Twilight Sleep: Simple Discoveries of Painless Childbirth ~ Chapter 8 (1914)

by faithgibson on September 9, 2013

Twilight Sleep

A Simple Account of New Discoveries
in Painless Childbirth

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

Written in Collaboration with Dr. J. Whitridge Williams,
author of ‘Williams Obstetrics’



            Even were local lying-in hospitals to be established everywhere, however, there would still remain much to be done before the needs of women in connection with the great function of child-bearing have been adequately met.

The reader will recall what has been said in earlier chapters about the relative backwardness of obstetrics in America, in comparison with other departments of medical practice.

It will be recalled that we presented, on the authority of one of the foremost American obstetricians, (i.e. Dr. JWW) a list of problems that concern every woman and which medical science has not yet been able to solve.

We were told that the most skilled practitioner knows scarcely more about the cause and proper treatment of painful menstruation than did our grandparents of the supposedly pre-scientific days; that the ills that threaten the pregnant and parturient woman are a good many of them obscure as to origin, and hence, of course, obscure as to treatment; and that the displacement of the uterus {????} after parturition is a condition of unknown cause notwithstanding its frequency and the severe character of the suffering that it ultimately entails.

We were told also that the question of the best way to abolish the pains of childbirth is still a matter of debate in the profession, notwithstanding the interesting tests that have been made at Freiburg and the recognized value of anaesthetics under certain conditions.

Again, we were told that the standards of medical education in this country, as regards obstetrics, are deplorably low.  Few colleges indeed are adequately equipped to give the future practitioner such direct and practical experience as he should obviously have before he is called upon to conduct a delivery in private practice.

As to the remedying of all these matters, it is obvious that the local lying-in hospitals, the need of which was urged in the last chapter, could have but subordinate influence.  Each such local hospital will, to be sure, give opportunity for the training of a few obstetricians, and in the aggregate an enormous body of competent obstetricians will thus be developed.  But of course, in general, the physicians connected with these institutions will be largely occupied with outside practise, and it is obvious that institutions such as these cannot hope to be centers of research.  They can at best apply the knowledge that is gained in larger institutions under conditions that permit research work to be carried out in accordance with the exacting requirements of modern science.

Our survey of the subject would be far from complete, were we to fail to consider the needs of these institutions, the existing shortcomings of which have been so clearly presented to us.


            To make the matter tangible, I could not do better, perhaps, than to call attention to the existing conditions at the institution which has for many years been looked to as setting the highest standards of medical education – the Johns Hopkins Medical School and Hospital, at Baltimore.

Fortunately I am able to make this presentation with full authority, largely from a report made to the Trustees upon the conditions in the department of obstetrics in the Johns Hopkins Hospital by Dr. J. Whitridge Williams, Professor of Obstetrics in the Johns Hopkins University, whom I have previously quoted as to the inadequacy of obstetrical teaching in America, and the backward state of this branch of medicine.

Dr. Williams believes that the backward state of obstetrical medicine in America is partly due to the fact that laymen and the physician alike have been prone to regard the caring for women in childbirth as a more or less contemptible task, sharply distinguished from the work of the surgeon who deals with the other infirmities of women, – a large proportion of which, paradoxically enough, are due to mishaps of the child-bearing period.

He believes that the obstetrical and gynecological departments should be consolidated and housed together in a woman’s clinic.  Such is the practice in Germany, and to that fact he ascribes the present preeminence of that country in this field of medicine.

He urges the absolute necessity for the provision and proper equipment of large women’s clinics, both for the opportunity that would be accorded for research work in solving the obscure problems concerning the normal and abnormal sexual processes of woman, and for the teaching of medical students who cannot otherwise by any possibility be adequately prepared to practise this branch of their profession.

He declares his belief that neither gynecology nor obstetrics – which jointly have to do with all the medical needs of woman as woman – will attain full development until the two are combined and united into a single strong department under the control of a full time staff.

This means a professor, several assistant professors, and a number of assistants, who give their entire time to the work of the department, in teaching and in research.  Some of these men must be highly trained in the underlying sciences – really accomplished chemists, physiologists, pathologists and what not; and they must be paid salaries sufficient to enable them to give their entire time to the work and not be distracted by outside private practise.

“It goes without saying,” he says, “that the first function of such a clinic should be the relief of suffering and the treatment of disease; but almost as important is the proper teaching of students and the advancement of knowledge.  Indeed, a woman’s clinic should be regarded as a research institute having the closest affiliations with the departments of biology, embryology, and physiology.”

After pointing out some of the open problems, in words that I have quoted in an earlier chapter, Dr. Williams continues:

“These problems and many others are of immense importance to mankind and are capable of solution, but years of patient clinical and laboratory work by properly trained scientific men are necessary to effect it, and such work can scarcely be expected from those who are engrossed by the cares of private practice and who can give only a few hours each day to hospital and university work.

“At present, gynecology and obstetrics are too sharply divided and are conducted upon too practical a basis to give ideal results.  The progressive gynecologist considers that obstetrics should include only the conduct of normal labor, or at most of such cases as can be terminated without radical operative interference, while all other conditions should be treated by him – in other words, that the obstetrician should be the man-midwife.

“The advanced obstetrician, on the other hand, holds that everything connected with the reproductive processes of women is part of his field, and if this contention were sustained, very little would be left for the gynecologist.

“Where the two departments are conducted independently, both suffer; as the gynecological assistants are handicapped by knowing but little concerning the origin of many of the conditions which they are called upon to treat; for it is generally admitted that most gynecological complaints, except tumors and conditions following gonorrhea, are direct consequences of mismanaged labor and abortion; while the obstetrical assistants suffer from not being able to follow to their conclusion the complications developing in the course of their work, as well as from lack of proper training in operative technique.  Indeed where the two departments are active, differentiation is extremely difficult, and it is often effected only by an arbitrary time limit.

“Thus, a pregnant woman with an ovarian tumor is considered a gynecological patient in the first seven, and as an obstetrical patient in the last three months of pregnancy.

“Furthermore, the division of the two departments greatly hampers research.  The gynecologists, for example, are not interested in the study of normal menstruation, which must be the basis for the rational treatment of its abnormalities, yet they object to normal non-pregnant women being admitted to the obstetrical ward for study and investigation.  Consequently this problem and many others remain untouched.

“How much simpler and more effective it would be if the two departments were consolidated into a single one, which could be housed in a commodious and suitably equipped woman’s clinic, with sufficient endowment to care for the necessary number of additional patients and to provide requisite facilities for teaching and research.”


            In the same communication to the Trustees, Dr. Williams states that the Johns Hopkins Hospital now maintains 56 gynecological and 39 obstetrical ward beds; including 12 or 15 for women awaiting confinement, as well as accommodations for the requisite number of private gynecological, but none for private obstetrical patients.

The ward accommodations of the gynecological patients, he says, are satisfactory, but the department suffers from the fact that the operating-rooms, private patients, and white and black ward patients are in four separate buildings; but more particularly because it is inadequately supplied with proper quarters or equipment for teaching and research work.  And then follows this surprising statement:

“The obstetrical department, which is altogether unworthy of a great hospital and medical school, affords fair accommodations for 17 out of the 39 patients and their babies, except for scant provision for toilet and general administrative purposes.  The remaining 22 are housed either in the basement of the obstetrical or in the third story of the colored ward, which were not intended for use by patients, as they are unventilated, poorly heated, and devoid of all conveniences.

“Furthermore, the operating and delivery rooms are defective, and nursery overcrowded and ill-adapted for the proper care of the babies, while the teaching and laboratory facilities are so entirely inadequate that at different times of the year I am obliged to wander from building to building in order to find a meeting-place for my classes.  The number of obstetrical patients is sufficient for the instruction of only one-half our present number of students.  And if the Examining Boards of other states followed the example of Pennsylvania in demanding a decent minimum of experience before granting a license to practice medicine, our students would be excluded from the examinations.”

Such, then, are the deficiencies of the hospital connected with what is generally regarded as the foremost of American medical schools, as regards the study and teaching of a department of medicine that is vitally important to every woman in the land.

And, having stated the deficiencies, Dr. Williams goes on to point out specifically what added accommodations and facilities would be required fully to meet them:

“A woman’s clinic adapted to our needs,” he says, “should provide accommodations for 60 gynecological and 50 obstetrical ward patients, not including the babies, and 15 or 20 normal women awaiting confinement, but the latter should scarcely be counted as patients, as they are not sick and do a great deal of work in return for their board.  They are also used several times each week for teaching students the technique of various examinations.

“Private gynecological patients could be cared for in the private ward, but accommodations are needed for 10 private obstetrical patients, whose board and fees would be a source of revenue to the hospital.  In order to facilitate the care of patients and to concentrate the work, both black and white patients should be housed in the same building, but on separate floors.

“In addition to providing proper accommodations for patients, the clinic should be provided with the necessary operating and delivery rooms and all that goes with them, and particularly with suitable laboratories for pathological, bacteriological, chemical, and physiological investigation, together with a small museum.  Teaching quarters should also be provided, including one room capable of seating 100 students, a number of smaller rooms for section work, as well as several rooms in which students can sleep while awaiting calls to labor cases.”

That such an institution might operate with maximum efficiency, it would be necessary that the joint department of gynecology and obstetrics should have at its head a physician who devoted his entire time to the work of the women’s clinic, directing the investigations of his associates, and himself given the leisure to conduct personal investigations and coordinate the studies to others.

“Such an institution,” Dr. Williams concludes, “would afford accommodations for 110 ward patients (not including pregnant women awaiting confinement), and would make possible the treatment of say 1,200 gynecological and 1,000 obstetrical patients each year, which would be available for teaching purposes.  In addition to making possible this amount of humanitarian work, I believe that it would set a new standard for teaching and research throughout the English-speaking world, and would enable us to send forth each year one or two exceptionally trained young men, who would be preeminently fitted to go elsewhere and do likewise.”


             Here, then, is a brief outline of a project for the carrying out of investigations in the interests of womankind, and for the better education of the physicians who are to minister to her physical needs.

            And what, it will naturally be asked, stands in the way of the immediate carrying out of so beneficent a project?

The answer may be given in this brief sentence:  Lack of funds.

The initial endowment left by Johns Hopkins for the foundation of the hospital that bears his name has been kept intact.  But the entire income from it is required to conduct the various departments of the hospital on the existing basis, and it is impossible for the Trustees to apportion money, without an unjustifiable infringement on the capital, for the development of such a woman’s clinic as is absolutely prerequisite to the carrying out of such a project as Dr. Williams outlines.

How much money would be required?

The answer seems almost ridiculous in these days of large financial enterprises.  For we are told, on competent authority, that the paltry sum of $200,000 would suffice to enlarge the present buildings devoted to the obstetrical and gynecological departments at Johns Hopkins Hospital, and that $300,000 more would suffice as an endowment for the maintenance of the additional patients.

Half a million dollars, then, entrusted to the wise stewardship of the Johns Hopkins authorities, would suffice to establish a woman’s clinic, in which matters that vitally concern the twenty million mothers of America would be investigated, as they are being investigated nowhere else in this country.

The General Education Board has recently made a gift of a million and a half dollars to make possible (in connection with funds formerly allotted by the University and Hospital) the placing of the departments of medicine, of surgery, and of pediatrics on a full-time basis.

The Board has made it understood in a general way that when funds for a suitable building are available, they will similarly provide the money necessary to put the obstetrical department also on a full-time basis.  So the donation of half a million from another source would do the work of a far larger sum, in that it would make available resources that cannot be utilized until the present obstetric quarters of the hospital are enlarged.  It is useless to ask any physician to give his full time to work in this department of the hospital until {clinical teaching} material is available to supply full opportunities for investigation and progressive work.

Surely there must be in America a hundred, or perhaps five hundred, philanthropically inclined capitalists to whom a half million dollars is a mere bagatelle, any one of whom would regard it a privilege, should the opportunity be brought to his attention, to associate his name with an enterprise fraught with such beneficent meanings for the mothers of the race.