Dr J Marion Sims (1813–1883) was one of the most prominent physicians of the mid-19th century, especially noted for his development of the first consistently (but not universally) successful operation for the closure of obstetric vesico-vaginal fistula. He developed his surgical technique through a series of operations conducted on enslaved African-American women with this condition during the 1840s.
By today's societal standards, many regard what Sims did as a medical ‘atrocity’. In an article published in the British Journal of Midwifery, volume 27, issue 10, entitled ‘The forgotten women of gynaecology’, Heidi Downes (2019) argued that the contributions to medicine made by the fistula patients of Dr J Marion Sims (1813–1883) should be more widely recognised.
Downes' article offers an opportunity to consider the difficulties of rendering judgment on the clinical practice of past times and different places. If we judge the past on the basis of present assumptions rather than attempt to understand how those who lived in the past saw, experienced and interpreted their circumstances, it is easy to become angry. Although retrospective indignation may be emotionally satisfying, it rarely illuminates what the past meant for those who actually lived it.
Sims himself agreed with the call to recognise the contributions that his fistula patients made to the advancement of surgical practice. He succeeded in developing his technique for closing vesico-vaginal fistulas by operating on a handful of enslaved African-American women with this condition between 1846–1849. His operations were ‘experiments’ in the sense that there was no recognised technique for fistula closure at that time; however, these operations were all carried out with the direct therapeutic intent of benefitting these women.
In his 1857 address to the New York Academy of Medicine in which he discussed his operations for fistula repair, Sims said:
‘To the indomitable courage of these long-suffering women, more than to any one other single circumstance, is the world indebted for the results of these persevering efforts. Had they faltered, then would women have continued to suffer from the dreadful injuries produced by parturition, and then should the broad domain of surgery not have known one of the most useful improvements that shall forever hereafter grace its annals’.
The historical context in which Sims' first fistula operations took place is far more complex than Downes acknowledges. To begin with, Downes' understanding of the pathophysiology of these injuries is inaccurate. Obstetric fistulas are not ‘tears’; rather, they are crush injuries resulting from compression of the vesico-vaginal tissues between the fetal head and the pelvic bones during prolonged obstructed labour. As the blood supply to these tissues is cut off, necrosis occurs, tissue is lost and a vesico-vaginal fistula forms (Wall, 2006). This ischemic injury produces a heavily scarred defect that is far more difficult to repair than any laceration. The horrible tragedy was that women were trapped in obstructed labour for three or four days without relief – and usually without emptying their bladders – only to deliver a dead child and to face thereafter a future of total urinary (and sometimes, faecal) incontinence, hygienic misery and social rejection.
What was the treatment of obstetric fistula prior to Sims' surgical operations? The options were permanent exclusion from social life (which usually involved sitting all day on a chair or stool with a hole cut in its bottom to allow the egress of urine), attempting to close the fistula using intravaginal cautery with a red-hot iron (this requiring multiple cauterisations over several months), or attempting a surgical operation to close the defect using silk or linen sutures (which almost always failed). No wonder obstetric vesico-vaginal fistulae were called ‘the opprobrium of surgery’ before Sims succeeded in repairing them using fine silver wire as suture material. These advances transformed reconstructive pelvic surgery, along with the lives of countless suffering women around the world.
We are not used to thinking about the social and ethical problems involved in providing patient care in a slave-holding society. How do you provide ethical medical treatment to an enslaved woman? Sims was not responsible for the slave-holding system and his actions were constrained by living in a society that accepted slavery as legitimate. Things are different today; but from a legal point of view then, Sims had no choice but to get permission from the slave owners to perform any operation; however, he also had to enlist the cooperation of the women themselves, without which he could not have been successful. This he did.
In a paper published in the New York Medical Gazette in 1854, Sims wrote of these first patients:
‘…I was fortunate in having three young healthy coloured 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—their owners agreeing to let me keep them (at my own expense) till I was thoroughly convinced whether the affection could be cured or not’.
These women became part of the sisterhood of shared suffering so common among fistula patients even today (Wall, 2002). Not only did they care for one another's injuries, they helped Sims operate on each other and provided mutual emotional and psychological support as they jointly made their way slowly towards their shared goal of surgical cure (Doss, 2017). These surgical operations were actually a ‘team effort’ between Sims and his patients.
No wonder that the noted African-American medical educator, physician, anthropologist and anatomist W Montague Cobb would write of these events:
‘To refer to Anarcha, and the five other vesico-vaginal patients whom Sims treated with her, as human guinea pigs, would be grossly unfair, as Sims continued to treat and provide for these girls at his own expense for three years in the little hospital in his yard, against enormous pressures from his family, the profession and the public. Because their condition made these patients social outcasts obnoxious even to themselves, Sims' unswerving persistence must be regarded as one of the great humanitarian as well as scientific landmarks of American Surgery’.
It is true that Sims' operations were carried out without anesthesia but when Sims began his attempts to repair these injuries in January 1846, anaesthesia had not yet even been discovered. It was not until October 1846 that the anaesthetic effects of sulfuric ether were first demonstrated in Boston. Even thereafter, there was widespread debate about when, how or even if anesthesia was merited in surgical operations. It took several decades before ether and chloroform were regarded as routine adjuncts to surgical care (Wall, 2018a) and fistula operations were then generally regarded as minor operations compared to amputations or other major surgeries.
‘These surgical operations were actually a “team effort” between Sims and his patients’
Because the vesico-vaginal septum is relatively insensitive to pain compared to the external genitalia, many surgeons felt it was completely acceptable to perform fistula repair operations without anaesthesia. Indeed, James Young Simpson, professor of midwifery at the University of Edinburgh and the discoverer and advocate of chloroform anesthesia in childbirth, would say in his public lecture on vesico-vaginal fistula in 1859 – over 12 years after the introduction of ether and chloroform – that three or four surgical assistants were required to carry out a fistula repair operation. Most of the time, three would do, but if needed, ‘the fourth attends to the exhibition of chloroform, provided the patient is placed under its influence. The mere amount of pain endured by the patient is perhaps less than in most surgical operations, as the walls of the vesico-vaginal septum are far less sensitive than you would a priori imagine' (Simpson, 1859). This would not be acceptable practice today but we must judge Sims by the medical standards of 1846, not 2021. We have learned a lot about anaesthesiology in the last 175 years that was not obvious when anaesthesia was first discovered.
Much has been made of the fact that these women endured multiple operations before their fistulas were closed. This was, in fact, the sad but expected course of fistula surgery in the 19th century, before Sims' breakthrough innovations. In 1829, for example, London surgeon Henry Earle wrote of vesico-vaginal fistula repair:
‘It must be confessed that, under the most favourable circumstances, these cases present the greatest obstacles and are certainly the most difficult that occur in surgery. I do not mention this to discourage you from making attempts to relieve patients suffering under this great calamity; on the contrary, I would strongly urge you not to abandon them and not to be deterred by many failures. I have succeeded in perfectly restoring three such cases; in one of which I performed upwards of thirty operations before success crowned my efforts’.
Women with fistulas sought out such care and endured repetitive surgeries because the constant, unremitting urine loss that resulted from living with an unrepaired fistula was unbearably miserable.
As a consequence, there is a strong case to be made that Sims' operations on Betsy, Lucy, Anarcha and the other fistula sufferers were legal according to the statutes of the time, were done expressly for the therapeutic purpose of repairing their injuries, were performed in accordance with existing ethical expectations of the time, and were accomplished with the patients' knowledge, cooperation, assistance and assent (Wall, 2018a). The way these operations were done then would not pass ethical scrutiny today but then again, much of our own current clinical practice will probably be looked upon with ethical distaste by midwives and obstetricians 175 years from now. We cannot know now what standards will be acceptable then any more than Sims could have been expected to explain 21st century standards of practice 175 years before they came about.
As a general rule, ethical practice means doing the right thing, all things considered. This view requires a deep understanding of the context within which decisions are made. Without understanding the context in which Sims and his patients lived, it is not possible to determine what would have been the best/right course of action under the circumstances. Rather than condemn Sims for what he did on the basis of our own retrospective indignation, consider how the following questions might be answered. Honestly, contemplating these questions will help us consider how ethical decisions are made under other difficult circumstances.
If you lived in a society where slavery was legal and was an accepted social institution, how would you provide medical care to an enslaved woman? This question is not an attempt to justify slavery; rather, it is an exercise in considering how ethical decisions may be complicated by difficult surrounding circumstances over which the participants have no control.
Depending on the answer, what would have been the potential consequences of that choice for you, for your patients, for your professional standing in the community and for your family? Should Sims have simply ignored these women's suffering and turned them away as incurable? Should he have tried to repair their injuries surgically? To suggest (as some might) that Sims should have become an abolitionist before providing any care to these women is certainly to underestimate the consequences of such a decision for someone in his position in 1846.
If a woman has a condition such as vesico-vaginal fistula that is causing her great suffering and for which there are no accepted treatments that work, is it permissible to try innovative therapies aimed at curing the patient? How would you have carried out such a programme of therapeutic innovation with enslaved patients in Alabama in 1846?
At the time of their discovery, ether (and later) chloroform were untried anaesthetic agents, whose risks were largely unknown. What ethical questions might arise in starting to use such agents in practice? What were the risks of using such untried agents in 1846? Are there special considerations in the use of pharmacological agents that render patients unconscious and powerless to resist? Would there have been special considerations in the case of enslaved women?
By all means, let us celebrate the perseverance and contributions that these birth-injured women – who lived in very difficult times and very different circumstances – made to the advance of medical care. Let us also not forget that there are hundreds of thousands of similar women living with fistulas today in the resource-poor countries in Africa and Asia (Wall, 2006). While we cannot change the past, we can remedy present suffering. We must strive to eliminate the ancient malady of obstetric fistula from the childbearing experience of women everywhere, just as it has long since vanished from the affluent countries of Europe and North America (Wall, 2018b). That was what Sims and his first patients were striving for. The battle is not yet over.