Dr. J. Whitridge Williams: Part 1 ~ the dream, the motives, the methods & enduring impact of his 1914 book “Twilight Sleep ~ Simple Discoveries in Painless Childbirth,

by faithgibson on February 26, 2018

in Historical Childbirth Politics 1820-1980, OB Interventions: Dubious or Detrimental

Tiny URL to this essay ~ https://tinyurl.com/ycee9xv7

Originally posted in 2010 }


This is a synopsis of my most important breakthrough in researching the history of obstetrical medicine in the US and its relationship with normal childbirth practices and midwifery in America.

I discovered the missing piece of the puzzle in a small book published in 1914 ‘TWILIGHT SLEEP ~ Simple Discoveries in Painless Childbirth {original source material}.

It was written by Dr. J. Whitridge Williams, a famous obstetrician, with the help of Dr. Henry Smith Williams, a physician colleague and famous science-writer of his day.

In 1914, Dr. J. Whitridge Williams, former chief of obstetrics at Johns Hopkins and current Dean of the University’s medical school, commissioned and personally participated in the writing of a book called “Twilight Sleep: Simple Discoveries in Painless Childbirth”. Despite its provocative title, its target audience was not childbearing women but the medical profession itself, public officials and wealthy philanthropists likely to provide generous endowments to Johns Hopkins and similar large teaching hospitals

The main purpose of the book was to introduce and develop support for Dr. JWW’s plan for a nation-wide system of general hospitals. He envisioned a coast-to-coast network of small and medium full-service community hospitals equipped to provide the same 20th-century state-of-the-art medical services (in quality if not quantity) as his own alma mater, Johns Hopkins University Hospital in Baltimore, Maryland.

As a fully-equipped general hospital, Johns Hopkins was able to provide the same high level of comprehensive medical and surgical services as had been available in Western Europe for two centuries through a nationalized system of general hospitals. Unfortunately, there was no such ‘system’ in the United States and only a dozen or so big general hospitals in the entire country.

Dr. Williams’ book was a blueprint for dramatically changing the business model of American hospitals to make them dependably and increasingly profitable by re-writing the economic contract between society and hospitals.  Topics covered in depth in this little book (128 pages) were the urgent need to develop a new countrywide system of modern, fully-equipped general hospitals and Dr. Williams innovative ideas for funding such a massive project without involving the federal government or depending on any financial scheme that the AMA thought smacked of its dreaded bug-a-boo:  ‘socialized medicine’.

Last but certainly not least was a controversial topic that occupied the first four of the book’s eight chapters and might best be described as a fanciful and fact-free form of “Obstetrical Darwinism“. Dr. Williams tells an incredible story about a new childbirth-related pathology identified by him that only affected “civilized” and “cultured” women of the “most highly developed type” (i.e. healthy middle and upper-class white women).

He described the problematic effects of civilization on this particular demographic of smart, socially sophisticated, educated, and economically-secure American wives, noting that: “such cultured women are precisely the individuals who should propagate the species and thus promote the interests of the race“.

Dr. Williams paints a Darwinian picture of a devolving evolution due to “the hot-house conditions of civilized existence.” He explains:

These artificial conditions often determine that the less fit rather than the most fit individuals shall have progeny and that undesirable rather than the desirable qualities shall be perpetuated.”

The problem Dr. William’s alluding to is a pathological level of childbirth-related pain experienced by healthy women in this demographic. This extreme pain caused dangerous levels of psyche distress that were a shock to the system of these naturally “nervous and sensitive women” were overwhelmed and mentally unable to cope. This was especially severe for the most ‘delicate‘ type of women. The normal pain of a spontaneous labor and birth put these women at great risk of a nervous breakdown so severe that prolonged hospitalization in a mental institution would become necessary.

Dr. Williams pointed out the many problems that could befall husbands if they were so unlucky as to have their wives languishing away in an asylum for weeks or months after giving birth, leaving their husbands to care for the older children and a newborn while also attempting to earn a living and pay the mental institution.

To prevent these horrific problems in wives that are intelligent, sensitive or delicate (and whose wife doesn’t fit into at least one of those categories), Dr. Williams instructed husbands about the “Simple Discoveries in Painless Childbirth” described in his book, and strongly recommends that they no longer permit their wives to have a baby at home under the care of a community midwife or country doctor.

Instead, the smart thing to do is insist that their wives go immediately to the hospital when labor begins. Then their wives should be properly medicated with frequently repeated doses of Twilight Sleep drugs throughout the many hours of labor and only be allowed to give birth after being rendered unconscious by general anesthesia.

This would prevent the ‘little woman’ from having a postpartum psychotic episode and protect her husband from becoming a victim once-removed from the dangers of a ‘natural birth’ in this ‘delicate’ demographic — that is, one without the benefit of drugs and anesthesia and associated obstetrical interventions, such as episiotomy, forceps delivery, manual removal of the placenta and stitches to close the sizable episiotomy incision.

Fortunately, and no doubt by the sheerest of happenstances, the pathological level of childbirth-related pain that required hospitalization only affected the very same middle and upper-class families that luckily could afford these much more expensive hospital-based obstetrical services.

In his own words: Dr. JWW’s explained that:

“… women of primitive and barbaric tribes appear to suffer comparatively little in labor, coupled with the fact that it is civilized women of the most highly developed nervous or intellectual type who suffer most.”

“… the cultured woman of to-day 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….”

“… every [labor] patient who goes to the hospital … will pass through what otherwise would be a dreaded ordeal in a state of blissful unconsciousness.”

“In Johns Hopkins Hospital, no patient is conscious when she is delivered of a child. She is oblivious, under the influence of chloroform or ether.

       The book’s target audience was definitely not childbearing women or even the public, but certainly would be of interest to husbands who could afford to pay for hospital-based maternity care and to all the hospitals of the era that were eagerly lining up to provide this very profitable fee-for-service that included the elective hospitalization of a million or more healthy childbearing women every year as paying customers.

Inventing the Economic Engine for America’s private and corporate-owned Hospital System

Portrait Photo of Dr. J. Whitridge Williams, MD, a gynecological surgeon, professor of obstetrics, Chief of Obstetrics, Johns Hopkins University Hospital, Dean of the university’s School of Medicine, author of the 1914 book on “Simple Discoveries in Painless Childbirth” and one of two “Titans of American Obstetrics” (along with his arch-rival, Dr. Joseph De Lee of Chicago)

In the early 20th century, Dr. J. W. Williams invented the economic engine that first created and now maintains America’s private, for-profit and most often, corporate-owned hospital system. This certainly is an odd heritage for a professor of obstetrics at Johns Hopkins University Hospital who became chief of obstetrics in 1901 and then was appointed Dean of the university’s prestigious School of Medicine at the pinnacle of his career in 1910.

Nonetheless, compelling circumstances in Dr. Williams’ life molded him into an unexpected, even accidental visionary. He saw a ‘big picture’ that was invisible to his elders and his contemporaries and boldly took action. 

As a patriotic American and the single most influential physician-leader of his generation, his private dream and public passion was a nation-wide system of general hospitals to rival the nationalized system used in Western Europe for more than two centuries.

As long ago as the 17th century, Western European countries began developing a government-sponsored system of general hospitals, with a dozen or more institutions dispersed between the different regions based on population size. All were available to the public, irrespective of ability to pay.

Medical and nursing staff of London hospital, circa 1912

By the early 20th century, these general hospitals were typically staffed by well-trained professionals, had up-to-date medical equipment and were able to provide comprehensive services to all ages and for all types of medical and surgical problems.



Typical one-room, 8-bed private, doctor-owned and run hospital of the late 19th and early 20th century


By comparison, the US in the late 19th and early 20th century had plenty of hospitals — 8,000 by one count — but they were very small, private 2-to-10 bed hospitals owned and operated by one or more local doctors.

These overnight clinics and one-room hospitals could not afford to buy state-of-the-art medical equipment (ex. x-ray machines, microscopes, autoclaves), nor did they have an emergency room available to the public. As a for-profit business, their policy was not to provide care to anyone who couldn’t pay out of pocket at the time of service.

The Birth of Technologically-enhanced ‘Modern Medicine’ in the late 19th and early 20th-century

Portrait photo of Louis Pasteur, Father of the Germ Theory of Infectious Disease

However, the problem Dr. Williams’ identified — lack of a modern, nationwide general hospital system — was real and brought about by the new, world-altering discoveries of biological science made during the late 1800s (Pasteur’s germ theory of infectious disease published in 1881 and first x-ray machine in 1895).

For the first time in human history, the practice of medicine was predictably able to cure many previously uncurable conditions, successfully treat many otherwise fatal injuries and dramatically reduce the suffering of millions.

But many of these scientifically revolutionary breakthroughs required new technologies — diagnostic methods and scientific treatments that depended on large capital outlays for specialized medical equipment. This created a miniature Tsunami of “must have” technology for every ‘modern’ hospital and made running them ever so much more expensive.

Modern medical miracles did NOT come cheap!

Now every ‘modern’ hospital suddenly had to have autoclaves for their surgical instruments, laboratories had to be equipped with microscopes and sterilizers, and radiology departments needed several expensive x-ray machines, lead aprons, and oceans of photographic film. Of course, hospitals had to be remodeled to include operating rooms and other specialty areas and all these new services needed new buildings to house them in.

Small private hospital in an old colonial mansion, circa early 1800s


Unfortunately for the tiny 2-10 bed, one-room private hospitals, the capital-intensive purchases necessary to provide technologically-enhanced care were neither affordable nor available to their patients.


“Follow the Money”

By 1910, hospitals of all kinds — the dozen or so big charitable institutions, teaching hospitals run by universities and 10-bed, one-room for-profit hospitals — were all bleeding red ink. Actually, this was not unusual in the history of hospitals, which goes back to 600 CE. That’s when the Catholic bishop of Paris (later to become St. Landry), started the first charity hospital —  Hotel de Deu — on the banks of the Seine (which is still there and still treating patients). This was the start of the Europen tradition of charity hospitals operated by religious orders as part of their vocation to serve the poor.

Large 19th-century charity hospital

During this pre-scientific, pre-medical technology era, all big hospitals were charitable institutions, typically run by monks and nuns as places of ‘hospitality’ (the origin of word “hospital”).

These early institutions did NOT provide medical care — no doctor, no therapeutic effort to cure patients of their diseases. Effective medical treatment and pharmaceutical drugs hadn’t been invented yet, so hospitals really were publicly-support hotels that just provided compassionate custodial care — a clean bed, nursing care, hot meals and a friendly environment. This was labor-intensive but not expensive, as the staff consisted of mostly unskilled and semi-skilled workers who cooked and cleaned, changed bandages, gave back-rubs and emptied bedpans, etc.

It was very clear to everyone involved with these charity hospitals that sick people were, in general, a disenfranchized class. As a category, the ill, injured, infants and the elderly have always and will always be the world’s very worst demographic for anyone running a profit-making business. Prior to the 20th century, all big hospitals were either financially supported and run by the Church or funded by State governments. The oddity was the idea that hospitals could and should be run as a profitable business venture. After all, if you want to make money, you go where the money is; when you “follow the money“, it doesn’t lead to sick people.

But our relationship with illness and injury and the people we called ‘healers’ (doctors) and the kind of hospitality dispensed in hospitals was dramatically changed by the startling new discoveries in the biological science in the latter half of the 19th-century dramatically changed.

Before Medical Science, hospitals had little to offer beyond the services of a medical hotel with handmaidens (i.e. nurses) who provided palliative care for symptoms. This could include a potion for pain made from poppies. This opium tincture is known as laudanum, but that was the only effective ‘drug’ in the store. Historically, the relationship of the human species with ill health, grievous injury, horrible disfigurement, debilitating birth defects and the like was prayer, hand-wringing, resignation and ultimately acceptance that “nothing could be done”.

But After Medical Science, the role played by hospitals was almost instantly changed as modern scientific medicine was now able to cure the uncurable, treat otherwise untreatable fatal injuries and dramatically reduce the suffering. To accomplish these medical miracles, scientific ideas were turned into new diagnostic methods and scientific treatments that required new medical technologies. Suddenly hospitals needed to purchase very capital-expensive equipment just to stay competitive and maintain their hospital’s reputation.

19th-century charity hospital in a wooded area of a large city

Prior to this era of great change, there were only a dozen or so ‘general hospitals in the entire United States. These were usually large charity hospitals supported by the Catholic Church or state governments in the biggest cities of the Eastern seaboard, Chicago, New Orleans, Denver, and on the West Coast, Washington State, San Francisco, and LA.

In single-pointed and solitary pursuit of his dream, Dr. Williams wanted to match the modern national system used in Europe and make fully functional, scientifically equipped general hospitals the rule instead of the exception, so Americans were not dying needlessly because the nearest general hospital was 300 miles away.

How Dr. Willams dream got started

Vienna Hospital — 1800s — biggest and most famous general hospital in Western Europe

When Dr. Williams first graduated from medical school in 1888 he sailed to Europe so he could take clinical training in pathology and obstetrics in some of the biggest and best hospitals in Europe. At that time, there was little to no clinical training available in American medical schools, mainly because there were no hospitals with a large enough patient census to provide interesting and instructive ‘teaching cases’.

As Dr. JWW rotated thru the obstetrical departments of big busy hospitals in Germany, France, and Vienna, he realized that hospitals in Europe were remarkably different than those in the US. Europe’s national system of very large “general” hospitals were enormous institutions that could deal with any type of medical, surgical, pediatric, obstetrical or emergency situation and at the same time, they functioned as medical school training centers.

Turn-of-the-century medical school auditorium for demonstrating clinical procedures to students

Dr.Willias was very impressed with the quality and quantity of medical services available to the population of each country. He was also excited about the opportunities for clinical training these big hospitals provided to medical school student and graduate students like himself and acutely aware the US had nothing that compared.

Upon his returned to America, he was shocked by just how inadequate our tiny one-room hospitals were when compared to the quality and quantity of medical and surgical services provided by Europe’s big regional hospitals. He was also burdened by the knowledge that the small town doctors who owned and ran these one-room hospitals in the US had both hands tied behind their backs when trying to match the care available in the European system. It was the proverbial problem of what happens when you bring a knife to a gunfight.

It cannot be emphasized enough that the old era — best described as your “grandfather’s version” of hospitals, which was to say, the equivalent of medical hotels with amenities such as room service and a nurse to help patients to the bathroom — had been rendered obsolete by the current two generations that made the big scientific leaps at the abstract level of modern medical knowledge.

An operation being conducted under the principles of asepsis and strict sterile technique

This began in 1865, when Sir Joseph Lister, royal surgeon to Queen Victoria, developed and implemented the general principles of asepsis and the particular idea of ‘sterile technique’ to be used during surgical operations. This was largely based on the unpublished work of Louis Pasteur, who discovered the Germ Theory of contagion and infectious disease in the 1860s, but these extraordinarily important ideas were not published and accepted by the international community of scientists and physicians until 1881.

Many other scientific discoveries in the area of medicine followed, one of the most important being the discovery of radium and harnessing of ‘x-rays’ in 1895 into a machine that allowed doctors to see inside living people for the first time.

Now it was up to the next generation — the grandsons —  to implement all this at the practical level by making scientifically-based medical care available to the ill and injured in ‘modern’ general hospitals. And as noted earlier, modern medicine was capital intensive and thus, very expensive.

How best to implement these important insights?

Dr. Williams simply wanted to make modern ability to diagnose and treat serious injuries and illnesses and effectively cure previously fatal diseases available to the rest of the country via the trifecta of modern medical science — advanced understanding of the human biology, trained professionals. and use of modern technologies.

What was needed to fix the problem was crystal clear to Dr. Williams. America needed to replace the thousands of old-fashion 2-10 bed 19th-century hospitals with a modern nationwide system of full-service hospitals that were able to provide comprehensive medical and surgical services to the general public, as well as providing round-the-clock emergency services.

Dr. Willams’ personal goal was to make these state-of-the-art institutions the new standard of care, available from sea to shining sea. He envisioned at least one of these facilities in every town of 3,000 or more, and looked forward to the day when they become as “uniform, if not quite as abundant, as schoolhouses and libraries“.

Definition of a 20th-century General Hospital: The services of a general hospital are available to the public, irrespective of ability to pay and provides care across the entire spectrum of health-related needs for all age groups and all conditions.

It also has emergency services immediately available to anyone with an acute illness or life-threatening injury. It is staffed 24-7 and fully-equipped with relevant supplies, medical equipment, and scientific technology of the era, such as x-ray machines, microscopes, and ‘state-of-the-art’ operating room and good lighting.

This also includes the vital support services for any acute-care medical facility — a hospital kitchen and laundry and the all-important central supply department to purchase and stock necessary medical supplies and autoclaves to sterilize equipment and surgical instruments.

This already was the standard in European countries, but when Dr. Williams was writing his book in 1914, the United States had yet to develop a comparable system and was still 200 years behind the curve. Not only was there a general failure of imagination (neither doctors nor patients knew just how much was missing from the system of medical care), but even those who recognized the enormous advantage to everyone in the entire country were stopped cold by a single word — MONEY — that is, the lack of funding.

The Big Brick Wall that couldn’t be reasoned with, hollowed out, broken thru, tunneled under or gone around!

The biggest financial stumbling block in the US was organized medicine. Since the inception of the AMA in 1847, the organization has always been fiercely opposed to any ‘meddling’ by the government in the provision of medical services or the running of hospitals.

This was in large part a reaction to and rejection of the European system of nationalized hospitals. From a physician’s perspective, that system was the public equivalent of our modern-day VA hospital system, that is, is funded by the federal government, with medical services provided at the local level by salaried physicians who are in the employ of the federal government.

Historically preserved building that was originally a small private hospital owned and run by a much-admired local doctor



However, doctors saw the practice of medicine very differently. They believed it was and should stay a small business and their relationship to this ‘free market’ was that of plucky entrepreneurs. It was as natural for a medical doctor to expand his medical practice by opening a clinic or small hospital in an older mansion (picture scenes from “Downton Abby”) as it was for a farmer to open a roadside fruit and vegetable stand and eventually find himself running a busy chain of grocery stores.

The Wild West — not just for Wyoming cowboys but a way of thinking about the American free-market

Organized medicine considered any attempt by the government to use public tax money to build hospitals and to hire doctors as salaried employees to run them to be “socialized medicine”, which was the worst kind of insult. American doctors considered all aspect of medical practice to be their private property/business opportunity, to do with as they pleased. They were fiercely against the nationalized systems in Europe, which they believed violated the economic ideal of our free enterprise system and the bureaucratic management of such bigger nationalized facilities interfered in the sacred “doctor-patient relationship”.

The idea here is that the doctor’s loyalty, motivations, and contractual obligations would first go to whoever was paying the bill for his services. As an employee, that would mean “the system”, which theoretically killed off his motivation to do ‘better’, to innovate, work harder, etc. since none of these professional qualities would translate into a bigger paycheck.

The AMA line also claimed that ‘socialized medicine’ was a real disservice to patients. The particular issue was decision-making control over the patient’s treatment: Who decides what is ‘best’ — her own doctor or would he be ‘second-guessed’ by his supervisor or be forced to follow the hospital’s policies and protocols?  These two factors are the core of the sacred “doctor-patient relationship” as it was (and is) seen by the AMA.

In general, the strong opinion of organized medicine in 1914 was that doctors were professionals, which meant being their own boss. It was an insult to one’s professional status to become a ‘mere’ employee and have to work under someone else’s supervision and be bossed around. Due to their superior medical education, a doctor’s role was to boss other people around — just ask the nursing staff of any hospital!

Bottom line, virtually everything about socialized medicine was so deeply repugnant to doctors that they were willing to fight to the death. At a practical level, this was achieved by paying their membership dues to the AMA and depending on the organization’s crack lawyers and PR experts to stave of any “well-meaning” but nonetheless incremental encroachments on their freedoms.

During this period of time, the unquestionedunbreachable political influence exerted by the AMA on politicians of that era (1850 to 1990s) equaled, if not exceeded, the influence currently exerted and ‘enjoyed’ by the NRA had in relation to its total embargo of any effective action to improve gun safety in the US.

Both ‘movements’ share the characteristic of having become a quasi-religious belief; one is either “with us or against us” in an emotion-centric stance that logic plays no part in.  This allows it’s adherents to vilified their oppositions as treasonous and treacherous infidels. However, at the bottom of this quasi-religious fervor by both organized medicine and the NRA’s organized resistance to sane gun laws is the very samefollow the moneydynamic.

Whether it is profiteering hospitals or greedy gun manufacturers, once such a money machine has been fired up and starts pumping out cold cash, it’s perpetuation trumps every other ethical or social consideration. Like a religious belief, it becomes an obsession, and soon thereafter, a hopeless helpless addiction in which the sufferer is forever locked in his or her irrational mind, impervious to the reach of reason or any form of common sense.

Photograph of Johns Hopkins Hospital in Baltimore during the late 19th century

It was not lost on Dr. Williams that the AMA’s reiteration of Patrick Henery’s famous diatribe: “give me liberty or give me death” didn’t mean that doctors actually were willing to die for their cause, but that ordinary Americans who couldn’t afford to pay for proprietary medical services would die as a result.

Even worse, Doctor Williams knew full well these deaths could be prevented by timely access to state-of-the-art medical services. He knew this because comprehensive medical care was already available publicly to those living in the Baltimore area by his very own employer – Johns Hopkins University Hospital. This was the model of medical care that he believed should be accessible everywhere in the country as it was already available in Western Europe.

Lacking a public tax-supported national system as existed in many parts of Europe, the technologically-rich hospital business in the US was forced to look to their patients, which by definition are people that are sick, injured, infected w/ communicable diseases like TB or suffering an acute mental breakdown. It became increasingly clear that hospitals could no more depend on the seriously ill or injured to pay for their medical care than we can expect school children can pay their teachers’ salaries or prison inmates to reimburse their jailers for the cost of their incarceration. In fact, we don’t even ask people who borrow libraries book to pay a hefty charge for the privilege.

The conclusion was inescapable to Dr. Williams: Without a public tax base, there were just not enough sick people (as paying customers) to support 20th century ‘modern’ medicine. The apparently insurmountable problem was money — how to finance a nation-wide system of general hospitals without public funds?

The big paradigm shift for American Medicine ~ inventing the economic engine for private profit-making hospitals

Despite the intense need abd given the resistance by organized medicine to federal money and predictable blocking of any attempt to work out a some kind of public-private partnership, there was just no obvious way to underwrite a national hospital system.

In the first part of the 20th century, the typical acute-care hospital patient was gravely ill or injured and might linger in the hospital for weeks or months, in need of intensive, expensive care that often they were unable to pay for. Dependent as hospitals were on sick people as paying customers, the traditional business model of American hospitals was often drowning in its own red ink.

It was obvious to everyone in the inner circle that hospitals themselves would never be able to pay for their own transformation — the paradigm jump from their grandfathers’ 19th pre-scientific hotels to the post-science era of hospitals as the modern font of all medical miracles.

But Dr. Williams was both undaunted and determined. History doesn’t tell us if the idea came to him like a lightning bolt out of the blue or snuck up quietly on soft cat paws in the middle of the night.

Whichever it was, there was a moment of inspiration when Dr. J. Whitridge Williams invented a brand new economic model for running hospitals as a profitable business. This also simultaneously created the pot of gold that would finance his dream for a national system of well-staffed and fully-equipped general hospitals – one for every community with a population of 3,000 souls or more.

The lynchpin of Dr. JWW’s business plan was pure genius – a truly innovative idea for a newly expanded and profitable market for hospital services. The secret sauce was to electively hospitalized healthy patients as paying customers, specifically, the million-plus healthy middle and upper-class childbearing women that gave birth every year in the US

Dr. J. Whitridge Williams’ new model would, for the first time in the history of American hospitals, be able to provide them with a dependable and profitable revenue stream by dramatically expanding ratio of profit-generating patients to non-paying sick people, thus turning hospitals into profit-making businesses. However, Dr. JWW’s plan, with its ambitious goals, also had many ‘moving part’ and would require a number of coordinated and interlocking phases that would take several decades to play out.

Selling the public, childbearing families, local hospitals & philanthropists

Dr. Williams’ 1914 book frequently acknowledged the need to convince the public that such a ‘sea change’ or historic departure from the traditional care of midwives and ‘country doctors’ was reasonable and advantageous to them. Dr. Williams wanted people to see hospital-based maternity care for healthy women as leavening the bread dough that would soon give rise to a full-service community hospitals that had a surgery department, clinical labs, x-ray departments and other services that would be useful to every citizen — men of any age, children, the elderly and women who were not of childbearing age.

As for convincing women themselves, here is his “pitch” in his own words, taken from his 1914 book:

“To meet their needs [childbearing women], 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.”

Original Sub-heading:  “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 ….

… 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.

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.”

When Dr. Williams was soliciting active support from husbands and public official or making a pitch for capital endowments from philanthropists — Dr. JWW’s emphasized the benefits of his new system of lying-in hospitals to men and other segments of society.

“the male population of the community will also benefit directly from … 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.”

As for the cost of all this, JWW remarked:

“There will arise the inevitable question of the monetary cost, and … how such institutions are to be financed. …. once public interest is aroused, the matter of monetary cost will prevent no serious obstacles.”

His historical “plan”, sometimes also refer to by Dr. JWW hiself as a ‘scheme’, included three elements:

  • That each individual hospital would add a new or expanded maternity ward and hire nurses and other necessary hospital staff.
  • The next phase was to promote the patronage of a sufficient number of healthy women as maternity patients and paying customers.
  • The last phase began when the hospital was able to use the new revenue generated by their new maternity ward to upgrade, expand and equip itself as a general or ‘community’ hospital capable of providing state-of-the-art comprehensive medical services to local citizens.

Dr. Williams’ plan for the elective hospitalization of healthy maternity patients was not a temporary flash-in-the-pan, it was designed to be a permanent feature of the new business model for general hospitals. This dependable form of patronage (and resulting revenue stream) was correctly identified as necessary to the profitability of hospitals as a stable business model.

The Problem no one ever talked about by never putting the words ‘sick people‘ and ‘paying customer‘ into the same sentence!

While the idea of hospitalizing healthy childbearing women seems to come out of left field, Dr. Williams was proposing a solution to a historical problem of great importance that apparently was invisible to all the rest of us (even my hero, Paul Starr, author of The Transformative Social History of Medicine).

Briefly stated, the historic problem of great importance was (and remains!) the simple fact that we don’t have enough sick people as ‘paying customers to support the business model of a first class “modern”, technologically-enhanced hospital; since 1847 (when the AMA came on the scene), America also put taxpayer-generated revenue off-limits as an unacceptable form of “socialized” medicine. And trapped between these two impossibilities is the Reality that modern medical miracles cost a lot of money and somebody, somewhere has to pay up!

A new mom who gave birth at home and the family had enough money to hired a nurse to come in every day to provide postpartum care, fix meals and help with the older children. Families that could afford a nurse were seen by Dr. Williams as being able to pay for hospital-based birth services.

Dr. Williams’ solution to this dilemma was to devise a plan to convince healthy middle & upper-class white women to have their babies in a new system of a lying-in ward in existing hospitals, or new ‘maternity’ hospitals of the tiny 2-10 bed variety owned and run by the town doctor as the first step in creating a revenue stream that would eventually finance a regional general hospital, at least one in every country seat.

When most contemporary Americans hear the word “childbirth”, the very next word in their mind is “dangerous”, followed by “hospital” as a place that changes something horrifically dangerous into something that is very safe.

But Dr. Williams had a very different perspective on normal childbirth, danger, and hospitals. For him, the elective hospitalization of maternity patients was not about the safety of childbearing women or their babies. Considering that in 1914, hospital-acquired (nosocomial) septicemia was the cause of death for more than a third of all maternal deaths (10,000 out of 25,000), so no one, not even Dr. Williams, would or even could credibly claim that hospitalizing healthy laboring women during this pre-antibiotic era was primarily for their safety.

It was like admitting laboring women to a gay bathhouse during the AIDs epidemic before anyone knew how to prevent contagion or successfully treat a rare infection and doing so because it was profitable.

Nope, the hospital problem was lack of money and its solution was more money — lots of it for over a long period of time. Two million American women gave birth every year, which made for a potentially large and steady revenue stream if even half of these women gave birth in a hospital. Electively hospitalizing healthy maternity patients instantly and permanently changed the business model of American hospitals from one that at best was hanging on by its fingernails to gratefully welcomed financial solvency for hospitals that adopted the new market-based model.

Hospital birth in the early 1920s – note that the nurses are standing and moving about, while the new mother, as a “patient”,  is appropriately passively as she lies in bed.

Unlike illness, which is seasonal, and injury which is erratic and unpredictable, childbirth, postpartum care for new mothers and nursery care for newborns is a steady, dependable and a stable year-round source of patronage, thus providing the bread and butter income for hospitals.

Hospital administrators, who had been depending solely on sick people for income (established centuries ago to be a failed business model), immediately realized the benefits of expanding their hospital’s acutely-ill patient census to include a large percentage of ‘paying customers’. This market-based model would provide a healthy profit margin simultaneously making up for less profitable hospital services (sick people who couldn’t pay), while eventually allowing them to invest in capital improvements such as new construction and upgraded equipment.

Opening the door to even more innovative and creative ways to monetize hospitals

In addition to new lying-in wards for healthy childbearing women, hospitals began to explore other opportunities to monetize medical and ancillary (non-medical) services. Over subsequent decades, these hospitals started providing outpatient laboratory and x-ray services, diagnostic tests and procedures, cafeterias for the public, gift shops, valet parking, parking garages and as the country’s standard of living rose, so did the idea of elective hospitalization for cosmetic surgery.

Controlling the narrative: QUESTION ~ Are hospitals places where sick people go to die or the place where healthy women go to give birth, a place where babies are born and happy things happened to young healthy families?

An accidental or serendipitous consequence of incorporating normal childbirth into the acute-care setting of hospitals is that it allowed hospital administrators to control the narrative of their business. This PR activity was critical to the overall success (i.e. profitability) of their venture.

As anyone who has ever visited a medical, surgical or pediatric ward of in a hospital can tell you, there are a lot of disturbing sights and smells. Its beds are filled with the ill and injured who are lost behind a tangle of tubes, and machines that go ‘ping’. Its halls have patients sitting in wheelchairs and others shuffling up and down the halls, while pale and much too quiet small children whose hair has all fallen out and their bodies hooked up to tons of tubes attached to medical equipment are being pulled down the hall in a red wagon by their worried parents.

Meanwhile, one’s sense of smell is registering the vague smells of alcohol, disinfectants, and the kind of flowery scents that reminds people of a funeral home. It hard not notice that visitors coming out of patient rooms look sad, anxious or preoccupied at best, and sometimes found the corner of a waiting room, sobbing while a family member or nurse tries to comfort them after obviously being told very bad news.

For centuries, people have quite rationally seen hospitals as a place where people go when something terrible happens to them, or the very old and very sick people go to die. The moniker over the door should be “Nothing nice happens here“. Obviously, this is a ‘hard sell’.


But what if YOUR hospital could be associated with the happiest event of all — the birth of a new baby. What if you saw happy families carrying in pink and blue balloons, gifts in colored paper with pretty bows, smiling dads and grandparents as visitors and young women with a pretty new baby in their arms being wheeled down to the door to be discharged?

Consider this scene: A family of three – parents and their son Johnny — are out for a Sunday drive and their route takes them by the local hospital. The boy’s mother point to the hospital and one of the two following dialogues occur:

In a sad voice, mom says “Oh look, honey, that’s where  Gramps died”

Or in an excited and happy voice, mom says: “Oh look, honey, that’s where you were born. I remember the day like it was yesterday, it was such a special and happy time for us.”

It’s not hard to guess which scenario our mythical hospital administrator would prefer, nor to miss just how high the stakes are, what a boon the baby business is to the hospital business turning the “Nothing Nice Happens Here” narrative into “Wonderful  Magical Things Happen Here“. The stakes are high for any hospital that wants to stay in business in a country were organized medicine has made publicly funded health care quasi-illegal and instead depends on seducing people into electively hospitalizing is healthiest (but in many ways its most vulnerable) individuals as paying customers.

Bundled together, the category of elective hospitalization of paying customers for private hospitals was nothing short of a financial miracle. Of course, the beating heart of this new paradigm was the million economically secure (i.e. middle and upper-class) maternity patients that, as paying customers, would give birth in a hospital each year. In addition, there would be a million-plus newborn babies admitted to the hospital nursery and charged for these services.

And best of all, this accomplished without a single cent of public money or whiff of ‘socialized medicine’, so obviously, the AMA, doctors and hospital administrators were all enormously pleased.

Certainly, this was a Eureka moment for the entire industry. As for Dr. Williams, he realized that the wheels of a perpetual-motion machine of his making would eventually make his dreams come true — bright shiny new general hospitals would indeed become “as ubiquitous, if not as abundant, as schoolhouses and libraries”.

By the early 1920s, the new baby business, combined with other types elective hospital care, outpatient services and non-medical profit centers such as dining rooms, parking garages, and gift shops quickly became the economic model for our 20th and 21st-century for-profit hospital system.

This stood in bright contrast to the nationalized system that served our distant relatives on the other side of the “pond” (as Brits like to call the Atlantic Ocean). In the European system, every gainfully employed or independently wealthy adult paid more in taxes every year than a similar American but never had to worry that they, or their children, or an unemployed neighbor would be turned away at the hospital door for lack of funds.

But more to the point being made here, the Brits and other European countries did not turn down public funding from a tax base distributed fairly by income across the country’s entire population and instead chose to funded the country’s hospital system by taking money under false pretenses from childbearing families as an ipso facto tax that fell ONLY on this small (and often financially insecure) segment of their population to provide the bread and butter funding for their hospital system.

Even more bizarre is telling the healthy and wealthiest of these families that for them, normal childbirth is uniquely dangerous because smart, socially successful, educated and economically-secure women have some kind of genetic damage caused by “the hothouse conditions of civilization” that doesn’t affect immigrants and poor working-class women, and therefore they NEED massive amounts of medical and surgical interventions in what otherwise would have been a natural spontaneous biological process.

The Dark Side of the Moon – Institutionalizing maternity care and its consequences for healthy childbearing women and their families

Unfortunately for us, Dr. J. Whitridge Williams’ plan was a two-edged sword. He was a true hero that did marvelous things for the American people by providing them with dependable access to state-of-the-art hospital services. Modern medical miracles, which would someday include heart transplants and re-attaching severed limbs, were for the first time available to everyone in their own community or within reasonable driving distance. Over the last century, this certainly has saved many million lives and untold suffering.

But at the same time, Dr. JWW was also a villain. His economic “plan” for electively hospitalizing healthy maternity patients, which successfully financed a for-profit general hospital system all across the entire country, ALSO resulted in the most profound change in normal childbirth practices in the history of the human species.

Hospital-based obstetrical services, as the new and modern standard for childbirth in America immediately replace the personal services of a midwife with institutional-based care provided by virtual strangers.

1917: Profoundly-medicated and semi-conscious laboring woman under the influence of powerful Twilight Sleep drugs. She has been encased in the hospital’s version of a ‘straight jacket’ for her own ‘safety’. Her arms are bound so she won’t hurt herself and the restraint device is tied to the rails of the bed to prevent her from falling out bed and breaking an arm or knocking out one of her teeth in case she gets agitated (a side-effect of the drug scopolamine)

In Dr. JWW’s own words:

“… 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.”

On his watch, healthy childbearing women were turned into the hospitalized patients of the new surgical specialty of obstetrics and gynecology and normal childbirth became a surgical procedure ‘performed’ by a physician using forceps on a mother rendered unconscious by general anesthesia.

“In Johns Hopkins Hospital,” said Dr. Williams, “no patient is conscious when she is delivered of a child. She is oblivious, under the influence of chloroform or ether.

“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.”

As for the effect of narcotic drugs, scopolamine and anesthetics gases on the unborn baby, Dr. William’s book boldly makes the case that the baby is it is actually safer for the baby when its mother is medicated with hallucinogenic and amnesic drug scopolamine.

The very early days of hospital nurseries, in which 6 babies are bunked together in a special hospital bed

Famed scientists disputes fetal-neonatal damage as a result of the scopolamine narcosis of its mother:

“the tendency to retard respiration on the part of the child may sometimes be beneficial, preventing the infant from inhaling too early, thus minimizing the danger of strangulation from inhalation of fluids.

It appears that statistics of the Frauenklinik show that the percentage of infant mortality is low.”

“As against an infant mortality of 16 percent [editor’s note ~ that is 160 baby deaths per 1,000 births] for the state of Baden [Germany] in the same year, a report on 421 ‘Twilight Sleep’ babies showed a death-rate of 11.6 percent [i.e. NNMR of 116 per 1,000]

“For this strikingly low mortality of the children during and after birth under semi-narcosis, an explanation was sought of Professor Ludwig Aschoff, the great German authority on morbid anatomy.

He offered the theoretic explanation that slight narcotization of the respiratory organs during birth by extremely minute quantities of scopolamine[e] is advantageous to the child, as it tends to prevent permanent obstruction of the air-passage of children by premature respiration during birth.”

Dr. JWW’s plan from the perspective of the hospital system:

Phase #1: The first coordinated step required that all existing hospitals in the US open new ‘lying-in wards’, hire a nursing staff and arrange for the medical management of normal childbirth by local doctors. After the birth, both mother and new baby would remain hospitalized for the following two-weeks, requiring a postpartum ward for new mothers and a newborn nursery to provide care to babies.

Phase #2 was to identify or create a demographic or ‘target population’ whose use of these new services would be profitable to the hospital. Dr. Williams answer was to target middle and upper-class healthy maternity patients who were financially able to pay for these services came up with was both an obvious and at the same time, a brilliant idea — what he and many others considered to be  w was middle and upper-class women those families who could afford to pay for hospital-based maternity services

Phase #3 closed this innovative financial loop. What started as relatively the small idea (offering maternity services) expressly for the purpose of making a profit, were carried out at a scale that would fundamentally and forever change the nature of the hospital business. The old restraints that keep hospitals unprofitable were being swept away, to be replaced by a model that ultimately created a modern nationwide system of well-equipped general hospitals as the ‘gift that kept on giving’.

Imagine if all the families Dr. JWW was trying to seduce into having hospitals they didn’t want or need were to simply agree to pay a local hospital “tax” (or voluntary contribution) in an amount equal to the hospital bill, but skipped the often degrading hospital experience.

In Dr. Williams own words:

“With this kind of dependable patronage, lying-in hospitals would be able to provide laboratory, x-ray and other services necessary to provide for a well-equipped surgery department.

In a remarkable bit of reverse engineering, Dr. Williams turned the story as we think of it today on its head. To our modern perspective, this seems like a “tail wags the dog” scenario, but in his version, the ‘tail’ was what we now think of as the full-service community hospitals.

The profitability of the ‘baby business’ is what made everything else – the modern hospital system — possible.

Telling the Truth, the whole Truth, and Nothing but the Truth, so help me GOD!

But we cannot ignore the unintended consequences associated with Dr. Williams’ plan use the elective hospitalize of healthy maternity patients as paying customers as the cash cow of this new system and a bridge that was to lead directly to the bigger goal of financing general hospitals.

We dare not pretend that all this was primarily done to benefit the safety and well-being of childbearing women and their unborn and newborn babies. The fact as clear and unambiguous — electively hospitalizing healthy for normal childbirth was not invented to provide better safer care for mothers and babies, it was about developing the ‘patronage’ of childbearing families so their normal biological acts would occur in a proprietary setting and families bill for these services and the money generated would be used to upgrade and remodel hospital building and purchase capital-intensive equipment like x-ray machines.

When all this was sorted out, the newly upgraded hospital would be able to charge even MORE for its services and be in a better position to compete with its competition. Nowhere in those economic statistics does it mention that hospital-acquired septicemia — the potentially-fatal infection historically known as childbed fever — was responsible for the deaths of 10,000 new mothers every year (actually that rose to 25,000 in the year 1925) until the bacteria-killing drug sulfa and the antibiotic penicillin became widely available to the public in March of 1945

What all this means in our own time

Today over 4 million American women have hospital births every year. Approximately 70% to 80% of these women are healthy and have a normal pregnancy with one baby in a head-down position that delivers at term. Instead of chloroform, up to 95% of labor patients are given epidural anesthesia. And like a magic trick for the hospital, (pulling a rabbit out of a hat!) this biological process automatically makes a second ‘paying customer’ — the new baby that is officially admitted to a hospital nursery and billed to the mother’s account.

It is not unusual for a healthy woman who gives birth to a healthy term baby with good Apgars to receive a hospital bill for her two-day stay that varies from a low (!) of $12,000 to as much as $50,000. I personally know a family that has a normal birth at a local hospital who received a bill for $50,000.

Approximately 30 million people in the US are admitted to acute-care hospitals every year. Maternity ‘patients’ (i.e. mothers and babies) account for 8 million of those annual admissions. Decade after decade, the two most frequent admitting diagnoses are ‘normal childbirth with no complications’ and ‘newborn with no complications‘.

In this rase to fill up hospital beds with paying customer, second place goes to x-ray angioplasty procedures, which is a mere 700,000 a year.

Dr. JWW’s plan to use electively hospitalized maternity patients as the cash cow of hospitals as profit-making businesses is still alive and well in the 21st century.

However, this fascinating historical story is far from over, and in many ways, the next stage — Part 2 — is even more riveting.

So stay tuned!

TinyURL for Part 1 ~https://tinyurl.com/ycee9xv7

Continue to Part 2 ~ The story of the  “Dark Side of the Moon” continues.

Taken as a whole, the 128 text pages of Dr. Williams’ little book are the political equivalent of the Pentagon Papers that more than a hundred years later exposes a hidden agenda and several undeclared motives by the obstetrical profession that finally tell us exactly “how healthy childbearing women were turned into the patients of a hospital-based surgical specialty, normal birth became a surgical procedure performed by an obstetrical specialist and this expensive hospital-based, obstetrician-centric model — one that is directly harmful to mothers and babes, was nontheless  institutionalized as the “American way of birth’” for healthy childbearing women.

What this book reveals and promotes are ideas about eugenics and discrimination against the poor working women, immigrants, and non-white populations, a prejudiced perspective that fueled a sub rosa campaign to increase the birth rate in the white ‘race’ (his word) by normalizing the use of amnesic drugs and chloroform anesthesia that erased all memory of labor and birth. Dr. JWW obviously believed that white women could be enticed to have larger families if they couldn’t remember ever having had labor pains or giving birth.

Misdirection and a bait-and-switch plan sold hospital birth services to a specific demographic of childbearing women not because it was an advantage to them but as an undeclared financial plan make private hospitals into profitable businesses.

This included deception in their public relations campaigns and hidden motive to professionalize childbirth services as a proprietary business that restricted the provision of care to obstetrically-trained MDs and the place of birth to acute-care hospital settings. Future generations will see this as having characteristics of the pre-Germ Theory when doctors refused to wash their hands, no matter how much evidence was provided to them of a great harm that had been institutionalized, systemized and monetized.

And that list does NOT even include our current, profoundly dysfunctional medical services delivery system (hospitals and health insurance).

This document (will have) more background information and links to an eye-popping, mind-boggling quote from ‘TWILIGHT SLEEP ~ Simple Discoveries in Painless Childbirth“.

The working title of my research is (so far):

How Childbirth Got Trapped on the Wrong Side of History: How healthy women were turned into the patients of a surgical specialty and normal birth into a surgical procedure — the last and most important UNTOLD story of the 20th century”.

@@@@@@@@temp hold for copy-paste text @@@@@@@@@

difference btw ‘care’ and services’

The purpose was to dramatically increase the hospital’s profitability, elective maternity hospitalizations would become the economic engine of American’s free-enterprise private hospital system.

At the same time, the therapeutic ability of modern medicine was so often successful that hospitals could promote themselves as able to cure disease rather than just medical hotels with personalized room service. This introduced the unwelcome burden of legal liability for bad outcomes and adverse events.

The basic problem is that the people who proselytize their organization’s position actively solicit ‘converts’ by misrepresenting the truth, particularly by feeding mis- and dis-information to people that makes them afraid of other people, that ascribes dark motives   

The next arena for this same scenario is our current public school systems. Once a significant portion of schools are in the hands of private corporations and their investors, its appointed leaders will endlessly repeat the same talking points about how bad/dangerous the “old way” was and how the new, profitable way is so, so much better and safer and everything else that is wonderful!


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