By Claire Brock
The Royal College of Surgeons (England) runs a scheme called ‘Women in Surgery (WinS)’ to ‘encourage, enable and inspire women to fulfill their surgical ambitions’. Its aims are five-fold: to raise the profile of women in surgery; to work towards an understanding of the issues facing these women; to encourage attitudinal change ensuring women are seen as an integral part of the profession; to provide advice, guidance and pastoral support for those already in surgery or considering entering it; and to support the Women in Surgery network. As this organization and its goals make clear, women are still not fully ‘in’ the surgical profession, neither psychologically (whether that be in their own minds, in those of their colleagues, or the wider public) nor actually. Although more than half of applicants for medical degrees in Britain are women, in 2014 only just over 10% of consultant surgeons were female.
However, perceptions of women’s place in surgery are changing. In April 2017, the New Yorker ‘Health, Medicine and the Body’ issue ran a cover by Malika Favre entitled ‘Operating Theater’. It showed a stylized graphic of four female surgeons peering at the reader as if over a patient on the operating table. In response, women surgeons across the globe staged the image in their own work spaces and put the results on social media. Their concerted effort aimed to deter doubters, showing that women can, as the hashtag put it, ‘#LookLikeASurgeon’ too.
Not ‘looking like a surgeon’ has affected how female aspirants to medicine have been treated since the mid-nineteenth century when Elizabeth Blackwell in America and Elizabeth Garrett Anderson in Britain sought entry into the profession. If women were unsuited to medicine, then they were considered even less able to wield a scalpel, cut into human flesh, and stand the sight of blood. Women, according to contemporary detractors, were too weak, both in mind and in body, to operate effectively; they could never look like surgeons because surgery was male, with its thrusting bravado. Such an attitude persisted even after the development of anesthetic practice had meant that brute strength was no longer needed to restrain a conscious, thrashing patient or hack off a limb with as much speed as possible to prevent fatal blood loss. None of these attributes were apparent in or appropriate for Victorian ladies; any attempt to embody them would render the female pretender masculine and immodest. In 1876, H.W. Sharpin argued that ‘practical knowledge’, acquired through experience in dissection, in post-mortem rooms and in the operating theater would be enough to ‘change their very nature’. While concerns about female ‘delicacies’ have since abated, surgical practice (especially at the profession’s pinnacle and in certain fields) is still largely male-dominated as the statistics above reveal.
If the female surgeon is an anomaly for many, even today, it can be hard to convince many that women have been operating for centuries. Minor procedures, such as stitching wounds or soothing burns, were carried out by women in the home or local community and, providing they confined themselves to this space, treated only their own sex or children and assisted rather than led, they were tolerated. In the mid-nineteenth century, when women sought professional recognition – meaning payment and competition – detractors of both sexes deemed this an inappropriate step. Early campaigners to join the profession focused on female patients’ reticent embarrassment in seeking help from male practitioners, especially for gynecological conditions, with often fatal consequences. With a member of their own sex in attendance, lives could be saved through prompt examination and necessary surgery. From the earliest attempts at gaining entry into the profession, women stressed that they were only interested in treating those for whom they had traditionally cared. Until 1914, when wartime circumstances meant that they were finally able to operate on men, and when shortage of male colleagues allowed them to take up positions in general hospitals, prejudice, but also inclination, meant that women were confined to treating surgically their own sex and children. This is not to suggest that they were parochial in their practice, however, even if their patients were limited. A willingness to take on risky, experimental surgical procedures in order to improve chronic and acute female conditions characterized the work of many early female surgeons.
While pioneer campaigners, such as Blackwell, Garrett Anderson and Sophia Jex-Blake, attracted a great deal of attention in the contemporary press due to their presumptuous campaign, those who came later operated in a less visible, but no less important, manner. In an 1861 letter sent by Garrett Anderson to her friend, suffragist and educational campaigner Emily Davies, she described the key ingredient for professional success as ‘quiet unexcitability’. Garrett Anderson’s route to a medical career was not always thus, but those who followed her sought to maintain such a professional demeanor. In one of many fin-de-siècle addresses reflecting on the surgical developments of the century, Garrett Anderson noted that manual skill, rapidity, courage and perfection had been surmounted by ‘sense of personal responsibility combined with attention to detail and patience’ in surgical practice. By 1900, for Garrett Anderson, showmanship was a less important surgical skill than careful precision and doing the best for one’s patient through considerate attention to each case. Women surgeons in Britain would place themselves deliberately in the vanguard of such surgical artistry.
Ethel Vaughan-Sawyer (1868-1949) is not a well-known name within or outside the history of medicine, but her career is indicative of the ways in which women surgeons after Garrett Anderson operated. In 1902, she became Assistant to Mary Scharlieb at the Royal Free Hospital’s Gynecological Department in London. Scharlieb had previously been Senior Surgeon at Garrett Anderson’s New Hospital for Women and these two positions signaled the first foray of women surgeons into a general hospital which was not run by their own sex. Over the next decade and a half, Scharlieb, Vaughan-Sawyer and later Lady Florence Barrett operated upon thousands of women who flocked to them with obstetrical and gynecological problems. With an interest in psychology, Vaughan-Sawyer believed in the importance of understanding the patient’s condition through their own words. In January 1911, she gave a lecture to the London School of Medicine for Women’s Medical Society, which pleaded for careful consideration of the ‘peculiarities and personality’ of the individual patient. Rather than viewing each case as a condition or as a disease to be cured, Vaughan-Sawyer pleaded for ‘the individuality and feelings of the sufferer’ to be a serious subject of study and attention. Vaughan-Sawyer practiced what she preached. She often wavered over the treatment of her patients, waiting, observing and considering circumstances before operating: the epitome of the modern surgeon according to Garrett Anderson’s analysis. Her case notes often contained follow-up letters from patients’ doctors and sometimes even the patient themselves, indicating an interest above and beyond the operating theater.
As an operator, Vaughan-Sawyer was an early adopter of radical gynecological surgery. In particular, she was an ardent and successful proponent of the radical Wertheim method for cervical cancer. This controversial procedure involved the removal of the uterus via the abdominal route, the cervix protected with a clamp, which was named after Wertheim. Additionally, cellular tissue and lymphatic glands were removed, in case the disease had spread. For some gynecological surgeons, the risks of this lengthy, tricky and complicated operation were too great, but for others such as Vaughan-Sawyer, who perfected the procedure over a decade at the Royal Free, the potential benefits to the patient were incalculable. For Vaughan-Sawyer, a Wertheim bought the patient more time, relieved suffering and potentially cured. She was always willing to take the risk, even on those deemed unsuitable for surgery, and, as her powers of persuasion were legendary, to the extent that patients ‘tolerated whatever she prescribed’, very few refused the most radical surgery. Ethel Vaughan-Sawyer was a consummate surgical artist, her contemporaries believed. As an ‘excellent diagnostician’ and a ‘meticulously careful surgeon’, she did not allow this success to supersede great interest ‘in the lives of her patients’.
Early professional women surgeons encountered opposition, but they also had support from their patients, the general public and male colleagues alike. Surgery developed swiftly from the mid-nineteenth century and female practitioners embraced its varied challenges, adopting and adapting techniques and procedures to fit their specific areas of expertise. They believed that surgeons could be women and it is thanks to their example that others could follow. Just before her death in 1949, and despite a decade without sight, Ethel Vaughan-Sawyer exclaimed: ‘I’ve had a wonderful life, and am still thrilled when I think about it’. Any aspiring female surgeon should be bolstered by the history of their counterparts, but this background also reveals how and why there are still insecurities about women’s fit in professional surgery. If the New Yorker’s ‘Operating Theater’ image goes viral again, maybe the simile can be removed and replaced with the more secure statement, ‘#IAmASurgeon’.
Claire Brock is an Associate Professor at the University of Leicester. She has recently published British Women Surgeons and their Patients, 1860-1918 (Cambridge University Press, 2017), the research for which was funded by the Wellcome Trust. This monograph is available to all through Open Access.
 For the foundational account of surgery in historical perspective, see Christopher Lawrence, ‘Democratic, divine and heroic: the history and historiography of surgery’, in Medical Theory, Surgical Practice, edited by Lawrence (London and New York: Routledge, 1992), 1-47.
 H.W. Sharpin, ‘An Address Delivered at the combined Annual Meeting of the South Midland and Cambridgeshire and Huntingdonshire Branches’, BMJ, 2. 813, 29 July 1876: 144-145; 144.
 See, for example, A.L. Wyman, “The Surgeoness: The Female Practitioner of Surgery 1400-1800”, Medical History 28 (1984): 22-41 and Celeste Chamberland, “Partners and Practitioners: Women and the Management of Surgical Households in London, 1570-1640”, Social History of Medicine 24 (December 2011): 554-569.
 Elizabeth Blackwell, Pioneer Work in Opening the Medical Profession to Women. Autobiographical Sketches (London and New York: Longmans, Green and Co., 1895): 27.
 Elizabeth Garrett to Emily Davies, Aldeburgh, January 1861, HA436/1/1/2, Elizabeth Garrett Anderson Letters, Ipswich Record Office, Suffolk.
 Elizabeth Garrett Anderson, ‘An Address on The Progress of Medicine in the Victorian Era’, BMJ 1.1900, 29 May 1897: 1338-1339; 1338.
 For more on Vaughan-Sawyer, see Claire Brock, British Women Surgeons and their Patients, 1860-1918 (Cambridge: Cambridge University Press, 2017) and ‘Obituary: Ethel Vaughan-Sawyer’, BMJ 1.4602, 19 March 1949: 503-504.
 Ethel Vaughan-Sawyer, ‘The Patient’, London (Royal Free Hospital) School of Medicine for Women Magazine volume 7, no. 48, March 1911: 350-358; 350.
 For the original operation, see Ernst Wertheim, ‘A Discussion on the Diagnosis and Treatment of Cancer of the Uterus’, BMJ 2.2334, 23 September 1905: 689-704; 689-695.
 See Dr Lina M. Potter’s addition to Vaughan-Sawyer’s ‘Obituary’, BMJ 1.4604, 2 April 1949: 595.
 ‘Obituary’, BMJ, 19 March 1949: 504.
 ‘Obituary’, BMJ, 19 March 1949:504.