Wednesday, December 11, 2013

Elizabeth Blackwell Breaks the Bonds— “Women will not be what they are now”

From: The FASEB Journal, Gerald Weissmann, Editor-in-Chief

You ask me what I did, and what can be done as a lady. I entered the Maternité, dissected at l’Ecole des Beaux-Arts alone, employed a répétiteur who drilled me in anatomy and smuggled me into the dead-house of La Charité at great risk of detection, where I operated on the cadaver. I once made the rounds of his wards in the Hôtel-Dieu with Roux, heard his lectures, and saw his operations. I attended lectures at the College of France and Jardin des Plantes…It is my impression, for I ought only to put it in that modest form, that the ruling class in America is less humane, more addicted to money-getting and party spirit; and that reform ideas in America are much more talked of, but less acted on.
Elizabeth Blackwell, Letters to her sister Emily (1850–54)

The images above document a sea change in American medicine. After Elizabeth Blackwell broke the bonds, women were no longer there simply to be acted upon (left), but could themselves take action (right). The New York Times noted the critical event in adjacent news reports on March 1, 1867. The evening before, at Steinway Hall on 14th Street, Dr. Albert Lewis Sayre had presided over the graduation ceremonies of Bellevue Hospital Medical College at which 140 gowned men marched down the aisle to the music of Wagner (2)⇓ . A founder of the school, and the first Professor of Orthopedic Surgery in the US, he was famous not only for his “suspension” treatment of spinal deformities but also for his textbook illustrated by provocative dorsal views of female patients. On the same evening, and only three blocks away at the New-York Historical Society on 11th Street, Dr. Elizabeth Blackwell had addressed an audience of men and women on the subject of “The Medical Education of Women.” The Women’s Medical School that she founded with her sister had just been chartered, and she appealed for funds to permit women to gain “a thorough knowledge of the science of medicine (3)⇓ .” Scientific knowledge of the body, she pleaded, could only be obtained by practical, hands-on work, as in the revolutionary practice of learning anatomy by dissection. Leslie’s Illustrated Newspaper spread the shocking news that a woman could become a doctor over the dead body of a man [see above, .

The founding of a medical school for women had its origins in 1854 when Elizabeth Blackwell, described by Lancet as “the first woman medical graduate in the modern meaning of the phrase (5),” arrived in New York after clinical work in Paris and London. In Paris she had been exposed to the bracing notion of Lamarckian evolution at the Jardin des Plantes and to the experimental medicine of Magendie and Claude Bernard at the Collège de France. In London she caught the fervor of sanitary and social reform and became a lifetime devotee of Florence Nightingale.

America in 1854 was not ready for Elizabeth Blackwell, nor for other women of her stripe and, alas, our country remains unready for them today. Although many women have found places in the public sphere, some near the very top, our country seems forever committed to customs Blackwell called “money-getting and party spirit” (read zealotry). Two current items remind us of the pre-bellum country that Blackwell encountered on her return, an America where money-getting trumps the facts of science and zealots wave the flag of bigotry:


Mr. Vandehei: I’m curious, is there anybody on the stage that does not agree—believe in evolution? [Senator Brownback, Mr. Huckabee, Representative Tancredo raise their hands.


A hate-crimes bill passed Thursday by the House, extending coverage to people victimized because of sexual orientation, gender identity or disability, is attracting opposition from an unusual… coalition of evangelical, fundamentalist and black religious leaders that is mounting a furious assault on the bill, airing television ads and mobilizing members to stop its progress. And President Bush has said he may veto the measure.

Born in England to Samuel Blackwell, a well-off sugar refiner and dissident lay preacher, Elizabeth Blackwell was brought to Cincinnati in 1832. Her education was peripatetic, in circles where abolitionist politics and Transcendental values held sway. She received medical tutorials in the private practices of Philadelphia doctors, but despite her thorough preparation in textbook anatomy and a solid educational record, she was refused admission by 17 medical faculties in the United States. However, there was a small college in Geneva, New York, that granted the degree of Doctor of Medicine, provided lectures were attended for two years and a thesis was written. In those pre-Flexnerian days, Geneva’s requirements for the M.D. degree were par for the course, as it were.

Blackwell matriculated in November 1847, was more or less well received by town and gown, and performed splendidly in all courses, especially therapeutics. In the summer of 1848, she undertook clinical instruction at the Philadelphia Hospital where “ship fever” (epidemic typhus) had broken out among Irish immigrants. Blackwell carefully recorded its spread from case to case and recommended prevention by light, air, and washing hands with soap and water. This exercise in clinical epidemiology became her doctoral thesis, a work almost as persuasive as that of Oliver Wendell Holmes on puerperal fever (1843). Indeed, Blackwell’s thesis relied heavily on the work of Holmes’s teacher, Prof P. C. A. Louis of Paris, who first distinguished typhoid from typhus. By February of 1849, Blackwell’s thesis had been published in the Buffalo Medical Journal and Review, and all that remained for her doctorate was to graduate with distinction.

The degree won, Blackwell determined to obtain the best clinical training possible. Since in those days young American doctors properly regarded Paris as the center of clinical science, Blackwell sailed off to the City of Light. She arrived with an introduction from her Philadelphia preceptors to none other than Professor P.C.A. Louis himself “then at the height of his reputation.” She felt instinctively that his visit was one of inspection and passed with flying colors. Thanks to Louis’ intervention, she was admitted in autumn of 1849 for a six months course at the Maternité lying-in hospital. In that convent-like atmosphere her most intellectually stimulating companion was the interne, M. Hippolyte Blot. [In later years, Blot (1822-1888) went on to a professorship at the Maternité, having discovered the relationship between eclampsia and albuminuria.

Interne Blot and pupil Blackwell exchanged lessons in English and histology, spending hours over the young man’s microscope. Blot taught Blackwell that the erythrocyte was biconcave, streaking a drop of blood on a slide to show “that what appeared to be a central spot in each globule was owing to the convexity not being in focus, and it disappeared when the focus was a little lengthened.” In the Paris of 1849, experimental medicine was everywhere in the air. Hippolyte Blot told Blackwell of his friend,

Claude Bernard, a distinguished young inquirer, who is now, he thinks on the eve of a discovery that will immortalize him … of the power which the liver has of secreting sugar in a normal state when animals are fed on certain substances which can be so converted; also of the curious experiment by which a dog was made, in his presence, to secrete albuminous or diabetic urine .

Attending to her patients at the Maternité, a grave accident befell Elizabeth: “in the dark early morning, whilst syringing the eye of one of my tiny patients for purulent ophthalmia,” some of the water spurted into her left eye. By nightfall of November 4, the eye had become swollen, and by the next morning, the lids were “closely adherent from suppuration.” The diagnosis of purulent ophthalmia (the dreaded venereal disease of newborns and those that attended them) was made and the 28-year-old Blackwell was placed in the student infirmary. The disease is caused by the gonococcus, is due to chronic gonorrheal infection of the female reproductive tract, and was part of the load borne by the prostitutes and working women who gave birth in the public hospitals of Paris. The bacteriologic revolution has all but eliminated it, but Albert Neisser did not discover the microbe until 1879, and it was not until 1884 that Carl Credé made it clear that eyedrops of 1% silver nitrate on the lids of newborns were an effective prophylactic. Thanks to rigorous maternal health laws, by the turn of the century, prophylaxis had pretty much eliminated neonatal ophthalmia from advanced countries. Today resistant strains are making an unfortunate comeback in many parts of the globe.

Elizabeth Blackwell was treated by the accepted methods of the day: cauterization of the lids, leeches to the temple, cold compresses, ointment of belladonna, opium to the forehead, purgatives, and footbaths. Dr. Blot came in every two hours, day and night, to tend the eye. But despite his efforts, after three days it became obvious to her doctors that the eye was hopelessly infected:

"Ah! how dreadful it was to find the daylight gradually fading as my kind doctor bent over me and removed with an exquisite delicacy of touch the films that had formed over the pupil! I could see him for a moment clearly, but the sight soon vanished, and the eye was left in darkness."

She lay in bed with both eyes closed for three weeks, but then the right eye gradually began to open. Soon she could start to do little things for herself and assured an uncle in England that she could write without difficulty, read a little, and hoped to return to her studies. She was discharged permanently blind in one eye, and because of this handicap disqualified herself from surgery or obstetrics as a career.

Blackwell next applied to St. Bartholomew’s Hospital in London, then, as now, perhaps the strongest teaching hospital of the city. The illustrious Sir James Paget endorsed her admission as a student “in the wards and other departments of the hospital,” and on the 14th of May 1850 she was accepted at Bart’s. Once on the wards, she soon spotted the difference between the medicine of Paris and London at mid century:

"I do not find so active a spirit of investigation in the English professors as in the French. In Paris this spirit pervaded young and old, and gave a wonderful fascination to the study of medicine, which even I, standing on the threshold, strongly felt.".

But overall, her London hours were instructive, she made many new female friends; some were socially prominent, among them Miss Nightingale. She also encountered more than the expected rebuffs. Her mentor gave her sound advice, which elicited a passionate response:

Mr. Paget who is very cordial, tells me that I shall have to encounter much more prejudice from ladies than from gentlemen in my course. I am prepared for this. Prejudice is more violent the blinder it is…but a work of the ages cannot be hindered by individual feeling. A hundred years hence women will not be what they are now.

Her experiences in Paris and London made her anxious to start out on her own in America. In November of 1850, she wrote of her future plans to her sister Emily, who had decided to follow in her sister’s footsteps: “I shall commence as soon as possible building a hospital in which I can experiment.” On her return to New York she was too poor to realize the dream of building an experimental hospital. “If I were rich,” she had told her sister, “I would not begin private practice, but would only experiment. As however I am poor. I have no choice.” She set up a general practice and spent cold winters and steaming summers in the city trudging the pavements with her black bag. Her early years as this country’s first woman doctor of medicine were not encouraging. She confessed deep unhappiness: “I had no medical companionship, the profession stood aloof, and society was distrustful of the innovation. Insolent letters occasionally came by post, and my pecuniary position was a source of constant anxiety.

It was impossible to rent an office, the term “female physician” having been preempted by ill-trained abortionists, and she went into debt by buying a house on East 15th Street. She worked in the attic and basement, renting out the remainder of the house. Her isolation prompted her to adopt a seven-year-old orphan, Katharine Barry, and this young child became a life-time companion, friend, and housekeeper.

Slowly, Elizabeth Blackwell began to attract support from the New York Quaker community and by 1854, opened a one-room dispensary on the Lower East Side in which she treated over two hundred women in the first year. By 1856, she was reunited with her sister who had received medical training in Europe after an M.D. from Western Reserve. In 1857, with the help of progressive philanthropists like their good friend Horace Greely, the Blackwells established the New York Infirmary for Women and Children at 64 Bleecker Street. They successfully overcame each of the social objections of the time: that female doctors would require police protection on their rounds; that only male resident physicians could control the patients, that “classes and persons” might be admitted whom “it would be an insult to treat” (i.e., beggars and prostitutes); that signatures on death certificates might be invalid (the legal rights of women in the pre-suffrage era were fragile); that the male trustees might be held responsible for any “accidents”—and that, in any case, no one would supply women with enough money to support such an unpopular effort.

With Emily now in charge of a going concern, Elizabeth traveled back to England and became the first woman to be registered as a physician in the UK. She studied programs of maternal hygiene, looked over public health programs for women and children, and toyed with the notion of spending the rest of her life working in a country hospital together with Florence Nightingale, with whom she had formed an intense personal relationship.

When Elizabeth returned once more to New York in 1860, the sisters enlarged the infirmary, added new staff, and put in place the preventive measures of the Sanitarian revolution. The Civil War fully engaged their abolitionist spirit. On the day after Fort Sumter was fired on, the Blackwells helped to found the National Sanitary Aid Society (in turn, the Sanitary Commission), a major service to public health in the Union cause. With war over, Elizabeth’s dream was realized: a hospital in which to experiment. In 1867–1868, the sisters founded the Women’s Medical College of New York Infirmary, which by 1899 had graduated 394 women doctors! The laboratories for instruction in both basic and applied sciences were among the most up-to-date in the country, and the three-year curriculum exceeded in rigor much of what passed for medical education in this country. Elizabeth Blackwell became the first Professor of Hygiene and it was due to her efforts that hands-on science—anatomy, histology, physiology—came first:

"It is observation and comprehension, not sympathy, which will discover the kind of disease. It is knowledge, not sympathy, which can administer the right medicine; and though warm sympathetic natures, with knowledge, would make the best of all physicians, without sound scientific knowledge, they would be most unreliable and dangerous guides."
On the one hand, the social causes to which the Blackwells devoted themselves have by and large prevailed: medical education of women advanced, the Union preserved, sanitation promoted, infections curbed, child and maternal health protected by the state, and so forth. On the other hand, we have a way to go. The personal lives of Elizabeth and Emily Blackwell remained private and monogamous. Aside from that passionate episode with Florence Nightingale, Elizabeth spent all of her life—the last thirty years in seaside retirement—with her adopted daughter/friend Kitty Barry. Emily and her lifelong companion, Dr. Elizabeth Cushier, spent 28 happy years together in a Gramercy Park brownstone and on the coast of Maine.

Sadly, these days, perhaps the only place Elizabeth Blackwell and Florence Nightingale could live together in legal peace would be Massachusetts. We are still some distance from realizing her fondest hope, written in reply to an invitation from the Convention for Women’s rights in Worcester, Massachusetts (1850):

The great object of education has nothing to do with woman’s rights or man’s rights, but with the development of the human soul and body. My great dream is of a grand moral reform society, a wide movement … combined that it could be brought to bear on any outrage or prominent evil.



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