinctions. It diminishes the social value of those who have any; but, on the other hand, it invests with an otherwise unattainable interest those who are quite lacking in social charm -- the stupid, the vulgar, and even the vicious. The physician is, indeed, the only person who can "go about among all sorts of people," unbored and uncontaminated. When the priest does the same thing, it is because, as far as may be possible, he imitates the bearing of the physician.
The only possible excuse for this wide-spread assumption, that women physicians must be inferior to men in personal refinement and social culture, may be found in the conditions under which women have hitherto been obliged to study medicine. The obloquy heaped upon women students of medicine has been so great that many women of refinement have been repelled from a pursuit to which their natural taste inclined them. Conversely, many women have entered upon it without taste or understanding, but merely attracted by the flavor of notoriety and the enjoyment of something slightly turbulent and very eccentric. Not these ignorant women, but society, are to blame for the opportunity accorded to put forth their absurd pretensions. A Nemesis waits upon the rejection of just demands. The refusal to admit to a disciplined education and to submit to suitable tests the women who were really fitted for both, has merely resulted in the rather extensive education of the unfit; and this has often been carried on in the very least suitable manner which human ingenuity could devise for the purpose.
Considerations of delicacy have been urged, as is well known, in a special manner, both for and against the admission of women to medicine. On the one hand, the association of
women with male students in professional schools and medical societies, has been denounced as an indelicacy which rather more than borders upon immorality. On the other hand, the treatment of female patients by male physicians -- especially in a certain class of diseases -- is shown to involve a straining of delicacy which cannot but be most undesirable, even when it is submitted to as inevitable. In the most populous quarter of the globe, in all the countries of Asia, it is known that such submission is not considered inevitable -- is, indeed, not allowed. The alternative is invariably accepted of leaving the female half of the community entirely unprovided with medical attendance for any disease whatever. (1)
No hard names which have ever been heaped upon the women who want to study medicine can exceed those once lavished on the presumptuous men who first forced their way into midwifery. As late as the seventeenth century, even at the time that Chamberlain was inventing the forceps, the term "man midwife" was as much a term of reproach as that of "female physician" often is at the present day. The feeling of delicacy, permissible, even imperative in itself, was compelled to yield to the still more imperative claims of superior knowledge and capacity. If this has ever been accomplished, it is not doubtful that a legitimate feeling of delicacy -- as that which makes many (not all) women dislike to be treated for at least uterine diseases by a man -- should, if once thoroughly reënforced by legitimate confidence in feminine skill, overpower the quite superficial ideas of delicacy in regard to co-education in medicine. We call these ideas superficial, for they only represent further misconceptions of the mental attitude of true medical students. The scope of the subjects studied is so immensely wider than the public can imagine; the mass of its details so much greater; the intellectual aspect so different; even the material conditions so changed, (2) that it is quite impossible for any one on the outside to judge of the form of feeling likely to be excited by the actual circumstances within. (3)
From all this series of misconceptions to which women are exposed in common with men physicians, and, for many reasons, more conspicuously than they, it would seem as if members of the profession should naturally be exempt. "It is an ill bird that fouls its own nest"; and it seems scarcely credible that any physician who loves and honors his calling as it deserves, should dare to pronounce it too coarse or too hardening a pursuit for women. Whenever this has been done, the argument is necessarily insincere. It is like the outcry of school-boys when their sisters beg to be allowed to play ball with them. "Go away! You are a girl! Girls don't play ball!" The school-boy is usually unable to enforce this brief but effective dictum by dissertations on the difference in the form of the clavicle between the male and the female, and consequent inferences as to the necessary inefficiency of girls in the art of pitching and catching. Grown to manhood, however, he learns to justify his opinions by formidable weights of erudition. These arguments vary from age to age, and to-day the fashionable one is drawn from natural history. By laborious researches into the comparative weight of the brain, (4) the strength of the muscles, the depth of the respiration, the powers of digestion, the richness of the blood, it is established that the typical woman, wherever she appears, must be an inferior animal to the typical man, wherever he may be found. The rapidity with which this abstract conclusion is applied to such a concrete problem as the capacity of women for the practice of medicine is amazing. Were the feat performed by feminine reasoners, it would, no doubt, be cited in proof of the hasty generalizations of the shallow female intellect. But we remember the fable of the wolves and the shepherds!
The logical inference from such data as we have quoted, precisely because they have recently been re-adduced in the argument about women physicians, can only apply to the relative positions of men and women in the social organism. We might infer, if we admit the validity of such researches and the reality of their statistical value, that the highest, and weightiest, and greatest amount of effective work must always be performed by the masculine half of the race. But it by no means follows that the work of the medical profession lies on this loftiest plane, and, consequently, the argument in question has nothing to do with the matter at issue.
Here is the point which, so far, we have hardly ever seen distinctly appreciated, namely, -- that, as the gamut of human intelligence goes, a third-class intellect is quite sufficient to make a first-class doctor.
This will be clear when it is remembered that by first-class intellect is meant that of creative genius; by the second, that of inventive talent; by the third, the mind possessing the power of generalizing, adapting, and coördinating what others have created, discovered, or invented. If we take Newton as an illustration of the first class, Faraday of the second, Trousseau of the third, it will be evident that the great mass of even our first consulting physicians occupy a lower rank still. On this calculation the trustworthy but undistinguished family physician, the sheet-anchor of many homes, must modestly acknowledge that he holds only the fifth place, -- often, indeed, not that!
Surely the natural history argument, which gives the abstract estimate of woman's capacities as so little lower than those of man, cannot be used to consign her to the perdition spread out below this fifth circle! Were it necessary to apply the interpretation, it would be that if all men were Newtons, no woman would rise higher than Faraday. If the mental development of the race had paused at the level of Faraday, no woman could claim more than the erudition of Trousseau, and so on.
The absurdity and uselessness of such a discussion is fully paralleled by that of the innumerable discussions which have been solemnly sustained on this basis. This is our excuse for pausing to consider it.
Some years ago, Huxley took occasion to say in public: "No scientific man, well acquainted with the quality and quantity of the intellectual work actually performed by the average medical practitioner, could doubt that any vigorous girl could be trained for the same."
The intellectual work required of physicians is of two kinds. They must learn an art, and become experimentally skilled in its various applications. And, during the exercise of this art, they may collect data which shall contribute to the advancement of the science upon which the art reposes.
The relation between these two branches of work much resembles that which exists between the art of musical execution and the science on which depends musical composition. Now, it is well known that abilities in these two different departments exist in no necessary proportion to each other in the same person. Brilliant performers are known whose compositions are thoroughly mediocre; the most profound musical writers may be relatively inferior in the technique of fingering. In the conservatory at Stuttgart, we have been told that the female pupils are restricted to the study of execution, and receive no instruction in the principles of harmony or theoretical music. They are not expected to compose.
The mental powers involved in the application to concrete problems of the principles of so great and complex an art as that of medicine, may easily seem to the outsider to be identical with those concerned in scientific research. This is not, however, the case, and therefore objections made to the education of women as physicians because, without education, they have made no important scientific investigations, should fall to the ground by their own weight. Such objections, if maintained, must rule out of practice the great majority of successful practical physicians.
Another consideration: Persistent innovations are rarely one-sided. When new claims are made, we may be sure that they have a foundation in facts. It is so with medicine. Its modern development renders it more accessible to women. Thus, the discovery of anæsthetics has thrown open to women almost the entire field of operative surgery, from which, formerly, purely physical disabilities must have excluded them. This is a branch of medicine capable of being taught with great precision: and, accordingly, we find that a taste for surgery develops rapidly among women wherever they can obtain for it the requisite personal training. (5) Again, the immensely greater attention paid in modern times to the chronic diseases of all the organs of the body, opens not one but many fields where care, patience, solicitous observation, detailed attentions, are more required than the prompt courage supposed to be necessary, for startling emergencies. But, finally, the majority of emergencies cease to be startling, because, owing to the greater precision of medical knowledge, they can be far more often foreseen and far more often coolly analyzed and interpreted.
In a word, whatever tends to perfect the art of medicine, tends also to render it more susceptible of being taught with positiveness, hence more accessible to persons susceptible of training, but liable to be deficient in originality and initiative. It is the achievements of masculine genius which, in medicine as in other departments of life, facilitate the work of women. To what extent real genius for medical science may develop among women remains to be seen. The conditions for such development do not yet exist. Medical training is, in America, everywhere extremely imperfect, and in regard to women, the imperfection becomes more obvious on account of the habitual defects in their ordinary education. They are, as has been already said, deficient in mental initiative; the deficiency is not counteracted but aggravated in the great majority of cases by almost all the influences to which they are subjected from their cradle upward. Few agree with Mr. Morley "that there is probably nothing which would lead to so rapid and marked an improvement in the world as a large increase of the number of women in it with the will and capacity to master Newton as thoroughly as she (the Marquise du Chatelet) did.'" (6) Everything in ordinary life is opposed to the thorough mastery of anything by women. The study of medicine necessitates, in this respect, an entirely new departure. Experience shows that this is not difficult to effect wherever women students are submitted to an authoritative and imposing discipline -- as in the European universities to which they have been admitted. But the self-enforcement of such a discipline is necessarily rare. The capacity of women for purely mental initiative is often at present encroached upon by the severe struggle with practical and pecuniary necessities to which so many of them are subjected. The self-denial, energy and pluck, ingenuity and perseverance of hundreds of women students would make, if published, an heroic record. Through poverty, opposition, ill health, often with insufficient daily food, -- often compelled to work, in addition to their studies, to earn their daily expenses, -- these women struggle on uncomplaining. They are obscure, unknown -- often remain so; often fail from attempting the impossible, yet, oftener than could be imagined, succeed at least in rising to the standard which is established for them. It remains, perhaps, for another generation to do more.
From what has been just said we certainly would not have it inferred that we argue the necessity of accepting women as an inferior grade of practitioners, to be tolerated in trifling ailments and to be set aside in serious illness. Our argument is simply that, at the present stage of medical development, the mental powers exercised in the treatment of the most serious illness lie, both as to quality and quantity, within the range of the theoretical estimate now generally made of the intelligence of women. These powers are apt to seem more extensive than they are, because, from the nature of the case, they usually come into play in the presence of persons unqualified to criticise them. So long, however, as the physician confines himself to the application of the rules of diagnosis and of treatment contained in his art, his work, however judiciously and skillfully performed, must, as an intellectual performance, be ranked as second-rate. To say, therefore, that the intellectual capacities of women are only second-rate by no means excludes them from the most responsible duties of practical medicine.
Again, chased from the first assumption, the determined prejudice finds refuge in a second, and we are confronted by the assertion that women physicians must be lacking in the moral qualities of self-reliance, steadiness of nerve, self-control, etc. Here again, we believe, the fallacy lies, first, in taking for standards of comparison women quite untrained for the work; second, in misunderstanding the effect of knowledge in dissipating the alarms principally excited by mysteries. To be firm, self-reliant, and steady in dealing with the friends of the patient is no harder for a woman involved in medical than in other responsibilities. To assume the burden of such responsibilities in regard to the patient requires the ability to say: "I know the condition of this patient at least as well as any other person to whose opinion I could have access. I am also acquainted with the nature and extent of the resources which the art of medicine at present possesses for such a case. It is my business to apply those resources with all possible care and diligence, and to await the result."
This is not the frantic "wrestling for the life of the patient'' which figures in popular imagination, but it is the sober truth. It is not the language of an excitable person, bewildered in a dramatic situation, but that of a well-balanced intelligence, thoroughly trained for the work which it has undertaken.
If a really first-class intellect be often rather out of place in the practice of medicine, a high degree of vitality, of organic vigor, is certainly needed. Now, it is not usually recognized to what an extent the organic vigor of women is naturally destined to be increased by child-bearing. The prevalent American notion is that maternity is the signal for an inevitable collapse of all mental and physical powers. The reverse is certainly intended in the scheme of Nature. The key-note to the difficulties of the position of women in regard to the achievement of distinction in any form of work, lies in the fact that the degree of their physical, and probably, therefore, of their mental, development before child-bearing is always rudimentary, relative to that attainable after it; while, nevertheless, the risks, duties, and social consequences of maternity tend to so completely absorb this increased vitality that none remains over to be expended in external work.
It is foolish to overlook or to dispute this fundamental fact. But it is equally useless to insist upon it, as in itself sufficient to decide the social destinies of woman.
The "social consequences of maternity" vary indefinitely with the social class. Immense numbers of women are compelled, by the most inflexible economic conditions, to work as hard, in factories or elsewhere, after marriage as before. "If," says Simon, "the family can only be supported by three francs, and the man can only earn two, there is no alternative but for the woman to labor to secure the remaining franc." The range of non-domestic industry rises, without changing its essential nature, from the level of the European factory operative to that of the American farmer, where the share of the married woman in the conduct of the farm is considerable. Marriage cannot be said to withdraw from non-domestic industry the majority of women, but only to increase their burdens, and set them to work at a disadvantage.
On the other hand, in another immense class; or, rather, series of classes, the amount of work performed by women in the discharge of household duties is fully equivalent to the amount of non-domestic industry performed previous to marriage. The difference lies in the arrangement; and it is claimed that this facilitates the duties of maternity, and care of children, while any non-domestic labor must disastrously antagonize these.
Finally, for much the smallest, but also the most influential because the most distinctly articulate class, marriage means, or is expected to mean for the woman, liberation from any definite industry. The work of the household is performed by servants; and the funds are entirely supplied by the external work of the husband. This, indeed, in theory; in fact, in all dense social communities, and there especially in professional circles, the wife is often expected to contribute an essential quota toward the maintenance of the household, by means of an inherited fortune or of the dowry received from her father. As it is evident that physicians must come, not from the so-called laboring classes, but from those where the married woman either works in the house or does no real work at all, the practice of medicine by married women becomes involved in the following problem: To so arrange, at least certain forms of non-domestic labor, that even a married woman should be enabled to engage in them if her taste so inclined, either in preference to the domestic work which she would otherwise be compelled to perform as a substitute for a dowry, without which she might be compelled to remain unmarried, or as a substitute for an elegant leisure, which, to an energetic temperament, is often a refined torment.
On the theory that work is a mere personal hardship, to be evaded whenever possible, to be sought only for an indispensable pecuniary return, and always, even in our democratic country, implying for women a faint social disgrace, there is not likely to be any enthusiastic support among married women of professional or other work to be performed by any of their number. This is why the frequent denunciation of such work by fashionable women is always open to suspicion. On the broader theory, that the amount of work to be done in the world implies a collective fund of activity, to which all human beings may lawfully desire to contribute, each freely choosing such portions of it as are most suited to his or her special capacities, the matter assumes a different aspect. Whatever real difficulties may lie in the way, the one at least should disappear which is created by the half-avowed dictum: "No woman has any right to work who can get a man to support her."
This excursion into the general considerations about the work of women is necessary in order to understand the real force of much of the more obscure opposition which exists to women physicians. As has already been said, the profession of medicine cannot be taken up and laid down again, like the lower positions in industrial occupations, or even like the profession of teaching. It must be adopted, if at all, for a life-time. Its ripest fruits cannot be gathered until a ripe age, long past that most suitable for marriage. On this account, and because the women who are most likely to succeed in medicine have often also marked capacities for success in marriage, and because their ability to perform such work as that involved in the practice of medicine, and demanding high organic vigor, tends to be increased after marriage and the possession of children, -- for all these reasons, it is felt that the question of women in medicine touches upon ground not covered by their pre-marital work elsewhere. To the question, "Is it possible for married women to practice medicine?" experience might already be supposed to return an answer. A very considerable number of women now practicing have either married after entering upon practice, or were already married when they began. To what extent either their households or their practice may have suffered by the combination, it is almost impossible to ascertain by the most carefully prepared tables of statistics. It is not yet even certain whether the combination influences the size of the family. As far as can be judged, this remains at the measure most habitual in the families of professional men. Since this paper is intended to discuss rather theories than facts, it is worth while to outline a typical case, such as is not unfrequently realized:
A healthy girl of eighteen, with an ultimate view to the study of medicine, enters upon a university course, and, at the age of twenty-two, begins medical study. She is ready for practice at twenty-seven, marries at the same time or a year later. Her children are born during the first years of marriage, thus also during the first years of practice, and before this has become exorbitant in its demands. The medical work grows gradually, in about the same proportion as imperative family cares grow lighter. The non-imperative duties -- the sewing, cooking, dusting, even visiting -- are susceptible of such varied modifications of arrangement as it would be trivial to discuss in these pages. So great is the division of labor in medical work that it is indeed rather the minority of physicians who can consider themselves fortunate in being "overwhelmed" with practice. In respect to the quantity of work performed by women, the same rule may be applied as has been laid down for the admissible proportion for the laboring classes -- namely, about one-third of that performed by men of the same grade of success and ability. This fact need not impair the quality of the work. Professional work, which must remain a form of personal or hand labor, cannot be measured by commercial estimates. Beyond a certain point, increase of its quantity tends to impair rather than improve its quality. A mass of work sufficient to involve serious drafts on physical strength must, in medicine as elsewhere, put nearly all women at a disadvantage. But the handling of such large masses is neither necessary nor desirable for any other than pecuniary reasons, and these, both for physicians and for women in general, may be left in the background. To neither is the attainment of a fortune important; for the majority of both it is impossible. This must always remain true of physicians; whether it always remain as true of women as it seems to be at present, depends upon the extent to which they may rise from the bottom of the industrial scale, where they swarm at present, to the top -- a question which, however interesting, does not concern our present subject.
The character of medical work, in its external and obvious aspect, -- that of examining, watching, and prescribing for sick people, -- suggests a degree of adaptability to the exigencies of domestic life which especially commends it to women. This is one reason why so many choose it, in preference to other occupations. In these reasons for a choice, there lurks, however, a danger, which it is well to distinctly recognize. It is that of overlooking the importance and extent of that part of the physician's work which is performed outside of the consulting-room, and away from the patient's bedside. In the mind of the true physician, this bears about the same proportion to the work of practical intercourse with the sick, as for the pianist exists between his hours of preparation and practice and those devoted to public concerts or teaching. It is true that this ideal is rarely maintained; but it exists, and tends to become more and more frequently realized during the progressive development of modern medicine. Now, it is in regard to this ideal that the present generation of women physicians are more liable to be deficient than in regard to the energy or solicitude of their attention to patients. It involves some vigor of mental initiative, and, as has been already noticed, the same women who will respond admirably to training, to direction, or to the pressure of practical necessities, are apt to be unexpectedly deficient in this.
Since it is only the gradual progress in mental culture which has, for men, aroused mental initiative in the field of medicine, we may reasonably hope that the same process will have the same result for women also. Already a sufficient number of feminine examples exist to prove that this is quite possible. There is a gradual, but undoubted, increase in the capacity for mental initiative on the part of women in general. Those who study medicine must first share in the general movement; afterward, must become more energetically animated than at present by the intellectual impulses of modern medical thought.
We have already asserted that the idea that culture is a means, not only of training, but of developing force, is not generally accepted among current popular notions. It is, however, fully recognized by authorities, and we need, therefore, spend no time in defending it. Our commentary upon the practice of medicine by women does not profess to be very systematic; it evades arguments of rights, statistics, and historical statements, partly because these have already been made in an admirable manner, (7) partly because, in our opinion, sufficient data do not yet exist for statistical conclusions. The whole number of women at present practicing medicine is small; thus, only about four hundred can be reckoned in America; only nineteen are registered in Great Britain. From this small number, with the imperfect preparation and surroundings of so many among them, to attempt to draw any inferences as to the theoretical grade of capacity of women for medicine, is absurd. Still more absurd to attempt to deduce general conclusions in regard to the mental capacity of women in general -- its development, progress, or unimprovability.
Deferring exact researches, our modest intention is simply to attack the floating mass of vague ideas, prejudices, preconceptions, and misconceptions which, in this as in so many other matters, really decides the practical action of the community. Drawing to the close of our brief discussion, we are aware that it will seem to leave several questions not only unsettled, but untouched. If there are so few women who, after all, come forward to study medicine, why is it necessary to disturb oneself, or, in the slightest degree, society, about them?
We answer: It is scarcely forty years since the first woman physician graduated in America; not more than thirty since the first school was opened to them; not more than fifteen since, anywhere in the world, they could obtain a university education, and from this, in many parts of the world, they are still excluded. It is not, therefore, surprising that the number of women in medicine is still small.
Further, the demands of these few have involved a sacred question -- that of justice. It is this little band of women physicians who most conspicuously represent the modern claims of women to share in the general intellectual development of the race. Their demands have not only been refused, but refused with contumely, and themselves treated with the tyrannical contempt which Prussians and Anglo-Saxons habitually reserve for those who urge a claim without the physical force to secure it. This is the first reason why the question, insignificant as regards number, has a real social importance.
The question at issue does not concern the training of scientists or the development of original genius, but the training for a practical work of persons who have demonstrated at least very many of the abilities requisite for it. In this they have put themselves, so far as regards native capacity, on a level with the great majority of the members of the medical profession. It is possible, if not probable, that they have shown themselves less able to dispense with thorough training than their masculine colleagues, less able to compensate its deficiencies by self-imposed efforts. No practical inference can be drawn from this other than one which applies to the entire relations of the state to medical education, viz., that every practitioner should be much more closely supervised. Efficiency should be more seriously and more often tested, and the public far better protected than it is at present from the incompetence of both male and female practitioners. It is the height of folly to trust to American ingenuity and quickness to escape the consequences of imperfect knowledge. If it be desirable to establish a rigorous discipline for women physicians, it is no less important to do it for men, so that, practically, the distinction disappears.
In regard to any unpleasant modification of female character, likely to result from medical or other superior education, it cannot be too frequently noted that nothing further is proposed than to make room for the varying types of women which actually exist. Mr. Bagehot declares that an unvarying type of character is characteristic of a barbarian community, because essential to its safety, and is, therefore, enforced by all penalties, even to that of death. Only civilization is flexible enough, and stands on a broad enough basis, to permit internal variations. Surely women may share sufficiently in civilization to be allowed, without social disgrace, to exhibit such variety? The taste for medicine, when profound and genuine, is certainly peculiar enough to establish a decided variation on the most conventional type of women. But many other tastes do the same; and choice remains free.
"The crane, I said, may chatter with the crane,
The dove mate with the dove, but I
An eagle, clang an eagle in my sphere!"A final reason to be considered in regard to the professional work of women, and its possible continuance after marriage, lies in the re-arrangement of domestic work which has gradually been brought about by the growth of modern industries. As every woman knows, these are built up of tasks which have been withdrawn, one by one, from the control of the household and of its mistress, and have been combined, perfected, amplified to wholesale and often gigantic proportions. The process necessarily liberates the energies of the woman formerly absorbed by these same necessary tasks of preparing food and clothing. The process is still going on, and is constantly simplifying the material mechanism of household existence.
The "invasion of foreign spheres," for which women are so often reproached, is only the natural result of the double pressure of an economic and of a psychological necessity. It is always necessary that human beings be occupied: if driven from one thing they must take up another: if all employment be taken away from them, they must at least pretend to be busy. On the other hand, it is not only obviously desirable that unmarried women find as many avenues for employment as possible, but the possibility of contributing toward the support of a family may decide, for many women, the alternative of marriage or celibacy. The traditional method of effecting such contribution is by means of a dowry; in many cases, it both has been and is the only possible way, since neither the strength nor the ability of the woman would enable her to engage in any non-domestic work, and yet do justice to her children and household. Any woman, however, who is possessed of the requisite physical and mental strength should be allowed, at her choice, to contribute the profitable work for which she has been trained, in lieu of a dowry which she may very easily not happen to possess, or in lieu of certain domestic labor which she would otherwise be compelled to perform on account of the narrow income of her husband. Is the sentiment of marriage endangered by the habits of pecuniary self-reliance and independence which should tend to free marriage from its burdensome aspect as a "career," and as an indispensable means of livelihood?
All professional work constitutes a form of personal service, and, as such, is much better suited to the prevailing instincts of women than industrial or commercial pursuits. The adaptation on this side is indeed so great as to constitute a danger; for it should never be permitted to obscure - and, in fact, it sometimes does - the cardinal question of capacity. We have said what we think there is for the present to say, in regard to the proof of such capacity in women. Here, in closing, we only wish to refer to its desirableness as a means of stimulating to better efficiency much existing feminine occupation. When room is made so near the top as is the high, difficult, and responsible work of practical medicine, the lower ranks may thin out by promotion. The pitiful overcrowding of the meanest employments by the huddling together of all grades of capacity, from that of the raw Irish girl to that of the reduced gentlewoman, might cease when fair play was once allowed for superior energies.
Have we not had enough of the dictum, "Women cannot do men's work"? In reality, some women can do the easy work of some men; others can do the more difficult work of more powerful men; finally, there are some men whose work, either for mass or quality, has so far not been equaled by the achievements of any woman. And this is all there is to say about it. It is desirable that every woman remain as inferior to her own husband as may be feasible and convenient; it is for that purpose she marries him, or should do so. But the generalization of this relative inferiority to the comparative capacities of all men and all women, in regard to every work that both undertake, is a most injurious absurdity.
When we shall be rid of the injustice, the unfairness, the monstrous pretensions, and arrogant argument with which the subject of the admission of women to medicine has hitherto been so largely treated; when the mass of women students can obtain the same education and women physicians the same facilities that men do, a sound theoretical conclusion may then be reached, if required. But by that time the practical conclusion will probably have established itself, and people will cease to interest themselves in dissertations on the true theory of un fait accompli.
Author's Notes
"TO THE EDITOR OR THE PALL MALL GAZETTE.
SIR: The October number of the "Indian Female Evangelist" supplies an interesting piece of evidence on the disputed point as to whether properly educated medical women would or would not be acceptable to the native ladies of India. It appears that the Maharajah of Punna, in Bundelcund, applied to Miss Beilby, a female medical missionary at Lucknow, to treat his wife, who had long been suffering from some painful internal ailment. Miss Beilby spent some weeks in attendance upon the Maharanee, and happily was able to effect a cure:
When the time of her departure from Punna arrived, she was desired to present herself at the palace to take leave of her royal patient, on Wednesday, the 13th April last. The Maha-Rani received her in her private room, and almost immediately dismissed all her attendants and ladies, so that she might be quite alone with her. The Maha-Rani then said she wished Miss Beilby to make her a solemn promise. Without knowing what it might involve, she was reluctant to do this, but at length the Maha-Rani said: "You are going to England, and I want you to tell our Queen and the Prince and Princess of Wales, and the men and women in England, what the women in the zenanas in India suffer when they are sick. Will you promise me to do this?" She explained that it was no social change in their condition she sought, but relief in their cruel sufferings. She charged Miss Beilby to give this message herself to the great Queen of England; not to send it through any other channel, but to take it herself, or her Majesty would think less of it. Miss Beilby represented to the Maha-Rani the difficulty she would have in getting access to the Queen -- that with us it is not as in the East, that any one can go to the palace and lay a petition before the native sovereign. Besides, she told her she hardly knew what good it would do if she could do as she wished, and take her message to our Queen. The Queen could not make lady doctors, or order them to go out. It was not in the power of even the great Queen of England to do this. "But," said the Maha-Rani, "did you not toll me our Queen was good and gracious, that she never heard of sorrow or suffering without sending a message to say how sorry she was, and trying to help! Did you not show me a picture of a train falling into the sea, where a bridge broke, and did you not tell me how grieved our Queen was Well, it was very sad those people should have been killed, but our condition is far worse; if you will only tell our Queen what we Indian women suffer when we are sick, I am sure she will feel for us and try to help us." Miss Beilby felt she could no longer refuse to promise to convey this message, if possible. The Maha-Rani next bade her write it down at once (giving her pen, ink, and paper), lest she should forget it, and added, "Write it small, Doctor Miss Sahiba, for I want to put it in a locket, and you are to wear this locket round your neck, till you see our great Queen and give it her yourself. You are not to send it through another."
On reaching England, Miss Beilby communicated with some of the ladies about the Court, and on July 13, 1881, the Queen received her at Windsor Castle:
Her Majesty listened to Miss Beilby's statement with great interest, asking many questions, and showing the deepest sympathy. Turning to her ladies, she said: "We had no idea it was as bad as this; something must be done for these poor creatures." The Maha-Rani's locket with its message was given to the Queen, and Her Majesty entrusted Miss Beilby with a message in reply, which was intended for the Maha-Rani alone. But the Queen also gave Miss Beilby a message which might be given to every one with whom she spoke on the subject of the poor suffering Indian ladies: -- "We should wish it generally known that we sympathise with every effort made to relieve the suffering state of the women of India."
We fear the Maha-Rani would after this be disappointed if she were told that three weeks later the medical women of Europe and America were excluded from the International Medical Congress held in London last August, and that this exclusion was effected by the Queen's private physician, threatening the Congress with the loss of the Queen's name as patron if medical women were admitted. If this were anything more than an unauthorized application of the influence of royalty, it would be desirable for the Queen to remember that it will not assist in relieving the suffering state of any of her Majesty's subjects to prevent their medical attendants from keeping au courant with every advance in the knowledge of the complex art of healing, and that it is not true that a very much less educated practitioner than those who desired to attend the Congress would be good enough for India. The fact of the skin of the patient being some shades darker than our own does not, as some people seem to imagine, simplify alike the physical organization and the abnormal conditions of the body, and if good medical women are wanted for India, they must receive as thorough a training as the best medical schools in England can give to men. The recent successes of the students from the London School of Medicine for Women in the Honor List of the London University show that in this school, at any rate, the education given is good and thorough, and we hope her Majesty will in due time have the gratification of knowing that many medical women who have been trained there are at work in India and England in relieving the sufferings of her subjects.
I am, Sir, your obedient servant, B.
October 25.
[ Back ]As in the dissection or post-mortem examination of dead bodies.
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Not to interrupt the course of the text, we would here note that schemes of co-education which, in some shape, are really essential to the proper professional education of women, are always compatible with isolated instruction on the very few special subjects where the association of young men and women students might be an embarrassment. But these topics occupy, after all, a very small part of medicine.
[ Back ]It will not be forgotten that the latest tables of Bischoff give the proportions of the brain to the weight of the body as 1 to 36 for women, 1 to 37.5 for men.
[ Back ]Dr. Van de Warker says that we are yet to see the female ovariotomist. We know of at least seven ovariotomies performed by women, of which five were successful.
[ Back ]Life of Voltaire, p. 100.
[ Back ]See "Study and Practice of Medicine by Women," Dr. J. R. Chadwick, "International Review"; "Study of Medicine by Women," Miss Jex-Blake, "Fortnightly," March, 1875; "Reply to Bischoff on the Admission of Women to the School of Medicine at Zurich," Prof. Herman; Speech of Dr. Henry Bowditch on the Admission of Women to the Massachusetts State Medical Society; Report of Committee on Admission of Women to Harvard Medical School, Chairman Prof. Alex. Agassiz; "The College Story," Prof. Rachel Bodly; "Practice of Medicine by Women in the United States," Drs. E. & A. Pope, and G. L. Call; "Early Practice of Medicine by Women," Prof. Bolton, "Journal of Science," January, 1881; "Women in Medicine," "Michigan Exchange," Lydia Welch.
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Edited by Terry Heller, Coe College
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