The Walsh terms of reference were defective. Crucially, they excluded survivor testimony, which would have nullified the report’s most fundamental findings, that symphysiotomy was done mainly as an emergency procedure and that it was ‘safer’ than Caesarean section.
Hospital reports bear out the fact that this operation was almost always planned and survivor testimony shows that it was more dangerous than CS. Over 150 key witnesses could have testified as to the surgery’s side effects, but they were not interviewed on the spurious ground that to do so would have compromised the report’s ‘independence’. The consequences of this high risk, experimental surgery included bowel and bladder injuries, organ prolapse, chronic pain and mental health issues as well as lifelong walking difficulties and incontinence.
The terms also excluded pubiotomy, an operation that incises the pubic bone.
Walsh mentions pubiotomy, but fails to address it. Hospital reports show that pubiotomy was performed in preference to Caesarean section as a procedure of choice, especially at the Rotunda. At the National Maternity Hospital, pubiotomy was described as ‘a complication’ of symphysiotomy: doctors who failed to locate the symphysis pubis cut the pubic bone instead. Survivor testimony shows that this operation was also performed in other hospitals. Even the most ardent champions of symphysiotomy, such as Dr Kenneth Bjorklund, reject pubiotomy on safety grounds.
The Walsh report got the years wrong:
hospital reports record the performance of symphysiotomy from 1942, the operation has been documented in the late 1980s and one done as late as 2005 was the subject of a successful High Court action last year.
The oft-repeated statement ‘search of records confirmed no symphysiotomies’ wrongly suggests that the non-existence of hospital records is indicative of the non-performance of the operation. All the absence of records shows is the absence of records.
Medical records bear out that the operation was performed at UCHG, while survivor testimony indicates that the surgery was performed in Port Laoise and Dundalk Hospitals. The assertion that ‘fewer than 5 symphysiotomies were performed at Airmount Hospital’ must also be open to question, given that this hospital was owned for four decades by the Medical Missionaries of Mary, the owners of the the International Missionary Training Hospital, Drogheda, where very high numbers of symphysiotomies were carried out.
Wrongly, Walsh states that symphysiotomy was ‘never proposed as an alternative to Caesarean section’. Dr Morrissey’s work shows that symphysiotomy was revived at NMH in the mid-1940s as a planned procedure, to replace Caesarean section in selected cases: hospital clinical reports and survivor testimony bear this out.
Caesarean section was the standard treatment for obstructed labour at that time, as Dr Peter Boylan, a leading member of the IOG, has confirmed. Walsh neglects to address the fact that symphysiotomy was a long discarded and discredited operation by the time it was exhumed at the National Maternity Hospital in 1944. Destructive operations, such as craniotomy and embryotomy, were practiced in preference to symphysiotomy and pubiotomy. History shows that symphysiotomy was never the norm in any country at any time, because the surgery never succeeded in overcoming its dismal reputation as a dangerous operation. Walsh looks at the 20th century, and neglects to consider the history of these pelvis-breaking operations. The surgery’s side effects for mothers, such as walking difficulties and fistula, were known since 1777. Ireland was the only country in the developed world to practice these discarded and dangerous operations in the mid to late 20th century. Caesarean section began its upward curve as the treatment of choice for difficult births in the 1880s. Popular in England from the early 1920s, CS had established itself as the accepted treatment for difficult births in Ireland by the end of the 1930s.
Wrongly, Walsh finds that the practice of symphysiotomy as a planned procedure was justified in certain cases of ‘disproportion’, where there was some perceived lack of fit (minor to moderate) between the baby’s head and the mother’s pelvis.
In every other industrialised country in the world, however, in the 1940s and 50s, and later, this complication was treated by Caesarean section. Walsh wrongly suggests that contracted pelvis and/or disproportion was common in Ireland during those decades. This view, first advanced by a former Chairman of the IOG, Dr Conor Carr (letter, Irish Medical Times, 25 March 2010), is disputed. Dr Peter Boylan (letter Irish Times 6 October 1999) has stated that disproportion was an imaginary complication. Walsh argues that malnutrition and, by extension, deformed pelves made the practice of symphysiotomy necessary, but survivor testimony and medical research show this to be false. Walsh provides no evidence of malnutrition among those women selected for symphysiotomy. Survivors who gave birth to 8, 9, 10 and 11 lb babies, as many did, were not suffering from malnutrition, and they have found this suggestion offensive. Research shows that rickets, the bone condition that gives rise to contracted pelvis, was rare. A national nutrition survey carried out over 1941-43 showed no evidence of rickets in pregnant women, only in small children: action was taken to improve the quality of the flour and rickets disappeared. And later research proved that disproportion was an imaginary complication. Virtually every woman could give birth to the child she was carrying, Dr Kieran O’Driscoll showed. The NMH Master looked for evidence of disproportion in 1,500 first-time mothers at his hospital: he later told the Royal Academy of Medicine that ‘disproportion is a mote in the eye of the obstetrician––it does not exist’.
Walsh’s finding that symphysiotomy was ‘safer’ than C-section in the 1940s and 50s is false. The ‘safety’ of symphysiotomy is a myth that was first advanced by Prof Bonnar, then Chairman of the IOG,
in a letter to the Chief Medical Officer (4 May 2001). Symphysiotomy was inherently high risk: if the knife cut into the ligaments or the bladder, for example, a mother could be left with lifelong walking difficulties or severe incontinence, as many were. Doctors who promoted symphysiotomy admitted that babies died who would otherwise have been saved had a CS been performed. Caesarean section was the accepted, and infinitely safer, treatment for difficult births in Ireland from the end of the 1930s. But while Walsh argues for the safety of symphysiotomy, the report fails to prove its own case. Walsh’s claim that symphysiotomy had ‘a far lower maternal and fetal mortality rate’ than Caesarean section is untrue. The report’s tables are fundamentally flawed, because they do not compare like with like. Caesarean section was done on a variety of women, including those who had underlying health problems, such as heart disease and tuberculosis, while, as Dr Jacqueline Morrissey’s work shows, symphysiotomy in the 1940s and 50s in Dublin was an experiment aimed at healthy, young women (expecting their first child). A further confounding factor is that some of these Caesarean deaths were anesthetic-related, and symphysiotomy done under local anesthetic avoided the dangers of general anesthesia. Even taken at face value, the Walsh tables give a fetal death rate for symphysiotomy of 8.0 per cent and of 8.2 per cent for Caesarean: there is no significant difference in these rates. If one includes data for the years 1944-49 for all three hospitals and calculates the overall mortality rates for 1944-65 for the institutions in question, the fetal death rate is lower for CS than for symphysiotomy. If one were also to include data from IMTH for the relevant period, the superior safety of Caesarean section for babies would very likely be demonstrated. Walsh’s own figures for the three Dublin maternity hospitals, the tables show only 0-1 excess deaths per annum for symphysiotomy compared with C-section. Most importantly, the argument that symphysiotomy was a ‘safer intervention’ that Caesarean section ignores the long term consequences of symphysiotomy for mothers. This reflects the silencing of survivors in Walsh: survivor testimony (see attached) shows that symphysiotomy led, in very many cases, to a lifetime of ill health. The notion that symphysiotomy was safe from a maternal health perspective also reflects the extreme paucity of research on the topic, both nationally and internationally, as is evident from this report.
Walsh finds that symphysiotomy was done mainly as an ‘emergency response to obstructed labour’, a presentation first advanced by the IOG in a letter to the Department of Health in 2001. Hospital reports, medical records and survivor testimony show that the operation of symphysiotomy was almost always planned;
and that it was carried out by doctors as a procedure of choice before, during and after labour. Cases where the surgery was performed before the onset of labour were relatively common at IMTH. One survivor had it done there under general anesthetic, at 34 weeks of pregnancy: her baby was extracted six weeks later, again under general anesthetic. Also, the report suggests that symphysiotomies done during labour were ‘emergency’ by definition: this is fundamentally wrong. The report omits to mention a vital point: the medical drill on symphysiotomy––taken from tropical literature––that required that the cervix be well dilated, which meant labour had to be well advanced before symphysiotomy could be performed. Clinical reports from IMTH detail the number of hours a mother was allowed to spend in labour prior to surgery, and medical records and survivor testimony also show that women were left for 12, 24, 36, 48 hours or more before being operated upon. To argue that these operations were emergencies is false.
Walsh justifies the latterday practice of symphysiotomy in Ireland by claiming that the safety of repeat Caesarean was unproven and suggests that, until the era of artificial contraception, doctors had little choice but to cut the pelvis. This is an argument that was advanced, unsuccessfully, by the Medical Missionaries of Mary,
in a recent case (Kearney v McQuillan). The theory that the safety of repeat Caesareans sections was ‘unproven’ in the 1940s and ’50s was advanced by Boylan (1999), who argued that symphysiotomy was ‘driven not by Catholic teaching, but by the medical risks associated with repeated Caesareans’. To suggest that it was appropriate for doctors to subject women to the material and corporeal risks involved in severing the pelvis with a view to ‘saving’ them from whatever theoretical and statistical risks may have been associated with repeat Caesareans is absurd. Moreover, the infrequency of uterine rupture––one of the main complications of repeat Caesarean––in the main Dublin maternity hospitals in the 1940s suggests that claims about the dangers of repeat Caesarean are inflated. The bald assertion that repeat Caesareans were dangerous hides the critical fact that not only was vaginal birth after Caesarean permitted in Dublin in the 1940s but repeat Caesarean sections were common. The issue then becomes how many repeat Caesareans can safely be performed, but there was little agreement among doctors as to what constituted an upper safety limit.
Walsh’s assertion that symphysiotomy was ‘a clinical response to the legal limits on contraception and sterilisation for contraceptive purposes’ is without foundation. Contrary to what Walsh asserts, sterilisation was not illegal in the 1940s and 50s.
Dr Morrissey makes the point that sterilisation in the 1940s was unavailable, not because it was illegal, but because doctors refused to carry it out. Dr Arthur Barry actually railed at the demand for sterilisation––in his hospital, presumably––so not all women were in thrall to Catholic teaching, contrary to what Walsh suggests. The 1935 Criminal Law Amendment Act––struck down in 1974––did not outlaw the use of artificial contraceptives, nor did it prevent the ‘Pill’ from being distributed. History shows that symphysiotomy was performed for non-medical reasons, a belief in childbearing without limitation being one of them. Those who revived symphysiotomy saw Caesarean as a moral hazard that led women to practice birth control: the writings of Drs Alex Spain and Arthur Barry reveal their opposition to artificial contraception and sterilisation. Doctors who performed symphysiotomy as a planned procedure put their own personal beliefs before the welfare of their patients, by choosing to perform an aberrant operation––instead of the much safer norm of CS–– that they saw as more in keeping with their religious views.
Sustaining its theory of uncontrolled fertility, Walsh wrongly conflates artificial birth control and family limitation: they have never been synonymous, however. History shows that Victorian women limited their families. Family limitation was practiced in Ireland from the beginning of the last century:
from 1911 to 1946, family size shrank by 20 per cent, as historian Diarmuid Ferriter records (2009: 297). Magazines containing articles on family planning flooded into Ireland in the postwar years without let or hindrance: periodicals were outside the powers of the Censorship Board–– a fact occluded by Walsh––as Ferriter has underlined. Nor was the Catholic ethos as monolithic as Walsh suggests: the Church did not condemn birth control in principle. Addressing Catholic midwives in 1951, Pope Pius XII justified the use of her safe period. Couples marrying in the 1950s had fewer children. In 1954, for example, just 23 per cent of Irish couples had five children or more. The trend continued and intensified, and, by 1973, over 20, 000 women in Ireland were taking oral contraceptives. And still the practice of symphysiotomy continued in Ireland. Other Catholic countries did not resort to symphysiotomy. But to point the finger at the Catholic Church, as Walsh has done, is to exculpate the doctors. No laws, and no ethos, however, forced doctors to sever a woman’s pelvis in childbirth.
Walsh denies that the surgery was done for training and experimentation purposes, but fails to explain why some doctors in Ireland performed symphysiotomy in preference to Caesarean section, while their colleagues in a hospital 50 or a 100 miles away did C-sections for those same cases.
Walsh ignores the fact that symphysiotomy was most prevalent in teaching hospitals, and that it tended to be done by senior doctors. Survivor testimony shows that women were used as ‘clinical material’ for training purposes, and historian Tony Farmer bears this out, underlining how useful symphysiotomy was seen to be in the 1940s for trainees from Africa and India.
In relation to experimentation, Dr Morrissey’s work illustrates the scope and nature of ‘the Dublin experiment’, which was conducted at the National Maternity Hospital from the mid-1940s to the mid-1960s.
Hospital reports indicate the experimental nature of some of these operations. The Dublin experiment appears to have been continued and extended at the International Missionary Training Hospital into the 1970s. In 1962-3, for example, symphysiotomy was tested at IMTH at both ends of the gestational limits, at 27 and 29 weeks of pregnancy, when the baby had less than a 50:50 chance of survival, and also at 43-44 weeks, when fetal viability was also at risk. Survivor testimony shows that women were used as ‘clinical material’: many have related how their operations were witnessed by large numbers of trainees, 17 or 18 in some cases, or more, in the crowded upper balconies of the Rotunda. It is doubtful if CS would have attracted such crowds of medical and nursing students. One mother recalls seeing a camera in the operating theatre of the Lourdes Hospital before being rendered unconscious. Another has the term ‘candidate’ for symphysiotomy written on her antenatal records from NMH, where she was subjected to the surgery electively in 1972. If symphysiotomy was not performed for training purposes, why did doctors continue to perform it, sporadically, in training hospitals as a procedure of choice until 1992?
Finally, Walsh justifies doctors’ failure to seek informed consent from women by claiming that consent to medical intervention was not legally required until the ‘late 1990s’. This is baseless:
the principle of informed consent was established in 1914 in a New York court. Article 40.3.2 of our Constitution, which was adopted in 1937, further safeguards the legal requirement for informed consent.
Walsh fails to justify the performance, in preference to Caesarean section, of a mutilating operation that unhinged the pelvis–-a major bodily structure––and inflicted serious injuries on patients.
Walsh’s homogenising narrative glides over different time periods, eliding the 1940s and 50s with the 1960s and 70s to form a seamless narrative that wrongly portrays symphysiotomy as a life saver for mothers, in an era of allegedly uncontrolled fertility, before the supposed advent of safe Caesarean section. The report wrongly portrays symphysiotomy as both necessary and appropriate, finding that only those symphysiotomies carried out in the aftermath of Caesarean section––a tiny number–– were wrong. All symphysiotomies, except those done in a dire emergency, that were carried out electively in Ireland from 1942-2005 were grossly negligent.
The Walsh Report is an apologia for an atrocity, the mid to late 20th century practice in Ireland of symphysiotomy and pubiotomy.
These were operations that unhinged the pelvis, and led in many cases to lifelong disability, incontinence, chronic pain, organ prolapse, depression and post-traumatic stress disorder. Symphysiotomy was not carried out for reasons of medical necessity, nor was it done for the benefit of the patients who were subjected to it.
These surgeries were done gratuitously in preference to Caesarean section generally by male doctors, who were determined to ensure childbearing without limitation.
Their difficulties with Caesarean were moral rather than medical: symphysiotomy was a pre-emptive surgical strike against contraception and sterilisation. History shows that these pelvis-breaking operations were also done for training purposes from the 1940s, and survivor testimony amply bears this out, while the continued, if sporadic, practice of these operations into the 1980s also suggests a training dimension. Hospital reports show clear evidence of patient experimentation, both at NMH and, more widely, at IMTH. The surgery reflected the strength of a patriarchal culture warped by misogyny and clericalism, with women being used as vessels for procreation and as clinical material in operations that were at all times involuntary and breached women’s constitutional and human rights.
For and on behalf of Survivors of Symphysiotomy