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30. J. Marion Sims: Gynecologic Surgeon

THE IDEA that health problems peculiar to women deserve separate and distinct medical and surgical attention simply had not been conceived before the middle of the nineteenth century. Some physicians even refused to examine women or to treat them for other than ordinary afflictions. Their reasons ranged from realization of their own shortcomings to ludicrous pseudo modesty. Meanwhile, sick women suffered in silence and in seclusion.

In maintaining this attitude, New World doctors of the early 1800’s followed the practice of European physicians, to whom they looked for leadership in medicine. They were importers of ideas; seldom exporters. However, there were a few, but important, exceptions. Rugged physicians, faced with the myriad medical problems of the new American frontiers, and without consultants or publications to fall back upon, were forced to improvise, to invent, to experiment, to take chances. Out of their experiences, when they could find time to write them down, came some remarkable contributions to medical knowledge; and medical communication across the Atlantic began to acquire a two-way flow.

Near the frontier village of Danville, Kentucky, Dr. Ephraim McDowell (1771-1830) performed the first of a series of ovariotomies in 1809, about which he published a report in 1816. These intra-abdominal operations, eight of thirteen of which were successful, were performed without benefit either of anesthesia or of antisepsis. Although John Light Atlee (1799-1885) of Lancaster, Pennsylvania, performed ovariotomy successfully in 1843, as did his younger brother, Washington Lemuel Atlee (1808-1878) in Philadelphia, no European physician followed McDowell’s lead for several decades.

In 1833, Army Surgeon William Beaumont (1785-1853) published reports of his remarkable studies on secretion of gastric juice in his famous patient, Alexis St. Martin, which he began while stationed at a frontier fort on Mackinac Island, now a part of Michigan.

On the Georgia frontier, Dr. Crawford W. Long used ether to anesthetize patients undergoing surgical procedures, as early as 1842; but reports from surgeons at Massachusetts General Hospital in Boston of demonstrations by Dr. William T.G. Morton in 1846 gave basic principles of surgical anesthesia to the world.

During early decades of the nineteenth century, a penniless South Carolina country boy was growing up. In his youth and early manhood he showed little promise beyond the ordinary-but he was destined to launch a new medical specialty, gynecology, land not only to take the lead in surgery for women in the United States, but to become an accepted leaders and teacher abroad. His name was James Marion Sims.

Eldest of eight children fathered by a tavern keeper and local politician, James Marion Sims was born January 25, 1813, near Hanging Rock Greek, Lancaster County, South Carolina. He grew to manhood in Lancaster. His mother wished him to become a minister; his father, a lawyer, Having no enthusiasm for either of these callings, Marion Sims decided upon medicine. Perhaps the fact that the father of Eliza Theresa Jones, the girl he loved who lived “on the other side of town,” had been a physician, helped him make his decision. Sims began study in the office of Theresa’s uncle, Dr. B.C. Jones, then registered for a course of lectures in the Medical College at Charleston, from which he graduated in 1834, at the age of twenty one. The following year Sims attended Jefferson Medical College In Philadelphia, receiving his M.D. degree in 1835.

Nothing pointing to future greatness was evident either to Dr. Sims or to his home town neighbors when he returned to Lancaster, South Carolina, to practice. Of himself, Dr. Sims wrote: “When I graduated, I felt absolutely incompetent to assume the duties of a practitioner…I had had no clinical advantages, no hospital experience, and had seen nothing at all of sickness. I had been able to buy a full set of instruments for surgical operations, land I laid in a full stock of medicines in Philadelphia. My father rented me a office on Main Street, I had a sign painted on tin…”To detract further from the young physician’s confidence, his first two patients, infants, died under his care. Had he not been completely without means, Sims would have given up medicine then and there; he did decide to leave Lancaster, and proceeded by horseback to the frontier town of Mount Meigs, Alabama, a trip requiring three weeks of difficult travel. In Mount Meigs, his fortune changed; most of his surgical patients recovered; most of his medical patients got well; his practice thrived.

Dr. Sims married Theresa Jones in 1836. For the next three years Dr. Sims practiced successfully – then he and his family were struck down by a series of attacks of malarial fever. These so reduced Sims’ ability to practice that his savings were exhausted. He determined to seek a healthier climate and relocated in Montgomery, Alabama.

In addition to regaining his health, Sims, who previously had had little interest in medicine except as a means of making a living began to mature professionally. He developed a successful general practice, and increased his reputation as a skillful surgeon. At the rear of his home he built a one-story frame building that would accommodate eight beds, to serve as a hospital. He also began training young men in medicine and surgery.

In Montgomery, too, Dr. Sims performed a clever, difficult operation for harelip and missing upper jaw, the report of which became his first paper published in a major journal. There, too, he believed he had discovered the cause of trismus nascentium, a condition of tetanus in infants. Sims ordered infants showing signs of this condition removed from their strait-jacket-like cradles, where they lay on their backs virtually immobilized, and saw to it that they were placed on their sides and their positions changed frequently to relieve pressure on the point where the spine joins the skull.

Until 1845, Dr. Sims had taken little interest in women patients beyond caring for ordinary ailments. Until June of that year, he had never encountered a patient suffering with vesicovaginal fistula-an opening resulting from tears in tissues between vagina and bladder, or rectum, from difficult childbirth, permitting drainage either from the bladder or from the rectum, or sometimes from both, into the vagina. Continuous uncontrollable leakage of urine or feces from the vaginal caused both physical and mental agony to unfortunate victims, who not only were shunned by family and by friends, but hated themselves while doomed to an almost intolerable lifetime of discomfort and of seclusion. However, in the course of two months, Dr. Sims was called upon by owners of three young female slaves. Anarcha, Betsey, and Lucy, who suffered from such fistulas, and he was requested to do something to relieve them. Sims, finding no published report of successful surgical treatment for vesicovaginal fistula, pronounced them incurable. However, the owner of Lucy insisted upon sending her to Dr. Sims office for examination. The doctor was regretfully about to send Lucy back home when a set of circumstances altered the young surgeon’s life – and Lucy’s life, as well.

Dr. Sims was called that morning from his routine rounds to care for a woman who, thrown from a horse, had injured her pelvis and was in great pain. Sims, having determined that there were no fractures, was faced with the problem of relieving her intense pain. According to his own report: “If there was anything I hated, it was investigating the organs of the female pelvis. But this poor woman was in such a condition that I was obliged to find out what was the matter with her. It was by a digital examination, and I had sense enough to discover that there was retroversion of the uterus…” A long forgotten aphorism of one of his former teachers came to mind: he placed the patient in the knee-chest position, and with further digital manipulation, air was admitted to the vagina, pressure restored the uterus to its normal position, and the patient was relieved of her pain almost instantly.

The thought flashed through Dr. Sims’ mind could he not put Lucy in a similar position and see the relationship of the fistula to surrounding tissues: “Fired with this idea,” wrote Sims, “I forgot that I had twenty patients waiting to see me…I jumped into my buggy and hurried home. Passing by the…store, I bought a pewter spoon…”

Calling his two assistants, Dr. Sims went to the hospital and told his patient he wished to re-examine her. Placing her on a table, he directed her to assume the knee-chest position. As Sims inserted the bent handle of the spoon into the patient’s vagina, he reported: “I saw everything, as no man had ever seen before. The fistula was a plain as the nose on a man’s face…I said at once, “Why can not these things be cured?” I immediately went to work to invent instruments for performing the operation…”He was so confident that he not only kept Lucy at the hospital, but he sent also for Anarcha and Betsey, telling their masters he would them up at his own expense until they were well.

Dr. Sims’ confidence that he could cure vesicovaginal fistula surgically was to be sorely tried. His first operations proved failures; while the fistulas might be greatly reduced, infections resulted around silk sutures, and small opening remained – small opening that leaked as much as large ones. Three years of trial and error and discouragement followed. Finally, in 1849, Dr. Sims determined to use thin pure silver wires as sutures, securing them with pieces of lead. Anarcha became subject of the experiment; it was her thirtieth operation. The operation was successful; there was no infection about the silver wire sutures; the fistula was closed. In the next two weeks, Lucy and Betsey were cured by similar operations.

Dr. Sims was amazed at the number of women suffering from vesicovaginal fistula who came out of seclusion to seek his help, when word of his success got around. The Sims position, a more comfortable adaptation of the knee-chest position, and the Sims speculum, bear the doctor’s name even today.

Just when Sims seemed to be on the road to success, fate dealt him more blows. His second son died; and Sims himself became victim of a chronic intestinal infection – a disease that was proving fatal to many persons in the Southern states. After trying for three years to regain his health, the discouraged doctor, believing death was near, decided to publish his manuscript on operations for vesicovaginal fistula. It appeared in the January, 1852, issue of the American Journal of Medical Sciences. Needless to say, it met with more skepticism than enthusiasm.. .

In a desperate effort to regain his health, Dr. Sims finally decided in 1853 a move permanently to New York City. This was quite an undertaking for the family rooted for generations the South. He struggled to gain a foothold; but poor health, irritability, poverty, and jealousy on the part of his colleagues in the city, held him back. Though he had opportunities to demonstrate his operation, surgeons frequently adopted his techniques and sent no more referrals to Sims.

Out of meditation during idle time came his conviction that women deserved greater consideration by the medical profession. Gradually in Sims’ mind a new idea developed; a special hospital for care of women and for performance of the operation at which he had become so adept. Dr. Sims gained little support or interest until by chance he struck up a friendship with Henri Luther Stuart, former newspaper-man and free lance writer with many contacts. With Stuart’s aid and introductions, Dr. Sims met a number of New York’s wealth philanthropic leaders. With the help of an active group of influential women, Dr. Sims was able to overcome almost insuperable obstacles of finance, of prejudice, and; of opposition from medical men. On May 4, 1855, Woman’s Hospital – the first gynecologic hospital in the United States – opened its doors. At first it had but 30 beds and Dr. Sims was its only surgeon. Constant charitable activity and much ingenuity on the part of the Lady Managers’ committee were required to keep its doors open. Gradually, however, the hospital grew. Other gynecologic operations were undertaken; the staff was increased; doctors from near and far were welcome to visit the operating room to observe Dr. Sims’ methods. Eventually, land for expansion was secured between Forty-ninth and Fiftieth streets (now the site of the Waldorf-Astoria Hotel) and foundations were laid in 1863 for a new and expanded state-chartered hospital – The Woman’s Hospital in the State of New York. Dr. Sims continued as titular head of its surgical staff.

Meantime, however, other events were developing that were to influence Dr. Sims’ life. The War between the States put him in an embarrassing position; he and his family could not put out of mind their Southern ties, and such beliefs were highly unpopular in New York. Sims decided to take a vacation trip to Europe – a sort of “postman’s holiday” – for European surgeons had heard of him, and he was invited to demonstrate his vesicovaginal fistula operations in leading continental medical centers. Dr. Sims then became an international commuter, he moved his family to Paris for the duration of the war. He became physician to queens and empresses, as well as to charity patients. In 1870 and 1871, he served as military surgeon in the Anglo-American Ambulance Corps during the France-Prussian war. For his impartial services to sounded soldiers, he was decorated both by French and by German governments.

Dr. Sims returned to New York in 1872, and again took part in activities of the expanding Woman’s Hospital. His staff and patient load had grown rapidly. In 1874, however, the Board of Lady Supervisors passed bylaws limiting the number of visitors who could witness operations and refusing admission to cancer patients. Dr. Sims’ ire was aroused; he arose and vehemently, perhaps undiplomatically, voiced his opposition. He announced that unless the two rules were repealed at the next meeting, he would leave the hospital. Dr. Sims’ resignation was accepted, December 22, 1874. This was a great blow to the aging surgeon; but if his popularity was at a low ebb in New York, the condition did not prevail elsewhere. The following year, 1875, he was elected president of The American Medical Association.

Dr. Sims’ work was not limited to gynecologic surgery; he also did basic work on control of dysmenorrheal, on overcoming sterility, and on artificial insemination. In 1878, he initiated an operation for removal of gallstones and gave it the name cholecystotomy. In 1880, Dr. Sims was named president of the American Gynecological Society, an organization which he had helped to found. In the same year, he was reinstated as consulting surgeon to Woman’s Hospital. Dr. Sims, by then, however, was spending much of his time in Europe, where his reputation was a great as it was in the United States. In 1881, he was made honorary president of the International Medical Congress at Geneva.

About to return to Rome, where he had built a successful practice, Dr. Sims, in his seventy-first year, seemingly in good health, while sitting in bed working on his autobiography early in the morning of November, 13, 1883, had a seizure of dyspnea. His son, Dr. Harry Marion Sims, rushed to his side, but the father died without a word.

Dr. Marion Sims, to whom so many women owed lifelong debts of gratitude, indeed had a fruitful, inspiring career. His first operations on suffering women were performed without benefit either of anesthesia or of antisepsis; yet, within his lifetime he was to add both these booms to mankind – and to womankind – to his operating techniques. Not only are the surgical feats he performed still outstanding; he led pioneers in gynecology to respectability and to recognition on a high plane. He invented new instruments to meet new requirements. He brought to medicine a new concept; hospitals devoted to the special surgical and medical needs of women. Equally important, he carried these bold, brilliant ideas, pioneered in America, back to Europe, and taught Old World physicians how to use them for relief of countless thousands of women world-wide.

THE PICTURE

Little did James Marion Sims, M.D., (1813-1883) dream, that summer day in 1845, as he prepared to examine the slave girl, Lucy, that he was launching himself on an international career as a gynecologic surgeon; or that he was to raise gynecology from virtually an unknown to a respected medical specialty. Nor did he realize that his crude back-yard hospital in Montgomery, Alabama, would be the forerunner of the nation’s first Woman’s Hospital, which Sims helped to establish in New York in 1855. Dr. Sims, who became a leader in gynecology in Europe as well as in the United States, also served as president of The American Medical Association in 1875-1876.

REFERENCES:

Ackerknecht, E.H.: unpublished monograph.

Ackerknecht, E.H.: American Gynecology Around 1850. Reprint from the Wisconsin Medical Journal, March, 1952.

A Century of Service. The Times – News of the Woman’s Hospital, Division of St. Luke’s Hospital, New York, Vol.7, No.2, May 1955.

Harris, Seale, Woman’s Surgeon. New York, Macmillan Company, 1950.

Heaton, Claude E: The Influence of J. Marion Sims on Gynecology. Reprint from the Bulletin of the New York Academy of Medicine, Second series, Vol.32, No.9, September, 1956.

Marr, James Pratt, James Marion Sims, New York, 1949.

Marr, James Pratt, Pioneer Surgeons of the Woman’s Hospital, Philadelphia, F.A. Davis Company, 1957.

Delphia, F.A. Davis Company, 1957.

Sims, J. Marion: The Story of My Life. New York, D. Appleton & Co., 1889.