In this month's edition of the Southern Medical Journal, Jeffrey Sartin, MD, elucidates certain aspects of the practice and life of J. Marion Sims, the legendary founder of the specialty of gynecology. (1) This discussion is faithful in its depiction of many of the events in Sims' life and practice, although the overall tone of the article raises several moral and ethical questions. In the end, Sartin concludes that Sims may have used the downtrodden, indigent, and slaves of the day for his own personal gain, especially with regard to the condition of vesicovaginal fistula.

The condition of vesicovaginal fistula is arguably one of the most devastating complications of childbirth. In his article, Sartin questions the propriety of Sims having performed multiple surgical interventions on patients with this entity. The author also questions the fact that appropriate anesthetic considerations were not given to these patients. Although the points raised by Dr. Sartin are pertinent, they may slightly overestimate certain aspects of medical care in the mid-19th century.

Vesicovaginal fistula, even for modern medicine, can be a devastating problem. With the constant bathing of the vagina and perineum with urine, matters of hygiene are difficult if not impossible to control. Women with this condition have a miserable existence, often being ostracized by society and their families, and occasionally are relegated to a hermit's existence.

The most common cause of vesicovaginal fistula then, as now, was related to a prolonged second stage of labor, especially in women with poor or nonexistent prenatal care. It is also more common to see this injury in patients who are younger and in women who are malnourished. With improved obstetric care, vesicovaginal fistulae are now extremely uncommon in developed countries; however, the incidence of this devastating problem remains high in third-world countries.

In this article, Dr. Sartin criticizes Sims, and in his title even raises the specter of villainy. His criticism can be segregated into three zones: 1) Sims performed multiple procedures on his patients; 2) the patients were slaves; and 3) Sims did not use anesthesia for the procedures. Sartin contends that Sims breached our current standards of medical ethics in the areas of autonomy and benevolence.

Sims, in his own autobiography, written in the twilight of his life, freely admits to the facts as outlined by Sartin. However, before we ostracize this venerable gentleman of history, certain factors might be worthy of consideration.

It is clear from Sims' own writings and the writings of others that Sims really did care about his patients, notwith-standing the fact that they were slaves. In addition, it has been clearly documented that he discussed the options (which were few and all ineffectual) with his patients before he performed the procedures described. Sartin alleges in his work that these slaves belonged to Sims. That would not appear to be the case, especially as to the circumstance of his first patient. The story, as recounted by others, was that Sims was called to see this patient after she had been in labor for a protracted period of time. Within days after delivery, she developed the fistula. The slave owner and the overseer asked Sims to continue to care for the woman. Sims actually moved the woman to his own home and continued to minister to her until the fistula was surgically closed. It is true that this patient and others required numerous procedures, especially in the period before Sims' discovery that a sterling silver wire was a more effective suture material than the then-current standard materials of silk and catgut. Even today, surgical repair of this condition has a relatively high recurrence rate.

It was during this time that Sims discovered the knee-chest position for examining female patients and the extreme left lateral position with the right hip flexed, a position now commonly known as the Sims position. To facilitate exposure, he also developed a vaginal retractor that allowed better observation of the fistula. With this combination of maneuvers, he claimed that he was able to successfully close fistulas which, heretofore, had not been curable.

The question of anesthesia is also broached. Sensation in the upper vagina, especially in areas that have been rendered fibrotic from chronic infection, are substantially less sensate than, for example, the skin. Therefore, the manipulations of these fistulae would not have produced the same type of discomfort as an incision made through a fistula that exited through the dermis.

We should also consider that these patients were operated on between 1845 and 1850. Anesthesia was first demonstrated successfully at the Massachusetts General Hospital in Boston in the latter part of 1846 by Morten. He followed certain of the techniques previously demonstrated by the dentist Wells of Hartford, CT. Communications in 1846 were certainly not what they are now, and it is doubtful that Sims would or could have known of this monumental demonstration until substantially later. A Georgia surgeon, Crawford Long, had used anesthetic agents to render his patient insensate in 1843, but this was not reported until almost a decade later. It should not be assumed that anesthesia was a safe experience at the middle of the 19th century. Ether was the agent of choice and was administered by pouring the volatile substance onto a cloth covering the patient's nose and mouth. Positive-pressure ventilation, orotracheal tubes, and even monitoring were unknown at this time. Even as late as the 1950s, most anesthesiologists relied on palpation of the pulse in the temporal artery to determine the cardiovascular state of their patient. With patients in the knee-chest position or even in the Sims position, the administration of an anesthetic had to be a relatively risky procedure. The standard anesthetic agents used at the time Sims performed his procedures were opiates, and sometimes alcohol, that were administered in large quantities. Sims administered opiates to his patients not only preoperatively, but during the postoperative period.

Although Sims' outcomes will always be debated, it is clear that at least some of his patients were cured. Sims was the product of the medical education of his time. Schools were proprietary and success was measured by their financial viability, not the product of their educational endeavor. Research was unheard of in medical schools. Scientific reporting in the middle of the 19th century was considerably less sophisticated than the type of outcomes-research we are accustomed to seeing today. His results were questioned by a number of physicians of the era, but it is interesting to note that each of these physicians was engaged in a vitriolic confrontation with Sims on other fronts. Their criticisms of his outcomes may have been substantially colored by their general feelings toward this bombastic man. There is, however, no question that some of the fistulae were closed.

Sartin discusses two ethical principles that might have been violated by Sims. The first is the issue of beneficence, and the second is autonomy. With regard to beneficence, it would appear that Sims truly cared for and about his patients. He actually built a small hospital for these women on the grounds of his home and ministered to the needs of his patients at this site. Preoperative and convalescing patients constituted the staff of this makeshift clinic. If the agony produced by his procedures was of the magnitude suggested by Sartin, then it is unlikely that these women would have undergone the therapy after having seen it ministered to their confreres. It also should be noted that the condition of vesicovaginal fistula was so onerous that, at least in the patients' opinion, the risk to benefit ratio was acceptable.

These facts also speak to the concept of autonomy. The women in Sims' early experience were slaves, but it has been previously noted that Sims described to them the procedure, and although there was no documented informed consent, by virtue of the simple fact that all of these women had an opportunity to observe the procedures performed, it is highly likely that they at least had a reasonable understanding of the procedure. Such could also be said of the destitute immigrant Irish women who came under his care in New York City.

It is clear that the level of sophistication and understanding of the moral and ethical aspects of medicine were substantially less developed in the mid 19th century when compared with the current time. I would caution us not to hold our current state of knowledge in this area as an icon with which to compare all other decisions. It was but a short time ago (the early 1960s) that a radical mastectomy was considered the best and perhaps only treatment for breast cancer. This concept was adjusted to a modified radical mastectomy, and now the "gold standard" would be considered lumpectomy and sentinel node sampling of the axilla. It was also in the mid 1950s and 1960s that convulsive shock therapy was used in the treatment of severe depression. This was first done with an anesthetic but without paralyzing the patient. Subsequently, we have learned that many of these patients did not need this type of intervention and, if the intervention was to be given, deep paralysis was imperative to prevent injury to the patient. It was not that long ago that the Tuskegee experiment was performed long after slavery had been abolished in the United States. This experiment would certainly be considered unethical today. Historic treatments such as vena section, bleeding, purging, smoke enemas, and the application of boiling oil to the site of wounds or amputations boggles the mind. Even in our current medical environment, we apply a number of remedies with faint hope of cure and certain knowledge that our patients will experience at least temporary ill health from the treatment (eg, various oncologic drugs, radiotherapy).

One of the most egregious experiments performed occurred less than 50 years ago. It was in the late 1960s that a surgeon of international note opened the chest and, to revascularize the heart, used the inferior mammary artery. After the artery had been mobilized, he made a tunnel through the myocardium with a large clamp and then placed the bleeding artery into this cavity. Results were thought to be excellent. Another, even braver surgeon opened the chest in a similar manner, dissected out the internal mammary artery, and then left it in place along the chest wall. He reported results that were similar to the former surgeon. One wonders what our current community of medical ethicists would think about those studies today.

In summary, J. Marion Sims was an innovative member of the medical community more than 100 years ago. It is impossible for me to "get into his mind" about the use of slaves in developing an operative approach to cure their devastating condition. It is quite likely that the slaves who had a successful outcome (although numerous procedures were required) lived a better life because of it. I do not believe that the use of anesthesia is an indictment of Sims' disregard for human suffering. I believe that it is reasonable for us to assume that Sims did not know of this advance during his time in Mount Meigs and Montgomery, AL. He used the best anesthetic known at the time, and that is the standard to which he should be held. I believe that he applied the concepts of autonomy and beneficence to a reasonable standard that might be expected of a physician of that era.

It would appear clear to me that Sims' personality was, at times, cantankerous and, at other times, intolerable. I do not believe that the fact that he may have been a complete and unadulterated "jerk" requires us to assume that he was amoral or unethical.

Accepted October 21, 2003.

Copyright [c] 2004 by The Southern Medical Association

0038-4348/04/9705-0427

Please see "J. Marion Sims, the Father of Gynecology: Hero or Villain?" on page 500 of this issue.

Reference

1. Sartin, JS. J. Marion Sims, the father of gynecology: hero or villain? South Med J 2004;97:500-505.

J. Patrick O'Leary, MD

From the Department of Surgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Suite 714, New Orleans, LA 70112. Email: jpolea@lsuhsc.edu