Sims used enslaved African-American women as experimental subjects in the development of this important surgical breakthrough. This work has been regarded by many modern historians and ethicists as unethical. He has been described as "a prime example of progress in the medical profession made at the expense of a vulnerable population." But his contributions are also defended. Physician L. L. Wall emphasized that Sims conformed to accepted medical practices of the time, that he performed surgery for a therapeutic result, and that the women he operated on suffered what could be a catastrophic condition for their health and quality of life.
J. Marion Sims (called Marion) was born in Lancaster County, South Carolina, the son of John and Mahala (Mackey) Sims. For his first 12 years, Sims's family lived in Lancaster Village north of Hanging Rock Creek, where his father owned a store. Sims later wrote of his early school days there.
After his father was elected as sheriff of Lancaster County, he sent Sims in 1825 to the newly established Franklin Academy for white youths. In 1832, after two years of study at the South Carolina College, where he was a member of the Euphradian Society, Sims worked with Churchill Jones in Lancaster, South Carolina, and took a three-month course at the Medical College of Charleston. He moved to Philadelphia, Pennsylvania in 1834 and enrolled at the Jefferson Medical College, where he graduated in 1835. He returned to Lancaster to practice. After the deaths of his first two patients, he left and set up a practice in Mount Meigs, Alabama.
Sims returned to Lancaster in 1836 to marry Theresa Jones, whom he had met in his youth at Franklin Academy. In 1840 they moved to Montgomery, Alabama, where Sims took up surgery and gynecology.
In the 19th century, vesicovaginal fistulas was a common, socially destructive, and "catastrophic complication of childbirth," that affected many women and had no effective cure or treatment. Women generally had a high rate of childbirth, increasing their rate of complications. Vesicovaginal fistulas occur when the woman's bladder, cervix and vagina become trapped between the fetal skull and the woman's pelvis, cutting off blood flow and leading to tissue death. The necrotic tissue later sloughs off, leaving a hole. Following this injury, as urine forms, it leaks out of the vaginal opening, leading to a form of incontinence. Because a continuous stream of urine leaks from the vagina, it is difficult to care for, creating personal hygiene issues that may lead to marginalization from society for the woman, and vaginal irritation, scarring, and loss of vaginal function. Sims also worked to repair rectovaginal fistulas, a related condition in which flatulence and feces escape through a torn vagina, leading to fecal incontinence.
In the mid 19th century, gynecology was not a robustly developed field: social norms regarded the medical study and examination of female reproductive anatomy as immoral. In medical school, doctors were often trained on dummies to deliver babies. They did not see their first actual cases of women in need until beginning their practices. As a result, Sims had no formal background in gynecology prior to beginning his practice in Alabama.
When a woman came to him with an injured pelvis and retroverted uterus from a fall from a horse, he placed her in a knee-chest position and inserted his finger into the vagina; this triggered a full distention of the vagina with air, allowing Sims to see the vagina clearly. The distention inspired him to investigate fistula treatment. Soon after, he developed a precursor to the modern speculum, using a pewter spoon and strategically placed mirrors.
From 1845 to 1849, Sims started doing experiments on slave women to treat vaginal problems. He developed techniques that have been the basis of modern vaginal surgery. The Sims' vaginal speculum aided in vaginal examination and surgery. The rectal examination position, in which the patient is on the left side with the right knee flexed against the abdomen and the left knee slightly flexed, is also named for him.
In Montgomery, Alabama between 1845 and 1849, Sims experimented by surgery on 12 enslaved women with fistulas, who were brought to him by their masters. Sims took responsibility for their care on the condition that the masters provide clothing and pay taxes. He named three enslaved women in his records: Anarcha, Betsy, and Lucy. Each suffered from fistula, and all were subjected to his surgical experimentation. From 1845 to 1849 he experimented on each of them several times, operating on Anarcha 13 times before her fistula repair was declared a success. She had both vesicovaginal and rectovaginal fistulas, which he struggled to repair.
Although anesthesia had recently become available, Sims did not use any anesthetic during his procedures on Anarcha, Betsy, and Lucy. According to Sims, anesthesia was not yet fully accepted into surgical practice, and he was unaware of the use of diethyl ether. Ether as an anesthetic was available as early as the beginning of 1842.
A contemporary review of the ethics of Sims work in the Journal of Medical Ethics stated ether anesthesia was publicly demonstrated in Boston in 1846, a year after Sims began his experimentation. The article notes that, while ether's use as an anesthetic spread rapidly, it was not universally accepted at the time of Sims' experiments.
In addition, a common belief at the time was that black people did not feel as much pain as white people, and thus did not require anesthesia when undergoing surgery. One patient nearly died from septicemia. He had operated on her without anesthetics in the presence of twelve doctors, following the experimental use of a sponge to wipe urine from the bladder during the procedure. He did administer opium to the women after their surgery, which was accepted therapeutic practice of the day.
After the extensive experiments and complications, Sims finally perfected his technique. He repaired the fistula successfully in Anarcha. His technique using silver-wire sutures led to successful repair of a fistula, which Sims published in his surgical reports of 1852. He proceeded to repair fistulas in several other enslaved women under his medical authority. According to Durrenda Ojanuga from the University of Alabama, "Many white women came to Sims for treatment of vesicovaginal fistula after the successful operation on Anarcha. However, none of them, due to the pain, were able to endure a single operation." The Journal of Medical Ethics reports a case study of one white woman, whose fistula was repaired by Sims without the use of anesthesia, in a series of three operations carried out in 1849.
Sims later moved to New York to found a Women's Hospital, where he performed the operation on white women. According to Ojanuga, writing for the Journal of Medical Ethics, Sims used anesthesia when conducting fistula repair on white women. L. L. Wall, also writing for the Journal of Medical Ethics, states that as of 1857, Sims did not use anesthesia to perform fistula surgery on white woman, citing a public lecture where Sims spoke to the New York Academy of Medicine on November 18, 1857. During this lecture, Sims said that he never used anesthesia for fistula surgery “because they are not painful enough to justify the trouble and risk attending their administration”. While acknowledging this as shocking to modern sensibilities, Wall noted that Sims was expressing the contemporary sensibilities in the mid-1800s, particularly among surgeons who began their practice in the pre-anethestic era.
During his early medical years, Sims also became interested in "trismus nascentium", also known as Neonatal tetanus. It is a form of generalised tetanus that occurs in newborns. Infants who have not acquired passive immunity from the mother having been immunised are at risk for this disease. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with a non-sterile instrument. In the 21st century, neonatal tetanus mostly occurs in developing countries, particularly those with the least developed health infrastructure. It is rare in developed countries.
"Trismus nascentium" is now recognized to be the result of unsanitary practices and nutritional deficiencies. In the 19th century its cause was unknown, and many African slave children contracted this disease. It is now believed that the conditions of the slave quarters were the cause. While Sims alluded to the idea that sanitation and living conditions played a role in contraction, he believed that the disease could be attributed to the idea that enslaved Africans were intellectually and morally inferior.
"Whenever there are poverty, and filth, and laziness, or where the intellectual capacity is cramped, the moral and social feelings blunted, there it will be oftener found. Wealth, a cultivated intellect, a refined mind, an affectionate heart, are comparatively exempt from the ravages of this unmercifully fatal malady. But expose this class to the same physical causes, and they become equal sufferers with the first."
In addition to these beliefs, Sims thought trismus nascentium arose from skull bone movement during protracted births. To test this, Sims used a shoemaker's awl to pry the skull bones of enslaved women's babies into alignment. These experiments had a 100% fatality rate. Sims often performed autopsies on the corpses, which he kept for further research on the condition. He blamed these fatalities on "the sloth and ignorance of their mothers and the black midwives who attended them," as opposed to the extensive experimental surgeries that he conducted upon the babies.
Sims' experimental surgeries without anesthesia on enslaved African-American women who could not consent have been described since the late 20th century as an example of racism in the medical profession. This sheds a light on the historically violent oppression of blacks and vulnerable populations in the United States. Patients of Sims' fistula and trismus nascentium operations were not given available anesthetics. He caused the deaths of babies on whom he operated for the trismus nascentium condition.
In regards to Sims' discoveries, Durrenda Ojenunga wrote in 1993:
"His fame and fortune were a result of unethical experimentation with powerless Black women. Dr Sims, 'the father of gynaecology', was the first doctor to perfect a successful technique for the cure of vesico-vaginal fistula, yet despite his accolades, in his quest for fame and recognition, he manipulated the social institution of slavery to perform human experimentations, which by any standard is unacceptable."
Author Harriet Washington, in her 2007 book Medical Apartheid, writes of Sims' experiments: "Each naked, unanesthetized slave woman had to be forcibly restrained by other physicians through her shrieks of agony as Sims determinedly sliced, then sutured her genitalia." Facing South, a publication of The Institute for Southern Studies, wrote that enslaved women were forced to hold each other down during surgery.
Physician L.L. Wall, writing in the Journal of Medical Ethics, says fistula surgery on non-anesthetized patients would require cooperation from the patient, and would not be possible if there were any active resistance from the patient. Wall writes that surviving documentation from the time says the women were trained to assist in their own surgical procedures. Wall also argues the documentation suggests the women consented to the surgeries, as the women were motivated to have their fistulas repaired, due to the serious medical and social nature of vesicovaginal and rectovaginal fistulas.
In his autobiography, J. Marion Sims said he was indebted to the enslaved women. After multiple failed operations he was discouraged, and the enslaved women encouraged him to proceed, because they were determined to have their medical afflictions cured. Shortly after Sims' successful repair of Anarcha's vesicovaginal and rectovaginal fistulas in 1849, he successfully repaired the fistulas of the other enslaved women. They returned to their plantations.
Sims has been criticized for operating on the enslaved women without their consent. Wall writes in the Journal of Medical Ethics, that legally consent was granted by the slave's owners, while noting that enslaved persons were a "vulnerable population" with respect to medical experimentation. Wall also writes that Sims obtained consent from the enslaved women themselves.
He cites an 1855 passage from New York Medical Gazette and Journal of Health, where Sims wrote:
"For this purpose [therapeutic surgical experimentation] I was fortunate in having three young healthy colored girls given to me by their owners in Alabama, I agreeing to perform no operation without the full consent of the patients, and never to perform any that would, in my judgment, jeopard life, or produce greater mischief on the injured organs—the owners agreeing to let me keep them (at my own expense) till I was thoroughly convinced whether the affection could be cured or not."
Deirdre Cooper Owens wrote: "Sims has been painted as either a monstrous butcher or a benign figure who, despite his slaveowning status, wanted to cure all women from their distinctly gendered suffering." She describes these opposing views as overly reductionist, saying his history is more nuanced. He lived in a slave-holding society and expressed the racism and sexism that were considered normal during his time. She also credits him as "the father of gynecology". He contributed significantly to the field of gynecological surgery. Sims' suture technique developed in the 1800s for fistula surgery is still in use by modern-day physicians.
Sims moved to New York in 1853 because of his health and determined to focus on diseases of women. In 1855 he founded the Woman's Hospital, the first hospital for women in the United States. Here he performed operations on indigent women, often in a theatre so that medical students and other doctors could view it, as was considered fundamental to medical education at the time. Notably, the patients remained in the hospital "indefinitely" and underwent repeated procedures.
In 1861, during the American Civil War, Sims moved to Europe, where he worked on several fistula patients in London, Paris, Edinburgh, Dublin and Brussels. In 1863, he was summoned to treat Empress Eugénie for a fistula, solidifying his worldwide acclaim as a surgeon.
After Sims returned to the United States, he raised his charges in his private practice, effectively limiting it to wealthy women. He became known for the Battey surgery, which contributed to his "honorable reputation". This involved the removal of both ovaries, which became a popular "treatment" for insanity, epilepsy, hysteria, and other disorders of the nerves. At the time, these were believed to be caused by disorders of the female reproductive system.
Sims received honors and medals for his successful operations in many countries. Since the 20th century, the necessity of many of these surgeries has been questioned. He performed surgery for what were considered gynecological issues: such as clitoridectomies, believed to control hysteria or 'improper' behavior related to sexuality. These were done at the requests of the women's husbands or fathers, who were permitted under the law to commit the women to surgery involuntarily.
Under the patronage of Napoleon III, Sims organized the American-Anglo Ambulance Corps, which treated wounded soldiers from both sides at the Battle of Sedan.
In 1871, Sims returned to New York. After quarreling with the board of the Woman's Hospital over the admission of cancer patients (which he favored and which the board opposed because of the mistaken belief that cancer was contagious), he became instrumental in establishing America's first cancer institute, New York Cancer Hospital.
From 1876–77, Sims served as president of the American Medical Association
In 1880, Sims contracted a severe case of Typhoid fever. W.Gill Wylie, an early 20th-century biographer, said that although Sims suffered delirium, he was "constantly contriving instruments and conducting operations". After several months and a move to Charleston to aid his convalescence, Sims recovered in June 1881. He traveled to France. After his return to the United States in September 1881, he began to complain of an increase in heart problems. He had suffered two anginas in 1877.
According to Wylie, Sims consulted with doctors for his unknown cardiac condition both in the United States and in Europe, and was "positive that he had a serious disease of the heart and it caused deep mental depression." He was halfway through writing his autobiography and planning a return visit to Europe when he died of a heart attack on November 13, 1883 in Manhattan, New York City. He had just visited a patient with his son, H. Marion Sims. He is buried at Green-Wood Cemetery in Brooklyn, New York.A bronze statue by Ferdinand Freiherr von Miller (the younger), depicting Sims in surgical wear, was erected in Bryant Park in 1894. It has been moved twice and is now located on the peripheral wall at Fifth Avenue and 103rd Street, opposite the New York Academy of Medicine.
This statue became the center of protest August 19, 2017, due to his having operated on enslaved black women.Other memorials were installed on the grounds of his alma mater, Jefferson Medical College, and in both the South Carolina State Capitol in Columbia and Alabama's capitol in Montgomery.
The historical marker of his birthplace honors him for “his service to suffering women. Empress and slave alike."
Vaginal surgery: fistula repair.
Instrumentation: Sims' speculum; Sims' sigmoid catheter.
Exam and surgical positioning: Sims' position.
Fertility treatment: Insemination and postcoital test.
Cancer care: Sims argued for the admission of cancer patients to the Woman's Hospital, despite contemporary beliefs that the disease was contagious.
Abdominal surgery: Sims advocated a laparotomy to stop bleeding from bullet wounds to this area, repair the damage and drain the wound. His opinion was sought when President James Garfield was shot in an assassination attempt; Sims responded from Paris by telegram. Sims' recommendations later gained acceptance.
Gallbladder surgery: In 1878, Sims drained a distended gallbladder and removed its stones. He published the case believing it was the first of its kind; however, a similar case had already been reported in Indianapolis in 1867.