Twilight Sleep Book ~ Best 50 pages of the first half

by faithgibson on January 19, 2024

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’

EDITOR’S NOTE:

This 1914 book is from Stanford University’s Lane Medical Library collection of historical medical books. It was scanned into Google’s on-line library in 1998. However, the older, pre-PDF software of that era produces text that cannot be copied, so I and another midwife volunteered to typed the entire book to a WORD document and I subsequently posted it to this website.

“A Simple Account of New Discoveries In Painless Childbirth” is a decidedly unimposing little book, 6’ by 4 inches wide with only 128 pages divided into 8 chapters. But don’t let it small size fool you, it’s a bombshell. The information between those 130 pages tells for the first and only time, the economic story of how and why we developed our current nation-wide system of modern, hospital-based healthcare.

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Official author: Dr Henry Smith Williams, MD, LLB, born 1863-1943, was both a physician and lawyer. He and his also brilienty brother and authored over 200 very dense. fact-based book a variety of topic in medicine, science, and history. The best of is their “History of Science” which can be accessed vie the Internet Archive or “The Wayback Machine”

Historical Figure, Contributor-Main Collaborator: Dr. J. Whitridge Williams, MD, 1866-1931; his father was Dr. Philip C. Williams, a physician who received his medical education in Philadelphia and Paris.

Dr. J. Whitridge Williams was born in Baltimore and received a Bachelor of Arts from Johns Hopkins University. After graduating from John Hopkins School of Medicine, he went abroad to study gynecology and obstetrics. He receiving his clinical training in the great hospitals of Europe in Paris, Prague, Vienna, and since he spoke fluid German, Berlin, Leipzig, and Heidelberg.

He was appointed associated professor of gynecology in at Johns Hopkins University Hospital beginning in 1894; was vice-president of the American Gynecological Society in 1903-04, and Chief of Obstetrics at Johns Hopkins University Hospital from 1895 to 1910 and Dean of the JH’s Medical School from 1911 to 1923.

Historians consider him, along with Dr. Joseph De Lee to the ‘two Titians and fathers of American obstetrics’, but he is most remembered today for being the original author of Williams’ Obstetrics (1908), an obstetrical textbook that is currently in its 26^th printing.

However, Dr. J. Whitridge Williams’ most lasting legacy was not in obstetrics but the economic foundation of 20^th century American hospitals. His brilliant insights put him an entire century ahead of his time, and his unique plan to reconfigure the market place for hospital services provided us the business model for 20^th century hospitals. He personally and permanently reshaped hospital economic in the US.

After years of medical training in the large public hospitals of Europe, Dr. JW Williams was intimately familiar with the comprehensive hospital-based medical system in European countries that its citizens had enjoyed for two or more centuries.

Dr. Williams realized the need to create the same kind of comprehensive and high-quality system in the US. But unlike the Europe’s nationalized system, which as described by the AMA as the dreadful ‘socialized medicine’, Dr. Williams knew he would have to accomplish this without going over the dark side of tax-based care.

While his ideas seem inexplicable at first glance, Dr. J.W. Williams was proposing a brilliant solution to a complicated set of economic problems that while very apparent Dr. Williams, were invisible to everyone around him. These basic questions about the economics of America hospitals have continued to be an invisible aspect of the public debate on how healthcare in the US should be paid for, but these basic issues are never articulated. As a result, the critical building blocks of our fee-for-service system remain largely unknown, but continue to exert a powerful influence over the quantity and quality of our hospital-centric ‘health’ care system.

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In 1914, it was startlingly clear to Dr. J Whitridge Williams that the scientific discoveries of Pasteur (germ theory), Lister (surgical sterility), Roentgen (x-ray machine) and Morton (discovered anesthetic properties of ether) had forever ended the pre-scientific, thousand year-old model of hospitals as places of low-cost, low-tech custodial or palliative care.

This forever changed the basis of care as provided by physicians and hospitals. The classic practice of medicine was based in and revolved around the trained mind, powers of observation and the skilled hands of the physician as a diagnostician and a healer. These attributes were not location-specific but accompanied the physician wherever he was and wherever he went – doctor’s office, patient’s home, the battlefield. There was very little that a hospital could provide that could not as well be accomplished by the doctor in a variety of other settings.

However, the scientifically-based medicine expanded the practice of physicians to a whole new order of magnitude that built on but did not stop a trained mind, good eyesight and a talented touch. The efficacy of these attributes now depended on things — specialized equipment and medical devices and all manor of technologies which in our day includes computers and robotic surgery

This permanently reconfigured the professional life of physicians and role and status of hospitals by inventing the new category we describe as an ‘acute care’ institution – one technologically equipped and staffed by those trained to use these life-saving technologies

The 19^th century the role of hospitals as places of ‘hospitality’ – medical hotels that provided nursing services — had suddenly catapulted by the breakthroughs in medical science

He’d personally witnessed the bold new potential of medical science to be both safe and therapeutically-effective – actually able for the first time to cure formally fatal diseases. This new style of medical practice was already being implemented in teaching hospitals and large urban institutions. He saw the best and newest these new ideas and technologies were already in daily use at Johns Hopkins, Harvard, Columbia-Presbyterian, Stanford and other big-name teaching hospitals.

But Dr. JW Williams also realized that marvels of modern medicine, with its technology-enriched care, would remain unavailable to the vast majority of Americans unless there was a way to provide this same quality of service in every community coast-to-coast. He envisioned a national system of independently-run, privately-owned general hospitals supported by the local patronage of those who used its services.

Ideally, there would a minimum of one general hospital in each county seat, with more in towns over 3,000. Each hospital was to include fully functional surgery and x-ray departments, as well as clinical laboratory services and a central supply facility. In Dr. Williams’ vivid imagination, he expected these community hospitals to become “as ubiquitous, if not as numerous, as schools and libraries”.

That meant that every community either had to build a brand new general hospital, or upgrade an existing one to include at least one state-of-the-art x-ray machine, a ‘modern’ operating room and the ability to sterilize surgical instruments, a clinical laboratory equipped with microscopes, a central processing unit with giant sterilizers (autoclaves) to kill bacteria and other germs on everything that touched or was touched by a patient. New categories of specially trained professionals were needed to run all these new departments and expanded functions.

The miracles of modern medicine didn’t come cheap! Nonetheless, hospitals were a business that had to pay their bills just like any other business.

Dr. Williams’ unique insight recognized the five immutable factors at the bottom of these new and extremely challenging economic problems for 20^th century hospitals. These were the:

need to dismantle the old 19^th century model of tiny 2-10 bed specialty hospitals and replace them with modern fully-equipped, technologically-enriched general hospitals
relentlessly expensive & capital-intensive nature of modern medicine
economic realities of organizing services around illness, injury and major disease – a patient census based on these events is always unpredictable in number and erratic in timing, and makes staffing a nightmare
sobering reality that depending on sick people as ‘paying customers’ was a basically risky and unsatisfactory business model; and last but certainly not least
historical opposition of allopathic medicine to any nationalized system for financing medical care or nationalized health insurance.

The very people that most need and benefit from technologically-enriched hospital services – the ill, injured, disabled – are the demographic least able to pay these big bills. This observation is so startlingly simple it’s almost insulting, but it was unique in 1910 as it is now in 2011, which is to say, these facts are still not acknowledged in the public debate over healthcare policy.

Faced with these four immutable facts, Dr. Williams devised a ‘plan’ that was to run between the raindrops, while he developed a business that used some of these factors to his advantage, while he figured out how to do an end-run around the others.

He details is ‘plan’ (sometime referring to it as a ‘scheme’, to eliminate opposition and successfully addressed these issue so as to achieve this worthy goal. This included inventing the idea of ‘elective hospitalization’ – a new demographic of ‘healthy’ patients as ‘paying customers. This allowed American hospitals to substantially expand the market for in-patient services.

The economic potential of this electively hospitalized healthy cohort was up to 2 million hospital admissions a year. This steady stream of revenue would financially enabled American hospitals to make the new, capital-intensive purchase of modern medical equipment and technologies that are the very core of ‘modern’ medicine.

For the inordinately curious, a brief synopsis can be read by clicking this link. Opps!

To better understand the motives and intentions of its main contributor an collaborator – Dr. J. Whitridge Williams — I divided the 8 chapters in two unequal haves, then reversed the order in which the synoptic material is presented.

The “Introduction” presents an overview of the book’s main ideas through brief quotes. Then longer excerpts and quotes from chapter 6, 7 and 8 are provided first, followed material from by chapters 1-5.

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The complete text in its original sequence is available
@ http:faithgibson.org/ as a Word document

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Extensive Excerpts

Introduction and Overview of Topics and short quotes reflecting the major themes

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Dr. JW Williams’ vocabulary describing motherhood and childbirth:

The role of mothers:

… this most sacred function of maternity, beneficent meanings for the mothers of the race; mothers of the better class;

Normal childbirth:

…. ordeal, terror, useless suffering, acute suffering, agonies of childbirth, traditional terrors of childbirth; agonies of tortured humanity, millions of suffering sisters; the dangerous ordeal of motherhood; incidental evils and danger of motherhood; women bring forth their children in sorrow; shock that ordinarily attends the ordeal of childbirth

The role of obstetrics:

… the vitality important project of lessening the sum total of human suffering by systematically and habitually assuaging the pain needlessly suffered by the mothers of the race in carrying out their essential function of motherhood

P10 … Even in this second decade of the 20^th century, the generality of women bring forth their children in sorrow, quite after the ancient fashion, unsolaced by even single whiff of the beneficent anesthetic vapors through the use of which, in the poetic phrasing of Dr. Oliver Wendell Holmes, the agonies of tortured humanity may be stepped in the waters of forgetfulness.

p.12 …how has it come about that this most natural and essential function should have come to be associated with so much seemingly useless suffering.

…something has been told of the wonderful effort that has been make by a band of wise physicians in Germany to give solace to the expectant mother, and to relieve the culminating hours of childbirth of their traditional terrors.

The wise physicians in question are associated with the University and Hospital of Freiburg. For years they have labored to perfect a method that shall make childbirth painless.

Ch. 4: “Nature provides that when a woman bears a child she shall suffer the most intense pain that can be devised! The pain of childbirth is the most intense, perhaps to which a human be can be subjected.”

38 ….if we look deeply enough, that the suffering of women in childbirth serves a beneficent, even though occult purpose in the scheme of human evolution?
39 …. an inkling of the answer is found when we learn 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.

This seems to suggest that the excessive pains of childbirth are not a strictly ‘natural’ concomitant of motherhood, but rather that they are an extraneous and in a sense an abnormal product of civilization.

Every one knows that the law of natural selection through survival of the fittest, which as Darwin taught us, determined the development of all races in a state of nature, does not fully apply to human beings living under the artificial conditions of civilization. These artificial conditions often determine that the less fit, rather then the most fit, individuals shall have progeny and that undesirable than the desirable qualities shall be perpetuated.

40 …… any trait or habit may be directly detrimental to the individual and to the race and they may be preserved, generation after generation, through the fostering influence of the hot-house conditions of civilized existence.

Is there not fair warrant for the assumption that the pains which civilized women—and in particular the most delicately organized women –suffer in childbirth may be classed in this category?

I believer the answer must be an unqualified affirmative. Consider from an evolutionary standpoint, the pains of labor appear not only uncalled for, but positively menacing to the race.

67 “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. I could not see wherein the patients at Freiburg have a great advantage over those under chloroform narcosis; I certainly think the condition of the latter is a more pleasant one for the attendants and surrounding patients. But the obstetricians of Europe do not use chloroform and ether to assuage the pains of labor as we do here in American and this perhaps accounts in part for the interest that has been shown in the morphine-scopolamin[e] method.”

Note: possible damage to the baby as a result of the scopolamine narcosis of its mother, famed scientists or “authorities” of the day contended that:

“the tendency to retard respiration on the part of the child may sometimes be beneficial, preventing the infant from inhaling too early, 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.

Let me quote:

“As against an infant mortality of 16 percent [in today’s terms, 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 [NNMR of 116 per 1,000]

“For this strikingly low mortality of the children during and after birth under semi-narcosis, 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.”

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

“Have you ever considered,” he said, “the economical significance of the fact that three out of every five women are more or less incapacitated for several days each month, and that one of them is quite unable to attend to her duties. Granting that the two sexes are possessed of equal intelligence, it means that women cannot expect to compete successfully with men. For until they are able to work under pressure for 30 days each month, they cannot expect the same compensation as the men who do so.”

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

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

Dr. Williams says:

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

“The laity should also be taught that a well-conducted hospital is the ideal place for delivery, especially in the case of those with limited incomes.

“Moreover, they should learn that the average compensation for obstetric cases is usually quite inadequate; and should realize, … that doctors who are obliged to live on what they earn from their practice cannot reasonably be expected to give much better service than they are paid for.

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

OBJECTION 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 ….

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

Suppose we consider … a typical county… Such a county will be about 25 to 35 miles square, and will have a population of about 20,000. The count seat is a town of from 3,000 to 5,000 inhabitants. There are half a dozen smaller towns … scattered throughout the country, making up something less than half the population.

In a population of 20,000 there will occur, on the average, abut 700 births in a year. So the obstetrical needs of such a community … are by no means insignificant when considered in the aggregate. There is ample material for the patronage of a small hospital located at the county seat if even a large minority of the women of the community can be induced to patronize it.

But the small lying-in hospital with it s average of 1 or 2 births per day, will be provided of course with a resident physician and with a staff of nurses competent to give the first dose of the drugs. So… 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 anesthetics, 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.

What a boon it will be then to the 6 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

I think it may safely be asserted that once public interest is aroused, the matter of monetary cost will present no serious obstacles.

Recall that the average annual birthrate is about 35 to every 1,000 inhabitants; that is to say, about one to every 6 families and that sooner or later there are children in every normal household. We are dealing them with a project 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 the levying of a special tax

Once the hospital is in operation it will in many regions be self-supporting – for 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 willingly submit to taxation than for this institution which so manifestly adds to the comfort and well-being of the mothers and wives and daughter of the community.

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 danger and practically annul the pains of women of the community …

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 … wards or department of general surgery for the treatment of various disease 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 [of childbearing women] 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 b e considered seriously and a function 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 conditions of women through the amelioration of the evils incident to the performance of her supreme function.

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 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 women in childbirth may be given the solace of the “Twilight Sleep”, with all the attendant blessings that the word in its widest implication is here meant to connote.

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

…. 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.

TRAINING THE OBSTETRICIAN

Fortunately I am able to make this presentation with full authority, largely from a report make to the trustees on the condition 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 tot hat fact he ascribes the present preeminence of that country in this field of medicine.

…. [obstetrical professors] must be paid salaries sufficient to enable them to give their entire time to the work and NOT be distracted by outside private practice.

“At present, gynecology 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 by him [the gynecologist] — 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 process of women is part of his field and if this contention were sustained, very little would be left for the gynecologist.

NEEDS OF A GREAT HOSPITAL

In the same communication to the Trustees, Dr Williams states that the Johns Hopkins Hospital now maintains 56 gynecological and 39 obstetrical ward beds….

…. 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.

“Such an institution,” Dr Williams concludes, “would afford accommodation for 110 ward patients … and would make possible the treatment of say 1,200 gyn and 1,000 ob patients each year 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.”

WHAT A HALF MILLION WOULD DO

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

And what …stands in the way of the immediate carrying out the way of the immediate carrying out so beneficent a project?

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

How much money would be required?

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

Half a million dollars 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 20 million mothers of America would be investigated, as they are being investigated nowhere else in the country.

The Board [of Johns Hopkins] 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. It is useless to ask any physician to give his full time to work in this department of the hospital until [clinical] material [i.e., patients as teaching cases] is available to supply full opportunities for investigation and progressive work.

Surely there must be in America a 100 or perhaps 500 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.

End of excerpts

======================= Begin Full Text of Book ===

Chapter 6

BEING A WOMAN [faith àTHE SEXUAL FUNCTION OF WOMEN AS WRITTEN BY MEN!]

It is peculiarly appropriate that the test which will probably determine the availability in this country of the twilight sleep should be made at the Johns Hopkins Hospital; both because this institution stands admittedly first as a seat of research and education among institutions of it kind in American and because Dr. Williams, its chief obstetrician, is the most aggressive advocate of new standards and methods of medical research and instruction with regard to the betterment of the condition of women in all that pertains to the sexual function. (this sentence is 89 words long!)

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

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

Few subjects could be of greater importance of wider appeal, and … Dr Williams’ sober presentation of facts and analysis of conditions will have … a somewhat startling revelation.

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

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

During parturition, not alone is the woman afflicted with the excruciating pains to which we have all along referred, but she is subject to the dangers of serious laceration of the cervix of the uterus, or of the perineum; there may occur contusion involving the wall of the bladder; and there is always the possibility of … placenta previa, with attendant certainty of severe hemorrhage.

Then in the puerperal period immediately following delivery, there is a danger of infection, now fortunately minimized by modern asepsis, but formerly a menace of appalling significance; there is the possibility that the uterus may not contract and resume its normal size; and there is a chance – becoming a reality with every 3^rd or 4^th women— that the uterus will be come displaced …. if the displacement is not early corrected, it become a permanent source of discomfort and even serious illness remediable on by a sever operation.

“It is my experience,” says Dr. Williams, “that 8 % of white and 33% of black women going through my hands have abnormal pelves. …. The minor grades may not do much harm, while the marked degrees are usually recognized; but the trouble come in the large group lying between the two extremes, which is ordinarily recognized only after serious trouble has occurred and when it is too late to obtain ideal results.”

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

THE OBSTETRICIAN TO THE BAR

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

…verbatim for recent utterances of Dr. J. Whitridge Williams, that there may be no possible question about the authenticity of the verdict:

“Those who are not familiar with medical topics,” say Dr. Williams, “will be surprised to hear that we are almost as ignorant concerning the significance of menstruation and the cause of labor as were Adam and Eve’s first children’ that difficult menstruation which disables millions of women several days each month is a great a problem to us as to our forefathers….

And that we know practically nothing concerning the model of production and the means of preventing displacement of the womb.”

The as to the medical supervision of childbirth itself, Dr Williams has something to say that is even more startling. In the course of the address before the American Association for the Study and Prevention of Infant Mortality…:

“In this country, …. Obstetrics has suffered greatly from the so-called maternity hospital, with its narrow ideals and its restricted opportunities.

Doubtless, most non-medical members of this audience believe that American women are the recipient of the most expert obstetrical care in the world and that obstetrics as attained its highest development in this country. I am here to tell you that such is not the case…I have no hesitation in stating that in this country obstetrics is the most poorly taught of all the major branches of medicine and the average practitioner leaves the medical school very poorly equipped to carry on this import part of his work.

“This is ….. attributable to the peculiar development of medical education in the country. Until recently the medical schools were entirely in private hands and no under the control of strong universities. Any one was considered good enough to be made a professor of obstetrics, and was very fortunate if charitable persons make it possible for him to direct a small lying-in hospital, where he might enlarge his own experience and give meager instruction to his students. [Note; This is a barb aimed at Dr DeLee, who personally founded the Chicago Lying-In Hospital in 1896 and was a professor of obstetrics at the University of Chicago]

75 “…at the moment I know of only one school in this country which possesses adequate facilities for the instruction of its students. [Note – he means Johns Hopkins]

“As the professors are usually poorly paid, they are obliges to devote the greater part of their energy to making a living by private practice, and necessarily regard the conduct of the small lying-in hospital and the training of students as a very secondary consideration.

“Faulty training, meager facilities and the lack of time make it impossible for them to investigate the fundamental problems of the subject, with the result that our professors are the least productive in the world and have contributed practically nothing to the scientific side of their profession. …. I know of only two American who have made fundamental contributions to the subject and neither of them were obstetrical teachers.” [Another barb to DeLee, who was an immigrant to the US from South American, while JW Williams was a many generation blue blood whose great-great-great grandfather was lawyer who immigrated from London when Jesus was still in diapers]

76 ….the investigation which Dr. Williams epitomizes in the address just noted were published in the Journal of the American Medical Association for January 6, 1912. Therein were detailed the results of a questionnaire containing some 50 questions concerning obstetrical education and the midwife problem, which was sent to the professors of obstetrical through the country, and to which 43 sets of replies were received, “representing 1/2 of the acceptable and 1/5^th of the non-acceptable medical schools,” and indicating, so Dr. Williams declares, “a most deplorable condition of affairs, briefly as follows:

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

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

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

In commenting at length on the different aspects of the matter, as revealed by his investigations, Dr. Williams says: “The replies clearly demonstrate that most of the medical schools included in this report are inadequately equipped for their work, and are each year turning loose on the community hundred of young men whom they have failed to prepare properly for the practice of obstetrics and whole lack of training is responsible for unnecessary deaths of many women and infants, not to speak of a much larger number, more or less permanently injured by improper treatment or lack of treatment.”

“… The fault lies primarily in poor medical schools, in the low ideals maintained by inadequately trained professors and the ignorance of the long-suffering general public.

THE EDUCATION OF THE LAITY

As to the last named point, Dr. Williams has some pertinent things to say…

“The public should be taught,” he declares, “that only the well-to-do, who can afford to employ competent obstetricians, and the very poor, who are treated free in well-equipped lying-in hospitals or out-patient department [which describes a ‘domiciliary’ or home birth service staffed by interns and residents], receive first-rate attentions during childbirth; while the great middle class and particularly those at its lower end, is obliged to rely on the services of poorly trained practitioners. It should be taught that while pregnancy an labor is normally a physiologic process, it is not always so, but is liable to so many aberrations and abnormalities that the pregnant women should early place herself under the care of an intelligent physician who may detect and cure in their early stages many complications which if neglected, might place her life and that of her child in serious jeopardy.

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

“Every effort should be made to emphasize the great responsibility which the obstetricians must bear in the management of abnormal cases. ……. At present, … the average practitioner does not recognize the existence of the former [contracted pelvis] until irreparable damage has been done and usually considers himself quite competent to treat the latter {eclampsia or placenta previa], instead of immediately placing his patient under expert care, as he would were she suffering from even a minor surgical ailment.

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

“The laity should also be taught that a well-conducted hospital is the ideal place for delivery, especially in the case of those with limited incomes.

“Finally, the laity should be impressed with the fact that the remedy lies in their hands, and that they will continue to receive poor treatment as long as they do not demand better.”

Here I must be content to quote in the briefest summary the reforms which Dr. Williams names as in his pinion the most urgently needs and most important. He summarizes them thus:

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

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

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

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

“5. The requirement by state examining boards that every applicant for license to practice shall submit a statement certifying that he has seen delivered and personally examined, under appropriate clinical conditions, at least 10 women.

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

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

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

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

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

Chapter 7 – WHAT THE AVERAGE LAYMAN CAN DO

We are told on 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 an adequate practical knowledge of the routine practice of delivering a women of a child, should the accouchement chance to be one that depart in the slightest degree from the normal.

With the average practitioner, it s 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.

….the safety of the average woman in parturition would be by no means assured, ecause it is matter of record that in many of our larger cities from 40% to 60% 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 care 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 danger in the performance of this most sacred function of maternity?

How can it be arranged that all women, or a large percentage of women, in particular that middle class which we are told no 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?

…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 co-operation 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 wish to inquire what the laymen can accomplish, individually and collectively, toward bettering conditions in hi own community. The answer is found 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.

OBJECTION 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 ….

But … it will not be easy to gain this assent. A large number of women … will declare that the bearing of children is a natural and physiological function, and that no women worthy to be a mother should car e 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 function 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; subjects her to a series of surgical operation and perhaps leaves her permanently incapacitated for normal activities—such a process is not a normal one, whether or not it be physiological one.

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.

91 [end of my highlighting with bold or red text or box]

Moreover, the cultured woman of today has a nervous system that makes her far more susceptible to pain and to resultant chock that 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 individual 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 omen themselves, but eh coming generation.

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 STRONGET WOMEN ARE MENACED

But … even the women 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 phlegmatism of temperament will not shield her from the danger of hemorrhage if the placenta that supports the lifeblood to her child changes to be lodged near the mouth of the uterus [placenta previa]; 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 and size may suffer a displacement that if not corrected will make her a chronic invalid.

Take as a single illustration the matter of displacement of the uterus. I have quoted Dr. Williams … that no one know just why such displacements occur, or in what cases they are likely to occur.

What de do know is that in a certain large proportion of cases, such a displacement does occur in the course of he few weeks succeeding delivery. …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.

But if the difficulty is not discovered in its early stages, and thus remedied, the maladjustment become permanent and can be corrected only by a surgical operation of a rather serious character. Thousands of women go through life without enjoying a really well day because ofusch a uterine displacement, undiagnosed or uncorrected.

Yet it goes without saying that the women who is attended by a midwife or y an unskilled practitioner is usually never so much as examined to determine whether the uterus has or has not maintained its natural position after childbirth.

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

But it is needless to elaborate. I have already quoted Dr Williams to the major part of the surgical operations with which so large a number of gynecologists are busied are make 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 … if conditions could be so altered that every women 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 … except by the extension of a lying-in service far beyond the bound 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 3,000 or 4,000 inhabitants.

…if we consider the matter with attention without for a moment overlooking the practicalities we shall see that such a project by no means presents insuperable difficulties.

Suppose we consider … a typical county… Such a county will be about 25 to 35 miles square, and will have a population of about 20,000. The count seat is a town of from3,000 to 5,000 inhabitants. There are half a dozen smaller towns … scattered throughout the country, making up something less than half the population.

In time every mother in the community should come to patronize such a hospital’ for it will come to be know that the home is no place for a women during the ordeal of childbirth. May women in the cities have learned this…. The conditions there are far superior to what they can be in any private dwelling and the women who has experienced the comforts of a good lying –in hospital will never willingly be confined again elsewhere.

These comforts it must be born in mind include the use of pain-annulling drugs. In this country it is customary to anesthetize the patient with chloroform, though some … practitioners prefer ether. We have already seen the merits of the morphine-scopolamin[e] treatment, including the Twilight Sleep, are to be fully tested at the Johns Hopkins Hospital and it may be that this treatment …will presently come into vogue in all well-conducted lying-in hospitals.

…the small lying-in hospital is precisely the place where the morphine-scopolamin[e] treatment may be carried out to best advantage. We have seen that this treatment cannot be utilized in large hospital with a relatively limited staff. Obviously, it could not be applied in the private practice of the average obstetrician, even though he were thoroughly skill in the administration of the drugs because the demands on his time would not permit him to observe the patient continuously from the early state of labor as is necessary during scopolamine anesthesis.

Until …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. ….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 though of the average wife is that she cannot possibly be sparted from home and that the idea of going to the hospital is not even to be considered. But 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 practiced medicine in the country can 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 is attendance has been desired at the same moment in two farm-house, one located perhaps 6 or 8 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 paste from a patient 8 or 10 miles to the east should arrive while the perplexed physician is endeavoring to decide, fro the testimony of the messenger or the telephone messages, which of the tow cases already reported is the more urgent.

… no woman can be sure that she is to have medical attendance at all during the period when attention is acutely needed … mere statement of that fact should be enough to make it apparent that the existing conditions are intolerable.

COUNTING THE COST

….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 along to every women 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 think it may safely be asserted that once public interest is aroused, the matter of monetary cost will present no serious obstacles.

No project could more justifiably call for the expenditure of public money – money raised if need be by the issuing of bonds or the levying of a special tax

[i.e. the ‘free’ hospital beds, clinics and outpatient services identified earlier as Dr. Williams ‘solution’ so obstetricians can provide painless childbirth to the medical indigent are to be funded by collecting tax money to reimburse the hospitals and to pay the professional fee of the obstetrician]

In many places small public or semi-public hospital already exist. These can be enlarged at relatively small cost or their existing wards – which in many cases are for the most part vacant – may be utilized as lying-in quarter. [note – the hospitals already in existence are under used]

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

[A business model by any other name!]

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 … wards or department of general surgery for the treatment of various disease 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 [of childbearing women] 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 b e considered seriously and a function that is scarcely to be referred to in general conversation.

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 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 women in childbirth may be given the solace of the “Twilight Sleep”, with all the attendant blessings that the word in its widest implication is here meant to connote.

It is not worth your while to have a share in the beneficent movement?

Chapter 8 WHAT SOME PHILANTHROPIST MAY DO

Even were local lying-hospitals to be established everywhere, there would still remain much to be down before the needs of women in connection with the great function of childbearing 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 department of medical practice. We were

We were told that the most skilled practitioner knows scarcely more about the cause and proper treatment of painful menstruation that did our grandparents of the supposedly pre-scientific days; the ills that threaten the pregnant and parturient woman are a good many obscure as to origin and

Again we were told that the standards of medical education in the 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 the local lying-in hospital could have but subordinate influence.

Each such local hospital will 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 practice and it is obvious that institutions such as there 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.

TRAINING THE OBSTETRICIAN

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 tot hat fact he ascribes the present preeminence of that country in this field of medicine.

Her urges the absolute necessity for the provision and proper equipment of large women’s clinics both for the opportunity … accorded for research work in solving the obscure problems concerning the normal and abnormal sexual processes of woman and for the teach of medical students who cannot otherwise by any possibility be adequately prepared to practice 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.

…. They must be paid salaries sufficient to enable them to give their entire time to the work and NOT be distracted by outside private practice.

“It goes with saying … 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.”

“These problems … 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 practise and who can give only a few hours each day to hospital and university work.

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

“Were the two departments are conducted independently, both suffer; as the gynecological assistants are handicapped by know 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 mis-managed 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 often effected only by an arbitrary time limit.

“Thus, a pregnant woman with an ovarian tumor is considered a gynecological patient in the first 7 months and as an obstetrical patient in the last 3 months of pregnancy.

“How much simpler and more effective it would be if the two department 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 po provide requisite facilities for teaching and research.

NEEDS OF A GREAT HOSPITAL

In the same communication to the Trustees, Dr Williams states that the Johns Hopkins Hospital now maintains 56 gynecological and 39 obstetrical ward beds….

The ward accommodations … are satisfactory but the department sufferes from the fact that the operating room, private patients and white and black ward patients are in four separate buildings; but more particularly because it is inadequately supplied with proper quarter 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 the 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 over-crowded and ill-adapted for the proper care of babies, while the teach 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 ½ 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 e 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 women in the land.

119 …accommodations are needed for 10 private 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.

… 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 investigations, together with a small museum. Teaching quarter should also be provided, including one room capable of seating 100 students, a number of smaller room for section work [dissection of cadavers], 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 woman’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 accommodation for 110 ward patients … and would make possible the treatment of say 1,200 gyn and 1,000 ob patients each year would be available for teaching purposes. In addition to making possible this amount of humanitarian work, I believe that ti 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.”

WHAT A HALF MILLION WOULD DO

And what …stands in the way of the immediate carrying out the way of the immediate carrying out so beneficent a project?

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

How much money would be required?

The Board [of Johns Hopkins] 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 the it would make available resources that cannot be utilized until the present obstetrics quarter 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 material [patients as teaching cases] is available to supply full opportunities for investigation and progressive work.

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Chapter 1

P10 … Even in this second decade of the 20^th century the generality of women bring forth their children in sorrow, quite after the ancient fashion, unsolaced by even single whiff of the beneficent anesthetic vapors through the use of which, in the poetic phrasing of Dr. Oliver Wendell Holmes, the agonies of tortured humanity may be stepped in the waters of forgetfulness.

p.12 …how has it come about that this most natural and essential function should have come to be associated with so much seemingly useless suffering.

…something has been told of the wonderful effort that has been make by a band of wise physicians in Germany to give solace to the expectant mother, and to relieve the culminating hours of childbirth of their traditional terrors.

The wise physicians in question are associated with the University and Hospital of Freiburg. For years they have labored to perfect a method that shall make childbirth painless.

Some thousands of mothers from all parts of the world stand ready to testify to the success of this beneficent quest. These women will tell you that they have had ‘painless babies’ in the hospital at Freiburg.

p.14 – define technical medical process of Twilight Sleep:

Stated in the fewest words, this method consists essentially in the hypodermic administration (an injection or ‘shot’) of certain drugs, given just at the incipiency of the acute pains of childbirth (i.e. active labor), and calculated to render the patient oblivious of the pains—or, to be quite accurate, to modify her consciousness in such a way that she has no recollection of suffering went the ordeal is over.

The drug chiefly depended on to produce this condition of painless childbirth at Freiburg is know as scopolamine[e]. With it is associated, in the first dose, the more familiar drug morphine, or, more recently, another opium derivation called narcophin. The success of the treatment depends largely upon the skill with which the doses of the drugs and in particular the successive doses of the scopolamine[e].

The results in Dr. Von Steinbuchel’s skillful hands were gratifying. And subsequently, when Dr. Bernhardt Kronig, a famous gynecologist from [the University of] Jena, came to Freiburg as director of the Frauenklinik, her continued the experiments, and, with the aid of Dr. Karl Gauss, perfected a system of dosage the ultimately let to the perfection of the now famous Freiburg method of painless childbirth.

Partial Narcosis

A distinguishing peculiarity of the scopolamine[e] treatment, as thus perfected at Freiburg, is that it does not produce complete narcosis. If it were merely a question of giving hypodermic injections of a drug, until the patient became unconscious, the case would be quite different. But scopolamine[e] is not a drugs that lends itself to such as use as this. With a patient thoroughly narcotized the muscular contraction would cease, and the birth of the child would be retarded, even if the life of the other were not jeopardized.

So it is necessary to restrict the dosage, and to regulate it very carefully. In fact, therein lies the entire secret of the Freiburg method.

18 The essence of the matter is that when drugs are given in just the right quantity, the patient retains consciousness, and (except that she may fall asleep between pains) is at all times more or less cognizant of that is going on about her, but is singularly lacking in the capacity to remember any of the happenings that she observes.

She may seem to be conscious of the birth of her child, and may give evidence of apparent suffering. Yet when a few moments later the child is brought in by the nurse from the neighboring room where it has been cared for, and placed in the mother’s arms, the patient does not recognize the child as her own, or realize that she has yet been delivered.

This curious evanescence of memory is precisely the test according to which the dosage of the drug is graduated at Freiburg.

19 The first dose of morphine and scopolamine[e] in combination is given at an early state of labor. Half an hour or so later a second dose, of scopolamine[e] alone is given. After that the patient is test from time to time as to her capacity to remember. She is shown an object, and a few minutes later is shown it again and asked if she has seen it before. If she remembers, another dose is indicated. If she has no recollection of having seen the object, this indicates that her condition is just what it should be, and no other dose is required until memory is again restored.

….[this] is the actual and definite result of the action of scopolamine[e] on the central nervous system.

Twilight sleep! A pleasing and suggestive term, is it not? To scores of English-speaking women it has come to be a synonym for painless childbirth. And enthusiasts are not lacking ho express the hope that in the future it may become a household word throughout the English-speaking world.

Thousands of women have experienced the blessing of having the agonies of childbirth assuaged to the point of annulment by the Freiburg method. Why should not their millions of suffering sisters through-out the world be given the boon and blessing of the twilight sleep or its equivalent?

Why not, indeed?

Chapter 2 TO BE AND NOT TO BE

This condition of twilight sleep—this being awake and yet registering no metal record of events—is so interesting a psychological condition that I am tempted to dwell on it for a few minutes before going on to consider other aspects of the problem of painless childbirth.

Be it understood that the patient under scopolamine[e] at the Freibur Hospital give every outward evidence during her confinement of acute suffering. She cries out as other do under suffering; tell the doctor perhaps that her pains are severe beyond endurance. And the doctor smilingly admits that this is true—unperturbed, because he know that an hour later, and throughout the future, the patient will have no recollection of having suffered at all.

And the curious question arises as to whether, under such circumstances, the women has really suffered.

p.23

Yet it is undeniably true that pains and disagreeable experience in general would lose very much of their terror if we knew that they were absolutely transient, and would leave no record in memory. And, making application to the case in hand, I think most women will be disposed freely to admit that they would regard the pains of childbirth as at least relatively trivial if they know that knew that these pains would be absolutely forgotten soon as they were over.

…to some persons it will seem that under such conditions it might properly be said that pain did not really exist, even though there were reflex actions that to an onlooker seemed to give evidence of their existence.

p.24.

The case of the twilight sleeper may be said to be closely comparable to that of the somnambulist.

If the paradox be permitted, the individual personality may be said to be and not to be at the same moment. But let us not puzzle too much over such subtleties.

Let it suffice that the woman in labor who comes under the beneficent guidance of the Freiburg physicians, finds presently that her baby has come into the world without her knowledge, and that she either remembers nothing at all of what took place during the hours of delivery, or—exceptionally—retains a vague mental picture of pleasing hallucinations as meaningless and unsubstantial as dreams.

But a highly important question must be asked by the physician who ……wishes to gauge the Freiburg method: the question, namely, as to whether the patient who has undergone this treatment show any unpleasant after-effects of the narcotic.

And here, fortunately, it would appear that the answer is altogether gratifying. It is claimed that an analysis has been made of more than three thousand cases that have taken this scopolamine[e] treatment at Freiburg, and that the statistics show that in general women who have had this treatment make better and more rapid recovery than women in general who go through the ordeal of labor in the old-fashioned way.

Parenthetically, I may add that it is claimed as a mater of course that the babies suffer no injury; but that is another story, to which I shall revert.

[faith’s comment: no harm to baby — scolopolamine claimed to reduce forceps from 40% to only 6% when ‘sensitive, intellectual women who otherwise beg for the doctors to end her suffering by using forceps is instead under the influence of morphine and scopolamine.]

It is claimed that not a single [maternal] fatality can be charged to the scopolamine method practiced at Freiburg, notwithstanding the conceded danger that would attend the use of this drug in reckless or unskiful hands. Again, it is claimed that the use of forceps has been reduced to a minimum at Freiburg, thereby lessening greatly that danger of injury or infection.

And it is further claimed that the patients make astonishingly rapid recovery, their nervous system seeming to have been spared the shock that ordinarily attends the ordeal of childbirth and their nervous energies thus having be conserved. Tails are told of women sitting up to eat a hearty meal within a few hours after delivery; being up and about their rooms for a few minutes the next day; going for drives on the fifth day; and being out returning the call of congratulation by the end of the week.

For the average mother is perhaps suffices to know that the twilight sleep is a condition from which she emerges as from a restful sleep, conscious only that in some miraculous way the child that aforetime nestled beneath her heart is now crooning at her bosom and that the wonderous transition has caused her no suffering.

Faith’s comment: this describes a way that some women figured out to have the guys have the baby for them — Arnold Swartznager in pregnant drag — and is curiously consistent to the conversations women still have about a way that men could take on the pain as their “fair share” of the pain.

28 … the mothers of our day are freed more or less from the old bonds of superstition, and are ready to welcome emancipation from that primal sentence which, what ever its original significance, was cared out in full measure generation after generation from the earliest recorded periods of civilization to our own day; cut which, in future, thanks to the twilight sleep or some equivalent, must be forever abrogated.

Chapter 3 WHAT IS PAIN—AND WHY?

29 An old adage tells us the “The burnt child dreads the fire”. [remainder of p. 29 to 31 not transcribed

32 The memory of that injury will have become a permanent part of the child’s mental endowment. So long as it lives, though its finger may never again come in contact with a glowing ember, that child will remember that fire is a dangerous plaything. In the current phrase, it will “dread the fire.”

And the only way we can explain this is by supposing that the central mechanism of the brain has had stamped on it a record—comparable if you please to the records of a phonograph – which will reproduced, is the sole foundation for memory. The reproduction of the record is never quite so intense as the original production; so the agony of a remembered pain is not quite comparable to the pain itself. Yet in quality the two are closely akin or better stated, one is a replica of the other. And all mentality is built up out of such reproductions of past experiences.

If the burnt child dreads the firs, it is because the brain cells of the child register permanent records of the burning. [followed by conclusion that pain teaches the child not to touch dangerously hot surfaces, which makes pain a protective mechanism that favors survival of the species]

Pain and Evolution

The simple truth is that every organism must learn in the school of experience, there being no other school. ….among the multitudinous experiences that come to guide us each and all, there are perhaps no others that are fundamentally more important than those that when first experienced were registered as painful sensations.

The purpose of pain is to preserve the individual and make possible the evolution of the race.

BUT WHY THE PAINS OF CHILDBIRTH?

Shall we then infer that the purpose of the pain suffered by the parturient women is to give her clear warning that she had best never have another child?

That question answers itself. …. Clearly if every women brought to childbed were to make such interpretation of the warning, and never repeat the experiment of motherhood, the human race would dwindle at a geometrical ration and incur every probability of elimination….

So here we are confronted with a fine paradox. The purpose of pain in general we seem clearly to know. Yet the pain of childbirth – the most intense, perhaps to which a human be can be subjected—can only be interpreted in a directly inverted sense.

Suppose we state the matter thus ; Nature desires that women shall bear a large number of children. Nature provides pain as a warning against repetition of a pain-engendering experience, Therefore, Nature provides that when a woman bears a child she shall suffer the most intense pain that can be devised!

Stated thus, the non sequitur is obvious. Our attempted syllogism does not work out at all. There must be a lost link in the reasoning somewhere. It is worth inquiring a little farther to endeavor to find out wherein lies the weakness of our argument.

Chapter 4 ~ ARE LABOR PAINS A DISGUISED BLESSING?

This much, at least, is certain. If the pains of labor are a disguised blessing, the blessing is singularly well disguised.

….if we look deeply enough, that the suffering of women in childbirth serves a beneficent, even though occult purpose in the scheme of human evolution?

Otherwise, how harmonize the phenomena of painful childbirth and the accepted thesis of evolution through natural selections – the thesis according to which useful traits are the ones preserved?

The question is undeniably puzzling. But an inkling of the answer is found when we learn 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.

This seems to suggest that the excessive pains of childbirth are not a strictly ‘natural’ concomitant of motherhood, but rather that they are an extraneous and in a sense an abnormal product of civilization.

Every one knows that the law of natural selection through survival of the fittest, which as Darwin taught us, determined the development of all races in a state of nature, does not fully apply to human beings living under the artificial conditions of civilization. These artificial conditions often determine that the less fit, rather then the most fit, individuals shall have progeny and that undesirable than the desirable qualities shall be perpetuated.

When we observe certain characteristics or habits in connection with animal races in a state of nature, we may fairly assume that these characters and habits are beneficial to the species, harmonizing it with its environment; but it is never safe to draw a similar conclusion unreservedly regarding any trait or habit may be directly detrimental to the individual and to the race and they may be preserved, generation after generation, through the fostering influence of the hot-house conditions of civilized existence.

Is there not fair warrant for the assumption that the pains which civilized women—and in particular the most delicately organized women –suffer in childbirth may be classed in this category?

I believer the answer must be an unqualified affirmative.

Consider from an evolutionary standpoint, the pains of labor appear not only uncalled for, but positively menacing to the race.

From the standpoint of evolution, it might rather be expected that the experience of childbirth would be the most pleasurable of human experiences. That in point of fact it is the most painful, seems in itself to demonstrate that it is not a “natural” experience in the broad sense of the word.

Rather is it to be regarded as an abnormality calling for the careful attention of the pathologist, that a means me be sought to eliminate it, as we seek to eliminate all other abnormal conditions.

….we have the testimony of experimental physiologists and pathologists who tell us that pain has a directly exhausting influence on the brain and nervous mechanism, lowering the vitality and decreasing the powers of recuperation. Arguing from such data, it would appear that the women who suffers greatly during childbirth may be expected to make a retarded recovery and is physically less well fitted to care for her infant….

faith’s comment: It is odd that these men, not a one of whom has ever had a single uterine contraction or given birth, have become elevated themselves to the role of sole spokesperson for exactly what the nature of childbirth is from the standpoint of the childbearing woman’s experience.

More important however is the obstetricalization of normal birth as founded on eugenics with this convoluted explanation of pain as the rational — the idea that these men decided that ‘delicate’ women who are more intellectually accomplished and do the ‘hard mental work’ should be the ones to breed and the women who work with their hands — manual labor — should not and are being wrongly favored by Mother Nature.

These “Fathers of civilization” are crafting social policy thru the biology of childbirth and know better than normal biology.

p.42

Then there is the confirmatory evidence of practitioners who have used anesthetics to less or annul the pains of labor,……testifying that women who are not permitted to suffer, but are given the blessing of anesthesia, or of the “twilight sleep,” rally quickly from the ordeal, recuperate rapidly and in general make better recoveries…..

…by way of summary as to the abnormalities … and the needlessness and harmfulness of painful labor, I cannot do better … than quote Dr. Kronig himself. ….the Freiburg specialist. in addition to pointing out the exhausting and harmful effects of painful labor on the women of sensitive organization, has something to say also about an aspect of the matter to which I have hitherto referred but very briefly–… namely that when women are given respite from the pains of labor, there is much less liability of the use of forceps.

43 Dr Kronig speak[s] for himself:

“Of late,” he says, “the demand made of us obstetricians to diminish or abolish suffering during delivery has become more and more emphatic. The modern women, on whose nervous system nowadays quite other demands are made than was formally the case, responds to the stimulus of severe pain more rapidly with nervous exhaustion and paralysis of the will to carry the labor to a conclusion. The sensitiveness of those who carry on the hard mental work is much greater than that of those who earn their living by manual labor.

“As a consequence of this nervous exhaustion we see that precisely in the care of mothers of the better class the use of forceps has increased to an alarming extent, and this where there is no structural need of forceps.

“When one goes into the record of the cases of women like these concerning their previous confinements, one is almost driven to the conclusion that spontaneous birth is, in their cases, practically impossible. It is by no means unusual to hear that the forceps had to be used at every previous confinement. Neither structural difficulties nor muscular weakness had indicated the necessity for operative interference. The forceps had been used simply and solely to shorten the pains of labor.

“On the occasion of a meeting of the Berlin Obstetrical society, it came t light that obstetricians practising in the best society in Berlin were obliged to use the forceps in nearly 40% of their cases.

Danger in the use of forceps

“Although in the hands of a skilful operator the forceps is NOT so DANGEROUS as in those of an inexperienced one, yet for those who know how great is the local susceptibility to infection it is hardly necessary to say that the chances of a favorable confinement and recovery are considerably diminished by any operation.

“If you follow the lyings-in, even in the best hospitals, you will find the number of cases of temperature considerably higher where there was not spontaneous delivery. In the unfavorable external circumstances of ordinary practice, all these injurious results increase. The great increase of the spread of puerperal fever corresponds to the increasing frequency of operations shown in the statistics of the larger towns.

“It might have been thought that the introduction of asepsis in obstetrics, and its careful application outside the hospitals as well as in, would have decreased the number of deaths in childbirth in comparison with those under former conditions. But we note a not inconsiderable increase. Every one agrees that the absence of reduction in the number of cases of puerperal fever is chiefly caused by an enormous absolute increase in the number of operations, and especially a huge increase in deliveries by the use of forceps.”

[In the Frauenklinik, since the introduction of the Twilight Sleep method, the frequency of forceps cases, we are told, has settled down to an average of from 6 to 7 percent.]

“In theoretical medical instruction, the ‘rescuing’ forceps finds no place. In practice the conditions are different.

“The cases available for obstetrics study in the hospital consist, for the most part, of women of no great intelligence, who earn their bread by manual labor.

“In private practice, we not infrequently have to do with women of nervous temperament who declare themselves incapable of enduring the pains of labor to the end. A medical man often in such cases finds himself before the alternative either of ending the delivery operatively with the forceps, or of retiring in favor of another doctor.

“If we take the trouble to sit at the bedside of women of some sensitiveness during the whole course of labor and to observe the state of their nervous system, we are compelled to admit that all power of will to hold out till the end of the birth is paralyzed.

“ I hardly believe that any one who takes the opportunity of observing a birth in the case of one of these women, from beginning to end, would afterwards agree with the statement that the pain of birth is a physiological pain which is really of advantage to the mother ……

“Acute pain at birth cannot, in the case of sensitive women, be termed physiological, for it frequently occasions a condition of severe exhaustion even after birth.

“Any gynecologist who considers that he ought to be something more than merely as good an operative manipulator as possible –who thinks that he should observe the nervous condition of the mother—will not infrequently note that neurasthenic symptoms appear in immediate connection with the delivery. One is only astonished that the long-continued exhaustion does not occur more frequently, when we realize what a sensitive women has to endure during her confinement, even taking into consideration the mental impressions alone.

“The preliminary pains are probably stood well. But with their increasing frequency and violence the moral resistance breaks down. She feels her strength giving way, and does nothing but beg the doctor to use forceps and put an end to her agony, and longs only for the moment when she will be released from pain by the chloroform or ether.

“If as often enough happens in private practice, the forceps is used without an anesthetic, because the doctor is afraid to trust the continued administration of the anesthetic to an unexperienced helper, then in addition to the ordinary pains of birth, the women has the pain of the operation, The loss of blood, especially in the case of a first child, is relatively great, and bodily exhaustion is thus added to the mental.

“It is true that robust women can stand all this without consequent injury to their nervous system; but is equally undeniable that, if there is the slightest inclination to a neuropathic condition, such severe bodily and psychical injury is the cause of a long period of exhaustion.”

I think we may take it as settled, without further discussion, that the agonies of childbirth do not benefit the mother. No one has claimed, I believe, that they benefit the child.

Shall we not say unreservedly … that painful childbirth in this age of scientific medicine is an unwarranted anachronism?

And when we have said this, why not go farther and say that is a reproach to medical science and a blemish on our boasted 20^th century civilization?

Chapter 5 THE TWILIGHT SLEEP AND ANESTHESIA

It remains now to consider the Freiburg method from a somewhat different standpoint; to give audience to the criticisms that have been passed on it, and to inquire whether it probably represents a final method or whether it only recall vivid attention to the problem, and points the way to its solution.

We must inquire also whether there are alternative methods or methods that may be used in combination with that devised at Freiburg.

…my object is not …to sanction or exploit the method of making childbirth painless that is employed at Freiburg but to emphasize the desirability of investigating that method, searching diligently for a better method, if such can be found, and in general taking up on a comprehensive scale the vitality important project of lessening the sum total of human suffering by systematically and habitually assuaging the pain needlessly suffered by the mothers of the race in carrying out their essential function of motherhood.

FAITH’S COMEMENT: In the US, the use of morphine, with or w/o scopolamine during labor, was always followed by volatile gas (general) anesthesia – ether, chloroform, nitrous oxide, or cyclopropane for delivery. In the 1960s in larger metropolitan areas, spinal anesthesia or self-administered trilene gas was used for delivery by some (but not all) doctors. In the early 1970 and depending on the physician’s personal preference, some women who wanted the new ‘awake and aware childbirth’ were given a local anesthetic (ex. Novocain) injected into the cervix or perineum (para-cervical or pudential block). By the late 1980s, epidural became the popular choice. Epidural replaced narcotics and scopolamine in labor and general anesthesia for delivery, reducing maternal deaths from general anesthesia and asphyxiation of the newborn associated with repeated doses of narcotics and the depressing effects of general anesthesia.

As childbirth became the focus of the new surgical discipline of obstetrics, the obstetrician’s role was more and more restricted to ‘the delivery’. Under the germ theory of disease (1881) and the influence of Dr Joseph Lister, the principles of aseptic technique were applied to ‘the delivery’. The ultimate expression of this was ‘surgical sterility’, and within a decade or so, the delivery became a surgical procedure conducted there was, functionally speaking, the expectation that anesthesia was just as necessary for ‘the delivery’ as it would have been for any operations. The Hx of the last 100 yrs is a fixation with childbirth as an ‘ordeal’ and obstetrical care as organized around relieving the mother’s ‘suffering’. The obstetrician defined his role as the alleviation of pain. This was all predicated on “the evils of labor”, the nervous sensitivity of the ‘better class of women’ and the idea of eugenics or making sure that it was the ‘better’ class of women whose work was mental and not menial or manual who had lots of children and populated the America.

Defects of the Method

… the administration of scopolamine[e] and morphine, as practiced at Freiburg is a rather delicate operation. …it is not something that can be done as a mere routine dosage, to be practised by nurses, or even physicians untrained in the particularities of the method. …with the use of other drugs the physician gives a dose of recognized standard size and repeats it if certain rather clearly defined symptoms do not manifest themselves.

But with scopolamine[e] treatment, the tests of full dosage are not physical; they are mental. The patient who is narcotized to the full extent desired does not seemingly have her suffering alleviated in the least during the period of the vigorous uterine contraction, which is commonly described as a ‘pain’. … even the skilled observer could not determine from direct observation of the patient whether or not the dosage has been sufficient. But immediately after the pain the patient falls into a deep sleep and if awakened and questioned about the pains she has had, she has no recollection of … any pains at all.

It is this forgetting that constitutes the test, and according to the authorities at Freiburg, the sole dependable test of the sufficiency of the scopolamine[e] medication.

“As technically described by Gauss, ‘Twilight Sleep’ is accomplished successfully when there is an adequate abolition of the apperception of pain. It is to be looked upon as a kind of sub-consciousness in which the cortex of the cerebrum is completely cut off from the reflex columns of the spinal cord.”

The entire condition is well described by Dr. H. Fuchs, of Danzig, analysis of different methods of narcosis in childbirth, as follows: “When the pains come, the women usually cry out just as loud as any other lying-in women, answer the question whether they have pains in the affirmative, but during the intervals between the pains fall into a deep sleep. If awakened from this sleep and questioned about the pains they have suffered, there is a complete loss of memory, that is, if the semi-sleep is complete. Psychologically the facts of the case are that the pains are perceived at the moment but they make no impression. They leave behind the higher cerebral centers no memory picture. It results that if the semi-sleep is properly produced the whole of the processes of labor are banished from remembrance.”

Faith note: This one of the reasons that husbands and family members were banned from the L&D, since they would have been shocked by a scene that was like a psychiatric unit. They expected the promised ‘painless childbirth’ would look like the mother was peacefully asleep and would not have appreciated the fine distinction between the obvious displays of pain and the fact that the drug would block the mother’s memory of the pain she experienced.

Another useful aspect of the use of this amnesic-hallucinogenic drug, strong doses of narcotics and general anesthesia was that, except for the nurses, there were no witnesses. Family was never allowed and the women either couldn’t remember or their reports were dismissed as unreliable flights of fancy or outright hallucinations.

It remains to be said however that the morphine-scopolamin[e] treatment, even in the hands of the skilful exponents of the Freiburg, is by no means certain in its beneficent action.

Dr Gauss himself has given an analysis of the 3,000 cases treated at the Frauenklinik up to 1911, from which it appears that there is a great difference in susceptibility to successful treatment ….according to the temperament of individual women. In general, it appears that the women of the upper classes are more amenable to the treatment and that successful results are gained with them in much higher percentage of cases than with women of the peasant class.

p.55

It appears that the lying-in department of the hospital is divided into four classes, according to the accommodations, which grade all the way from the well-furnished private rooms to open wards. Dr Gauss’ report shows that among patients of the first class 82% of the cases were successful, in the sense that they experienced “perfect Twilight Sleep” (with attendant loss of memory) under the treatment. But among patients of the second class only 66 percent of the cases were successful; with the third class only 59%; and with the fourth class only 56% or slightly more than half of the cases treated.

In other words, even under the condition that obtain at the Freiburg Frauenklinil, only two women in three who receive the morthine-scopolamin[e] treatment are blessed with the painless delivery that they sought.

FAITH’S COMMENT: Now day we use this thinking to justify the ‘excess’ maternal mortality associated with Cesarean section — sacrificing a small percentage of mothers to theoretically improve make the lives of other mothers better or to ‘save babies’.

But who will deny that to give surcease of sorrow to two women out of three the brought to childbed, is a very notable achievement?

IS THERE INJURY TO THE CHILD?

There remains one other important point to be considered. This is the question of the effect of the treatment on the child.

It is well known that the nervous system of the infant is peculiarly susceptible to the effects of the drugs.

Opiates in the smallest quantity sometimes have an alarming effect when administered to your children. It is not surprising then to learn that the critics of the method have declared that the morphine-scopolamin[e] treatment not infrequently has more or less alarming effect on the child. According to the analysis of Dr. Fuchs: “The excitability of the respiratory center is lowered, with the result that one-fourth of the children are born in a state of oligopnea or apnea” —that is to say, in a state of partial asphyxiation.

The authorities at Freiburg contend, however, that the tendency to retard respiration on the part of the child may sometimes be beneficial, preventing the infant from inhaling too early, 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. Let me quote:

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

“For this strikingly low mortality of the children during and after birth under semi-narcosis, 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.”

…it would appear from Dr. Gauss’ figures that the morphine-scolpolamin[e] treatment as practiced under the skilled direction at Freiburg does not very greatly endanger the life of the child. The partially asphyxiated condition in which some of the children are born is one from which they recover under the skilled and vigorous treatment given them.

But on the other hand, it must appear that a drug which produces such effects, even when given in just the right quantity, might readily produce effects not so remediable if given in slightly larger quantity. So the necessity for exceedingly careful dosage of the morphine-scopolamin[e] treatment in careless or unskillful hands are very apparent.

WHY THE METHOD HAS NOT BEEN WIDELY ADOPTED

p.59

At the Freiburg clinic only about three patients are confined daily on average, and yet it has been necessary entirely to remodel the obstetrical department. Just why this is necessary and why the method cannot be applied in large hospital is well stated by Dr. Kronig himself:

“The proper carrying out of the method,” he says, “demands concentrated attention of the part of the obstetric staff … for giving it the widest possible application to all classes of the population. We are able, thinks to the Grand Duke of Baden, to triple the obstetric staff in the delivery room.

….our procedure can be employed with any prospect of success only when a complete administrative reorganization has been affected in the assignment of duty in the delivery ward. If, as is the case in large hospital, the medial man on observation duty is relieved every 12 hours, the colleague who comes on duty will not be sufficiently well-informed as to the condition of the various patients in labor. In such a case failure is certain beforehand.

“In large hospitals, with many thousands of births in a year, as in the case of the large hospitals of Berlin and Dresden, our procedure has proved a total failure.

“This is easier to understand when we remember that the surrounding of the patient have an importance which we should not underestimate for the success of the method. Sense impressions, loud noises, bright light, etc, considerably disturb the half-consciousness. When six or seven parturient patients lie side by side in one ward, it is obviously impossible to obtain an even fairly effective semi-consciousness.

Faith’s Comment: specialized (and expensive) hospital environment incl. a separate room for each laboring woman, semi-darkness (sometimes achieved by putting a hood over the mothers’ head like recent seen in the treatment of military prisoners and so-called terrorists at Abu Garab in Iraq & Gitmo in Cuba.

“The number of cases in which we obtain loss of memory or amnesia is in Freiburg far smaller in those deliveries which occur in the general ward than in the case of patients treated in our private wards, where they lie in a separate room protected as far s possible from all impressions of sight or hearing.”

IS THERE AN ELEMENT OF MENTAL SUGGESTION?

It may be added as further illustrating the difficulties of the method, that a patient in a private room, where the best results are attained as we have seen is kept in semi-darkness until just the moment of delivery when the electric lights are suddenly on with a dazzling glare; which seems strongly to argue that there is a pronounced element of suggestion or hypnosis int eh Freiburg method.

All in all, … it appears on critical analysis that the Freiburg method, whatever its merits, cannot be pronounced ideal.

Nevertheless it has profound interest because this method, whatever it limitations, has been so energetically and systematically carried out through a term of years as to command the attention of obstetricians all over the world; because it calls persistent attention to the idea of making childbirth painless; and because finally, it seems more than probable that there is a measure of permanent value in the morphine-scopolamin[e] treatment. It is hard to question this in the face of the testimony of thousands of women who have shared it benefactions.

And even if the Freiburg method now lacks something of perfection, it may very well serve as a forerunner of methods that will accomplish what it fails to accomplish.

It is at least possible that the morphine-scopolamin[e] treatment may be used advantageously in connection with ether or chloroform, and that the combination may produce a really ideal result.

And even if the morphine-scopolamin[e] treatment itself should ultimately be altogether abandoned for some better method, it still will have served a useful purpose in calling attention to a great need and in stimulating experiment through which that need will ultimately be met.

p.63

THE METHOD TO BE TESTED AT JOHNS HOPKINS

…The Freiburg method is to be put to a careful test in the near future at the Johns Hopkins Hosptial in Baltimore, under the skilled direction of the Dean of the Medical Fculty of the Johns Hopkins University, who is also the Professor of Obstetrics and the Obstetrician-in-Chief to the Johns Hopkins Hospital, Dr. J. Whitridge Williams.

I talked with Dr. Williams about the matter not long ago. He told me that he had made tentative tests of the morphine-scopolamin[e] method at the Johns Hopkins Hospital in the past, and not been favorably impressed with it.

Moreover, he personally visited the Freiburg Frauenklinik two years ago and there witnessed the delivery of two women under the conditions of the Twilight Sleep. The fact that the women appeared to suffer and were even more vigorous in their outcries than women usually are who receive no medication made an unfavorable impression on his mind, despite the fact that the women ma afterward had no recollection of what had occurred.

“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. I could not see wherein the patients at Freiburg have a great advantage over those under chloroform narcosis; I certainly think the condition of the latter is a more pleasant one for the attendants and surrounding patients. But the obstetricians of Europe do not use chloroform and ether to assuage the pains of labor as we do here in American and ths perhaps accounts in part for the interest that has been shown in the morphine-scopolamin[e] method.”

Nevertheless this leader among American obstetricians went on to say that his preconceptions would not be allowed in any way to influence his final judgment on the Freiburg method….

“A physician who has spent an entire year in the Frauenklinik at Freiburg studying he method at first hand is coming to Johns Hopkins as a assistant next fall,” he said, “and he will be given every opportunity here to apply the method and test it fully. When these facts have been carried out for a sufficient period, we shall be in a better position than we are at the present to pronounce judgment on the morphine-scopolamin[e] method.”

Such … is the attitude of mind of one of the foremost obstetricians and teachers of obstetrics in America.

p.66

It is perhaps not too much to say that every prospective mother in the land should feel a vital and personal interest in the outcome of the unprejudiced and scientific investigation of the Twilight Sleep that is thus about to be carried out at the Johns Hopkins Hospital.

Resistance is futile!

===================== end ===== TWILIGHT SLEEP ====== end ==============

Other direct quotes from Dr J.W. Williams, Dr Joseph DeLee and other contemporaries from the published record of the Society for the Study and prevention of Infant Morality in 1910-1915

=====================================================================

“German medical schools, which, unlike the US, had historically included clinical training in obstetrics and enjoyed a superior reputation with the European aristocracy. [1912-B, p.224]

So much is needed before we can hope to give to the students gradating from our medical schools adequate training in obstetrics and before we can hope to compete with the German medical schools.” [1912-B — Ziegler, MD “The Elimination of the Midwife”, p. 222-224]

“In general, …the medical schools in this country and the facilities for teaching obstetrics are far less that those afforded in medicine and surgery; while the teachers as a rule are not comparable to those in the German Universities. …yet young graduates who have seen only 5 or 6 normal deliveries, and often less, do not hesitate to practice obstetrics, and when the occasion arises to attempt the most serious operations.” 1911-B; Williams, MD p. 178

“It is generally recognized that obstetrical training in this country is woefully deficient. There has been a dearth of great obstetrical teachers with proper ideals and motives but the deficiency in obstetrical institutions and in obstetrical material for teaching purposes has been even greater. It is today absolutely impossible to provide {teaching} material.” [1912-B, p. 226

Illustrative of the sentiments of the day, which generally believed that each midwife attended birth was a “waste of clinical material” are the following quotes.

~ “I should like to emphasize what may be called the negative side of the midwife. Dr. Edgar states that the teaching material in NY is taxed to the utmost. The 50,000 cases delivered by midwives are not available for this purpose. Might not this wealth of material, 50,000 cases in NY, be gradually utilized to train physicians?” [1911-D, p 216]

~ “Another very pertinent objection to the midwife is that she has charge of 50 percent of all the obstetrical material [teaching cases] of the country, without contributing anything to our knowledge of the subject. As we shall point out, a large percentage of the cases are indispensable to the proper training of physicians and nurses in this important branch of medicine..” [1912-B, p.224]

~ “In all but a few medical schools, the students deliver no cases in a hospital under supervision, receive but little even in the way of demonstrations on women in labor and are sent into out-patient departments to deliver, at most, but a half dozen cases. When we recall that abroad the midwives are required to deliver in a hospital at least 20 cases under the most careful supervision and instruction before being allowed to practice, it is evident that the training of medical students in obstetrics in this country is a farce and a disgrace. It is then perfectly plain that the midwife cases, in large part at least, are necessary for the proper training of medical students. If for no other reason, this one alone is sufficient to justify the elimination of a large number of midwives, since the standard of obstetrical teaching and practice can never be raised without giving better training to physicians.” [1912-B, p.226] {emphasis added}

~ “Any scheme for improvement in obstetric teaching and practice which does not contemplate the ultimate elimination of the midwife will not succeed. This is not alone because midwives can never be taught to practice obstetrics successfully, but most especially because of the moral effect upon obstetric standards.” [The Teaching of Obstetrics”, American Association of Obstetrics and Gynecologists]

“Only with the knowledge of the status of obstetrical science in the United States in the early 1900’s can one reasonably evaluate the obstetricians’ campaign to eliminate the midwife. Obstetrical education in the early 1900s in United States was not based on clinical training — that is actual hands-on practice, but rather textbook learning, lectures by professors and “observation” of care rendered by others.”

~ “In 1850, Dr. James P. White, introduced into this country clinical methods of instruction in obstetrics. Yet, during the following 62 years … our medical schools have not succeeded in training their graduates to be safe practitioners of obstetrics.” 1911-B; WilliamsMD

~ “After 18 years of experience in teaching what is probably the best body of medical students every collected in the country — the student body at the Johns Hopkins Medical School for the years 1911-1912 …. — I would unhesitatingly state that my own students are absolutely unfit upon gradation to practice obstetrics in its broad sense, and are scarcely prepared to handle the ordinary cases.” [1911-B; WilliamsMD p. 178]

~ “In 1911, the great American obstetrician, J. Whitridge Williams, (original author of “Williams Obstetrics”), completed a survey of obstetrical education in United States medical schools. [this was 2 yrs after Flexner’s fly-by evaluation of general medical education – as they say, “imitation if the sincerest form of flattery!”]

Williams found that more than one-third of the professors of obstetrics were general practitioners. ‘Several accepted the professorship merely because it was offered to them but had no special training or liking for it.’ 13 had seen less than 500 cases of labor, 5 had seen less then 100 cases and one professor had never seen a woman deliver before assuming his professorship. Several professors of obstetrics were not able to perform a Cesarean section. [DeVitt, MD, 1975] {*}

Before a (medical) student was licensed to practice, Dr. Williams reported that :

~ “the actual figures show that in 25 schools, each student see 3 (deliveries) or less, in 9 schools, 4-5 cases and in 8 others, 5 or more cases, while in some of the smaller hospitals this is possible only by having 4-6 (medical students) examine the each patient…”

Dr. Whitridge Williams, the original author of “Williams Obstetrics” was highly critical of this situation:

~ “The generally accepted motto for the guidance of the physician is ‘primum non nocere’ (in the first place, do no harm), and yet more than 3/4 of the professors of obstetrics in all parts of the country, in reply to my questionnaire, stated that incompetent doctors kill more women each year by improperly performed operations than the … midwife….” 1911-B; WilliamsMD p.180

~ “A priori, the replies seem to indicate that women in labor are safer in the hands of admittedly ignorant midwives that in those of poorly trained medical men. Such conclusion however, is contrary to reason, as it would postulate the restriction of obstetrical practice to the former (midwives) and the abolition of medical practitioners, which would be a manifest absurdity.” [1911-B; WilliamsMD]

The Flexner Report, published in 1910, severely criticized the lack of clinical training in U.S. med schools, especially as contrasted with the highly-prized medical training available on ‘The Continent’.

~ “The story of medical education in the country is not the story of complete success. We have made ourselves the jest of scientists through out the world by our lack of a uniform standard. Until we have solved the problem of how NOT to produce incompetent physicians, let us not complicate the problem by attempting to properly train a new class of practitioners. The opportunities for clinical (i.e. “bedside”) instruction in our large cities are all too few to properly train our nurses and our doctors; how can we for an instant consider the training of the midwife as well?” [1911-C, p. 207]

~ “No one can read these figures without admitting that the situation is deplorable, and that the vast majority of our schools are not prepared to give the proper clinical instruction to anything like the present number of students. …. The paucity of material (i.e. teaching cases) renders it probable that years may elapse before certain complications of pregnancy and labor will be observed … to the great detriment of the student. Moreover, such restriction in [teaching] material greatly hampers the development of the professor and his assistants by the absence of suggestive problems and his inability to subject his own ideas to the test of experience.” 1911-B; WilliamsMD p.171

Since it was considered inappropriate to use private patients as teaching cases (primarily ‘upper-class’ women), the ‘lower-class’ — often immigrant population — of childbearing women cared for by midwives was looked to as the ideal source for this coveted “clinical material”. Midwives and midwifery training were both considered to be expendable in exchange for the “greater good” as defined by Dr. DeLee’s paper on “Ideal Obstetrics”.

~ “It is, therefore, worth while to sacrifice everything, including human life to accomplish the (obstetric) ideal “. Dr. DeLee, 1915 {*}

~ “If such conclusions are correct, I feel that …[we must] insist upon the institution of radical reforms in the teaching of obstetrics in our medical schools and upon improvement of medical practice, rather than attempting to train efficient and trustworthy midwives.” 1911-B; WilliamsMD p.166 {*}

The plan for up-grading medical education was proposed by a small number of well-placed physicians representing the interests of medical schools. They sought to increase the status and income of physicians and promote a more flattering “scientific” image of the profession of medicine and to establish as obstetrics as a specialty branch of surgery.

~ “For the sake of the lay members who may not be familiar with modern obstetric procedures, it may be informing to say that care furnished during childbirth is now considered, in intelligent communities, a surgical procedure.” [1911-D, p. 214]

~ “Engelman says: ‘The parturient suffers under the old prejudice that labor is a physiologic act,’ and the profession entertains the same prejudice, while as a matter of fact, obstetrics has great pathologic dignity —it is a major science, of the same rank as surgery“. [1915-C; DeLeeMD p. 116]

~ ” ….. the ideal obstetrician is not a man-midwife, but a broad scientific man, with a surgical training, who is prepared to cope with most serious clinical responsibilities, and at the same time is interested in extending our field of knowledge. No longer would we hear physicians say that they cannot understand how an intelligent man can take up obstetrics, which they regard as about as serious an occupation as a terrier dog sitting before a rathole waiting for the rat to escape.“ 1911-B;WilliamsMD {*}

However, this recommendation did not of itself have any scientific basis and in fact, required ignoring maternal mortality and morbidity statistics (both world-wide and in the US), which argued against such a plan. For instance:

~ “Maternal mortality in the country when compared with certain other countries, notable England, Wales and Sweden is, according to Howard, “appallingly high and probably unequaled in modern times in any civilized country”.

~ “…in 1921 the maternal death rate for our country was higher than that of every foreign country for which we have statistics, except that of Belgium and Chile.” 1925-A; HardinMD, p.347

~ “The “International Year Book of Care and Protection of Children: gives emphasis to the fact that the Untied States has still a higher rate of maternal mortality than any other of the principal countries of the world and that in the United States pregnancy causes more deaths among women ages 15-40 years of age than any other disease except tuberculosis. Twenty five thousand women die in the United States every year from direct and indirect effects of pregnancy and labor. Three to 5% of all children die during delivery and thousands of them are crippled.” 1925-A .p. 350]

~ “Statistics (Howard) show that the [overall] stillbirth rate in the birth registration area [of the US] is 60% higher than Stockholm (2.16%); that rates for New York (4.38%) and Philadelphia (4.39%) are 35% higher than Birmingham, (England) (3.24%) and over 100% higher than …Stockholm.” [1922-A; ZieglerMD, p.405]

~ “These rates …of 88.48 per 10,000 birth are on a par with those of Sweden 110 years ago; are 75% higher than those of England and Wales 60 years ago; are 120% higher than England and Wales in 1911-1915 and exceed the rates of England and Wales for 1918 by nearly 75% for puerperal fever and 150% for all other afflictions of the puerperal state combined. Howard shows also that New York City’s rates 46.11, which is much lower than that of any other American city, is 35% higher than that for Birmingham, England (33.49).” 1922-A; ZieglerMD

In 1915 Dr. P.W. van Peyma, Buffalo, NY, 40 years of experience working with midwives and was a member of the Board of Examiners in Midwifery for 25 years stated that:

~ “The essential difference between a midwife and a physician is that (physicians) are free to hasten delivery by means of forceps, version, etc. This, in my experience, results in more serious consequences than any shortcomings of midwives. …Time is an element of first importance in labor, and the midwife is more inclined to give this than is the average … physician. … The present wave of operative interference is disastrous. … The situation would not be improved by turning (the clients of midwives) into the hands of such medical men ….”.

~ “Obstetric training in the medical colleges is recognized as inadequate, [yet] there is no voice raised to eliminate the doctor from the practice of midwifery. Dr. Hirst is at present circularizing the State Board of Health to establish a standard for obstetrical experience for (physician) candidates for licensure, and … he suggests the personal delivery of 6 women. In NYC, the midwife is required to have the personal care of 20 women before a permit is granted to her.

~ “It is in the outdoor (domiciliary) service especially that we are able to appreciate the approach to the irreducible minimum {of mortality} to be obtained in private practice and where the figures are not distorted by the inclusion of the emergency failure of others.” [1917-A; HarrarMD]

~ “From the organization of the service of the Lying-In Hospital in 1890 until July, 1917, the institution has cared for, in the wards and in the homes of the patients, 115,439 women. Of these … 37,483 were parturient and recent admissions to the wards, and 70,743 were labors conducted in the tenements.” [1917-A; HarrarMD]

~ “For purposes of study it is necessary to divide the mortalities in to groups. In the outdoor service [planned home birth attended by interns and residents], in 69,081 actual confinements, 218 women died. …. This represents one death in every 317 women confined, or 0.31 per cent mortality. …. On the indoor service, of 23,130 regular applicants confined, 109 died. This is one death in every 212 women confined, or 0.47 percent..”[1917-A; HarrarMD] {*}

As indigent women were brought into the system as teaching cases (receiving free care) it was discovered that they were willing to pay a small sum for their 2 week stay ($1.28) and that even that small amount represented a profit to the hospital. Maternity patients were beginning to be viewed as not only as valuable “clinical material” for medical education but also as a source of profit to the hospital.

~ “The hospital is to care for all who, for one reason or another, cannot secure proper attention at home and the dispensary for those are delivered at home. In the majority of them, her presence in the home is necessary to order and discipline. Then too, the cost of caring for patients in hospital is much greater than in their own homes.” [1912-B, p.231] {*}

~ “The Boston Lying-In Hospital Out-patient department (domiciliary service) cared for 2,007 cases with no deaths, the dangerous cases being sent to the hospital, where all recovered.” [1911-D, p 216]

~ “But another encouraging and very practical feature has been that these 2,007 patients voluntarily contributed to the support of the hospital the some of $2,571 or, on the average, $1.28 contribute by each patient and the total expenses of the out-patient department were $1,763, leaving a net gain of $807”. [1911-C, p. 211]

Twilight Sleep Book ~ Best 50 pages of the first half

Twilight Sleep ~

A Simple Account of New Discoveries
in Painless Childbirth

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

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Twilight Sleep Book ~ Best 50 pages of the first half

Twilight Sleep ~

A Simple Account of New Discoveries in Painless Childbirth By Henry Smith Williams, B. Sc, MD, LLD ~ 1914

Recent Posts

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A Simple Account of New Discoveries
in Painless Childbirth

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