Anarcha

A Note on the Scientific & Historical Context of BEHIND THE SHEET

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In the spirit of the EST/Sloan Project’s commitment to “challenge and broaden the public’s understanding of science and technology and their impact in our lives,” we offer this essay on some of the scientific and historical background to BEHIND THE SHEET by Charly Evon Simpson, the 2019 EST/Sloan mainstage production. BEHIND THE SHEET begins previews on January 9 and runs through March 10. You can purchase tickets here.

Background essay by Rich Kelley

The first Women’s Hospital in America is thought to be the four-story, 20-bed institution that used to stand at Madison Avenue and 29th Street in New York City, founded by Dr. J. Marion Sims in 1855 where he operated on ailing white women. That claim, however, ignores the two-story, eight-bed “sick house” Sims had set up on a small slave farm in Mount Meigs, Alabama, where from 1844 through 1849 he performed surgical experiments on between 10 and 17 enslaved women, most of them suffering from what we now call obstetric fistulas. 

Left, First Woman’s Hospital in New York City, 1857; Right, Dr. Sims’ first women’s hospital, Montgomery, Alabama (photographed in 1895 by Edward Souchon. Courtesy of the Reynolds Historical Library at the University of Alabama at Birmingham)

Left, First Woman’s Hospital in New York City, 1857; Right, Dr. Sims’ first women’s hospital, Montgomery, Alabama (photographed in 1895 by Edward Souchon. Courtesy of the Reynolds Historical Library at the University of Alabama at Birmingham)

Dr. Sims had come to Alabama in 1840, at the age of 27, to open a new medical practice. He had closed his first practice in South Carolina after his first two patients, infants, had died, probably from cholera. Sims quickly developed a reputation as a skilled surgeon. In those days bleeding to death was a constant danger during surgery and Sims describes in his memoirs how he relied on speed in the surgical area to save his patients.

Sims’ speculum

Sims’ speculum

While widely known as the “Father of Modern Gynecology,” Dr. J. Marion Sims was quite frank in his memoirs about his initial distaste for the field: “If there was anything I hated, it was investigating the organs of the female pelvis.” Little was known of female anatomy at the time and, frustrated by what he couldn’t see in 1845 during his first case of an obstetric fistula, Sims turned a pewter spoon into a kind of duck-billed retractor. Describing the first use of the “Sims speculum,” he wrote, “I saw everything as no man had ever seen before. The fistula was as plain as the nose on a man’s face.” 

What he saw led Sims to believe he could find a way to repair a devastating condition that had plagued women for centuries. “I said at once, ‘Why cannot these things be cured?’” The case at hand involved the pregnancy of Anarcha, a seventeen-year-old slave girl who had been in labor for three days when Sims was called. He was not able to save the baby, and, days later, he observed that she had developed both kinds of obstetric fistulas: a vesico-vaginal fistula and a rectal-vaginal fistula. These can occur during long, obstructed labors when the infant’s head is too large to pass through the pelvic canal. The infant’s head traps the soft tissues of the pelvis up against the pelvic bone, cutting off the blood supply. When labor continues for several days, the tissues die. In a vesico-vaginal fistula, the wall between the bladder and the vagina breaks down and creates a hole, leading to uncontrollable urine leakage. In a rectal-vaginal fistula, the wall between the rectum and the vagina breaks, causing fecal leakage. The ensuing incontinence often produces infections, strong odors, and, over time, the painful inflammation and scarring of the inner legs. Fistula patients quite often become ostracized from family and friends, depressed recluses, unable to live in their homes.

“J. Marion Sims: Gynecologic Surgeon,” painting by Robert Thom, from the Great Moments in Medicine series, shows Sims with Anarcha, as Betsey and Lucy look on.

“J. Marion Sims: Gynecologic Surgeon,” painting by Robert Thom, from the Great Moments in Medicine series, shows Sims with Anarcha, as Betsey and Lucy look on.

To test his idea, Sims needed more patients with the same condition. We know from his records the names of two others, Betsey and Lucy. As Sims writes, “I made this proposition to the owners of the negroes: If you will give me Anarcha and Betsey for experiment, I agree to perform no experiment or operation on either of them to endanger their lives, and will not charge a cent for keeping them, but you must pay their taxes and clothe them.”

He kept them for five years. Each had a fistula and was experimented on several times, Anarcha perhaps as many as thirty times. When two years passed without a breakthrough, the white colleagues who had assisted Sims drifted away and he had to train his slaves to assist him in the experiments, including restraining patients during surgery, which was performed without anesthetic. Many became addicted to the opium he gave them to ease their pain.

Illustration from a contemporary medical textbook shows patient in “Sims position”

Illustration from a contemporary medical textbook shows patient in “Sims position”

By continually operating on these women, Sims perfected many of his techniques. To improve his ability to visualize the fistula, he invented the “Sims position,” when the patient lies on her left side with her left leg straight but flexing her right knee and hip, pulling the right leg up.

Sims eventually realized he needed something stronger to hold the repair. On June 21, 1849, he used fine silver wire on Anarcha for the first time. On day seven after the operation he re-examined her and found that the fistula had healed perfectly. Sims was ebullient: “I realized that in fact at last my efforts had been blessed with success and that I had made perhaps one of the most important discoveries of the age for the relief of suffering humanity.”

Sims would go on to a storied career as a surgeon in New York and Europe, but questions continue to rage about his contention that his patients consented to his experiments. Sims defenders make the case that these women had much to gain from these operations given the crippling effects of fistula and that no other treatment existed.

In Medical Bondage: Race, Gender, and the Origins of American Gynecology, historian Deirdre Cooper Owens presses the case that we understand Sims in his historical context:

“Gynecological surgeons during the early and mid-nineteenth century were neither exceptionally cruel nor sadistic physicians who enjoyed butchering black women’s bodies, as some scholars have argued. They were elite white men who lived in an era when scientific racism flourished. Ideas about black inferiority were established and widely believed, as was the underlying assumption about black people’s intelligence. Black women, particularly those who were enslaved, were a vulnerable population that doctors used because of easy accessibility to their bodies. Further, the value of black women’s reproductive labor demanded that it be “fixed” when it was seen as “broken” by those who depended on their labor.”

Many question why Sims did not use any anesthetic in his operations on slave women but later did so in New York when his clientele were mostly white women. Some contend that Sims believed that African American women had a higher tolerance for pain. Additionally, when he began his experiments in the 1840s, Sims may not have had full knowledge of what anesthetics were available. The first public lectures about nitrous oxide and diethyl ether did not take place until 1845 in Boston and their use did not become common in surgical practice until the 1850s. But even in the 1850s, Sims remained skeptical about the use of anesthesia. In a lecture to The New York Academy of Medicine in 1857, Sims remarked that the Sims position “permits the use of anesthetics if desired, but I never resort to them in these operations, because they are not painful enough to justify the trouble. “

Owens’ book presents an even-handed account, but importantly, much of the book turns our attention and appreciation to the unheralded experiences and contributions of the women Sims and others experimented on:

“Beginning with those nearly ten black bondwomen who labored under Sims as leased chattel, patients, and nurses, they serve as the counter to Sims’s designation as ’father’. They are the rightful ‘mothers’ of this branch of medicine.  . . . Their bodies enabled the research that yielded the data for white doctors to write medical articles about gynecological illnesses, pharmacology, treatment, and cures.”

The statue

The Sims statue when it stood on Fifth Avenue outside Central Park

The Sims statue when it stood on Fifth Avenue outside Central Park

Sims was the first medical professional to have a statue in his honor in New York City in 1894. It was first in Bryant Park and then moved to Central Park where it stood outside the New York Academy of Medicine on Fifth Avenue. In response to protests about the statue during the summer of 2017, Mayor Bill de Blasio charged the Public Design Commission with determining what should be done. In its January 2018 report, the commission was quite scathing in its recommendation that the statue be moved.

“In short, especially in its current location, the Sims monument has come to represent a legacy of oppressive and abusive practice on bodies that were seen as subjugated, subordinate, and exploitable in service to his fame. To confront this legacy in accordance with the principle of Historical Understanding, the Commission feels that the City must take significant action to reframe the narrative presented in the monument.” The status has been relocated to Greenwood Cemetery, where Sims is buried, and there are plans to add in both locations a plaque adding the names of Anarcha, Lucy, and Betsey along with a description of the roles they played in Sims’s life.

The state of obstetric fistulas today

In the developed world, ready access to obstetrical care, and especially caesarean section, have virtually eliminated the problem. However, fistulas remain an urgent problem in the developing world. The World Health Organization reports that more than two million young women live with obstetric fistulas in Asia and sub-Saharan Africa and 50,000 to 100,000 new cases occur each year.  When those afflicted are able to get timely access to quality obstetrical care, 80% to 95% of them can be repaired surgically.

BEHIND THE SHEET by Charly Evon Simpson, the 2019 EST/Sloan mainstage production, begins previews on January 9 and runs through March 10. Tickets are available here.

Recommended Reading

 Books

 Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present by Harriet A. Washington (Doubleday, 2007)

 Medical Bondage: Race, Gender, and the Origins of American Gynecology by Deirdre Cooper Owens (University of Georgia Press, 2017) Note: the opening to this essay was inspired by the opening of the introduction to Medical Bondage

 The Story of My Life by J. Marion Sims (D. Appleton & Co., 1884) 

 Journal Articles

 The medical ethics of Dr J Marion Sims: A fresh look at the historical record” by Lewis Wall in Journal of Medical Ethics, June 2006.

 “J. Marion Sims, the Father of Gynecology: Hero or Villain?” by Jeffrey S. Sartin, MD in Southern Medical Journal, May 2004.

 “A History of Obstetric Vesicovaginal Fistula” by Robert F. Zacharin in Australian and New Zealand Journal of Surgery, June 2008.

 “On the Treatment of Vesico-Vaginal Fistula” by J. Marion Sims in The American Journal of Medical Sciences, 1852. Reprinted in International Urogynecology Journal, 1998.

 “The medical ethics of the ‘father of gynaecology’, Dr J Marion Sims” by Durrenda Ojanuga in Journal of Medical Ethics, March 1993.

 Radio shows/Podcasts

 “Remembering Anarcha, Lucy, and Betsey: The Mothers of Modern Gynecology” on an episode of NPR’s Hidden Brain, February 7, 2017

 “The Controversial Figure of J. Marion Sims” Episode 51 of Legends of Surgery

 Websites

 J. Marion Sims in the online Encyclopedia of Alabama

 J. Marion Sims in Wikipedia

A Dr. J. Marion Sims Dossier at the University of Illinois – poets on J. Marion Sims

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Charly Evon Simpson on medical experiments on slaves, the birth of gynecology, lost voices, and BEHIND THE SHEET

Charly Evon Simpson

Charly Evon Simpson

On Tuesday, April 3, the EST/Sloan Project, as part of the 2018 First Light Festival will present the first workshop of BEHIND THE SHEET, the powerful new play by Charly Evon Simpson about how medical experiments on plantation slaves in Alabama in the 1840s led to the birth of the science of gynecology in America. The playwright has much to tell us.

(Interview by Rich Kelley)  

How did BEHIND THE SHEET come to be? How has it changed through different drafts?

Statue of J. Marion Sims at 103rd Street and Fifth Avenue in NYC

Statue of J. Marion Sims at 103rd Street and Fifth Avenue in NYC

A few years ago, I read an article about a group of women protesting at a statue of J. Marion Sims. As someone interested in how black women’s bodies have been seen and treated throughout history, I found myself trying to learn more about Anarcha, Betsey, and Lucy (the three enslaved women we know Sims experimented on) and how slavery intersected with the rise of gynecology. When it came time to apply for an EST/Sloan commission, my brain immediately went back to this history.

The play has changed since the proposal. For example, my first proposal included a more contemporary piece—a black woman gynecologist having to reconcile this history of her field. I soon decided to just focus on the history. Characters have come and gone, scenes have been cut and added, and history has made its way in and out of the story. My first draft was very true to what we know happened. This current draft allows a little more room for my voice and imagination, while staying true to the basic facts.

As you say, the play tells a story strongly inspired by the work of J. Marion Sims, a physician often referred to as the "father of gynecology" who practiced medicine in Alabama in the 1840s. He is credited with inventing the speculum and, most notoriously, trying out new gynecological surgical procedures on slaves without using anesthesia. But you don't use his name for your main character, whom you call George, and you give the female characters names different from the ones we know from history. Why the name changes? How is the story in the play different from Sims’?

“J. Marion Sims: Gynecologic Surgeon,” painting by Robert Thom, from the Great Moments in Medicine series, shows Sims with Anarcha, as Betsey and Lucy look on.

“J. Marion Sims: Gynecologic Surgeon,” painting by Robert Thom, from the Great Moments in Medicine series, shows Sims with Anarcha, as Betsey and Lucy look on.

I’ve gone back and forth on the name changes. And, you never know, perhaps the name changes won’t exist in a future draft, but for right now, it allows me some distance from the real story. It allows me to play as a writer in a way that I wasn’t able to when I was using their real names and really focused on getting every historical detail right. With the name changes, I am acknowledging that some of this is fiction. It is historical fiction. I am very aware that we don’t know what Anarcha, Betsey, and Lucy were thinking or saying. I have J. Marion Sims’ book, for example, and what he says about them, but I don’t have their words. And I didn’t want to put words in their mouths. I want to shed light on this history and I want to give voice to the experience from the women’s perspective. For me, it is easier to explore the possibility of their perspectives without using their real names. That said, we make a point at the end of the play to bring it back to Anarcha, Betsey, Lucy, and J. Marion Sims. I don’t want to lose them or ignore them. I want the audience to know their names.

Why this play? Why now?

In December 2017, ProPublica published an article entitled “Nothing Protects Black Women from Dying in Pregnancy and Childbirth.” The article is heartbreaking and shows how much more at risk black women are when it comes to pregnancy and childbirth. Education, income…when it comes to black women successfully carrying a child to term and surviving the childbirth and weeks after, it seems nothing is protecting us. In February 2018, Serena Williams shared her own struggles and complications after giving birth. There is a long history of our physical pain being ignored. There is a long history of black women being used for medical innovation while at the same time being ignored by medicine. This history, whether we like to acknowledge it or not, has influenced our current medical systems. And it is important to know the history so that we can make strides away from it. 

Women of all races are fighting for their reproductive rights and their healthcare right now, and I think it is important to acknowledge that some women have to fight particular fights that their counterparts do not. This is one of the fights. 

Illustration of Sims repairing a vesico-vaginal fistula with silver wire sutures (1870)

Illustration of Sims repairing a vesico-vaginal fistula with silver wire sutures (1870)

BEHIND THE SHEET features five black slave women and one black slave man. How did you come to decide how many different black slave voices you wanted to dramatize? Did the number or the kind of voices change over time?

To be honest, I’m not sure. It just happened. I started with only three black women, but also wanted to somehow honor the other women Sims experimented on whose names we don’t know. So I felt free to move away from the three women and add the voices that came to me. 

There is an article in The Journal of Medical Ethics that states that "Although enslaved African American women certainly represented a ‘vulnerable population’ in the 19th century American South, the evidence suggests that Sims's original patients were willing participants in his
surgical attempts to cure their affliction." What do you make of this statement?

My first instinct is that, sure, if you are in pain and someone offers you a possible way out of that pain, chances are you might be willing to agree to experiments aimed at curing you. That said, “willing” is a…complicated word to use in reference to enslaved people. The power dynamic alone complicates any ideas around the word “willing”. What does willing even mean when your rights have been stripped away and your body is often being used in service of other people? When one does not own their own body, and when their worth is attached to said body, how does consent work? If any of them said “no,” how do we think their owners may have reacted? Also, if there was any notion of willingness and if it was respected at first, was there any room for that “willingness” to end? When Sims took on the financial burden of taking care of these women who were “unfit” to do much of what was expected to them, are we sure he would have been willing to stop?  Anarcha, Betsey, Lucy, and the other women—along with J. Marion Sims—didn’t know it would take numerous surgeries to find a cure for fistulas. If Anarcha wanted to stop at surgery 15, would she have been able to? What may have been done to “convince" her to keep going? 

We have a tendency to want to make our history seem way more light, bright, and friendly than it actually is. History is complicated. I’d rather we live in the complications than ignore them. 

What do you want the audience to take away from BEHIND THE SHEET?

Front page of New York Daily News on February 8, 2018 reporting on relocation of Sims statue to Green-wood Cemetery in Brooklyn.

Front page of New York Daily News on February 8, 2018 reporting on relocation of Sims statue to Green-wood Cemetery in Brooklyn.

When director Colette Robert first read the play, she said she had to put it down because it made her stomach hurt. I don’t want to cause people pain, but I do hope the audience feels the discomfort, feels the complicatedness, feels the pain that is intertwined in our history. You can be grateful there is a cure for fistulas. You can also be disappointed that it was found at the expense of black women’s bodies. Holding those two feelings inside is possible and it is messy and it is uncomfortable and I want us to do it anyway. I hope the audience walks away feeling that messiness, thinking about that discomfort, and wondering what systems we may have in place that continue this history.

What kind of research did you do to write BEHIND THE SHEET? Did you work with a consultant?

I didn’t have a consultant. I read J. Marion Sims’ book, The Story of My Life. I read numerous articles, listened to talks (like "Remembering Anarcha, Lucy, and Betsey: The Mothers of Modern Gynecology" on NPR) and parts of books like, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present by Harriet A Washington. I read Patient. by Bettina Judd which is a book of poetry intertwining her experience as a patient with the experiences of Anarcha, Betsey, and Lucy (as well as other black women who found themselves in the role of patient under racist conditions). I went to talks. Then I had to stop researching and just write the play. I wanted to respect and honor the history, but I also knew I was creating a piece of fiction and so I had to find a balance. 

How is BEHIND THE SHEET different from your other plays?

BEHIND THE SHEET is my most historical play. I have plays, like my play Hottenttotted, that has historical figures in them or attempts to discuss/shed light on an aspect of history, but this play is the most historical in that it is set in the past and tries to stay true to certain aspects of the history in a very big way.

You have been a member of EST's Youngblood program.  What impact did being a member have on your writing?

I have to say that I think the biggest impact for me was not on my writing, but on my understanding and participation in the theater community. I became a member of Youngblood only two months after moving back to NYC. While I knew a few people from college and high school doing theater in the city, being in Youngblood allowed me to meet a wide variety of actors, directors, writers, stage managers, etc. Many of my first theater opportunities came from people I met at EST. They helped me find my footing and place and continue to even after nearly two years out of the group. 

What's next for Charly Evon Simpson?

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I have a few readings of new plays coming up in April and May with SPACE on Ryder Farm and Clubbed Thumb, respectively. Next January, my play Jump premieres at PlayMakers Repertory Company in North Carolina. And there are some exciting things happening in between!

The 2018 EST/Sloan First Light Festival runs from February 5 through April 6 and features readings and workshop productions of eight new plays. The climax of every EST/Sloan season is the annual Mainstage Production, which this year is the world premiere of BUMP by Chiara Atik. Directed by Claudia Weill, BUMP is a wildly entertaining exploration of the history of pregnancy and childbirth, from colonial times until now. Tickets are on sale now for performances, May 9 through June 3. The First Light Festival is made possible through the alliance between The Ensemble Studio Theatre and The Alfred P. Sloan Foundation, now in its twentieth year. 

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