I have a not-so-secret weakness for historical fiction series. I think, in some roundabout way, this is what started me on the path to studying history. I read the Little House on the Prairie books as a child, John Jakes’ North and South series as a tween, and it’s been my genre-of-choice ever since. But there is one series in particular that really is my favorite. Maybe even an obsession. I have no idea how many times I’ve read and reread the now eight volumes in the series. I’ve even considered going on one of those themed-vacations, where you visit sites featured in the books. It’s that bad. My obsession, I mean. The books are simply that good.
When I say that I’m talking about the Outlander series by Diana Gabaldon, I imagine that most of you who have read the books will know what I am talking about. I say “most” because I have heard that there are people who have read the books and didn’t like them. Seriously, what’s not to like? There is adventure. There is drama. There is time travel. There is really great sex. Unlike so many other titles in this genre, the storyline and many of the characters are decidedly feminist. I could go on, but I think I’ve gushed enough to give you an idea of what I’m talking about. Here I actually want to focus on a particular facet of the series: Gabaldon’s careful attention to the history of medicine.
I read the first volume in the series just before I started graduate school, and as my interest in the history of medicine grew, I found the medical history embedded in the stories to be increasingly intriguing. Gabaldon does her research thoroughly, so what she offers of special meaning to the medical historian are scenes that bring to life 18th century medical practices.* They are still fiction and most certainly depend on imagination as much as factual evidence, but they are riveting. And, in my opinion, they function as a form of public history, teaching readers about little known facts related to the history of medicine and health care.
This June, the much anticipated eighth volume in the series, Written in My Own Heart’s Blood, brought the story into the early months of the American Revolution. There are plenty of battlefield medicine scenes both stomach-turning and impossible to turn away from. But the scene that stood out the most for me was when the main character, Claire Fraser, treated an enslaved woman suffering from vesicovaginal and rectovaginal fistulas.
For those of you who are thinking “Spoilers!” let me assure you that this has nothing to do with the plot of the volume or the series, and the scene was partially previewed by Gabaldon herself via Facebook and Twitter in the months leading up to the book’s release. And I’m not really going to tell you anything about the scene anyway, except to say that an enslaved woman (girl, really, as she is only thirteen) named Sophronia is the patient; she is suffering from a severe fistula after a fetus died in utero; and Claire, of course, saves her life.
What was compelling to me about this scene — and why after reading the preview I eagerly awaited reading the full version in the book — is the fact that fistulas are one of the most horrific conditions in the history of women’s healthcare. Moreover, so much of our contemporary gynecological care is based on knowledge gleaned from the treatment of this condition among enslaved women prior to the Civil War.
A fistula is a condition in which two organs that are not normally connected become so due to injury. A vesicovaginal fistula is an open connection between the bladder or urinary tract and the vagina; a rectovaginal fistula is an open connection between the rectum and the vagina. The result is chronic leakage of urine or feces through the vagina, causing a terrible smell, great embarrassment, high risk for infection, and overall misery and suffering. This condition is most common in women who give birth when they are young, with prolonged labors and no or limited access to proper care. Violent rape can also cause fistulas. In short, the women enslaved in the United States in the 19th century were textbook cases. More accurately, they were the cases the textbooks were based upon.
Most of the research done on fistulas — identifying suffering patients, examining their bodies, suggesting courses of treatment, experimenting with different treatment methods, developing tools to perform those treatments, monitoring recovery, etc — was performed on enslaved women. These women did not have the legal right to consent to the treatment; rather, that right was reserved for the men and women who owned them. The bodies of enslaved women were valuable commodities. After all, women were the ones who reproduced the enslaved population. Slaveholders had great stakes in ensuring that their female chattel were healthy enough to reproduce. That meant treating fistulas.
Many doctors experimented with this procedure, but the man who holds the honor of finding the best fix is J. Marion Sims. Sims was a physician practicing in Alabama who treated both white and black women with severe injuries, including fistulas, from difficult and frequent births. In order to pursue suitable treatment methods, Sims experimented on enslaved women he either bought or rented from their owners. Although anesthesia was known and available to him, he does not appear to have used it on his research subjects. This was not unusual for an era in which black bodies were perceived as being more resilient and less sensitive to pain than white bodies. Historians estimate that he operated on at least ten enslaved women in the late 1840s. Three women, Anarcha, Lucy, and Betsey, were his most frequent subjects. Sims claims that the women consented independently to the procedure, and given the horrors of life with severe fistulas, as well as the need for their cooperation during surgery by remaining absolutely still — not an easy thing to do without anesthetic — they may well have. Sims’ notes also reveal that he heavily sedated the women with opium post-surgery, which may call into question their ability to consent to subsequent procedures. In any case, Sims performed multiple surgeries on each of his patients. According to his records, seventeen-year-old Anarcha, who, like the character in Gabaldon’s book, suffered from both vesicovaginal and rectovaginal fistuals, endured thirty of these surgeries before Sims was able to repair her body. Thirty surgeries. Without antiseptics. Without anesthesia.
By 1849, he had perfected the surgical treatment for vaginal fistulas, and in the process invented a most illuminating tool — the speculum. In the 1850s, Sims moved to New York. In 1855, he opened the city’s first hospital dedicated to the care of women. He continued to experiment with surgical treatments, using the hospital’s white patients, particularly poor Irish immigrants, as his subjects. His work was celebrated by the medical profession. He became president of the American Medical Association as well as the American Gynecological Association. Statues in several cities were erected in honor of Sims, “The Father of Gynecology,” including one that still stands in New York’s Central Park.
In the scene in Written in My Own Heart’s Blood, the main character, Claire, acknowledges the work of Sims as she ponders how best to help the poor girl suffering before her. When I first read the preview of this scene many months ago, I wondered if Gabaldon would mention Sims, particularly a critique of his research methods. More explicit historical instruction via the words or thoughts of Claire would not be unusual for her, and an attack on Sims’ character would be in line with the anti-slavery and anti-racist views Claire expressed in other times and places.
Much to my disappointment, Claire does not rail against Sims. In considering her ability to perform the surgery, she merely reflects that the technique “had taken him years to develop” and in the process he “had more or less invented the entire practice of gynecological surgery.” (Gabaldon, 719) To a historian of women’s health care, this was a much glossed over account. And it really upset me, until I read Gabaldon’s “Author’s Notes,” which function as a brief historiographical essay. In explaining her use of “Scots/Scotch/Scottish” Gabaldon notes that she uses the terms appropriate for the era of which she is writing, not the present day. “Personally,” she writes, “I don’t think political correctness has any place in historical fiction.” (Gabaldon, 821) This got me thinking about the fistula scene.
The fact is, as a physician trained in Boston in the 1950s (remember, there is time travel), Claire Fraser most likely would not have known the larger history of Sims’ work. The first volumes that exposed Sims’ history of experimenting on enslaved women appeared in the 1970s. They are part of the important legacy of women’s history and second wave feminism in academia. But even in the twenty-first century, as a 2011 review of urology journals and textbooks revealed, there is no critical discussion of Sims’ methods in the professional sources available to most physicians and medical students. Instead, these “medical sources have continued to portray him unquestionably as a great figure in medical history.” In other words, doctors today might be just as uninformed about the origins of Sims’ legacy as the fictional Claire Fraser was in the 1950s. I found myself wishing that I could travel through time (and, you know, into a fictional world) so that I could tell Claire what we now know. Claire Fraser, I have no doubt, would want to have known about Anarcha and Lucy and Betsey and all the other unnamed women whose bodies Sims exploited when she thought about how best to care for Sophronia.** I hope that medical students today share her respect for the history of medicine and health care.
* Gabaldon always credits specific resources in her acknowledgments, but the most recent volume also provides information about how to access her reference collection on LibraryThing. It is an impressive list.
**Interestingly, Claire briefly considers sterilizing Sophronia during the surgery. Claire’s motivations are to spare the thirteen-year-old Sophronia further fistulas and, perhaps, the continued sexual abuse of her master, as well as the pain of losing a child to the auction block. The conversation debating this takes place between Claire and Mrs. Bradshaw, the wife of Sophronia’s master, while Sophronia lies unconscious before them. The woman who finally speaks for the silenced Sophronia is a Quaker woman who suggests that, despite all the pain, emotional and otherwise, that it might bring, Sophronia would prefer the chance — the choice — of being a mother. Given the long history of forcible sterilizations of women of color in this country, this is a discomforting aspect of the scene. It demonstrates, among other things, the potential for even well-meaning white liberals*** to do great harm by attempting to presume they know what is best for people of color. It also underscores just how limited the choices of enslaved women actually were.
***Although she never identifies a political affiliation (despite the fact that she lives in the United States in the 1960s) Claire’s personal choices and thoughts are consistent with someone who would identify as a liberal in that era. So, I feel confident in labeling her as such. If you don’t believe me, read the books, and then I’d be happy to discuss it because I could be persuaded otherwise, with the right evidence. But I will only respond to book-based evidence.
For further reading:
McGregor, Deborah Kuhn. From Midwives to Medicine: The Birth of American Gynecology. New Brunswick: Rutgers University Press, 1998.
Pernick, Martin S. A Calculus of Suffering: Pain, Professionalism, and Anesthesia in Nineteenth-Century America. New York: Columbia University Press, 1987.
Schwartz, Marie Jenkins. Birthing a Slave: Motherhood and Medicine in the Antebellum South. Cambridge: Harvard University Press, 2010.
Washington, Harriet A. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. New York: Doubleday, 2006.
Featured Image: J. Marion Sims statue in Columbia, South Carolina. Photo by Billy Hathorn, used in accordance with Fair Use Doctrine.