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Mid-Nineteenth Century Attitudes Toward Women Physicians:

Reflections on Elizabeth Blackwell and
the 150th Anniversary of Women in Medicine

Eric v.d. Luft, Ph.D., M.L.S.

Invited paper presented at the College of Physicians of Philadelphia as a
Seminar of the Francis C. Wood Institute for the History of Medicine, March 23, 1999

1. From Midwives to Physicians and Beyond

The credentials by which one is properly constituted a "physician" vary with the era. No one disputes that Hippocrates, Celsus, Galen, and Avicenna were physicians. They did not have the letters "M.D." after their names, but they were recognized as physicians nonetheless. In the days when surgery was rigidly distinct from the practice of medicine, when most remedies were either herbal or manipulative, and when anatomical, physiological, and pathological knowledge was based more upon tradition, speculation, and theology than upon systematic empirical methods, nearly anyone who had any practical success in the healing arts could be accepted as a physician. That included women too, in almost all cultures. For example, Chun Yu-yen, approximately a contemporary of Galen, is traditionally known as the first Chinese woman physician. Many women openly practiced medicine in southern Italy in the eleventh century, including the renowned Trotula of Salerno; and similarly in thirteenth century France. Although Hildegard von Bingen would be just a folk herbalist by modern standards, in her own twelfth century Germany she was specifically called "physician." Ancient Greek, Roman, and Christian records, as well as medieval literature such as "Erec et Enide" by Chrétien de Troyes, all testify matter-of-factly to the existence of women physicians in those cultures.

Standards for entrance into the medical community of Western Europe and its satellites gradually began to tighten in the wake of:

  1. New medical knowledge in the post-Vesalian, post-Harveian world.
  2. New moral standards, especially in Northern Europe, brought about by the Reformation.
  3. New social roles brought about in the Renaissance by the decline of agrarian feudalism and the rise of the bourgeoisie.

In this process women healers were marginalized, shunned, banned, and sometimes even persecuted as witches. Their practice, if it continued to be allowed at all, was generally restricted to midwifery. This "tightening" of standards did not in any way approach the high level of standards for the education and credentialing of physicians today. But because medicine came to be regarded in the Renaissance and after as more an academic discipline and less an aspect of home economy, it meant that women, who were generally prohibited from attending universities and discouraged from becoming apprentices, were effectively prevented from any longer being able to train as physicians and having society recognize them as such.

The era when any male, either self-educated, trained by apprenticeship, or taught in a medical school, could with impunity hang out a shingle proclaiming himself a physician lasted until between the sixteenth and eighteenth centuries in Western Europe, until the mid-nineteenth in the eastern United States, until the late nineteenth in the western United States, and well into the twentieth in parts of the so-called "Third World." Even though it was basically the universities and the medical associations and which shut women out of medical practice in the Renaissance and post-Renaissance worlds, the irony is that as standards of medical education (regulated by universities) and practice (regulated by medical associations) have improved since the mid-nineteenth century in these various places, so concurrently have the conditions and status of women physicians, medical students, and even patients.

Midwifery was the exception to the post-Renaissance rule of forbidding women to practice the medical arts. At least four distinct strains of male opinion about women's medical practice vis-à-vis midwifery were discernible from the Renaissance through the end of the nineteenth century:

  1. Women may be neither physicians nor midwives, because the science of bringing healthy babies into the world is better left to trained male obstetricians (e.g., Channing 1820, "Females as Physicians" 1855, "Female Physicians" 1856, "Female Practitioners" 1867, Hutchinson 1876). Walter Channing's early nineteenth-century argument was typical; i.e., in order to do the best job, midwives must be physicians; women have finer sensibilities and tend toward more delicate feelings; there is no place in medicine for the "display and indulgence" (p. 5) of such feelings; therefore, women ought not to be midwives.
  2. Women may be midwives but may not be physicians and therefore may not perform complex obstetrical or gynecological procedures (e.g., Colby 1844).
  3. Women may be physicians if and only if they restrict their practice to midwifery, obstetrics, gynecology, and/or public health (e.g., Gregory 1850, Wilson 1854, Gregory 1862, Gregory 1868).
  4. Women may be physicians as freely as men and need not restrict their practice to certain specialties (a rarely held view, e.g., Schwerin 1880).

In the eighteenth and nineteenth centuries, France and Germany were the two most enlightened or liberal cultures in this regard. (In fact, it was probably this very legacy which induced Elizabeth Blackwell to decide -- correctly -- that she could best further her postgraduate medical education in Paris.) Female students of midwifery in the mid-nineteenth century in Germany received a level of medical education superior to that which was offered to female medical students in the same era in America. For example, Marie Elizabeth Zakrzewska (1829-1902), who had received a midwife's diploma with highest honors from the Hospital Charité in Berlin before immigrating to America in 1853 and receiving her M.D. from Cleveland Medical College in 1856, learned to use a microscope as a student in Germany but, as Professor of Obstetrics at the New England Female Medical College in Boston from 1859 to 1861, was refused permission to order one for the school. One of her male detractors retorted, "That is another one of those new-fangled European notions which she tries to introduce. It is my opinion that we need a doctor in our medical department who knows when a patient has fever, or what ails her, without a microscope. We need practical persons in our American life" (Zakrzewska 1924, pp. 250-251).

The respect generally afforded to professional midwives in Germany in the nineteenth century, before there were regular female physicians in Germany, is attributable to the legacy of Justine Dittrich Siegemund (1636-1705). Through both her practice and her writing, she had elevated midwifery to a careful science in Germany. After her death German midwifery again fell into disrepute. But in 1818 Prussia enacted a law which made it illegal for women to practice midwifery without sufficient education. In order to enable compliance with this law, the government established several schools of midwifery, including the one affiliated with the University of Berlin, and instituted in these schools the most rigorous standards of the time (Zakrzewska 1924, pp. 36-39).

Louise Bourgeois (1563-1636), Marie Louise La Chappelle (1769-1821), and especially Marie Anne Victoire Boivin (1783-1841) uplifted French midwifery just as Justine Siegemund uplifted that profession in Germany. Boivin published her improvements in the design of the speculum, her advances in internal pelvimetry, her classic descriptions of several intrauterine masses, and many other important medical works. The University of Marburg even bestowed an honorary M.D. upon her in 1827. Her memory was still fresh when Elizabeth Blackwell arrived in Paris in 1849. Yet it is generally conceded that Madeline Brés, who received her M.D. in Paris in 1875, was the first French woman physician.

Despite its longstanding acceptance of women as professional midwives and its insistence upon rigid governmental control of the training and licensing of midwives, Germany was slower than most of the rest of Europe to allow women to study for the M.D. within its borders. As a result of this reluctance, many German women from the 1870s until well into the twentieth century chose to obtain the M.D. outside Germany, then return to Germany to practice. Zürich, a German-speaking city, soon became the most popular destination for this purpose. Its university first permitted women to study medicine in 1864; and two other Swiss universities, Bern and Geneva, did so in 1872. The first woman to receive an M.D. in Switzerland was Marie Heim Vögtlin (1845-1916), who was graduated at Zürich in 1874. Soon after Tiburtius and Lehmus received their M.D.'s there in the mid-1870s, Zürich became almost a haven for Central European women seeking medical degrees. The first women to practice medicine legitimately in Serbia and Croatia, Draga Ljocic Milosevic and Milica Sviglin Cavov, were both Zürich graduates, receiving their degrees in 1879 and 1893, respectively. The program for educating women physicians at Zürich became a model for those male American physicians, e.g., Henry Ingersoll Bowditch (1879A, 1879B, 1881) and J.J. Putnam (1879), who vigorously advocated -- but failed to achieve -- the opening of Harvard Medical School to women in the late nineteenth century. Sophia Jex-Blake (1840-1912), after losing a protracted trans-Atlantic struggle to be admitted to either an American or a British medical school, a struggle in which she wrote two polemical essays (1872) and enlisted the help of several American women physicians, e.g., Marie Zakrzewska, finally triumphed with an M.D. from Bern in 1877 and a place in the British Medical Register. She practiced as the first woman physician in Scotland.

The Austrian situation was similar to that of Germany. The medical school at Vienna was not opened to women until 1900. The first woman licensed to practice medicine in Austria was Rosa Kerschbauer in 1895. Another early Austrian woman physician, Gabrielle Possaner von Ehrenthal (b. 1860), had a Swiss M.D. but was required by Austrian authorities to retake her exams in Austria before she would be allowed to practice. Her Austrian M.D. was granted in 1897. The first woman to study medicine and thereby obtain the M.D. within Austria itself was Margarete Hoenigsberg Hilferding in 1903.

In the late nineteenth century, European women who had earned their M.D.'s in Switzerland campaigned actively to open medical education to women in their respective native countries. A prime example is Anne Van Diest (1842-1916), a Belgian with an 1877 Bern M.D. Even before returning to Belgium, she was already fighting hard for the acceptance of women into Belgian medical schools. The first woman to receive the M.D. by studying medicine in Belgium was Clemence Everaert at Brussels in 1893.

Many nineteenth century women discovered that international educational and professional experience would improve their prospects for medical careers. Many found it easier to gain acceptance as physicians outside their native country. Many had career experiences on both sides of the Atlantic. The British-born but American-educated Elizabeth Blackwell, unable to gain acceptance as a physician in America, spent most of her career in Europe. Prussian-born Marie Zakrzewska created her career in America. Sarah Loguen Fraser (1850-1933), the fourth African-American woman physician, achieved greater success as the first woman physician in Santo Domingo (now the Dominican Republic), and spent several years in France in the 1890s. Lydia Folger Fowler (1822-1879), who was graduated in 1850 from the eclectic Central Medical College in Rochester, New York as the second woman to earn an M.D. in America, had a mediocre career of mostly midwifery and hygienics, including stints in New York, Paris, and London, as well as lecture tours of both America and Europe (Waite 1932). Mary Edwards Walker (1832-1919), who earned her M.D. at the eclectic Syracuse Medical College in 1855, practiced in Ohio and New York, served as a surgeon in the Civil War, and was for her time such a radical feminist that the suffragists shunned her, also lectured widely in Europe, mostly on topics of hygiene, dress reform, and politics (cf. her Hit, 1871), but was received mostly with derision ("Dr. Mary Walker" 1867). Emeline H. Cleveland (1829-1878), Professor of Obstetrics at Woman's Medical College of Pennsylvania (WMCP), received her M.D. at WMCP in 1855, but most of her obstetrical training at La Maternité in Paris. Mary Putnam Jacobi (1842-1906), who received her M.D. from WMCP in 1864, followed Blackwell's and Cleveland's lead in choosing Paris hospitals for her postgraduate training. She received a second M.D. from L'École de Médecine in 1871, returned to America, and became the first woman admitted to the New York Academy of Medicine. Like the medical school at Zürich, L'École de Médecine was frequently a refuge in the late nineteenth century for foreign women seeking degrees in medicine; of the 183 female medical students there in 1894, only sixteen were Frenchwomen (Bluhm 1895). Medical schools and teaching hospitals in that era seemed generally more willing to admit foreign than native women, perhaps because foreign women were likely to return to their own home countries afterward and thus not trouble further the society of the country in which the school or hospital was located.

Emily Jennings Stowe (1831-1903) became Canada's first woman physician in 1867. Prohibited because of her gender from studying medicine at the University of Toronto, she got her M.D. instead from the New York Medical College and Hospital for Women, a homeopathic school. She had a dreadful fight to establish her credentials when she returned to Canada and tried to set up practice, but in 1871 she and Jennie Trout were permitted to attend lectures at the University of Toronto School of Medicine. Both women were subjected to much more than the usual amount of harassment. Stowe failed the course; Trout passed but left Toronto to win her M.D. from WMCP in 1875. Upon her return, Trout became Canada's first licensed regular woman physician. Stowe's daughter, Augusta Stowe Gullen (1857-1943), at Victoria University in 1883, became the first woman to receive an M.D. in Canada.

By the 1870s, women were well established as co-educational medical students in the United States. By 1889 Elizabeth Blackwell could write, "The avenues by which all may enter into the profession are now so much more widely thrown open, that there is little difficuly in the way of any man or woman who may wish to acquire a legal right to practice medicine" (Blackwell 1889, p. 1). Blackwell, ever the optimist, painted perhaps too rosy a picture of the situation. Yet in the late nineteenth century America was slightly ahead of Europe in regard to women's medical education. At the Syracuse University College of Medicine, for example, no fewer than eleven women received the M.D. between 1873 and 1878. Sarah Van Tuyl was the first of these, and there is no indication that she was the victim of any sort of sustained or systematic gender prejudice as a medical student. Syracuse University was founded by socially progressive Methodists in 1871, and was co-educational in all departments ab initio. Its medical school was the reincarnation of Geneva Medical College, which had recently been abandoned by its parent institution, Hobart College. In 1876 it graduated Sarah Loguen Fraser, the country's fourth African-American woman physician (Luft 1998). The first three were Rebecca Lee at the New England Female Medical College in 1864, Rebecca Cole at WMCP in 1867, and Susan Smith McKinney Steward (1847-1918) at the homeopathic New York Medical College and Hospital for Women in 1870.

In nineteenth century America, women were much more likely to be admitted to homeopathic, eclectic, botanic, or other so-called "irregular" medical schools than to those approved by the state medical societies and the AMA. Relations between female physicians trained alternatively and those trained regularly or allopathically were not always cordial. For example, an 1853 M.D. graduate of the eclectic Syracuse Medical College, Clemence Sophia Lozier (1812?-1888), founded the predominantly homeopathic New York Medical College and Hospital for Women in 1863, just two years before the Blackwell sisters succeeded in obtaining a charter for the Women's Medical College of the New York Infirmary for Women and Children.

Generally speaking, by the late nineteenth century American medical education for women was superior to European in availability, with a few notable exceptions such as Switzerland; but European was superior to American in quality, again with a few notable exceptions such as WMCP and the Syracuse University College of Medicine.

On both sides of the Atlantic, acceptance into medical societies and professional organizations came a bit slower for women than acceptance into medical schools. We have already mentioned the difficulties women encountered in getting listed in the British Medical Register. American medical societies used consultation restrictions to exclude women and blacks (Konold 1962, pp. 22-24). In 1876 Sarah Hackett Stevenson (1849-1909), the first woman delegate to the AMA annual meeting barely survived an attempt to unseat her (Barker-Benfield 1977, pp. 16-18).

Also on both sides of the Atlantic, the struggle of women to be allowed to earn and receive M.D. degrees, to be licensed as physicians, to become members of medical societies, to be listed in medical directories, and in general to be admitted into the medical profession as full colleagues of the men was only half the battle. The other half of the struggle was to win acceptance as physicians who could specialize in any field they chose. Even after the female M.D. was more widely accepted toward the end of the nineteenth century, women physicians were still expected to provide only obstetrical and gynecological services. Men were willing to accept women physicians as glorified midwives, but as little else. One particularly striking example is that when Sarah Loguen Fraser became the first woman physician in Santo Domingo in 1883, she was strictly forbidden by law to treat any adult male patients, and was allowed to treat only those women and children whose husbands and fathers explicitly approved of her (Goins).

Women are generally defined in terms of their sex rather than in terms of their humanity (e.g., the English word 'man' can mean either 'male human being' or just 'human being', but the English word 'woman' can only mean 'female human being'); thus society expects female physicians to be "female physicians," not "female physicians." That is, women doctors are generally associated in some way with sexual matters. They are expected to be concerned professionally with "women's health," not with just "health," and to practice only such gender-oriented specialties as obstetrics, gynecology, etc. Gender-neutral specialties such as ophthalmology, orthopedics, and neurosurgery have until very recently been mostly off-limits to them. Most nineteenth century women physicians were only midwives, obstetricians, gynecologists, pediatricians, hygiene specialists, public health physicians, or general practitioners (cf. Schultze 1888, 1889). The first woman to earn a medical degree in the Netherlands, Aletta Jacobs (M.D. 1879, Groningen), became a sort of medical missionary to prostitutes (Stamhuis 1998). Elizabeth Blackwell had wanted to become a surgeon; it would have been interesting to see what shape her battle would have taken if her accidental loss of the sight of one eye in November 1849 had not effectively precluded a career in surgery.

The two main reasons given in the mid-nineteenth century for denying medical education to women were what we may call "the physiology argument" and "the delicacy argument." The former held that women naturally lacked the intellectual and physical attributes to tolerate the rigors of medical education and practice, and that women physicians would thus be naturally inferior to men in the same role. Among the most outspoken promulgators of this view was Harvard Professor of Materia Medica Edward H. Clarke, who admitted freely that women had the right to study and practice medicine, but denied that they had the physical, mental, or emotional nature to exercise this right, especially at a certain time of the month (Clarke 1869). The latter argument held that it was immoral for women to listen to talk about male genitalia, to dissect male bodies, to discuss anatomy with men, to perform any medical or surgical procedure except obstetrics and/or gynecology, etc. Some who held this belief (e.g., Colby 1844, Gregory 1850) also held that it was morally improper for men to attend women in childbirth. One of these, Samuel Gregory, was specifically interested in training female midwives and obstetricians. For the former argument there was no solution; but for the latter there existed the possible remedy of establishing parallel single-sex medical education.

Single-sex medical schools for women began to emerge in America in the 1840s and 1850s. The analogous development in Europe was minimal, e.g., the efforts of Sophia Jex-Blake in the founding of the London School of Medicine for Women in 1874 and the Edinburgh School of Medicine for Women in 1888. Samuel Gregory founded the Boston (after 1856 New England) Female Medical College in 1848; Quaker physicians led by Bartholomew Fussell founded the Female (after 1867 Woman's) Medical College of Pennsylvania in 1850 (Marshall 1897); and some institutions, such as the eclectic Penn Medical University of Philadelphia, offered medical courses for men and women in segregated departments. Citing the delicacy issue, i.e., the concessions to modesty that would have to be made if medical education were co-educational, but still advocating with apparent sincerity the best possible medical education for both sexes, some male physicians argued that Harvard should create its own separate single-sex medical school for women ("Admission" 1878). But with men such as Clarke on the faculty, Harvard remained unwilling to consider educating women in any way for any kind of medical career.

Men were divided on the question of delicacy and/or discretion. Some believed that the idea of any woman exposing her body to any man other than her husband, even for medical care, was morally repugnant, and thus the woman's health must either be sacrificed on the altar of modesty or else consigned to the care of other women, even though such care would naturally be medically inferior to the care that a male physician could have given her. Other men believed that the health of women was sufficiently important to permit the temporary suspension of the religious and social demands of modesty in order that a sick, pregnant, or nursing woman could be treated by a qualified male physician, thus saving her from the inferior care that a female physician, healer, or midwife would be likely to give her.

Plenty of pure misogyny disguised itself as sanctimonious appeal to delicacy in the nineteenth century (e.g., "Admission" 1879).

The predominant attitude of nineteenth century professional men toward women was condescension, either non-misogynistic (e.g., Williams 1850, Späth 1872, Clarke 1874, Fowler 1877) or misogynistic, as epitomized by Schopenhauer, the most widely read Continental philosopher in the latter half of the nineteenth century:

You need only look at the way in which she is formed, to see that woman is not meant to undergo great labor, whether of the mind or of the body. She pays the debt of life not by what she does, but by what she suffers; by the pains of childbearing and care for the child, and by submission to her husband, to whom she should be a patient and cheering companion. The keenest sorrows and joys are not for her, nor is she called upon to display a great deal of strength. The current of her life should be more gentle, peaceful and trivial than man's, without being essentially happier or unhappier. (Schopenhauer 1967, p. 295; cf. Stoll 1815, Bischoff 1872, Zehender 1875)

2. The Struggle of Elizabeth Blackwell

1999 marks the 150th anniversary of the entrance of women into the modern medical profession. On January 23, 1849, Elizabeth Blackwell (1821-1910) received her M.D. from Geneva Medical College in Geneva, New York, the first such degree earned by a woman anywhere in the world. In reaction to the general outrage of the medical community, Geneva Medical College immediately shut its doors to women. Even though Elizabeth Blackwell had been graduated at the top of her class, the powers-that-be declared her a freak whose unnatural example ought not to be followed by other women. In the early 1850s not even Elizabeth's sister Emily could persuade Geneva to relax its new policy (although there is a record of a Martha A. Rogers receiving an M.D. from Geneva over a decade later, in 1865, i.e., at a time when that medical school was in deep financial trouble). Emily Blackwell (1826-1910) finally received her M.D. from Cleveland Medical College in 1854, after having been rejected by several other American medical schools besides Geneva, and after having been expelled from Rush Medical College in Chicago because of her gender (Waite 1930).

Elizabeth Blackwell was not the first woman to practice medicine or to be recognized as a physician. Women have been practicing medicine, both openly and secretly, since ancient times (Hurd-Mead 1938). She was not even the first to practice in America (Hurd-Mead 1933). That distinction probably belongs to Harriot Kesia Hunt (1805-1875), who practiced openly for about twenty years in Massachusetts before being allowed to attend lectures at Harvard Medical School in 1850 and receiving an honorary M.D. from WMCP in 1853. But by modern educational and credentialing standards, Blackwell was the first woman in the world to earn a regular M.D. degree from a regular or accredited medical school by means of satisfying the standard requirements of a full course of study.

A cogent challenge to Elizabeth Blackwell's status as the world's first regular woman physician could be made by partisans of Dorothea Christiane Leporin Erxleben (1715-1762), a German practitioner who was awarded the M.D. by the University of Halle in 1754 on the then usual basis of writing a dissertation and passing an examination. She had already been in medical practice long before 1754, having been taught medicine at home by her physician father. But in 1753 three local male physicians with M.D. degrees brought suit against her for, so they alleged, practicing medicine illegally. In response to this lawsuit, she exhumed an old special decree of Frederick the Great, King of Prussia, from 1741, which allowed both her and her brother extraordinary dispensation to take the medical examinations at Halle. Taking advantage of this document, she turned the lawsuit in her favor, won the degree, and merely returned to her everyday life.

After Dorothea Erxleben, several other German women claimed to have M.D. degrees, but in general they were just highly credentialed midwives. Blackwell (1847; cf. Waite 1947) mentions a Fräulein Sebold whom she believed had earned a German M.D. and was practicing medicine in Berlin in the 1840s, but she was probably misinformed. Sebold was perhaps an independently practicing midwife -- they were common enough in Europe in that era -- but apparently there were no women practicing in Germany as genuine physicians with M.D. degrees until Franziska Tiburtius (1843-1927) and Emilie Lehmus returned to their homeland with Swiss degrees in 1876; and apparently, although many women with foreign medical degrees practiced legitimately in Germany in the late nineteenth century, no woman received a regular medical degree within Germany itself until 1906. There were several prominent German midwives named "von Siebold" in the late eighteenth and early nineteenth centuries; perhaps Blackwell had one of them in mind.

Also before Blackwell's time there were quite a few women who obtained M.D. degrees by deceit, i.e., by pretending to be men. The most successful of these was Miranda Stuart (1792?-1865), who, calling herself "James Barry," was graduated with an M.D. from the prestigious medical school at Edinburgh in 1812, served as a high-ranking career medical officer in the British army, particularly in Canada, and was discovered to be female only at her death, when her request to be buried in whatever clothes she happened to be wearing when she died was disregarded (Russell 1943, Binnie 1992).

The story of Elizabeth Blackwell's fifteen months as a student at Geneva Medical College epitomizes the nature of mid-nineteenth century prejudice against women physicians and medical students. There is evidence that the greatest social and professional obstacle for her and other early women physicians was not the no-holds-barred hostility or the direct opposition of some segments of the medical community, but rather the secret machinations and hypocritical decisions of those medical men who assumed a limited acceptance or toleration of women studying medicine. Whereas the hostile component would simply deny all women the opportunity to become physicians, the tolerant component, on the other hand, tended to see woman physicians as freaks, as legitimate exceptions to the natural position of women, and thus in effect denied women physicians the right to be fully human.

With few exceptions, the Geneva community treated Elizabeth Blackwell terribly. Her very admission to medical school itself was just a practical joke that the students played on the faculty. Doctors' wives refused to speak to her. Townies stared at her as if she were an exotic animal. Many regarded her as either a lewd woman, or insane, or both, and in any event someone sure to be a bad influence on children. Professor James Hadley, the Registrar, promised her letters of recommendation but never sent them.

Professor of Anatomy James Webster was her only champion among the faculty. He supported her forthrightly, personally, and actively. Having been there only four days, and after only two days of lectures, she wrote to one of her sisters on November 9, 1847, "I feel sunshiny and happy, strongly encouraged, with a grand future before me, and all owing to a fat little fairy in the shape of the Professor of Anatomy."

Geneva was a rowdy place in 1847. Webster's colorful vulgarity made him exceedingly popular in this macho environment. Prior to Blackwell's arrival, he enjoyed a grand reputation among the students for his jovial manner and especially for the ribald jokes he would tell in connection with his dissections of the male reproductive system. Although he had welcomed Blackwell from the start, he politely suggested that she not attend that particular session. But when she offered him sound reasons why she should attend, he relented, and confessed to the whole class that he had been justly rebuked. Stephen Smith (1895) discussed this incident at some length and concluded that her presence in Webster's course lifted the minds of professor and students alike out of the gutter and forced the students to concentrate instead on actually learning the material.

Forty years later, Blackwell wrote that the duty of women in medicine was not to imitate men in medicine, but to define ever more clearly what is morally right and wrong in medicine (1889, pp. 5-7). For her, the entrance of women into medicine made the profession in general more moral, i.e., more responsive to a wider variety of human needs than men alone recognize. This is because the "high moral life, enlarged by intelligence" is the natural "ideal of womanhood" (1889, p. 9). "It is through the moral, guiding the intellectual, that the beneficial influence of women in any new sphere of activity will be felt" (1889, p. 9).

As Dean of the Faculty of Medicine, it was Charles Alfred Lee who delivered the valedictory address at her commencement. In this speech he invariably called his audience just "Gentlemen" -- as if sarcastically alluding to the fact that not all of the people in his audience were physically capable of ever becoming gentle "men." Yet his rhetoric, if he had been sincere (and Blackwell apparently thought it was), may have been applauded even by feminists, for at one point he said, in specific praise of the thoroughness and integrity of Blackwell's study of medicine:

Such an instance of self-sacrificing devotion to science; of perseverance under difficulties, and obstacles next to insurmountable -- of unremitting, unrelaxing toil, in pursuit of that knowledge, so important to, and yet so rarely possessed by her sex -- and all this for the purpose of mitigating human misery, relieving the sick, and extending her sphere of usefulness in the world -- this, I say, deserves as it will receive, the heart-felt approbation of every generous and humane mind. This event will stand forth hereafter as a memorable example of what woman can undertake and accomplish, too, when stimulated by the love of science and a noble spirit of philanthropy. Why should medical science be monopolized by us alone? Why should woman be prohibited from fulfilling her mission as a ministering angel to the sick, furnished not only with the softer and kindlier attributes of her sex, but with all the appliances and resources of science? If she feels called to this life of toil and responsibility, and gives evidence of her qualifications for such a calling, in humanity's name, let her take her rank among the disciples of Aësculapius, and be honored for her self-sacrificing choice. Such cases must ever be too few, to disturb the existing relations of society, or excite any other feeling on our part than admiration at the heroism displayed, and sympathy, for the sufferings voluntarily assumed! God speed her, then, in her errand of mercy, and crown her efforts with abundant success! (Lee 1849, pp. 27-28; italics added)

The actuality of Lee's position, however, is not what he indicated in this speech. He and most of his colleagues would have been quite happy if Elizabeth Blackwell had been not only the first, but also the last woman ever to receive a degree in medicine. The published version of Lee's valediction contained this footnote to the exact passage quoted above:

Since the above discourse was delivered an article has appeared in the Boston Medical and Surgical Journal, condemning in very severe terms, the conduct of the Faculty of Geneva College, in allowing Miss B. admission to their courses of lectures, and of the Trustees in conferring upon her the degree of M.D.

The writer, while he acknowledges the validity of the argument, so far as it is founded on the general physical disqualifications of the sex for the medical profession, and the incompatibility of its duties, with those properly belonging to the female portion of society, believes, nevertheless, that instances occasionally happen, where females display such a combination of moral, physical, and intellectual qualifications for discharging creditably and skilfully the duties belonging to our calling, that it would seem equally unwise and unjust, to withhold from them those advantages and those honors, which are open to nearly all others, whether deserving of them or not. While he holds this opinion, he at the same time feels bound to say, that the inconveniences attending the admission of females to all the lectures in a medical school, are so great, that he will feel compelled on all future occasions, to oppose such a practice, although by so doing, he may be subjected to the charge of inconsistency.

Lee's public pronouncements on her behalf were really just defenses of his institution for having admitted and graduated a woman and thinly disguised apologies to male medical students for having "inconvenienced" them with her. In other words, Lee would rather be both "unwise and unjust" than participate in creating any further "inconveniences" for men. For him (as also for "Justus" below), the only way in which a woman could legitimately become a doctor would be to first "defeminize" herself and assume instead the purely "masculine" moral and intellectual characteristics of medical men, since women are "generally supposed to be wanting in the physical, if not moral qualifications necessary for the successful practice of the Healing Art" (Lee 1849, pp. 26-27). Of course, such a process of "defeminization" is contrary to nature, and is thus to be condemned. The "argument" in BMSJ of which Lee acknowledged the validity was contained in a particularly venomous letter to the editor (D.K. 1849) in reply to the journal's simple reporting, without judgment ("Doctress" 1849), of Blackwell's commencement:

Whatever may be the character and acquirements of this individual, it is much to be regretted that she has been induced to depart from the appropriate sphere of her own sex, and led to aspire to honors and duties which by the order of nature and the common consent of the world devolve alone upon men. And I am sorry that Geneva Medical College should be the first to commence the nefarious process of amalgamation. Hitherto an intuitive sense of propriety has induced all civilized nations to regard the professions of law, medicine and divinity as masculine duties, and by the universal acceptation of both sexes, the sterner offices and responsibilities incident to these vocations have been considered most compatible with the physical and mental constitution of the male sex. ... The distaff, the needle and the pencil look better in [a woman's] hand than the hoe or the scythe, the trephine or the gorget. The course of "domina Blackwell" cannot be justified by any urgent necessity. The profession was quite too full before, and could well afford to dispense with her services. I know we sometimes hear of runaway maidens serving in disguise in the army or on shipboard, but such heroines deserve very little commendation, and the rudest commander has always had a sufficient sense of propriety to discharge such "dominae" as soon as their sex was known. Would either of the other learned professions have received and graduated a female? Would any amount of study or learning have gained her admittance to the bar or the desk? Certainly not. Then why desecrate the profession of medicine, and publicly disparage it? If a clique of pseudo-reformers, or some mushroom Thomsonian or hydropathic association, had conferred this degree, it would have been a matter of no surprise, because it would be in perfect keeping with their transactions. As this is the first case of the kind that has been perpetrated either in Europe or America, I hope, for the honor of humanity, that it will be the last. And I trust that the high-minded members of the profession will so manifest their disapprobation of the transaction, as to teach other similar institutions the impropriety of following the example.

This letter, signed only "D.K.," was answered the following week by the pseudonymous "Justus":

D.K. ... seems shocked at the conferring of the degree of M.D. upon a female at the recent commencement at Geneva College. Your correspondent is decidedly behind the age. How long is it since the leading physicians of Boston sent out a circular, recommending the establishment of an institution for the education of females in the art and science of Midwifery? Prof. [John Collins] Warren can enlighten him on this point, should he need information. Are there no female accoucheurs in this country? Are there none in France and Great Britain? Were there none in Egypt in the time of the Pharaohs, about the period of Moses' birth? How was it in New England, in the time of our forefathers? ... Has D.K. never heard of Madame [Marie Anne Victoire] Boivin, M.D. [sic], of Paris, the distinguished lecturer and writer on obstetric science? The fact is, there are, and always will be, female accoucheurs; the only question is, shall they be educated? There can be but one opinion on this point. As to females engaging in the general practice of medicine, the idea is absurd; D.K. need have no fears of a rivalry, which he seems to dread, as about to jostle him uncomfortably. ... D.K. talks of "the professions of law, medicine and divinity, as masculine duties." Are there no masculine females? ... I see no reason, why, if a female has made the proper acquisitions, and proved herself worthy of the honor, she should not receive the degree of M.D., as well as Mr. D.K., or any other person. ... We honor [Geneva Medical College] for its liberality; and we believe the profession will sustain it still more generously for the disinterested betstowal of its honors on the deserving, irrespective of sex or condition. Even admitting the correctness of D.K.'s remarks in general, with respect to woman's unfitness for engaging in the practice of medicine, it would be strange indeed if exceptions did not occasionally occur. From all we have been able to learn respecting Miss B., she is emphatically an exception. "Exceptio probat Regulam."

The names 'D.K.' and 'Justus' are both phonetic puns on the word 'justice', the latter directly, the former indirectly by way of the Greek dikê. Why did these two authors, presumably each secure in the courage of conviction, yet feel the need to hide behind the veil of noms de plume? Plainly the greatest "next to insurmountable obstacle" that Blackwell had to overcome was neither the alleged physical, intellectual, and moral limitations of her sex nor even the open hostility of conservatives such as "D.K.," but rather the entrenched hypocrisy or crypto-misogyny of liberals like Lee, "Justus," and their fellow "gentlemen."

Elizabeth Blackwell concluded -- correctly -- that she would meet a bit less resistance in Europe than in America. After Geneva she pursued postgraduate medical studies first in Paris, then in London.

One curious consequence of her seeking professional refuge in Europe was that, in addition to being the first woman doctor in America, Blackwell herself was also the first woman doctor in Great Britain. That is, in 1858 she became the first woman to be entered in the British Medical Register (Gillie 1958). When the young British feminist Elizabeth Garrett (1836-1917) met Elizabeth Blackwell in 1859, she was inspired to try to become the first woman to earn a medical degree in Britain. Even with the support of her father, Newson Garrett, a wealthy but lowborn merchant, she was unable to overcome the prejudice of the male medical community and was refused admission by every British medical school. She then tried to sneak into medicine by the back door. She became a nurse at Middlesex Hospital and there attended lectures given by and for physicians and medical students, but when the medical students complained about her presence at these lectures, the administration forbade her to attend any more. She then discovered a loophole in the British Society of Apothecaries regulations, sat for their qualifying examination, passed it, and thus in 1865 obtained the certificate necessary for her to practice medicine (Anderson 1893). Her father's money established her practice in London; the Society of Apothecaries immediately changed its regulations specifically to bar women; and the British Medical Association refused to include her in the British Medical Register. Even after she earned a genuine M.D. degree in Paris in 1870, the British Medical Association still would not accept her until 1873. Perhaps her marriage in 1871 to James Anderson, financial advisor to the East London Hospital, had something to do with that.

The struggle of women physicians since the time of Elizabeth Blackwell has been both to gain acceptance as doctors, i.e., to live up to their medical credentials, as all physicians are expected to do, and to gain acceptance as women, rather than being regarded merely as freaks of nature, male minds in female bodies, "masculine females," or the like. In the nineteenth century, both the proponents and opponents of women's medical education agreed on at least this point: A woman as a woman could not become a doctor; in order to become a doctor she must first become "manlike" in the appropriate ways. Moreover, such "defeminization" must always remain the exception. Exceptio probat regulam. As long as the consensus of the medical community remained that women doctors were to be "exceptions," every woman doctor was placed by society in the demeaning psychological dilemma of having to choose between her success as a doctor and her identity as a woman. She could not have both. She could either deny her femininity and gain some measure of respect as a physician in a male world, or be true to herself as an integral woman and lose a proportionate degree of the trust of her patients.

To illustrate this last point: In the second appendix to Pioneer Work, Blackwell quotes a satirical poem about her from an 1849 issue of the British humor magazine Punch. Among the images in this poem is "a gold-handled parasol," the reference being to the gold-handled cane as a traditional emblem of the medical and surgical professions. Now if, in the nineteenth century, a woman doctor were to carry a gold-handled cane, she might be taken seriously as a doctor, but at the cost of undermining her feminity by assuming a distinctly male accessory. By the same token, if she were to attempt to preserve her idea of her own femininity by carrying a gold-handled parasol as the emblem of her profession, then she would certainly not have been taken seriously as a doctor. The struggle, then, continuing with the metaphor, would be to create a social climate in which women physicians could carry such things as gold-handled parasols or pink stethoscopes if they so chose and still be taken seriously as doctors. We may well ask whether this struggle has yet been won in the twentieth century, whether medicine is now generally taken to be a "human" rather than a "masculine" profession, and whether women physicians are now no longer regarded as freaks, but accepted as natural beings, female minds in female bodies, "feminine females," and so on.