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Susan Dimock, Pioneering 19th Century American Surgeon/Physician

2022; Wolters Kluwer; Volume: 3; Issue: 4 Linguagem: Inglês

10.1097/as9.0000000000000208

2691-3593

Jane A. Petro, Susan Wilson, Megan Catalano,

Medical History and Innovations

Susan J. Dimock, MD (1847–1875), was among the first women surgeons in the United States and was recognized as a uniquely skilled woman surgeon in America in the 1870s. Born and raised in the slaveholding South, she lost both her home and her father in the Civil War, fled North during wartime, and connected in Boston, MA, with Marie Zakrzewska, MD. Dr. Zakrzewska was the founder of the city's New England Hospital for Women and Children (NEHWC), itself a pioneering institution and the first hospital in Boston to offer obstetrics, gynecology, and pediatrics under one roof. Opened in 1862, it was the second hospital in the US run by and for women (the first was the Blackwell sisters' New York Infirmary for Women and Children [NYIWC], NYC, NY). THE HEADLINE STORY On May 8, 1875, Boston's newspapers broke the tragic news. "ANOTHER OCEAN DISASTER," read the Boston Evening Transcript headline in a story cabled direct from London. "Intelligence of a shocking marine disaster has just reached this city. The Eagle line steamship Schiller...which sailed from New York April 28... has been wrecked off the Scilly Isles. It is believed that 200 persons have perished." Over the next few days of search and rescue off the turbulent, foggy English coast, the news reports became increasingly dismal. All told, 37 of the Schiller's passengers had been saved, but a staggering 335 were dead or missing. Among the tragedies most widely lamented—on both sides of the Atlantic—was the drowning of one of Boston's most respected, talented, and beloved surgeons, Dr. Susan Dimock. To her contemporaries in Boston of the 1870s, Dr. Dimock was well known as a strong, selfless pioneer in American medicine—one of the first group of physicians to provide professional health care both by, and for, women. More than just a standard-bearer for women entering the field of medicine, Susan Dimock also set a precedent of excellence for women pursuing a specialty in surgery. After Dimock's death, her mentor and employer, Dr. Marie Zakrzewska, worried that "Many years will probably elapse before Dr. Susan Dimock's place can be filled." Dr. Mary Putnam Jacobi, an honors graduate of L'Ecole de Médecine at the Sorbonne in Paris, agreed that "both the surgical talents and surgical training of Dr. Dimock are certainly, at the present date, exceptional among women. It is on this account that her loss is literally irreparable, for at this moment there seems to be no one to take her place."1 With this article, the authors hope to share some of Dr. Dimock's legacy and provide a glimpse into both the world in which she operated and her contributions to women in medicine. THE BACKSTORY: MARIE ZAKRZEWSKA AND THE NEW ENGLAND HOSPITAL Although trained as a midwife in Berlin, Marie Zakrzewska (1829–1902) deemed the Old World too confining for an ambitious woman like herself. A mentor had convinced her that, "In America, women will now become physicians, like the men; this shows that only in a republic can it be proved that science has no sex."2 To pursue her dreams, she emigrated to New York and connected with sisters Elizabeth and Emily Blackwell, whom she assisted in setting up and operating the NYIWC. Finding Zakrzewska both clever and hardworking, Elizabeth Blackwell arranged for her to matriculate at Cleveland Medical College (now Western Reserve), where she graduated with honors in 1856, along with Emily and 4 other women.3 The male students were so upset by her presence that the college immediately agreed to stop admitting females for the foreseeable future. Zakrzewska's father was equally unsupportive, lamenting in a letter from Berlin, "If you were a young man, I could not find words … to express my satisfaction and pride in respect to your [medical career] … but you are a woman, a weak woman; and all that I can do for you is to grieve and to weep. O my daughter! return from this unhappy path."4 Among Zakrzewska's assignments while with the NYIWC was traveling to liberal New England to fundraise for the Blackwells' hospital. Numerous progressive Bostonians—including fellow abolitionists and suffragists—developed such an admiration for Zakrzewska that in 1859 they encouraged her to move from New York to Boston, where she was offered a job as Professor of Obstetrics and Diseases of Women and Children at the New England Female Medical College. Founded by Samuel Gregory in 1848, the New England Female Medical College was formed to teach midwifery and instruct mothers on how to care for their children, although a program was later added, training women for careers as physicians. "Dr. Zak," as her friends and colleagues came to call her, soon became frustrated with the mediocrity of the school's medical education. Dissatisfied with the college's inability to give its students adequate clinical experience—a failing quite common in all-male American medical schools as well—she also objected to Dr. Gregory's insistence on calling his graduates "Doctress" rather than "Doctor." Dr. Zak was especially incensed at Gregory's resolve to graduate all his women students, rather than just those who excelled at their studies and passed their exams. In an effort to practice and teach the best medicine possible, Marie Zakrzewska left Samuel Gregory's school to open her own women's hospital in Boston. Unlike Dr. Gregory, Dr. Zak did not attempt to create a medical college. Instead, she envisioned a working hospital that offered a hands-on postgraduate program for physicians as well as a nurses' training school. There, she would be able to teach practical as well as theoretical skills to her female students and even introduce scientific instruments like microscopes and thermometers into the curriculum—which Dr. Gregory had resisted. There she could prove her professionalism in mainstream ("allopathic") medicine, while distancing herself from those increasingly disparaged purveyors of "irregular" alternative practices like homeopathy and phrenology, as well as from midwives, mesmerists, spiritual mediums, and clairvoyants. There she could also be living proof that the words "female physician" did not mean an untrained back-alley "abortionist." It's not that Dr. Zak believed that mainstream medicine was significantly more successful in curing patients than alternative practices. It wasn't. Just a decade before she opened her hospital, medicine was still more a trade than a profession. In the mid-19th century, America's allopathic doctors were only beginning to move away from 18th century beliefs and ineffective practices, while inching toward the world of scientific medicine. Most still thought that putrid air, or "miasma," could cause disease. Many still engaged in what was known as "heroic" medicine, where the natural balance in a patient was allegedly restored by administering debilitating drugs or purging. Among the most popular purging practices were "bleeding" out evil toxins by slicing open veins, pressing warmed glass cups over open cuts until the cup filled with blood, or using hot plasters to create blisters, then methodically draining them. Meanwhile, too much surgery remained in the bloody hands of barbers (the classic red-and-white striped barber pole symbolized red blood and white bandages). As might be expected, mainstream medical treatment of "women's diseases" was particularly primitive. Classic examples were those surgeons who inserted leeches into the vaginas of female patients to stimulate menstrual flow or to "cure" other feminine disorders (this was in stark contrast to the women/midwives practicing "menstrual restoration" using herbs and other natural remedies). Dr. Marie Zakrzewska was personally more interested in the future of science than honoring the medical traditions of the past. But she also realized that being accepted by, and someday even admitted to, the conservative and adamantly all-male Massachusetts Medical Society, founded in 1781, or the American Medical Association (1847) would require a firm, orthodox stance. Dr. Zak's NEHWC opened its doors in a rented wooden house at 60 Pleasant Street (today's Stuart/Kneeland streets) in downtown Boston on July 1, 1862. Like many other hospitals of the era, the facility was run essentially as a charity, catering primarily to the "worthy" poor. Those patients included immigrants, military wives, and hardworking women who had fallen on hard times. They came to NEHWC not only from Boston, but from all over New England. These "worthy" poor were treated side-by-side with wealthier paying clients described as "friendless"—women who had no one to care for them at home when sick or delivering. African American women who had formerly been enslaved in the South were welcomed. Prostitutes were not, since they had chosen an unacceptable lifestyle, as had chronic alcoholics (their cases might only be considered if pleaded by a clergyman or some compassionate, upstanding citizen). Unwed mothers may have been taken in by the hospital as charitable cases, but not if they were having a second "illegitimate" pregnancy. That, apparently, was one fault too many.5 In taking in this variety of needy patients, the New England Hospital was initially considered only a few steps above the almshouse, combining what would later be called "social work" with medical treatment. Hospitals of the mid-19th century—when invasive and abdominal surgeries were quite rare—were often filled with patients suffering chronic illnesses that necessitated prolonged periods of both treatment and rehabilitation. When the New England Hospital officially incorporated in March of 1863, Dr. Zak and her colleagues delineated 3 primary goals: To provide for women medical aid of competent physicians of their own sex. To assist educated women in the practical study of medicine. To train nurses for the care of the sick.6 ENTER SUSAN DIMOCK On January 10, 1866, when Susan Dimock walked into the New England Hospital to begin life as a student, she was greeted by Dr. Zak. At the time, Dimock was 18 and Zakrzewska twice her age. Although both women sported the classic, conservative, Victorian coiffure of the day—long hair, neatly parted down the middle, then pulled back into a chignon at the nape of the neck—that's where any physical similarity ended (Fig. 1). Dr. Zak tended to be quick, intense, and somewhat curt, with a pronounced German accent. With a protuberant nose and a broad mouth, she was seen by her contemporaries as a plain, practical, no-nonsense professional. Dimock, in contrast, spoke with a gentle Southern drawl. Remembered by her contemporaries for her quietly pretty face and gentle mannerisms, she was described by friends as having "a certain flower-like beauty, a softness and elegance of appearance" (Detractors who assumed that any woman pursuing a medical career must be "manly," "unsexed," or even bearded were confounded by Dimock, who was "as fresh and girlish as if such qualities had never been pronounced by competent authorities to be incompatible with medical attainments").7 Yet the traits shared by these 2 determined women—intelligence, zeal, and an unflagging devotion to the science and practice of medicine—were far more important than these superficial physical differences.FIGURE 1.: Painting of Susan Dimock by the Swiss-born Boston painter, Edward L Custer, displayed at the Dimock Center. Marie Zakrzewska about 1870, photo in "A Woman's Quest" by Agnes C. Vietor. Images match their approximate ages at the time the 2 women worked together. Permission courtesy Dimock Center.Although Susan Dimock had neither a college degree nor even a high school diploma, she was a prodigy who, by the age of 13, had learned to read Latin, had studied medical books, and had apprenticed herself to Solomon Sampson Satchwell, MD (1821–1892), the local physician in her hometown of Washington, NC. During the last year of the Civil War, when she and her widowed mother fled their fire-ravaged town to find relatives and relative safety, they eventually landed in Hopkinton MA, where teenaged Dimock briefly taught school to local youngsters. There, Dimock found yet another mentor in Jefferson Pratt, MD (1803–1883), one of the town's wealthiest citizens and most prominent physicians. Thanks to connections in Boston's extensive and tight-knit abolitionist community—which included prestigious antislavery voices like William Lloyd Garrison and Lucy Stone—she was introduced to Dr. Zakrzewska, who realized that the young North Carolinian was exceptionally bright, talented, and driven. Throughout her career, Dimock attracted numerous supporters who seemed almost compelled to assist her in her journey. Susan Dimock worked tirelessly as a student at NEHWC for more than 2 years. Seeing her potential and wanting her to receive the best medical education possible, Dr. Zak and her colleagues encouraged Dimock to attend Harvard Medical College in Boston. In 1867, Dr. Dimock and her classmate, the English-born Sophia Jex-Blake (1840–1912), applied to Harvard. Founded in 1782, following America's War for Independence, Harvard Medical College was the third medical school in the nation—but the first choice of elite New Englanders and others who were dazzled by its high reputation. Harvard's medical school was the first to introduce smallpox vaccinations in 1799, and the first to publicly demonstrate diethyl ether as a general anesthetic, in 1846. Its faculty, student body, and graduates included some of the finest minds and wealthiest families in 18th and 19th century medicine, including a long line of Warrens, all related to Revolutionary War hero, Joseph Warren, himself a physician. When viewed through the lens of modern medicine, however, that reputation appears diminished. In 1869, any man who paid the required fees could be admitted to Harvard Medical College. Only one-fifth of the school's students held college degrees, and more than half could not write. Two 4-month series of lectures constituted the curriculum, and there were no written exams. Classes depended almost exclusively on lectures, textbooks, and demonstrations and students had only to pass five out of nine 5-minute oral exams in order to graduate. Students in clinical subjects engaged in no patient care whatsoever, and whatever hands-on experience students were able to muster was thanks to the school's proximity to Massachusetts General Hospital (MGH).8 Despite these flaws, Harvard Medical College was deemed superior to most American medical schools of the era. Henry Jacob Bigelow, a Harvard professor of surgery, admitted in 1871 that no successful medical school in the nation seemed willing to trade high student enrollment and high cash receipts for the dubious task of giving those students a more thorough education. Quite predictably, Susan Dimock and Sophia Jex-Blake applied twice, and were denied entrance twice, solely on the basis of their gender (Fig. 2). They were neither the first nor the last women so refused. Harvard didn't begin accepting women into its medical school until 1945.FIGURE 2.: Harvard rejection letter to Susan Dimock and Sophia Jex-Blake; Harvard University Archives; no restrictions on use.Although the university rejected the admission of women, several prominent male physicians from Harvard consulted and actively advocated for the NEHWC throughout the 19th century. While she was preparing for medical school, Dimock was able to observe and befriend Dr. Samuel Cabot (1815–1885), one of the chief surgeons at the MGH, and Dr. Edward Hammond Clarke (1820–1877), an otologist at Massachusetts Charitable Eye and Ear Infirmary, both of whom supported and encouraged her. Clarke is best remembered for a writing a popular diatribe against the education of women, "Sex in Education; or, A Fair Chance for the Girls," that remained a bestseller for more than a decade after its initial publication in 1873.9 Cabot was no such fair-weather friend, and consistently supported the medical education of women. He also observed the 2 surgeries reported in this article. It was not uncommon for women doctors to mentor one another—that regularly occurred both at NEHWC and in the women's medical community at large—but to have the attention of someone of Cabot's stature was remarkable. EUROPEAN TRAINING PREPARES A RESIDENT PHYSICIAN Discovering that the medical college at the prestigious and liberal University of Zurich in Switzerland was admitting a small number of women as an experiment, Dimock was encouraged to apply and was immediately accepted. Her international coterie of women classmates became known as "The Zurich Seven." Because the classes were all given in German, Dimock studied the language for months before and throughout her stay in Zurich to keep pace with her classmates and coursework. Although the standard time to complete medical studies at Zurich was at least 5 years, Dimock graduated with honors in only three. This graduation was so remarkable that it was reported in The British Medical Journal on November 18, 1871. Titled "Another Lady-Doctor," the notice read, "Miss Susan Dimock, a young American lady, has just graduated with distinction in medicine, surgery, and obstetrics, at the University of Zurich."10 After graduation, Dr. Dimock attended lectures in Vienna, Austria, where she was inspired by noted surgeon Theodor Billroth, MD (1829–1894), visited La Maternité, the lying-in hospital for the poor women of Paris, and traveled to Britain, where she met Florence Nightingale (1820–1910). One of the greatest compliments given to her during her European sojourn was from Dr. Marcus Funk, a Viennese medical professor who taught in the departments of obstetrics and gynecology: "The question, whether a woman can be fit for the study and practice of medicine, has been definitely answered by the appearance of Dr. Susan Dimock." When asked for advice to aspiring young doctors, he replied simply, "Make yourself to be like Miss Dimock."11 Dr. Dimock returned to Boston to begin her 3-year tenure as resident physician of the NEHWC. From 1872 to 1875, she professionalized the first formal nurses training program in the United States, established a busy private clinical practice, and supervised both the care of patients and the education of students at the hospital. The influence of Dr. Billroth's great attention to detail in surgery was apparent in Dr. Dimock's meticulous medical records as well as her use of thermometers, her daily charts to track patient wellness, her careful descriptions of her operations, and her intense interest in diagnosis (Fig. 3).FIGURE 3.: Page of the medical record files held at the Countway Library at Harvard; permission courtesy Dimock Center.Moreover, both Dr. Billroth and Ms Nightingale had stressed the significance of well-trained nurses in surgical settings. Inspired by these mentors, as well as by the nurses' training she observed at Kaiserworth, Germany, where Ms Nightingale originally studied, Dr. Dimock opened her formal nurses' training program at the NEHWC on September 1, 1872, only 12 days after assuming her position as resident physician. This was a year before the much-heralded "Nightingale schools" of nursing began at Bellevue Hospital, New York, NY, the New Haven Hospital (originally called the Connecticut Training School at the State Hospital), and the training school at MGH, Boston. Dr. Dimock also personally taught and graduated Linda Richards, renowned as the nation's first professionally trained nurse. As resident physician and chief surgeon at the NEHWC, Dr. Dimock impressed her patients and colleagues with her medical work, which combined gentleness, warmth, and a firm hand with surgical skills said to equal Boston's best male physicians. Although the hospital paid her only $300 a year, thanks to her successful private practice in downtown Boston, she was able to repay loans for her European studies and travels given to her by friends and family in less than 3 years. And while the all-male North Carolina Medical Society was delighted to grant Dr. Dimock honorary membership in 1872 (she was nominated by her old friend and mentor, Dr. Solomon Satchwell), the all-male Massachusetts Medical Society was not so welcoming. The Mass. Medical Society was a prestigious organization Dimock had dreamed about joining since her days as a student in Zurich. In October of 1868, she wrote to Dr. Samuel Cabot, "I hope to get my Degree here in three and a half years, and then to spend a year in Paris, pass my examinations there also, and get that Degree too to take home to the Mass. Med. Society." Four years later, it appeared that her dream might become a reality. On October 2, 1872, the council of the Mass. Medical Society accepted a letter requesting that Dimock be examined for admission. Despite agreement among council members that the request be considered early in 1873, and despite the fact that the idea was argued and fought for, a small but vocal group of dissenting male doctors caused the request to ultimately be shelved. And there it sat, shelved and unacted upon, for more than 2 years. Over the following years, "animated discussions" and heated debates about female inclusion in the Society often made reference to the remarkable Dr. Dimock. But each time the decision was stalled by minority protests. Finally, on June 13, 1882—10 years after Dimock's initial request and 7 years after her death—the subject of admitting women to the Society came to a vote and was accepted by a clear majority of the members. Two years later, in 1884, Dr. Emma Call became the first woman physician admitted to the Massachusetts State Medical Society. Following her training at the University of Michigan (1870–1873), and postgraduate work in Vienna (1873–1875), Dr. Call was a lifelong member of the staff of the NEHWC. She is best remembered for her description of "Call-Exner Bodies," pathognomonic of granulosa cell tumors. In the wake of the Mass. Medical Society's opening up to women, NEHWC founder Marie Zakrzewska was told she could take an examination and reapply. Having been turned down 3 times in the past, she declined, arguing that after 27 years of practice and the creation of a successful women's hospital, asking her to take an examination was a "condescending proposal." "[T]his venerable Society … must give me an honorary membership if it wants me at all," Zak insisted, adding that she was "happy that the younger women can have the benefit of an association which is very desirable for all beginners, and most desirable in assisting women to gain the position for which they strive."12 DR. DIMOCK AT THE NEW ENGLAND HOSPITAL At the NEHWC, Dr. Susan Dimock was both the resident physician and chief surgeon. No surgical specialty existed in the 1870s. After centuries of barbers offering haircuts and beard trims along with primitive surgical procedures, and after decades of dentists advertising themselves as "Dentist-Surgeons," mid-19th century physicians found that they could simply add "surgeon" to their title at will. Still, Dr. Dimock's experiences in Europe, where surgery was seen as a specialty, provided a stellar framework for her approach to a variety of complex and interesting surgical cases. When Dr. Dimock joined the staff at the NEHWC, on August 20, 1872, she entered the hospital's brand-new facility in Boston's Roxbury neighborhood. Medical opinion of the time emphasized air, sunlight, natural surroundings, and open space as key to medical therapeutics. Although the germ theory of disease was yet to be identified, various medical scientists, including Boston's Oliver Wendell Holmes, MD, and the Hungarian Professor Ignaz Semmelweis, were known to doctors Zakrzewska and Dimock, whose emphasis on good nutrition and general cleanliness became standard hygiene practices at the NEHWC. The main building on NEHWC's 9-acre campus emphasized its importance in both size and architectural detail. It was an imposing, High Victorian Gothic, red brick building with contrasting stone stringcourses, arched window heads, and multicolored roof slates covering numerous dormers and turrets (Fig. 4). Plentiful exterior windows and wide internal hallways were augmented by open-air porches, which wrapped around a portion of the building's upper stories (Fig. 5). The design stood in sharp contrast to the "hospitals" of earlier decades, where hygiene and ventilation were absent and spaces cramped. The New England Hospital was deliberately constructed to emphasize cleanliness and fresh air as remedies to the miasmas believed to transmit disease. The design was also award-winning: the hospital's architects, Cumming & Sears, were honored for the building's "well-studied design … good ventilation, and cheerful accommodation" during the Philadelphia World's Fair of 1876.13FIGURE 4.: Contemporary photo of the original NEHWC hospital building in Roxbury, MA (photo © Susan Wilson).FIGURE 5.: Architectural drawings by Cummings & Sears for the 1872 NEHWC. Note the surgical wards (suites) on the first and second floors above the basement level, with windows on the exterior sides. Held in the Sophia Smith Collection at the Smith College Library; permission courtesy Dimock Center.SURGERY FOR A NECK TUMOR While combing through the medical records of the NEHWC held at the Countway Library of Medicine, we discovered that two of Dr. Dimock's cases looked sufficiently well documented to be worth examining in detail. The first, a tumor of the neck, was accompanied by remarkable before and after photographs; the second, a secondary repair of a vaginal fistula, had a successful outcome demonstrated by the patient's longevity and her later success as a touring performer. The medical records documented each day's activities, including all the patients seen. None were filed separately by patient name. The medical records kept by Dr. Dimock reflected the evolving standards of the time, including a medical and social history, vital signs, comments on general health, and a detailed operative note—all of which had been recommended by the physician/surgeons visited and observed by Dr. Dimock in Vienna. These seem comparable to those medical records reported in detail elsewhere (at the request of the Countway Library, the patients' identities, although known to us, have been kept confidential). Dr. Dimock's medical records for both patients include her preoperative assessment, surgical procedure, and the postoperative care, all given in detailed, meticulous handwriting.14 The first patient, 7-year-old Sarah, was admitted in September of 1873. Two years previously, the Nantucket resident had been struck by a handcart on the right side of her neck, an inch below and behind her right ear. After 2 days, a swelling had appeared, which enlarged, first gradually and then more rapidly. On admission, the child was thin and malnourished, with a large tumor on the right side of her neck. On September 7, Dr. Dimock began surgery with the child under ether anesthesia. The operating room in the building had large windows, high ceilings, and strategically placed mirrors to enhance the available light (the gas lamps of the era would have been impossible to use due to the risk of explosion) (Fig. 6). Unlike some of the larger medical schools, there was no tiered amphitheater filled with students and onlookers. None of the standard modern-day operating attire was in use at the time—not gowns, caps, masks, or protective gloves. Dr. Dimock was generally outfitted in her simple black cotton dress, partly covered by a rubber apron. Based on images from the era, it's likely that the small number of observers to the operation included students in street clothes, surgical nurses in calico dresses and slippers, and consulting surgeon Dr. Samuel Cabot in his dark business suit. The surgical instruments used, including scalpel, forceps, scissors, and surgical needles (possibly cautery irons), would have been cleaned but not sterilized. Unlike today's all-steel tools, most had handles made of wood, rubber, ebony, or ivory that would be damaged by boiling water or carbolic acid. While Lister's principles of sterilization were recognized by many in Europe, they were not adopted in the United States until the 1890s (Supplemental Figure 1, https://links.lww.com/AOSO/A168).FIGURE 6.: Exterior view of the hospital surgery wards (photo © Susan Wilson).In the medical record, Dr. Dimock indicated that she used an ether anesthesia. Nitrous oxide, chloroform, or ether anesthesia were the main choices in that era, with ether predominating in Boston. Her notes describe her incision, division of the sternocleidomastoid muscle, and exposure of the tumor, which she describes as "many lobules ranging in size from a pea to a goose egg" enclosed in their own capsules. A total of 71 such masses were removed, with little bleeding. After the muscle was closed with wire sutures and the skin with 15 sutures, the neck was immobilized with a wooden splint held in place with roller bandages around the chest and head. The medical record's postoperative care notes describe nausea for which Sarah was given brandy followed by tablespoons of beef tea and milk. A few hours following the surgery, the patient's temperature dropped to 93°. She improved 10 minutes later, after hot water bottles were applied to the abdomen and aromatic ammonia brandy and water were administered. The next day, the wooden splint was exchanged for plaster board. Two days later, the skin sutures were removed and adhesive plaster placed over the incision. Sarah was kept in the hospital for 3-and-a-half months, and returned home in December 1873. A photographer was hired to do preoperative and postoperative images, which was uncommon for the era and a testament to the significance of the operation. Those images of Sarah, as well as the medical records, are maintained in the Boston Medical Library of the Francis A Countway Library of Medi