Susan Dimock, MD, pioneering American physician

Editor’s note: This study originated in research conducted by Susan Wilson for her work-in-progress, a full-length biography of Dr. Dimock titled Women and Children First: The Remarkable Life of Dr. Susan Dimock. This article was adapted and expanded from that text, as well as from the first-place poster in the American College of Surgeons History of Surgery poster contest at Clinical Congress 2020.

Susan Dimock, MD (1847–1875), was among the first women surgeons in the U.S. Born and raised in the slave-holding South, she lost both her home and her father in the Civil War, fled North during the war, and connected in Boston, MA, with Marie Zakrzewska, MD, founder of the city’s New England Hospital for Women and Children (NEHWC), which was itself a pioneering institution. Opened in 1862, it was the second hospital in the U.S. run by and for women (the first was the Blackwell sisters’ New York Infirmary for Women and Children, NY), and the first hospital in Boston to offer obstetrics, gynecology, and pediatrics under one roof.

Though Dr. Dimock had neither a college degree nor a high school diploma, she was a prodigy who, by the age of 13, had learned to read Latin, studied medical books, and apprenticed herself to Solomon Sampson Satchwell, MD (1821–1892), her family physician in Washington, NC. Soon thereafter, Dr. Dimock was accepted as a student at the NEHWC at 18 years old, and Dr. Zakrzewska (1828–1902) and her medical colleagues realized that Dr. Dimock was exceptionally bright, talented, and driven.

Seeing her potential and wanting her to receive the best medical education possible, they encouraged Dr. Dimock to attend Harvard Medical School, Boston. In 1867, Dr. Dimock and her classmate, Sophia Jex-Blake (1840–1912), applied to Harvard and were denied entrance on the basis of their gender (see Figure 1).

FIGURE 1. HARVARD REJECTION LETTER

They were neither the first nor the last women so refused. Harvard began accepting women into its medical school 78 years later, in 1945.

European training

Discovering that the medical college at the prestigious and liberal University of Zurich, Switzerland, was admitting a small number of women as an experiment, Dr. Dimock applied and was accepted. This small international coterie of women classmates became known as “The Zurich Seven.” Because the classes were all given in German, Dr. Dimock studied the language for months before and after arriving in Zurich to keep pace with her classmates and coursework. The standard time to complete medical studies at Zurich was five-and-a-half years; Dr. Dimock graduated with honors in only three years. 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.”¹

Following an internship in Vienna, Austria, where she was inspired by noted surgeon Theodor Billroth, MD (1829–1894), and by travels in Britain, where she met Florence Nightingale (1820–1910), she returned to Boston to become resident physician at the NEHWC. From 1872 to 1875, she professionalized the first formal nurses training program in the U.S., 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, her use of thermometers, daily charts to track patient wellness, careful descriptions of her operations, and intense interest in diagnosis.

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 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 Massachusetts General Hospital (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 that equaled Boston’s best male physicians. Though the hospital paid her only $300 a year, thanks to her successful private practice in downtown Boston she was able to repay all her medical school loans in less than three years. Although the all-male North Carolina Medical Society was delighted to grant Dr. Dimock honorary membership in 1872, the all-male Massachusetts Medical Society refused her admission in 1873.

A career-defining operation

From her first day as resident physician on August 20, 1872, Dr. Dimock was fortunate to be working in the NEHWC’s new facility on a spacious, tree-lined campus in Boston’s Roxbury neighborhood. Because Dr. Dimock and her fellow physicians believed that air, sunlight, natural surroundings, and open space were vital to healing their women patients, they sought those elements both in the hospital’s new site and in the design and construction of its buildings. Medical science in the 1870s clung to the notion that miasmas—easily transmitted, particle-laden clouds of noxious, foul-smelling air—could be mitigated if such poisonous vapors were regularly replaced with clean, fresh air.

The campus’ central edifice was an imposing Gothic red brick structure with contrasting stone stringcourses, arched window heads, multicolored roof slates, and a flurry of turrets and dormers (see Figure 2). Open-air porches wrapped around parts of the exterior on all three of its floors. Windows were plentiful and large and the hallways wide. Because antibiotics had yet to be introduced to medicine, it is fair to say that the best any physician could do in the 1870s was provide sunlight and cleanliness. Moreover, in an era when many American physicians failed even to wash their hands between autopsies, patient visits, and operations, Dr. Dimock—inspired by her mentors both at home and abroad—stressed the importance of hygienic habits recommended by Hungarian-born scientist and physician Prof. Ignaz Semmelweis and Boston’s Oliver Wendell Holmes, MD.

FIGURE 2. NEW ENGLAND HOSPITAL FOR WOMEN AND CHILDREN

In September 1873, Dr. Dimock admitted a seven-year-old schoolgirl from Nantucket, MA, into the NEHWC. Two years earlier, the child had been struck by a handcart on the right side of the neck, an inch below and behind her ear lobe (see Figure 3). Two days after the incident, the girl’s neck began to swell. As the months passed, what began as a slow rate of swelling increased rapidly. By the time the young girl arrived at the hospital, thin and malnourished, a large tumor had formed on the side of her neck (see Figure 4).

FIGURE 3. HOSPITAL ADMITTING NOTE

FIGURE 4. BEFORE AND AFTER IMAGES OF TUMOR PATIENT

At 10:00 am September 7, 1873, Dr. Dimock took the girl to the surgery ward. Operating theaters in the 1870s were a far cry from their 21st century counterparts. None of the standard modern-day operating room attire—gowns, caps, masks, protective gloves—was in use at the time. Outfitted in a simple black cotton dress, perhaps partly covered by a kitchen apron, Dr. Dimock likely was surrounded by a curious coterie: medical students in street clothes, a surgical nurse or two in calico dresses and slippers, and consulting surgeon Samuel Cabot, MD, dressed in a dark business suit. It’s likely that they all crowded around the operating table, with no barrier between them and the young surgical patient. Because electricity would not be introduced in Boston until the 1880s (and not widely used until much later), sunlight also played an indispensable role in the art of surgery, with well-placed mirrors and candles filling in the gaps.

Both ether and chloroform were in medical use at the time; Dr. Dimock selected ether as her anesthetic. Chloroform was a popular choice in Europe, but eventually was shown to be quite toxic, and never gained much popularity in the U.S. Ether, on the other hand, had gained approval since October 16, 1846, when William Morton etherized Edward Abbott as surgeon John Collins Warren, MD, removed Mr. Abbott’s neck tumor. This operation, credited as the first successful public demonstration of the use of ether as an anesthetic agent, took place at MGH.

By the time Dr. Dimock performed this operation in 1873, ether had been in use for nearly three decades. Still, timing and efficiency were vital because diethyl ether could be administered to patients going under the knife for only 10 minutes at a time. Both swift and sure with her surgical blades, Dr. Dimock proceeded with the delicate procedure once the patient was etherized.

Seeing that the skin stretched over the child’s tumor was moveable, she made two incisions directly above the mass—one along the sternocleidomastoid and the other at a right angle from the middle of the first incision. Dr. Dimock then cut the sternocleidomastoid muscle, exposing the tumorous mass, which consisted of many lobules ranging in size “from a pea to a goose egg.” Because each lobule was enclosed in its own capsule, Dr. Dimock opened each and removed the contents. Dr. Dimock removed 71 separate tumors from the young girl’s neck with little bleeding. She closed the sternocleidomastoid muscle with two wire sutures and the skin with 15. To enhance recovery and restrict motion, a wooden splint was placed along the girl’s head and spine, held in place with a roller bandage wrapped around the head and chest (see operative note, Figure 5).

FIGURE 5. THE OPERATIVE  NOTE

Following the operation, the girl was treated for nausea—a common reaction to ether—and given a bit of brandy. From a drachm to a tablespoon of water and ice also were administered every half hour, later alternated with tablespoons of beef, tea, and milk. According to Dr. Dimock’s surgical report, the patient “threatened collapse” by 1:00 pm. When her temperature dropped to 93 degrees Fahrenheit, nurses applied hot bottles to her body and administered aromatic ammonia, brandy, and water. Within 10 minutes of the initial application, her temperature rose.

The next day proved far more auspicious. Though there was still swelling near the wound, little bleeding ensued. Content that all was going well, Dr. Dimock’s nursing staff replaced the wooden splint with a pasteboard one.

Just two days after the operation, the sutures were removed and three strips of adhesive plaster were placed over the wound. Typical of many patients of the era, the young girl was held in inpatient recovery for about three-and-a-half months. Though hospital reports noted that the girl cried a lot and was homesick, Dr. Dimock and her staff successfully released the youngster to her parents in late December 1873.²

The significance of the neck tumor operation was attested to in more than one way. In a day when photography was still expensive, bulky, and not at all standard procedure, the NEHWC chose to hire a professional photographer to take “before” and “after” images of this particular case.

While visiting Boston almost a year later, Mary Putnam-Jacobi, MD, a pioneering woman surgeon herself, was shown those photographs of Dr. Dimock’s patient. After reading the case record, Dr. Putnam-Jacobi recalled that she had watched the renowned Charles Richet, MD, perform a similar operation in the Paris Clinique, France, and attended his subsequent lecture, “in which he described the great difficulty of removing a tumor so deeply embedded in so dangerous a locality.”³ Dr. Putnam-Jacobi observed that Dr. Richet both bragged about his success “and had taken care that a numerous auditorium should witness his triumph,” whereas her old friend Dr. Dimock was far more modest about her accomplishments. Dr. Putnam-Jacobi remembered that after hearing about Professor Richet’s self-aggrandizement, “Dr. Dimock laughed, and said, ‘I was asked why I had issued no invitations, but I had forgotten all about them.’ She added, ‘Indeed I have too little personal ambition to care who sees, when I am once assured my work is well done.’”³

Viewed through a 21st century lens

From a 21st-century perspective, we can see from the preoperative photographs that the tumor was multilobular and extended from the angle of the mandible, filling the neck posteriorly to the mastoid process and down to the clavicle. In describing the operation, Dr. Dimock noted that she made a T-shaped incision over the tumor and divided the sternocleidomastoid muscle to gain complete exposure, placing the tumor within both the submandibular and posterior triangles of the neck. The photos suggest that it extended from the base of the skull down to the clavicle, filling the neck. Dr. Dimock’s description of the tumor implies an avascular tumor, particularly because she described removing 71 such masses with little bleeding (see Figure 5).

Although we do not have a pathology report of the specimens removed, it is reasonable to consider several possibilities. Because this tumor arose following a blunt trauma, it is possible that a preexisting mass—such as lipoma, dermoid cyst, or even salivary gland cyst—was ruptured and grew over the subsequent two years. As a lateral mass, it is unlikely to have been a congenital cyst, such as a thyroglossal duct cyst, though it could have been a branchial cleft cyst. It also is possible that a foreign body was introduced, stimulating a reactive inflammatory process. We may also theorize that it was some sort of infectious or reactive lymphadenopathy, mycobacterial, tuberculous (TB) mass. Still, Dr. Dimock certainly would have been aware of TB and have recognized it.

We presented this case to the head-and-neck tumor conference in Aiken, SC, courtesy of Patrick McMenamin, MD, who provided a clear differential diagnosis. The consensus was that this tumor must have been a preexisting lipoma that ruptured in response to the blunt trauma the patient sustained and then proceeded to grow. The photo reveals no evidence of inflammation, and the description of the operation does not mention any adherence or the type of bleeding that would be associated with an inflammatory process.

Thus, lipoma would be the only extensive tumor—whether benign, malignant, or inflammatory—that would have had a thin capsule, been relatively avascular, and permitted such a relatively simple and complete evacuation of the multiple lobes described. TB, or an infection such as actinomycosis, would have had draining tracts; a cystic hygroma would have contained lymphatic fluid and would been described as water, not solid material. Other kinds of cysts would have had thick walls and not been easily and repeatedly evacuated.

During the patient’s prolonged recuperation, a blood sample was sent to be examined by Reginald Fitz, MD, the pathologist at MGH. The blood specimen was unremarkable, and it is possible that a still undiscovered microscopic examination of the tumor exists somewhere in the records of either the NEHWC or MGH, or even in Dr. Fitz’s collection preserved within the MGH pathology records. A further suggestion of his involvement comes from Dr. Putman-Jacobi’s observation that Dr. Cabot was on hand to witness the procedure. Dr. Cabot was on the surgical staff and would have known Dr. Fitz well. Dr. Cabot was an abolitionist and supported the work of the NEHWC, endorsing the role of women in medicine—not a common opinion among the Harvard men of that and later eras. He also was a personal mentor and friend to Dr. Dimock.

Significance in the history of surgery

Dr. Cabot attested to Dr. Dimock’s exceptional surgical skills. “It was not merely her skill, though, that was remarkable, but also her nerve, that qualified her to become a great surgeon,” Dr. Cabot wrote. “I have seldom known one at once so determined and so self-possessed. Skill is a quality much more easily found than this self-control, that nothing can flurry. She had that in an eminent degree…. And [is] sure to stand, in time, among those at the head of her profession.”⁴

Sadly, time was not on the side of Dr. Dimock. On May 7, 1875—while en route to Europe to connect with medical colleagues and purchase new surgical equipment for the hospital—the ship she was traveling on wrecked off Cornwall, England. Ninety percent of those on board—including Dr. Dimock—died. She had just turned 28 years old.

That same year, two years after the successful neck tumor operation, the nine-year-old Nantucket youth also died. It was unrelated to her successful operation, but instead due to what was popularly known as “dropsy” (generalized edema often associated with nephritic syndrome or heart failure).

In the three years that Dr. Dimock practiced in Boston, she came to be highly respected and loved. Her early death led to an outpouring of sympathy from patients, friends, colleagues, and members of the medical community, not only in Boston and her hometown of Washington, NC, but throughout the U.S. and Europe as well. Her funeral and subsequent burial at Forest Hills Cemetery were covered by the press and resulted in accolades and condolences from around the world. In 1884, the street alongside the hospital was named for Dr. Dimock, the same year the first woman was admitted to the Massachusetts Medical Society—an honor for which Dr. Dimock’s work paved the way. In 1969, the NEHWC was renamed the Dimock Community Health Center.⁵

The photographs and the complete medical record of Dr. Dimock’s neck tumor surgery, housed in the Boston Medical Library in the Francis A. Countway Library of Medicine at Harvard University, provide a unique window into the skills and accomplishments of this remarkable woman surgeon.

References

1. Another Lady-Doctor. BMJ. 1871;2(586):588.
2. Boston Medical Library in the Francis A. Countway Library of Medicine. Harvard University, Boston, MA. New England Hospital for Women and Children, Records of Medical Wards [B MS b19.2 vol. 1] and Surgical Wards [B MS b19.1 vol. 1B and 2].
3. Putnam-Jacobi M. An obituary of the author [Susan Dimock, M.D.]. The Medical Record: A Weekly Journal of Medicine and Surgery, Volume 10, January 2-December 25, 1875 (New York: William Wood & Company);358.
4. Samuel Cabot, quoted by James Freeman Clarke, in “Susan Dimock.” Boston Daily Advertiser. May 15, 1875.
5. Wilson S. Women and Children First: The Remarkable Life of Dr. Susan Dimock. Biographical manuscript-in-process, 2021.