All in Her Head: The Truth and Lies Early Medicine Taught Us About Women's Bodies and Why It Matters Today

by Elizabeth Comen

lingering associations between femininity and frailty in matters of the blood and heart.

But it is also thanks to Osler that cardiac medicine was designed with a male patient in mind, while women presenting with heart complaints were understood to be suffering from neurosis, anxiety, or hysteria.

And indeed, not only did physicians come to believe that heart attack in women was so vanishingly rare that it hardly needed consideration as a diagnosis, the study of cardiac medicine came to systematically exclude women as patients.

In matters of the heart, women were routinely and systematically excluded: from diagnosis, from treatment, from research, and from the medical consciousness at large.

A hundred years after William Osler declared that women’s heart failure is all in their heads, it is their leading cause of death: all too real, and all too often overlooked until it’s too late.

heart disease is different in women, with different symptoms, different risk factors, and different underlying causes.

the limitations of trying to diagnose women’s heart disease using tools and standards that were designed with men in mind.

And yet, due to the complex interplay of the era’s cultural, medical, and social mores, tuberculosis—particularly in women—nevertheless developed a certain cachet that eventually rendered it almost aspirational, founded in the then-fashionable idea that there was something wonderfully feminine about being frail.

This was a moment at which a woman’s value was strongly tied to femininity, fragility, and purity alike.

In short order, both the cultural and medical consensus surrounding tuberculosis shifted: now, it was seen as a biological scourge to be battled against through sanitary reforms and public hygiene initiatives, just like any other illness.

The idea was just this: that there is something beautiful, and wonderfully feminine, and powerful and empowering at once, about a woman who can’t breathe.

But Brill has another legacy, too, not in psychiatry but in respiratory medicine: he is the doctor who first made smoking into a feminist cause.

The ad campaign resulting from Bernays’s conversation with Brill is an early, notable example of how doctors would lend their expertise—and sometimes even a medical stamp of approval—to marketing products that were the opposite of healthy.

phenomenon known as “woke capitalism,” in which corporations sold products to women under the guise of helping to liberate them.

attending to the respiratory system has increasingly become coded as a matter of self-care for women, rather than healthcare.

women’s respiratory ailments frequently go undiagnosed,

Every year, more women die from lung cancer than from breast, uterine, and ovarian cancers combined,

ventilators, which can be a lifesaving intervention for patients with severe pulmonary issues, are generally calibrated to male patients; when a woman is hooked up to one, it’s hard to make sure she’s receiving the proper volume of oxygen.

the failure of doctors to ask women the right questions about their respiratory health inevitably leads to erroneous assumptions, to the wrong conclusions, and sometimes to fatal missteps.

Myriad risk factors for women go overlooked by doctors in this field, owing to continued ignorance within the medical system about the interaction between cultural and occupational gender norms and women’s pulmonary health.

The signs of strangulation in women aren’t always obvious.

Although strangulation is not a medical disorder per se, it is impossible to discuss the broader issue of women’s respiratory health without also discussing its intersection with domestic violence.

it is a key marker for the type of violence that eventually escalates to murder.

Referring to strangulation

In medical education, the harm caused to women’s health by abusive partners is an afterthought.

Notions of purity, femininity, and holiness are inextricably linked to the idea of appetite: for food and, of course, for sex.

These gendered ideas surrounding diet eventually calcified into social rituals,

If the notion of diet as gendered began as something of a meme, it soon took on the sheen of medical legitimacy.

The medical edicts surrounding what women should and should not eat were in many cases a transparent proxy for controlling their sexuality.

And because constipation disproportionately impacted women, doctors increasingly became convinced that women must be doing something to cause it.

“focal infection,” which centered on the idea that all diseases, including mental illnesses, stemmed from a single, often invisible, highly localized infection somewhere in the body.

the female gastroenterology patient is conceived of by contemporary doctors just as she was in Osler’s time: anxious, difficult, emotional, and challenging to treat.

the conflation of health with beauty was a powerful marketing tool.

Irritable bowel syndrome, constipation, gallstones, a delayed emptying of the stomach known as gastroparesis: these are among the many gastrointestinal ailments that still plague women disproportionately,

On the latter front, hormones have a lot to do with it. The female body contains higher levels of estrogen and progesterone, and both of these inhibit the contraction of smooth muscles like the ones that line the GI tract.

The anatomical differences in a female body make colonoscopies—a necessary procedure for diagnosing many GI problems—more difficult both for doctors to perform and for women to endure.

As Dr. Lucak explains, women aren’t born with the longer, more circuitous colon that makes their colonoscopies so much riskier to perform. At the age of twenty, a woman’s digestive tract is anatomically indistinguishable from a man’s, more or less. But all those years of holding it in—or not taking enough time to let it out—takes its toll.

constipation does trigger changes in the body. An overstuffed colon has two choices: to explode, or to expand, and so expand is what it does. Multiply that expansion over the course of a lifetime, and the changes are profound.

the general consensus was that the stereotype of these patients as draining and difficult was based entirely in truth. That stereotype has proved extraordinarily intractable, in spite of advancements in the field of gastroenterology generally:

The history of women’s urologic medicine is in many ways a history of unasked questions, unprobed possibilities, and unexplored territory, owing to the early and persistent perception that nothing could be done.

Women’s urinary issues went from being intractable to being invisible, a dark-matter universe of conditions that there was increasingly no way for women to talk about—even with each other.

Medicine began to fracture into the system of specialization that still exists today, as doctors began to conceive of patients less as whole people than as an amalgamation of systems and body parts.

It’s that urology is widely understood, by both the general public and its practitioners alike, to be a place for penises.

Urology is a male-dominated field in general—about 90 percent of urologists are male—but it’s hard to overstate just how absent women are from urological medicine at a conceptual level.

The notion of women’s urinary issues as either psychosomatic, sexual, or both, is a recurring theme in the medical literature.

When a medical field goes underdiscussed and unexamined the way that women’s urology has, the resulting knowledge vacuum attracts all sorts of peculiar theories to fill it, and peculiar people to go with them: doctors who are less concerned with healing patients than in using them to support a pet hypothesis

it’s part of a long tradition in which women’s urology has been not just medically but socially sidelined.

The treatment algorithms for urinary tract infections, which more than half of all women will experience in their lifetime, have been outdated and underresearched for years.

It’s a vicious cycle: women don’t bother to seek urological help because they think there are no treatment options,

But contemporary immunology understands that this system exists in a delicate balance, one in which an overzealous immune response can be its own sort of problem.

it took centuries for them to make the connection between bacteria and infection.