Twilight Sleep: Simple Discoveries of Painless Childbirth ~ Chapter 6 (1914)

by faithgibson on September 9, 2013

Twilight Sleep

A Simple Account of New Discoveries
in Painless Childbirth

By Henry Smith Williams, B. Sc, MD, LLD ~ 1914

Written in collaboration with Dr. J. Whitridge Williams,
author of “Williams’ Obstetrics’



            It is peculiarly appropriate that the test which will probably determine the availability in this country of the twilight sleep should be made at the Johns Hopkins Hospital; both because this institution stands admittedly first as a seat of research and education among institutions of its kind in America, and because Dr. Williams, its chief obstetrician, is the most aggressive advocate of new standards and methods of medical research and instruction with regards to the betterment of the condition of women in all that pertains to their sexual functions.

It chances that Dr. Williams has written extensively on this subject, and delivered addresses on it before bodies of his confrères, and that his views are so radical and so vigorously expressed as to have attracted wide attention; while his own personality and the position he occupies insure respectful attention for any views he promulgates.

I cannot do better here than very briefly to summarize these views of Dr. Williams as to the needs of American women.

In so doing we shall be led to see that the matter of painless childbirth, which I have hitherto used as a text, is after all only one of several questions that concern the interests of women in the relation of motherhood.

Few subjects could be of greater importance or of wider appeal, and for most of us Dr. Williams’ sober presentation of facts and analysis of conditions will have the effect of a somewhat startling revelation.  And what is equally or perhaps more to the point, we shall see that the analysis of conditions is followed by suggestions as to possible remedies.

Things are not what they should be with the women of America.  That fact should make universal appeal.  But things may assuredly be bettered if we will take the right action, and that fact should make still stronger appeal.

The peculiar ills to which women are subject in virtue of their sex are so familiar that we are apt to overlook their number and their importance.  Dr. Williams called attention to some of them in a recent address before the American Association for the Study and Prevention of Infant Mortality, and he emphasized others in a private conversation.

“Have you ever considered,” he said, “the economical significance of the fact that three out of every five women are more or less incapacitated for several days each month, and that one of them is quite unable to attend to her duties.  Granting that the two sexes are possessed of equal intelligence, it means that women cannot expect to compete successfully with men.  For until they are able to work under pressure for thirty days each month, they cannot expect the same compensation as the men who do so.”

The pregnant woman is subject to a multitude of dangers, some of which are by no means insignificant.  Overlooking the minor ills of the earlier period, with the danger of miscarriage and its attendant complications, there are frequently serious disturbances of the physiological functions in later stages when pressure on the kidneys and on the large vessels of the abdomen may lead to very grave interference with the normal functions of excretion, resulting, in exceptional but by no means rare cases, in actual toxemia that may even threaten life.

During parturition, not alone is the woman afflicted with the excruciating pains to which we have all along referred, but she is subject to the danger of serious lacerations of the cervix of the uterus, or of the perineum; there may occur contusions involving the wall of the bladder; and there is always the possibility of the condition known as placenta praevia, with attendant certainty of severe hemorrhage.

Then in the puerperal period immediately following delivery, there is danger of infection, now fortunately minimized by modern asepsis, but formerly a menace of appalling significance; there is the possibility that the uterus may not contract and resume its normal size; and there is a chance – becoming a reality with every third or fourth woman – that the uterus will become displaced, in which case, if the displacement is not early corrected, it becomes a permanent source of discomfort and even serious illness, remediable only by a severe operation.

Moreover, a large number of women are subject to peculiar dangers because of abnormalities (usually contraction) of the pelvis.  “It is my experience,” says Dr. Williams, “that eight per cent. of white and thirty-three per cent. of black women going through my hands have abnormal pelves.  Of course the minor grades may not do much harm, while the marked degrees are usually recognized; but the trouble comes in the large group lying between the two extremes, which is ordinarily recognized only after serious trouble has occurred, and when it is too late to obtain ideal results.”

If we add that the pelvic organs are peculiarly subject to become the seat of fibroid tumors, and of malignant growths, and that some of these are almost certainly stimulated to abnormal activity by incidents attendant on child bearing; reflecting further that cancer of the pelvis claims by death a really appalling percentage of the women who reach middle life, – the list of ills to which woman is subjected by her reproductive organs is by no means completed, but is rendered sufficiently impressive for our present purpose.

We are often enough reminded of the profound truth that mothering the race is a glorious function.  It would not be amiss to recall somewhat more vividly an allied truth – that being a mother is a rather dangerous vocation.


            And what, meantime, has been done in this boasted age of scientific medicine, to remedy the incidental evils and minimize the dangers of motherhood?

I can best answer that question by quoting verbatim from recent utterances of Dr. J. Whitridge Williams, that there may be no possible question about the authenticity of the verdict:

“Those who are not familiar with medical topics,” says Dr. Williams, “will be surprised to hear that we are almost as ignorant concerning the significance of menstruation and of the cause of labor as were Adam and Eve’s first children; that difficult menstruation which disables millions of women several days each month is as great a problem to us as to our forefathers, except when due to some gross lesion that can be removed by the knife; that we are grossly ignorant concerning the cause of most of the abnormalities of pregnancy, which we are therefore obliged to treat empirically, and that we know practically nothing concerning the mode of production and the means of preventing displacement of the womb.

Then as to the medical supervision of childbirth itself, Dr. Williams has something to say that is even more startling.  In the course of the address before the American Association for Study and Prevention of Infant Mortality (AASPIM), already referred to, he said:

“In this country, and to some extent in Great Britain as well, obstetrics has suffered greatly from the so-called maternity hospital, with its narrow ideals and its restricted opportunities.  Doubtless, most of the non-medical members of this audience believe that American women are the recipients of the most expert obstetrical care in the world, and that obstetrics has attained its highest development in this country.  I am here to tell you that such is not the case; and, while I have no desire to deny that there are many expert obstetricians, I have no hesitation in stating that in this country obstetrics is the most poorly taught of all the major branches of medicine, and that the average practitioner leaves the medical school very poorly equipped to carry on this important part of his work.

“This is due to no fault of his own, but is attributable to the peculiar development of medical education in this country.  Until recently the medical schools were entirely in private hands and not under the control of strong universities.  Anyone was considered good enough to be made a professor of obstetrics, and was very fortunate if charitable persons made it possible for him to direct a small lying-in hospital, where he might enlarge his own experience and give meager instruction to his students.  Even now, after the stronger schools have come under the nominal or actual control of the universities, somewhat similar conditions prevail, and at the moment I know of only one school in this country that possesses adequate facilities for the instruction of its students.”

“As the professors are usually poorly paid, they are obliged to devote the greater part of their energy to making a living by private practice, and necessarily regard the conduct of the small lying-in hospital and the training of students as a very secondary consideration.  Faulty training, meager facilities and lack of time make it impossible for them to investigate the fundamental problems of the subject, with the result that our professors are the least productive in the world and have contributed practically nothing to the scientific side of their profession.  I am sure that you will be surprised when I tell you that I know of only two Americans who have made fundamental contributions to the subject and neither of them were obstetrical teachers.”

The results of the investigation which Dr. Williams epitomizes in the address just noted were published in the Journal of the American Medical Association for January 6, 1912.  Therein were detailed the results of a questionnaire containing some fifty questions concerning obstetrical education and the midwife problem, which was sent to the professors of obstetrics throughout the country, and to which 43 sets of replies were received, “representing one-half of the acceptable and one-fifth of the non-acceptable medical schools,” and indicating, so Dr. Williams declares, “a most deplorable condition of affairs, briefly as follows:

“1.  Generally speaking the medical schools are inadequately equipped for teaching obstetrics properly, only one having an ideal clinic.

“2.  Many of the professors are poorly prepared for their duties and have little conception of the obligations of a professorship.  Some admit that they are not competent to perform the major obstetric operations, and consequently can be expected to do little more than train men-midwives.

“3.  Many of them admit that their students are not prepared to practice obstetrics on graduation, nor do they learn to do so later.

“4.  One-half of the answers state that ordinary practitioners lose proportionately as many women from puerperal infection as do midwives, and over three-quarters that more deaths occur each year from operations improperly performed by practitioners than from infection in the hands of midwives.

In commenting at length on the different aspects of the matter, as revealed by his investigations, Dr. Williams says:

“The replies clearly demonstrate that most of the medical schools included in this report are inadequately equipped for their work, and are each year turning loose on the community hundreds of young men whom they have failed to prepare properly for the practice of obstetrics, and whose lack of training is responsible for unnecessary deaths of many women and infants, not to speak of a much larger number, more or less permanently injured by improper treatment, or lack of treatment.”

“I do not wish to convey the impression,” he adds, “that all practitioners are included in this condemnation, as I am glad to say that I know many, and there are thousands of others in the country, who, from natural ability or from extensive experience and study, are thoroughly accomplished in the management of all but the most complicated cases.  Furthermore, I desire to go on record as stating that the average practitioner is not entirely to blame for his ignorance in obstetric matters, as he is usually as benevolent, as intelligent, and as anxious to do good work as any one else.  The fault lies primarily in poor medical schools, in the low ideals maintained by inadequately trained professors, and in the ignorance of the long-suffering general public.”


            As to the last named point, Dr. Williams has some pertinent things to say that are peculiarly interesting in the present connection.

“The public should be taught,” he declares, “that only the well-to-do, who can afford to employ competent obstetricians, and the very poor, who are treated free in well-equipped lying-in hospitals or out-patient departments, receive first-rate attention during childbirth; while the great middle class, and particularly those at its lower end, is obliged to rely on the services of poorly trained practitioners. 

It should be taught that while pregnancy and labor is normally a physiologic process, it is not always so, but is liable to so many aberrations and abnormalities that the pregnant woman should early place herself under the care of an intelligent physician who may detect and cure in their early stages many complications, which, if neglected, might place her life and that of her child in serious jeopardy.

“The laity should also learn that most of the ills of women, with the exception of those due to tumors and gonorrhea, are the result of bad obstetrics, and could have been prevented, or at least materially mitigated, had they received proper attention at the time of labor or during the weeks immediately following it.  Stress should also be laid on the fact that obstetric operations are not trifling, but are fraught with grave danger to mother and child, and that the more serious ones should be performed only by experts, preferably in well-conducted hospitals.

“Every effort should be made to emphasize the great responsibility which the obstetrician must bear in the management of abnormal cases. The public must be taught that the conduct of labor complicated by a moderate degree of pelvic contraction is quite as serious as a case of appendicitis, and that its proper management requires the highest degree of judgment and skill, while eclampsia or placenta previa are even more serious.  At present, however, the average practitioner does not recognize the existence of the former until irreparable damage has been done, and usually considers himself quite competent to treat the latter, instead of immediately placing his patient under expert care, as he would were she suffering from even a minor surgical ailment.

“The public should also learn that the repeated birth of dead children indicates ignorance or neglect, and can in great part be prevented under proper care; and furthermore that the development of ophthalmia in the children indicates neglect of the most rudimentary precautions.

“The laity should also be taught that a well-conducted hospital is the ideal place for delivery, especially in the case of those with limited incomes.  Moreover, they should learn that the average compensation for obstetric cases is usually quite inadequate; and should realize, although I regret to confess it, that doctors who are obliged to live on what they earn from their practice cannot reasonably be expected to give much better service than they are paid for.

I think I may safely state that obstetric fees are generally as much too low as those for many gynecologic and surgical operations are absurdly high.  I am loath to mention so sordid a matter, and I do so at the risk of being misunderstood, but I know from my own experience that many well-to-do patients object to paying as much for the conduct of a complicated labor case, as for the simplest operation which involves no responsibility.

“Finally, the laity should be impressed with the fact that the remedy lies in their hands, and that they will continue to receive poor treatment as long as they do not demand better.  Moreover, as long as they choose their medical attendant by the way he curls his mustache, or on the recommendation of some foolish or ignorant woman, they will get what they deserve.  If they desire competent attention, they should go for advice to conscientious medical men.

I have not space here, nor would it comport with the main object of the present work, to quote in detail, as I should like to do, Dr. Williams’ suggestions as to remedies needed to meet the really amazing condition of things which his questionnaire revealed.  Something more as to practical remedies will be said in the ensuing chapters.  Here I must be content to quote in the briefest summary the reforms which Dr. Williams names as in his opinion the most urgently needed and most important.  He summarizes them thus:

“1.  Reduction in the number of medical schools, with adequate facilities for those surviving, and higher requirements for admission of students.

“2.  Insistence in university medical schools that the head of the department be a real professor, whose prime object is the care of hospital patients, the proper training of assistants and students and the advancement of knowledge, rather than to be a prosperous practitioner.

“3.  Recognition by medical faculties and hospitals that obstetrics is one of the fundamental braches of medicine, and that the obstetrician should not be merely a man-midwife, but a scientifically trained man with a broad grasp of the subject.

“4.  Education of the general practitioner to realize that he is competent only to conduct normal cases of labor, and that major obstetrics is major surgery, and should be undertaken only by specially trained men in control of abundant hospital facilities.

“5.  The requirement by state examining boards that every applicant for license to practice shall submit a statement certifying that he has seen, delivered, and personally examined, under appropriate clinical conditions, at least ten women.

“6.  Education of the laity that poorly trained doctors are dangerous, that most of the ills of women result from poor obstetrics, and that poor women in fairly well-conducted free hospitals usually receive better care than well-to-do women in their own homes; that the remedy lies in their hands and that competent obstetricians will be forthcoming as soon as they are demanded.

“7.  Extension of obstetric charities – free hospitals and out-patient services for the poor, and proper semi-charity hospital accommodations for those in moderate circumstances.

“8.  Greater development of visiting obstetric nurses and of helpers trained to work under them.

“9.  Gradual abolition of midwives in large cities and their replacement by obstetric charities.  If midwives are to be educated, it should be done in a broad sense, and not in a makeshift way.  Even then disappointment will probably follow.”

Here, obviously, are suggestions for a comprehensive educational campaign, – a campaign involving the interests of every woman in the land, and therefore calculated to make the most universal and the most insistent appeal.  Let us inquire specifically as to practical ways in which this appeal may be met in the interests of the mothers and wives and daughters of the race.

Continue: Chapter 7