Science Has No Sex
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After the move to Roxbury, hygienic needs were met by keeping hospital rooms small. Thus the rooms in the medical ward had one to four beds and those in the surgical ward one to three beds. The maternity ward, now housed in a separate cottage, had rooms with no more than two beds and a separate delivery room. Zakrzewska, as we have seen, drew special attention to the way
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in which the new hospital met hygienic standards, emphasizing that the new institution permitted her to leave rooms vacant for the purposes of purification.
This strategy permitted the resident physician in 1873 to brag that in the new hospital’s first year ‘‘we have had the great happiness not to lose one patient, notwithstanding the prevalence in Boston and vicinity of puerperal fever, and notwithstanding the several very serious cases of septicaemia, pyoemia and peritonitis, which have occurred in the Maternity Ward.’’≤∫
Anyone familiar with nineteenth-century hospitals would recognize that to some extent there was nothing novel about Zakrzewska’s insights. The di≈-
culty of controlling the spread of infectious diseases in hospitals had even led one physician to coin the term ‘‘hospitalism’’ in the mid-nineteenth century to describe the periodic outbreaks that seemed nearly impossible to control.
The widespread explanation for these occurrences drew on miasmatic theory and postulated that the generally unhealthy air within hospitals, consisting of a combination of urban fumes and bodily emanations, led to such periodic eruptions—hence the near obsession among hospital directors in the nineteenth century with clean air, good ventilation, and ample sunlight. This also explains the standard practice of occasionally closing hospitals, or at least wards, in order to whitewash them and take care of repairs.≤Ω
From this perspective, one could simply say that Zakrzewska managed to implement hygienic practices whereas others remained in the realm of theory.
But Zakrzewska’s insistence that hands be washed, her division of maternity cases by stages of delivery, and her isolation of suspicious cases all suggest that she held a more complicated view of infection that did not attribute the spread of disease to the air alone. Indeed, in 1862, three years before Lister published his findings, Zakrzewska noted after contracting an infection that ‘‘when my finger became infected, it was apparently perfectly sound, yet there must have been some point of entrance for the infection which followed.’’≥≠ Her comment
suggests her awareness and acceptance of a view of disease that enjoyed considerable popularity among German academic physicians in the 1840s. Rudolph Virchow, whose work Zakrzewska knew, and Jacob Henle, among others, had defined disease as the response of the body’s normal physiological processes to abnormal conditions; according to this definition, the abnormal conditions could be ‘‘contagions’’ or ‘‘miasmas.’’≥∞ Acting on these beliefs allowed Zakrzewska to limit the spread of infection even before the application of antiseptic techniques.
According to Emma Call, who practiced medicine at the New England
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Hospital in the 1870s and 1880s, there was little evidence of any such antiseptic techniques before 1877, when the hospital finally introduced the use of carbolic acid and disinfected, through antiseptic douches, before, during, and after labor. Yet even then, she contended, the meaning of the germ theory had not yet penetrated, for these douches were often left in the drawer by the patient’s bed,
‘‘with innocent disregard of the colonies of bacteria which might be reposing there.’’≥≤ It should not, of course, be surprising if, in the 1860s and 1870s, Zakrzewska had not yet fully embraced the germ theory. Few Americans or, for that matter, Germans had. But, as we have just seen, those who questioned whether bacteria were the sole cause of infectious diseases did not necessarily reject the idea that infections could be stimulated by the entry of some kind of external agent into the body’s system. Of importance here, this view provided Zakrzewska with su≈cient motivation to adopt rigorous standards of hygiene.
In her own words, ‘‘carelessness and want of thorough cleanliness is at the bottom of epidemics of puerperal fever.’’≥≥
Zakrzewska had set out to create an institution as mainstream as Massachusetts General or any of the other highly esteemed hospitals at the time. She sought to achieve this by sta≈ng her institution with the most highly educated women physicians she could identify, by ensuring that members of Boston’s medical elite served as consultants on her sta√, and by implementing the most advanced medical techniques available at the time. But the New England Hospital was not merely a way of showcasing the skills and successes of a small group of highly accomplished women; it was also a teaching hospital, committed to providing the next generation of women doctors with the clinical training denied them at most other hospitals in the United States.
. . .
When the New England Hospital for Women and Children first opened its doors in 1862, it was only the third institution in the country where women could acquire clinical training at the bedside.≥∂ It was thus filling an important
niche. Like the New York Infirmary for Women and Children, which had opened with twenty-four beds, and the Woman’s Hospital of Philadelphia, which had twelve beds, the New England started small, with just ten beds at its disposal. But by 1865 it had expanded to forty beds, and by 1872 to fifty-five.≥∑
This paralleled both an increase in the number of interns—three a year between 1862 and 1876 and six a year thereafter—and an increase in the number of patients admitted to the hospital, climbing from 118 in 1863, to 244 in 1873 (the first full year in Roxbury), to 585 in 1893 (the year Zakrzewska retired). Al-
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though in absolute numbers this increase might still be considered small, this would not be true of the number of dispensary patients. Here, the hospital cared for 1,507 patients in 1863, 2,905 in 1873, and 3,859 in 1893. ≥∏ Clearly, the interns and resident physicians had ample opportunities to observe a variety of disease conditions and to learn how best to translate medical knowledge into practice.
Interns in the first decades of the New England’s existence consisted of a diverse group of women. Some already had medical degrees; others were in the midst of their studies; and still others had not even begun their formal education. Such diversity reflected, at least in part, the unregulated nature of the profession itself. At a time when medical licensing was nonexistent, it is not surprising to find great variation in the way people acquired their medical expertise. But more than likely Zakrzewska was also responding to the particular situation faced by women: since they were denied entry to most medical schools, she probably considered it unfair, at least initially, to restrict the clinical internships to those with a medical school a≈liation.≥π
The clinical program was built on the assumption that engaging students in
‘‘the actual care of and attendance upon the sick’’ was far better than ‘‘travers-ing the wards of a hospital in the suite of a professor.’’≥∫ Thus the interns, who usually remained one year, accompanied physicians on their daily rounds; assumed responsibility for the patients’ care during the day; and kept the hospital notebooks, recording all prescriptions and describing each visit with the patient (sometimes twice a day), including the patient’s condition and the treatments administered. Interns also occasionally assisted in operations; they frequently attended women during their confinements; and they may have learned to perform ‘‘version,’’ the manual turning of a baby in utero to assist in a di≈cult delivery. Eliza Mosher, who trained at the New England Hospital in 1869 before entering medical school, later recalled that the interns ‘‘were permitted to examine as carefully as we wished, all the confinement patients in the di√erent stages of labor. During those months there were over fifty confinements in the hospital. We were expected to make a diagnosis of position and condition and
watch every delivery.’’≥Ω She remembered finding the obstetrics classes she later attended at the University of Michigan to be a waste of her time.
Sarah J. McNutt, who interned at the New York Infirmary for Women and Children around 1880, had a similarly positive experience. She described visiting the wards daily, assisting in surgical operations, taking charge of more than fifty maternity cases and observing another hundred or so, and mixing medicines in the dispensary.∂≠ The point, of course, is not that interns at all-women’s
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hospitals received better or more extensive training than did male interns at other institutions. Rather, what the New England Hospital, New York Infirmary, and Woman’s Hospital of Philadelphia provided was an opportunity for women to compete for elite hospital internships, which were few and far between even for men.∂∞
Whatever independent work the interns might have been permitted to carry out in the hospital wards, nothing compared to their experiences in the dispensary. It was here, in the words of one hospital doctor, that interns learned
‘‘practically what it is to be a physician.’’∂≤ Sophia Jex-Blake, who volunteered for three months in 1865, described her day as follows: she was up every morning by 6:30, ate her breakfast at 7:00, and began her rounds with the doctors, making up the medicines ordered by the physicians. By either 9:00 or 10:00, depending on the day of the week, she was in the dispensary, where she spent the rest of the morning, ‘‘making up prescriptions as fast as [Dr. Sewall] writes them (two of us generally have our hands full, but sometimes I am alone), and very often we have not got through our work when the dinner-bell rings at 1 p.m.’’∂≥
In subsequent years, interns assumed more responsibility, especially for patients too ill to make it to the clinic. Thus, interns assigned specifically to the dispensary (after 1875 there were two) lived on the premises in order to be available when word came that someone was ill. Similarly, it was the student’s job to attend the sick person at home and determine whether a physician needed to be called. Although statistics from the 1860s and 1870s are lacking, by the 1880s each intern made roughly a thousand visits during the four months that she spent doing rotation in the dispensary. It is not clear whether the interns administered any medical treatments during these visits, but chances are they had authorization to treat minor cases and to take care of any follow-up the physician deemed necessary.∂∂
By the early 1870s, moreover, interns were responsible for recording various physiological processes on a daily basis. These included the patients’ pulse, respiration, and temperature. One student remembered the thermometers Susan Dimock had brought back from her studies in Europe: they were ‘‘nearly a foot in length, and were not self-registering, so that they could only be read in situ, a feat not easy to accomplish in a poor light. They were used chiefly in the axilla
[in the armpit].’’∂∑ Interns then prepared charts from this information, which they presented to the resident physician twice weekly. According to one historian, the New England was the first hospital in Boston to keep such charts on a regular basis.∂∏
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Record of a patient at the New England Hospital for Women and Children. (From the collection at the Boston Medical Library, Francis A. Countway Library of Medicine) In the early 1870s, it also became more routine to conduct microscopic examinations of tumors and bodily discharges. And by the early 1880s a detailed analysis of the patient’s urine was included in the standard physical examination, in which the amount, acidity, specific gravity, albumen, sugar, pus, blood corpuscles, and casts were all recorded.∂π That students performed these analyses themselves is clear from the experience of Kate Campbell Hurd-Mead, who interned at the hospital in 1888. ‘‘Those were the days,’’ she later wrote, ‘‘of carbolic steam in the operating room, of instruments boiled and washed in corrosive sublimate solutions and scrupulously scoured by the internes, of all-night vigils with each abdominal case, besides crude bacteriological tests and sputum stainings in the cellar pharmacy where, with an old microscope and after a hard day’s work, any interne not otherwise busy examined specimens of cancer or of urine, and made chemical investigations of any material sent to the laboratory.’’∂∫
To the modern eye, none of this appears to be highly advanced science, but it
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was as advanced as one would find anywhere in the country at the time and considerably more sophisticated than in most hospitals. Of marked importance, considering complaints that would surface in the 1880s, the first generations of interns valued highly the kind of education they were receiving. ‘‘You don’t know what an immense thing it is for us to have got free admission to the Woman’s Hospital life here,’’ wrote Jex-Blake in 1865.∂Ω Whether delivering babies, visiting the poor in their homes, or writing down directions for food and medicine, they appreciated both the novelty and the quality of their experiences.
Denied access to most medical institutions in the United States, the first generations of interns and sta√ physicians felt deep gratitude toward Zakrzewska and the New England Hospital for providing them an opportunity to study at the bedside. Filled with the excitement that comes when one is helping to chart a new path, the women who practiced medicine at the New England in its first years formed a close-knit group, often choosing to socialize together after a long day at the hospital. In her letters home to her mother, Jex-Blake described evenings spent at the theater, visiting ice cream shops, or simply spending time together in the hospital, singing songs, playing card games, and losing themselves in ‘‘roars of laughter.’’∑≠ Zakrzewska had set out to create a woman’s hospital at the forefront of medical teaching and medical science, and judging by the standards of the regular medical profession—and the experiences of the first generations of interns—she had accomplished that and more. She had also fostered a shared sense of mission, which united sta√ and students in promoting
‘‘the cause of women-practitioners in medicine.’’∑∞
. . .
The euphoria of the first years did not last. As early as 1876, some interns were already registering minor complaints. The situation was eventually resolved to everyone’s satisfaction, but the tensions that surfaced set the stage for more serious problems later on. We know of this first encounter only from a text Zakrzewska prepared in anticipation of a meeting she arranged with the interns; a formal complaint was never submitted. But if Zakrzewska accurately represented the interns’ concerns, then the central issue had to do with respect: the interns felt that the hospital sta√ ’s insistence on addressing them as Miss or Mrs., rather than Dr., belittled them before their patients. Zakrzewska, showing her usual impatience, turned the tables and accused the interns of being disrespectful themselves by failing to learn about ‘‘the motives and reasons for the existence of this Hospital.’’∑≤ Their needs, she implied, were petty compared with the greater mission of the institution. But she also found them silly. Inter-
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preting their criticisms as an attack on her own pedagogical style, she insisted that she showed more respect toward them than any title ever could. In her eyes, her scrutiny of their clinical skills was designed to ‘‘teach them to form an opinion of their own’’; moreover, she expected them to question her style of practice whenever they deemed it appropriate.∑≥ In other words, Zakrzewska imagined herself to be educating critical thinkers by fostering an open exchange of ideas. What she failed to understand was the power she wielded, unaware that students may have felt uncomfortable questioning her ways. Even turning their request for greater respect into a defense of her own pedagogical style may have made many uneasy. Certainly, the picture she painted of them as cowardly and self-centered, focused more on their own selfish desires than the needs of the hospital as a whole, would hardly have encouraged an open excha
nge.
More, however, was going on in this disagreement over the meaning of the title ‘‘Dr.’’ Zakrzewska did not simply find it inessential; she also believed that the interns did not yet deserve it, even those who had already earned the M.D.
No one, she insisted, yet knew enough to take responsibility for her own patients; only at that point would one earn the right to be called ‘‘Dr.’’ ‘‘I, for my own self,’’ she announced at this point, ‘‘would prefer never to be called ‘Dr.’ but rather ‘Miss’ or ‘Madam’ as so many of my patients like to address me. For me, it is far more agreeable to be considered first, a woman, and secondarily a ‘Dr.’ ’’∑∂
This last line has received considerable attention from historians, who discern here a growing divide between a younger generation more committed to professionalism and an older generation for whom a commitment to female solidarity reigned supreme.∑∑ It is easy to see why Zakrzewska’s comment would be interpreted in this light. She was announcing unequivocally that her identification as a woman was stronger than her identification as a physician, that she cared less about her professional identity than about the political work she was doing to help break down the barriers keeping women out of the medical profession or, for that matter, out of the public sphere at large. Indeed, later in the report, in a moment of exasperation, she wrote: ‘‘I only wish all women to have the right to do and to study what they like best.’’∑∏