Introduction to a series on the book: Twilight Sleep: Simple Discoveries in Painless Childbirth, published 1914

by faithgibson on February 17, 2018

in Contemporary Childbirth Politics, Historical Childbirth Politics 1820-1980, Historical Publications

https://tinyurl.com/y8pgewkg

As a long-time student of the history and practice of obstetrical medicine in the US, my discovery of this 1914 book Dr. J. Whitridge Williams — Twilight Sleep: Simple Discoveries in Painless Childbirth — was (and still is) my most important breakthrough. This out-of-print book only became available in modern times after being scanned and posted online in 2008 by the Google Library project.

It contains a wealth of compelling and previously unknown facts about the American medical profession during the early decades of the 20th-century. This particular historic period was marked by an acrimonious turf war between gynecology, which was a surgical specialty, and obstetrics, which has always been a medical discipline (i.e. a specifically non-surgical practice).

Disputes over the legal right of doctors without special surgical training to routinely use forceps, or whether a gynecological surgeon was contacted soon enough to perform a Cesarean, resulted in frequent arguments between the two doctors, with insults, name-calling, and hard feelings. When tempers reached the boiling point, an occasion punch was thrown and the resulting black-eye an embarrassment to both professions.  To stop this unproductive hostility, influential leaders of both professions decided to combine the non-medical discipline of obstetrics with gynecological surgery to form the new American hybrid surgical specialty of obstetrics and gynecology.

Dr. J. Whitridge Williams’ Dream

Although Dr. J. W. Williams was trained as a gynecological surgeon in the late 1800s, served as chief of obstetrics for more than a decade, and authored “Williams Obstetrics” (the most famous obstetrical textbook in America), the practice of ob-gyn was no longer his all-consuming passion. In his new role as Dean of Johns Hopkins’ School of Medicine, he dreamed of a modern nationwide system of full-service general hospitals in the US like ones used for the last 200 years in Western European countries.

These European hospital systems provided medical and surgical care to patients of all age and types of problems or disease. Big general hospitals were sponsored by the national government, supported by public taxes, and had large, state-run bureaucracies that managed institutions in each geographical area and population center. In addition, public hospitals played an important role in medical education, as for centuries their patients, in exchange for free medical care, became ‘teaching cases’ for the clinical training of hundreds of medical students each year.

The insurmountable problem for Dr. Willimans was how to create the same kind of general hospital system in the US without involving or depending in any way on the federal government or any ‘nationalized’ bureaucracy. The American medical profession pejoratively defined all types of nationally-supported system as ‘socialized medicine’ because it reduced the role of doctors to ‘mere’ employees of the system. The AMA thoroughly despised and vilified any form of government funding (and its bureaucratic control over doctors), so that kind of funding would never be accepted by the American medical profession. Dr. Williams had to really “think outside the box”.

But Dr. Williams’ was undaunted, determined, and filled with an entrepreneurial zeal.  One day he became inspired and figure out an effective “workaround” that, as the saying goes, killed two birds with one stone. He did this by inventing a brand new category of hospital patient — the electively hospitalized healthy childbearing woman of ‘means’ (middle or upper-class) as a paying customer.

This turned out to be a double whammy that was even more satisfying he could imagine at first.  Without ever involving state or federal governments (and its suffocating bureaucracies), his plan created a dependably profitable revenue stream which handsomely paid for the actual cost of care (which was very low) and the remaining profit available to build a nationwide general hospital system. But even more exciting, the idea of ‘elective hospitalization’ allowed general hospitals to exchange the money-losing model they were historically stuck with (i.e. sick and injured people die or become disabled and can’t work, thus can’t pay) for a dependably profitable, market-based economic model on a par with any other business.

Fatal Fly in the Ointment

But Dr. JWW’s little book also provided irrefutable evidence that his profound enthusiasm and emotional investment in his big “Plan” dramatically interfered with his ethical judgment. As a result, he drastically misrepresented important facts (“alternative facts” in today’s lingo) at a level that would be considered unethical, if not actually criminal. Unfortunately for all of us, this propaganda campaign of mis- and dis-information became the raison d’etre for the new surgical specialty of hospital obstetrics as the “modern” American standard for all childbearing women.

For the entire 20th century, these new hospital policies and obstetrical protocols consistently caused enormous harm to healthy laboring women who lost ground every time their normal biology was disrupted by a hospital protocol or medical or surgical intervention and at same time, these interventions exposed them and their unborn baby to the risks and side-effects of unnecessary medical and surgical procedures.

A potentially deadly roll of the dice

In 1931, Testimony on the efficacy of midwifery care was presented to the White House Conference on Child Health and Protection by the Committee on Prenatal and Maternal Care: Dr. Reed concluded:

~”…that untrained midwives approach and trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child. On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course.” (original emphasis)

In 1932, an American physician and statistician for the Metropolitician Life Insurance Company calculated that 70,000 maternal-infant deaths could be prevented each year — 10,000 mothers, 30,000 stillbirths, and 30,000 newborns — if the quality of professional midwifery care provided by the Kentucky Frontier Nurse-midwifery program was made available to all healthy childbearing women in the United States.

“In 1933, the New York Academy of Medicine published a shocking study of 2,041 maternal deaths in childbirth. ”

“At least two-thirds, the investigators found, were preventable. There had been no improvement in death rates for mothers in the preceding two decades; newborn deaths from birth injuries had actually increased. Hospital care brought no advantages; mothers were better off delivering at home with a professionally trained midwives.

Investigators were appalled to find that many physicians simply didn’t know what they were doing: they missed clear signs of hemorrhagic shock and other treatable conditions, violated basic antiseptic standards, tore and infected women with misapplied forceps. The White House followed with a similar national report. Doctors may have had the right tools, but midwives without them did better.”

{{ Annals of Medicine The Score: How childbirth went industrial” By 

But the obstetrical profession’s stubbornly ignored this advice. Their refusal to provide physiologically-based childbirth services to healthy women (or allow professional midwives to do so) resulted in thousands of unnecessary maternal deaths from the routine use general anesthesia (3rd leading cause of maternal mortality in 1960), postpartum hemorrhage and infection.

Hundreds of thousands of newborn babies suffered permanent brain damage as a result of the narcotics and other drugs given repeatedly to their mothers during labor (and causing respiratory depression at birth), and the routine use of forceps during delivery.

Childbirth-related deaths and permanent injuries in essentially healthy women and babies occurred year after year, from the early 1900s until the mid-1940s. That is when several scientific breakthroughs in medicine made it possible to treat previously fatal iatrogenic complications caused by unwise and unnecessary obstetrical interference in normal childbirth. These life-saving developments included the antibiotic drug penicillin to treat hospital-acquired infections in new mothers, better anesthesia to prevent anesthetic-related deaths, safer blood transfusions to treat hemorrhages following routine manual removal of placentas and generally improved surgical techniques developed on the battlefield during WWII.

The profession of obstetrics continues to reject and vilify normal childbirth practices (physiologically-based care) in 2018

Sadly, Dr. J. Whitridge Williams’ original ideas still form the bedrock of 21st-century American obstetrics. While our contemporary problems are not so grim or drastic as those in the 1920s or 30s (before the discovery of antibiotics), routine obstetrical interventions are still associated with preventable mortality and morbidity in previously healthy mothers and their newborn babies. But this is a well-kept secret, as it’s rare for the public to find out that these childbirth-related deaths were preventable. Instead, they are blamed on the women themselves for being older or fatter, or having some mysterious or undiagnosed medical problem.

Dr. Williams’ book reveals the basic economic motive behind the new profession’s troubling relationship with normal childbirth. It was during this historical period that healthy pregnant women were identified as the patients of a surgical specialty and normal childbirth became a surgical procedure to be ‘performed’ by doctors trained in obstetrical surgery.

For this reason, I refer to this situation as the last and most important UNTOLD story of the 20th century.

The danger associated with using obstetrical intervention routinely during the care of healthy women with normal pregnancies must become common knowledge. Then so we can build on the actual strengths of modern obstetrical medicine, which are substantial and life-saving when disengaged from their inappropriate use on healthy women, while we work to eliminate the profession’s historical errors.

Truth and Reconciliation Commission to heal the hurt and hostility between the obstetrical profession, consumer groups of healthy childbearing women, and physiological management by non-obstetrician birth attendants

To bring about the level of change that is needed will require some version of a “Truth and Reconciliation Commission” in which the earlier errors are acknowledged and a structure put in place to keep them from being repeated.

The eventual goal is a maternity care system for healthy women with normal pregnancies that is based on physiological principles and practices. Normal childbirth services for healthy women will be provided by professional midwives and family practice physicians in the setting chosen by the parents; obstetrical intervention will be reserved for women who develop a complication or if an informed mother-to-be requests medical treatments or surgical procedures.

 

Continue to Part 1: The Dream, the Motives, the Methods & Enduring Impact of 1914 book “Twilight Sleep ~ Simple Discoveries in Painless Childbirth ~ by famous American obstetrician: Part 1-a ~ Overview

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