Background material about the American influential obstetrician Dr. J. Whitridge Williams, and his role in portraying childbirth in white middle and upper-class women as a quasi-pathology process
This story was memorialized in a book published in 1914 entitled “Twilight Sleep: A Simple Account of New Discoveries in Painless Childbirth“.
It also was recorded in the annual publications of the AASIMP (American Association for the Study and Prevention of Infant Mortality1910 to 1923)
First a word about myself ~ When I graduated from nursing school in 1962, my first job was working nights as an L&D nurse in a busy obstetrical department that sometimes had a dozen births in
an 8-hr shift. I’ve often referred to this era as the “Dark Ages of the Deep South”, which is to say that our unit followed the same obstetrical protocols developed in the very early 20th century (1910 and 1920s) that you will read about in this post.
This began with the routine use of Twilight Sleep drugs – 100 mg of the narcotic morphine (replaced by Demeral in the 1950s) and 1/150th grain of scopolamine given IM immediately on admission and repeated q 2-3 hours until she was taken to the delivery room and narcosis was replaced by rendering her unconscious under general anesthesia.
The effect of this combination of drugs equates to a chemical lobotomy.
The woman’s personality and all executive function were simply erased, and many of these medicated labor patients became like caged animals desperately trying to escape. This frequently required me and the other nurses to use four-point leather restraints from the psychiatric unit to keep these mothers from biting or hitting the nurse, falling out of bed and breaking their arm, or otherwise hurting themselves.
were By 1910, hospital obstetrical protocols in America (but not in most other developed countries) called for all labor patients to give birth under general anesthesia. As soon as these patients were moved to the surgically outfitted delivery room, they were rendered unconscious under general anesthesia.
Then their OB doctor and a resident routinely performed a “generous” episiotomy, followed by the doctor inserting forceps up into the mother’s birth canal, and then in coordination with the L&D nurse providing a dangerously forceful form of “fundal pressure”, the doctors used the forceps to extract the unborn baby from its mother’s inert body.
Considering the amount of narcotics, the psychotropic drug scopolamine, and general anesthesia (chloroform or ether) that these unborn babies received from their mother via the placenta and umbilical cord, virtually none of them were respiratorily depressed, and far too many never breathed on their own, despite our best efforts to resuscitate them.
Manual removal of the placenta was also the norm, as well as suturing the episiotomy incision and being sure to include the “husband stitch” to return his wife’s vagina to its virginal state. Obstetricians explained that this was to keep husbands from coming back to them later and complaining that:
“Ever since my wife had the baby, having sex with her is like walking into a warm room”
Hence the invention of the infamous “husband stitch”.
My reporting reflects the fact that I was an up-close and personal witness to two very different and mutually exclusive protocols for childbirth services routinely provided healthy women with normal pregnancies to give birth in our hospital.
**** In the 1960s, the South was still segregated, so the whites-only ward was upstairs on 1-North and the all-black ward was in the basement next to the hospital laundry on 1-South. As a student nurse, I was frequently present as our black moms, who did not receive any kinds of pain medication or other drugs during labor, simply pushed out their babies and then reached down to pick up a vigorously crying newborn, exclaiming “Look what I did!”.
Needless to say, normal childbirth on 1-North as recounted above, was the polar opposite.
As a result of these unique experiences, I believe I am able to accurately describe the Twilight Sleep era and its consequences for healthy women with normal pregnancies. I define the combined effects of Twilight Sleep drugs, general anesthesia, routine episiotomy, forceps delivery, manual removal of the placenta, and perineal suturing as the most profound change in normal childbirth practice in the history of the human species.
When I think about this incredibly dangerous and inhumane system and its continuing contemporary effects, I know my job as a reporter and witness is far from finished.
Exploring the historic and contemporary consequences of the 1914 book: Twilight Sleep: Simple Discoveries in Painless Childbirth by Dr. J. Whitridge Williams, MD, written in collaboration with the famous science writer, Dr. H. Smith Williams, MD
Early in the 20th century, Dr. J. Whitridge Williams was the most influential American obstetrician of his era. He invented the economic engine — elective hospitalization of healthy maternity patients — that created our country’s hospital system as primarily a corporately-owned for-profit business.
The following report is based on a forensic* examination of the statements and information provided in Dr. JWW’s 1914 book Twilight Sleep: Simple Discoveries in Painless Childbirth, in conjunction with historical information taken from the published reports of the annual meetings American Association for the Study and Prevention of Infant Mortality (AASPIM) for 1910 thru 1915 and other historical and contemporary sources.
The information in Dr. JWW’s 1914 book and the annual meeting reports of the AASPIM were reviewed in conjunction with other published documents recording the historical practice of midwifery, obstetric, hospital-based obstetrical practices and the maternal-infant morbidity and mortality in the United States from the late 1890s to the early 1940s in juxtaposition to maternal and neonatal mortality rates in other similarly industrialized, wealthy and democratic countries.
Russian Nesting Dolls as a Metaphor
When this story is traced back to its beginning, it is like a set of Russian dolls that nestle together, each one containing a slightly smaller doll until you get the small figure in the middle. The story of 20th-century American hospitals begins with that smallest figure and generation after generation, it has re-iterated a deeply flawed system until the very last figure represents our current dysfunctional system in the second decade of the 21st century.
Over the last hundred or so years, the historic humanitarian principles traditionally associated with medical care have slowly disintegrated and been replaced by a corrupted system – that people set out to be corrupt but the aggregate effect was to functionally corrupt the systems so it was no longer had the ability to provide care based on humanitarian principles. This dysfunctional version was institutionalized as private for-profit hospitals that over the course of the 20th century have morphed into the current system of corporate-owned and run ’for-profit’ hospitals. Unfortunately, this also includes a significate number of supposedly non-profit hospitals that violate the spirit of the law by paying top executives $6 million-dollar annual salaries.
@@@@@@@@@@@@@ Mission Impossible @@@@@@@@@@@@@
Without knowing why, where, and how this distorted process started, it is impossible to understand how to fix it. From that standpoint, this essay might better be called:
“Mission Impossible: Fixing our hospital system by Understanding and Reversing the Effects of the historic decisions made by Dr. J. Whitridge Williams, the most influential obstetrician in America at the time, former Chief of Obstetrics at Johns Hopkins University Hosptial in Baltimore, the original author of the”Williams Obstetrics”, Dean of the University’s school of medicine.
According to information published in the 1914 book “Twilight Sleep”, Dr. JWW knew the US desperately needed a system of acute-care general hospitals. Since public funding was not an option (see info below about opposition by the AMA), Dr. JWW had to either find or create a new financial scheme (his words, not mine) able to underwrite such a country-wide and decades-long undertaking.
Western Europe had created an effective publicly-funded system of general hospitals centuries ago, but the American Medical Association (AMA) would never permit government funding — the despised “socialized medicine” — to be used in the US. Without state and federal funding, Dr. JWW knew the United States would be able to develop a comparable system of acute-care general hospitals. This would be a tragedy for patients who suffered needlessly or died because there were no acute-care hospitals within driving distance. This was also a travesty for our country, which Dr. JWW described as a rising star, soon to become a leader among the other wealth industrialize countries.
Faced with the impenetrable brick wall of organized medicine, Dr. JWW was forced to think outside the box and find a suitably private “workaround” for an undertaking that in every other wealthy country was publicly financed. Seen from Dr. JWW’s perspective, the only option for financing a nationwide system of a general hospital system – a complex undertaking that would take decades – was the three-step economic plan that he developed, promoted, and wrote about in his 1914 book. Luckily for him and the future patients of these new hospitals, his economic plan would, for the rest of the 20th century, finance the building and running of a nationwide system of acute-care general hospitals.
Dr. JWW’s Economic Plan in Three Parts
Dr. Williams started by creating a brand-new economic model for small and medium-sized private hospitals. This was a two-step process that began by urging small hospitals to rebrand themselves as dedicated lying-in hospitals and medium-sized hospitals to put in a new lying-in (maternity) ward in any available empty room or unused space. His goal was a lying-in hospital for every community over 3,000, which he said would be “…as ubiquitous, if not as numerous, as schoolhouses and libraries”.
Part 2 of Dr. JWW’s new economic plan began with his invention of “elective hospitalization” – a demographic of healthy hospitalized patients as paying customers. He instinctively knew that the perfect income-generating demographic for electively hospital patients was none other than healthy (white) middle- and upper-class childbearing women. All he had to do was convince white women whose families could afford to pay for hospitalization to eschew midwifery care at home and instead have their babies in the nearest privately-owned “lying-in” hospital or ward.
Following the Money
By hospital standards, the cost of hospital care for healthy childbearing women and the traditional 14-day “lying-in” period for new mothers and their newborns was (and still is), ridiculously inexpensive. The reason is obvious – healthy childbearing women are neither sick nor disabled.
The daily needs of maternity patients – generally a young and healthy bunch — were essentially hotel services easily provided by semi-skilled workers under the supervision of a nurse – a dry bed, clean sheets, a carafe of fresh water at her bedside, and three hot meals a day. What new mothers mostly did all day was to lie around (origin of the concept “lying-in ward”) breastfeeding their babies and chatting with the other new mothers in their ward.
Billed at the hospital’s usual “patient-day” rate, its maternity wards were extraordinarily profitable and generated a dependable revenue stream that paid for itself many times over and covered losses in other departments AND generously provided money for modernizing and expanding the hospital’s facility as Dr. JWW predicted.
Numbers Needed to Assure Profitability
Dr. JWW did extensive research on the demographic of childbearing women. According to him, the average county population in the United States was 20,000 inhabitants, and each county’s average birth rate was 700 annually.
Using these numbers, he calculated that if only half of the childbearing women in a county (350) could be convinced to give birth in a lying-in hospital ward, maternity care would become the goose that laid golden eggs for each of these hospitals.
Childbirth — A “two-for-one” gift!
One aspect of that equation is totally unique to maternity care — the obvious fact that every hospitalized pregnant woman performs the greatest of all magic tricks by ‘producing’ another human being, which immediately becomes another hospital patient(s) as newborns are admitted to the hospital nursery and charged separately as a hospital patient for services rendered.
Dr. JWW concluded that the annual patronize of just 350 women who gave birth at their local hospital would generate revenue of 9,800 “patient days”. This is the combined hospital charges for the new mother’s 14 days of lying-in services and the baby’s 14 days in the hospital nursery (ie. 350 women Xs 28 hospital days for each mother-baby pair = 9,800). This would be more than enough to keep the lying-in hospital in the black and enough extra to keep its doctor-owners fat and happy.
A very successful self-funding scheme that allowed hospitals to use the fees paid by well-off childbearing families to modernize their facilities and purchase capital-intensive medical equipment.
Dr JWW was convinced that his ideas for the elective hospitalization of healthy maternity patients precisely meet the needs of his economic plan. Since hospital maternity wards, were grinding out a new baby every hour of every day, 365 days a year, they would dependably provide a profitable economic engine that would underwrite the modernization of small and medium hospitals all across the country for decades to come.
However, it is important to pause for a minute and understand Dr. JWW’s economic plan at a granular level. Viewed strictly from that perspective, it was a brilliant trick in which hospitals essentially pulled a rabbit out of their own hat under circumstances in which the hospital was the hat and childbearing women (unfortunately) were the rabbit. Dr. JWW’s economic prescription was that small hospitals underwrite their own “first step” in the transformative process of eventually “growing” into general hospitals. In the modern sense of “Pay to Play”, they paid themselves to play.
Instead of using government funding to create the same kind of general hospital system enjoyed in Western Europe, or private money by suggesting that hospitals ask for a bank loan or line of credit to finance their new lying-in ward, Dr. JWW’s economic advice was to simply re-purpose their current facility or makeover an empty room or unused space into a lying-in ward.
This was a combination of: “don’t bite off more than you can chew”, coupled with a “start small and slowly get bigger” plan.
In that way, these tiny hospitals could literally “underwrite” (self-fund instead of big bank loans!) their own expansion. All they had to do was provide lying-in care and then use the revenue stream generated by providing maternity care to modernize, upgrade and remodel their facility. As these plans played out, smaller hospitals would logically merge with other small and medium-sized institutions to create a large general hospital that served several surrounding communities.
What seemed like a clever “Win-Win” solution
The ability of small hospitals to self-fund their own modernization was a”dream come true” for Dr. JW Williams, but even more important, it would provide access to the desperately-needed services of a general hospital to people living in small towns, farms, and rural areas all across the country.
Wonder of wonders, this self-funding economic mechanism could be endlessly repeated all over the country, this would provide the United States with its much-needed nationwide system of acute-care general hospitals, while the high-profit margins of hospital maternity wards would continue to be the cash cow that easily made up for losses in the hospital’s other departments, as well as providing generous executive salaries and future expansion.
What was not to like about that?
Romancing the Obstetrical Ego — clinical “material” for medical students
Even more exciting to Dr. JWW as a former professor of obstetrics was the opportunity for larger institutions to use their maternity patient population as an inexhaustible pool of “obstetrical material” (i.e. the warm bodies of laboring women as teaching cases) for the new clinical training programs for medical students. Prior to this, the typical medical school in the US provided little if any clinical training, which meant doctors graduated from medical school having watched other doctors deliver 5 or 6 babies. If they wee exceptionally lucky, they might get to “catch” a couple of babies but had no actual clinical training in managing the various complications sometimes associated with labor and birth.
This was particularly important because the obstetrical profession in the early 20th century was looked down on by the larger medical community, and frequently became the target of insults and mean jokes by other doctors.
One particularly telling example occurred during a 1911 meeting of the American Association for the Study and Prevention of Infant Mortality. The topic was the dire need for, and positive consequences of, better obstetrical training for medical students. Dr. J. Whitridge Williams (author of “Williams’ Obstetrics”) prophesized that when the “appropriate” educational goals of obstetrics were finally accomplished:
“No longer would we hear physicians say that they cannot understand how an intelligent man can take up obstetrics, which they regard as about as serious an occupation as a terrier dog sitting before a rat hole waiting for the rat to escape” (TAASPIM Dr. JWW, 1911-B)
As an obstetrician, that imagery of a dog waiting before a rat “hole” for the rat to ‘escape’ was a humiliation not soon forgotten and never forgiven. But despite Dr. JWW’s best efforts to the contrary, the vast majority of medical doctors believed that attending normal “cases of childbirth” was clearly “woman’s work”. That pejorative gender association meant that doctors who provided attended births were considered to be mere “man-midwives” and certainly not practitioners of the high arts of modern medicine!
In this 1915 comment, Dr. Joseph DeLee, the other obstetrical Titan of the early 20th century and famous as founder of the Chicago Lying-in Hospital for immigrant women, and author of “The Principles of Obstetrics”, also acknowledged the low status of the obstetrical profession, which he blamed squarely on midwives:
Obstetrics is held in disdain by the [medical] profession and the public. The public reasons correctly. If an uneducated woman of the lowest class is instructed by doctors and licensed by the State certainly it must require very little knowledge and skill — surely it cannot belong to the science and art of medicine. [1915-C, p.117]
In a paper published in AAOG titled “The Teaching of Obstetrics”, Dr. DeLee doubled down on his unbridled excoriation of midwives:
The midwife has long been a drag on the progress of the science and art of obstetrics. Her existence stunts the one and degrades the other. For many centuries she perverted obstetrics from obtaining any standing at all among the science of medicine.
The midwife is a relic of barbarism. In civilized countries, the midwife is wrong, and has always been wrong. The greatest bar to human progress has been compromise, and the midwife demands a compromise between right and wrong. All admit that the midwife is wrong. [TASPIM- 1915-C; p 114]
If the profession would realize that parturition [childbirth], viewed with modern eyes, is no longer a normal function, but that it has imposing pathologic dignity, the midwife would be impossible to mention.” [1915-C; p.117]
Sadly, the professional bravado of Drs. JWW, DeLee, and several other influential obstetricians did not make the poor performance of the American obstetrical profession go away. When compared to other 1st world countries in Europe and the Americas, the US had the second* high rate of maternal deaths and birth injuries in newborns during that period. {** Brazil had 1st place for childbirth-related deaths}
While Dr. JWW and other leaders in the obstetrical field insisted that was the result of midwife-attended home births, the actual statistic found the highest rate to be for doctor-attended hospital births.
This reflects two very negative realities – the high rate of routine interventions in labor (use of Twilight Sleep drugs) and the conduct of the “delivery” as a surgical procedure that included general anesthesia and routine use of invasive procedures of episiotomy, forceps, and manual removal of the placenta. As inherently risky as these interventions are in the hands of experienced obstetricians, they were frequently a disaster in the hands of unsupervised medical students and new graduate MDs in an era that had so little clinical training.
In many medical schools, its students only stood by while 5 or 6 women gave birth and were never actually responsible for managing a birth before they graduated. Dr. JWW reported that one professor of obstetrics admitted that he’d never even seen a baby be born before being appointed chief of obstetrics.
Nonetheless, licensed medical doctors were legally permitted to perform any procedure or operation, no matter how risky, even ones they were not taught or never even saw performed while in medical school. Doctors often gave general anesthesia to healthy women and routinely performed mid- and high-forceps deliveries to ‘save time’. This dramatically increased number of complications and preventable deaths for both mothers and babies.
As a result, the country’s most influential obstetricians, including Dr. JWW and other famous obstetricians who spoke at the annual meeting of the American Association for the Study and Prevention of Infant Mortality (AASPIM ~ 1910-1915) talked endlessly about how “appallingly” bad the training and practice of most American doctors was when it came to managing childbirth. Year after year, they espoused an endless stream of suggestions in hopes of quickly turning this situation around and redeeming the reputation of the obstetrical profession.
In addition, there was the intensely embarrassing fact that professional midwives in European countries had far better outcomes than medical doctors in the US, which had the 2nd highest MMR in the world (Brazil being the highest). All agreed that obstetrical education had to be drastically overhauled, starting with the creation of clinical training programs in large hospitals, with students supervised by an obstetrical professor from a nearby medical school.
Dr. JWW and his peers believed that clinical training programs, to be successful, required unlimited access to an unlimited supply of “obstetrical teaching material” – i.e. childbearing women as hospital patients whose labors, births, and postpartum care could be used to advance medical education.
Medical students would “practice” (in the most elemental definition, as in “to practice the piano”) on these women as if they were lab monkeys or bio-medical mannequins that didn’t feel pain, whose consent and dignity were both irrelevant and no matter how egregious that student’s mistake, these women would never die or become permanently disabled.
Nonetheless, the expected proliferation of maternity patients in larger hospitals was welcomed as providing a steady supply of “teaching cases” for these clinical programs. Thus Dr. JWW’s plan to hospitalize large numbers of maternity patients was viewed as greatly improving the ability and skills of its doctors, which in turn would elevate the reputation and status of obstetricians to that of other medical specialties.
However, obstetrical education too often did not have the effect Dr. JWW hoped for and expected. A 1933 study by the New York Academy of Medicine reported 2,041 maternal deaths in physician-attended childbirth and found that:
“At least two-thirds [or 1,361 of the maternal deaths] the investigators found, were preventable. … newborn deaths from birth injuries had actually increased. … Investigators were appalled to find that many physicians simply didn’t know what they were doing: they missed clear signs of hemorrhagic shock and other treatable conditions, violated basic antiseptic standards, tore and infected women with misapplied forceps. Hospital care brought no advantages; mothers were better off delivering at home.”
The 1931 White House Conference on Child Health and Protection by the Committee on Prenatal and Maternal Care (Dr. Reed ~ 1932) concluded:
“…that untrained midwives approach and trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child.
On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course.”
However, in 1914, Dr. JWW couldn’t know how limited the effect of advanced obstetrical education would be in the following decades. As the author of Twilight Sleep: Simple Discoveries in Painless Childbirth, and inventor of an economic plan that first created a nationwide system of self-funding lying-in hospital wards and then catapult from there to a nationwide system of self-funding general hospitals, he saw all this as a ‘win-win’ situation.
As a result, Dr. JWW increased the energy he put into his grand plan for financing a nationwide system of general hospitals, beginning with more lying-in wards and more childbearing women as paying customers who very conveniently also served as “obstetrical material” (shortened by many obstetrical writers of the day to just “material”) for the education of medical students and dramatic improvement of the obstetrical profession’s economic and social status.
Childbearing families – the national ATM for building general hospitals
Apparently, Dr. JWW was confused, or perhaps simply thought it unwise to acknowledge the actual source of the so-called “self-funding” of lying-in hospital wards, which was never money provided by the doctors who owned these lying-in wards, but instead came from the childbearing families who paid a disproportionately high fee for the simple services they’d been tricked into receiving.
This system of voluntary patronage of hospital lying-in wards did not happen by accident but was a direct result of a well-funded public relations campaign that went on for decades, often as stories written by obstetrical ‘experts’ and published in newspaper columns and popular women’s magazines. Most important was the string of large and small lies endlessly repeated about midwives and old-fashioned “country doctors”, along with pro-obstetrics propaganda and shamelessly scare tactics.
In the background, the decades-long manipulation of well-off middle- and upper-class families marched on, accompanied by an outspoken obstetrical propaganda campaign. It was a one-two punch, as parents were first scared into abandoning their traditional and safer birth attendants (midwives and GPs), then convinced that over-priced hospital services were the much better and more ‘modern’ way to have a baby.
Unfortunately, this included the promise of a “painless childbirth”. However, these women were never told what that actually meant or what would actually happen to them during their labor and birth. The actual answer was routine and repeated doses of mind-altering drugs, strong narcotics, and chloroform general anesthesia that would pass thru the placenta. This often meant their babies were not able to breathe on their own after being born.
They also weren’t told that having a baby in many large hospitals meant providing their drugged and anesthetized laboring bodies to become “obstetrical material” for medical students – all without their informed consent.
In addition to laboring under Twilight Sleep’s amnesic and hallucinogenic drugs, they would be giving birth under the dangerous effects of chloroform, as a profoundly unconscious and totally inert physical body, while the OB doctor (or medical student, intern, or resident) cut a ‘generous’ episiotomy and extracted their baby with forceps and may or may not have been able to breathe on its own.
The “clever win-win” solution that really was a “we-win-big-while-you-lose” proposition
Instead of a nationwide general hospital system funded by public tax dollars, which is to say, a small financial burden distributed across the entire population and including billionaires and those of modest means in which we all pay our ‘fair share” to be able to access the life-saving services of a general hospital within reasonable driving distance, generation of childbearing families, from 19114 to 2023, would continue to pay the big bills for induces labors, obstetrical interventions, Cesareans surgeries and other interference we didn’t need, as well as the very highest maternal mortality rate in the industrialized world just because Dr. JWW tapped childbearing women on the shoulder in 1914 as part of a new economic model for hospitals, and declared “tag, you’re it”. Then he left us as childbearing women holding the bag.
For a century, childbearing families have been paying a disproportionately high level of the hospital’s expenses, which now include a six or even seven-figure salary for the hospital’s top executives, while the AMA, which was the reason that Dr. JWW had to invent this complex ” workaround” in the first place, are laughing all the way to the bank.
