Women in Surgery – 20th Century Experiences
RCSEd Communications Team
This International Women’s Day, Surgeons' Hall Museums Curator Louise Wilkie looks back at women in surgery in the 20th century and the trailblazing work that ensured a pathway for women in surgical careers.
If you have ever visited Surgeons' Hall Museums at The Royal College of Surgeons of Edinburgh, you may have noticed as you walked through our History of Surgery gallery that there are no women present in the interpretation panels. This gallery takes the visitor from our creation in 1505 as the Incorporation of Surgeons and Barbers of Edinburgh right through to the introduction of aseptic technique in the 19th century. The gallery ends here, as this breakthrough was what set surgery on the course to which we know it today. The history of surgery, from 1505 to the 1870's, does not include women.
Medicine from the 17th century through to the 20th century became increasingly regulated and academic. Surgery and traditional female roles like midwifery became a profession requiring admittance to a university or medical college. As women were largely excluded from higher education, it was challenging for a woman to pursue a career in medicine until the latter half of the 19th Century.
Famously, seven women now known as the Edinburgh Seven were the first women admitted to Edinburgh University in 1869, all of whom studied medicine. Despite passing the exams, some were top of their class, yet they were eventually barred from graduating. This was due to some loud and influential male medical voices who were in opposition to women in medicine. Consequently, women had to find other means of qualifying. One route was academic learning abroad in women-friendly European universities. Thanks to the very public campaign of the Edinburgh Seven, a Government Bill of 1876 ensured that women who qualified abroad could obtain a licentiate from one of the Royal Colleges and therefore practice in the UK. This then allowed those early pioneers to work in the UK and open female-run medical schools such as the Edinburgh School of Medicine for Women, opened in 1886, and female-run hospitals for women and children.
These developments were crucial for women in medicine, as one of the biggest hurdles was the concept that men and women could not study together, nor be allowed on the same wards in hospitals, and that women could not treat men. It would not be until 1892 by another government act that Scottish universities were forced to allow women to graduate and all courses were made to be taught co-ed. That did not include medicine, which was not taught on an equal basis until 1916.
Here in Scotland, the Triple Qualification (TQ) introduced in 1884 offered a qualification which could be attained by studies outside of the main universities and was open to women. It was jointly awarded by The Royal College of Surgeons of Edinburgh, The Royal College of Physicians of Edinburgh, and The Royal College of Physicians and Surgeons of Glasgow. The first woman to attain the TQ was Emma Littlewood in 1886. However, it was not until 1920 that this College allowed women to sit the Fellowship examination, which finally opened up the opportunity for women to focus on a surgical career.
First World War: Gertrude Herzfeld
The 20th century witnessed two world wars, which aided women in gaining a foothold into surgical positions across the UK. During the wars, positions normally reserved for men were left vacant, and female surgeons found previously tightly closed doors left slightly ajar. A key example is Gertrude Herzfeld, the second woman to become a Fellow of this College in 1920 but the first to practice in Scotland. She had qualified in medicine in 1914 on the outbreak of the First World War, and became the first female house surgeon to Sir Harold Stiles at the Edinburgh Royal Hospital for Sick Children. She continued her journey into surgical practice with brief work at the Royal Army Medical Corps Hospital in Aldershot, followed by an appointment as house surgeon at Bolton Infirmary from 1917-1919. Gertrude was under no illusions regarding these opportunities, with her declaring:
…it was the First World War that gave me my chance
In 1920, Herzfeld was the first woman to be appointed Honorary Assistant Surgeon at the Royal Edinburgh Hospital for Sick Children, later becoming Senior Surgeon in 1925. It was here that she carved out an expertise in paediatrics, and helped to change the view that paediatrics was merely an element of adult surgery but instead a field of its own. She was also Lead Surgeon at the Bruntsfield Hospital for Women and Children, thus covered a range of surgical fields.
Having undergone her medical education in separate classes from men, and relying heavily on senior male surgeons for appointments and patient referrals, Herzfeld was active in encouraging change in the surgical world. Determined to promote career opportunities for women in surgery, she became President of the Women’s Medical Federation and was involved in the British Medical Association.
Second World War: Betty Slesser
The Second World War offered another opportunity for newly qualified female surgeons. Betty Slesser, when qualifying from the University of Edinburgh in 1941, was one of around 30 women in a class of 150 men. She began applying for general surgical posts on the outbreak of WW2, and in 1942 after a brief stint as house surgeon in the ENT department at the Royal Infirmary became a house surgeon in Plymouth. Desiring to be of more assistance to the war effort, she applied and was accepted to the Royal Air Force Medical Service. This decision was almost immediately reversed by committee, however, due to their perceived lack of need for more women doctors in the service.
In a write-up of Betty Slesser’s career, a fellow female medic wrote:
In those days it was most unusual for female doctors to get junior house-jobs in general surgery and medicine in Edinburgh, and most had to apply to the specialist departments, such as eyes, skins and V.D.
Desperate for a post, she applied for a job at a convalescent home for miners near Sheffield. As a consequence of a beautiful chance encounter at this interview, she was instead offered a position as First Assistant to Sir Ernest Finch (1884-1960) in Sheffield. There, she worked with Alan Fawcett (1896-1969) who was developing an interest in thoracic surgery. With all this impressive experience she passed her Fellowship at this college in 1945. With the knowledge that men were now returning from the war, she returned south and continued her work as a registrar rather than trying to pursue a position at a teaching hospital.
In August 1951, Slesser was appointed Consultant Surgeon to the thoracic unit in Leicester where she helped to develop the rapidly-expanding specialty of cardiothoracic surgery, becoming a key member of the Society for Cardiothoracic Surgery of Great Britain and Ireland. Her efforts in this field were recognised in 1974, when she was awarded an Honorary Fellowship at the Royal College of Surgeons of England by the President of the College.
Solitude
To emphasise how isolated women were in surgery in the early 20th century, by 1959, 39 years after Gertrude became the second female Fellow, the Royal College of Surgeons of Edinburgh had elected only 23 female Fellows in total. Despite the war providing opportunities for women to enter surgical positions, it became all too apparent that doors began to close when men returned from war. The difficulty was that women were seen as suited to care-giving or traditional roles, such as childcare and female health. Consequently, the only option for most women entering the surgical field was paediatrics, and within the wider medical world, obstetrics, gynaecology, or similar specialisms.
The work female doctors and surgeons have accomplished in these areas is profound, and it is thanks to trailblazers like Gertrude Herzfeld and others who paved the way, that it was made much more acceptable to have female surgeons at all. Though as we will see moving into the 1950's, the increase in surgical fields and specialisms created the idea of male specialisms which ultimately reduced the options for our later trailblazers.
Male-Dominated Specialisms
During the late 19th and early 20th centuries, surgery had begun to break into specialised fields. As we can see from Herzfeld’s work, paediatrics had separated from general surgery to become its own field in the early 20th century, as had urology and orthopaedic surgery. These were followed with cardiothoracic surgery in the 1930's and 1940's. Neurosurgery, whilst it had its beginnings in the 19th century, didn’t really become a fully-fledged specialty in the 1940's.
The breaking down into specialities in some ways further restricted the career freedom for women in surgery. Certain specialisms were deemed unsuited to women and were therefore male-dominated, and those doors would remain firmly closed for many decades. In fact, regrettably we are still witnessing ‘firsts’, as it was only in 2020 that Ireland appointed its first female consultant neurosurgeon.
What was evident is how paediatric surgery opened the door for female surgeons. This allowed pioneers a foot in the door and crucially, the chance to gain positions in leadership roles. It was these roles that paved the way and reshaped surgery for future generations, and slowly broke down male-dominated specialties.
Late 20th Century - Caroline Doig
Caroline Doig released her autobiography in 2018, which offers a fantastic insight into the environment of a female surgeon beginning her career in the latter half of the 20th Century. Doig graduated in medicine from the University of St Andrews in 1962, and immediately understood that gaining a foothold into a surgical career would not be straightforward. She noted that even her forward-thinking, renowned male mentors tried to discourage her from her chosen path in surgery. During interviews she was constantly questioned on marriage and children, indicating that it was not then believed that these were possible within a surgical career.
When I was interviewed, I was subjected to “You don’t really want to do surgery do you?” and “You’re going to get married”
To put into context what Miss Doig was confronting; when she passed her Fellowship examination in Edinburgh in 1967, she became one of just 76 female Fellows of the Royal College of Surgeons of Edinburgh. Women only made up roughly 1% of all surgeons in the UK in the 1970's. One particularly disturbing story from her early struggles, which is hard to hear today, was during one of her Fellowship exams here at the College, where she recalls the horrifying experience of the examiner consistently patting her upper thigh after asking each question. She stated,
Naturally I froze and made a mess out of my answers in the oral exam
and added:
thankfully it was all sorted out in the end.
This unsettling incident highlights the often misogynistic environment women were facing scarcely fifty years ago.
I do not think his unsuccessful attempts to deter me were because of my ability or lack of it, but simply because I was a woman.
She was told by a senior paediatric surgeon that to be taken seriously she would require both the English and Edinburgh Fellowship, plus an academic thesis. In her books, she recalls many years later that the senior surgeon admitted that while those requirements were true, he had been trying to dissuade her. Miss Doig gained all the above requirements within five years.
Trying to get a senior house officer post proved my worries about doing surgery.
Having realised early on in her introduction to surgery that a career in general surgery would be difficult, she decided to focus on paediatric surgery (she described children as the perfect patients, being faultlessly honest with their symptoms and pain). The problem lay in that, to become a paediatric surgeon, Miss Doig was advised she needed further general surgical experience. She was eventually appointed Registrar of Durham Hospital in 1968, however the committee took a while to appoint her given that this was a new precedent, contemplating between her abilities and the fact she was a woman (a first for that department). However, she was obviously a success in her position in Durham and evidently forged a trail, as the next two Registrar posts appointed there were subsequently women.
The next step in her career was to apply for Senior Registrar, which incurred further setbacks with her applications returned ‘practically unopened’. Consequently, she even considered changing her name on applications to 'C Doig' in the hope she would be mistaken for a Charles. Encouragement did come from some, and Professor Andrew Wilkinson (1914-1995) at a meeting here at the College urged Doig to persevere. In 1970, he would oversee her training when she was appointed as Paediatric Senior Registrar at the Great Ormond Street Hospital, London. Five years later, desiring to be closer to family in Scotland, she gained a consultant post in Manchester in 1975 as a Senior Lecturer in Paediatric surgery for the Department of surgery at Manchester University.
My first medical staff meeting was interesting. Although there was a locum female neurosurgeon… there was no established female consultant in the hospital, never mind a female surgeon!
She recalls having to be determined and confident in her first medical staff meeting. Knowing that if she didn’t proceed with strength and determination she would forever be on the back-foot. After having to shut down suggestions of reductions to her department, victory was hers when a slightly difficult orthopaedic surgeon passed her a note at the end of the meeting that said ‘Please, may I always fight on your side’. This was to be the beginning of a long and successful career in paediatric surgery lasting 25 years in Manchester.
Being Visible
I was the role model I never had.
In her book, Miss Doig outlines the next chapter of her life as ‘medical politics’ and here too she made inroads. In her words, the world she entered did not have female mentors, and it was not until well into her consultancy years that she could even change in a surgical changing room; the rooms provided until that point were either nurse or male.
She became actively involved in the Medical Women’s Federation (MWF) at the start of her career, later becoming President in 1985. Her Presidential address was entitled ‘The Hands of a Lady’, a reference to the traditional, somewhat ironic notion that surgeons should have small and delicate hands, despite the difficulties women were facing gaining acceptance. In this role and throughout her career, she assisted many young women with advice and more importantly encouragement, no doubt helping to attract more women to the profession.
There were no role models for me when I started out, but throughout my working life, I acted as such for many girls who came to me for advice - and perhaps more who had became aware of the existence of a female surgeon.
In 1984, Miss Doig made history by becoming the first female surgeon elected to the Council of RCSEd. She had been encouraged to do so by the very mentor who had tried to dissuade her from undertaking a career in surgery! She served on Council for over 15 years, sitting on numerous committees, and particularly enjoying travelling the world representing the College and examining future surgeons.
I had made medical history, even if it had taken women four hundred years. It was sixty-four years since a woman had got the fellowship in 1920.
Miss Doig was then elected to the General Medical Council (GMC) in 1989, and in 1994 became Chairman of the Oversees Registration Committee, making history again by becoming the first woman to chair one of the main committees of the GMC.
In these ground-breaking roles, female surgeons like Caroline Doig helped not only to bring about practical change but also stood as high-profile examples of successful female careers in surgery. This significantly helps encourage the next generation by simply being visible.
Her final gift to the College was establishing the Hunter Doig Medal, which commemorated two firsts for women in medicine: her appointment to Council in 1984, and Alice Headwards-Hunter, the first woman to pass the Fellowship examinations of RCSEd in 1920. The Hunter Doig medal is awarded to female Fellows or Members of RCSEd who demonstrate career potential and ambition. Caroline requested that the recipient ‘must be one who people think will make her mark’. She had the pleasure of presenting this medal to many recipients prior to her passing in 2019.
Where we are now
What is clear from the history of women in surgery is the challenging and often-hostile environments early female surgeons encountered and the difficult paths they forged. Their achievements, however, have helped to improve the treatment of women in surgery and to highlight that women can succeed in this career.
The numbers are testament to this: If we take the number of female Fellows in 1959 as 23, we can see that just over 60 years later, in the year 2021 alone, 451 female surgeons became Fellows. The current ration of male to female consultant surgeons within the UK is around 8:1, which shows significant improvement to the 1% in Caroline Doig’s day.
As of today, women make up around 60% of all medical graduates but still only make up around 25% of surgical trainees. Surgery is therefore looking at ways to encourage a bigger uptake by female graduates to prevent future surgical shortages. This will most likely mean continual changes in attitudes and work environments, and of course in work-life balance, ensuring that it is no longer a choice between career and family.
Surgeons' Hall Museums aims to update the women in surgery exhibits in 2024, to put more focus on this area of the history of surgery, and the museum is actively collecting around women in surgery and welcomes new collections.
Crucially, I think the most important act performed by all the women mentioned was upon succeeding in their own careers, they turned around and offered a helpful hand up to the women climbing the ladder behind them. That is something I am sure we can all aspire to.
If you are interested in donating surgical instruments or similar items from a career in surgery, please reach out to the Curator for an initial discussion: l.wilkie@rcsed.ac.uk. The College Archivist is also actively collecting archival collections relating to female surgical careers: j.cahif@rcsed.ac.uk.
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