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Rhoda Wynn
Baylor College of Medicine, Houston, Tex

JAMA. 2000;283:668-669.

The heritage of women in medicine spans ancient history to the present, with female practitioners weathering fluctuations in status influenced by the religious, social, and scientific milieu in which they lived.

Ancient Goddesses and Healers
Female practitioners of the medical arts were active in the ancient world. Worship of Isis, the great goddess of medicine, was universal among ancient Egyptians; magnificent temples were built in her honor^1-2 and priestesses of Isis were regarded as physician-healers who obtained their healing powers from the goddess.² At Sais, a city at the mouth of the Nile, women were both students and teachers at a women's school specializing in child-bearing issues.¹ Egyptian records also show that women studied at the royal medical school at Heliopolis as early as 1500 BC.³ Illustrations of women performing surgery were common on tombs and temples throughout Egypt,³ suggesting that female physicians were widely accepted by the general population.

In ancient Greece, the goddesses Athena, who cured blindness; Hera, the chief healing deity; and Leto, the surgeon, were worshiped for their healing skills.^{1, 4} Hygeia and Panacea, like their father Aesculapius, were "sainted mortals" who probably also had been independently practicing physicians.^{1, 4} Statues of Hygeia and Panacea were located in over 300 healing temples throughout Greece, where oracles were interpreted by male and female priests who prescribed treatments to their patients.^4-5

Subsequent Greek women doctors taught medicine, took care of patients, performed operations, and provided obstetrical care.¹ Galen, the renowned physician, recorded the activities of several women physicians, including Margereta, who held a prestigious position as an army surgeon, and Origenia, whose remedies for hemoptysis and diarrhea he praised.¹ The skills of Greek medical women were highly sought after, and they commanded high prices in the Roman slave markets as captives after the fall of Corinth.³ Female physicians in ancient Rome, called medicae, managed busy practices and were on equal footing with male physicians.⁵

Of Saints and Witches
Art, literature, and medical science declined as the Roman Empire disintegrated under the pressure of the invading barbarian tribes.⁶ The practice of healing fell to women at home and within the holy orders. A few holy women were canonized for their work. St Bridget practiced medicine and midwifery in Ireland and St Scholastica aided her brother St Benedict during the plague.⁵ As the medieval period progressed, the education of women in medicine suffered a decline as the early church stressed the inferiority of women.^5-6

In contrast, the school of medicine at Salerno, Italy, accepted women.⁵ The climate of tolerance in this city allowed influences from Arab, Jewish, Roman, and Greek cultures to coalesce in intellectual achievements that included medical concepts to which women contributed.⁷ The best known woman on the faculty was Trotula, a magistra medicina, who wrote a book on obstetrics and gynecology that was used for more than 400 years.^{1, 7}

Witch-hunting swept through much of Europe as the Middle Ages waned. Because women were not allowed to study medicine, skill in healing was assumed to have been obtained from the devil.^{2, 8} Spinsters, widows, and other women who refused to conform to the expectations of their low social status, including female healers and midwives, were frequent targets of witch-hunts.² Scant evidence was required to convict.

During the witch-hunts, occurring from roughly the 13th to 18th centuries, women had been edged out of the medical profession and had lost access to formal medical education. In England and France, the passage of licensure laws and the formation of guilds in the 13th century further prohibited women from the practice of medicine.⁴ Even midwifery, previously a woman's field, was dominated by men by the 17th century.³ Women were excluded from practicing in a professional capacity, though they continued to practice medicine in the domestic setting as nurses and midwives, who were considered subordinate to male physicians.

Victorian debate eventually helped women enter medicine. Egalitarian views espoused by writers such as John Stuart Mill and Havelock Ellis held that no limits should be imposed on any individual's potential.⁹ This conflicted with the prevailing "scientific" view of biological determinism that deemed women unsuitable for careers in medicine.^{4, 9}

Early Strides in the 19th Century
The drive to reclaim a place in medicine during the 19th century began with the efforts of several enterprising women. The prevailing view was still that women were unsuited for the profession of medicine. In 1873, one Harvard Medical School professor, Edward Clark, wrote that the end result of medical education for women would be "monstrous brains and puny bodies"; another, Horatio Storer, theorized that menstruation caused "temporary insanity."^10-11

Among the pioneers was Harriet Hunt, the first woman physician in early 19th-century America. She represented the initial group of women physicians who, like her, trained in irregular apprenticeships and were largely ignored by the medical establishment.¹² Elizabeth Blackwell achieved the next milestone by gaining admission to the Geneva Medical College and becoming the first woman to receive a medical degree in the United States. Stymied in her attempts to obtain hospital privileges, she practiced out of her own home and later founded the New York Infirmary for Women and Children, the first hospital in the United States staffed by women, and offering more women the opportunity for advanced training.^{3, 12}

Increasing numbers of women were admitted to medical schools during the mid-1800s. Financial forces aided their entry as supporters of feminism made major contributions to schools accepting women.¹⁰ By the late 1800s, several previously all-male schools were admitting and graduating women, and legislators allowed the charters of medical schools specifically for women.¹² Social acceptance also grew as women physicians increased their visibility by giving lectures on topics such as hygiene.¹²

A few women, such as Mary Putnam Jacoby, who consulted at major New York hospitals and was the first woman inducted into the New York Academy of Medicine,¹² came to be regarded by male physicians as peers in professional accomplishment. At the end of the 19th century, more than 7000 women were practicing medicine and another 1200 were in medical school.¹²

Aftermath of the Flexner Report
The number of medical schools open to women sharply declined during the early 20th century, hastened by the Flexner report.^11-12 Reforms were already under way when inadequate instruction was reported at many schools that coincidentally admitted the most women.¹² While these schools sought to maintain high standards, they had limited financial resources, and many closed.¹¹ Flexner himself, while stating that "privileges must be granted to women . . . on the same terms as men," believed that the declining numbers of women was due either to their lack of desire to be physicians or lack of demand for female physicians, as opposed to diminished opportunities.¹³

Additionally, many women's medical colleges had merged with male medical colleges, anticipating greater equality. However, coeducational schools with higher percentages of women tended to have less prestige and they began reducing the number of women enrolled.¹⁰ By 1914, only 4% of medical students were women.⁸ Aside from small increases during World War I and World War II, when there were fewer men to fill medical school slots, female enrollment remained low.¹⁰ As recently as the late 1960s, many school administrators continued to openly state preferences for males and had internal quota systems that limited the percentage of women admitted.¹¹

The Emergence of New Opportunities
During the 1970s, the rise of the feminist movement and affirmative action created an atmosphere more conducive to women becoming physicians. In 1960, only 5.8% of incoming medical students were female, but the proportion increased to 13.7% in 1971 following the passage of the Equal Opportunity Act.¹⁰ By 1990, the number of female physicians in the United States had increased 310% from the 1970 level, when women represented 1 in 5 physicians.¹⁴

Despite progress, problems linger. Female physicians lag in income and are underrepresented in research and leadership positions. Concerns that women lack the physical and mental capabilities to practice medicine continue to be raised. Many women correctly perceive that department chairs consider pregnancy to be a risk when hiring a female resident.^{11, 15} Although many physicians feel positive toward pregnant colleagues, several studies have indicated that a significant number of physicians consider working with a pregnant colleague stressful or inconvenient.¹⁵ Studies showing that women physicians have a higher incidence of depression and suicide compared with male physicians have been interpreted as evidence that women may not be capable of dealing with the stress of a medical career.^10-11

As we enter the third millennium, women have made spectacular advances. Women now comprise nearly half of incoming medical students¹⁶ and will represent a third of all practicing physicians by 2010.¹⁴ The roles of women in medicine have ranged from healers with skills derived from deities, to respected colleagues, to alleged witches, to intruders into the male medical establishment, to respected peers once again. Alternately aided and hindered by education and by opportunities to practice, women have persisted throughout time and shifting social, religious, and scientific ideologies to make strides in medicine.

REFERENCES
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