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Monday, March 2, 2015

J. Marion Sims, the Father of Gynecology: Hero or Villain?

By Jeffrey S. Sartin
From: Southern Medical Journal


J. Marion Sims (1813-1884) has been called the Father of Gynecology for his revolutionary approach to treating the diseases of women. He rose from humble origins to become a successful surgeon, teacher, and writer. His innovations included the first successful treatment for vesicovaginal fistula, the first gallbladder surgery, and the introduction of antiseptic principles in all areas of surgical treatment. The Sims position and Sims speculum are eponymic tributes to his accomplishments. In recent years Sims has, however, become a focus of controversy because of his experimental surgeries on slave women. His powerful personality and messianic attitude led him to minimize moral problems, and to bristle against opposition. Ethical principles of autonomy and beneficence are important criteria for evaluating Sims' research. An exploration of the nature of Sims' work and the atmosphere in which he practiced will illuminate the critical ethical questions surrounding Sims' use of slave women as experimental subjects.

J. Marion Sims (1813-1884) has been called The Father of Gynecology, and was the first physician to have a statue erected in his honor in the United States. During his lifetime he treated European royalty and was rivaled only by William Osler in his reputation abroad. He is credited with originating the first successful treatment for vesicovaginal fistula, a common and odious condition in the mid-1800s. He made great strides in introducing antisepsis into the surgical modus operandi. Every day physicians refer to the Sims position and use the Sims speculum, eponymic tributes to his accomplishments.

In recent years, however, Sims has become increasingly famous as a focus of controversy. From 1845 to 1849 he carried out a series of experimental surgeries on slave women that would bring him fame and fortune, as well as controversy. Indeed, controversy dogged him throughout life, even as his reputation grew, fueled by his forceful personality and self-righteousness. It is certainly ironic that an icon of medicine like Sims could be mentioned in the same context as Nazi medical experimenters and the authors of the notorious Tuskegee study on syphilis. An exploration of this apparent paradox reveals as much about the state of medicine during Sims' lifetime as about the man himself.

J. Marion Sims was born in 1813 in Lancaster County, SC, to a father of modest means and a mother from a somewhat more respectable family. Education was for him, like so many other Americans of his background, a ticket out of a hardscrabble and uncertain life. His early college career was undistinguished: I never was remarkable for anything while I was in college, except good behavior, Sims later wrote. At age 20 he had to choose a professional course of study, and he chose medicine by default. I would not be a lawyer; I could not be a minister; and there was nothing left for me to do but to be a doctor. Sims found medicine very stimulating, and worked hard in medical school. Upon graduation in 1835, however, he went back to Lancaster County to establish a practice with more than a little trepidation because of his lack of practical knowledge and experience.

This anxiety was soon borne out by events, as he lost his first two patients, infant children afflicted by persistent diarrhea. Deciding his luck might be better out West, he moved to Alabama in October 1835 and hung out his shingle. He mostly floundered that first year, finding himself compelled to treat grave conditions with the inadequate medical armamentarium of the times. The possibilities of aggressive empiricism were, however, suggested by an early experience in which a patient developed abdominal pain, with certain signs pointing equivocally toward a liver abscess. Sims convinced the reluctant patient to undergo surgery without anesthesia, and later recorded: I think it was one of the happiest moments of my life when I saw the matter [pus] flow and come welling up opposite that bistoury [scalpel].

Sims had an active but uneventful career in Mount Meigs, AL, until 1840, at which time he moved with his young family to Montgomery. We had no money, and always lived from hand to mouth, Sims later recalled of his arrival in the city. In Montgomery he began to make a name for himself as a respectable physician. He boasted of being the first doctor in the South to successfully treat club-foot and cross-eyes.

In the latter part of 1845, Sims' fortune took a decided turn for the better. According to his autobiography, Sims had been referred a young female slave named Anarcha, who suffered from a vesicovaginal fistula as a consequence of protracted labor. Sims pronounced her incurable, and was on the verge of sending her away, when an incident of pivotal importance occurred. A middle-aged woman was thrown from a horse, sustaining a pelvic injury. The young physician, then 32 years old, was called to examine her. His initial examination suggested uterine malposition as the cause of her pain, and in the attempt to examine her more thoroughly he had her squat on her knees and elbows in bed. He then introduced both his forefinger and middle finger into the vagina, and immediately the pelvic organs relaxed and the woman experienced relief.

This experience led Sims to an epiphany: he could use the same unconventional position to examine and treat his patient with the vesicovaginal fistula. That same day he bent a pewter spoon into a crude instrument and introduced it into the vagina of another slave patient named Betsey, and, according to his account, I saw everything, as no man had ever seen before.

This was a literal as well as a metaphorical statement, for Sims was resolved to approach the examination and treatment of diseases of women in a new way. He modified his improvised speculum and began to design instruments for the surgical repair of this condition. Within three months he was ready to try the new techniques on his first slave patient, Anarcha, as well as another half-dozen female slaves with similar fistulae. He set them up in a special hospital building adjacent to his family home, making arrangements with their masters for their upkeep while under his care.

The next 3 years were trying for Sims, as he operated again and again in an attempt to solve the problem of persistent fistulae. He came to realize that closure of the surgical wounds with the standard, unsterilized silk or gut sutures was the cause of the operation's failure. He read of a Virginia surgeon's use of lead sutures and had a local jeweller make sutures of silver wire. This innovation prevented the wound infection which would predictably result in breakdown of the suture line.

When Sims examined Anarcha one week after her thirtieth surgery for fistula repair, he found "no inflammation, . . . no tumefaction . . ., and a very perfect union of the little fistula." In fact, more than that, he knew he was revolutionizing medicine, not just in the form of an innovative surgical technique, but in terms of the approach of physicians to diseases in women.

At the time of this success Sims became chronically ill with a diarrheal illness. He traveled extensively to find the right combination of climate, water, and food to improve his health, and eventually decided to move to New York City in 1853. One year earlier he had published his account of the fistula repair in the Journal of the American Medical Sciences. This article, while well received, was not quite enough to provide Dr. Sims with a suitable medical practice in New York, and he and his family (including now six children) struggled for several years until a fortuitous series of events culminated in the establishment in 1855 of the Woman's Hospital, a publicly and privately funded charity hospital exclusively for the treatment of female disorders. By that time Sims' health had improved, and he was up to the task of moving forward as a charismatic teacher and the leading surgeon on the hospital's staff.

Over the next several decades, Sims' reputation grew. His hospital attracted a core of physicians–Drs. Thomas Emmet, Edmond Peaslee and T. Gaillard Thomas–who may be fairly said to be the progenitors of gynecology as a respected medical specialty in America. Sims, at first the most reticent of men, began to draw crowds of students in the surgical amphitheater, to write prolifically on all manner of diseases, and to lecture far and wide. His fame preceded him to Europe, and he moved there semipermanently during the American Civil War. In 1863 he ministered to the health of Empress Eugenie, wife of French Emperor Napoleon III. That year he began writing his innovative work Clinical Notes on Uterine Surgery, which was controversial but widely read. All over the world doctors read Sims' casual, chatty text and promptly revolutionized their treatment of women's ailments according to its precepts. Its straightforward approach to female diseases was refreshing, and its emphasis on treatment of sterility, including artificial insemination, was ahead of its time.

In the latter part of Sims' career he remained a forceful presence in gynecology. Perhaps his chief mark of distinction was a willful empiricism, the belief that no medical problem was insoluble, given enough thought and effort. He became an expert on pelvic and abdominal surgery, performing the first documented gallbladder surgery in 1878 and helping to usher in the new era of therapeutics made possible through the use of general anesthesia. He authored a highly influential pamphlet heralding the role of Crawford Long of Georgia in discovering ether and helped cement Long's role in the medical history books. He was a forceful advocate for the use of Lister's antiseptic principles in surgery, leading the vanguard for this then-controversial theory. His reputation is only slightly tarnished by his promotion of certain now-discredited techniques, such as cervicotomy for sterility and dysmenorrheaand ovarian removal (ovariotomy, or Battey's procedure) for various physical and psychosomatic conditions then termed hysterical diseases. He was an enthusiastic practitioner of these techniques, but hardly as evangelical as many of his colleagues at the Woman's Hospital, who reflected peculiarly Victorian notions regarding sexuality, organic disease, and mental illness.

After Sims was comfortably ensconced in his New York practice at Woman's Hospital, he began to display a habit of occasional intemperate outbursts which provoked conflict and alienated many of his colleagues. In 1857 he used the occasion of a prestigious address before the New York Academy of Medicine (reprinted as Silver Sutures) to criticize his former protégé Nathaniel Bozeman, who revised Sims' vesicovaginal procedure and had the temerity (from Sims' point of view) to try to claim some of the glory for himself. Notwithstanding the fact that [Bozeman was] without any professional position till I gave it to him, that he is indebted to me for what he could never have obtained without my aid, he appropriates to himself every step of the operation that resulted from my own individual and unaided efforts..., Sims complained in the introduction to his honorary address. He made a lifelong enemy of Dr. Bozeman, a result which would vex Sims again and again over the next 20 years.

In 1870 Sims published a newspaper account of his treatment of a famous actress, Charlotte Cushman, and found himself accused of ethical charges before the New York Academy of Medicine. He received a reprimand for resorting to paid advertising, and betraying the secrets of a patient. This did not have a material effect on his practice, embarrassing though it was. In 1871 Sims was involved with helping to develop emergency medical services for the French during their conflict with Prussia. During a meeting of the American Sanitary Committee in Paris, he engaged in a heated quarrel with an American dentist named Evans. Sims grabbed him by the neck and punched him in the face before being forcibly restrained. Sims left Paris before charges were filed.

In 1874 Sims committed a more critical error. For at least 2 years a great deal of personal animosity had simmered between Sims and the other eminent surgeons at Woman's Hospital, Drs. Emmet, Peaslee and Thomas. A large portion of this was professional jealousy, fueled in no small part by Sims' egotism, which led him to regard Woman's Hospital as his own personal fiefdom. The other board members voted to ban cancer surgery from the hospital and to limit the number of spectators at surgeries. Sims saw these restrictions as aimed directly at him, but kept quiet initially. At the hospital's anniversary party in November (normally a staid affair of good cheer) he let loose. I have never heeded your edict and never will; and if you are aggrieved at this you can have my resignation at your next meeting if you wish it. To his surprise and regret, the hospital board took him up on his offer, and Sims was unceremoniously relieved of his association with the preeminent women's hospital in the country, which he was instrumental in founding 20 years earlier.

In 1875 he was elected president of the American Medical Association, partly based on the efforts of partisans who were upset at his treatment during the Woman's Hospital affair. His tenure was energetic, if not eventful. He continued to spend much time abroad, while managing a small boutique practice in New York. In 1877 he plunged into a reopening of the Woman's Hospital controversy by responding to a pamphlet written by Drs. Emmet, Peaslee and Thomas, and which was highly critical of his behavior. As biographer Seale Harris points out, It was one of the unwisest things he ever did. The resulting publication ensured that J. Marion Sims would continue to nurture enmity for many years until a belated reconciliation with his erstwhile friends and colleagues.

As the accolades accumulated in the latter part of his career, Sims' health declined. He suffered from recurrent episodes of diarrhea throughout his adult life, and in later years was troubled by the angina of ischemic heart disease. In 1883 an ailing Sims dictated The Story of My Life to a young secretary, covering his career up through the Civil War years. It would remain unfinished, cut short by his sudden death due to myocardial infarction on November 13, 1884, less than one day after performing a complicated operation upon a woman of some prominence.

J. Marion Sims has become an icon of medicine because of his accomplishments, which are truly too numerous to mention in a short paper. His keen intellect was always open to innovation. He overcame an unpromising background and the opprobrium arising from his Southern origin to make a name for himself not just in the quintessential American city of culture and knowledge, New York, but also in London and Paris. Monuments bear his likeness in New York City and the capitals of Alabama and South Carolina.

He reflected the heroic ideal in medicine, which became prominent in the 19th century. Famous practitioners such as Jean-Martin Charcot and Francois Broussais (a strong advocate of bloodletting) in Paris; Robert Liston, James Syme and James Young Simpson in Britain; Theodor Billroth in Vienna; and William Halstead at Johns Hopkins in the United States, tried ever more radical cures for challenging conditions. They refused to let Nature merely take its course, but boldly went against the grain of received medical wisdom.

So, Sims fit in with these iconoclasts in his search for new therapies. And yet, the ethical dilemma remains: was it proper for Sims to carry out his experimental surgeries as he did?

The question is bound up in issues of race and class. Sims' neglect of anesthesia illustrates this point. He considered his vaginal surgeries to be minor procedures and did not use anesthesia with either his African-American or Irish-American patients, for the most part. However, he found that upper-class white women could not tolerate surgery without ether. As McGregor states, Throughout his medical career Sims maintained a classbound prescription for the use of anesthesia with an unspoken premise that those women in the wealthy tier were by far the most vulnerable to pain. To be fair, this was not untypical of practitioners in the latter 1800s. Use of ether during surgery and childbirth had been reported in 1846 and 1847, respectively, but only after the Civil War did the surgical use of anesthesia become widespread, and even then cultural values intervened in its acceptance.

Sims was also of his time with regards to race relations. He owned slaves in Alabama, and in fact actually purchased one or more of the slave women he experimented on. After the end of the Civil War he defended the system of slavery in his letters. His writings are littered with uses of pejorative terms for African-Americans. However, he was not a virulent racist, and by all accounts treated black patients politely, if in a patriarchal fashion. In the early postwar period he urged the South to accept the 15th Amendment freeing the slaves, and move on.

While Sims did not disguise the facts of his cases, he did not trumpet them, either. It is implied that he was particularly keen to avoid the details of the women and their situation when he was trying to get established in New York. His 1852 paper on the successful vesicovaginal repair and his 1857 Silver Sutures lecture referred to his patients as healthy young negro women, failing to mention that they were slaves. Early illustrations from his writings show the women as white.

Some critics have suggested that the reason Sims left his native South had more to do with gossip about his immoral slave experiments than with his physical health.[13] In fact, he found himself in a similar situation in New York, as his Woman's Hospital catered to destitute Irish immigrant women, whose inferior social status did not allow them to decline questionable treatments. He was criticized directly for unethical experimentation by his colleagues and the hospital administration during the acrimonious debates of the 1870s: The Lady Managers began to be convinced that the lives of all the patients in the institution were being threatened by these mysterious experiments.

In the end, the critical questions are not whether Sims was biased regarding race and class, or whether he was embarrassed by how others would perceive his past actions. They revolve around standard ethical principles of beneficence and autonomy, judged both by the standards of his times, as well as through the filter of history.

Regarding beneficence, ample evidence exists that Sims wished the best for his patients and for the broader community of female patients. He undertook the experimental treatments on his patients with the understanding that no operation would endanger life, or render their condition any worse. As he wrote mellifluously 12 years after he saw his first case of vesicovaginal fistula, I thought only of relieving the loveliest of God's creation of one of the most loathsome maladies that can possibly befall poor human nature.

However, one inescapable conclusion is that Sims' optimism, tinged with messianic fervor, blinded him to the suffering of his patients and any associated ethical implications. His brother-in-law Dr. B.R. Jones implored him to give up his surgeries, but Sims avowed, I felt that I had a mission . . . of divine origin . . . I could not have ceased my labors if I had tried. With the hindsight of history and a more mature ethical framework, we may ask if Sims' ends justified his means, or, more accurately, if the subjects were merely means to Sims' ends. It is quite clear that Sims falls short of modern Kantian ethical principles: To treat persons merely as means, strictly speaking, is to disregard their personhood by exploiting them . . . without regard to their own thoughts, interests, and needs. In that vein he sketches only the briefest of details of the effect of his surgeries on the health of his patients, and never records the ultimate outcomes. (In fact, arch-nemesis Bozeman scathingly questioned Sims' results after his death.

The concept of autonomy is a similar ethical morass where Sims is concerned. Obviously, slaves had no autonomy, by definition. The Irish patients of Woman's Hospital had little autonomy. Can we judge Sims not by the standards of our times, but by those of his? Critics point out that many contemporaries made medical advances without the use of uninformed captive patients. Kentucky's Ephraim in 1809 performed perhaps the first successful abdominal operation, and in 1842 Georgia's Crawford Long used ether as an anesthetic for the first time, in both cases on informed, free, white patients. James Simpson of Edinburgh, a fierce rival of Sims, was critical of Sims' early work and made the following barbed observation in 1863: I took occasion to make an extensive series of experiments . . . upon the relative qualities of different metallic threads . . . [on] a number of unfortunate pigs, which were always, of course, first indulged with a good dose of chloroform.

ne cannot escape the implication that if it were not for Anarcha, Betsey, Lucy, and the other unknown slave women undergoing dozens of operations without anesthesia while under bondage to Sims, he would have ended up an anonymous practitioner in Alabama. This dependence of the southern professional on chattel slavery was exemplified by J. Marion Sims no less than the masters of cotton plantations. The stain of the most shameful portion of America's heritage cannot be whitewashed when we consider his place in history, even as we recognize his many accomplishments.

J. Marion Sims was simultaneously a man of his time and a man ahead of his time. While it might be concluded that his place in history results from the latter, and any ethical questions arise from the former, the truth is complicated. Though modern critics may not wish to remove Sims' monuments from their current homes, they would not be remiss in asking to have monuments erected beside them to Lucy, Betsey and Anarcha.

From: medscape.com



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