The eponymous Dr James Marion Sims MD,LLD (1813–1883)

Introduction

The Sims speculum and the Sims position, both used on a daily basis in gynaecological examination and surgery, are two recognisable eponymous tributes to the accomplishments of the ‘Father of Gynaecology’. Now, nearly two centuries after he lived, what achievements earned this grand title and how did Sims become responsible for the development gynaecology into a separate specialty?

The first surgeon of the ages in ministry to women, treating alike empress and slave

He founded the science of gynecology, was in all lands honored, and died with the benediction of mankind ¹

James Marion Sims

Born on 25 January 1813 in Lancaster County, South Carolina, Sims read medicine at Charleston in 1833 and a year later moved to Jefferson Medical College in Philadelphia from where he obtained his medical degree in 1835. Following the deaths of his first two patients to infantile diarrhoeal illness, he left his general practice in Lancaster to establish himself in Mt Meigs, Alabama in 1840. Here his first patient succumbed to post-partum puerperal sepsis but, in a characteristic exhibition of the determination that would later mark his pioneering surgery, he persevered and before long developed a reputation as a fine surgeon, performing new operations within a large practice.^3–6 OPEN IN VIEWER

It was customary for each physician to be a generalist and, although Sims was no exception, in his biography he describes how he favoured surgical practicality over a physicians’ deliberations, feeling uncomfortable and unprepared in managing many medical complaints. ⁶ During his time in Montgomery a contemporary colleague commented that Sims ‘had about finished up and straightened all the cross-eyes and club-feet within forty or fifty miles of Montgomery’.6

Vesicovaginal fistula

Throughout the centuries, surgical repair of vesicovaginal fistula had been limited by the narrow operative space, the proximity of the ureters and the passage of urine, while post-operative difficulties included poor tissue opposition, inflammation and ulceration. The condition has been recorded since antiquity, frequently due to obstructed labour, with the earliest evidence provided by the remains of Queen Henhenit, wife of the Egyptian Pharaoh around 2050 BC. ⁷ Between the seventeenth and nineteenth centuries European surgeons had attempted repair which repeatedly had resulted in residual defects and so surgical treatment was believed impossible. It was during the nineteenth century that small steps were made in discovering operative principles; in 1838 the bright surgeon John Peter Mettauer in Virginia, followed in 1839 by surgeon George Hayward in Massachusetts, succeeded in closing isolated fistulae. Mettauer reported his success and confirmed the relationship between fistula and obstructed labour, although it went largely unread at the time. ⁸

Concurrently, the eminent English surgeon Montague Gosset published his use of silver wire secured with lead shot. However, no-one had yet been able to produce consistent results with established surgical technique and post-operative care.^7–11 This outstanding landmark in medical history was to be heralded in 1849 by Dr James Marion Sims who published his procedure in a superbly written and clearly illustrated paper in 1852. Sims had persisted for seven years, and combined and applied the different surgical techniques with skilful perseverance.^6,12

An unintentional beginning

In 1845, after practising for 10 years without particular interest in gynaecology, Sims was presented with his first patient with vesicovaginal fistula, a 17-year-old primigravida slave girl, Anarcha, who had developed the condition with resultant urinary and faecal incontinence after three long days of obstructed labour culminating in a forceps delivery of the dead baby.^3,5–8,10

Within a few weeks two further slaves, Betsy and Lucy, were also sent by their owners with fistula. Sims examined these three patients and spent time researching the condition, concluding eventually that unfortunately indeed there were no surgical options available for these hopeless cases. He told Anarcha’s employer that her condition was hopelessly incurable and that he should take care of her for as long as she lived. Moreover he paid the costs of sending Betsy back to her owner, while providing Lucy with a bed in his small practice hospital as she awaited her return train.^4,7,11

The Sims speculum

Within a day of deciding to return these three unfortunate patients to their homes, Sims was summoned in an emergency to Mrs Merrill – a stout lady, thrown from her startled pony by an unruly pig. Landing awkwardly on her pelvis, she was in intense pain and had sustained a uterine retroversion.

This was a new and unfamiliar situation for Sims. He placed the women in the knee-chest position and with firm peritoneal pressure from his middle and index fingers per vaginum attempted to push the uterus back into place. During this procedure a significant amount of air entered causing vaginal distension and assisting the uterus in returning to its anteverted position. While wondering what he had done and why he could not feel the uterus or vaginal walls, Mrs Merrill is reported to have graciously informed Sims ‘Why doctor, I am relieved’. Not one to miss an opportunity, and in characteristic inquisition, he requested she lie down on her side, promptly causing Mrs Merrill shocking societal embarrassment as air forcibly expelled from her vagina. Sims realised that her position, the rapid increase in air pressure and the dilated vagina had all acted to restore the retroverted uterus back to the correct position.

He reasoned that a speculum designed to retract the perineum, unlike his pronged model, would expose the upper vaginal vault and surrounding tissues, the common site of vesicovaginal fistula.^3,5,7,12

Enthused and excited, Sims is reported to have forgotten his house calls and instead returning swiftly home he stopped on the way to purchase a pewter spoon which he bent into a U shape. At his practice, with the assistance of two medical students, he placed Lucy into the knee-chest position and proceeded to use the spoon as a speculum. Writing long afterwards in his biography, with supreme reflective self-confidence, ‘I saw everything as no man had ever seen before.The fistula was as plain as the nose on a man’s face. The edges were clear and well defined and distinct, and the opening could be measured as accurately as if it had been cut out of a piece of plain paper. I said at once, Why can not these things be cured? There is nothing to do but to pare the edges of the fistula and bring it together nicely, introduce a catheter in the neck of the bladder and drain the urine off continually, and the case will be cured. I felt I was on the eve of one of the greatest discoveries of the day’.^3–4,6–8

Sims was convinced his discovery held great surgical potential and set himself deliberately to the pursuit of vesicovaginal fistula repair. He wrote to the owners of Anarcha and Betsy, requesting their return, and began actively looking for further cases, while time was not lost in designing new instruments and the bent pewter spoon undergoing refinement into the Sims speculum, the modified form still used in current gynaecological practice (Figure 2).^7,11,13 OPEN IN VIEWER

OPEN IN VIEWER

Figure 3.

Sims speculum and Sims position (from Sims’ original text, Silver Sutures in Surgery, 1858). ¹⁵

The Sims position and fistula repair

The first operation, performed on Lucy, was followed by significant post-operative complications – septicaemia, high fever and inflammation of the urethra and bladder. Recognising that urine required drainage from the surgical site, a sponge containing a silk capillary string was inserted into the bladder neck but the absorbent material had become encrusted and Lucy was seriously ill and the sponge had to be removed forcibly and painfully. Learning from his mistake, Sims used a different catheter for Betsy. However, after removing the sutures small fistulous openings were visible around the original fistula. Anarcha’s surgery also failed although Sims was able to make changes and learn these lessons. One modification was that the exaggerated left lateral position afforded a better view of the upper and anterior vagina and was more comfortable for his patients and also more acceptable since the woman could not see the physician, thus maintaining the emotional distance achieved by the ‘sightless’ examination procedure. This Sims position is used in current gynaecology and proctology practice, with the patient semi-prone on her left side and the right knee drawn up.^3,7,8

During the next four years Sims continued to operate numerous times on these poor women without permanent success. Colleagues deserted him and those friends who remained advised him to stop his self-funding foolishness. He persevered with his long-suffering patients and gradually began solving the technical problems until the operation was as near perfect as he could make it, yet still not successful since inflammation and ulceration still prevented healing.^5,7,11

Recalling how earlier surgeons had used metal sutures, in 1849 Sims operated on Anarcha for the thirtieth time using fine silver wire instead of his usual silk sutures, as John Peter Mettauer had done successfully in 1838, fixed with lead shot compressed in a pair of forceps to enable the sutures to be tied high in the vagina.^11,15

After one week, with Anarcha in the left lateral Sims position and using the adapted Sims speculum, he ‘saw the surgical site and sutures exactly as placed. No inflammation, no ulceration, and a very perfect healed union of the fistula’. Over the next few weeks Lucy and Betsy and other patients similarly were cured. Sims was in no doubt concerning the importance of what he had done and wrote confidently ‘I realised the fact that, at last, my efforts had been blessed with success, and that I had made, perhaps, one of the most important discoveries of the age for the relief of suffering humanity’ (Figure 4).^4,6 OPEN IN VIEWER

Some have cast doubt on Sims’ claims because, following structural repair and apparent complete cure, stress or urge incontinence may persist. However, Sims undeniably had made great progress in the understanding and techniques of fistula repair and had developed the speculum and the position that bear his name.^7–9,17

Later life

In 1853, after 18 years ‘general’ practice in Alabama and just four years after the first successful fistula repair and a year after publishing his results, Sims sold his medical practice and moved to New York with his wife and children, with the vision of starting a hospital devoted entirely to the diseases of women. Only eight years previously Sims had confessed no interest in women’s health but now he planned the first women’s hospital in the modern era, with gynaecology as an independent specialty. Suffering from chronic dysentery, after an initial severe bout which invalided him for six months, he found the northern climate and water favourable to his condition. ⁶

Sims planned initially to focus entirely on the treatment of vesicovaginal fistula with expansion into other gynaecological conditions. Later, after being dismissed as fanciful and with much opposition from other New York doctors who failed to see a need for a separate women’s hospital, he enlisted the influence of a newspaper reporter, Henry L Stuart, who had heard of Sims’ work. Further support was provided with the help of the highly esteemed Dr John W Francis and from a group of wealthy New York ladies already involved with helping poor women.

Within two years, in 1855 a provisional Women’s Hospital had been established and by 1866 the purpose built Women’s Hospital for the State of New York was opened. The hospital also provided teaching and instruction for students and physicians in gynaecological surgery. With the renowned surgeon Thomas Addis Emmet as his assistant, Sims operated on his first fistula patient, Mary Smith, an Irish immigrant who after many failed operations had been left with a crude wooden float to plug the opening. Now Sims was able to cure her permanently in one operation, with Mary proceeding to serve as a nurse in the hospital. The fistula repairs were consistently producing permanent results with dramatic life changing improvements in personal wellbeing and public acceptance for the women, such that before long the hospital was inundated with patients. Many women travelled from afar to receive treatment, at no cost for those without means, including many New York’s poor Irish immigrant women (Figure 5). OPEN IN VIEWER

While on the Board of Directors of the hospital, Sims argued unsuccessfully for a change in policy to allow the admission of cancer patients, a position that was fought as many believed the condition to be contagious.^3,4,6 Further controversy ensued when the board passed a rule to limit the number of surgical spectators to ‘just fifteen’ to ‘help the modesty of the patient’; Sims however had no limit to his spectators. These two issues forced Sims’ resignation in 1874 yet in a short while he had established a separate hospital that later became the Sloan Kettering Memorial Centre for Cancer and Allied Diseases.

Sims was asked to demonstrate his skills internationally and during the 1860s he travelled to Europe demonstrating his surgical skills, professionally drawn by the invitations while also disillusioned with the politics surrounding the Civil War. Among those treated were both poor and Royalty, including the Empress Eugenie, wife of Napoleon III of France, alleged to have suffered an obstetric fistula. During the 1870 Franco–Prussian war, Sims helped organise and participated in the Anglo–American Ambulance Corps, treating the wounded of both sides. He was surgeon in charge of a military hospital in Sedan, for which he received honours from France, Belgium and Spain. Upon returning to America he became President of the American Medical Association from 1875 to 1876, and Founder and then President of the American Gynaecological Association in 1880, while in 1881 he was conferred with the degree of Doctor of Laws from Jefferson University, his graduating medical college 46 years earlier. ¹ Sims continued to operate and, having recently been reinstated to the Woman’s Hospital Board, was planning a return visit to Europe, when he died of a heart attack on 13 November 1883 in New York, aged 70 years, husband to Eliza Theresa Jones with five surviving children.^5,8 He was buried in Greenwood Cemetery, Brooklyn, itself a National Historic Landmark famous for numerous notable burials since its 1838 foundation as a model cemetery. ¹

Soon after the death, a suggestion was made in the Medical Record that a statue be erected in his memory. Sims had become so famous that a Euro-American Committee had to be assembled to discuss and facilitate the matter. The statue was erected in 1894, the first to be erected in the United States in honour of a physician, standing today in Central Park (Figure 6).^19,20 OPEN IN VIEWER

The inscription on the original pedestal of this monument relates the story of his career

J. MARION SIMS, M.D., LLD.

Born in South Carolina, 1813, died in New York City in 1883 Surgeon and Philanthropist.

Founder of the Woman's Hospital of the State of New York

His brilliant Achievements carried the fame of American Surgery throughout the civilized world

In recognition of his services in the cause of science and mankind.

He received the highest honors in the gift of his countrymen

And decorations from the governments of France, Portugal, Spain, Belgium, and Italy.

Presented to the City of New York By His professional friends, loving patients

And Many Admirers Throughout the World. ¹

The eponymous Sims

Sims success with fistula surgery was due to a combination of access and exposure of the defect by posture and with his speculum, the aseptic silver wire sutures, a self-retaining catheter and a technically straightforward approach. He emphasised adequate resection of the lesion and damaged tissue, and the vital importance of continuous post-operative bladder drainage. ¹¹

His pioneering work provided the impetus to move from the conservative treatment of women’s disease to establishing gynaecology as a medical speciality and surgical specialty. Associated with Sim’s position, speculum and fistula surgery, are other eponymic tributes and accomplishments, particular to women’s health.^3,4,8,19

One of the significant developments, while refining his fistula surgery, was the invention of the Sims sigmoid (self-retaining) catheter, emptying the bladder while the fistula healed. Made of malleable block tin enabling the curve to be altered to fit each individual case, it protruded beyond the vulva to drain into a small china dish and had to be washed several times a day with syringe forced water and wire brush to remove deposits. ²¹ The silver sutures used in the fistula repairs became known as Sims suture, used to avoid sepsis and to promote wound healing.^15,22

During his later gynaecological surgery, the Sims uterus curette was developed to aid removal of fungoid granuloma ²³ while the Sims uterus probe was utilised in measuring the length of the uterus. After assessing the uterus using the probe, a Sims uterus elevator often was used to manoeuvre the uterus back into position in cases of retroversion (Figure 7).^24–26 OPEN IN VIEWER

During his lifetime Sims designed dozens of innovative and fascinating instruments that can be viewed in print or electronically, as in the range produced in the last century by Tiemann and company. ²¹

While in Paris, as part of his extended voluntary stay during the Civil War, between 1864 and 1865 Sims described his pioneering work into conception and infertility. He analysed the conditions necessary for conception and he records the first documented post-coital test with which sperm motility could be observed in cervical canal mucus: ‘If we take a drop of semen from the vagina immediately after intercourse, and place it under the microscope, we shall see the hurried movements of seemingly thousands of spermatozoa’. Perhaps even more radical at the time was his achievement of the first successful artificial insemination, performed after washings of spermatozoa were injected with modified instruments into the uterus of a young women, in keeping with the menstrual cycle and resulting in a live male infant. ²⁶

He was the first surgeon in the South to treat clubfoot successfully, and one of the first to operate on strabismus. He also operated with success on cleft lip, to the delight of the lady patient described in his first publication. ²⁷ He was the pioneering surgeon in the anterior wall approach for cystocoele and in operations to remedy various types of prolapse. Other major achievements include in 1878 an early drainage of a distended gallbladder and removal of stones. A similar case was reported in Indianapolis in 1867 and so he missed the first cholelithotomy and cholecystectomy although he was able to name a type of cholecystostomy, one of two eponymous ‘Sims operations’, the second being surgery to transect the sphincter cunni bilaterally in vaginismus in 1861, ²⁸ while also being an advocate of surgical curettage for persistent menorrhagia. ²⁹ In 1865, while performing ovariotomy for a tumour, he achieved haemostasis at the pedicle with his favoured silver sutures, thereby significantly reducing the previously high rate of infection and post-operative haemorrhage. ³⁰

With a reputation as a capable and inventive surgeon, he operated successfully for an abscess of the liver in 1835, removed maxilla and mandible bone in cases of tumour,^31,32 while in 1861 describing methods for amputating the cervix uteri in cases of uterine cancer and cervix injury.^33,34 In 1881 Sims developed a careful method of invading the peritoneal cavity aseptically for the arrest of haemorrhage, and he advocated that following abdominal bullet wound injury a laparotomy was required to arrest bleeding, repair the damage and drain the wound. Thus his opinion was sought when President James Garfield was shot and duly transmitted by telegram from Paris – with his recommendations gaining wider acceptance after his death.^17,19

Perhaps one of the most striking of his accomplishments in the pre-Lister era was the introduction of antiseptic principles in all areas of surgical treatment and his meticulous cleanliness and insistence on hand washing. In an 1861 letter to his wife, Sims wrote ‘My hands are then henceforth, washed of chloroform and devoted to ether’. ⁶ Although exposed to some of the early trials of anaesthesia, he was not reckless in embracing it at an early stage in his rural practice. Once anaesthesia had become safely accepted, Sims rapidly adopted it for the benefit of his patients. ³⁵

Controversy

Over recent years in post-modern and increasingly liberal society, Sims has become a focus of controversy, described variously as callous, paternalistic and racist, while the traditionalist view of him has been challenged. ³⁶ Some of the more severe unilateral analysis among feminist scholars, historians and political activists has portrayed Sims as an ambitious Southern doctor typically benefiting from routine experimentation and exploitation of the region’s enslaved population. Commentary frequently explores his ‘choice not to use anaesthesia’ or asserts that he ‘based his discoveries on experiments conducted on slave women forced to submit to the most invasive and often harmful procedures’. ³⁷ Those analysing Sims need to do so in the light of the times in which he lived. He was a controversial figure with flamboyant descriptions and an egotistical approach in some journal articles and letters, and a readiness to attribute achievements to himself, often bringing chastisement from journal editors and authors.^38,39

One controversial area was his research into neonatal tetanus, understood today to be a form of generalised tetanus caused by environmental exposure to the bacterium, Clostridium tetani, often precipitated by infection of the unhealed umbilical stump. Trismus nascentium, as then known, was a common cause of mortality particularly among infants born into slavery. Between 1844 and 1849 in his published observations based on enslaved infants, Sims attempted surgery believing that the condition was due to increased intracranial pressure secondary to spinal haemorrhage. His procedure involved making incisions in the skull to lift the bony plates and rectify their abnormal displacement, thereby removing the theorised pressure. Controversy surrounds the fact that when presented with an equal number of white and slave cases it was only his slave patients that were subject to surgery and post-mortem. ⁴⁰ Following autopsy results Sims relinquished his theory, even though many years after his death it was still incorrectly endorsed. ⁴¹

His initial operations, whether they be viewed as experiments or as attempts to treat a pathological condition for functional and holistic improvement, were performed exclusively on slave women and indeed he did not use anaesthesia. Several historians have accused Sims of buying and experimenting on Negroid slave women with a view to later treating wealthy Caucasoid women. A cursory internet review reveals strongly opinionated articles arguing similarly that Sims ‘experimented on his African slave women without the benefit of anaesthesia just to improve his gynaecological techniques, and that credit should be given to the black women who suffered and died from his research’.^42,43 It is to these women that robust credit is indeed given, since they remain intrinsic to any biographical article concerning James Marion Sims.

However, all factors must be considered when evaluating these points and the life of Sims. In his autobiography, Sims honestly explains that slaves were subject to numerous attempts at fistula closure and repair. He discloses how the preferred analgesic, opium, was administered during and after the procedures in therapeutic doses in accordance with standard surgical practice of the time. Sims writes that he explained his intentions and the nature of the operations each time to the women, who were agreeable and participated without coercion, despite modern accusations that such slaves, with the lowest status and shunned by owners, had little choice but allowing him to operate repeatedly. ⁶

Further attention is directed to whether Sims purchased the slave women on whom he operated. The slaves were entirely held as property of their owners and for Sims to take them into his extended 12 bed hospital more than likely would have meant a payment to their owners. Although such ‘ownership’ could precipitate a more ready acceptance of Sims suggestions to the women, rather than analysing nineteenth century morality from contemporary perspectives it is perhaps constructive to consider it a social system that Sims himself could not change. Instead he was able to change the entire miserable situation surrounding the individual fistula patients and also transfigure medical practice through his innovations.^6,12,14,37 In his later writing he expresses concern for the welfare of the individual women under his care, actively demonstrated in his provisions for Lucy, Betsy and Anarcha when assessed initially as inoperable. Overall, while his autobiography demonstrates flamboyant descriptions of self-confident success, they are tempered by sober reflection of failure and loss.^3,4,6–8

Sims at least demonstrated his preparedness to try to alleviate the slave women of a miserable existence, leaking urine and frequently faeces. Their lives would have been even more wretched without surgery and the knowledge and skills gained have subsequently been applied to achieve successful fistula repairs for thousands of women. As a young doctor treating slave women with a condition largely associated with their poverty, and while the subject of ridicule from colleagues and dissuasion from friends, Sims could not have anticipated his future professional career, his life course or that fistula repair would lead him into gynaecology, a specialty that did not exist in the 1840s. Surely Sims was motivated, at least in part, by a desire to improve the life and wellbeing of his slave patients and later the poor women of New York, equal to many nineteenth century pioneers who have laid the foundations of current surgical practice.^44,45

Sims did not use anaesthesia for his early fistula repairs since it had not yet become widely available and its usefulness in surgery not immediately appreciated. Moreover, the use of ‘novel drugs’ presented a risk not acceptable in combination with pioneering surgery. It was not until the 1850s that ether was introduced for surgery and chloroform was slowly accepted in obstetrics from the 1870s. ⁷ Perhaps it is fitting to remember that before Sims developed his technique, many surgeons had attempted to repair fistula that resulted in additional suffering and inconvenience.^6,48 Although his practice in New York catered for the wealthy elite, he also founded the Woman’s Hospital and Sloan Cancer Hospital where many poor women were treated and he also founded the J Marion Sims Asylum for the Poor in Lancaster, South Carolina.

Sims clearly expressed his compassion for the young slave women, already segregated and shunned. ⁶ He records his elation at the successful operation on Anarcha: ‘I thought of only relieving the loveliest of all God’s creation of one of the most loathsome maladies that can befall poor human nature… full of sympathy and enthusiasm, thus I found myself running headlong after the very class of sufferers that I had all my life most studiously avoided’. ⁴

In reviewing controversy surrounding Sims, critics could well consider the frequent examples of exploitive human experimentation and ethically questionable research undertaken on various groups and individuals throughout more recent American history. ⁴⁷

Conclusion

James Marion Sims’ role in the development of gynaecology is indisputable, his pioneering work initiated a new era in gynaecological surgery, for the first time offering hope to women afflicted with previously untreatable conditions. The British Medical Journal recorded in his obituary ‘he must be considered as the establisher of that branch of medical science (gynaecology) which before his day had been looked upon as a mere accessory of obstetrics’. ⁴⁸ Despite modern controversy, in his time Sims was known by colleagues and patients alike as a kind-hearted but impulsive man and one of the most gifted of American surgeons.^4,5

In remembering his beginnings with vesicovaginal fistula repair, the names and forbearance of Anarcha, Betsey and Lucy should also be remembered. More than 150 after Sims’ first successful repair, more than two million women in the world suffer from preventable vesicovaginal fistulae. Most are in developing countries where antenatal and intrapartum care are minimal or non-existent and where early childbearing and poor nutrition contribute significantly. It occurs especially in these countries where women marry young before menarche and before growth is complete, factors implicit in the obstructed labour that commonly causes fistula and, all too frequently, maternal death.^49–51

Inscription upon a Plaque near Birthplace

Birthplace of James Marion Sims, m.d.

James Marion Sims, world famed physician, father of modern gynecology

a blessing and a benefactor to women

was born in the farm house of his parents near this site January 25, 1813

doctor to empress and slave alike

founder of woman's hospital of the state of New York

knight of the legion of honor of France

honored by European and American governments

he died in the city of New York November 13, 1883

erected by Lancaster County, 1949 … ⁵²