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Try out PMC Labs and tell us what you think. Learn More. Vesicovaginal fistula was a catastrophic complication of childbirth among 19th century American women. The first consistently successful operation for this condition was developed by Dr J Marion Sims, an Alabama surgeon who carried out a series of experimental operations on black slave women between and Numerous modern authors have attacked Sims's medical ethics, arguing that he manipulated the institution of slavery to perform ethically unacceptable human experiments on powerless, unconsenting women.
This article reviews these allegations using primary historical source material and concludes that the charges that have been made against Sims are largely without merit. Sims's modern critics have discounted the enormous suffering experienced by fistula victims, have ignored the controversies that surrounded the introduction of anaesthesia into surgical practice in the middle of the 19th century, and have consistently misrepresented the historical record in their attacks on Sims. J Marion Sims — was arguably the most famous American surgeon of the 19th century and today he is generally acknowledged as the founder of modern surgical gynaecology.
His rise to prominence began with his development of the first consistently successful operation for the cure of vesicovaginal fistula, a catastrophic complication of childbirth in which a hole develops between a woman's bladder and her vagina and le to constant, unremitting, and uncontrollable urinary incontinence. Attempts to cure this condition had eluded many generations of surgeons who had tried to repair these devastating injuries time and again, but without ificant success.
Between late and the summer ofhe carried out repeated operations on these women in a dogged effort to repair their injuries. One young woman, a slave named Anarcha with a particularly difficult combination vesicovaginal and rectovaginal fistula, underwent 30 operations before Sims was able to close the holes in her bladder and rectum. In interpreting these historical events, some modern writers have denounced Sims with the kind of righteous indignation that is usually heard only from pulpits. Distilled to their essential points, Sims's modern critics make three major claims about Sims and his early operations for vesicovaginal fistula.
The second assertion is that Sims's failure to use ether anaesthesia during these operations was racist: that he did not use anaesthesia when performing fistula surgery on black women, but later, after he had developed his operation and moved to New York to found the Woman's Hospital there, he routinely used anaesthetics when operating on white women who, it is alleged, unlike blacks, were unable to stand the pain involved.
The inevitable conclusion seems to be that the accusations levied against Sims by modern authors are largely the result of the unquestioned presuppositions that these authors have made regarding the clinical problem Sims and his first patients faced; shoddy historical research, and an abysmal lack of understanding of the future life prospects faced by a woman who had a vesicovaginal fistula in What is a vesicovaginal fistula and how does it originate?
In the presence of absolute cephalopelvic disproportion, the contracting uterus tries to force the fetus through the birth canal but only succeeds in gradually wedging the fetus more and more tightly into the maternal pelvis until eventually it can no longer be moved at all.
At this point, the soft tissues of the woman's bladder, cervix, and vagina are trapped progressively more and more tightly between two immovable bony plates—the fetal skull and the mother's pelvic bones—and the blood supply to the entrapped tissues is shut off. In such cases the fetus almost invariably dies from asphyxiation, and if the mother lives through her ordeal and does not herself die from uterine rupture, sepsis, haemorrhage, or the sheer exhaustion of labouring in this fashion for days on end, a day or two later the fetus decays, macerates, and finally softens enough to slide out of its mother's vagina.
Some time thereafter, a slough of necrotic tissue comes away from the injured woman's vesicovaginal septum, and a fistula forms. To the agony of days of unrelieved labour and the sorrow of delivering a dead child is now added the physical and social calamity of complete loss of urinary and often faecal control. The injuries that women receive from prolonged obstructed labour are not limited to vesicovaginal and rectovaginal fistulas.
The cumulative devastation wrought by this process can be appalling. In alleging that it is unethical for slaves to participate in any form of medical experimentation, Ojanuga and other writers seem to imply that it would never have been appropriate for slaves to undergo innovative surgical operations, no matter what their problems might have been. In the former case, participants can have no reasonable expectation of obtaining direct personal benefit from whatever is done, but in the case of therapeutic experimentation research participants may gain direct—and sometimes substantial—medical relief as a result of their participation in a clinical trial.
At the time Sims began his attempts to repair the fistulas afflicting his African American slave patients, there was no effective therapy for a vesicovaginal fistula. Many surgeons in different countries had made repeated but unsuccessful attempts to close vesicovaginal fistulas and put an end to the tormenting loss of urine that these suffering women experienced. With rare exceptions, all such attempts failed. The French surgeon Ladies seeking sex Marion Alabama Velpeau, writing inmaintained that the medical community had not accepted a single reported case of successful cure of a vesicovaginal fistula without dispute.
Because Sims's patients had a condition that was generally acknowledged to be incurable, they had only two therapeutic choices: they could continue as they were, with whatever palliative treatment might be provided, or they could agree to undergo experimental surgical operations that might offer them some relief, perhaps even a total cure, for their condition. What would the first alternative have been like? The poor woman [with a vesicovaginal fistula] is now reduced to a condition of the most piteous description, compared with which, most of the other physical evils of life sink into utter inificance.
The urine passing into the vagina as soon as it is secreted, inflames and excoriates its mucous lining, covering it with calcareous depositions, and causing great suffering. It trickles constantly down her thighs, irritates the integument with its acrid qualities, keeps her clothing constantly soaked, and exhales without cessation its peculiar odour, insupportable to herself and those all around her. In cases where the sloughing has been extensive, and the loss of substance of the tissues great, and where neither palliative nor curable means have availed for the relief of the sufferer, she has been compelled to sit constantly on a chair, or stool, with a hole in the seat, through which the urine descends into a vessel beneath.
Given the choice between living the rest of their Ladies seeking sex Marion Alabama in this manner or of taking a chance—however remote—that Sims might be able to cure them, it is not surprising that these Ladies seeking sex Marion Alabama, even though they were enslaved, would have jumped at the opportunity to have surgery. That patients with a vesicovaginal fistula are desperate for a cure and will willingly submit to almost any therapy that is proposed to them is the universal experience of surgeons who have worked with this condition, both in the 19th century and today.
Sims gave numerous s of these early fistula operations during the course of his career, and, although they differ in some details, they all state quite plainly that he discussed what he proposed to do and obtained consent from the patients themselves before undertaking any operations.
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.
It is true that under Southern law, slaves were the property of others and Sims could not have legally operated on them without the consent on their owners; however, this cannot be taken as a priori proof that these slaves were unwilling patients.
As a matter of surgical practicality, considering the delicate and tedious requirements of performing surgery inside the vagina and the exceedingly difficult circumstances of exposure and inadequate lighting under which he was forced to operate, Sims could not have carried out these operations successfully without the cooperation of the women involved.
Even the slightest movement, much less the active resistance of these patients, would have rendered it impossible for him to have completed his operative procedures. Indeed, when his regular medical assistants tired of working with him, Sims trained the patients themselves to act as his surgical assistants and they thereafter helped him operate on one another in turn!
No wonder he owed these women a debt of gratitude for their persistence and their cooperation—a debt that he readily acknowledged publicly on numerous occasions. Why did Sims not use anaesthesia when carrying out these operations? Vanessa Northington Gamble—for example, maintains that, in contrast to the way he treated slaves, Sims only operated on white women using anaesthesia.
Sims grew up as a surgeon in the days before anaesthetics and was accustomed, as were all of his contemporaries, to the pitfalls and requirements of preanaesthetic surgery. Lucy was operated on without anaesthetics as Sims was unaware of the advances which had been made in this area of medicine.
Sims began his fistula operations on his enslaved patients in latebefore the anaesthetic properties of ether were known. Ether anaesthesia was not discovered and publicly demonstrated in Boston until October 16,nearly one year later. As historian Martin Pernick has written:. Our twentieth century sensibilities recoil at the thought that sane, responsible physicians could ever have opposed the use of anaesthetics. Today, the concept of operating on a fully sentient patient conjures up only hellish images of concentration camp doctors.
Neither sadists nor fools, these critics alleged a variety of rational drawbacks to the use of anaesthesia. Many 19th century surgeons felt that attempts at repairing vesicovaginal fistulas were neither serious nor painful enough operations to warrant the risks of general anaesthesia. Sir James Young Simpson, the discoverer of chloroform and probably the most vigorous advocate of the use of anaesthesia on women during the 19th century, was one of these people. However, none of them, due to the pain, were able to endure a single operation. For example, Sims published a detailed case study of a white woman who came to him with a fistula inwhich he was eventually able to repair after three operations, none of which involved the use of anaesthesia.
It is also worth pointing out that if Sims had used anaesthesia in operating on his first fistula patients before the safety and efficacy of ether and chloroform Ladies seeking sex Marion Alabama been sufficiently established for routine clinical use, this, too, would have constituted another therapeutic experiment on slaves. In her final assault against Sims, Durrenda Ojanuga maintains that ificant medical breakthroughs were achieved in the antebellum South without using slaves in therapeutic experiments. With her consent, McDowell removed a 22 pound benign ovarian tumour from Jane Todd Crawford, a white woman, on December 13,without anaesthesia, carrying out the operation on a kitchen table.
She recovered completely and survived to a ripe old age. He decided to try ether as an anaesthetic agent during surgical operations. In he successfully removed a small tumour from the neck Ladies seeking sex Marion Alabama James Venable, a white man, who had given his consent to the procedure. These examples are true as far as they go, but both s given by Ojanuga selectively omit major pieces of information that, once known, completely deflate the case she is attempting to make against Sims.
Although it is true that McDowell performed his first ovariotomy on Jane Todd Crawford, a white woman, Ojanuga neglects to inform her readers that McDowell performed this operation at least seven more times during his lifetime and that four of these patients were black slave women, one of who died from complications.
For example, Long wrote the following in his article on the anaesthetic use of ether in the Southern Medical and Surgical Journal of December, Surgical operations are not of frequent occurrence in a country practice, and especially in the practice of a young physician; yet I was fortunate enough to meet with two cases in which I could satisfactorily test the anaesthetic power of ether. From one of these patients I removed three tumours the same day: the inhalation of ether was used Ladies seeking sex Marion Alabama in the second operation, and was effectual in preventing pain, while the patient suffered severely from the extirpation of the other tumours.
In the other case, I amputated two fingers of a negro boy: the boy was etherized during one amputation, and not during the other; he suffered from one operation, and was insensible during the other. Both free whites and enslaved blacks were involved in all of these experimental surgical operations. McDowell's operations were clearly performed with therapeutic intent, although it is unclear to what extent some of these black patients consented to surgery. If one assumes that the amputations performed by Long were clinically indicated, then he was performing necessary surgery while conducting a rather brutal and Ladies seeking sex Marion Alabama unnecessary comparative trial of the effects of ether on surgical pain.
It is difficult to make fair assessments of the medical ethics of past practitioners from a distant vantage point in a society that has moved in a different direction, developed different values, and has wrestled—often unsuccessfully—with ethical issues of sex, race, gender, and class that were not perceived as problematic by those who lived during an earlier period of history.
J Marion Sims was a dedicated and conscientious physician who lived and worked in a slaveholding society. As such, he was often called upon to care for slaves with legitimate medical needs. Among the needs that many 19th century women faced—both white and black—was the need for treatment of catastrophic complications of childbirth such as vesicovaginal fistulas.
The operations carried out by Sims on black slave women from — represented his attempt to cure them of an odious and devastating condition that was then considered incurable. His operations, which at first were unsuccessful, were performed explicitly for therapeutic purposes and, as far as we can tell from the surviving sources, were carried out with the patients' cooperation and consent. At the time Sims began his efforts to close vesicovaginal fistulas, there was no effective alternative to surgical treatment and the quality of life to which such patients were reduced by their injuries was acknowledged by all medical writers of the time as unendurable.
To suggest, however, that for that reason alone no attempts should have been made to cure the maladies of such enslaved women, especially when they were desperate for help and no other viable alternatives existed, seems ethically bankrupt itself. Whatever his other failings may have been, J Marion Sims pursued this clinical goal with vigour, determination, and perseverance, and both his patients then and countless thousands of women since, benefited from his success.
National Center for Biotechnology InformationU. Journal List J Med Ethics v. J Med Ethics. L L Wall. Author information Article notes Copyright and information Disclaimer. This article has been cited by other articles in PMC. Abstract Vesicovaginal fistula was a catastrophic complication of childbirth among 19th century American women. Keywords: J Marion Sims, human experimentation, research ethics, surgical ethics, vesicovaginal fistula.
Writing in the New York Medical Gazette and Journal of Health in January, —for example, Sims declared: 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.
As historian Martin Pernick has written: Our twentieth century sensibilities recoil at the thought that sane, responsible physicians could ever have opposed the use of anaesthetics. For example, Long wrote the following in his article on the anaesthetic use of ether in the Southern Medical and Surgical Journal of December, Surgical operations are not of frequent occurrence in a country practice, and especially in the practice of a young physician; yet I was fortunate enough to meet with two cases in which I could satisfactorily test the anaesthetic power of ether. Conclusion It is difficult to make fair assessments of the medical ethics of past practitioners from a distant vantage point in a society that has moved in a different direction, developed different values, and has wrestled—often unsuccessfully—with ethical issues of sex, race, gender, and class that were not perceived as problematic by those who lived during an earlier period of history.
References 1. Sims J M. On the treatment of vesicovaginal fistula. Am Journal Med Sci 23 59— Harris S. Woman's surgeon: the life story of J Marion Sims. New Ladies seeking sex Marion Alabama Macmillan, New York: Harper and Row, Gamble V N. Under the shadow of Tuskegee: African Americans and health care. Am J Pub Health 87 — Axelson D E. Women as victims of medical experimentation: J Marion Sims's surgery on slave women, — Sage 22 10— McGgregor D K. From midwives to medicine: the birth of American gynecology. An American health dilemma: a medical history of African Americans and the problem of race, vol.
New York: Routledge, [ PubMed ]. Kapsalis T. Public privates: performing gynecology from both ends of the speculum. Ojanuga D. J Med Ethics 19 28— Butterfield H. The whig interpretation of history. New York: W W Norton, Emmet T A. The necessity of early delivery, as demonstrated by the analysis of one hundred and sixty one cases of vesicovaginal fistula.
Trans Am Gynecol Soc 3 — Obstet Gynecol Survey 60 suppl 1 1—55S. Wall L L.Ladies seeking sex Marion Alabama
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