Until a way could be found for tightly closing those obnoxious, persistent little holes everything else seemed of very minor consequence. Yet actually many things of fairly major importance were happening during these years.

For one thing, the Sims family was increasing. In addition to Mary and Eliza and Granville there were now two more little girls: Carrie and Fannie, born in 1843 and 1847. Between Carrie and Fannie there had been a second boy who, having come into the world on December 25, 1845, labored under the name of Merry Christmas Sims. In 1848 he fell victim to a severe form of diarrhea then widely prevalent in Alabama. His parents' frantic efforts prolonged his life for several months, but that was all. He died before he was three, and his family, which up till then had known much illness, but no death, was plunged in grief. Merry's father, in particular, had a hard time recovering from the blow; surely a physician ought to know how to save his own child's life!

He was devoted to all his little girls, but for his boys he had a special feeling which his girls, much as he loved them, could not share. He and his contemporaries might place women on a pedestal, but a pedestal offered little scope for ambition or distinction, and for his sons Sims was filled with vast ambitions. And now Merry was gone, and Granville was again the only boy!

Another feature of these years was their momentous ferment. For all his absorption in work and family Sims could not overlook it wholly. Never for a minute did the nation or its people stand still. The Mexican War, unpopular as it had been, had ended with a vast accession of territory for the United States, and now the populace (including one of Theresa's uncles and several of Sims's brothers and sisters and cousins) was following its flag westward into the new lands. The urge to mobility was contagious, and even communities as newly settled as those in Alabama lost many of their members overnight. Sims himself received a flattering offer to move to the teeming commercial port of New Orleans, where he might have a larger field for his surgery and perhaps teach in the university's medical school besides; but he was too happy and busy in Montgomery---and too terrified at the mere thought of the public speaking involved in teaching---to think of making the change.

If the prevailing ferment had been limited simply to the desire to move from place to place its repercussions in Montgomery (where population continued to grow) would have been fairly mild. But it had a far more ominous aspect: the rapid growth of sectional antagonism. While for months on end Congress debated the problem of extending or not extending slavery to the new territories of the West, many Southerners grew more and more indignant. The industrial North, they felt, was trying to dominate them; they wanted to pursue their own traditional way of life without interference. Even Marion Sims, who always had avoided becoming seriously entangled with political or economic issues, could not help sharing the thrill of shock which ran through Montgomery early in 1848 when his friend and fellow townsman, that fire-eating Congressman William L. Yancey, persuaded the State Democratic Convention to pass the "Alabama Resolutions" declaring that Alabama would secede from the Union if Congress interfered with slavery in the territories. The section around Montgomery was one of the densest slave belts in the whole country; nearly two thirds of the population were slaves. The Simses themselves owned a number of Negroes; Theresa's mother and her brothers owned many more. It was the only way of life that they knew, and to them it seemed a good one; nevertheless they were worried by the flood of inflammatory talk; they had no desire to see their state secede from the Union.

Yet in the face of all these threats of disunion the medical profession throughout the country was drawing closer together. Montgomery's Sydenham Medical Society, which Sims had helped to organize several years before, was merely the local evidence of a nation-wide trend. Thoughtful doctors everywhere were beginning to realize that their profession was being harmed by the existing prevalence of squabbles and libel suits among physicians and by the absence of any general set of standards designed to keep the practice of medicine on an ethical basis. In the spring of 1847 Montgomery's medical society, like all others throughout the country, was invited to send delegates to a general congress of physicians held in Philadelphia. At this gathering a national body calling itself the American Medical Association was organized. One of the new Association's first concerns was with the drawing up of a set of rigid professional standards---christened the A.M.A. Code of Ethics---exhorting the nation's physicians to remember their duties to their patients, to each other, to the profession at large, and to the public. In Montgomery, where relationships among physicians were exceptionally amicable and where medical men were little given to the mutual recriminations so common elsewhere at the time, there was comparatively little discussion of the new Code of Ethics, and Marion Sims, engrossed as he was in his struggle with the riddle of vesicovaginal fistula, paid but slight attention to it, not anticipating that the time might come when he would find himself in sharp conflict with some of its pontifical edicts.

What interested him rather more was a paper just published in the New Orleans Medical and Surgical Journal by his old South Carolina friend Dr. Josiah Nott, now Mobile's leading physician and surgeon. Nott contended that the South's recurrent waves of yellow fever, malaria, and other epidemics very possibly might owe their origin to some infection carried by insects, which were manifold in the region. Sims had had but little experience with yellow fever, but to a man who had been through several desperate sieges of malaria there was a strong appeal in any new theory about the cause of such epidemics, however revolutionary it might be (and Nott's was so unheard-of that it received but little attention at the time). For all his preoccupation with surgery, Sims was eager to lend a hand to any venture designed to lessen the toll of the terrible endemic diseases which were Alabama's perennial bane.

Such a venture was the one conducted in the summer and fall of 1846 by his good friend Dr. William O. Baldwin. It had to do with quinine, which had proved itself so invaluable in the treatment of malaria that many Southern doctors had adopted the habit of prescribing it in enormous quantities---sometimes as much as 100 grains in twenty-four hours. Baldwin had come to the conclusion that whatever quinine's virtues (and certainly they were many), its use on such a lavish scale was a mistake. To test and prove his contention as to the possibly poisonous properties of the drug he embarked on an extensive series of experiments on dogs, and in these Sims volunteered to help him. What they found out was that quinine---so beneficent when taken in moderation---could cause blindness, convulsions, and even death when used in excessively large doses.

These experiments of Baldwin's made a deep impression on Sims, whose onetime lack of interest in medical research had been transformed by experience and expanding awareness into a perpetual eagerness to venture down new trails and to seek new explanations for age-old ills. One of his most productive expeditions along such a trail was his experience with trismus nascentium.

It all began at very nearly the same time as his initiation into the mysteries of vesicovaginal fistula. In July of 1845 a plantation-owning friend asked him to examine an infant born a week before to one of his slaves. It had had spasms, said the planter, and it was unable to suck, and altogether it seemed to be extremely ill. Even before he saw the child Sims guessed from the description of symptoms what was the matter: trismus nascentium---the dread lockjaw of newly born infants. In the five years which had passed since his own baby daughter Eliza had had her apparently miraculous escape from death he had learned to recognize this terrifying ailment, but he had learned also, to his sorrow, that there seemed to be nothing which the medical profession could do to relieve it. He had found descriptions of it all through medical history---sometimes not under the impressive appellation of "trismus nascentium," but under such homely names as "nine-day fits" or "seven-days' disease"; but none of these accounts presented any successful method of treating it. Therefore he told the ailing infant's owner that he could be of no help whatever to the child; nevertheless he agreed to examine it.

He found the baby lying absolutely rigid on its back in a deep, narrow cradle, with its tiny hands tightly clenched and its skeleton. like face drawn up into a sardonic grin. The slightest touch or noise threw the tiny sufferer into convulsions. Sims, feeling helpless, yet anxious to make such efforts as the planter and the child's distracted mother might expect, prescribed a regimen involving various medicines, enemas, and baths. When he returned the next day, bringing with him his friend Dr. Vickers, who was anxious to make a study of the case, he found as he had feared that none of the measures prescribed had been of the slightest benefit. The baby was obviously at the point of death. Knowing that nothing he could do would make the infant's situation any more desperate than it already was, he performed a number of experiments to demonstrate to Dr. Vickers its rigidity, reflex actions, and other characteristic symptoms. In the process he ran his hand under the back of the child's head to raise it from its deep cradle. Immediately his sensitive surgeon's fingers detected a remarkable irregularity in the feeling of the bones. This was no normal cranium, he realized: the bones forming the top and sides of the skull seemed to be projecting, while the bone at the back of the head was pushed in deeply under them.

The baby seemed to breathe somewhat more easily as long as he held it upright, but soon after he laid it down again it died. The next day, in the presence of several other physicians, he made a post-mortem examination and discovered enough disarrangement of the bones and blood vessels at the base of the brain to convince him and his attending colleagues that this death---and presumably most other deaths from trismus nascentium---stemmed from the prevailing practice of keeping a newborn baby, with its still-soft head, lying always flat on its back in a wedgelike cradle or (as so often happened in Negro cabins) on a hard wad of folded blankets or rags. Sims felt sure that such long-continued pressure on the back of the malleable head might easily displace the whole cerebral mass, thereby cutting off circulation to the brain and causing all the fatal symptoms.

Two months later, after seeing meanwhile several similar cases where the malady was too far advanced for him to prevent a fatal termination, he at last had the satisfaction of being able to save the life of a ten-day-old trismus sufferer, his only therapy being to insist that it be laid on its side instead of on its back. Elated at this turn of events and at several local physicians' corroboration of his findings in their own practice, he jubilantly wrote an article on the subject which was published by the American Journal of the Medical Sciences.

The medical profession as a whole showed a marked lack of enthusiasm for his thesis. A few physicians wrote to him or to various journals to say that their own experience bore out Sims's theory; many more, however, contended that he was wrong. The trouble was, apparently, that these doctors usually saw the victims of trismus too late to give relief by any change of posture. More than that (and Sims himself realized this) his observations were but a small beginning which, because of other concurrent preoccupations, he never adequately followed through. He continued to take a lively interest in such cases, however, and in 1848, two years after his first report, he published another long paper describing later experiences which had caused him to modify his views to some extent. He still stuck to his main thesis that trismus was caused by prolonged mechanical pressure on the base of the brain, but he had discovered that this might come not only from laying a child perpetually on its back but also from keeping it constantly in any one position. Moreover, he had found that in certain desperate cases he could bring dramatic relief by puncturing a dying baby's scalp with the point of a short, strong knife and prying up the edges of the bones which were causing the fatal pressure.

Even his good friends, he admitted in these later articles, tended to banter him about his theories, as on the occasion when an emergency call elsewhere forced him to turn over to Dr. Boling's care a trismus case which he had been handling. When he returned Dr. Boling told him that the baby was about to die and that he had better hasten to make sure that it died in the proper position! Such good-natured rallying, however, did not bother him; he was sure he was right, even though it was not until thirty-five years later that he was to have the satisfaction of seeing other men bear out his early theories about trismus by thoroughgoing research on a scale large enough to convince even the most skeptical.

That Sims himself never was able to assemble a sufficiently convincing body of evidence to convert the medical profession to his views was due to the fact that at the time when he was in interested in trismus (after the '40's the crush of circumstances crowded it quite out of his field of activity) it was merely a subsidiary concern, as all his major energies and thoughts were concentrated on one consuming interest, one paramount problem: how was he ever to get himself out of the embarrassing predicament, the frustrating impasse, to which his vesicovaginal-fistula experiments had led him?

It was embarrassing in more ways than one. Professionally, of course, it was no asset to be known as a surgeon who failed and failed and failed again on his most treasured project. Financially it was a great drain to support half a dozen nonpaying patients year after year. And socially the whole business was becoming a marked liability, for all kinds of whispers were beginning to circulate around town---dark rumors that it was a terrible thing for Sims to be allowed to keep on using human beings as experimental animals for his unproven surgical theories.

The human guinea pigs themselves, however, made no complaints on this score. Only in a small degree was their complaisance due to the fact that, as slaves, they were conditioned to yield implicit, unthinking obedience to the white man's orders, even if, as in this case, the white man was not their legal master. To a much greater extent their voluntary submission to a seemingly endless series of operations stemmed from their consciousness---far more acute than any outsider's could be---of how insufferably loathsome was their present condition. Sims's experiments brought them physical pain, it is true, but they bore it with amazing patience and fortitude---a grim stoicism which may have been part of their racial endowment or which possibly had been bred into them through several generations of enforced submission.

Against these repeated sieges of pain their only defense was the opium which the surgeon administered to them generously---far too generously, by any modern standards. At that time it was the practice of Sims (as it was of many other surgeons) to give some form of narcotic in tremendous quantities in order to prevent any activity of the bowels which might endanger the success of an operation. This locking up of the bowels was not for just a day or so, but for weeks on end---never less than ten or fifteen days, according to Sims's own report, and sometimes for as long as three or four weeks. That he suffered no fatalities under such a regimen as this is little short of miraculous, for nowadays such prolonged narcotization, arresting all the normal vital secretions, would be considered little short of murderous. As far as he was concerned the opium apparently had none but beneficial effects: 'It calms the nerves, inspires hope, . . . prevents a craving for food, produces constipation, subdues inflammatory action, and assists the patient, doomed to a fortnight's horizontal position, to pass the time with pleasant dreams and delightful sensations instead of painful forebodings and intolerable sufferings."

What even opium could not do, however, was to solve the two main problems which were still troubling him and keeping him from success: how to tie the ligatures tighter and further up in the body, so that no tiny gaps would be left; and how to prevent the ulceration and cystitis which resulted so recurrently from the infection which the silken sutures caused. He had reached a point where he realized that it was futile for him to perform any more operations until these defects were overcome. By now, with ever-increasing dexterity and speed, he had operated twenty-nine times on Anarcha alone and with comparable frequency on all the others. Not until he could perfect his technique would there be any value in subjecting either himself or his patients to further strain.

Nearly a month passed, therefore, with activities at a complete standstill. Betsy and Lucy and Anarcha and the rest begged for a renewal of the experiments; to their way of thinking even repeated disappointment was better than stagnation. For a long time, however, Sims was forced to disregard their pleas, for his inventive imagination, usually fertile in expedients, remained quite barren. He could not conjure up those missing links he needed. Then came at last the night when, lying sleepless in bed mulling over for the thousandth time the perennial problem of how to tie the sutures firmly and high, he suddenly saw it all just as clearly as, nearly four years before, he had first visualized the working of his speculum All he needed to do, he decided was to perforate a birdshot pellet, run it onto the suture threads, pull the threads tightly, and then compress the hole in the shot with a pair of forceps, thus making the fastening perfectly secure. "I was so elated with the idea," he himself wrote of this experience, "that I could not help waking up my kind and sympathetic wife {the time was three in the morning] and telling her of the simple and beautiful method I had discovered. . . I lay there till morning, tying the suture and performing all sorts of beautiful operations."

Beautiful it may have been in imagination, but when put into practice on the ever-willing Lucy the result again was failure, just as it had been so many times before. When the surgeon examined his patient after a week's impatient wait he found that while the shot pellets had held in place, the urethra, as usual, was inflamed by cystitis, and the ligatures had cut through the swollen tissues, leaving little openings---only tiny openings, to be sure, but more than adequate for the mocking, incessant dripping of the urine.

He could not hope nor want to draw the sutures tighter than the perforated shot had done, so now but a single avenue of approach remained: he must do something about the sutures themselves. Perhaps the trouble lay in using silk. Some of his predecessors he knew (notably Gosset of London and Mettauer of Virginia), had experimented with ligatures of metal. Impressed by Mettauer's published reports of his success in mending vaginal lacerations with Sutures made of lead, Sims tried using leaden ligatures instead of silk, but these he found too clumsy for his purpose;

When he twisted them with his forceps they invariably broke.

What happened next is open to some doubt. Sims himself, who sometimes was inclined to pleasing flights of fancy, said in later years that just at the time of his deepest discouragement and tribulation he happened to pick up in the yard of his home a bit of fine brass wire of the type then used in suspenders, and that immediately he was struck by the possibility that a similar wire constructed of silver might make just the kind of ligature he needed. Less romantic commentators observe that it was hardly necessary for him to depend on a chance-found bit of wire for his inspiration, since he already was thoroughly familiar by report with the results achieved with metal sutures by Gosset and Mettauer and Dieffenbach. Whatever its genesis, however, the silver suture proved to be the answer to his long-continued quest.

He had a jeweler make the wire of unalloyed silver, drawn about as thin as a horsehair. Then in May of 1849 he prepared Anarcha for her thirtieth operation. He brought the edges of the fistula close together with four of his fine and flexible new silver wires, passing them through little strips of lead to keep them from cutting into the tissue and fastening them tightly by using once again his perforated shot. Then he introduced the essential catheter and steeled himself for the usual tedious week of waiting. On a score or more of earlier occasions he had been sure that when the week was over he would witness a successful cure; this time he was filled with anxiety and dread. It seemed to him that he had played his last trump; if he failed to win now the game was really lost; even with his fanatical devotion he could not keep on forever.

When the week rolled around-almost four years to the day from the time when he first had seen those gaping, mocking holes which were Anarcha's souvenirs of childbirth labor---he had Anarcha placed again upon the operating table. With pounding heart and fearful mind he introduced the speculum. There lay the suture apparatus just as he had fixed it, quite undisturbed by swelling or inflammation. The fistula? There was no longer any fistula. Its edges had joined close in perfect union.

The weeks which followed were a period of joyful, if somewhat feverish, activity. For the present there could be no letdown from the concentrated effort of the last four years. Sims felt fairly sure that at last he had accomplished something of real importance, but he could not be positive until he had done it over and over again and had constructed an absolutely foolproof formula. This was no time as yet to rush into print telling the world of his success. First the permanence of that success must be assured.

After the triumphant cure of Anarcha came similar happy experiences with Lucy and Betsy and with the little hospital's other long-time fistula patients. There were no untoward incidents; the formula seemed to be working perfectly. The convalescents, veterans of so many operations, were returning now as normal women to the world from which for four years they had been cloistered, but their places in the hospital would not long be vacant, for the good news had traveled fast and far, and applicants for operations were many.

Faced with the prospect of all the work he could handle for years to come, Sims came up for a moment for air and did two things designed, he thought, to make his life a little easier in the future: he became a capitalist and he began to train an assistant.

Becoming a capitalist was a symptom of the times. Every week fresh reports were being received of fortunes made overnight in California's gold fields. Marion Sims had too much at stake in Montgomery to be tempted to join the gold rush, but in the last few years of passable health and prosperous practice he had managed to accumulate something rare in the previous annals of the Sims family: a substantial backlog of savings. It would be wise, he decided, to put these to work for him, so that he need not always be dependent from day to day upon the skill of his fingers. Therefore he invested five thousand dollars in the drugstore which his brother-in-law Rush Jones and his friend W. O. Baldwin were starting.

Having achieved part ownership of a business as partial insurance of an easier existence he realized that another advisable step would be to train a protégé to share with him the arduous responsibility of his highly specialized operations. Hence he thought that fortune was favoring him (later he changed his mind about this) when fate threw into his path a young man who seemed to be precisely what he needed.

The young man's name was Nathan Bozeman. A native Alabamian, he recently had set up practice in Montgomery after spending several years at the University of Louisville, where, following receipt of his medical degree, he had had some months of exceptionally valuable training as assistant to the distinguished Samuel D. Gross, who was then serving as professor of surgery at Louisville before returning to Philadelphia for his long and eminent career at Jefferson. Under Gross, Bozeman had acquired a familiarity with the best surgical methods far beyond that of the average Alabama practitioner of the period. To Sims the fact that someone he admired as much as Dr. Gross had selected Bozeman for preferment was testimony enough of his special aptitude, and before long he developed the habit of asking the young man to assist him in his numerous operations. Bozeman was an apt pupil, and within a short time he was privy to every detail of the technique for repair of vesicovaginal fistula which Sims had struggled so long to develop. They were an oddly assorted pair, the surgeon and his occasional assistant: Sims with his slight figure, his delicately chiseled face, his tenuous hold on health, his darting mind, and his gay, mercurial charm; Bozeman with his large stature, strong physique, and heavy features, his solemn concentration on details, and his infinite capacity for painstaking hard work. For the time being the combination showed every promise of working out well. New patients were pouring in constantly, and it was Sims's hope that Bozeman soon would be able to take some of the burden of their care off his hands, leaving him partially free for new explorations.

For a month or so all went swimmingly. Then the whole structure came tumbling down. Sims's old nemesis, ill-health, struck again; and, as if to snake amends for leaving him comparatively untouched for seven years, it struck harder than ever before. This time his trouble was not malaria, but an extremely wasting form of acute diarrhea which was currently epidemic in Montgomery and which (its cause being then unknown) physicians were quite powerless to check. Many of its victims died in short order; others progressed from the first acute stage into a condition of chronic suffering which lingered indefinitely. Sims was one of those in whom the malady became chronic, prostrating him for the major part of four years.(3)

All of his just-budding plans to accomplish bigger and better things in surgery gave way to the single desperate struggle to stay alive. At first he thought optimistically that he might be able to combine illness and recuperation with a little surgery, so he went to Butler Springs, a small resort only fifty miles or so from Montgomery, taking with him not only his entire family but also three or four patients on whom he hoped to be able to operate during his healthier moments. The trouble with that arrangement was that there were no healthier moments; he was completely prostrated by his disease. Pitifully weak and emaciated, and all too familiar from his medical experience with the fate awaiting victims of uncontrolled diarrhea, he began to realize that if he were to survive he would have to do something more drastic than merely transplanting himself to a near-by watering place. What he needed was a complete change of climate; perhaps in the North, far away from the epidemics and endemics of the South, he could regain his strength.

So began his restless, discouraging, four-year odyssey in search of health. Each year he would set forth from Montgomery for various northeastern points; out of all the places he visited in his desperation the two where his condition seemed most inclined to improve slightly were New York and Philadelphia, presumably because the water in those two cities had a comparatively soothing effect upon his complaint. He was far too ill to travel alone, so usually his anxious and devoted wife felt it necessary to accompany him; and since she had six children to care for (a son whom they named Harry Marion Sims had been added to the family in 1851) these perennial pilgrimages were costly and difficult to arrange. It became a regular routine: two or three months in the North, accompanied by a mild betterment in health and spirits and an eventual decision that now the father of the family had recuperated sufficiently to go home; a hopeful return to the beloved associations of Montgomery; a couple of months of attempting to rebuild shattered fortunes through surgical practice; a revival of the old thrill in the exercise of ingenuity and skill---and then collapse again, and renewal of the cycle, occasionally varied somewhat by expeditions to Mississippi or Louisiana or Georgia instead of to the North.

The first trek to New York, in the summer of 1849, came at exactly the same time as the great cholera epidemic which hit the metropolis that summer, causing at its height a thousand deaths a week. The medical profession, overwhelmed by the demands of this catastrophe, was unable to be of much assistance to a lone outlander seeking advice on a malady quite as mysterious as cholera but rather less dramatic. In Philadelphia, too, Sims consulted outstanding physicians, but to no advantage. They knew no more about what to do for him than he knew himself.

Once during these lean years he thought for a while that he had found the key to health---not in the distant North, but in his own South. By purest chance, in the form of conversation with a man on a railroad train, he heard of a little place named Cooper's Well in Mississippi where a number of soldiers returning from the Mexican War had recovered from chronic diarrhea contracted during their military service. Seizing at any straw, Marion Sims and Theresa, with two of their children, made a long and wretchedly uncomfortable cross-country trip by stage and horseback through swamps and flooded roads and assorted privations, consuming two whole weeks on their 250-mile journey, only to arrive at last at a godforsaken-looking place consisting of nothing but a small clearing and a few log cabins. This was Cooper's Well.

When Sims came to this gloomy outpost he had been existing for weeks on a diet of boiled milk with crackers or stale bread. His weight was down to ninety pounds, and he was in a mood to grasp at any straw that was thrown to him. Mr. Cooper, the Methodist circuit-rider who had dug the well, advised him to drink several quarts of the water each day and to eat generously of the fresh and salt pork which made up the major part of the little resort's diet. This advice he followed as docilely as if Mr. Cooper had been the medical man and he himself the layman. Immediately a miracle seemed to have been wrought: the diarrhea was checked; he had a ravenous appetite and ate and ate and ate with the gusto of a starving man brought back to plenty.

In the twenty-seven days that he remained at Cooper's Well he gained twenty-seven pounds. He ought to have stayed there longer, but, believing that now he was surely on the road to recovery, he felt that he could not afford any further extension of his absence from work. On his homeward journey he traveled by way of New Orleans, lingering there a while in order to visit the hospitals and the medical school, where the professor of surgery, Dr. Warren Stone, had an outstanding reputation for knowledge of many of the same problems which had engrossed Sims's own attention. His preoccupations in New Orleans were not entirely professional in nature, however, for the aspect of his visit which remained longest in his memory was the chance it gave him to hear a song recital by Sweden's matchless Jenny Lind, then on her first triumphal American tour, and to get to know (through residence at the same hotel) her impresario, the fabulous P. T. Barnum. Sims had a great love for the theater and everything dramatic, and he was fascinated by Barnum's combination of master showmanship (for which he himself had a not inconsiderable gift) with his strict advocacy of temperance and Sabbatarianism, both of which were causes close to Sims's heart.

While he was in New Orleans word got around of his accomplishments in the repair of vesicovaginal fistula (because of ill-health he had had no chance as yet to publish anything on the subject), and he was importuned to examine a slave who was suffering from this affliction. Eager to restore the woman to health, he requested her master to let him take her back to Montgomery and keep her until she was cured. The slave's owner, rendered skeptical by experiences with several New Orleans doctors who had operated on the woman with no success, was not receptive to this idea; so Sims, determined that no wretched victim of a ruptured bladder should go unrelieved when her salvation lay in his power, bought the Negro himself and took her home with him. It was true that he could ill afford such a magnanimous gesture at the moment, having nearly exhausted his savings in his health-seeking travels, but with the new hope he had gained at Cooper's Well, plus the demijohns of water from there which he carried with him as insurance, he felt that soon he would again be on the road to happiness and fortune.

Back in Montgomery his friends' obvious amazement at his improvement in health and appearance made him realize how completely they must have abandoned hope for his recovery. Eager to show them (and himself) that he was as good as ever, he plunged at once into a surgical practice which certainly had not lessened perceptibly because of his long absence. His young protégé Bozeman had been able to care for some of his cases, but many patients---despite Bozeman's confidence that his training under the great Dr. Gross had made him a better surgeon than Sims---had preferred to postpone their operations on the off-chance that Sims, instead of dying, might return.

It was heartening to find that absence had not dimmed people's awareness of his skill. He was still much in demand for general surgical operations, to be sure; but more and more, it seemed, he was beginning to be considered the particular court of last resort for ailments peculiar to women---all as a result of his speculum's revelations and the apparent wizardry of his vesicovaginal-fistula operations. By now he had quite forgotten his former distaste for this particular field of activity, but still he was acutely aware that he had a great deal yet to learn about gynecology to make up for many years of neglect. Soon, however, he came to the realization that no one else knew very much more on the subject than he did himself, and his own examinations and operations became his principal classroom.

Letter from the Duchess of Hamilton notifying Sims of his first appointment with Emperor Napoleon III, May 1863 (Courtesy of the Southern Historical Collection.)

Announcement of the granting of Sims's French medical diploma, 1863. (Courtesy of the Southern Historical Collection.)

About vesicovaginal fistula he kept learning more all the time. One of the things he found out was that usually it was far harder to operate on white women than on the Negroes who had been the loyal and uncomplaining subjects of his countless experiments. Despite the successful ether experiments of Long and Morton, and despite the wide publicity which had followed Simpson's development and use of chloroform in England, the medical profession in general had not adopted anesthesia as yet, and Sims's operations around 1850 still were being conducted without it. A number of white women suffering from vesicovaginal fistula were brought to him as soon as his success in curing the slaves became generally known, but they seemed unable to bear the operation's pain and discomfort with the stoicism shown by the Negroes. Sims's notes on operations during this period are studded with such remarks as: "The pain was so terrific that Mrs. H. could not stand it and I was foiled completely," or "The patient insisted that it was impossible for her to bear the operation," or "Patient, assistant, and surgeon were all worn out."

In spite of these morale-shattering experiences, each new operation that he performed added that much more to the body of precedent he needed in order to build up a dependable code of technique---rules as to how soon after the operation the sutures should be removed, how long the catheter should be used, how many days the patient should remain in bed, and the like. With these definitive findings added to his previous store of experience he now possessed adequate material to permit him to write a report to the medical profession on his achievements in the repair of vesicovaginal fistula. This was an essential thing for him to do, he realized, if knowledge of his work was ever to extend beyond his home district. But still the report was not written, for its preparation would have consumed many precious hours, and by now Sims was fully aware that he was fighting against time. The improvement in his health at Cooper's Well had been but temporary; he feared that almost any day he might collapse again, and before that collapse came there were many things he wanted to do.

For one thing, he wanted to find out more about the applicability of his precious silver sutures to all kinds of surgical operations. He employed them at every possible opportunity: for amputation of the leg, for surgery of the nose, for cancer operations on lips and jaw, and even for repairing abdominal wounds (abdominal surgery was rare in those days). With each new experiment he became more and more enthusiastic over the way the metallic ligatures seemed to be free from the suppurative aftereffects which so often had followed his use of ligatures of silk. At the same time he was not blind to the fact that the silver wire had certain disadvantages, chief of which was that, unlike silk, it could not be tied, but had to be held in place by twisting or clamping. So far he had not been able to develop any completely satisfactory method of clamping, but he hoped in time to make some improvements in this aspect of his technique. (What he did not know was that his now-and-then assistant, young Dr. Bozeman, had a similar ambition, and that this seemingly minor question of how to fasten a piece of wire was eventually to be the provocation for a bitter quarrel lasting a lifetime.)

Another matter which excited Sims even more than the virtues of silver sutures was his dawning interest in the problem of sterility. The impression had begun to get around that he was capable of alleviating all kinds of hitherto incurable feminine ailments; consequently women now were appealing to him to relieve them of a wide category of disabilities. Himself many times a father, and a doting one, he was heartsore to find how many of these appeals centered around one stark lament: these women desperately wanted children, but they were childless. Upon examining them he found that in many instances the uterus was not in its proper position. In several cases where he was able to correct this malposition he was delighted to learn a few months later that a child was expected. Such remarkable results as this from his first attempts at uterine manipulation opened dazzling possibilities for the future. All he asked now was that his health would permit him to continue his experiments.

Even with his deep absorption in this challenging new field Sims at this period managed to find some time for other concerns. Preeminently a family man, he was happiest when surrounded by his flock of lively children, with his ever-beloved Theresa near at hand. His was the kind of genius that tends to flower not in cloistered solitude, but amid sociability and distractions. Unless he actually was prostrated by illness he always took an active part not only in his family circle but also in the doings of the medical society and of the community. That very winter of 1850, for example, when he was overwhelmed with more medical and surgical cases than he could handle and was haunted by the imminent prospect of another battle with illness, he gave as much of his time as he could spare to supporting a New England woman, the famous Dorothea Dix, in her campaign to persuade the Alabama legislature ("our poor picayune legislature," he called it in a letter to a friend) to ameliorate the sad condition of the mentally ill by endowing a state asylum for the insane. His concern for the success of Dorothea Dix's crusade was a natural outgrowth of his own work, for many a time in his medical practice he had observed how narrow was the border line between mental and physical illness.(4)

All such interests as this had to go by the board, however, when illness struck again, as he had feared it would. After his brief interlude of tenuous health the diarrhea returned far worse than ever before. This time Cooper's Well, though revisited, failed to renew its magic, and there seemed to be no choice but to flee again to the North. For a man still under forty and with so much work crying out to be done it all seemed like a tragic waste of time; but this particular year the time was not entirely wasted, for during his exile divers conversations he held in Philadelphia and certain observations he made in New York were largely responsible for altering sharply the entire pattern of his future.

The Southerner who went to New York or Philadelphia in the early 1850's found conditions far less hospitable than those which had prevailed in the 1830's when Sims first ventured North to medical school. Physically, to be sure, the journey was a much easier one, requiring only four or five days from Montgomery to New York, for now there were railroad facilities of a sort most of the way, although boats or horse-drawn stages still were necessary for covering occasional gaps which the rail lines had not yet bridged. In the social and political atmosphere, however, there was a sharp change.

Northerners were feeling far from reconciled to Congress' recent passage of the Compromise of 1850, with its emphasis on a rigorous fugitive slave law. Nor were their tempers soothed by the tendency of many Southern statesmen, including Sims's own good friend, Congressman Henry W. Hilliard of Montgomery, to threaten secession from the Union and even war if their wishes concerning the extension of slavery were disregarded. No longer was it the fashion for Northerners to espouse the Southern viewpoint on slavery and to be captivated by the easy grace and charm of Southern visitors. Instead things were fast reaching a point where a newcomer's mere possession of a Southern accent was a signal for suspicion.

Yet in this atmosphere of incipient hostility Marion and Theresa Sims, Southerners to the core, managed always to find a kind reception as they came northward every summer in their flight from devastating illness. Partly this was due to the presence of a number of old acquaintances from Sims's days in medical school, partly it could be traced to a general human impulse to be compassionate toward victims of illness or adversity, but principally it was because of Sims's perennial talent for winning friends wherever he went. Even now, weak and irritable though he was from his protracted infirmity, he managed to retain something of the boyish openness of manner and enthusiasm of spirit which always characterized him; and these traits served to inspire the protective devotion even of those who were predisposed to distrust him because of his geographic affiliations.

Among the acquaintances whose good offices were enlisted thus spontaneously in his behalf in that summer of 1851 there happened to be two of Philadelphia's foremost men of medicine, Charles D. Meigs and Isaac Hays. Doctor Meigs, a dramatic lecturer and a prolific writer, was president of the Philadelphia College of Physicians and a member of the faculty of Sims's alma mater, Jefferson Medical College, where he was professor of obstetrics and the diseases of women---a field in which he was regarded by many as perhaps the nation's chief authority. When he met Sims he was bubbling over with enthusiasm at the recent achievement of one of his colleagues, Dr. Joseph Pancoast, professor of surgery and anatomy at Jefferson, in curing several cases of vesicovaginal fistula by an ingenious but extremely difficult operation involving fashioning the edges of the fistula into a plastic tongue-and-groove suture. Sims, though not lacking in appreciation of Pancoast's exceptional surgical skill, was convinced that his own method was far easier and more certain, and at some length he described to Dr. Meigs his technique and experience in the repair of fistulas.

Meigs might well have chosen to receive these accounts as the jealous boasting of a sick and disappointed man, but instead he became at once the Southerner's enthusiastic advocate. As the inventor of a number of ingenious devices to ease the lot of women suffering from uterine disabilities, he was impressed by the value of the new type of speculum Sims had produced and even more impressed by the effectiveness of the "Sims position" in facilitating examination and treatment of vaginal affections. Using his very considerable powers of persuasion, he impressed upon Sims the fact that it was his solemn duty to the medical profession to publish as soon as possible a full report of his work in the field of vesicovaginal fistula. More than this, however, he himself immediately rushed into print with praise of the wonders Sims had in store. As his platform for advertising the hitherto unknown Southern surgeon he chose, oddly enough, to use his report in The Medical Examiner on Dr. Pancoast's tongue-and-groove fistula cures. "I should commit an act of injustice," wrote Professor Meigs, after detailing Dr. Pancoast's methods, "if I should stop here without making an explanation due to a Surgeon who deserves, and indeed has, my highest respect. I speak of Dr. Sims, of Montgomery, Alabama, [whose] success . . . entitles him to the praise and gratitude of our whole profession." The ebullient Meigs then went on to describe in considerable detail the exceptional advantages of Sims's unique methods of approach, and he concluded with the earnest hope that Sims might "soon give his results to the profession. In the meantime, I trust I shall give no offence . . . if I take this early occasion to thank Dr. Sims for his information, and to acknowledge how much I am his debtor therefor."

To have a man of Meigs's established reputation and stature serve as his voluntary press agent was a boost that Sims, discouraged though he was by persistent invalidism, could not disregard. While he was still in Philadelphia he summoned up the energy to discuss the proposed article with Dr. Isaac Hays, one of the leaders in the new American Medical Association and the distinguished editor of the American Journal of the Medical Sciences, which already had published Sims's reports on harelip, osteosarcoma, and trismus nascentium. Fortified by Hays's cordial promise to publish his report as soon as it was written, Sims returned once more to Montgomery, hoping---as he always hoped---that this time he would be well enough to carry on his practice in peace.

Very soon, however, he was bedfast again and growing weaker so rapidly that he feared he never would be able to write the report. All around him friends and neighbors were dying from the same complaint that had laid him low; every day the bell tolled---not yet for him, but ever closer. Too feeble to handle a pencil himself, he called for his notes and dictated as best he could a discussion of vesicovaginal fistula, touching first on the work of his predecessors and then, in more detail, on his own experiences. He entered claim to originality for three features of his operative procedure: the unusual position employed, the suture apparatus, and the self-retaining catheter. He also expressed a belief (echoed by generations of gynecologists after him) that his speculum was an improvement over any previously devised, although he recognized that other speculums of various types had been in use for years.

When at last the task of dictating was finished he was so emaciated and exhausted that he felt sure that by the time the report was published he would not be alive to see it. Thanks largely to his wife's indefatigable efforts, however, he managed to pull through the winter, though by such a narrow margin that he knew he could not withstand a fresh attack. With the advent of spring, therefore, he made again the long and now familiar trip to New York, taking with him this time his entire family. By now, despite his prosperity of a few years before, his resources were severely strained by the demands of his long illness; Theresa had some money of her own, it was true, but whether it would be enough for them all to live on in the North was problematical. Yet if they stayed in Montgomery he could not live at all. It was a choice between the frying pan and the fire.

For a while New York seemed to have its usual beneficent effect upon his condition. What it was about New York that caused this improvement he could not be sure, but he believed that maybe it was the Croton water of which New Yorkers were so justly proud---the wonderful supply of pure water recently piped into the city through many miles of aqueducts leading from the new Croton Dam. More than once the thought occurred to him that perhaps the solution to his problems would be to live here all the time. Yet that seemed unthinkable; he and all his family were devoted to the South; Montgomery was home to them. In Montgomery, too, his reputation was made, while here he was a nobody. It was true that the recent publication of his vesicovaginal-fistula article in the American Journal of the Medical Sciences had aroused not a little interest (plus considerable incredulity) in medical circles, but he had seen enough of New York during his numerous visits to recognize the difficulties in the way of a middle-aged outsider without local academic or professional connections, no matter what his home-town record or claims to fame. Accordingly he said nothing to his family about his vagrant thoughts, trying instead to persuade himself that if only he could regain sufficient strength and stamina during his Northern sojourn he might be able to return to Montgomery completely cured.

Yet as he walked around the city and read the newspapers and talked with the people he met at his boardinghouse on Twenty-seventh Street he could not help reflecting that, for a surgeon considering specialization in the disabilities of women, New York would be an ideal location. So far, of course, he had not really specialized in gynecology, although recently he had begun to realize that only by giving all his time to this field could he hope to push back the barriers of mystery by which it still was obscured. In a town the size of Montgomery it hardly seemed likely that such specialization would be possible, but in New York, with its more than half a million people, the opportunities should be vastly greater. With all the thousands of immigrants who were pouring into the city from Europe every year, seeking the promised land and finding usually only hard labor at starvation wages, there were bound to be untold numbers of women who needed his services even more than did the slaves of the South. If only he were not so hounded by ill-health, so at a disadvantage here, so bound to Montgomery by a thousand and one ties of affection and obligation, he would be strongly tempted to try his fortunes in Manhattan.

All these castles in the air---signs of his returning strength---collapsed abruptly when in the early summer of 1852 he suffered a new and severe setback in health, brought on by a sunstroke. From then on his disease grew steadily worse, and not even the precious Croton water seemed capable of checking its ravaging course. Discouraged at the failure of New York's health-restoring qualities, on which he had built such hopes, he and his family moved on to Connecticut and then to Brooklyn, each time with no improvement. At last, feeling sure that his death was imminent and that the one provident thing he could do was to leave his widow and children in the place where he had more friends than anywhere else in the North, he returned again to Philadelphia.

There he and his wife decided that since the family funds were nearly gone and since the food to be obtained in hotels and boardinghouses was quite beyond his powers of digestion the best thing to do would be to rent a small house where Theresa herself might prepare the meals. After searching through the Spring Garden district at some length in a rented buggy, they found on Vine Street between Seventh and Eighth a little place to rent for twenty-five dollars a month. When its owner asked the prospective tenants how long they wished to occupy the house, Sims replied: "I want it as long as I live. I want to rent your house to die in." The landlord, contemplating Sims's appearance, obviously felt that on such a basis the lease would not be for long, but even so he agreed to let them have the place unfurnished. Within a few days the whole Sims family, equipped with a few rented chairs and beds and tables, was camping out in the bare and servantless little rooms on Vine Street, separated by a thousand miles and a thousand and one contrasts from their comfortable and well-staffed home in Montgomery.

As the weeks went by and his inability to retain nourishment continued Sims's condition grew steadily worse, and when at last he felt sure that he could not recover he sent for his friend and editor Dr. Isaac Hays, told him he was about to die, and asked him to look after his wife and children until relatives from Alabama could come to take them home. Dr. Hays, while not unwilling to provide post-mortem aid, suggested that maybe the need for it might be deferred or even entirely averted if Sims would take some cod-liver oil and cease being so despondent. Theresa hastened out to buy the cod-liver oil, but when she returned her husband, gazing with marked repugnance upon the bottle, asked her to place it unopened on the mantel, saying: "That gives me an idea. Cod-liver oil is a disagreeable thing to take; pickled pork is a good deal more palatable. Don't you remember how I ate pickled pork the first time we were at Cooper's Well, and how I gained, and how I got well from that very moment?"

Theresa, deciding that by humoring him she certainly could not make his condition any worse than it was already, proceeded without delay to provide a pickled pork diet as much as possible like that at Cooper's Well; and by some mysterious process of metabolism probably allied with psychology and with what now is called avitaminosis her patient's condition promptly began to improve. Within a week his diarrhea was under control, within a month he was able to walk around the neighborhood, within three months he was feeling so completely cured of his dread disease that he felt it would be quite safe (and certainly expedient financially) to return home to Alabama.

Just in time for Christmas of 1852 he and his family made their long-anticipated return to Montgomery, and before a week had passed it was obvious that once more they had made a mistake. Again there was collapse, again complete prostration and discouragement. Lying in bed one day, listening to the church bell ringing for another in a long succession of funerals, Sims began to count aloud the number of his friends- --many of them physicians in the prime of life---who had died within the past few years. "They all have died," he told his wife, "and now I must die too." Then, interrupting her as she tried for the thousandth time to cheer him, he went on: "But if I had the physical strength and the moral courage to do what I ought to do, I could get well."

Then it was that he told her for the first time of the half-formed dream which for a long time had been hovering in the back of his mind-his dream of selling out everything in Montgomery and moving the whole family to New York, where, with a permanent change of climate and water, he believed he might yet be cured. "But," he concluded, "of course that is impossible."

"No," responded Theresa instantly, "I don't think it is impossible."

From that moment on, despite the sick man's querulous protests that he was not fit to undertake such a move, that he could not stand the responsibility of preparation, and that probably he would die on the way to New York and leave her and the children stranded among strangers, Theresa took complete charge, employing the same quiet competence that she had used for the last sixteen years in running smoothly a complicated and frequently peripatetic household. The details involved in uprooting a large family and a whole way of life were, of course, manifold. The principal concerns were two: selling their financial assets---Sims's medical practice, his share in his brother-in-law's drugstore, and their home on North Lawrence Street-and (hardest of all) disposing of their Negroes.

The sale of the medical and surgical practice brought into the picture again young Dr. Nathan Bozeman, who was destined to play an important and not too happy part in Sims's later life. Bozeman was a skilled surgeon; he had helped Sims in a number of his operations, had cared for many of Sims's patients during the latter's repeated illnesses, and had revealed a capacity to carry on his mentor's specialized work in the field of gynecology. Too, he had been married recently and was in need of a home suited to his new station. Under all these circumstances he seemed like the ideal candidate to take over both the house and the practice. Arrangements were made for him to enter into a professional partnership with Sims, the only financial condition being that in return for the prestige thus acquired he should purchase Sims's house and land, over a period of years, for ten thousand dollars.(5)

The drugstore was prospering, and Rush Jones and W. O. Baldwin, both eager to help their unfortunate partner in his time of adversity, readily agreed to buy Sims's share for half again what he had paid for it, thus giving him, together with the money he hoped to receive from the sale of his house, a moderate nest egg for his New York venture.

Disposing of the Negroes, however, was not so easy, for they did not wish to be disposed of. Though the Simses, having no planting interests, had fewer slaves than many of their friends, their way of life was easygoing and lavish, and in the course of the years they had accumulated a dozen Negroes as household help and body servants. All of these they now called together, telling them that they would have to choose new masters; but the slaves, refusing to believe that the Sims family would not soon return from its exile in the North, begged that instead of being sold they be placed under the supervision of an agent who would hire out their services, sending part of their wages regularly to their masters in New York. To Dr. and Mrs. Sims this seemed like a satisfactory solution for the time being, postponing for at least a little while the dread moment when they would have to break their last remaining ties to Montgomery.

Some of the ties, of course, were never to be broken---the links to close relatives and devoted friends and to a way of living long beloved. Yet when it was a matter of dying in Montgomery or of trying to build a new life somewhere else there could be no turning back. Whatever the slaves might hope about the possibility of their masters' return, Marion and Theresa Sims themselves knew, when they stripped bare their pleasant home and set out for New York in that May of 1853, that this time it was final. From now on they might still be Southerners, perhaps, but only in the anomalous guise of Southerners transplanted.