Women’s History Month – Dr. Ruth Jackson

Dr. Ruth Jackson: the legacy of the first female spine surgeon
Dr. Ruth Jackson, born in 1902, was the first female spine surgeon on record. Her story of remarkable resilience and sacrifice is even more relevant given the stark gender disparities in orthopedic surgery and neurosurgery that remain today. Dr. Jackson entered the field during the Great Depression and overcame significant barriers at each step along the process. In 1937, she became the first woman to pass the American Board of Orthopedic Surgery examination and join the American Academy of Orthopedic Surgeons as a full member. Her work in the cervical spine led to a notable lecture record and the publication of several articles, as well as a book, The Cervical Syndrome, in which she discussed the anatomy, etiology, and treatment of cervical pathologies. Additionally, Dr. Jackson developed the Jackson CerviPillo, a neck support that is still in use today. She left a legacy that continues to resonate through the work of the Ruth Jackson Orthopedic Society, which supports women at all levels of practice and training. From the story of Dr. Jackson’s life, we can appreciate her single-minded determination that blazed a path for women in spine surgery, as well as consider the progress that remains to be made.
The search for the first female spine surgeon brings readers back through time, before the accomplishments of Drs. Diane Beck and Sofia Ionescu, before the pioneering work of Drs. William Mixter and Joseph Barr, before the founding of the American Association of Neurological Surgeons (AANS), and into the very early days of Dr. Harvey Cushing’s practice in Baltimore, Maryland. In those years, the young girl who would become Dr. Ruth Jackson (1902–1994), FACS, grew up around the dusty farm roads of early 1900s Iowa. By 1937, Dr. Jackson was the first board-certified female orthopedic surgeon and first female member of the American Academy of Orthopedic Surgery (AAOS), soon to be a respected lecturer and author of a lauded textbook on pathologies of the cervical spine.1 Her story, one of single-minded vision, resilience, and sacrifice, is relevant today both in our appreciation of her achievements and in consideration of the legacy she left behind in the culture of spine surgery.

With the continued blending of orthopedic and neurosurgical spine practice, it is valuable to consider a shared past, present, and future. The dearth of female orthopedic surgeons and neurosurgeons is well documented, as data from 2017 indicated that women represented just 5.7% and 8%, respectively, of practicing US surgeons in these fields. Although a significantly lower percentage of women overall pursue surgical specialties of any type, the fact that women make up 20.6% of general surgeons indicates a particular and exaggerated disparity in these fields.2 This reality is even more pronounced at the highest levels of academic medicine, where female neurosurgeons compose just 5.8% of full professor appointments.3 The most recent data on graduate medical education captures efforts to address these disparities, as women now comprise 19.3% of neurosurgical residents and 16.1% of orthopedic residents (but just 5.9% of orthopedic spine fellows), compared to 13% and 12% in 2009–2010. And yet, a long journey to gender equity remains.4,5 In a world with a now female-majority medical school matriculant pool, consideration of Dr. Jackson’s path into and through spine surgery is even more important.6 Understanding her legacy and the lessons it presents can help shape the lens through which we view gender disparities in the field and their implications for the future.

 

Early Years

The biography Ruth Jackson M.D., A Life on the Leading Edge captures the early years of Dr. Jackson in a way that glimpses of her future can be appreciated in its anecdotes.7 We were fortunate enough to speak with Ms. Patsy Jackson, the author of the biography and Dr. Jackson’s niece by marriage, for further insight. Dr. Jackson was a tough, headstrong child with a love of the outdoors, particularly horse-riding and hunting, which would persist throughout her life. Ruth Jackson was mischievous and clever; her family recalled episodes of childhood trouble-making, paired with precocious ingenuity, such as when she rebuilt an old carriage and bobsled using spare parts on the farm. A foreshadowing of Dr. Jackson’s formidable resilience can be found in the recollection of her journey across the untamed Texas frontier. Dr. Jackson, 3 of her siblings, and her brother’s child started off in the family’s King model cars, with their parents well in front as the leading party. When his infant son fell ill, the older brother traveled ahead by train and left the 3 youngest alone to drive, camp, and ford their way to the new family property.7 Her mother’s work as a midwife provided an early exposure to medicine. The resistance of Dr. Jackson’s father to that career path remained long into her training, until he appreciated her talents firsthand in an emergency operation for her nephew’s accidental gunshot wound.1 She eventually left home to matriculate at the University of Texas at Austin in 1920. Dr. Jackson (Fig. 1) initially pursued economics and sociology until a course assignment brought her to meet with an injured man unable to provide for his family; it was then she realized her interests lay more in helping him heal than organizing social supports.7 After adding two summer semesters to finish prerequisite classes, she graduated and entered the Baylor University College of Medicine in 1924, one of 4 women in a class of 112.7,8

 

Medical Training

Dr. Jackson excelled over the next 4 years despite a culture casually discriminatory toward her gender. On recollection years later, she described instances of both explicit and implicit sexism, from the grading double-standards by temperamental professors to the systemic exclusion of female students from the clinic treating male patients. However, Dr. Jackson, along with her 3 female classmates, was among the 58 to graduate from her class, and during her studies founded the Baylor chapter of a social fraternity for female medical students.7 Perhaps the seeds for the Ruth Jackson Orthopedic Society, founded later in 1983 by Dr. Jackson and her contemporaries to support female orthopedic surgeons, were planted at this stage as well. Dr. Jackson was intent on pursuing general surgery, but she discovered upon graduation that there were simply no surgical internships available for women in 1928 as a matter of hospital policies. Instead, she found an internal medicine position at an all-women residency program at Worcester Memorial Hospital in Massachusetts, and bided her time.9

 

Many years later, Dr. Jackson responded to a female high school student intent on becoming a surgeon with these words: “If you have a burning desire to study medicine no one can stop you.”7 This attitude is evident in her own relentless pursuit of surgical training despite the obstacles systemically placed in her path, as she applied to and was accepted into a second internship in orthopedic surgery at the University of Iowa under the mentorship of Dr. Arthur Steindler.1 Dr. Steindler, in his own right, left a mark on the history of orthopedic surgery with an extensive publication record on the origins, diagnosis, and treatment of musculoskeletal pathologies.10 Dr. Jackson originally intended to shift back to general surgery after her internship, but a short time in the program, particularly shaded by her work with polio-afflicted children, led her to later recall, “I can’t describe the feeling I had when I was helping one of these kids, but I knew then this experience was among the most rewarding for me. It was then that I decided on orthopedic surgery.”11 Dr. Jackson returned to the Worcester hospital to continue her studies in orthopedics, learning spinal fusion techniques under Dr. Charles Ayers, and finished residency training at Scottish Rites Hospital in Dallas, Texas.7

 

Professional Contributions and Innovations

During the period Dr. Jackson completed her education within Scottish Rites Hospital, the outside world was upended by the Great Depression. While she was not entirely spared its effects during training, the realities of this time further set in after graduation when Dr. Jackson opened her own clinic with financial support from Dr. Sim Driver (an eventual Chief of Orthopedics at Baylor University Medical Center) in 1932, during the throes of the economic crisis.12 In that first year, she supplemented her income by providing physical examinations under the Works Progress Administration for an additional $3 an hour, earning just enough to stay solvent.11 From these beginnings she built a practice in defiance of both colleagues and laypersons who resisted the idea of a female surgeon. The ingenuity she once showed as a child reared itself once again, as she improvised and adapted store-bought hardware tools to her operating room needs.7

At the time Dr. Jackson was building her reputation among the medical establishment of Dallas, a meeting took place far to the north at Northwestern University, where the founding of a new society for orthopedic surgeons was proposed. In 1933, the AAOS was established and all practicing orthopedic surgeons were automatically grandfathered into membership.9 At least, all but one, as Dr. Jackson was notably excluded from this policy and instead required to once again clear a set of hurdles separate from her peers. Consistent with the resilience she displayed throughout her life, Dr. Jackson passed the American Board of Orthopedic Surgery examination 4 years later and irrefutably claimed her place among the organization’s members. She was the first woman to accomplish each feat, and it would be another 6 years before the next female surgeon was inducted into the AAOS.7

While her track record of “firsts” is remarkable on its own merits, Dr. Jackson’s accomplishments reach beyond her barrier-breaking activities. Similar to many trailblazers, Dr. Jackson did not reach these goals by being equal to her peers but rather by excelling at each turn, and by being undeniable in her efforts and production. After a neck injury of her own, Dr. Jackson became particularly interested in pathologies of the cervical spine and dedicated increasing amounts of her practice to understanding and treating patients with these injuries. This focus led to her development of the Jackson CerviPillo, a contoured pillow for pain relief that remains in use today (Figs. 2 and 3).11,13 It also led to her authorship in 1956 of the book The Cervical Syndrome, in which her mentor Dr. Steindler contributed a foreword with the words, “One cannot help but credit Dr. Jackson of having developed on the foundation of basic facts a clear cut pattern of logical coherence between the manifestation and background which should do much for the understanding of a most difficult clinical entity… it has been my privilege to know Dr. Jackson for many years and to follow the keen interest she has taken in this subject and the earnest and intensive studies she has devoted to it.”14

FIG. 2.
FIG. 2.

Photographs and radiographs demonstrating the Jackson CerviPillo. From Jackson R, The Cervical Syndrome, 2nd edition, 1958. Courtesy of Charles C. Thomas Publisher, Ltd., Springfield, Illinois.

A review published in the Journal of the American Medical Association at the time recognized both her expertise and visibility in the field, stating, “For at least 20 years Ruth Jackson has been talking and writing about the cervical syndrome… Every physician who deals with the cervical syndrome and is faced with the problem of trying to relieve the pain should welcome this book.”15 Reading the book today through the prism of modern medicine leaves one struck by both how much has changed and how much has not. The extensive chapters on anatomy, an expected emphasis given her noted passion on the subject, remain relevant and understandable (Fig. 4). In fact, portions of the book may pass for a modern review if not for the distinct lack of modern imaging technologies, although it does give a new appreciation for the subtle inferential signs of plain films that have been made anachronistic by access to MRI. The voice that arises from the text is that of an expert in her field, one passionate about advancing the practice of spine surgery with a values system that places supreme emphasis on patient outcomes. Her conclusion features a lesson still taught today, proclaiming, “The surgeon who believes that his scalpel can cure the ills of the cervical spine should take time to live with patients before and after surgery… The most beautiful surgical technique may fail if there is not the proper indication for its execution. The patient’s future must be of prime concern.”14

FIG. 4.
FIG. 4.

The anatomy of the atlanto-occipital ligaments. From Jackson R, The Cervical Syndrome, 2nd edition, 1958. Courtesy of Charles C. Thomas Publisher, Ltd., Springfield, Illinois.

 

Legacy

Dr. Jackson ended her surgical practice in 1974, but she continued to care for patients in the clinic until 1989, and died peacefully in 1994.16 Her most lasting and wide-reaching influence is likely the Ruth Jackson Orthopedic Society, founded in 1983 by Dr. Jackson and 5 fellow female orthopedic surgeons. Originally established as a formalized social group for women in the field, the Society has since expanded to include trainees at all stages of education and practice, with programs for mentorship, research funding, student scholarship support, and annual conference events.1,17 With a membership of more than a thousand individuals, it has surely grown well beyond anything that could have been imagined on the day Dr. Jackson first walked into the University of Iowa hospital. Her accomplishments are celebrated today at that program as well, along with those of her mentor, Dr. Steindler, in a scholarship offered to support medical students committed to advancing diversity within the field of orthopedics.18 In these lasting structures, the footsteps of Dr. Jackson continue to echo in medical schools and operating theaters throughout the country.

Of course, such an extraordinary life does not come without sacrifice. Dr. Jackson’s life outside of the hospital was marked by periods of isolation. In her own writing early in life, she stated, “Whether I do or whether I don’t find that love and companionship doesn’t matter a great deal to me… My life has been built around one ideal – and that is service to others.” Her first marriage ended in divorce after two years and her second was a platonic arrangement to circumvent outdated property laws. In later years, without children of her own, she did find a degree of companionship as a mentor and benefactor to women in need. An excerpt from her diary in 1986 hints at the burden of her trailblazing, as she reflected, “I am alone, but with my head bowed I pray that I will be able to go on doing the most for the most people who need my services… Well, I am alone & lonely. My penchant for helping others has been responsible for my present status. But – one must not look back – only forward. Adelante siempre adelante.”7 A shadow of the cost exacted can be recognized in her writing, as well as the clear-sighted and relentless personality that fueled her success.

 

Conclusions

In reflection on the remarkable story of Dr. Jackson, the question arises as to what lessons we can draw for today’s times. Perhaps one lesson for consideration is both an appreciation for the insurmountable will of the pioneers’ past, and a duty to ensure that those following in their paths or carving their own not face the same morass of status quo. Benzil et al. brought the issue of gender disparity in neurosurgery to the forefront with their white paper in 2008 detailing the realities and obstacles facing women within the field.19 They, along with others since, suggested a number of steps to support increasing diversity, from cultural shifts focused on intentional recruitment, retention, and promotion at all levels, to policy changes including pay parity, onsite childcare, and normalized maternity/paternity leave.20,21 With these goals in mind, from Dr. Jackson we can take another word of advice and push forward, always forward.

 

Disclosures

Dr. Erickson reports receiving honoraria from DePuy Synthes. Dr. Shaffrey reports being a consultant for Medtronic, NuVasive, and SI Bone; receiving royalties from Medtronic, NuVasive, and Zimmer Biomet; being a patent holder for Medtronic, NuVasive, and Zimmer Biomet; being a stockholder for NuVasive; and being past-president of the AANS, president-elect of the Scoliosis Research Society, and a member of the board of directors of the Cervical Spine Research Society. Dr. Than reports being a consultant for Bioventus and receiving honoraria from LifeNet Health and DJO.

 

Author Contributions

Acquisition of data: Srinivasan. Drafting the article: all authors. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Srinivasan. Study supervision: Than.

References