Anarcha was 17 years old and went into labour with her first child. She struggled for three days before medical help was sought. When help arrived, it was a local doctor with no particular interest in reproductive health. In his own words, “[i]f there was anything I hated, it was investigating the organs of the female pelvis”. The doctor was able to deliver the baby using forceps. We know Anarcha survived but presume the baby didn’t and, as a result of the complicated labour, Anarcha sustained several fistulae.
Obstetric fistula is a debilitating condition caused by prolonged, obstructed labour, which tears the vaginal wall, resulting in permanent bladder or bowel leakage. For Anarcha, it was both. Some attempts at treatment had been made previously but either failed or were unrepeatable. It was therefore an untreatable condition of pain, incontinence, smell, infection and, ultimately, isolation from society, but it wasn’t fatal; although there is evidence to suggest it sometimes led to suicide.
J Marion Sims
We know a lot more about James Marion Sims, the doctor who created a reliable, repeatable surgical repair for obstetric fistula, than we do about Anarcha who suffered through it.
He began his medical studies in 1833. After graduation he returned home to Lancaster County, Alabama. Following several bouts of malaria, he relocated to Montgomery in 1840, which was considered a healthier climate. Here, he became a plantation physician, which was a very lucrative business with a large patient pool. And, though his primary source of patients was slaves, he worked with the broader community too.
When a local white woman was thrown from her pony and suffered retroversion of the uterus, Sims was called. He wrote that he placed the patient on her knees and elbows, and through digital manipulation was able to return her uterus to its rightful place. This experience gave him the inspiration to adopt the same position for fistula examinations. On his way home, he stopped to purchase a pewter spoon to fashion into a speculum which, he hoped, would aid in making the vagina visible to the naked eye.
And, as luck would have it, another enslaved woman with fistula was already in his eight bed hospital at the back of his house. Lucy was an 18 year old enslaved woman who had given birth about two months earlier.
Sims had been stopped in the street by a slave owner called Tom Zimmerman who wanted him to examine Lucy. Despite strong protests from Sims, Zimmerman insisted on sending Lucy to him. When Lucy arrived, Sims examined her and told her she would be returned the following afternoon as there was nothing he could do for her.
But now, he wanted to examine Lucy once again, using his pewter spoon. Sims wrote that she “[w]illingly consented” and, in his words “[i]ntroducing the bent handle of the spoon, I saw everything as no man had seen before. The fistula was as plain as the nose on a man’s face”. Sims was convinced that, having properly seen the fistula, he could now develop an operation to correct it.
A few months later he’d secured all the equipment he thought he’d need. He had recalled Lucy and Anarcha, along with Betsey who he had also seen previously, and he’d located another six or seven enslaved women with the same condition. They were all now living in the hospital in his yard. Sims did not record these other women’s names in his memoir.
He first operated on Lucy in December 1845.
The operation itself appeared to go well but the end result was blood-poisoning, which she recovered from after several months. He noted a marked improvement to the fistula but hadn’t affected a cure. After modifying the technique, he operated on Betsey. Again, there was an improvement of sorts, but not a cure. He then operated on Anarcha and this operation didn’t appear to make any advance on the previous two. For the next four years this process of operation and modification continued for Lucy, Betsey and Anarcha, as well as the other women whose names he didn’t record.
This experimentation began in the pre-anaesthesia era. But, within less than 12 months, ether had not only been successfully demonstrated to produce insensibility to surgical pain, it quickly travelled around the entire western world. Yet, for the entire four years of experimentation, Sims didn’t use any form of anaesthesia.
Originally, Sims had a lot of support from the local medical community. For Lucy’s operation he records another dozen or so doctors in attendance, offering support. As time passed, he received less and less support. His brother-in-law, also a doctor, begged him to stop, citing the expense of housing additional enslaved women, as well as the injustice to his young and growing family because his attention was so diverted. Sims had been cast into professional isolation. He wrote that, despite the many problems he experienced, his patients were “…all perfectly satisfied with what I am doing for them. I can not depend on the doctors, and so I have trained them to assist me”.
In 1849, Sims did develop a repeatable surgical solution. He also recorded that Anarcha had 29 failed operations before the successful one. He offers no specifics for the other women, but does describe a rotation of patients and it seems safe to bet they underwent a similar number of procedures in some sort of roster while they each recovered in turn.
Willingness and consent
Lucy was an enslaved woman. She had no bodily autonomy. Under antebellum law, Lucy was considered chattel. Deidre Cooper Owens wrote that, “[e]ven if an enslaved woman stated that she did not want to be operated on, once her owner granted permission to the surgeon to perform surgery, an operation occurred”. Not only was Lucy unable to give or withhold consent, her consent wasn’t required. The only consent that mattered was that of Lucy’s enslaver who, Sims tells us, sent Lucy to him despite his objections.
So, when Sims wrote “willingly consented”, it’s difficult to know exactly what he meant as her willingness and her consent are moot because of her status. However, his memoir was published in 1884, the year after his death. His son finished writing it and arranged for it to be published. By this time, slavery had been abolished for some 20 years. The end of slavery may have created a need for antebellum power holders to reframe the narrative about the treatment of formerly enslaved people.
Perhaps it’s more accurate to say Lucy offered no physical resistance that required restraining her to conduct the examination. And, we should also ask whether, given a true opportunity to consent or withhold consent, would Anarcha or any of the other women, have consented to 29 failed operations, or would they have withdrawn their consent at some earlier point, resigned to the fate brought about by their condition?
The women’s contributions to the experiments, through assisting Sims, fall somewhere into the same argument as the issue of consent. Their position as slaves within a slaveholding society rendered them incapable of refusing to assist. Sims doesn’t go into any real detail about what that assistance looked like, but it’s unfortunately easy to imagine these women having to hold each other down while Sims operated.
We also need to consider the lack of anaesthesia during the years of experimental surgery. Anaesthesia wasn’t met with universal approval. There was some resistance to its use. Nevertheless, word travelled quickly and within seven months of the first successful public demonstration of ether as anaesthesia, news had even reached Australia. Within four weeks of its arrival there, doctors and dentists were experimenting with ether anaesthesia in different parts of the country. Sims was working in Alabama and in the neighbouring state of Georgia, Crawford Long is said to have been using ether as anaesthesia from as early as 1842. Anaesthesia was available to him.
So, why wasn’t Sims using anaesthesia? Leonard F Vernon argues that Sims’ lack of training and experience in the use of ether would have prevented him from using it, as it may “…have been more of a danger than the actual surgery”. This idea recurs in defence of Sims. Yet, lack of training and experience didn’t stop him using forceps when attempting to deliver Anarcha’s baby, certainly didn’t stand in his way when attempting a surgical repair for obstetric fistula, and it didn’t prevent other medical practitioners from experimenting with anaesthesia in their day-to-day practice either.
Deidre Cooper Owens points to the idea that many antebellum era physicians believed Black people “felt little or no pain as they underwent invasive surgical procedures”.
This belief persisted well into the 20th Century. A 1914 article in the Journal of the National Medical Association urged physicians to “look upon the colored [sic] patient surgically as upon a patient of any other race” and understand they are in fact “favourable subject[s] for anesthesia”. Sixty eight years after the introduction of anaesthesia, physicians were still using it sparingly on Black people. The persistence of the belief that Black bodies have some sort of insensitivity to pain, lends weight to the idea that Sims himself believed this and saw no reason to use it. Although, in his memoir, Sims wrote that his experimentation occurred before anaesthesia “…and that poor girl, on her knees, bore the operation with heroism and bravery”. This statement tells us he wasn’t unaware of the pain caused, it is perhaps more that he was impervious to it, and saw no reason to address it.
Yet, how differently he treated a woman patient in France only a few years later. Armed with five assistants, Sims performed two operations on a 21 year old woman. She was, he wrote, “young, beautiful, rich, [and] accomplished” and he had “never seen a case of this kind which was attended with such suffering”. Telling the story of a complication with chloroform, Sims reveals the crucial difference in treatment for a “young, beautiful, rich, [and] accomplished” French woman, as opposed to his earlier patients – the use of anaesthesia.
Sims’ legacy to medicine?
James Marion Sims has been widely and, until fairly recently, uncritically lauded for his work. For a long time history judged that the end – surgical repair of fistula – justified the means – experimentation on enslaved women without anaesthesia, even though it was available for the majority of the experimentation period.
In November 2018 three surgeons published an article in the International Urogynecology Journal, expressing deep concern that a statue of Sims was removed from New York’s Central Park. They thought this was part of a campaign which rebranded Sims as a “symbol of hate”, and saw his character “assassinated, buried and airbrushed from its rightful place in medical history”. In that same year, the American Urogynecological Society abandoned their eponymous annual lecture, recognising that “…the dynamics of power cannot be separated from his story”.
The circumstances in which fistula repair was achieved were the direct result of the commodification of women’s bodies through chattel slavery. Under any other circumstances, Sims may not have had such “willing” subjects for his years of experiments, something even some of his defenders admit. Sims’ story reveals a coming together of gender, race and class systems which elevate Sims and vanquish the women into relative obscurity. Yet, even within his own time frame, there were those who questioned what he was doing and carefully distanced themselves from him, although that distancing wasn’t necessarily due to ethical concerns. James Marion Sims did do an incredibly important thing, and definitely deserves a place in medical history. But his “rightful place” is currently undergoing a necessary adjustment as we continue to examine the relationship between his professional reputation and the systems of oppression in which it was created. So, at the very least, while we shouldn’t forget him, we must also remember and elevate Anarcha, Betsey, Lucy, and the other women whose names he did not even record.
References and further reading
- Kaplan L. Changes in childbirth in the United States: 1750–1950 [Internet]. Hektoen International: A Journal of Medical Humanities. 2012 [cited 2019 Jun 4]. Available from: https://hekint.org/2017/01/27/changes-in-childbirth-in-the-united-states-1750-1950/
- Sims JM (James M, Marion-Sims H (Harry). The story of my life [Internet]. New York, D. Appleton and company; 1884 [cited 2019 Jun 5]. 490 p. Available from: http://archive.org/details/storyofmylif00sims
- Roberts D. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York: Vintage Books; 1997.
- Cobb A. Women and the Domestic Slave Trade in the Antebellum South. Armstrong Undergraduate Journal of History [Internet]. 2016 Nov [cited 2019 Jun 5];6(2). Available from: https://www.armstrong.edu/history-journal/history-journal-women-and-the-domestic-slave-trade-in-the-antebellum-south
- Numbers RL. William Beaumont and the Ethics of Human Experimentation. Journal of the History of Biology [Internet]. 1979 [cited 2019 Jul 10];12(1):113–35. Available from: http://www.jstor.org/stable/4330728
- Savitt TL. The use of Blacks for medical experimentation and demonstration in the Old South. The Journal of Southern History. 1982;48(3):331–48.
- Vernon LF. J. Marion Sims, MD: Why He and His Accomplishments Need to Continue to be Recognized a Commentary and Historical Review. Journal of the National Medical Association [Internet]. 2019 Mar 7 [cited 2019 May 29]; Available from: http://www.sciencedirect.com/science/article/pii/S0027968418302839
- Owens DC. Medical Bondage [Internet]. Athens: University of Georgia Press; 2017. Available from: http://www.jstor.org/stable/j.ctt1pwt69x
- Bourke J. Pain Sensitivity: An Unnatural History from 1800 to 1965. J Med Humanit [Internet]. 2014 [cited 2019 Sep 4];35(3):301–19. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4133135/
- Petros P, Abendstein B, Browning A. In defense of J Marion Sims | SpringerLink [Internet]. [cited 2019 Nov 7]. Available from: https://link.springer.com/article/10.1007/s00192-018-3708-1
- J. Marion Sims Lectureship – Awards | AUGS [Internet]. [cited 2019 Nov 19]. Available from: https://www.augs.org/about/j-marion-sims-lectureship/
- Kaiser IH. Reappraisals of J. Marion Sims. American Journal of Obstetrics & Gynecology [Internet]. 1978 Dec 15 [cited 2019 May 29];132(8):878–82. Available from: https://www.ajog.org/article/0002-9378(78)90715-9/abstract