Jefferson Medical College - Clinic Yearbook (Philadelphia, PA)

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e transformed the tra- ditional role of the American physician abroad from that of humble student to that of honored teacher t is popular to credit chance-or what Sir Walter Scott described as the happy combination of fortuitous cir- cumstances -for significant discoveries in medicine, as well as other fields. Thus, many writers have been over- impressed by the elements of fortune underlying the contributions of Cfor lamesl Marion Sims to medicine and particularly to gynecology. The barest research reveals, however, that years of hard work and frustration underlay Sims' initial-and probably his most important-Contribution in this field, the first successful surgical procedure for repair of a vesicovaginal fistula. The importance of his discovery is un- contested. Prior to Sims' operation, wo- men with this condition were classified as incurable and became outcasts, for- saken by the families as well as society. Many of them wished for death, some died by their own hand. For two cen- turies before Sims, leading surgeons of Europe had been unsuccessful in de- vising a successful operation for the condition. That there was some element of chance in Sims' achievement is unde- niable, especially in view of the fact that in the early days of his practice he referred all patients with female problems to doctors specializing in this field-known derisively at the time among physicians as male midwifery. In 1845 Sims had been practicing 10 years but had not seen a single case of vesicovaginal fistula. Then in three months while practicing at Montgom- ery, Ala., he saw three female slaves with the condition and was forced to report to their masters that their plight was not correctable and they would never return to the fields. The proximity of the three cases was the first element of chance, the second was the accidental discovery of the lateral kneechest position for good visualization of the pelvic organs. Sims had been called to see a woman who had fallen from a horse and was com- plaining of back pain and pressure on her bladder and rectum. He decided after physical examination that the woman's uterus had been displaced by the fall and should be returned to its normal position. But he had no idea how to go about the procedure. He tried to recall a medical school lec- ture 'll years before and, accordingly, placed the woman on her knees and elbows and began to probe her pelvis with two fingers. Suddenly, she WHS relieved-and no one was more sur- prised than Sims. Maintaining his air of professional omniscience, he calmly removed h1S hand and said, You may lie down now. As she did there was an em' barrassing rush of air. Sims realized quickly it was merely expulsion of alr he had introduced during the proce- dure and he concluded it was atm0S- pheric pressure that had restored the uterus to its proper place. He 1m- mediately saw clinical application Of this phenomenon. lt could be used'tO make the walls of the vaginal C3Vlty visible. His thoughts turned to the young slave girl waiting at his home for a train back to her plantation. She was the third patient with the dreaded fistula whom he had seen in three months. He enthusiastically began to plan an and the c0Il5ldeI His Cafe' eaIlY se establish native I marked He ing I0 tackle S0 first C09 3 dCSCUl 3 Cleft . adult W' lutiollall sarcoma disfiguri when 52 operatioi successh mostly C for whi throught I His sign of I his way girl he s spoon, vl varyingl instrume famous l It hroug into viev to Opera fruslratir his Colle heforeh ated on . -leading MOIilg01 humane SPire the been Sidi fhe 184i Plalnedi dolllli, tl slavery, dlle fri t lbs linoi onli' llc Ilormal 3 Sin Opefalioi ini i. 3SSl1med Clothing to Peffe Until 15 llhg H CUIS- uCCef fill

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e Com lg utheijseg Zh ls . 111 ,er the heal. l70SEd by W fat SUISCOHS 1 at the Uni. mf Williams SS fflremost ,C that Gross lnt. In 1918 'ears of the , Cf I iS cast aside TSC the then Listerismf' :haracteristic ready to ac. en he intro- rethodg of incidence of educecl. But hen younger :off surgical in North Other pioneers also received sup- port and encouragement from Cross. Nicholas Senn, the great Chicago sur- geon, revealed that he had dedicated his major work on tumors to Cross be- cause the jefferson surgeon had en- couraged him when he was despairing over criticism of an article he had written early in his career. Cross praised the article and urged the young surgeon to go on to greater things. Cross knew first-hand the struggle for greatness, and how helpful encourage- ment could be. His own struggle began inauspi- ciously after his graduation from jeffer- son in 1828. Prospects were lean for a young physician in Philadelphia at that time, so Cross and his new wife returned to Easton-hardly the place to build an international reputation- where he began to practice. In his spare time he worked diligently, dis- secting cadavers Cobtained quietly D and writing. His output was volumi- nous. Within 18 months of his grad- uation he had translated four major works and published a total of 11,000 pages. Nulla tlie sine linea Cno day without writingl was his motto, and he stuck to it. After his initial effort at translation, he embarked on a career of original contributions, writing a text entitled Diseases anal Injuries of the Bones and joints. - Soon after his original Writings were published CPost hoc ergo propter hoc?D, Cross headed West to teach anatomy at the College of Ohio. He was 28 years old and had only S150 to his name. He later was appointed pro- fessor of pathological anatomy at Cin- cinnati Medical School. While there, he published Elements of Pathological Anatomy, the first book on this subject in English. The text gained him recog- nition in Europe, for he was soon in- vited to membership in the Imperial Medical Society of Vienna. Member- ship in the Clinical and Pathological Societies of London and the Medico Chiurgical Society of Edinburgh soon followed. The significance of Cross' work can be gauged by the reaction of Virchow, father of pathology. Thirty years after Elements was published, Cross was honored at a banquet in Vienna and Virchow, his host, dis- played a copy of the text, describing it as one of the prized works in his library. At the age of 35, Cross left Cin- cinnati for Louisville, where he taught surgery from 1840 to 1856. While there, he completed his System of Sur- gery, which biographers believe was his greatest contribution. It took two vol- umes to encompass the 2,300 pages and it established Cross as America's fore- most surgeon at that time. When he retired, it had gone through six edi- tions and had been translated into most major languages. Years later, Keen de- scribed the work as a mine of informa- tion, a textbook worthy of its author. It has been the companion and guide of many generations of students. - Cross accomplished much at Lou- isville, but in 1856 he decided to re- turn to Philadelphia where he could limit his practice to surgery. At the age of 51, he resumed his association with jefferson and, in his introductory ad- dress, made this commitment: Whatever of life and health and strength remain to me I hereby, in the presence of Almighty Cod and this large assemblage, dedicate to the cause of my alma mater, to the in- terests of medical science and the good of my fellow creatures. He remained active at jefferson for 26 years, operating, teaching and writing. On the eve of the Civil War, the War Department asked him to prepare a Manual of Military Surgery. Published in 1861, it was rushed to Union surgeons treating battlefield casualties. The Confederacy published a pirated edition, giving Cross full credit but regretting that conditions beyond our control prevented the usual reprint arrangements with the author. Ironically, Cross became a uni- fying force in medicine after the war, just as his surgical manual had been during the conflict. He was one of the major factors behind the election of a Tulane professor as the 30th president of the American Medical Association. According to reports at the time, Cross backed the election to help obliterate the effects of the war in the profes- sion. Cross took a leading role in the A.M.A., just as he did in scores of other societies. He was the prime mover behind establishment of an alumni association at jefferson and served as its first president-exactly 100 years ago. His professional stature was apparent from his election as president of the World Medical Congress, which convened in Philadelphia in 1876 as part of the centennial of American independence. He had been invited to address the International Medical So- ciety, which met in London several months after his death in 1884. In death, Cross left enduring marks on his alma mater. Not the least of these is the Alumni Association, which is the most active and generous medical group in the nation. His name is perpetuated through the Samuel D. Cross professorship of surgery, which was the first endowed chair at jeffer- son. Chalmers Da Costa, the first Cross professor, hailed his surgical predecessor as the author, the oper- ator, the scholar, the teacher, the or- ganizer, the scientist who came to the foremost position ever occupied by a surgeon in this country. . Other men have had such honors, have worked diligently and have writ- ten prolifically. Yet few are remem- bered as Cross is. One of the major reasons, perhaps, is the famous Eakins painting of The Gross Clinic. The pro- fessor was a perfect subject for such a painting. He was a strong personality, a stalwart Hgure with a- beautiful benignant countenance, according to Garrison. Eakins, master of realism, captured Cross' personality in oil and created an immortal work. The artist had a personal stake in the painting, for he had studied' anatomy under Cross as a special student at jefferson. It has been described by some art publications as possibly the most im- portant painting by an American. When unveiled, however, the realism of the operating room scene horrified contemporary audiences and the work was rejected for showing in an art exhibition. Now the gigantic canvas hangs Cwhen not on loan to museums for exhibitl in a place of honor outside McClennan Hall, dominating the entrance to the College Building. Re- productions of the painting hang in thousands of jefferson graduates' of- fices across the land. Each year, return- ing alumni can be counted on to repeat a poignant scene. Stopping under the priceless canvas with wife and children in tow, they look up reverently and recite the legend of Samuel D. Cross. Can there be any doubt why the lustre of that legend refuses to fade?

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But he had no t the procedure. edical school lec- .md accordingllk 1 her liI1695 and probe her pelvis ddenly, 5115 was was more SUI' ' P pwfeioutl 1l'0rem0Ved hls .may he dorm was an fm' I Sims realllfd expllkion of an . g the pfmel it WHS amos' .d restored the Placer He f aPPlican0n 0 uld be usedto . ' al Cam 5 vaglgi to the hr it 511nmU0n'aed sith fhe.dI?geC IU 51 to im. aeallr' began plan an operation to cure the girl- and the others he had seen. He never considered the possibility of failure. His career, to this point-except for an early setback when he attempted to establish a medical practice in his native Lancaster, S.C. - had been marked by repeated success. He gained confidence after mov- ing to Alabama and had begun to tackle some very complicated cases. His first contribution to the literature was a description of the surgical repair of a cleft lip and the cleft palate in an adult woman. Others included a revo- lutionary procedure for removing osteo- sarcoma of the jaw that did not require disfiguring incision of the face. Clearly, when Sims began to plan his vaginal operation he was riding the crest of a successful medical practice, based mostly on his achievements in surgery for which he was gaining reknown throughout the South. - His first requirement was the de- sign of the necessary instruments. On his way home to reexamine the slave girl he stopped to purchase a pewter spoon, which he was able to bend into varying configurations. His improvised instrument became the basis of the famous duck-billed CSimsD speculum. It brought the fistulous tract clearly into View and confirmed Sims' decision to operate. He faced four years of frustration, doubt, loss of confidence by his colleagues and financial sacrifice before he would see success. He oper- ated on one of the slave girls 30 times -leading to charges by his critics in Montgomery that he was conducting human experimentation. However, de- spite the fact that anesthesia had not been adopted generally in surgery in the 1840's, Sims' patients never com- plained. This was due in part, no doubt, to the docility bred by years of slavery, but was in no small measure due to their confidence in Sims, plus the knowledge his operation was their only hope of being restored to a normal life. Sims became obsessed with the operation. He built an addition to the small hospital behand his home and assumed the obligation of feeding and clothing his patients while he worked to perfect his procedure. It was not until 1849-five years after his first unsuccessful attempt-that he effected a cure. The ingredients of success were five: the Sims position and Sims speculum, of course, a catheter to keep the bladder empty while the fistula healed, silver wire sutures and a new method for drawing them together. The last two were the most important, for without them success eluded the surgeon for years, with them he suc- ceeded in his first attempt. - After this, Sims turned much of his attention to the field he originally disdained-diseases of women. He was described even in his day as the father of gynecology, though he continued to be a gifted general surgeon. Sims be- gan to build a national and later a worldwide reputation after he moved from the South to New York, where he was able to find relief from chronic debilitating diarrhea. He left Alabama in 1853 and two years later was the primary force behind establishment of the Womanis Hospital of the State of New York. Here he collaborated with Thomas Addis Emmet, also a Jefferson graduate, and other gynecological pio- neers. With the approach of the Civil War, Sims' expression of Southern sympathies made New York increas- ingly inhospitable. So he Went to Europe, where he was called on to demonstrate his operation before lead- ing surgeons. He remained abroad longer than he had anticipated and engaged in private practice in both France and England. A biographer notes that his acceptance by European aristocracy allowed him to transform the tradi- tional role of the American physician abroad from that of humble student to that of honored teacher. His reputa- tion assured him an extensive practice in whatever country he chose to visit. While he commanded large fees from those who could afford them, Sims al- ways had an active charity practice. Biographers agree he practiced medi- cine for the sheer satisfaction of it- not financial reward. While in England in 1866 he published a textbook, Clinical Notes of Uterine Surgery, which stirred up a great deal of controversy because of its frank consideration of what were con- sidered indelicate topics at that time. His discussion of the treatment of sterility aroused the most criticism, es- pecially his advocation of postcoital microscopic examination of sperm. His proposal that artificial insemination could be an answer to sterility brought this retort from the Medical Times and Gazette of London: Better let ancient families become extinct than keep up the succession by such means. Soon, however, many of Sims' in- novations began to be widely accepted and on his return to New York in 1858 he was acknowledged as the world's foremost gynecologist. He returned to Woman's Hospital as senior consulting surgeon and accepted a position on the board of governors. Six years later, however, when his worldwide reputa- tion was at its peak, he became embroiled in a dispute with the super- visors of the hospital and resigned. So, as 1875 dawned, the foremost Ameri- can gynecologist was barred from the institution he was responsible for founding and forced to practice in a small ofiice in his home. As always, he continued to see charity patients, even on Sundays. His prestige outside of New York did not suffer, and the year he left the Woman's Hospital he was elected president of the American Med- ical Association. A year later he was a charter member of the American Cy- necological Society, which elected him president in 1880 Cthe year Woman's Hospital reinstated him as consulting surgeonl -The final task to which Sims turned his attention was an autobiog- raphy, Story of My Life, which he never completed. lt was published in unrefined form after his death in 1883 and has provided much of the source material for subsequent biographers. Seale Harris' version, W0man's Sur- geon, published 1950, includes this assessment of the man: Marion Sims was one of a few out- standing 19th century pioneers who added more to the basic knowledge of medicine and surgery in three or four decades than had been accumu- lated in all the thousands of years preceding. Chiefly, however, he was the physician who brought new hope and new life to women. Today at Jefferson, where he re- ceived his medical degree in 1835, a society bearing his name and founded in his honor, serves as the nidus for young men who hope to practice the specialty he developed. They, as he, may be aided by good fortune. But they will have to supplement it with keen minds and hard work.