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”

CHAPTER VII

WHAT THE AVERAGE LAYMAN CAN DO

            It will have been gathered from what was shown in the preceding chapter that there is an urgent need for improvement here in America of the facilities for the investigation and teaching of the practicalities of obstetrics.

We are told by the highest authority that the average young man who goes out with his degree of M.D. to practice his profession has had no opportunity to acquire adequate practical knowledge of the routine practise of delivering a woman of a child, should the accouchement chance to be one that departs in the slightest degree from the normal.

With the average practitioner, it is not a question of capacity to deal with the niceties of administering drugs to produce painless childbirth; it is a question of being able to carry the mother through the ordeal with safety to life itself, and with a reasonable regard for her future physical welfare.

And even if the average practitioner were thoroughly competent to meet these conditions, the safety of the average woman in parturition would be by no means assured, because it is matter of record that in many of our larger cities from 40 to 60 per cent. of all deliveries are made by midwives without the attendance of a legally qualified practitioner of medicine.

To be sure, we are told that midwives on the whole get along as well with the average normal case as does the average doctor; but who is to guarantee that any given case will be normal; and who will be satisfied with conditions that subject a majority of women – or for that matter a small minority – to needless dangers in the performance of this most sacred function of maternity?

But what, practically speaking, is the remedy?  How can it be arranged that all women, or a large percentage of women, in particular that middle class which we are told now suffers most, shall be given skilful medical attention in childbirth, and assured the best chance of passing through the ordeal in safety, whatever complications may arise?

Needless to say the change cannot be brought about in a day or in a year, or by ipse dixit of any individual, or any legislative edict.  Yet I believe that much can be accomplished in almost every community toward bettering conditions rather rapidly if a general interest can be aroused and the right sort of cooperation secured among citizens of all classes.

The matter of better medical education is one that obviously concerns a few leaders rather than the masses.  I shall have something more in detail to say about this presently.  But first I wish to inquire what the layman can accomplish, individually and collectively, toward bettering conditions in his own community.

            The answer is found, I think, in Dr. Williams’ suggestion that there should be an “extension of obstetric charities – free hospital and out-patient services for the poor, and proper semi-charity hospital accommodations for those in moderate circumstances.”

Let us briefly inquire just how this may be interpreted, and how such a project may be put in operation.

OBJECTIONS FROM WOMEN

            Of course there will be difficulties in the way of carrying out such a scheme, with its implied sojourn in a hospital for the great majority of women during their accouchement.

The chief objections will come from the women themselves. 

Indeed, this is about the only opposition that need be considered.  Woman is the ruler in America, and what she wishes is never denied her.  So it remains only to gain the assent of women to put the project for the wide extension of a lying-in service in line of application.

But, as I said, it will not be easy to gain this assent.  A large number of women, at the outset, will declare that the bearing of children is a natural and physiological function, and that no woman worthy to be a mother should care to minimize its dangers or to shun its pains.

But this is only a reminiscence of an archaic spirit the illogicality of which I have attempted to show in the earlier pages of this volume.

That word “physiological” has all along stood as a barrier in the way of progress.

Of course the bearing of children is a physiological process; all the functions associated therewith are physiological in one sense of the word.  But a physiological function that involves danger to the life and health of the individual; causes her months of illness and hours of agony; keeps her in bed for two or three weeks; subjects her to a series of surgical operations, and perhaps leaves her permanently incapacitated for normal activities – such a process is not a normal one, whether or not it be physiological.

The truth is that in assuming an upright posture and in developing an enormous brain, the human race has so modified the conditions incident to child-bearing as to put upon the mother a burden that may well enough be termed abnormal in comparison with the function of motherhood as it applies to other races of animate beings.

Moreover, the cultured woman of today has a nervous system that makes her far more susceptible to pain and to resultant shock than was her more lethargical ancestor of remote generations.

Such a woman not unnaturally shrinks from the dangers and pains incident to child-bearing; yet such cultured women are precisely the individuals who should propagate the species and thus promote the interests of the race.

The problem of making child-bearing a less hazardous ordeal and a far less painful one for these nervous and sensitive women is a problem that concerns not merely the women themselves, but the coming generations.  Let the robust, phlegmatic, nerveless woman continue to have her children without seeking the solace of narcotics or the special attendance of expert obstetricians if she prefers.  But let her not stand in the way of securing such solace and safety for her more sensitive sisters.

EVEN THE STRONGEST WOMEN ARE MENACED

            But, for that matter, even the woman whose constitution is such that she seems to suffer little during pregnancy, and whose nerves are so adjusted that she dreads but little the pains of childbirth, may need the attention of a skilled obstetrician no less acutely than another woman of quite different temperament.

For her robustness of physique and phlegmatic of temperament will not shield her from the danger of hemorrhage if the placenta that supplies the lifeblood to her child chances to be lodged near the mouth of the uterus; her very strength may cause the rapid delivery that will make her peculiarly subject to laceration of the tissues; and her womb in regaining its natural size may suffer a displacement that, if not corrected, will make her a chronic invalid.

As to all these, and a number of other less familiar conditions, the presence or absence of a skilled obstetrician may determine the difference between safety and health on one hand, and danger and invalidism on the other.

Take, as a single illustration, the matter of displacement of the uterus. I have quoted Dr. Williams to the effect that no one knows just why such displacements occur, or in what cases they are likely to occur.  What we do know is that in a certain large proportion of cases, such a displacement does occur in the course of the few weeks succeeding delivery.  And Dr. Williams is authority for the statement that the displacement may ordinarily be remedied effectually and permanently by the simple expedient of using a supporting pessary for a few weeks, if the condition is diagnosed at once and the remedial agency employed.

If the service of the lying-in hospital had no other merit than the single one of assuring to each other mother the normal involution, and retention of normal placement of her uterus, its service in the interests of the health and welfare of women would still be enormous.

Again there are hundreds of thousands of women who go through life with gross lesions, incurred in childbirth, that would be immediately corrected by any skilful obstetrician, yet which are allowed to go untreated, partially incapacitating their victims.  Every gynecological surgeon has had experience in cases of this sort, where a woman has suffered for perhaps thirty or forty years before she finally sought assistance, becoming more and more crippled and menaced by a lesion that could have been permanently cured at the outset by a half dozen stitches.

But it is needless to elaborate.  I have already quoted Dr. Williams to the effect that the major part of the surgical operations with which so large a number of gynecologists are busied are made necessary solely by the inefficient or inappropriate treatment of women in childbirth.  A considerable proportion of nervous disorders have the same origin.

What an incalculable boon and blessing it would be, then, if conditions could be so altered that every woman brought to childbed might be insured efficient and skilful service in carrying her through the ordeal that the performance of this physiological function imposes upon her.

And this can be accomplished in no other way that has been suggested, except by the extension of a lying-in service far beyond the bounds of anything that has hitherto been attempted.

A LYING-IN SERVICE FOR SMALL TOWNS

            The promoters of such a service must have in mind the needs not merely of the residents of cities, but of the population of small towns and of the rural districts.  Indeed, perhaps it is the latter that preeminently require attention.

To meet their needs, it would be necessary to have a small lying-in hospital located in every town of three or four thousand inhabitants.

At first thought, this seems an ideal impossible of realization.  But if we consider the matter with attention, without for a moment overlooking the practicalities, we shall see, I think, that such a project by no means presents insuperable difficulties.

Suppose, for example, we consider the conditions in a typical county of one of the states of the Mississippi Valley.  Such a county, let us say, will be about twenty-five to thirty miles square, and will have a population of about twenty thousand.  The county seat is a town of from three to five thousand inhabitants.  There are half a dozen smaller towns, some of them mere villages, scattered throughout the county, making up something less than half the population; the remainder being pretty evenly scattered on farms throughout the entire territory.

In a population of twenty thousand people, there will occur, on the average, about seven hundred births in a year.  So the obstetrical needs of such a community as this are by no means insignificant when considered in the aggregate.  There is ample material for the patronage of a small hospital, located, let us say, at the county seat, if even a large minority of the women of the community can be induced to patronize it.

In time every mother in the community should come to patronize such a hospital; for it will come to be known that the home is no place for a woman during the ordeal of childbirth.  Many women in the cities have learned this, and it has become not unusual for even the residents of luxurious homes to go to lying-in hospitals to be confined.  The conditions there are far superior to what they can be in any private dwelling, and the woman who has experienced the comforts of a good lying-in hospital will never willingly be confined again elsewhere.

Like the woman already quoted:  she “would walk all the way from San Francisco” if necessary, to secure the comforts of the lying-in hospital.

These comforts, it must be borne in mind, include the use of pain-annulling drugs.  (i.e. the Twilight Sleep drug scopolamine) In this country, it is customary to anaesthetize the patient with chloroform, though some competent practitioners prefer ether. 

We have already seen that the merits of the morphine-scopolamine treatment, inducing the Twilight Sleep, are to be fully tested at the Johns Hopkins Hospital, and it may be that this treatment, as used at Freiburg or in some modified form, will presently come into vogue in all well-conducted lying-in hospitals.

And in that connection, it is interesting to recall that the small lying-in hospital is precisely the place where, according to the experience of the Freiburg obstetricians, the morphine-scopolamine treatment may be carried out to best advantage.  We have seen that this treatment cannot be utilized advantageously in large hospitals with a relatively limited staff.  Obviously, it could not be applied in the private practice of the average obstetrician, even though he were thoroughly skilled in the administration of the drugs, because the demands on his time would not permit him to observe the patient continuously from the early stages of labor, as is necessary during scopolamine anesthesia.

But the small lying-in hospital, with its average of one or two births per day, will be provided of course with a resident physician and with a staff of nurses competent to give the first doses of the drug.  So the treatment may be carried out as it is at Freiburg, and a considerable proportion of patients will secure the hoped-for boon of the “Twilight Sleep.”

And where this treatment fails, it will be supplemented by the use of anaesthetics, so that every patient who goes to the hospital may have full assurance that she will pass through what would otherwise be a dreaded ordeal in a state of blissful unconsciousness.

THE NEEDS OF WOMEN OF THE FARMING COMMUNITY

            It is easy to see how the residents of the town in which the lying-in hospital is located can take advantage of its facilities.

But at first glance it may not be so obvious that, under modern conditions, the facilities of the hospital may be made almost equally available for the residents of neighboring towns, and even for the farming population to the remotest borders of the county in which the hospital is located.

Until somewhat recently, it would indeed have been difficult to accomplish this.  But now that the automobile is everywhere in evidence, and good roads are becoming universal, there would be no difficulty in transporting the expectant mothers from a distance of a good many miles. 

According to the suggestion made above, there would be a lying-in hospital at the county seat of every county.  Ordinarily the county is only twenty-five or thirty miles in diameter, so the longest distance to be covered would seldom be more than twelve or fifteen miles.  An automobile covers this distance in the fraction of an hour, so even a patient who has neglected to go to the hospital a few days in advance of her expected confinement might usually be transported after the preliminary labor pains had set in, without danger or exceptional discomfort.

Of course the farm wife must be educated before she could be made to see the desirability of this arrangement.  The first thought of the average wife is that she cannot possibly be spared from home, and that the idea of going to the hospital is not even to be considered.  But as soon as the advantages offered by the hospital – painless childbirth, safety to the offspring, and rapid and permanent recovery – come to be generally known the feasibility of the project will quickly be demonstrated.

No one who has not practised medicine in the country can perhaps adequately realize the exceeding discomforts and dangers that attend the average farm wife in giving birth to a child. The doctor who is to attend the case will more than likely be some miles away in another direction just when he is needed most.  Every country practitioner of large experience will recall cases in which his attendance has been desired at the same moment in two farm-houses, one located, perhaps, six or eight miles to the north of town and the other as far to the south.  And it is not without precedent that a third call, sent post haste from a patient eight or ten miles to the east should arrive while the perplexed physician is endeavoring to decide, from the testimony of the messengers or the telephone messages, which of the two cases already reported is the more urgent.

Such conditions, let it be recalled, represent the average conditions of the farm population in America, with its aggregate of thirty million souls.

Under such conditions, it is obvious that no woman can be sure that she is to have medical attendance at all during the period when attention is acutely needed, let alone skilful attendance; and the mere statement of that fact should be enough to make it apparent that the existing conditions are intolerable.

What a boon it will be, then, to the six million farm wives of America, when facilities have been provided, and customs have been established, making it certain that she may have the comforts of a lying-in hospital, with adequate medical attendance, to solace her in what would otherwise be the dangerous ordeal of motherhood.

COUNTING THE COST

            The more one considers the matter, the more obvious it becomes that the project of local lying-in hospitals, scattered everywhere across the country, as uniformly if not quite as abundantly as schoolhouses and churches are scattered, is one to appeal not alone to every woman but to every husband and father – in other words to the entire community.

But of course there will arise the inevitable question of the monetary cost, and the practical inquiry will be made as to how such institutions are to be financed.

I must not attempt to answer this question here in any detail.  The conditions and needs of different regions are so variant that it would be impossible to make specifications except in the most general way.  But I think it may safely be asserted that once public interest is aroused, the matter of monetary cost will prevent no serious obstacles.

Recall that the average annual birthrate is about thirty-five to every thousand inhabitants; that is to say, about one in every six families, and that sooner or later there are children in every normal household.  We are dealing, then, with a project that concerns not here and there an exceptional family, but one that concerns each and every family.  No project could more justifiably call for the expenditure of public money, – money raised, if need be, by the issuing of bonds or by the levying of a special tax.

In many places small public or semi-public hospitals already exist.  These can be enlarged at relatively small cost, or their existing wards, – which in many cases are now for the most part vacant, – may be utilized as lying-in quarters.

Once the hospital is in operation, it will in many regions be altogether self-supporting, – for, of course, all but the poorest classes will wish to pay for the services received.  And even where the funds received are inadequate to meet the necessary outlay, there will be no part of the public service for which the average citizen will more willingly submit to taxation than for this institution which so manifestly adds to the comfort and well-being of the mothers and wives and daughters of the community.

But even without resorting to public funds, there should be no difficulty whatever in any community in securing subscriptions for the erection and maintenance of the lying-in hospital, so soon as the need of it and its manifold beneficences are clearly understood.

Not long ago the women of New York raised the sum of four million dollars by public subscription in the course of two weeks, to be applied to the furtherance of the Young Women’s Christian Association movement.  It should be easily possible in any community to duplicate this record, in full proportion to the population, for the promotion of a movement wider in scope and more urgently needed.

Many a man who will give for almost no other object, will make liberal donations when he is convinced that the project is one that will immeasurably decrease the dangers and practically annul the pains of the women of the community in the condition which he has hitherto contemplated with the utmost apprehension as a menace, present or prospective, to the loved ones of his household.

How Adding Lying-in Wards will be of Direct Benefit to Men *+*

Incidentally, it should be noted that the male population of the community will also benefit directly from the introduction of such lying-in hospitals, because it will be possible to establish in connection with these hospitals, wards or departments of general surgery, for the treatment of various diseases, in many places where it would be impossible to maintain such a hospital service independently, because of insufficient patronage. 

The patronage of a lying-in hospital is an assured element, assuming good proportions even in districts relatively sparsely settled.

The need of such a service would long ago have been evident, had it not been for the current conviction that the bearing of children is a physiological function not to be considered seriously; and a function, moreover, that is scarcely to be referred to in general conversation.

Now that the time has arrived when a matter of such vital import can be frankly discussed in public, we may expect to see aroused a growing interest in the betterment of the condition of woman through amelioration of the evils incident to the performance of her supreme function.

There is no reader of these pages who cannot do his or her part toward bringing about this amelioration.

Whatever your position in the community, you can at least call the attention of your friends and neighbors to this vitally important matter.  And it may well be expected that the response will be quick and keen; that knowledge of the movement will spread from house to house; and that the public interest aroused will lead to active steps for the establishment in your midst of an institution where the woman in childbirth may be given the solace of the “Twilight Sleep,” with all the attendant blessings that the word in its wildest implications is here meant to connote.

Is it not worth your while to have a share in this beneficent movement?

Continue: Chapter 8