In 1800, France was the most populous nation in Western Europe; however, by the mid-century poverty conspired with malnutrition to wreck havoc on the peasantry. The mortality rate was higher than live births and the only population growth was from migration. In urban areas, an increasingly secular population largely ignored the rants of enraged priests who blamed the high death rate on moral degradation and condemned any attempt at contraception especially the most common, coitus interruptus and condoms made from the bowels of animals. The Church, always a major influence in French politics, laid society’s ills squarely on the shoulders of women who were powerless in the male dominated society. By the mid-1860s, the interest in women’s reproductive health gained prominence not only because of high rates of female and infant mortality but also because of growing threat of force from the German states. The government of the Second Republic called the French medical establishment to arms and physicians responded. Gynecological surgery emerged as a medical specialty.

The City of Lights glittered brightly. In the latter half of the 19th Century Paris was a hub of medical knowledge, a veritable Mecca for doctors throughout the world who were anxious to study French medical techniques. John Harley Warner chronicled the trek of American physicians across the Atlantic. American medical practitioners were drawn to “the vast Parisian network of hospitals, dissecting rooms, university facilities, museums, and medical fraternities. American physicians simultaneously reveled in, and were repulsed by, the ease with which they were allowed to examine portions of the human (especially female) anatomy that would otherwise have been unavailable in their homelands.”

American doctors were however, repelled by the general disdain with which French physicians treated their patients, particularly women. “Some aspects of Parisian medicine were deemed translatable into an American context, such as anatomical knowledge and statistical methodology, while others, such as the apparent "therapeutic nihilism" and indifferent bedside manner of French physicians, were not simply idiosyncratic, but downright undemocratic.”

This site’s expert on all things medical, Dr. Caroline de Costa, Professor of Obstetrics and Gynecology at James Cook University School of Medicine, noted that the French interest in women’s health and speculum examination (the speculum is an instrument used to open the vulva and explore the internal workings) began with Dr. Joseph Recamier in the early 19th Century. The vaginal speculum was widely used in ancient times. Assorted vaginal speculums were discovered among the ruins of Pompeii but fell into disuse in Europe by medieval times. The bimanual, a vaginal examination with the woman positioned on her back facing the physician or midwife, the modern technique that Pozzi perfected and taught, grew from there.

According to mid-wife Shira Happlin the speculum “was rediscovered and popularized by Joseph Recamier. He constructed a slender tin tube through which he could examine and inspect the uterine neck and the vagina. Because of the sight the speculum gave to gynecologists, it became a very controversial technology. In the mid to late nineteenth century, there was heated debate about the use of the speculum. Examinations by speculum involved exposure and penetration of what was "private". Most doctors outside of France felt that to look at and to touch female genitalia was unnecessary (for it) sacrificed female delicacy and ignored medical ethics.” Dr. de Costa has noted that though the French were pioneers in the field of gynecology and gynecological examination they were opposed by many British practitioners who thought French methods and techniques of examination immoral.

No other medical specialty engendered the visceral response that the field of women’s health did and continues to do. Besides prurient interest in the feminine anatomy, most especially the years from the onset of the menarche until the menopause, every aspect of this distinct medical discipline continued and continues to come under scrutiny from the Church and the State. Throughout most of human history, clerics and politicians had more power over a woman’s body then the individual woman and her physician. Is it possible that they still look upon females as the “daughters of Eve” and been less than enthusiastic about alleviating their suffering? This fact was just as much in evidence in 19th Century France as it is in any “red’ state in the 21st Century United States. Perhaps an undercurrent of Puritan guilt is responsible for the salacious innuendo that still surrounds Pozzi.

From the mid 19th century, when examining a woman, many physicians around the world utilized the technique perfected by Dr. James Marion Sims. The debate over his method stems from the fact that he performed his first gynecologic surgery on enslaved African women who were often forced to give birth alone in the cotton fields and developed obstetrics fistulas in the process. Any modern women would shudder at the crude methods Sims used on these early patients. In, order to examine the fistula more thoroughly, Sims had his patient squat on her knees and elbows, the woman positioned on all fours as he probed the vagina with a rudimentary speculum created by bending a pewter spoon into a shape that could be inserted into the vagina. Sims relied on inspection of the female genital tract; Pozzi also used the speculum, both Sims model and the bivalve models of which Recamier’s was the first modern example, but Pozzi also used and perfected the bimanual pelvic examination and went on to popularize it as an aid to gynecologi diagnosis.

In the bimanual, the patient is placed her back, facing the physician or medical practitioner who places one or two fingers are placed inside the vagina with the other hand flat on the lower abdomen. The bimanual method makes it possible to feel the womb, to determine its size and position and to detect whether cysts have enlarged the ovaries. The bimanual method of examination complements the speculum examination. With the combination of the two methods, the organs of the female pelvis could be both felt and, where visible, seen; this placed the diagnosis of gynecological complaints on a much more scientific basis. Pozzi wrote extensively about the bimanual method but often suggested the Sims method depending on the anatomy and symptoms of the patient.

Gynecology in the 19th century was a new and  separate, rapidly-developing discipline from obstetrics, which remained the domain of midwives. Midwives also performed pregnancy terminations, illegal procedures during the Third Republic. Apothecaries sold female contraceptive devices, such as safety sponges and silk rosettes, and spermicidal agents, such as powders, douches and suppositories. It would take decades before the Pap smear was invented and women did not make routine visits to gynecologists; gynecological issues involved quality of life for women, cancer of the uterus, fibroid tumors, enlarged uteruses and endometriosis.

Unlike many his French contemporaries, Dr. Pozzi was concerned about the comfort and well being of the patient. He demanded scrupulous cleanliness in the gynecological wing and suggested types of furnishing that could be easily cleansed. He used cocaine, a legal drug at the time, as a local anesthesia when examining his patients. He taught a distinct style of suturing, his uniquely “pretty stitches” for closure of the incision and minimizing scarring. In addition, Pozzi critiqued various speculums, determining which would best serve each individual patient and went into great length in his discussion of the machinery of autoclaving, the sterilizing of instruments prior to surgery. His attention to the comfort and dignity of his patients distinguished him from his peers and his fame continued to rise.

After the birthrate in France plummeted and the government turned to medical professionals in desperation, doctors were forced to deal with French hygiene or the lack thereof. Professor Mary Lynn Stewart paints a most grotesque portrait of Gallic hygiene. “In the Belle Époque, most city dwellers took two or three baths a year, in either portable tubs or public baths.” As a fervent disciple of both Pasteur and Lister, Pozzi insisted on cleanliness in the surgical theaters, hospital wards and in the preparation of his patients for surgery. He worked in spotless white overalls, covering his wavy hair with a black Florentine cap. Both the gynecological ward and Pozzi’s dispensary at the Lourcine-Pascal was unusually hygienic, well illuminated and decorated with the murals of famed artists Georges Jules Victor Clairin and Bellery-Desfontaines which he paid for from his own pocket. Health professionals and members of the upper classes flocked to see him perform his innovative surgical procedures and surgical gynecology soon became the hot ticket in French medicine.

Clairin’s mural in the gynecological wing of the Broca Hospital. The mural is named "Health Restored to the Sick" and the figure in the center of the painting is Sarah Bernhardt. This work was commissioned and paid for by Dr. Pozzi and decorated one of the walls of a room at the Broca Hospital (originally Lourcine) from 1898 to 1973.

As progressive as many of his ideas were, Pozzi was very much a man of his time in his attitudes toward women and the subject of women physicians in particular. Like many of his contemporaries, he was a student of Darwin and considered males physically superior to females; despite associating with the most brilliant women of his time, despite fathering a daughter whose intellect matched his own, Pozzi’s 19th century sensibility affected his attitude toward female interns. Though he eventually softened his Victorian attitudes toward women physicians and worked with female medical professionals throughout his career, Pozzi initially felt the feminine role in medicine should be restricted. According to Professor Mary Lynn Stewart, by the time Pozzi established himself as chair of the gynecology department, he was quite vocal in his opposition to female interns. Pozzi was aware of female physicians for according to Pozzi scholar, Alain Bugnicourt, Dr. Pozzi commenced his study of medicine at the same time that Madame Madeleine Brès began her studies. During the war of 1870, Madame Bres (a second year student) carried out the work of a ‘provisional’ intern in the service of Professor Broca at the Hospital of Notre Dame de la Pitié in the Rue Lacépède in Paris, the same hospital that an extern named Samuel Pozzy had began his studies the service of Professor Gosselin in January of 1867.

Claude Vanderpooten quoted Pozzi from an abstract of a medical review in 1884:

Since there was no reliable contraception during this period, it is possible that Madame Brès became pregnant during the course of her studies and had to abandon them during her confinement.

Samuel Pozzi continued giving theoretical lectures at the Hospital of Lourcine-Pascal from 1884 until he was able to establish his own chair of gynecology. As Dr. de Costa noted earlier in the 19th Century, gynecology and obstetrics were two separate disciplines. “Obstetrics and gynecology were separate entities in the 19th century, mainly because gynecology didn't really exist until the latter part of that century because there was no proper anesthesia or knowledge of antisepsis. Obstetrics on the other hand was an extension of midwifery. Even though the Cesarean section did not become a plausible and relatively safe operation until the 1880s, there were many skills involved in operative vaginal deliveries in complicated cases. Once ether and chloroform were introduced, from the 1840s onwards, and the need for antisepsis became clear from the work of Pasteur and Lister, gynecological surgery took off.”

Pozzi revolutionized the treatment of women and reacted against the systematic mutilation of the uterus and ovaries by many of his contemporaries. Because of his tremendous talent as a surgeon and a teacher, the Lourcine-Pascal Hospital soon became the center of a recognized school specializing in women’s health. In addition to his work with gynecology, Dr. Pozzi was also acknowledged as specialist in urology and bowel surgery and in 1889 performed the first gastroenterostomy in France. 

Pozzi continued to take educational sojourns to England, Germany, Austria, Latin America and the United States to share new technical approaches with physicians throughout the world. According to Dr. de Costa who studied many of Pozzi’s publications at the Welcome Library in London, “Pozzi dealt meticulously with anesthesia, antisepsis, indications for surgery, methods of surgery, post-op care and all kinds of pathology. There is no doubt that he was a magnificent and innovative surgeon. He was made an honorary Fellow of the American Gynecological Association. (This was mentioned in the forward of the English translation of the 2nd volume his Treatise on Gynecology.)

In 1904, he became one of the subjects of a series of celebrity biographies that was sold throughout Paris in the Felix Potin stores. The French Medical Society lauded Pozzi with a beautiful bronze medallion crafted by Jules Clement Chaplain and he joined the august body of France’s most honored citizens as a member of the Legion of Honor.

In 1909 he represented France in New York at a meeting to mark “One Hundred Years of Ovariotomy.” That year, the elegant doctor was caricatured surrounded by women as he brandished a fencing epée attached with an “O” for ovary at the tip. Ovariotomy was an operation to remove large ovarian cysts together with any tissue remaining of the original ovary. Prior to the advent of modern surgery and anesthesia such cysts often grew very large and could occupy the whole abdomen and contain many liters of fluid. In 1809 a country Kentucky doctor, the father of ovariotomy, Ephraim MacDowell, had operated, without anesthesia or antisepsis, on the cyst of a woman named Jane Crawford – the cyst had contained 15 liters of fluid, and Jane, operated upon while sitting in an armchair and held down by two men, survived the experience. By 1909 ovariotomy had become a safe procedure done under general anesthesia and in the sterile surroundings of an operating theatre, the success rate was high and mortality rates low. At the New York meeting, Pozzi, one of the most capable ovariotomists in France, said to great applause and a standing ovation that “ovariotomy is no longer an American operation but an operation belonging to all the civilized nations of the world!”

In 1874, Dr. Pozzi published his translation of Charles Darwin’s 1872 treatise, “The Expression of Emotions in Animals and Humans”. It was well-received, highly praised and is a possible indicator to many of his social attitudes, especially toward the female sex. In 1890, the first edition of his masterwork, “Clinical and Operative Gynecology”, appeared and became the definitive textbook on the subject, remaining a viable source until the 1930’s. The treatise, which is still available in most university libraries is clearly written, beautifully illustrated by Nicolet and is a fascinating read even to the modern lay reader. Ever the nationalist, Pozzi, in the introduction to the Treatise, mentions all surgical developments, abdominal and vaginal hysterectomy, repair of fistula, removal of ovarian cysts etc. as being French in origin. In fact surgeons in many different places including the US, Britain and Vienna were all doing exactly the same things and all make the same claims. However Pozzi’s textbook was outstanding in its scholarship and was translated widely.

While the antiseptic practices of French hospitals in the 1890s are horrific to the modern physician, (horsehair sutures, sprays of carbolic acid and silver nitrate) at the time they were state of the art, especially the information on general anesthesia, antiseptics and training of the surgical teams. In an interesting side note, Pozzi’s assistant at Lourcine-Pascal was Robert Proust, the younger brother of famed writer Marcel Proust. The younger Proust eventually joined Pozzi as a partner in his surgical practice in 1904 and became as brilliant a physician as his brother was a writer.

References

Thanks to Dr. Caroline de Costa for sharing her knowledge of gynecology and translating portions of Dr. Claude Vanderpooten’s Samuel Pozzi - Chirurgien et Ami des Femmes, Samuel Pozzi, Clinical and Operative Gynecology and Professor Mary Lynn Stewart for her work, For Health and Beauty, Physical Culture for Frenchwomen 1880s-1930s.

Special thanks to the Wellcome Trust for providing the engraving of Samuel Pozzi, below.

Visit The Medical Journal of Australia to read Dr. de Costa’s article on the work of the very controversial Dr. J. Marion Sims.

Thank you, Alain Bugnicourt, for your scholarship and your obtaining permission to use the color slide of G. Clarin’s mural in the gynecological wing of the Broca for us. Thank you to the Museum of Assistance Public-Hospitals of Paris for allowing us to show this beautiful painting.

To find more information about obstetric fistula, please visit these sites: