Out of the shadows: the legacy of racism in obstetrics and gynaecology
BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4675 (Published 11 December 2020) Cite this as: BMJ 2020;371:m4675Linked Editorial
Judging history’s heroes and monsters
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Dear Editor:
Sebastian Kaupp-Roberts’s recent article on J. Marion Sims contained much inaccurate and misleading information. The author distorts the context in which Sims performed his early fistula operations.
Sims spent considerable time between early 1846 and the summer of 1849 attempting to repair the fistulas that enslaved women had sustained during prolonged obstructed labor. To refer to these operations as "barbaric" ignores both the history of fistula surgery as well as the early history of anaesthesia. It is ridiculous to assume that ether and chloroform anesthesia in 1846-1847 were as safe, effective, and well-understood then as the anaesthetic agents we have today.
Prior to Sims, surgery was one of the mainstays of treatment of vesico-vaginal fistula (along with repeated cauterizations with hot irons and other ineffective therapies). These operations generally failed. Sims's "experimental" surgeries were attempts to improve previously-existing surgical techniques and they were performed with direct therapeutic intent. There are many documented cases of fistula patients (whose lives were utterly dreadful) undergoing repeated attempts at cure. Case series were reported from Britain by Henry Earle and Isaac Baker Brown, by Johannes Dieffenbach in Germany, by George Hayward in the United States, and by Antoine Joseph Jobert de Lamballe in France, among others. Multiple attempts at obstetric fistula closure are still quite common today, even with more advanced surgical capabilities.
Sims began his attempts to cure these women in January, 1846. Sulfuric ether (not ethyl ether, as Kaupp-Roberts claims) was not demonstrated as an anesthetic agent until October, 1846. It seems unreasonable to fault Sims--who like all surgeons of his generation was trained in pre-anesthetic surgical traditions--for not discovering ether anesthesia himself before beginning to care for these women.
The author assumes that ether anesthesia immediately became the "standard of care." This is completely untrue. Anesthesia was adopted early on by many, but by no means all, surgeons. Anaesthesia was controversial for many years after 1846, and its use was actually opposed for decades by many surgeons after its discovery. American surgeons did not use anaesthetics during the Mexican War (1846-1848), and large numbers of British surgeons refused to use it during the Crimean War (1853-1856), alleging poor patient outcomes and a variety of complications attributed to anaesthesia. For many years there were great debates about the safety, propriety, and efficacy of ether and chloroform. These vigorous debates and serious discussions about the ethical use of such powerful drugs cannot be ignored without seriously distorting the historical record.
The author's statement that Sims "relied on assistants to restrain his screaming victims" is pure fiction. In fact, delicate intravaginal repair operations required the cooperation of patients if they were to be completed successfully. Sims declared that his enslaved patients consented to surgery, and they even became his surgical assistants, helping him operate on one another as he searched for a technique that would cure their injuries.
Vesico-vaginal fistula repair was regarded as a relatively minor operation in the 19th century (although we would not so regard it today) and it was an operation that was usually easily borne by patients who were desperate for cure. When Sims made his remarks to the New York Academy of Medicine in 1857, he was still not using anaesthetics for fistula repair. His statement that "I never resort to them [anaesthetics] in these operations because they are not painful enough to justify the trouble and risk attending their administration" is taken out of context by Kaupp-Roberts, who presents this as a statement regarding his enslaved patients in Alabama. In fact, Sims was referring to how he had been practicing on all patients for over 10 years, and his most immediate reference was to scores of operations at the Woman’s Hospital, where the patients were virtually all white women, often of genteel middle-class origins. Anaesthetic use for reconstructive vaginal surgery was not common at that institution until the time of the American Civil War, a fact that is verifiable from the case logs of the hospital. Anaesthetics were generally reserved only for "major" operations, such a laparotomy for ovarian tumors. Sims was not an outlier in this practice either.
Indeed, James C. Warren, who performed the first operation under ether anesthesia in Boston in 1846, remarked in 1850 that "it has been pretty well settled, by the opinion of surgeons, that it is unwise to resort to it [anaesthesia] in small operations, where the patient, by a moderate effort, can support the infliction [of surgical pain] [1]. George Hayward, the first American surgeon to report a successful case of vesico-vaginal fistula repair (without benefit of anaesthesia) in 1839 said that “Every thing connected with this case proved more favourable than I had anticipated. The operation was not difficult, nor very painful; it was followed by no bad consequences and afforded complete relief“ [2]. And, quite remarkably, Sir James Young Simpson, the British discoverer of chloroform and the most strident 19th century advocate of its use in obstetrical and gynaecological cases, declared in 1859 (10 years after Sims completed his original case series) that it was often not necessary to use anaesthetics at all in fistula repair operations, writing “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 that you would a priori imagine” [3].
Perhaps the most serious objection to Kaup-Roberts’s narrative is the way he downplays the seriousness of an obstetric fistula. Because these injuries are almost completely unknown in industrialized, high-income countries today, it is easy to dismiss them as mere historical curiosities. But some 2 million women in the poor countries of Africa and Asia are living with these frightful injuries today, with tens of thousands of new cases occurring each year. That most of these fistulas could now be repaired if adequate political will and surgical resources were devoted to this task, is largely due to the achievements of J. Marion Sims and his successors [4].
1. JC Warren, “Dr. Warren’s valedictory address,” Boston Med Surg J 1850;42:407-413.
2. G Hayward, “Case of vesico-vaginal fistula, successfully treated by an operation,” Am J Med Sci 1839;24:283-288.
3. JY Simpson, “Clinical lectures on diseases of women 2: Vesico-vaginal fistula,” Med Times Gazette 1859;18(n.s.):25-30.
67. 4. LL Wall, “Obstetric vesicovaginal fistula as an international public health
Problem,” Lancet 2006;368(9542):1201-1209.
Very truly yours,
L. Lewis Wall, MD, DPhil
Selina Okin Kim Conner Professor in Arts and Sciences
Professor of Anthropology
Professor of Obstetrics and Gynecoloy
Washington University in St. Louis
St. Louis, MO, USA
Competing interests: No competing interests
Dear Editor,
I thank the author for bringing to light the work of Sims and the famed Sims speculum developed literally on the backs of enslaved women. I doubt the name will change. Instead, we can do our part: when we are teaching those medical students to use a Sims we should recall the enslaved women who were brutalized and suffered cruelly for its development and instill in them the first and foremost duty as a doctor- first do no harm.
Competing interests: No competing interests
Re: Out of the shadows: the legacy of racism in obstetrics and gynaecology
Dear Editor
There is no doubt that by our standards Sims was racist. Interpreting that out of context is difficult. Aside from slaves, women, children and in UK society lower class men were all regarded as inferior to wealthy or noble men and subject to their paternalistic governance. In theory this was benign. In practice as many well understood it was not. In the context of his time Sims’ work was likely seen as beneficial probably both to mankind and to the individuals. The lack of anaesthesia does not stand out really as a lot of surgery was done without anaesthesia at that time and of necessity restraint was the norm. Scrutinising the careers of most doctors at that time would likely expose things which today we would not accept such as Jenner’s use of a child to test his vaccine.
As Sims was an American it is not really in the gift of the UK Royal College to rename his speculum although they could advise an alternative name.
In the last 20 years or so there has been a lot of retrospective examination of historical facts with an attempt to apply our current ethics to a variety of situations and behaviours. In reality this is of limited value and the best thing is to note the history, accept the facts and learn that we must do better from now on.
Competing interests: No competing interests