What Abraham Flexner did in 1909 was probably every bit as important as what he wrote. He traveled to every medical school in the country, and there were about 160 at the time. Being from Carnegie, he smelled of money. Being a Flexner, he sounded like Science. His message was simple: conform to the John Hopkins model, complete with laboratories in all sciences, salaried professors, etc., or close. For the smaller, poorer schools, this could only mean one thing: close. For the bigger and better schools (i.e., those which, like Harvard, already had enough money to begin to institute the prescribed reforms), it meant the promise of fat foundation grants for further reforms. In fact, the published report was to serve as a convenient guidebook for medical philanthropists. It found that only about 15 percent of the nation’s medical schools began to meet “scientific” standards, and identified as salvageable those which were already big, rich, and prestigious. In the twenty years following the publication of the Flexner Report, the nine largest foundations poured over $150 million—one half of what they gave for all purposes—into medical education, adhering strictly to the standards set by Flexner.29
The effects of the crusade to “reform” medical education which had begun in the late nineteenth century and culminated, symbolically, with the Flexner Report, were already visible in the teens. Between 1904 and 1915, ninety-two medical schools closed down or merged.30 The “irregular” schools descended from the Popular Health Movement (which had been a haven for women students) closed in droves; and seven out of ten exclusively female medical colleges shut down. Between 1909 and 1912, the proportion of medical graduates who were women dropped from 4.3 percent to 3.2 percent.31 Blacks fared even worse, losing all but two (Meharry and Howard) of the original seven black medical schools.
When it came to the social-class composition of medicine, the “reforms” were equally decisive. The regular schools offering low-cost medical training to working- and lower-middle-class youths went the way of the schools for women and black people. Beyond that, Flexner had set a minimum of two years of college education as a requirement for entrance to medical school. At a time when less than 5 percent of the college age population was enrolled in a college or university, this requirement alone closed the medical schools to all but the upper and upper-middle class.
It could be argued that these measures were necessary. A majority of the schools closed by the medical reformers undoubtedly were too small and poorly equipped to offer an adequate medical education. But there could have been an alternative strategy for reform—to spread out the wealth so that many more schools could be improved. This would have left medical education open to large numbers of people. But that, of course, was exactly what the doctors were trying to avoid. With the strategy the foundations chose, medicine became ever more the property of an elite—white, male, and overwhelmingly upper-middle class. Beyond that, the scientific reformers never questioned the real medical value of the professional requirements they sought to impose. The requirement of lengthy scientific training, for example, guaranteed that doctors would be largely from privileged backgrounds, but it did not guarantee that they would have any more practical experience and human empathy than the uneducated healers they replaced.
The rank-and-file regular doctor watched the reforms with mixed feelings. By and large the rank-and-file distrusted scientific medicine and the elite doctors who crusaded for it. New York doctors used to walk out on medical papers dealing with the Germ Theory of Disease because “They wanted to express their contemptuous scorn for such theories and refused to listen to them.”32 Why blame disease on a hypothetical entity, germs, which no honest practitioner had ever seen? More generally, a prominent medical writer warned physicians in 1902:
Do not allow yourself to be biased too quickly or too strongly in favor of new theories based on physiological, microscopial, chemical, or other experiments, especially when offered by the unbalanced to establish their abstract conclusions or preconceived notions.…33
Only under pressure from public health authorities and the public would the doctors agree to try diphtheria antitoxin or report TB cases. Those who did subscribe to the Germ Theory of Disease often used it to justify the glad-handed prescribing of alcohol—it killed germs, didn’t it? Then too, it must have been painful to watch one’s alma mater branded as “third rate” by a mere layman like Flexner who had never driven out to an emergency in a blizzard or held a dying person’s hand. (Even the elite felt this change. Hopkins professor William Osler quipped to his colleague William Welch, “We are lucky to get in as professors, for I am sure that neither you nor I could ever get in as students.”)34
But despite all this, the rank-and-file were not about to buck the reform movement. Medicine’s scientific elite were achieving through a precise and methodical campaign what the rank-and-file could never have achieved through bluster and politicking. The competition was falling, and the regulars had all but captured the field. In the eighteen hundreds licensing laws which had been thrown out or emasculated in the thirties and forties had been reinstated, but the laws did not exclude “irregular” doctors, so long as they were trained. Now, as part of the scientific reforms, licensing examination were brought into line with the standards of the most scientific, regular schools. And, at the same time, most states ruled that practicing medicine without a license was a crime punishable not by a fine, or a reprimand, but a prison sentence. The regular sect had gained, at long last, a legal monopoly over the practice of medicine.
And, probably to the great relief of many a practitioner, all this was achieved without ever having to purge the ranks of the existing regulars. The purifying reign of terror which the reformers brought to the schools was never visited on the practitioners themselves. The average practitioner was still free to go around bleeding consumptives, mumbling about “humors,” and hooking housewives on opium. To this day, the profession views its most unscientific and outright murderous members with a spirit of gentle forebearance. The standards erected to exclude the “crude boys”—and the girls in general—have never been applied to those who have already entered the brotherhood.
A truly scientific medicine would, of course, have to be self-critical, would have to subject its practitioners to continual evaluation and review. But that could hardly be done without putting a few cracks in the patrician image which regular medicine had fought for so long to achieve. “I warn all of you not to uncover the mistakes of a fellow practitioner,” J. E. Stubbs, M.D., wrote in an 1899 issue of the Journal of the American Medical Association:
… because, if you do, it will come back like a boomerang, and it will sting to the bitter end.… We do wrong when we do not try to cover up the mistakes of our brethren. There are many cases that require extreme surgical dexterity and a large amount of knowledge in order to operate successfully; yet those who are operating all the time make mistakes. We have to do a great many things empirically, and if we tell people … this or that physician has made a great blunder, it hurts him; it hurts the community, because the opinion of the physician in society is considered authority, and particularly in the community in which he lives, among his associates and friends. They consult him as they do no other man; they consult him more confidentially and give up their secrets to him more unreservedly than they do to their priest or minister.35
Stubbs, clearly, was not tortured by a nagging loyalty to science. The doctor who aspired to the patriarchal authority once held by the “priest or minister” could not be bothered with picayune technical criticisms.
The aspirations—and achievements—of nineteenth-century regular medicine can all be summarized in the figure of one man: Sir William Osler. He not only played a role in the medical-reform movement; to thousands of admirers, he was the goal of it. He was a professor at Johns Hopkins medical school, author of the textbook that turned Frederick Gates on to scientific medicine, and, although he never did any original research in his life, he could expound on the scientific renaissance of medicine in hundred-word-long Victorian sentences graceful
ly adorned with references to the Greek and Latin classics. The rank-and-file regulars loved him. From “the Atlantic to the Pacific …[a visitor]… will find a picture of Osler hanging on the wall in almost every doctor’s house.”36 The Osler portraits reminded doctors that medicine was about something more than money, more, even, than science—a mystical kind of power that flowed not just from what the doctor did, but from who he was.
He himself was, by any standards, an aristocrat among physicians. The son of a clergyman (like a surprisingly large number of the scientists of his generation), he studied medicine at McGill and then made the pilgrimage to the great German university laboratories. His combination of good breeding and scientific education quickly brought him to the attention of America’s medical elite. According to Osler’s memoirs, S. Weir Mitchell traveled to Leipzig for the University of Pennsylvania:
… “to look me over,” particularly with reference to personal habits. Dr. Mitchell said there was only one way in which the breeding of a man suitable for such a position [professor of clinical medicine], in such a city as Philadelphia, could be tested—give him cherry-pie and see how he disposed of the stones. I had read of the trick before, and disposed of them genteely in my spoon—and got the Chair.37
Mitchell was so impressed that he wrote back, “Osler is socially a man for the Biological Club [an elite Philadelphia dining club] if by any good luck we can get him.”38 Osler’s subsequent career as a professor, author, lecturer, and physician to the social elite of Europe and North America (he treated the Prince of Wales) culminated in his receiving a baronetcy—hence the “Sir”—from Queen Victoria in 1911. He saw himself as one link in a genteel tradition which stretched back to Hippocrates, whom he credited with the first “conception and realization of medicine as a profession of a cultivated gentleman.”39 “The way is clear,” he told students, as if regular medicine had never known a moment of self-doubt, “blazed for you by generations of strong men.…”40
To a generation of doctors who were still anxious about evolution and skeptical about germs, Osler provided much-needed reassurance. The patriarchal authority of the doctor, he argued, rests on something more ancient and venerable than science. Science itself was not something integral to medicine; it was a kind of extra, “an incalculable gift,” a “leaven” to the hardworking practitioner. Science, in fact, was just one part of the general “culture” the physician needed if he was to serve a wealthy clientele. As part of the doctor’s general “culture,” science could also serve as a kind of disinfectant to protect him in “the most debasing surroundings,” such as those inhabited by the poor. “Culture” became all the more important, of course, with a wealthy patient clientele:
The wider and freer a men’s [sic] general education the better practitioner he is likely to be, particularly among the higher classes to whom the reassurance and sympathy of a cultivated gentleman of the type of Eryximachus [an aristocratic ancient Greek doctor], may mean much more than pills and potions.41
So if science was culture, and culture was really class, then, in the end, it was class that healed. Or rather, it was the combination of upper class and male superiority that gave medicine its essential authority. With a patriarchal self-confidence that had almost no further need for instruments, techniques, medications, Osler wrote:
If a poor lass, paralyzed apparently, helpless, bed-ridden for years, comes to me, having worn out in mind, body, and estate a devoted family; if she in a few weeks or less by faith in me, and faith alone, takes up her bed and walks, the saints of old could not have done more.…42
Now at last the medical profession had arrived at a method of faith-healing potent enough to compare with woman’s traditional healing—but one which was decisively masculine. It did not require a nurturant attitude, nor long hours by the patient’s bedside. In fact, with the new style of healing, the less time a doctor spends with a patient, and the fewer questions he permits, the greater his powers would seem to be.
Exorcising the Midwives
There was one last matter to clean up before the triumph of (male) scientific medicine would be complete, and that was the “midwife problem.” In 1900, 50 percent of the babies born were still being delivered by midwives. Middle- and upper-class women had long since accepted the medical idea of childbirth as a pathological event requiring the intervention and supervision of a (preferably regular) physician. It was the “lower” half of society which clung to the midwife and her services: the rural poor and the immigrant working class in the cities. What made the midwives into a “problem” was then not so much the matter of direct competition; the regular doctors were not interested in taking the midwife’s place in a Mississippi sharecropper’s shack or a sixth-story walk-up apartment in one of New York’s slums. (Although one exceptionally venal physician went to the trouble of calculating all the fees “lost” to doctors on account of midwifery):43 It only makes sense to speak of “competition” between people in the same line of business; and this was not the case with the midwives and the doctors.
The work of a midwife cannot be contained in a phrase like “practicing medicine.” The early-twentieth-century midwife was an integral part of her community and culture. She spoke the mother’s language, which might be Italian, Yiddish, Polish, Russian. She was familiar not only with obstetrical techniques, but with the prayers and herbs that sometimes helped. She knew the correct ritual for disposing of the afterbirth, greeting the newborn, or, if necessary, laying to rest the dead. She was prepared to live with the family from the onset of labor until the mother was fully recovered. If she was a southern black midwife, she often regarded the service as a religious calling:
“Mary Carter,” she [an older midwife] told me, “I’m getting old and I done been on this journey for 45 years. I am tired. I won’t give up until the Lord replace me with someone. When I asked the Lord, he showed me you.”
The [young] midwife responded, “Uh, uh, Aunt Minnie, the Lord didn’t show you me.” She say, “Yes Sir, you got to serve. You can’t get from under it.”
She did serve because, repeatedly, “Something come to me, within me, say, ‘Go ahead and do the best you can.’ ”44
All of this was highly “unscientific,” not to mention unbusinesslike. But the problem, from the point of view of medical leaders, was that the midwife was in the way of the development of modern institutional medicine. One of the reforms advanced by medicine’s scientific elite was that students should be exposed somewhere along the line not only to laboratories and lectures but to live patients. But which live patients? Given the choice, most people would want to avoid being an object of practice for inexperienced medical students. Certainly no decent woman in 1900 would want her delivery witnessed by any unnecessary young males. The only choice was the people who had the least choice—the poor. And so the medical schools, the most “advanced” ones anyway, began to attach themselves parasitically to the nearest “charity” hospital. In an arrangement which has flourished ever since, the medical school offered its medical trainees as staff for the hospital; the hospital in turn provided the raw “material” for medical education—the bodies of the sick poor. The moral ambiguities in this situation were easily rationalized away by the leaders of scientific medicine. As a doctor on the staff of Cornell Medical College put it:
There are heroes of war, who give up their lives on the field of battle for country and for principle, and medical heroes of peace, who brave the dangers and horrors of pestilence to save life; but the homeless, friendless, degraded and possibly criminal sick poor in the wards of a charity hospital, receiving aid and comfort in their extremity and contributing each one his modest share to the advancement of medical science, render even greater service to humanity.45
Medical science now called on poor women to make their contribution to that “most beneficent and disinterested of professions.” Obstetrics-gynecology was America’s most rapidly developing specialty, and midwives would just have to get out of the way. Training an
d licensing midwives was out of the question, for, as one doctor argued, these measures would
decrease the number of cases in which the stethoscope, pelvimeter, and other newly developed techniques could be used to increase obstetrical knowledge.46
A Dr. Charles E. Zeigler was equally blunt in an article addressed to his colleagues in the Journal of the American Medical Association:
It is at present impossible to secure cases sufficient for the proper training in obstetrics, since 75% of the material otherwise available for clinical purposes is utilized in providing a livelihood for midwives.47
Note the curious construction here: “the material … is utilized.…” The woman who was seen by her midwife as a neighbor, possibly a friend, was, in the eyes of the developing medical industry, not even a customer: she has become inert “material.”
The public campaign against midwives was, of course, couched in terms of the most benevolent concern for the midwives’ clientele. Midwives were “hopelessly dirty, ignorant and incompetent, relics of a barbaric past.”48
They may wash their hands, but oh, what myriads of dirt lurk under the fingernails. Numerous instances could be cited and we might well add to other causes of pyosalpinx “dirty midwives.” She is the most virulent bacteria of them all, and she is truly a micrococcus of the most poisonous kind.49
Furthermore the midwife and, as we shall see, dirtiness in general, were un-American. Overturning almost three hundred years of American history, obstetricians A. B. Emmons and J. L. Huntington argued in 1912 that midwives are
not a product of America. They have always been here, but only incidentally and only because America has always been receiving generous importations of immigrants from the continent of Europe. We have never adopted in any State a system of obstetrics with the midwife as the working unit. It has almost been a rule that the more immigrants arriving in a locality, the more midwives will flourish there, but as soon as the immigrant is assimilated, and becomes part of our civilization, then the midwife is no longer a factor in his home.50
For Her Own Good: Two Centuries of the Experts Advice to Women Page 12