Since the rebirth of the feminist movement in the Seventies, the theory and practice of medicine, and the role of women as patients and practitioners, have been strongly contested issues in sexual politics. Much recent feminist writing, especially in the United States, has interpreted the history of the modern medical profession as a succession of male impositions on women. The outlawing of folk (for which read female) medicine, the marginalisation of the traditional midwife, the medicalisation of childbirth, and the introduction of drastic surgical techniques for dealing with real or supposed dysfunctions of the reproductive organs, have all been characterised as examples of oppression and exploitation, inspired by greed, opportunism and, for good measure, possibly sadism and voyeurism.
Catriona Blake’s The Charge of the Parasols shows that these were all live issues for the 19th-century feminists on both sides of the Atlantic who campaigned for women’s entry into the medical profession. Ann Dally and Ornella Moscucci, who discuss British and American surgical practice in this period, address questions of feminist politics more obliquely: the former in a survey designed explicitly to dedemonise this history for the lay-person; the latter in a major work of research which fully explores the complexities of the subject. But neither Dally nor Moscucci can entirely lay to rest the disturbing questions which the 19th-century campaigners and their successors have raised.
The granting of formal medical qualifications to women such as Elizabeth Blackwell (1849) and Elizabeth Garrett (1859) signalled not so much the opening as the re-opening of the field of medicine to women: a first assault against a relatively recent exclusion. Before the 19th century, as all three authors show, the professional colleges had not been able to prevent a vast army of unlicensed women and men from making a livelihood out of treating the sick. Women may have had a near-monopoly on nursing and midwifery, but they were not confined to these areas: they could also be found, particularly in rural ‘family practices’, dispensing, bone-setting and practising minor surgery – the concept of a gender divide between curers and carers, or between scientifically-minded male medics and herb-and-simple-gathering female healers is an ahistorical sexual stereotype.
The expansion and restructuring of the medical profession from the middle of the 18th century onwards, designed to give practical effect to the colleges’ principles of exclusion, hit women hard. Training requirements increasingly favoured admission to institutions such as the newly-founded voluntary hospitals and anatomy schools – from which, as from the universities, women were debarred – over apprenticeship in the home and family of a practitioner, where wives and daughters had had opportunities for ‘learning by doing’. (Local historical studies furnish interesting examples of successful unlicensed husband-and-wife teams sending their sons to the new medical schools and grooming their daughters for a purely ornamental role as a professional man’s wife.) A more integrated procedure of registering medical qualification, introduced with the Medical Act of 1858, accelerated the marginalisation of unlicensed and informal practice.
From the viewpoint of these three studies, however, the most important aspect of this age of transition was the fact that licensed male practitioners, eager for work in an increasingly crowded profession, began to make inroads into previously all-female preserves. ‘Man-midwifery’ in Britain did not, as is sometimes implied, result in the elimination of the doctors’ female competitors in this area: but it did open the way to the development of surgical interventions in obstetric cases, which were pioneered in the new medical institutions controlled by male physicians and surgeons. Although the management of childbirth itself remained a predominantly domestic process, increasing numbers of women underwent ambitious abdominal operations – made easier by the advent of anaesthesia, and at least slightly safer by the adoption of anti- and aseptic procedures – which included Caesarian deliveries, reparative surgery and the removal of cysts and tumours.
The complicated relationship between obstetrics – which at the beginning of the 19th century embraced the management of pregnancy, childbirth and diseases specific to women – and gynaecology, which by the middle of the century was claiming the study and treatment of these diseases as a separate discipline, is carefully documented by Moscucci. Common to both specialisms was a growing conviction that woman’s entire physical, moral, intellectual and emotional existence was governed by the reproductive functions. The pathologist Virchow, quoted by Dally, expressed this ‘theory’ succinctly: ‘Woman is a pair of ovaries with a human being attached; whereas man is a human being furnished with a pair of testes.’ The hypothesis that any and every female complaint was in some way traceable to disorders of the reproductive system was eagerly embraced; despite the unprecedented opportunities available for the collection and evaluation of empirical data, this assumption was neither based on serious evidence nor submitted to rigorous scientific investigation.
As Dally comments, with particular reference to America: ‘there now began a period of intense surgical activity in which increasing numbers of gynaecologists removed more and more ovaries for symptoms whose severity decreased as the indications for the operation became ever vaguer.’ Both in Britain and America, this masculine folklore had by the 1870s emboldened a number of male practitioners to embark on adventurist programmes of removing ovaries for such conditions as missed periods, ‘nervous symptoms’ and ‘menstrual epilepsy’. Comparable justifications were found for the practice of female circumcision. Isaac Baker Brown’s London Surgical Home for Diseases of Women was established in 1858 largely for the performance of clitoridectomies on women whose illnesses were deemed the result of an excess of ‘peripheral excitement’: patients ranged from a dressmaker with ‘burning aching pain with great weakness in the lower back’ to five wives whose symptoms included ‘a desire to obtain a divorce under the new divorce act of 1857’. In 1867 Baker Brown was expelled from the Obstetric Society for failing adequately to inform patients (and/or their husbands or fathers) of the nature of the operation and the grounds on which he performed it, and clitoridectomy seems thereafter to have been largely discredited in Britain, though it flourished in the United States well into the 1920s.
In 1891 the eminent British surgeon, Thomas Spencer Wells, expressed his outrage at this state of affairs in images which no contemporary feminist could have bettered. He denounced the ‘gynaecological proletarians’ who performed ovariotomies on unscientific and frivolous grounds: ‘If we hold the mirror up to Nature, only changing the sex of the actors, the spectacle is not flattering. Fancy the reflected picture of a coterie of the Marthas of the profession in conclave, promulgating the doctrine that most of the unmanageable maladies of men were to be traced to some morbid change in their genitals, founding societies for the discussion of them and hospitals for the cure of them, one of them sitting in her consultation chair, with her little stove by her side and her irons all hot, searing every man as he passed before her; another gravely proposing to bring on the millennium by snuffing out the reproductive powers of all fools, lunatics and criminals ... if too, we saw, in this magic mirror, ignorant boys being castrated almost impromptu, hundreds of emasculated beings moping about and bemoaning their doltish credulity ... should we not, to our shame, see ourselves as others see us?’
Both Dally and Moscucci resist the temptation to paint this undeniably disquieting picture in shades of unrelieved black and white. Dally reminds her readers of the intense suffering caused by such conditions as non-malignant but massive ovarian cysts, and of the lifelong pain and incontinence endured if childbirth resulted in vesico- or recto-vaginal fistulas. Non-surgical methods of treatment provided no remedies. The first operations in these cases were, by definition, experimental, but for ‘experimental’ we should not be misled into reading ‘as in concentration camp’. If they were performed without anaesthetic, it was because none existed, not because surgeons were sadistic torturers. Many women were desperate for remedies, and the operations prolonged the lives and restored the health of those who survived them. Moscucci’s research shows that the medical profession as a whole did not adopt the new procedures unreflectingly: obstetricians and gynaecologists were constantly at loggerheads, with many physicians and surgeons arguing for extreme conservatism against reckless interventionism, demanding, if not obtaining, proper statistics on survival and recovery rates, and instituting disciplinary action where they suspected irresponsible professional conduct.
There is little foundation here for a theory of a grand patriarchal conspiracy to castrate half the population: nor, as it happens, is there evidence of a specifically female medical opposition to surgical intervention as such. Recent research, quoted by both these authors, shows that those women who did qualify as surgeons in the 19th century were almost as likely as their male peers to perform ovariotomies. It is perhaps unsurprising that this tiny minority of professionals should have subscribed to the prevailing orthodoxy. Moreover, the demand by feminists and others, chronicled by Catriona Blake, for female patients to be attended by doctors of their own sex, did not relate to forms of treatment, but to their context. The rise of teaching hospitals had undoubtedly made many processes of examination a public ordeal to be dreaded.
Blake writes of the British campaign for women’s access to formal medical education that ‘the primary purpose of those involved with the campaign was with women as patients, rather than with opening up another occupation to women as workers.’ However, neither she, nor Dally, nor Moscucci is able to produce much documentation on the feelings and motives of patients. If this discussion is ever to be taken forward, research on patients, and on the patient-doctor relationship, will be much needed. How willing were women to take the risks presented by drastic surgical techniques? In what sense can they be said to have consented to treatment, and on the basis of what information? What did each party to the transaction really want?
This is an issue which Dally, most disappointingly, fudges. Her material bristles with examples of unequal power-relations, both within and without the consulting-room, which she almost ignores. Having documented many instances of ovariotomies taking place without the full knowledge of the patient, it is begging the question casually to suggest that ‘it may be that middle-class women, with more time on their hands and free from the drive to earn a living, were, and are, particularly gullible.’ She writes that ovariotomists ‘must have persuaded the patients that they needed these operations and have given them enough confidence to submit to them’, but, in the light of the evidence she herself cites on Baker Brown’s clitoridectomies, where women were clearly brought to the London Home on the grounds that they were inconveniencing their parents or their husbands, we are entitled to ask who exactly was persuaded and confident about the proceedings.
Moscucci has attempted to study this question through the records of the Middlesex Hospital, the Hospital for Women, Soho Square, and the Chelsea Hospital for Women, but these do not reveal anything about women’s initial attitudes to gynaecological surgery, and where the records are silent she has not attempted to speculate. She has, however, used an important fictional source to enlarge our understanding of the controversies surrounding ovariotomy. In 1872 Dr Frances Hoggan resigned from her post as assistant to Elizabeth Garrett Anderson at the New Hospital for Women when the latter began to practise ovariotomy (the first woman to do so). In 1891 Dr Marie Zakrzewska wrote with horror of the troop of women requesting this operation at her Boston Hospital. Moscucci quotes extensively from Zola’s novel Fécondité (1899) where ovariotomy, under the guise of either curettage or treatment for gynaecological disease, is shown to be sought and practised for the purposes of contraception and abortion. While it is unlikely that a majority of the medical profession ever endorsed this practice, it is important to recognise that women patients, far from being passive partners in the decision to operate, may actually have initiated it in some circumstances.
The issue is, of course, more than a historiographical one. In the final section of her book, Dally quotes figures from contemporary sources which are, to say the least, perplexing. A study by Cornell University Medical College showed that 787,000 hysterectomies were performed in the United States in 1975, resulting in 1700 deaths. Surgery was regarded as ‘unnecessary’ in no less than 28 per cent of cases, among whom there were 374 deaths. The Congressional Commerce Oversight Committee in 1977 investigated hysterectomies which were performed for ‘hysterical’ symptoms such as ‘cancerphobia’ or ‘obsessive fear of pregnancy’. A survey published in Oxford in 1988 showed that, although the frequency of this operation is far less in this country than in the United States, it is still carried out more than twice as often as in Norway, and there are unexplained differences in the figures for different health districts.
Major surgical intervention always carries an element of risk, and is always expensive to provide. Why is it still so popular? Where Britain is concerned, the continued existence of the NHS allows us largely to discount the motive of personal greed in the operator. Some of the medical concepts of femininity which Moscucci discusses in the 18th and 19th-century context may still be relevant to an assessment of the motives of surgeons: the assumption of a relationship between diseases of the reproductive system and psychological disorders, or diseases of other organs, for example; or a deep-seated but not always conscious perception of the reproductive system as in itself pathological. A more significant factor may be that both patient and doctor are still strongly imprinted with the hierarchy of medical prestige which evolved in the 19th century, well-illustrated by Moscucci, when surgery, without ceasing to generate controversy and scandal, began to be characterised as ‘heroic’, and as a privileged sanctum from which not only unlicensed quacks but the licensed general practitioner had to be excluded.
Women are not, of course, the only patients to be affected by the surgeon’s aura of prestige and romance, as the history of transplant surgery (to take the most spectacular example) demonstrates. But in the United States, and probably elsewhere, five of the commonest ten operations are performed on conditions specific to women, often, as we have seen, unnecessarily. If the overwhelming advantage of professional expertise makes all doctor-patient relationships inherently unequal, common sense rather than ideology would suggest that this situation could be exacerbated where the patient is female and the doctor male. And, despite the efforts of the 19th and 20th-century feminist pioneers, the doctor – especially the obstetrician and gynaecologist – is, almost always, male.
Doubtless every female reader can bring her own anecdotal evidence to bear on this question. Not long ago your reviewer consulted her general practitioner about contraception. He promptly recommended sterilisation, to which she made her excuses – that a major surgical intervention seemed an inappropriate way of dealing with a minor administrative problem and left. Had she not been articulate, middle class and a student of medical history, how would she have been able to formulate and defend her own decision? And if she had failed to do this, in what sense might she have been said to have consented to treatment? Perhaps we should not speak in terms of a male medical conspiracy, or of a hegemonic patriarchal ideology: but both the record of the past and the balance-sheet of the present suggest that we are dealing with a set of unacknowledged fixations, probably of some considerable antiquity, and requiring a continuous programme of monitoring, dissection and analysis.