Chapter 4 THE SURGICAL THEATER
Black Bodies in the Antebellum Clinic

Sam, a forty-two-year-old laborer on a plantation in rural Alabama, had
become exhausted by pain and fear. For years, an incessant racking pain
in his jaw had kept him distracted days and awake nights, miserable and
dejected.When his owner learned of Sam’s pain around 1838, he decided
that Sam must have syphilis and applied a homemade concoction, whose
only effect was to produce a painful boil on Sam’s gums. Now Sam also
found it difficult to eat.He should have been a strong, productive worker
in the prime of his earning power, but Sam was finding it harder and
harder to work, even in the face of cajoling and threats. By 1845, he had
become worthless in the fields, and in desperation, his owner summoned
a physician, who determined that Sam was suffering not from syphilis
but from osteosarcoma—a cancer of his lower jawbone. The doctor
turned to a surgical colleague, Dr.Marion J. Sims, who declared to Sam’s
owner that only an operation carried hope of a cure. But Sam vehemently
and repeatedly refused, protesting that it would “hurt too bad.”
Today, refusing to undergo an operation for a treatable cancer is a
tragic mistake, because surgery is the most curative mode of therapy for
cancer. Today, anesthetics, antiseptics, and antibiotics banish or at least
mitigate the twin nightmares of surgical pain and infection. However,
Sam’s cancer predated the common use of effective anesthesia and of
sterile technique. Purgatorial pain was certain and a fatal infection all too
likely. What’s more, the disfiguring surgery might have been futile, be

cause only superficial, visible cancers were discovered during this era.
Not until Wilhelm Roentgen discovered X rays in 1895 could physicians
view the body’s interior without invasive surgery.No imaging techniques
allowed doctors to identify an internal cancer, and it could have spread
internally through the long years when Sam was being erroneously
treated for syphilis.
Sam’s version of events is not recorded, so we don’t know whether
more than a fear of pain caused him to balk at surgery. But we do know
that Sam might by this time have acquired a low opinion of Western
medicine’s ability to help him, thanks to the original misdiagnosis and
iatrogenic injury. If Sam had gotten wind of Sims’s dismal surgical statistics,
his famed fondness for forced experimentation on captive patients,
or of his penchant for taking shoemakers’ tools to black infants’
skulls, Sam’s opinion of Sims’s skill would have sunk low indeed. But he
would not have dared to openly voice doubts about Sims’s abilities, so refusing
treatment because of “the pain” may have been a canny dodge.
However, Sam was enslaved, so the decision was left not to him but
to his owner, who was eager to return his slave to profitable work. Sam
was sent to Montgomery despite his loud and constant protests.
Sims, for his part, stonily declared himself “determined not to be
foiled in the attempt” to operate. Sims had decided not only to operate
upon Sam but also to perform the surgery in a teaching clinic for a medical
audience of students and potential protégés. He hoped to immortalize
the operation in a medical publication, and no mere slave would
frustrate this bid for medical glory.
But when the two adversaries met, Sims was all smiles. He kindly inquired
into the slave’s health and graciously invited Sam to have a seat.
The barber’s chair into which Sam had been welcomed had been
surreptitiously fitted with wooden planks, and as soon as Sam was
seated, five young physicians bounded forward to restrain him with
straps about his thighs, knees, ankles, abdomen, chest, shoulders, arms,
wrists, elbows, and head. Sam, Sims noted, “appeared to be very much
alarmed!”While he was being immobilized, ten medical students and fifteen
interested “others” filed in to watch as Sims operated for forty minutes
to remove a large section of Sam’s lower jawbone, sans anesthesia.
When he finished, the surgeon noted with satisfaction that his surgical
innovation had “proved its practicality . . . whether the patient is willing
or not.” The editors of the New Orleans Medical and Surgical Journal enthused
that they were “pleased to record this highly creditable achievement
of a Southern surgeon.”
After he recuperated, Sam apparently lost no time in escaping into
rural Alabama again, certainly with a redoubled aversion to Western
medicine. There is no evidence that Sims ever saw Sam again, but his
medical report took this parting shot: “Sam’s mouth is always open in a
wide grin.”

Staging Disease: Treatment Under the Microscope

There were many Sams. Like circuses, clinics and hospitals had an abundance
of uses for the displayed African American body. After the mid-nineteenth
century, a supply of black bodies was key to the primacy of
the hospital as the new center for American medical instruction and
treatment. African Americans filled medical school rosters as well as circus
tents, because medical teaching, training, and research utilized black
bodies disproportionately, and in some southern venues, they were used
exclusively.
During the 1830s, a Dr. T. Stillman ran serial advertisements in the
Charleston Mercury for his infirmary, in which he principally treated skin
diseases. On October 12, 1838, he made a fascinating addendum:

Slaves who had become too old or too sick to work supplied the bulk
of hospital “clinical material.” They enjoyed no legal rights and could
mount no legal challenge to their incarceration and treatment.5 Stillman
advertised his desire for blacks who suffered from disorders far beyond
his own specialty, such as apoplexy, kidney disease, and stomach, intestinal,
bladder, liver, and spleen disorders, as well as scrofula and
hypochondriasm. He wished to test new techniques and medications he
had formulated on debilitated and chronically unhealthy blacks in the
same institution where he treated paying whites. He then marketed the
medications and techniques.
Slave owners were glad to rid themselves of old, sick, and unproductive slaves.6

It was a sage bargain on the slave owner’s part, because the
hospital took over all or most of the cost of feeding, housing, and treating
the unproductive slave. If the slave died, his owner was spared the inconvenience
and expense of burying him, because the hospital would
retain the body for dissection or experiment. If the slave recovered, the
master would once again profit from his or her labor and breeding.
Moreover, the slave owner could lay claim to benevolence; after all, he
was sending his old or sick slaves to a hospital for expert care. Free blacks
were also vulnerable because they were easily incarcerated in jails and
almshouses for a variety of minor infractions of the many regulations
governing free African Americans.
Why were blacks the chief denizens of teaching-hospital wards? In
the middle of the nineteenth century, the “hospital movement” finally
crossed the Atlantic from Europe. One-room, one-year medical schools
based upon the stereotyped dispensing of a few dozen nostrums fell out
of favor and began to close as medical training began to focus upon scientific
experimentation and anatomical knowledge. The new spirit of
clinical inquiry questioned heroic but ineffectual treatments such as
bleeding, purging, and cupping, causing them to quickly lose their cachet.
Medical students were now expected to undergo specialized training
during several years, not months, on the clinical floors of hospitals.
Diseases such as yellow fever, smallpox, malaria, and tuberculosis
still flared into epidemics with regularity, and the dominant class of
property-owning whites still relied upon private physicians to care for
them and their families. However, they increasingly expected those
physicians to have the professional benefit of hands-on clinical experience.
However, acquiring such experience presented a challenge because
hospitals were about as popular a destination as homeless shelters are today:
No one who had a family, access to a private physician, or financial
resources to rely upon was willing to enter one. American hospitals of
the 1800s were very different from the antiseptic, high-tech, ethics-obsessed
meccas of scientific medicine that we know today. They offered
few effective medications and there were no federal agencies exerting exterior
checks and balances to weigh the interests of patients against those
of the hospitals’ physician owners.Without the therapeutic options, patient
protections, medical advances, and knowledge that we take for
PDF
granted today, the hospital was less an institution for healing than a
physician-centered venue for learning, training, and experimental approaches.
These were conducted on black people and on other poor, desperate
people without resources.
Perhaps Thomas Jefferson said it best: “It is poverty alone which
peoples hospitals . . . to be exposed as a corpse, to be lectured over by a
clinical professor, to be crowded and handled by his students to hear
their case learnedly explained to them, its threatening symptoms developed
and its probable termination foreboded. . . .” The best one could
hope for in hospitals and “poor clinics” was shelter from the elements
and a minimum of dangerous untried treatments among the infectious.
One could, however, count upon exposure to a host of iatrogenic conditions
and upon being regularly displayed to students and faculty. Hospital
patients also risked involuntary treatment, including unnecessary
surgery, often without the benefit of effective anesthesia.Yet, the doctors-to-
be and their teachers needed “clinical material”—human bodies upon
which they could practice diagnosis, treatment, and, finally, autopsy and
dissection. Because no one entered a hospital voluntarily, this reluctant
“clinical material” emanated from the lowest rungs of society. Sick or old
people cast out of workhouses, almshouses—and, in the South, plantations
—filled hospitals. Clinic patients were not asked for their consent,
and any physician who hesitated to operate on protesting slaves found he
was legally bound to follow the wishes of not the slave but the owner.
In the South, African Americans were reluctant patients, but they
outnumbered poor whites in hospitals. When the city of Richmond,
Virginia, contemplated expending public funds to build a new
almshouse, the professor owners of the Medical College of Virginia proposed
a mutually beneficial alternative: They would take “all the sick and
infirm paupers” into their infirmary and, in exchange, pay the city the
funds it needed for a workhouse.In 1848, the faculty also proposed establishing
a hospital solely for blacks, thereby ensuring a supply of patients
for clinical instruction, although free blacks knew enough to give
hospitals a wide berth when they could. Even in the North, hospitals expected
blacks to submit to research as “payment” for having been treated
in charity wards; yet no amount of money could buy a black patient a
bed in the private ward where well-to-do whites received care. When a
black patient was admitted in error to Boston’s Massachusetts General
Hospital in 1829, his doctor, George W. Otis, M.D., was severely taken
to task.
...