Women and the medical professions

Lesley A. Hall

(Sorry, no illustrations here but many of the images used when giving the talk are now available at Wellcome Images)

Not to be quoted without permission

When people think of women entering the medical profession, they tend to think of a very circumscribed period of a couple of decades during the later nineteenth century, in which a group of heroic women determined to become doctors, and eventually achieved their aims of making medical education available to women and gaining recognition for them to practice medicine. I would like to suggest that the history of women and medical practice actually goes back a long way before Elizabeth Garrett Anderson took the Licentiate of the Society of Apothecaries in 186, and that gaining these minimal basic requirements was only the beginning of the story of women's entry to the British medical profession.

Women were a constant presence in medicine and health care for centuries This is Hygieia, the female aspect of Aesculapius, whose sphere is the maintenance of health and the prevention of disease, as opposed to interventionist measures to cure the already sick. That is, she is responsible for health-care tasks usually assigned to the female sphere: the maintenance of cleanliness of the person and the environment both private and public, eating sensibly, dressing appropriately. And taking a large leap over antiquity, pausing to mention that there is good historical evidence for female medical practitioners of various kinds in several ancient societies, this is Trotula, a physician of Salerno where the school of medicine included women in the eleventh century. She wrote works on obstetrics and gynaecology which remained authoritative for several centuries, this illumination comes from a manuscript of De Passionibus mulierum (on the sufferings of women) in the Wellcome Collections. And this is Hildegard of Bingen, the sibyl of the Rhine, who as a nun had access to formal learning in the twelfth century. She wrote on many subjects other than medicine, and her Physica was printed 400 years after her death. She was also a visionary , and this is an illustration of one of her visions: it has been suggested that these display certain patterns similar to the visual phenomena of the migraine aura.

However, this place in elite, literate, scholarly medicine was atypical for women throughout the middle ages: their role was more usually of a rather humbler nature, for example as nurses and caretakers for the sick. Outside institutions women operated as lay-healers of various kinds. One field in which women were acknowledged as practitioners was midwifery. Skills in this field were, however, largely acquired through experience, and presumably apprenticeship, perhaps passed on from mother to daughter. It is not until the seventeenth century that we find women themselves publishing on the subject: as Jane Sharp did in The midwives book. Excluded from surgery or pharmacy by the licensing system, women who wished to practise as midwives also had to be licensed, in a system regulated by the church on a diocesan basis: midwives were examined by surgeons and other midwives but presumably good character and religious orthodoxy mattered as much a professional skills, as midwives were permitted to baptise in cases where the survival of the child looked uncertain. From 1662 they were required to pay for their license. The image of the eighteenth century midwife is this : Rowlandson's midwife going to a labour, which is often shown to demonstrate what a good thing the rise of the man-midwife was. I should like to point out that grotesque as she is (and clutching a bottle) this midwife does appear to be turning out in the middle of a nasty-looking night!

However, much of women's practise in the area of health-care took place in the domestic and private sphere, where all maintenance of health and prevention of disease takes place. This is the title page of The accomplisht ladies delight, late seventeenth century; showing some of the accomplishments which a lady was expected to have, cooking, brewing and distilling. Manuscript family receipt books handed down from generation to generation promiscuously mingle cooking recipes with medical treatments. Primrose in Popular errours, 1651 depicts an old woman and her medicines interfering with the doctor's treatment: doctors, of course, were anxious to differentiate their professional learned skills from those of this domestic, even folk, tradition. It is, nonetheless, women who are expected to undertake the task of caring for the sick or disabled within the household. . Florence Nightingale's famous Notes on Nursing were addressed to the nurse within the home rather than in the hospital, and she claimed that 'every woman must, at some time in her life, become a nurse'. This image of mother's care for the family is still to be found in advertising: this advert for AntiKamnia dates from the turn of the century, but look in any women's magazine today!

This care for the domestic circle extended to the surrounding community with the involvement of women in formal and informal philanthropic care for others. In the Middle Ages nuns not only provided care within convents for the sisterhood but for the communities around them. In the tradition of the Seven Works of Mercy--one of which was visiting the sick-- this is St Elizabeth of Hungary, frequently depicted performing this particular act of charity. Women of the aristocracy and gentry often acted as informal physicians not only to members of their households but for the surrounding community; some ladies even ran what amounted to hospitals, or at least dispensaries. Works on domestic medicine, assuming that their readers would be engaged in charitable works, gave recipes for nourishing soups for the sick poor, gruel for the invalid diet and so forth. Women's involvement in medical philanthropy was not confined to this sort of social money-raising enterprise--A Fancy Fair in 1830--though it was often regarded as particularly women's sphere to get up bazaars and fairs in aid of good causes--there is a letter from Elizabeth Garrett Anderson about the University College Hospital Bazaar which suggests that being a professional medical woman did not exempt her from this female task.

Women were also involved in folk, alternative, and commercial medicine--not that these can be entirely distinguished from one another, or from domestic and philanthropic practice, much of the time. There is a nice tombstone inscription in the churchyard of Newton St Petroc in Devon, of Prudence Potter, the Rector's wife who died in 1689 aged 77 having spent her life in 'the industrious charitable and successful practice of physick, chirurgery and midwifery'. Here is The Village Doctress, one version of several treatments of this subject: a rather benign presentation of a folk healer, though we may note the cat, which perhaps makes an oblique allusion to witchcraft. In fact such women were often equally as well qualified as many male practitioners. In some cases a female practitioner was continuing a family tradition-- Sarah Mapp the famous bonesetter had learnt her skills from her father (a Mr Wallen). She was paid £1000 a year to reside at Epsom.

Women also made contributions to medicine which are hard to classify: Lady Mary Wortley Montagu discovered the technique of innoculation against smallpox (a disease which had killed her brother and disfigured her) in Turkey while her husband was Ambassador to the Sublime Porte, and introduced it into Britain. One might also mention the 'old woman in Shropshire' whose family receipt for treating dropsy led William Withering to the discovery of digitalis. On a more formal level, there were some institutions which admitted women, this is Anna Morandi Mazzolini, of Bologna, who introduced the innovative practice of using wax models of dissected specimens in medical teaching and was appointed Professor of Anatomy in 1760, only one of a number of women who form part of the distinguished Bolognese medical tradition.

Hostility towards women of lower social classes who practised medicine or surgery for as a paying occupation grew more intense throughout the eighteenth century and by the early nineteenth century women practitioners who were not nurses or midwives or retailers of medicines had entirely disappeared. Women were largely excluded from a medical profession increasingly defining itself through formal education and qualifications rather than apprenticeship, to create a professional medical monopoly from which women were excluded. It is possible that there were other women who followed the route taken by James Miranda Barry, who qualified in medicine in male disguise and had an impressive career in the Army Medical Service. However, nothing is known of them if so.

Women were active in the sanitarian movements of the mid-nineteenth century and it was argued that their private virtues should also find expression in the public sphere. By the middle of the nineteenth century there was growing demand for the admission of women to the medical profession. There were a number of aspects to this demand and I have laid out some dates and events on a handout in the hope of clarifying a picture which is quite complex. First, of course, women had to obtain medical education, which in itself was not easy. The medical curriculum involved much which was assumed to be highly inappropriate for a lady to have the faintest inkling of. If a women managed to acquire the theoretical and academic knowledge necessary clinical experience was not easy to come by. Even if she managed to obtain this training, she then had to find an institution willing to grant her a degree or able to license medical practitioners under the Medical Registration Act. Then, supposing qualification could be obtained, it was very unlikely that any hospital or other medical institution would employ a female doctor. She would thus be thrown back on the precarious course of setting up in private practice without any of the means--hospital practice and institutional appointments--by which male doctors were able to supplement their earnings, and get themselves known to potential private patients.

Meanwhile there was an active debate in journals both medical and lay about the very advisability of women becoming doctors. It was feared that they might take patients away from men, simultaneously as it was argued that no woman could possibly be intellectually and physically capable of successfully undergoing medical training. While the opponents of female medical education had such inconsistencies in their case, it must also be pointed out that the advocates for women doctors argued both from notions of the sexlessness of intellect and women's capacity for equal competence, and from notions of separate spheres. It was claimed that women would bring particular gifts to practice, and in particular they would be able to bring a specific sympathy to the ailments of their own sex and of children. It should not be forgotten that, although one can readily find furious male rhetoric defending the exclusivity of the medical profession, women could not have succeeded in gaining medical education and qualification without male allies.

I will turn to some of the approaches and strategies by which women did become doctors. The first woman doctor to appear on the British Medical Register was Elizabeth Blackwell, who had qualified at Geneva Medical College, New York in 1849 and was admitted to the Register in 1859, but in the following year a new charter empowered the General Medical Council to exclude holders of foreign medical degrees. It should be added here that universities in Switzerland and France began to admit women as medical students from 1864: Zurich led the way, followed by Paris, Berne, and Geneva.

In 1862 a Female Medical Society was established in London aiming, in the first instance, at improving midwifery by giving 'superior' women a professional training equal to that obtained by male medical students. This would not only provide a higher grade of midwives but it was envisaged that they would be able to deal with gynaecological and paediatric ailments as well. This was obviously threatening to the developing male medical speciality of gynaecology and obstetrics. A Female Medical College was opened in 1864 and attracted a number of women seeking medical education, however limited. They were able to acquire practical experience at the British Lying-In Hospital. There was some opposition not only from medical men feeling menaced, but from other women promoting female medical education, who had some doubts as to whether an exclusively female institution would ever be regarded as equalling the standards of the male schools (even though the teachers were men strongly committed to female education and women's rights): the situation in the United States, where women's medical schools existed but failed to enjoy full recognition, was felt to demonstrate the disadvantages of this approach. There may also have been other prejudices involved with the Female Medical College, which had strong associations with secularist, radical, neo-Malthusian circles: one of the teachers was Charles Drysdale, who contracted an alliance with one of the women studying there, Alice Vickery, another key member of the Neo-Malthusian movement in the later nineteenth century.

Inspired by Elizabeth Blackwell's example Elizabeth Garrett (1836-1917) sought qualification as a doctor. She had powerful advantages of social privilege and wealth, and her father's support in this pioneering project. In spite of finding medical schools and hospitals closed to her, and being refused matriculation by London University, Garrett gained considerable personal support and private tuition from individual medical men. She obtained a licence acceptable to the GMC by taking the examinations for the Licentiate of the Society of Apothecaries (which immediately closed the loophole which had permitted a woman to do so) in 1865, first appearing in the Medical Register in 1866. She established a Dispensary in a poor area of Marylebone for the treatment of women and children of the lower classes but the very existence of a woman doctor attracted numerous middle class women patients. Garrett also took in the aspirant medical women Frances Morgan, Eliza Walker, and Louisa Atkins for clinical instruction. In 1870 she obtained an MD from the University of Paris, and was appointed Visiting Medical Officer at the East London Hospital for Children, the first woman to obtain a hospital appointment. In 1871 she married James Anderson, but continued to practice. In 1872 the New Women's Hospital opened on the site of her Dispensary: this eventually transmogrified into the Elizabeth Garrett Anderson Hospital which can still be seen near here.

Sophia Jex-Blake (who had already obtained some medical training in America) and four other women attempted to obtain admission to the Edinburgh Medical School, but in spite of the sympathy of some members of the faculty there was furious resistance and the Medical Faculty refused Jex-Blake and her companions their degrees. They therefore--along with other aspirant lady doctors--sought qualification on the continent. Although British women were able to obtain a superior medical education at continental universities such as Paris, Zurich, Berne, at which several of them had brilliant careers, graduating at or near the top of their classes, foreign degrees did not qualify for admission to the Medical Register, although a number of women practised in the UK by virtue of these degrees. Also of course it required considerable financial resources to travel abroad for the course of study, limiting the numbers of women for whom it might even be an option.

In 1873 Eliza Walker Dunbar (who had gained her degree in Zurich) was elected as house surgeon to the Hospital for Sick Children in Bristol, although this caused not merely controversy but serious upheavals in the hospital administration, with some doctors actually resigning in protest. In 1876 an enabling act was passed by Russell Gurney, to permit (but not require) the various medical corporations entitled to license medical practitioners to examine women, in spite of any restrictions imposed by their charters. The first British medical corporation to take advantage of this Act was the King's and Queen's College of Physicians in Dublin. The first seven women presenting themselves were successful, and entered on the register.

There were still problems for women in obtaining a medical education, and it was felt that there should be a British medical school offering training to women, although Elizabeth Garrett (since her marriage Garrett Anderson) was not altogether convinced that a single-sex institution in London was preferable to the co-educational continental schools: she felt that there was some danger of creating a separate, inferior 'women's' qualification, which seemed to be the way things were going in North America at that period, An additional difficulty was the refusal of London hospitals to admit women students for clinical training. However, Garrett Anderson, Jex-Blake, and Blackwell worked together, with the assistance of male allies who included Thomas Henry Huxley, to set up the London Medical School for Women, which opened in 1874, absorbing the assets and existing students of the Female Medical College. In 1877 the Royal Free Hospital agreed to admit women medical students. As a result of personal tensions, and Garrett Anderson's appointment as Dean of the London Medical School for Women . Jex-Blake returned to Edinburgh, where in 1886 she started the Edinburgh School of Medicine for Women, which was not a success: Edinburgh finally conceded the admission of women to the medical curriculum in 1894.

By 1891, there were 101 qualified medical women in Britain. Obtaining education and licensing was only the start of the struggle. Once qualified, women had to build up a practice. Besides offering their services as general practitioners, with particular appeal to other women, women doctors managed to obtain some hospital appointments, mostly in provincial institutions catering for women and children. Women doctors themselves established 15 hospitals between 1866 and 1916 in the United Kingdom and India. Most of these directed their efforts towards the ailments of women and children, but at least one, the Nayland Sanatorium, was set up by Jane Walker in order to implement her own ideas about the treatment of tuberculosis. The Elizabeth Garrett Anderson Hospital has already been mentioned, these are the Duchess of York's at Manchester , Redlands Glasgow , the Bruntisfield, Edinburgh , the South London and Maud Chadburn the founder of the latter.

The entry of women to the medical profession was dramatic: it challenged men on their own ground. But other medical professions open to women were also changing or developing during the nineteenth century. It is not now thought that that the pre-Nightingale nurse was invariably an incompetent drunken slattern , reform and upgrading of the profession was already in train, but it is true that Nightingale's name and reputation were of considerable importance to the development of nursing as a profession rather than a version of domestic service. The new nurse was educated and trained and had her own expertise: she was not just a handmaid to the doctors but had her own sphere. There were attempts to improve the standing of the midwife, and to make it a profession rather than a skill handed down from woman to woman. The increasing regulation of midwifery however, was somewhat ambivalent in its effects: although the 1902 Midwives Act did admit to registration on the basis of experience it was intended that this would be phased out. Midwives' status as independent practitioners was consistently being eroded as they were placed more and more under the control of doctors. New professions came into being: physiotherapy, radiology , dieticians, health visiting and district nursing.

By the early twentieth century the heroic age of the woman doctor was past; the right of women to medical education and employment as doctors had been established. In contrast to many women's employments, women doctors could, in theory, command equal pay as a result of the professional protectionism of male doctors fearful of being undercut, although there were cases of women doctors accepting posts at lower rates, or in areas in which there was no comparable pay-scale. Considerable restrictions, both overt and tacit, in the pursuit of their profession remained.

With the outbreak of war in 1914 it was initially assumed by the Association of Registered Medical Women that women would be needed mostly for the care of the civil population, given the number of male doctors departing for the front: by February 1915 one-sixth of medical men in Scotland had joined the RAMC. Hospital residencies which had previously been beyond the wildest hopes of women doctors became available to them. By 1917 over half of all male doctors had been called up. Women were encouraged to enter medicine, teaching institutions which had previously scorned to admit women students threw open their doors. New posts for qualified doctors were created with the massive employment of women in, for example, munitions factories.

But some women also wished to take their medical skills into the war zone: a group of three women had already served in the First Balkan War, in Bulgaria, in 1912. It was--correctly--assumed that the War Office would not respond with any favour to medical women offering their services, so they offered these to the Allied governments. Women's hospital units were accepted by the French and Belgian Red Cross, and in Serbia and Russia (individual women also offered their services), and did heroic work. In 1915 the War Office gave the premises for a military hospital at Endell Street, London to a select group of medical women, including Elizabeth Garrett Anderson (although direction was in the hands of her daughter, Louisa, and Flora Murray)--it was felt that such an establishment, well away from the fighting front, made it suitable for staffing by women (it's worth commenting here that of course nurses and VADs, and ambulance drivers, were serving close to the frontline on the Western Front and elsewhere). The Endell Street Hospital operated until 1919 and treated some 26,000 patients, who provided the women doctors with exceptional opportunities for gaining surgical experience. By 1916 the demands for doctors in the Forces was so great that an appeal was made for women doctors to go out to Malta, and women were subsequently assigned to other areas in the Near and Middle East. However, the very uncertain position of women in these posts, as civilians temporarily attached to the RAMC without rank or status or any of the privileges male doctors with temporary commissions automatically received, created difficulties and much dissatisfaction. Women doctors also held posts in the recently created Women's Auxiliary forces. This war service, however, seems to have been for most women doctors a hiatus in their careers, not the start of a new direction--the same applied to most male doctors, of course.

After 1916 the flurry of foundation of hospitals by women died down, with only one, the Marie Curie in North London being established in 1929 to implement advances in radiotherapy for uterine cancer. Though their numbers were no longer being added to, such hospitals continued to play an important role in the provision of professional career positions for their sex: in 1925 the numbers of women holding honorary hospital staff positions reveal a noticeable concentration in areas where one of these hospitals existed. The decline in actual foundation of such hospitals raises various questions: were women coming to believe that such special institutions were no longer necessary, or were there broader economic factors involved, in the rising cost of bricks and mortar?

The major London teaching hospitals continued to be extremely grudging about admitting women as students, most doors slammed shut again in the decade after the end of the War, although at least some of them did occasionally admit women doctors to house appointments. The Royal Free continued perhaps the main single source of medical education for women; by 1950 it had trained 2688 women doctors, many of whom had been at the forefront of women's achievements in the profession: Royal Free alumni included the first women to achieve Fellowships of the Royal Colleges of Surgeons--Miss E Davies-Colley in 1911 --and of Physicians--Dr Helen Mackay in 1934, and the first woman Senior Medical Officer at the Ministry of Health, Dame Janet Campbell . There were other routes to medical training. From the 1890s further institutions joined the Royal Free and Edinburgh in offering medical education to women and are listed in the handout. By the end of the First World War more than a dozen medical schools accepted women, although several London schools, as you can see, were shortly to close their doors. While obtaining medical education was becoming easier for women, it was something of a 'double whammy' for a woman to have both the disadvantage of gender and a training perceived as less élite, it will be noticed that none of the most famous teaching hospitals admitted women until their arms were twisted in 1948.

Having acquired training women still faced many difficulties in pursuing a career in medicine and obtaining choice posts. Many of the avenues open to male contemporaries remained closed, and only women intending to go into the mission field could be sure of both an immediate appointment and the permission to 'marry and be fruitful into the bargain'. A handful of--mostly unpaid--appointments and a few assistantships in big general practices in English industrial towns were open to newly qualified women. Some posts of little desirability--such as those in the Highlands and Islands of Scotland--were held by women in default of available men. Many women were glad for the opportunity to be able to pursue their chosen career at all. Yet women doctors felt that 'better times were sure to come' and that by proving their worth new doors would open. The public, if not the more senior members of their own profession, approved of them.

In spite of all difficulties, by 1925 around 300 women were holding Honorary Staff positions in Hospitals, by no means exclusively in the hospitals founded by and for women. Women doctors were more likely to be employed in publicly funded institutions such as asylums or poor law infirmaries, rather than the more prestigious voluntary hospitals supported by philanthropic endeavour. The massive expansion of the public health field during the early twentieth century created opportunities for women, but under various constraints: local authorities usually imposed marriage bars on female employees, while posts to which women were likely to be appointed were often dead-ends. A few women achieved high positions-- such as Dame Janet Campbell, Senior Medical Officer at the Ministry of Health--but these were very definitely exceptions rather than the rule . A survey of 1000 of their members in Britain by the Medical Women's Federation (45 did not return the circular) in 1928 found 406 in general practice, 140 in specialist and consulting work, 127 working in hospitals or institutions, 156 in the public health field, 36 in research, and 90 retired--38 of these after years of active service, and 18 only temporarily, presumably while they had young children. These figures match up quite closely with those produced by surveys done around the same time of women graduates of specific medical schools. The 9% retirement/ wastage rate was comparable, even taking marriage and motherhood into consideration, with that of male medical graduates. Throughout the interwar period a considerable consolidation of women's foothold in the profession was undoubtedly going on.

I will considered how a few individual doctors fared in their chosen vocation between the two wars. A recurrent phenomenon was the non-linear progression of the female medical career, which does not necessarily correlate with lack of achievement or career satisfaction. Another element was the persistence of 'a missionary spirit as well as a desire to succeed'; a philanthropic agenda or service ethic was a recurrent theme among women doctors at this period, whether it took the form of medical care in slum districts or had wider aims of alleviating the sufferings of poverty, as in the dissemination of birth control or involvement in scientific research into nutrition.

Dr Isabel Elmslie Hutton (c.1880-1960) served in the Balkans and Turkey during and just after the War, and married an Army officer. When she wished to continue her work with the treatment of mental and nervous disorders, she found 'marriage was still a bar to salaried public health and hospital appointments. Women could, of course, take up general practice, but many wished to continue what they had been specially trained for'. The London County Council which controlled appointments at the Maudesley would not even look at her credentials upon hearing she was married. The post of junior Commissioner in Lunacy was similarly closed: when told this she 'replied in an angry staccato that it was a pity I had disclosed this heinous crime of marriage.... better... would it have been to live in sin and then all posts would have been open.'

In many ways Hutton enjoyed certain advantages. Her supportive husband was prepared to accept a semi-detached marriage while she built up a London practice, their marriage was childless, and she had acquired considerable career experience--including study abroad in Munich and Vienna-before the War. She decided to establish a consulting practice, combined with research, and finally obtained an honorary consultant's post at the British Hospital for Mental and Nervous Disorders, which she admitted was 'unorthodox, almost unknown, and had no prestige. They told me that few men would think of applying.' Nevertheless she was 'overjoyed at this appointment where I would have my own clinic and carry out treatment on my own lines' and stayed for 30 years. When her husband's career took them to India, Dr Hutton ended up as Director of the Indian Red Cross Welfare Service during the Second World War. Such versatility in turning her hand to whatever happened to offer in the situation in which she found herself, as opposed to planning out and following a definite career path, is I think a peculiarly female trajectory. However, although Hutton achieved considerable professional satisfaction in unpromising circumstances, her case clearly illuminates the difficulties the most dedicated and determined woman faced in wishing to combine marriage and a medical career, even when this was in one of the less glamorous--even, perhaps, somewhat despised--specialities.

Remaining unmarried had distinct advantages for a woman who wanted a career of administrative and policy-making responsibility. Dr Letitia Fairfield (1885-1978) was qualified in both law and medicine, a suffragette and a life-long member of the Fabian Society. Letitia is alleged to be the original of several unsympathetic characters in the fiction of her sister, the writer Rebecca West: a more positive or at least more tactful vision of the opinionated bossiness depicted by West was the obituary description of Fairfield as 'a delightful, vigorous, dogmatic and sometimes infuriating companion'. Acknowledged as a 'much appreciated medical administrator' she was reported as not always seeing 'eye to eye with her colleagues', though 'her integrity and loyalty were everywhere appreciated'. Although she was no bland bureaucrat, Fairfield's career followed a path almost comparable to that of a male doctor of her abilities and qualifications, even to the form of interruption caused by the two world wars. Joining the London County Council in 1911, she eventually became its first woman senior medical officer. During the Great War she was a medical officer in the Queen Mary's Army Auxiliary Corps (later the Women's Auxiliary Army Corps)--and later inspector of medical services, Women's Royal Air Force, and she was again active in the military medical services for women in the Second World War .

A woman of a younger generation was Joan Malleson (1900-1956). Educated at the pioneering coeducational establishment Bedales, while still a medical student she married the actor Miles Malleson--possibly a generational indicator--a new, 'having-it-all' concept of the professional woman's life. They had two sons, who also became doctors, but eventually divorced. She qualified in 1925 and held several posts, but is principally significant for belonging to 'a select and courageous group of women doctors who were pioneers in sexual reform. Their views and practice [were] considered heretical and shocking at the time'. Involved in setting up the Family Planning Association, she was one of the first doctors to run a clinic for sexual difficulties in conjunction with family planning work, at the North Kensington Women's Welfare Centre. She also taught contraceptive techniques at University College Hospital, at that time by no means a standard of the medical syllabus, and wrote a number of simple books of advice for a lay audience under the pseudonym 'Medica'. It was Malleson who was the moving force behind the famous Bourne case of 1938 creating common-law precedent enabling doctors to perform abortions on grounds of mental health .

The Family Planning movement provided opportunities for women doctors who for family reasons were unable to pursue a full-time career. They were able to do fixed sessions at agreed times, and while there may not have been much career progression open to them, they were using their professional skills and in touch with gynaecology, obstetrics and psychiatry as well as developments in birth control and marriage guidance, with opportunities for scientific research, and work in subfertility.

There were obviously a vast number of career patterns possible to women doctors at this period. Though they seldom obtained consultant positions at the most prestigious teaching hospitals, good work could be done at institutions which were not the glamorous flagships of medical science. Mary Walker (1888-1974) spent her entire career in 'the academic wilderness' of Poor Law, later municipal and National Health Service, hospitals in South London. Although such institutions did not 'stimulate or nourish the questing spirit', she was responsible for 'The Miracle at St Alfege's': research leading to the use of Prostigimine for treating the rare and debilitating muscular disorder myasthenia gravis. Her thesis won her the Edinburgh Gold Medal in 1937, but nonetheless she was denied opportunities to continue research. Restrictions on who could be admitted to the institutions where she worked meant patients could not readily be referred to her by other physicians. She was unable to take up an honorary post at the Elizabeth Garrett Anderson Hospital because of her dependence upon her full-time salaried job. 'Shy' and 'retiring', a 'great medical discoverer... relegated to... a lowly post at St Francis Hospital', she could have established a 'flourishing practice' in neurology .

With the scant information available it is hard to hypothesise whether it was simple timidity that kept Dr Walker in her humble salaried post, or whether there were other factors, for example family responsibilities--an elderly parent, an invalid sibling, even a child--deterring her from the risk of setting up in private practice. This raises questions as to whether in general women might have found the security of salaried posts in public institutions outweighing the possible, but by no means certain, rewards of private practice. Prejudice against women doctors, particularly in areas not intimately connected with female health or children, might have been felt to militate against the establishment of a viable specialist practice. The service ethic already mentioned might also have served to keep Dr Walker in a situation which sounds generally unrewarding and deeply frustrating for a researcher.

A far more successful figure was Dame Janet Vaughan, who died last year, and demonstrates a fascinating combination of socially-concerned physician with scientist, aided by the social assurance gained through being 'born and bred in Bloomsbury'. As a young doctor she was horrified by the slums of Camden Town, and took the floor, still a relatively junior doctor, at the Royal College of Physicians (at the time yet to appoint its first female fellow) to tell them that food was the best cure for the diseases she was treating. She developed her own extract of raw liver for the treatment of pernicious anaemia, trying it first on herself. It seems likely that Vaughan was a model for Virginia Woolf's fictional Chloe or Olivia, described in A Room of One's Own as 'engaged in mincing liver, which is, it seems, a cure for pernicious anaemia'. Her career did suffer from prejudices against women: at the London Hospital she held a research appointment but was not allowed to see patients on the wards. Involvement in the Spanish Medical Aid Committee during the 1930s familiarised her with Dr Duran-Jordan's work on the storage of blood, leading to her important contribution to the Blood Transfusion Service during the Second World War. Throughout her career Vaughan was notable for promoting both women's careers in medicine and their education more generally. She was the first women to be appointed a Councillor of the Royal College of Physicians.

It is possible that the restrictions on their advancement gave women doctors incentive to choose unusual career paths and experimental directions: if one knows that the Presidency of the Royal College of Physicians is not a reasonable career goal at least one does not have to pursue the kind of career pattern (and maintain the appropriate behaviour) which would lead to such an honour. It's noticeable that a number of women doctors around the turn of the century took a particular interest in the new developments in psychology and psychoanalysis, and in sexology.

Innes Hope Pearse (1890-1979) qualified in 1916 at the Royal Free and in 1919 became the first female medical registrar at the London Hospital. Severe illness frustrated her ambitions to be a surgeon, and she became the assistant to George Scott Williamson in his work on the thyroid gland. These two doctors, however, are best known for being the initiators of the famous 'Peckham experiment'--the Pioneer Health Centre, a unique experiment in community health .

But many women doctors must have found that the plight of Hilary Mansell at the beginning of Mary Renault's early novel, Return to Night, set in 1938, struck a chord. Hilary, passed over for a senior surgical post at a leading hospital, throws herself away on a country town practice, for which she knows she is over-qualified. Hilary is acutely sensitive to local prejudice against woman doctors, however competent. The novel opens with her growing dissatisfaction with the restricted outlets for her abilities--possibly not untypical for the period. Unfortunately the book does not go on to be a female version of Cronin's The Citadel but deals with Hilary Mansell's growing entanglement with an attractive, emotionally damaged younger man of the neighbourhood. I would not know how typical that was!

Some figures were collated as to what women were doing in medicine early in the 1940s, possibly to some extent skewed by wartime conditions. Out of the entire medical profession women made up slightly under 20%: around 7200 in 1944. 305 women held consultant positions (not much advance over 1925), a proportion of slightly under 10% of the whole, and it is interesting to note the fields in which they were most heavily concentrated: 44 in ophthalmology, 50 in anaesthetics, 52 in psychiatry and psychology, 56 in gynaecology and obstetrics. University College Hospital London boasted the highest number of consultants among its female graduates: with a mere 12 women in each year's intake I think we can assume that these were the pick, and constituted something of an elite. Somewhere between 30% and 50% of women doctors chose to pursue a career in general practice, in relation to numbers of men about 10%, or just over.

The proportion of women employed in public health work by central or local government authorities rose to nearly one-third of the total, predominantly in areas such as the school medical service, or mother and child welfare: women might of course have held part-time hospital or public health posts in conjunction with general practice. In terms of professional advancement through the system the areas in which women found themselves were something of deadends, though not necessarily, particularly when war shook up the system. In the CMAC at the Wellcome Institute we have a small group of papers of a woman doctor who worked in public health in South London, and managed--or was compelled--to move out of mother and child welfare into tuberculosis work during the Second World War. As she remained in this field after the war one assumes that she found it congenial, and might have wished to pursue such a line of work earlier in her career. In wholetime research some 20% were women--this is probably related to structures of grant-funding for research, whereby it was far easier for women to be elected to research fellowships for a period of years than to be appointed to staff positions, particularly if they were married. They were less well-represented in teaching posts, only around 7%.

The first women to become a president of one of the Royal Colleges was Dame Hilda Lloyd , who became President of the Royal College of Obstetricians and Gynaecologists in 1949, and beat the double whammy by being also the first Birmingham medical graduate to achieve such a distinction. She was also the first woman to take her seat on the General Medical Council (an earlier woman appointee had died before doing so). She was twice married, both times to fellow-surgeons. While her success was undoubtedly gratifying, demonstrating that women doctors could achieve professional eminence, it may have confirmed beliefs that if women doctors were good enough and worked hard enough they would achieve the same rewards as their male colleagues. This ignores the factors of being in the right place at the right time and having the right connections which affect anybody's success .

A number of career trajectories for women doctors in the earlier twentieth century can be seen. Some challenged the heights of a male-dominated profession, blazing a trail for those coming after. Others found at least, like Renault's Hilary Mansell, that by pursuing a career in medicine they were 'alive instead of dead', not the 'slowly decaying corpse' she believed she would have been had she given in to family opposition. Some made a strength out of their position of peripherality, following unorthodox paths and taking risks. Others made a hop-skip-and-jump progression through flexible openness to opportunity as it presented itself.

It was not until the recommendations of the Goodenough report, implemented through the National Health Act in 1948, that all medical schools were obliged to admit women; and did so for many years subject to stringent quotas, usually around 15%-20%. Even by 1975, women doctors, 19,000 in number, were about 20% of the total number of doctors, however the number of inactive women doctors was two and half times that of men. The numbers of women admitted to medical school was rising by then, with a 50% intake being predicted for the early 1980s. A conference in 1975 on the problem of the underuse of their training and skills by the National Health Service revealed that women, although because of the continuing medical school quotas they had to be superior to male applicants in the first place, still had to fight for a place in medicine, and to be alert to opportunities and flexible in order to maintain a career. This did not apply to single or childless women, but for married women, especially once they had started a family, there were considerable difficulties. Women were still unequally represented across the various medical specialities: nearly 50% of doctors in community health services were women, though few at the senior grades. In hospital medicine they were most highly concentrated in anaesthetics, paediatrics, psychiatry and obstetrics and gynaecology, with very few surgeons. I doubt that there has been radical change in this representation over the past twenty years.

I should like to end with the comment that now: just over one hundred years after Sophia Jex-Blake finally saw the walls of the citadel fall at Edinburgh, women make up approximately 50% of each year's medical graduates in the UK.