There are three statues of Dr. James Marion Sims on public display in the United States. Dr. Sims is known to some as the father of modern American gynecology for reportedly developing the first successful and reproducible surgical technique for vesicovaginal fistulas and for opening the first public hospital for women dedicated to repairing inuries from pregnancy and childbirth. Sims achieved his reputation because of experimentation on enslaved women and the whole sordid history of Sims has tragically been rewritten. This is what I know about Sims from reading multiple journals and textbooks from the 1800s (both before and after Sims infamy), his autobiography and the autobiography of Dr. Emmet, as well as the work of modern historians and ethicists and if you are defending anything to do with Sims you should know it as well.

Vaginal fistulas are connections between the bladder and the vagina or the rectum and vagina and the most common cause in Sims’ day was a long, obstructed labor with days of a fetal head sitting low inside the vagina reducing blood flow until the tissues died and sloughed off leaving gaping holes resulting in constant drainage of urine and/or feces through the vagina. The skin on the vulva and around the anus develops an intense irritant reaction from the constant bath of urine and/or feces and the odor, even with modern sanitation and absorbent garments, can be unbearable. In Sims’ era fistulas were more common among the poor, the result of nutritional deficiencies and lack of access to health care. Women who were enslaved were at highest risk as many had contracted pelvises due to rickets and more likely to have obstructed labors.

Dr. James Marion Sims, by his own admission, was a below average medical student who didn’t really want to be a doctor it was simply a way to make a living. At one point, long before his infamy, he thought of leaving medicine to go into a merchant clothing business. “What is the use of my struggling here always, for two thousand or three thousand dollars a year…” he wrote. In his autobiography he writes of actively seeking wealthy clients and Jews as they could pay. He also writes of disbelieving a nurse that a young baby was ill. When the baby died he claimed he was more upset than the parents because the bad outcome could end his practice. It’s not a crime to want to make money but it is sickening to read about it page after page from the man who is supposed to be the father of gynecology.

Sims did not start out with any desire to operate on women but as chance would have it in short succession he was referred three women who were enslaved for repair of fistulas. He turned down all three because at that time and with his knowledge base he believed fistula repair was hopeless. Almost immediately after seeing these three women Sims was called to help a white woman with severe pelvic pain. When he put her in a knee chest position to do an exam a sequence of events happened that allowed him to get a glimpse inside her vagina and Sims correctly deduced if he could see inside the vagina maybe he could actually see to operate and attempt to repair fistulas. He went home and used two spoons to facilitate an exam of Lucy, an enslaved woman who was still in his infirmary.

A typical scenario for a surgeon with a bold new idea would be to try his first surgery and then wait to see what happened. After reflecting on the success and/or failure and on the recovery and after discussing with like-minded colleagues perhaps another case would be found. This is the slow, meandering organic pathway of new surgical procedures and from reading the writings of many of Sims’ contemporaries what happened in the 1840‘s was not unlike what happens today. We surgeons tip toe into new procedures because unanticipated bad things can happen and we want to limit the carnage.

Sims chose another path. It is clear what he saw inside the vagina was not a fistula but cash. If there were three women in rapid succession with slave owners willing to pay there must be many more. Sims did not immediately operate on Lucy what he did was spend three months making surgical instruments and expanding the hospital in his backyard to accommodate twelve patients.

He was building a lab for human experimentation.

I cannot get that out of my mind and honestly that fact alone should be enough to remove Sims from any position of glory, but I also want the whole story to come out because that is the only thing I can offer to Lucy, Anarcha, and Betsey and the other eight enslaved women who suffered at Sims’ hands.

Lack of informed consent

Surgery was barbaric up to and including the 1840s. Many patients declined surgery because often the cure was a more certain death than the disease. In London the mortality rate from surgery in the first half of the 19th century was about 25%. Patients were held or strapped down for surgeries and there are numerous reports of the agony. We can simply not imagine. It is not surprising that surgical consent often involved badgering patients into procedures, a fact noted by Sims in his autobiography who detailed the steps he had to take to convince a white man to have surgery.

Sims did not obtain consent from Betsey, Anarcha and Lucy although he claims he told them he would treat them for free for six months, they’d be cured and that he would not “endanger their lives” (Sims was probably deluded enough to think he would master a fistula repair in six months and then make a fortune hence the hospital). Some who support Sims say this was informed consent of the day but of course it’s easy to promise outcomes for a surgery you’ve never performed on women who have no recourse for false claims and no ability to say no.

Some historians have also argued the enslaved women would have been suffering so much that they would have leapt at the chance for repair. Betsey, Lucy and Anarcha and eight other women have been rendered voiceless by history so we shall never know their thoughts. It is true as surgeons we see desperate patients with horrible conditions who say “I don’t care” when we detail complications but these patients are speaking about modern surgery with anesthesia and have the ability to make an autonomous decisions, they are not enslaved women who will be held down for a surgery that had never been tried before by this particular surgeon.

We have the words of one of Sims’ contemporaries, Dr. Cotting, on informed consent and fistula surgeries as recounted in 1844 when he saw a young woman who “resolutely refused to submit to any operation, in spite of earnest and repeated persuasion, and at length declined all further interference.” Despite the horrors of a fistula many women of Sims day who had the ability to decline surgery did so. To say that the enslaved women would have been willing participants is simply not supportable and is offensive.

Lack of anesthesia

Ether for anesthesia was first used publicly and successfully at the end of 1846 at Massachusetts General Hospital and Dr. Emmet, who trained under Sims, wrote ”anesthesia did not come into use, at least in the Woman’s Hospital except for special cases such as ovariaectomies, until about the close of our civil war.” Even in 1859 Dr. Simpson, the biggest advocate of chloroform for women during childbirth, felt fistula surgery wasn’t painful enough for anesthesia.

It is important in the hunt for truth to not use the ether argument against Sims as that is not what distinguishes Sims from his peers. What distinguishes him is his absence of empathy and absoluite lack of consideration of pain. Dr. Bozeman, who trained for a time with Sims in Alabama, wrote that he could only persuade a young enslaved woman with a fistula to have an exam with an anesthetic and there is mention in the writings of many of Sims’ contemporaries about the pain and suffering they were inflicting with fustula repairs.

In 1855 Dr. Emmet describes Sims removing an obstructed pessary from the vagina from an Irish immigrant, Mary Smith, and while Emmet remarks on Sims’ dexterity he also noted Sims was oblivious to Mary Smith’s “screams from intense suffering.” The passage is interesting because Emmet didn’t have to include that part and clearly Emmet was not oblivious. Many of Sims’ contemporaries had subtle and often not so subtle contempt for him in their wriitngs.

Sims was obviously oblivious to screams of pain. By his own account three women endured forty surgeries. Without anesthesia. They would have been held down, initially by the assistants who worked with him but as his assitants left the women would likely have been forced to hold each other down in a horrific Antebellum version of Saw.

Sims “success”

The enslaved African-American women lived in Sims’ infirmary not for six months but for four years. One women, Anarcha, endured thirty surgeries. In the end Sim’s declared success with the key methods being on hands and knees, a special clamp of his own design left inside as the tissues heal (like a binder clip), a special catheter to drain the bladder, the vaginal wall retractor or that he developed for visualization, and a silver (so non reactive) suture. He published his report in the American Journal of Medical Sciences in 1852 and achieved many accolades.

Sims was excellent at self promotion and so what has been forgotten by history about his report is that Sims was not the first to write about successfully closing a fistula. Dr. Hayward did in 1839, so several years before Sims even started. Many surgeons were tackling fistulas in different countries and it doesn’t appear from my research than any mentioned enslaved women. Knee chest or hands and knees position was known to those who read medical textbooks long before Sims first tried it. Other surgeons had invented catheters for this surgery. Many had developed retractors for the vaginal walls. Dr. Bozeman reported extensively (as did others) on the cumbersome and damaging nature of Sims’ clamps and so they were not used by other surgeons. Even silver sutures had been used for fistula surgery 15 years before Sims.

I doubt Sims knew about silver sutures as by his own admission he was not well read so whether he had access to the edition of the London Lancet that reported on silver sutures years before is not possible to know. What is possible to know is that every so-called “revolutionary” part of Sims technique was either not possible to reproduce by other surgeons (the clamps) or already known to other surgeons. Those who cling to defending Sims because he supposedly advanced health care for women have simply not done their research. We surgeons would have exactly what we have now if Sims had never set up his lab for human experimentation.

The Woman’s Hospital

Shortly after Sims “discovery” of how to repair fistulas he became ill again with dysentery, which put an end temporarily to his operating and he moved to New York for his health.

In his autobiography this move is dominated by his financial issues. He showed some local physicians how to do fistula repairs his way and then they started doing them without him. When he realized his “thunder had been stolen” he came upon the idea of a woman’s hospital so he could reap the financial rewards from his four years of human experimentation.

Sims had trouble getting other doctors on board and it is clear from his writings and from his contemporaries that he was not well liked. Eventually he recruited a board of women (a smart business decision) and secured the funding and the Woman’s Hospital opened May 1, 1855. It was a charity hospital and one of the by laws was that a woman had to be present for all surgeries. Sims was too ill to do much by his own accounts and so he hired another surgeon, Dr. Emmet who did the bulk of the operating and ran the hospital for 37 years. Dr. Emmet writes about Sims being at his own office seeing private patients in the morning and often not showing up for surgeries unless it was a special patient yet Sims gets much of the historical credit.

Sims was not a teacher and while Emmet says that Sims operated skillfully others did not. According to Emmet very few surgeons were able to receive much benefit from watching Sims operate because he was so fast and didn’t explain anything.

In 1861 Sims left the country for Europe supposedly for his health but Emmet wrote that Sims’ private New York practice was not thriving. “As a Southern man he had not been prudent in the expression of his beliefs and as a large proportion of his practice had always been from the South it naturally decreased, and ceased when the war began.” Whether he left because of health or finances is not known, but it is convenient that his health was bad enough to leave and yet it was restored so quickly by the climate that he was able to start operating rapidly. He promoted his method of fistula repair in England, Ireland, and France. He worked the medical scene enough to become the physician to the Duchess of Hamilton who lent him her château to live in for the summer. He established a reputation operating on royalty and on his return to the United States it was clear he hoped to use that infamy.

After his return Sims had a falling out with the board of directors of the Woman’s Hospital. The accounts vary, but it does seem that Sims pushed for unnecessary surgeries on women, was rarely there unless it benefited him, and wanted large amounts of observers for his surgeries. In one surgery he had 73 observers crammed into the theater. Whether he charged these visiting surgeons or if it was to raise his reputation or just pump up his ego I don’t know. The idea that he left the Woman’s Hospital because the board of directors were scared of cancer being contagious isn’t supported by the facts. The Woman’s Hospital was not suited to care for cancer patients as the wards were not built for the odor from the women with uterine cancer and Sims was too interested in having hoards of ego building units watching his every knife stroke.

The surgeons on the board of the Woman’s Hospital wrote at the time that he was “adverse to the rules and regulations.” He was furious and established another hospital for cancer and I can’t help thinking that he saw in cancer what he had seen earlier in fistulas, fame and fortune.

How Did Sims get known as the father of American Gynecology?

Sims was a master of self promotion and was at one point the president of the American Medical Association. In reading countless articles and textbooks from Sims’ day I am struck by the number of great, caring surgeons who worked to cure fistulas, who made important discoveries before Sims, and yet who we do not know. I don’t mean their erasure in any way equals the pain and suffering and erasure of the women who suffered under Sims rather I am simply stunned at how masterfully and terribly the history of fistulas and Sims have been completely rewritten. Shame on all of us in medicine.

Here are the facts:

Sims writings and actions embody the overconfident, arrogant, below average white man who gets ahead by simply being an overconfident, arrogant, below average white man. Nothing Sims left to modern OB/GYN is unique to him. Had Sims actually read a textbook or articles on fistulas, which is what one does when one wants to help women not build a laboratory, he would have known what to do for the first three enslaved women he saw with fistulas. Other surgeons of the day working to advance fistulas operated on women from all walks of life. Other surgeons of the day had empathy for the suffering of their patients. Sims’ writing and his behavior suggests his empathy was reserved for the wealthy. Sims initial success was based entirely on completely unethical medical experimentation on 11 enslaved women. He built a laboratory for this purpose. If that doesn’t shame someone over supporting Sims then I truly believe nothing can. Sims sought out famous patients in Europe, was a shameless self promoter, a poor teacher and abused his position at the Woman’s Hospital for fame and regularly flouted the rules at the hospital.

The body of Sims work and how he lived his life tells us that his medical experimentation on enslaved women was a purposeful exploitation of the most vulnerable of patients for profit.

We must take down his staues and rename anything associated with his name.

References:

Diseases of Females: Pregnancy and Childbed, Churchill, 1843 Lea and Blanchard

Vesico-Vaginal Fistula, Sims, 1953 Blanchard and Lea

Vesico-Vaginal Fistule, Bozeman, Montgomery, 1856

Cotting. Vesico-Vaginal fistula-spontaneous relief. “The American Operation.” The Boston Medical and Surgical Journal. July 1861, No. 23

Reply to James Marion Sims by his former colleagues, Pamphlet, Drs. Peaslee, Emmet and Thomas

Sims, MJ. The Story of My Life D. Appleton and Company

Wall LL. The medical ethics of Dr. J. Marion Sims. J Med Ethics. 2006 Jun; 32(6): 346–350.

Wood Library Museum of Anesthesiology accessed September 8, 2017 https://www.woodlibrarymuseum.org/history-of-anesthesia/

Emmet T. Incidents of my life. https://books.google.com/books?id=xg8TAAAAYAAJ&pg=PA475&dq=Dr.+Emmet&hl=en&sa=X&ved=0ahUKEwi4uc6pjZbWAhUP92MKHYIOABYQ6AEIUzAI#v=onepage&q=Sims&f=false

Vesico-vaginal fistula from parturition and other causes: with cases of recto-vaginal fistula, Emmet TL, January 1, 1868, W. Wood & Company

Washington, HA. Medical Apartheid: The dark history of medical experimentation on Black Americans from Colonial times to the present. Harlem Moon Broadway Books. New York.