BOOK REVIEW

Sisters who kicked down the door of the US medical establishment

Elizabeth and Emily Blackwell fought to be doctors in the mid-nineteenth century, and to train more women as physicians.
Hannah Wunsch is a professor in the Department of Anesthesiology and Pain Medicine and the Interdepartmental Division of Critical Care Medicine at the University of Toronto in Canada, and Canada Research Chair in Critical Care Organization and Outcomes.
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Portraits of Elizabeth Blackwell and Emily Blackwell

The first woman to receive a medical degree in the United States, Elizabeth Blackwell (left), and her younger sister Emily, also a doctor.Credits: Colport/Alamy

The Doctors Blackwell: How Two Pioneering Sisters Brought Medicine to Women and Women to Medicine Janice P. Nimura W. W. Norton (2021)

Introduced as ‘Mrs’ when giving a plenary lecture; asked by a patient, just after explaining the medical plan, when the doctor will be coming; seated at a table where all the other physicians are white men. These are not historical experiences from 50 or 100 years ago; they are my own, from 10 years as a critical-care physician and epidemiologist. Worldwide, there have never been so many women in medicine and research — and therefore on the front lines of the pandemic. Still, we grapple with a system that for centuries viewed only men as capable of being doctors.

Writer and historian Janice Nimura takes us to an era when the mere idea of a ‘lady doctor’ (in the parlance of the time) caused befuddlement at best and condemnation at worst. In The Doctors Blackwell, she reveals the struggles faced by the first female physician to practise in the United States, and her sister Emily, also a doctor. In this honest narrative, the path for women in medicine was not created by an army of kind, like-minded people, but by determined individuals, each with her own agenda. These might not be heroines we can wholeheartedly admire, but they dared to kick down the door of the all-male US medical establishment.

Caged force

Elizabeth Blackwell was the first woman in the United States to receive a medical degree. Born in England in 1821, she was one of nine children in a close-knit abolitionist family. Financial difficulties drove the Blackwells to the United States in 1832. Within a few years the children were fatherless and penniless, having to earn their own living.

In 1837, chafing at the limited options for women, Elizabeth wrote: “the restrictions which confine my dear sex render all my aspirations useless”. Work as a schoolteacher left her bored and anxious — a “caged force”, writes Nimura. Elizabeth did not have an overwhelming drive to alleviate pain and suffering, and wrote of her disgust with bodily ailments. But once she decided that becoming a doctor was a “noble ideological quest”, she set out to gain admittance to a respected medical school.

Medical education (and practice) was still unregulated. The United States had a mixture of apprenticeships, for-profit schools offering short courses and a few more rigorous medical colleges. In Europe, medical education was more established, having grown out of guilds and universities, although these courses were often theoretical rather than practical. One universal? Women were not welcome.

Graffiti of “Super Nurse” by artist FAKE on a wall in Amsterdam, Netherlands

Graffiti in Amsterdam pays tribute to the women fighting COVID-19 as doctors and nurses.Credit: Paulo Amorim/VW Pics via Zuma/eyevine

Ultimately, in 1847, Elizabeth Blackwell was admitted to Geneva Medical College (now Hobart and William Smith Colleges) in western New York, at the discretion of the other students — all male. They voted her in as a prank, but she won them over, finishing top of her class and receiving applause at graduation. With degree in hand, her path was no easier. To gain experience in obstetrics in a hospital in Paris, Elizabeth had to become a student midwife, unable to receive recognition as a qualified physician.

In the family

Emily, the younger sister, had only a slightly easier experience. She studied at Rush Medical College in Chicago, Illinois, but was not allowed to finish her degree. She graduated from Cleveland Medical College (now part of Case Western Reserve University) in Ohio in 1854. Eventually, the Doctors Blackwell ran their own hospital, establishing the New York Infirmary for Indigent Women and Children in 1857.

The sisters relied on exceptionalism and a few open-minded men they encountered at select hospitals and medical schools. When a door opened, it did so solely for an individual woman or owing to a loophole, promptly shutting again; each hard-won victory was for a special case. Women as a whole were still viewed as completely unsuited to the medical profession.

The few women who began to populate the medical landscape of the United States and Europe in the 1850s and 1860s disagreed on roles and approaches. The Blackwells’ acquaintance Florence Nightingale, famed for her epidemiology and sanitation reform during the Crimean War, believed that women should be nurses, and physicians should all be male. Also contentious was the best way to educate female physicians.

A wood engraving of women medical students dissecting cadavers at the Medicine College for Women in 1870

Female medical students dissect cadavers at the Medicine College for Women, which was founded by Elizabeth and Emily Blackwell in 1868.Credit: Everett Collection/Alamy

Elizabeth Blackwell had no interest in training separately from men. But others began to set up medical schools for women only, such as the Female Medical College of Pennsylvania in Philadelphia. In 1868, the Blackwells bowed to pressure (and the ongoing lack of coeducational opportunities) and established the Woman’s Medical College of the New York Infirmary. Their work was a constant financial battle. Elizabeth struggled to attract benefactors and frequently clashed with potential allies.

Nimura has remarkably detailed insight into the thoughts and views of the sisters through a trove of letters between them (and their siblings), as well as diaries that reveal a complicated picture. Pioneering spirit and dogged determination did not always go hand in hand with opinions aligned with modern views.

Elizabeth, in particular, is a challenging figure. Sincere and direct, she was prickly, lacking in benevolence and extraordinarily disparaging of many of the women around her, including others who obtained medical degrees. In modern parlance she would be considered a ‘queen bee’.

Both sisters remained a force and were revered, if not loved, for what they accomplished. The book traces them to their deaths, both in 1910. But the more triumphant ending to the story is the admittance of women to two medical schools that opened in the 1890s: Johns Hopkins in Baltimore, Maryland, and Cornell in New York City, both designed to be coeducational. The Blackwells’ medical school for women closed in 1899; Elizabeth’s goal of equality in educational opportunities had finally been realized.

Yet it took until 2017 — more than 150 years after the first women’s medical colleges opened in the United States — for women to make up more than half of US medical-school enrolment. And scepticism remains rampant that a woman, or a physician from a minority group, can wield a scalpel or provide expert advice as well as a white man. We are still too close to the world of the Doctors Blackwell.

Nature 589, 192-193 (2021)

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