Science Has No Sex

by Arleen Marcia Tuchman

  As far as the transformation to a community hospital was concerned, my guess is that Zakrzewska would probably have signed on. Most likely this would not have reflected a renewed commitment to charity—at the end of her tenure at the New England, Zakrzewska had announced her lack of interest in the institution’s charitable work∞≠∞—but rather a belief that research institutions did not provide the best environment for training physicians. In the early twenty-first century, we have come to believe that research hospitals provide both the best care and the best educational setting, but Zakrzewska may not have been so quick to agree. Her understanding of science translated into a commitment to careful bedside investigations, advanced diagnostic techniques, hygienic practices, and, increasingly in the 1880s and 1890s, surgery. But to the extent that the twentieth-century hospital became increasingly defined by a research ethic that at times placed the acquisition of medical knowledge before improvements in medical care, the New England Hospital was only tangentially a part.∞≠≤ Zakr-

  zewska never saw herself as educating female scientists who conducted research in the laboratory or even, for that matter, at the bedside. In this regard, she could not have di√ered more from her colleague Mary Putnam Jacobi. Rather, her entire goal had been to educate good practitioners. Something regarded as ‘‘scientific thinking’’ or ‘‘scientific rationalism’’ had been an integral part of that, but scientific investigations had not been. Thus, as other hospitals strengthened their ties to medical schools and integrated themselves more directly into the emerging scientific complex of university/laboratory/hospital, Zakrzewska showed little interest in pursuing that path.∞≠≥ Indeed, as the cen-

  tury wore on, she joined the critics of bacteriology and even some branches of surgery. Zakrzewska may never have abandoned her commitment to science, rationality, and materialism, but she did hold on to an understanding of these categories that seemed increasingly out of place as the new century dawned.

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  The last decade of Zakrzewska’s life was one of increasing disillusionment with the direction the medical world was taking. The battles with the interns at the New England Hospital had been only one manifestation of this. In a number of public and private writings in the late 1880s and 1890s, Zakrzewska criticized the increased use of instruments in the birthing process, bacteriology, vaccination, gynecologic surgery, and the narrowing of the definition of disease to the pathophysiological changes of the body. In their stead, she promoted prevention, hygiene, and therapeutic restraint, thus linking herself with an older style of medical practice that had assumed the primacy of the doctor-patient relationship, the notion of stewardship, and an expansive notion of science that was closer to a worldview than a specific method for acquiring knowledge.∞ In some

  ways, Zakrzewska had come a long way from the public pronouncements she had made in her youth when she had paraded the instrumental savvy of the New England Hospital’s physicians and appeared more inclined to view the body in strictly biological terms. Yet in other ways, much had stayed the same, for Zakrzewska’s criticisms of modern medicine stemmed largely from her inability to reconcile recent changes with the understanding of science and morality she had developed around midcentury and nurtured ever since.

  Zakrzewska was not alone in her complaints. The last third of the nineteenth century was marked by contentious battles over the path modern medicine should pursue. Elizabeth Blackwell, certainly at one extreme, blamed laboratory medicine, especially vivisection, for blunting the medical student’s sense of morality. Other critics of the laboratory, more moderate in their views, worried nevertheless about the denigration of the clinic and thus the kind of knowledge acquired at the bedside. The targets of their criticisms were, for the most part,

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  young disciples of the rapidly proliferating German laboratories, who imagined a day when the specialized scientific knowledge produced in the laboratory would be capable of driving therapeutic practices.≤

  Zakrzewska, as we will see, occupied a somewhat anomalous position, in part because of her roots in German medicine, but there is no question that she, like many of her generational peers, questioned both the scientific and the moral legitimacy of the direction in which modern medicine was moving. True to her lifelong beliefs, however, she did not frame these tensions in gendered terms, although others certainly did. Indeed, one of the strategies of those enamored of the German laboratories was to discredit earlier approaches by gendering them feminine, implying that only the work that went on in the laboratory could wear

  the mantle of masculinity.≥ Elizabeth Blackwell, too, gendered these competing medical approaches, but instead of lauding such masculine endeavors, she held them responsible for injuring medical students’ ability to sympathize with the su√ering of their patients.∂ Zakrzewska shied away from such gendered stereotypes, preferring to attribute di√erent viewpoints to a generational divide. Nevertheless, through her promotion of prevention, hygiene, and therapeutic restraint and her rejection of bacteriology, she ended up aligning herself more closely with Blackwell and others who maintained that women practiced a di√erent style of medicine. This alliance was strengthened, moreover, as she came to view women’s bodies as sacred and childbirth as a central event in a woman’s life. Zakrzewska never stopped promoting the virtues of science and rationality, and she never abandoned her belief in materialism, but the meanings she ascribed to these terms brought her, by the end of the century, closer to those who believed in a woman’s distinct sphere of influence than she had ever been in her life.∑

  . . .

  One of the first public venues in which Zakrzewska criticized modern medicine was an article she published in 1889 in the Boston Medical and Surgical Journal.

  ‘‘Report of One Hundred and Eighty-Seven Cases of Midwifery in Private Practice’’ was the first and only article Zakrzewska ever published in a medical journal.∏ It was, as Zakrzewska announced, intended to counter the image young practitioners were receiving of obstetrics as a highly complex field of study that required the use of instruments. At the time she wrote this article, Zakrzewska’s voice was one among many calling attention to the dangers of what was often referred to as ‘‘meddlesome midwifery.’’ Although such cautions were not new—for at least the previous sixty years medical journals had

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  Marie Zakrzewska, perhaps around her sixtieth birthday, 1889.

  (Courtesy Archives and Special Collections on Women in Medicine and Homeopathy, Drexel University College of Medicine)

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  been carrying articles admonishing physicians to show restraint when attending women in labor—the proliferation of di√erent types of forceps, the increased availability of anesthetics, and the greater percentage of laboring women who chose to have physicians in attendance rather than midwives had all so acceler-ated the tendency on the part of practitioners to intervene in the birthing process that the number and frequency of concerned voices had also grown.

  Thus, when Zakrzewska chose in 1889 to publish her views on childbirth, she was joining a large group of male and female physicians who had come to disparage not so much the use of instruments and drugs as their overuse.π

  ‘‘I present here the summary report of these 187 cases in my private practice,’’

  Zakrzewska wrote, ‘‘recorded in the succession in which they occurred at the beginning of my obstetrical career.’’ These cases were intended to demonstrate that childbirth was ‘‘the most natural process in a woman’s life’’ and did not, therefore, require that a physician bring along ‘‘a well-equipped bag, containing instruments, disinfectants, drugs, etc.’’ when attending a woman in labor. On the contrary, she insisted, since it is the woman, not the physician, who ‘‘brings the child into the world,’’ the latter should play an active role only in the event of a complication. Oth
erwise, he or she had no reason to intervene until the baby crowned. At that point, the physician’s job was to support the perineum to prevent tearing and then to wait again for the delivery of the placenta. Those who interfered by putting their hand in the uterus often caused inflammation and fevers. ‘‘Only in cases of haemorrhage or appearance of abnormal pains,’’

  Zakrzewska wrote, ‘‘do I interfere with nature.’’∫

  In Zakrzewska’s estimation most of the complications that arose during and after delivery occurred because of the unwillingness of physicians ‘‘to wait quietly for the natural process to take its course.’’ Instead, anxious to hurry labor along, they used forceps to deliver the child and then forcibly removed the placenta, both of which practices often required physicians to intervene further and sew up the tears they had caused. These, Zakrzewska remarked, are the

  ‘‘sorts of ‘scientific’ measures’’ that physicians employed ‘‘to bring a woman through.’’Ω

  This was certainly quite a di√erent picture than the one Zakrzewska had presented in the 1860s, when she had emphasized the instrumental skills of the physicians who trained at the New England Hospital. Now, however, faced by changes in medical practices of which she disapproved, Zakrzewska used language that not only sounded similar to that embraced by advocates of gender di√erences in medical practice but also harkened back to her earlier nemesis

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  Samuel Gregory. Indeed, someone who read in this article about the tears and ruptures caused by physicians, who ‘‘performed all sorts of ‘scientific’ measures’’ rather than allowing nature to take its course, might have thought that he or she had mistakenly picked up a copy of Man-Midwifery Exposed and Corrected.

  In portraying herself as someone who viewed childbirth as a natural process, promoted restraint rather than intervention, and heralded patience as one of the physician’s most important attributes, Zakrzewska seemed almost to be modeling herself on Gregory’s ideal female physician.∞≠

  She certainly seemed to be drawing considerable inspiration from her years as a midwife. Tellingly, Zakrzewska’s first lengthy story in this article dealt with the time she spent both studying and then teaching midwifery at the Charité.

  Modeling this story closely upon that of Ignaz Semmelweis, she explained that the Charité midwives were instructed to let ‘‘nature do the work,’’ with the result that they rarely used forceps and rarely had childbed fever in their wards.

  In contrast, when the male students received their instruction, ‘‘every third case was made a forceps-case, by untimely rupturing the membranes, or by other meddlesome interference with nature.’’ Zakrzewska also had particularly harsh words for Dr. Credé, Joseph Hermann Schmidt’s successor, who instructed the male students in the active removal of the placenta. The outcome, she claimed, was the persistence of ‘‘fevers, purulent ophthalmia, and peritonitis.’’∞∞

  Clearly, Zakrzewska’s outlook on obstetric practices had changed—or perhaps all one can say is that she had chosen to give a di√erent face to the style of practice she wished to promote publicly. Caution is necessary because we lack documents that would allow us to determine whether she had in fact always practiced restraint. There are also reasons to question the complete accuracy of the story she told about the Charité, not the least of which is its uncanny resemblance to the well-known account of Semmelweis.∞≤ Zakrzewska also failed to mention that midwives were forbidden by state law to use forceps.

  Hence, the di√erences in their education may very well have been as much legally as ideologically determined. Moreover, had she so clearly preached against the teaching methods of her superior, chances are that would have been mentioned in the archival records that discussed the conditions of her dismissal, and no such reference was ever made. But whether Zakrzewska o√ered an accurate appraisal of her earlier pedagogical style or not, what is significant is her decision, in 1889, to portray herself as someone who had always been a proponent of a noninterventionist approach to childbirth.

  Still, before we erase any distinctions between Zakrzewska and Gregory, we

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  must keep two caveats in mind: first, a careful reading of her story indicates that she was not in fact attributing any di√erences in practice to gender. Unlike Gregory, or a good number of women physicians for that matter, she was not claiming that women had less of a tendency to intervene or that male physicians had a greater tendency toward ‘‘meddlesome interference.’’ Rather, in her story about the Charité, her message was that the male students had been taught incorrectly and that she had corrected this when she assumed the position of head midwife. At that time, so she claims, she adopted a di√erent teaching method, instructing the male students in ‘‘the mechanism of normal labor, showing them when and how to assist nature in case of an abnormal deviation, using for this purpose the manikin, instead of the living woman.’’ Furthermore, she added, she actively discouraged the male students from using the Credé method for removing the placenta. She was, in fact, so successful at altering the way her male students practiced medicine that ‘‘not one single time, were we removed to the isolating building during that summer.’’∞≥

  Second, unlike Gregory, Zakrzewska did not link her advocacy of restraint and nonintervention to a critique of science. On the contrary, this article, like all her other previous writings, argued for the virtues of proceeding scientifically.

  Indeed, she presented obstetrics not as an art but rather as the branch of medicine that most approached a science because of the near certainty with which one could make diagnoses and prognoses. Even her attack on the ‘‘ ‘scientific’ measures’’ of some physicians was meant to rescue ‘‘science’’ from the hands of those who misappropriated the term. Her complaint was that what they labeled as scientific was actually grounded in a fallacious understanding of the birthing process.

  Thus Zakrzewska had neither abandoned nor even modified her commitment to science. Still, in 1889 the meaning of science she promoted looked backward, not forward, grounded in anecdotes that were intended to demonstrate her ‘‘rational’’ approach to practice. For example, although she added statistical information to support her claim that childbirth was a natural process, her method more closely resembled the style of counting popularized by the early nineteenth-century French clinician Pierre Louis than the sophisticated statistical techniques that had taken hold by the end of the century.∞∂

  Indeed, when Zakrzewska finally turned to the 187 midwifery cases in her private practice (on page 3 of a four-page article) she did little more than inundate the reader with as much information as possible. Thus, she recorded the ages of the mothers, the number of children born and their weight, the

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  number of miscarriages and premature births, the length of labor, the time at which membranes ruptured, the number of normal births compared with the number requiring forceps, and so on. Nowhere did Zakrzewska o√er any interpretation of this data. In fact, rather than conclude by calculating her infant and maternal mortality rates, her rates of complication, or even her rates of intervention, she ended with the description of a case involving a woman who gave birth to a stillborn after su√ering from both typhoid fever and pneumonia during her pregnancy but who recovered within six weeks. The anecdote, not the numbers, was to Zakrzewska the more powerful form of persuasion. ∞∑

  The centrality of the anecdote and, indeed, her older style of practice were even more evident in an article Zakrzewska published four years later in the Woman’s Journal, the o≈cial publication of the American Woman Su√rage Association. Here, Zakrzewska told the story of a farmer’s wife who came to her seeking medical advice. Despite the woman’s glazed eyes, a pale complexion, and complaints of ‘‘sleeplessness, utter lack of appetite, backache, depression of spirits, etc.,’’ a thorough examination revealed no evid
ence of disease. Zakrzewska did not, however, tell the woman that there was nothing she could do.

  Rather, suspecting exhaustion, she recommended ‘‘six months of rest.’’ However, when the woman returned ten days later looking even more haggard, Zakrzewska realized she had misjudged the situation and needed to hear the woman’s entire story. It turned out that earlier in the year the woman’s husband had invested all the family’s savings in the purchase of a Jersey cow, which had recently fallen ill. As a result, they were paying a hired man to tend the cow, which meant that they had to let the charwoman go who had been helping the wife with her housework. ‘‘The case looked so sad and hopeless,’’ Zakrzewska commented, ‘‘that I sat silently thinking for a moment, when suddenly a bright thought sprang into my mind, and I said, ‘Why don’t you nurse that cow and let the charwoman do your work in house, kitchen and dairy?’ ’’ The farmer’s wife at first dismissed such an idea, but Zakrzewska explained how ‘‘with my vivid power of imagination, I overthrew all of her objections one after another, until her conversation became really animated, and the plan appeared so plausible to both of us that the good woman went out of the o≈ce with no stronger tonic than hope and courage can bestow.’’∞∏

  The story ends with the return to Zakrzewska’s o≈ce months later of ‘‘a plump, sunburnt, cheerful-faced woman.’’ The farmer’s wife, who had succeeded in persuading her husband to go along with Zakrzewska’s plan, had spent every day since she had last visited Zakrzewska out in the field, helping

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  feed the cow, even reading to it, while the two of them grew healthy together.

  The cow had even o√ered a return on its investment: it had given birth to a heifer, which her husband had already been able to sell for half the price he had paid for the cow. For Zakrzewska, this was clearly a success story, an example of hygiene and education in practice.