A report on a 1914 book by Dr. Henry Smith Williams and Dr. J. W. Williams Twilight Sleep: Simple Discoveries in Painless Childbirth 1914
This post begins with a synopsis of the three critical aspects of Dr. J. Whitridge Williams’s “grand plan” as discussed in the 1914 Twilight Sleep book
The primary issue for Dr JWW always pointed to his North Star – which was to find or invent a brand new way to finance a nationwide system of privately-owned of general hospitals that were able to provide life-saving medical and surgical care to every American within reasonable driving distance.
Synopsis #1 ~ Americans badly needed, but did not have, a nationwide system of general hospitals able to provide comprehensive medical, surgical, and emergency services for the acutely ill and injured.
Lack of access to comprehensive medical services sentenced thousands of men, women and children to preventable deaths, life-long disabilities and untold suffering. Dr Williams saw this as a national disgrace when compared to the highly-evolved regional hospital systems in most European countries already in use for more than 200 years.
Dr. J. Whitridge Williams knew that the United States desperately needed a national system of regional general hospitals that were staffed and equipped to provide comprehensive medical, surgical, and emergency services to patients of all ages.
Dr. JWW believed the American public both needed and deserved access to well-equipped and fully-staffed general hospital in every geographical region. This nationwide system of general hospitals had been the standard of care in many European countries for two centuries, so no need for anyone to “re-invent the wheel”. However, there was one obvious and really big problem – where does the money come from to pay for this kind of coordinated nationwide system? There were only two potential sources for funding – healthy and employed taxpayers, or seriously ill and injured patients as “paying customers”.
To achieve that without any form of government funding required Dr. JWW to either find or invent a systematic method that would privately finance a badly-needed nation system of large general hospitals, like the nationalized systems of large regional medical centers in Western Europe. This system has served its population for more than 200 years, so there is no question that this was a much-needed and honorable goal.
While there were thousands of these 2-to-10-bed hospitals, there was nothing ‘systematic’ about it. Unlike our current interrelated system that transfers critically ill or injured patient to a higher or “comprehensive” level of care. In these “bad old days” if the MD-owners of the hospital couldn’t adequately treat your critical condition, you’d simply die.
But the American medical profession was uniformly opposed to anything that smacked of “socialized medicine”.
Instead, Dr. JWW and the AMA both believed that hospitals should be privately owned profit-making businesses. They saw medical practice as an unlimited entrepreneurial opportunity that fulfilled the American dream of wealth and independence. Each MD had a chance to profit from the business generated by his privately-owned hospital, clinic, or doctor’s office. The only exception to this entrepreneurial model was a small number of charity hospitals owned by the Catholic Church and private entities like the Mariners’ Union.
The second reason for Dr. JWW’s effort to protect the private ownership of hospitals and clinics was the medical profession’s intense fear of “government interference”. This would be attempts by non-MD individuals (i.e. bureaucrats) or government entities (state and federal agencies) to exert control over the practice of medicine, which obviously would threaten their independence. They believed, with some justification, that the bureaucratic practice of medicine was a bad idea.
The AMA’s often-quoted phrase was about “the sacred doctor-patient relationship”. For the AMA and many physicians, the sanctity of the doctor-patient relationship communicated their fierce resistance to any attempts to control (i.e. “interfere”) with an MD’s practice of medicine, and all attempts to second-guess what the MD should have done after the fact were deemed illegitimate.
As an active member of the AMA himself, Dr. Williams worked very closely with its upper-echelon leaders throughout his entire career. He was particularly involved with the AMA in 1909 when this well-funded organization decided to financially underwrite a series of annual national meetings known as the American Association for the Study and Prevention of Infant Mortality. For the next two decades, obstetricians, pediatricians and GPs who attended births came from all over the country to attend these AASPIM conferences that met every year from 1910 to about 1925.
From a historical perspective, the annual AASPIM meetings provided a golden opportunity for obstetricians to come together and develop an effective campaign for legally eliminating the economic competition (and professional embarrassment) posed by practicing midwives. This was easily achieved by lobbyists for the AMA who convinced state legislatures to define care provided by midwives during childbirth to be an illegal practice of medicine and therefore a criminal act.
Synopsis #2 ~ Dr. JWW’s eventual goal — a nationwide system of privately-owned general hospitals — suffered from the very same lack of funding that also trapped most small hospitals at the lowest level of medical services. While most of these 2-to-10-bed hospitals could pay their bills and provide a reasonable income for their MD-owners, they weren’t able to upgrade their facilities or purchase modern capital-intensive equipment such as a new x-ray machine or clinical laboratory equipment.
While Dr. JWW’s “Grand Plan” for a system of a privately-owned general hospital was counter-intuitive, it also was brilliant and ultimately successful. Dr. JWW purposefully began at the very bottom with the 8,000 small and medium-sized private hospitals sprinkled in small towns all across America. He saw each one of these hospitals as having the potential to generate a dependably profitable revenue stream that could be immediately turned around and the money used by the hospital to self-fund its own expansion and modernization.
Dr. JWW supplied one of the most critical ingredients of his plan by inventing a brand new category of hospital-based services — the “elective hospitalized” patient. Prior to this, hospitals only provided in-patient services to the seriously ill, injured, or dying. Since normal childbirth occurred in healthy women, hospitals did not see themselves as an appropriate place for healthy maternity patients.
But Dr. JWW turned all this on its head by promising these little hospitals that all they had to do to bring such riches to their doors was to put in a lying-in ward and fill it up with middle- and upper-class maternity patients as paying customers. Equally exciting was the near guarantee of an endless stream of “repeat business”, since the average married woman in the early 1900s conceived 12 times, had 9 pregnancies, and gave birth to 6 living children.
From the hospital’s perspective the open “secret” was how inexpensive maternity care was. In addition to the labor and birth, lying-in services included the traditional 14-day “lying-in period”. This custom called for newly delivered mothers to stay in bed and breastfeed their newborn babies while others cared for them.
Dr. JWW started by strongly urging the physician-owners of 2-to-10-bed hospitals to immediately put in a “lying-in (maternity) ward” in some “unused ward” or an “empty storage unit”. Then the doctor-owners of small hospitals were to immediately put notices in the newspaper and women’s magazines to promote the patronage of lying-infacility by the white and well-off upper-class childbearing women.
This PR campaign was to include the wonders of Twilight Sleep drugs that “guaranteed” that laboring women would not remember their labor pains, and after being “put to sleep” with chloroform or ether for the delivery, they would never have to experience any of the “unbearable pains” normally associated with giving birth.
This was the first and most critical step in self-funding that allowed hundreds of small hospitals all over the country to upgrade and expand their physical facilities and purchase new medical technologies. However, the benefit of a lying-in ward as a self-funding strategy was the archetypical “gift that kept on giving” far into the future.
Without ever taking a dime from anybody else, providing maternity care to a healthy population reliably generated revenue “in perpetuity” that not only allowed a hospital to become comfortably “profitable”, but actually used these new maternity-ward profits to remodel, expand, modernize their facilities and purchase capital-intensive electronic equipment.
Some of these hospitals went on to use the profits generated by their lying-in ward to finance a decades-long process of upgrading their facility into a well-equipped general hospital. To the outside world, the metamorphosis of previously small and ill-equipped hospitals into badly needed general hospitals able to provide comprehensive medical, surgical, and emergency services to the population in their geographic region must have seemed like something of a miracle.
But what mattered most to hospital administrators, irrespective of the size of their facility, was the dependably profitable revenue stream generated by hospitalizing healthy maternity patients as paying customers. Electively hospitalized healthy patients were always orders of magnitude more profitable than the intense nursing and medical care required by seriously ill or injured hospital patients.
Today when people think of childbirth, our thoughts often fixate on bad outcomes and multi-million dollar malpractice suits against the doctor and the hospital. But in the first half of the 20th century, the traditional 14-day “lying-in period” for maternity patients was ridiculously simple and inexpensive and ever so much more profitable when compared to the needs of most other hospitalized patients. Better yet, the typical married woman typically had 6 babies and every birth added a second hospital birth in the form of a newborn baby to occupy a crib in the newborn nursery.
This made the elective hospitalization of healthy maternity patients the archetypical “gift that kept on giving”. Unfortunately, there were two opposite effects of these so-called “gifts”. In the pre-antibiotic world prior to 1945, one of the ‘gifts’ associated with hospitalization annually exposed two million healthy women (1900 to 1945) to potentially fatal bacteria that was rare in their own homes but both frequent and virulent in hospital settings. Unfortunately 10,00 times every year a new mother, often women with 5 or 6 older children, died from an hospital-acquired infection for which there was no effective treatment and would not be for another 30 to 40 years.
As a result, an average of 10,000 new mothers became septic and died of septicemia, what today is often referred to as “septicemia”. Today septemia is extremely rare, and due to access to antibiotics, it now can be successfully treated.
@@@@@@@@@@@@@@@@@@@@@@@@
Synopsis #3
??placement ?? During the first 2 decades of the 20th century, most childbearing women still had their babies at home under the care of a doctor or a midwife. Pre-antibiotic world, hospitals as a source of extremely virulent bacteria, and the single most frequent cause of maternal death was septicemia (i.e. fatal infection) 10,000 annual deaths
In contemporary times, Dr. J. Whtriridge Williams is universally described as the most influential obstetrician of the 20th century and author of “Williams’ Obstetrics” which is now in its 27th printing. As the chief of obstetrics at Johns Hopkins Hospital, Dr. JWW targeted a specific demographic for special attention — middle- and upper-class white maternity patients whose families could easily afford to pay for a hospital birth and remain hospitalized during the traditional 14-day lying-in period. From Dr. JWW’s perspective, the perfect category of maternity patients for their hospital lying-in ward were paying customers from the upper-classes of white and well-off women.
We will never know exactly what Dr. JWW’s motives were, but in the years before the writing and publication of his many interviews in the 1914 Twilight Sleep, he began to claim that this demographic of white upper-class lying-in patients suffered from a “evolutionary fluke” that *?* caused them to have a strong pathological reaction to the pain of normal labor. This pain was so intolerable to this
a demographic of well-off childbearing women during childbirth
Dr. JWW was a product of his time (1866 to 1931), his economic and social status as a white upper-class male in a racist and misogynist culture in which his peers expected him to be both racist and misogynist
Dr. JWW, as a practicing obstetrician and a political activist for organized medicine, insisted that middle- or upper-class white maternity patients suffered from an “evolutionary fluke” that caused them to have a pathological response to normal labor pains. As a result, this this economically privileged demographic of maternity patients needed to be hospitalized as soon as they went into labor so Twilight Sleep drugs could be administered to them and their birth could be conducted as a surgical procedure that used chloroform or ether to render them unconscious
Whenever describing Dr. J. Whitridge Williams’ comments and actions of as a politically active obstetrician, its important to factor in the motives behind the actions that he took or recommended and urged others to take.
came from families that had no problem paying for a hospital birth
Best way to understand D.r JWW’s world is to let him tell the story in his own words
This potentially dangerous syndrome”
to justify the routine of hospitalized
white and well-off maternity patients
This already was the norn in Western Europe and had been for more than two centuries. Dr. JWW this because he enrolled and graduated from two different clinical training programs in Europe (which were not yet available in the US) in the biggest and best hospitals in Europe.
Having graduated from medical school, Dr. JWW was able to provide obstetrical services in several of these big nationalized hospital systems. He also was only too well aware of how amazingly (and wonderfully!) different this was from hospital care in America, which had no regional system of general hospitals. Instead we had a private, for-profit system with over 8,000-plus doctor-owned hospitals that often lacked the most basic of medical services.
While there were thousands of these 2-to-10-bed hospitals, there was nothing ‘systematic’ about it. Unlike our current interrelated system that transfers critically ill or injured patient to a higher or “comprehensive” level of care. In these “bad old days” if the MD-owners of the hospital couldn’t adequately treat your critical condition, you’d simply die.
Dr JWW was 100% certain that what the America public needed and deserved access to well-equipped and fully-staffed general hosptials in each and every geographical region. This nationwide system of general hospitals had been the standard of care in many European countries for two centuries, so no need for anyone to “re-invent the wheel”. However, there was one obvious and really big problem – where does the money come from to pays for this kind of coordinated nationwide system. Basically there were only two options – tax payers, or the ill and injured as “paying customers”?
The US had long ago made a different choice — public access to general hospitals were a bridge too far for the pre-revolution colonial government, and that didn’t change after were won the War of 1776. These early political leaders already had more on their plates than they had the resources to meet. Both medical and nursing care for the seriously ill or injured took place in the home, with the patient’s basic needed met by a wife or mother and the doctor making house calls to provide necessary medical services. During the first decades of the post-Revolutionay era, There were a few hospitals that were funded by the Catholic Church or the Mariner’s association but nothing like the
– that was always and only financed from private sources. This boiled down to following the AMA’s policies to the letter and never, under any circumstances. taking single penny from any state and federal government. The reason was simple enough — keep government bureaucrats from having any power ownership and running of privately give working for the ability to in essence “practice medicine without a license” by their ability to control. the government
To achieve that without any form of government funding required him to find or invent a systematic method that would privately (and reliably) finance a badly-needed nation system of large general hospitals, like the nationalized systems of large regional medical centers in Western Europe that had serviced its citizens for more than 200 years. No question that this was a much needed and honorable goal.
However, Dr. JWW lived in world dominated by the politics of the AMA and those policies opposed any kind of “government money” for anything that had to do with the practice of medicine. During this historical period the AMA they insisting that any “government money” would pollute the “sacred doctor-patient relationship”. This slammed the door on the possibility of Dr. JWW asking to US Congress to fund a nation-wide system of well-equipped, well-staffed general underwritten by the federal government.
So Dr. JWW had to look elsewhere for a dependable process that would ultimately, in a life-threatening medical emergency, provide the average American with access to the life-saving services of a general hospital that was pithing reasonable driving distance.
a nationwide finance the modernization of thousands of small privately-owned, for-profit hospitals become their own “money-making machine” by adding a lying-in ward in some unused storage room. They they would mount a public relations aimed at middle and upper class women campaign promoting the wonder of Twoghl sleep and urging them to finance the modernize and transform thousands of by urging them them to . They there were to aggressively promote the middle and up-class t hospital the routine hospitalization of maternal patient in the big black lie
dream up a fact-free “explanation” () for why white labor patients, as a demographic of paying customers, needed to have hospitalized and given Twilight Sleep Drugs, general anesthesia, and forceps delivery, He blamed this “evolutionary fluke” & modern civilization as a mandate for use of
as the new standard of care for to have on
In the 1914 book “Twilight Sleep: Simples Discoveries in Painless Childbirth”, the pain of normal labor contractions in the more affluent classes of women described as pathologically painful. Dr JWW defined labor in these women as no longer normal or a benign aspect of biology, but an intensely pathological process. According to him, this pathological pain turned an otherwise normal childbirth into an unbearable ordeal characterized as “useless suffering”.
The adjectives used to identify this cohort of women so disfavored by Mother Nature included civilized, cultured, intelligent, sensitive, and delicate. While Dr. Williams never defined ‘delicate’, it was for him a negative attribute that specifically applied to educated, socially-astute and economically-secure white women from the middle- and upper-classes. According to this theory, the “hot house” conditions of modern civilization resulted an evolutionary fluke that left an entire demographic of childbearing women in the United States unable to withstand the pain and strain associated with normal childbirth without risking a psychiatric breakdown. According to Dr. JWW, this was not a weakness on the part of the individual, but a pathology in the evolutionary process – a mistake by Mother Nature.
In support of his “evolution gone wrong but only in the upper classes” theory, he was quick to say this pathology didn’t affect native American women, immigrants and the ethnic minorities who made up the working poor. Dr. JWW assumed their lives of manual labor produced women who were more physically “robust” and resilient. Dr. JWW described this category of women as “phlegmatic”, using a word from Hippocrates’ theory of the Four Humors.
In addition, he assumed that unschooled and mentally simple women simply didn’t think too much about their bodily functions. Therefore, they typically had effective and efficient labors that they were able to tolerate with little or no complaint about the pain or the hard work of pushing their baby out under their own power. This generally resulted in a good outcome for both mother and baby. However, he claimed that none of this normally functional biology applies to the upper classes of white women of Western European heritage.
In convincing others, particularly upper class wives and husbands — that the root cause of these pathological labor pains was strictly a problem of evolution and not the particular fault of his labor patients, Dr. JWW cited Darwin’s theories of evolution as support for the origin of his pathological pain syndrome, it’s very negative consequences, and what the obstetrical profession should do about it — hospitalize, give Twilight Sleep drugs, anesthetize, and perform a forceps delivery.
He began by explaining that:
“…… any trait or habit may be directly detrimental to the individual and to the race and may be preserved, generation after generation, through the fostering influence of the hot-house conditions of civilized existence.
Then he explains the laws of Darwinian evolution — the idea that Nature naturally selects for success and betterment of each species:
“does not fully apply to human beings living under the artificial conditions of civilization”.
With this in mind, he describes these pathological labor pains as an “abnormal product of civilization” that are the result of the “hot house conditions of civilized existence”, and only affects stay-at-home married women and mothers with husbands employed full time or independently wealthy. Quite obviously such delicate and nervous wives are the polar opposite of those “robust” “nerveless” and “phlegmatic” immigrants and poor working women.
“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?
As already pointed out by Dr. JWW, labor in poor working women was as different as day and night from the experience of these “delicate” and “sensitive” types. Their labors were neither efficient or effective as these mothers-to-be were tormented and ‘terrorized’ by their labor pains and the shock of this extreme pain produced a level of pure “agony” that was psychologically damaging.
For some of women in these upper-classes, the pain and suffering became so unbearable that it would literally drive them crazy. These resulting mental breakdowns would be so severe that new mothers would be unable to care for their newborns or other children and even need to be institutionalized.
I believe the answer must be an unqualified affirmative. Considered from an evolutionary standpoint, the pains of labor appear not only uncalled for, but positively menacing to the race.”
“The problem of making child-bearing a less hazardous ordeal and a far less painful one for these nervous and sensitive women is a problem that concerns not merely the women themselves, but the coming generations.
Let the robust, phlegmatic, nerveless woman continue to have her children without seeking the solace of narcotics or the special attendance of expert obstetricians, if she prefers. But let her not stand in the way of securing such solace and safety for her more sensitive sisters.”
In further describing the effects of these pathological labor pain in these “civilized” and “cultured” women who were unfortunate victims of a defective form of evolution, Dr. JWW noted 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” {p. 39}
“…. the cultured woman of to-day has a nervous system that makes her far more susceptible to pain and to resultant shock than was her more lethargical ancestors of remote generations.”
“such cultured women are precisely the individuals who should propagate the species and thus promote the interests of the race “
“This seems to suggest that the excessive pains of childbirth are not a strictly a ‘natural’ concomitant of motherhood, but rather that they are an extraneous, and in a sense, an abnormal product of civilization.”
“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?
Since these “civilized” women were being treated so unfairly by Mother Nature, Dr. JWW believed doctors should treat:
“…the agonies of tortured humanity” with “the waters of forgetfulness” {Twilight Sleep pg 10}
Based on Dr. JWW’s “labor pain as a pathology” theory, healthy middle- and upper-classes women were not getting the medical and surgical interventions they so obviously needed and deserved. This put them in danger of a mental breakdown that might require them to be committed to a psychiatric institution. To prevent this, Dr JWW decreed that healthy women in the upper classes should be electively hospitalized and given Twilight sleep drugs during labor and general anesthesia for the birth.
The unquestioned moral authority of the most influential obstetrician in America
Apparently, Dr. JWW assumed people would not question the correlation between a woman’s supposedly “nervous” or “delicate” condition and the economically-advantaged status her family. As a former obstetrical professor appointed chief of the obstetrics at Johns Hopkins University Hospital, author of the most authoritative obstetrical text of the era “Williams Obstetrics” and Dean of the University’s School of Medicine, readers would assume that Dr. Williams was truthful. Surly what he conveyed was an honest account of his professional experience and such ‘insider information’ was straight from God’s lips to their ears!
As a result, no one questioned his totally illogical claim that the only demographic of childbearing women who suffered pathological levels of pain during an otherwise normal labor were those whose husbands could afford, in addition to the doctor’s professional fee, to pay a substantial bill for hospital labor and birth and 14 days of hospital lying-in care for the new mother and 14 days of hospital nursery care for her new baby.
Dr. William’s message to Husbands
Dr. JWW’s specifically aimed a number of passages in his book at middle- and upper-class husbands. He described the “shock” of labor specifically affecting these sensitive, delicate and intellectual women as being so sever as to cause mental breakdowns. For some women, this could be so overwhelming that their wives might need to be institutionalized for weeks or months or even longer.
I imagine that most husbands think their wives as having at least one of these desirable feminine traits, so the idea that a normal labor could cause their sensitive or delicate wife to have a mental breakdown must have been “shocking” to these concerned, but medically-unsophisticated husbands.
Mixed Motives or Hidden Agenda?
There is something of an unspoken challenge in providing this kind of inflammatory information to a lay audience of husbands and fathers. It’s as if the subtext of Dr. JWW comments are asking husbands they really want to risk having their wife, and mother of their children, suffer from a mental breakdown and be locked away in a psychiatric ward? Unspoken but very much on the minds of these husbands was the frightening thought of being left alone to care for several older children and a newborn infant while also trying to support their families, never mind the cold empty side of their marriage bed where his wife normally slept.
After giving husbands a made-up reason to be afraid, be really afraid, Dr. JWW relieved their anxieties with these simple instructions:
All a husband had to do to prevent such a disastrous mental breakdown was take their delicate and/or intelligent wife to the hospital as soon as she went into labor.
Once hospitalized, she would be given repeated injections of morphine and scopolamine and never feel or remember anything until long after the baby was born. Her mental facilities, as a matter of course, would be protected by the use of Twilight Sleep drugs, and then his lovely wife would be rendered unconscious under general anesthesia while her baby was being born.
Bada bing, bada boom, problem solved!
Eugenics & Dr. JWW’s concern about the changing demographics of the United States
As noted earlier, the target audience for Dr. JWW’s book was not childbearing women but wealthy and influential men in general, and husbands in particular. Dr. JWW connected his new discovery of labor pathologies in the upper classes with racial fears. He also informed his male readers that America’s white European population was in great danger of being outstripped the black, brown, red and yellow, non-protestants and other newcomers and assuring them that he would institute measures to increase the birth rate of middle and upper class white women whose families could afford to pay for hospital-based maternity care.
The problem was simple: white women of northern European heritage were having too few babies, while black and brown populations, and new immigrants such as the Roman Catholic Irish and Italians, were having far too many babies. The type of woman that most patriotic (i.e. white) Americans wanted to see populate the great span of America were not the lower classes of women who gave birth so easily and so often.
Apparently, Dr. Williams thought the mental anguish of a natural labor and normal birth in such ‘delicate and sensitive’ women would keep a significant number of them from fulfilling “sacred maternal duties”, that is — have as many more children as possible! In an era when contraception was not available, the only way for a married woman to avoid unwanted pregnancy was to not have sex with her husband. The thought that wives might decline the favors of their marriage bed based on the fear of giving birth was guaranteed to get the full attention of husbands.
The idea that an aversion to labor pains might reduce the birth rate in that highly favored demographic of white and well-off families got the full attention government officials, politicians and others worried that the non-white birth rate would outstrip that of whites unless something was done to reverse this trend.
Dr. Williams’ thought that making childbirth painless for the more affluent classes would convince white women to have more babies. This was based on his desire to see Caucasian Europeans “propagate the species and promote the interests of the race“ in order to preserve the country’s white majority and European heritage and culture.
As outlined in his book, providing Twilight Sleep drugs totally obliterated the laboring woman’s memory of childbirth. The combination of morphine and the amnesic-hallucinogenic drug scopolamine made her unable to remember anything that happened during the labor; then she was given a general anesthetic that would render her unconscious during the birth.
Many people – doctors and lay public alike – saw these new drugs as a medical miracle that wiped out the biblical Curse of Eve which for thousands of years had sentenced Judeo-Christian women to give birth in toil and sorrow. Instead the ‘little lady’ was put to sleep in early labor, and thanks to the “blessed waters of forgetfulness”, only awoke up after all those sensations, associated suffering and hard work of pushing their baby out was long over and her little bundle of joy laid in her arms and she had no memory any ‘unpleasantness’ or anything else for that matter.
This all seemed like the height of perfection in which a “new medical science” was able to provide a totally painless childbirth to the “new modern woman”. What more could anyone want? Perhaps remembering your baby’s birth? But I guess that was asking too much of modern obstetrics.
Dr. JWW was Wrong!
However well-intentioned, what Dr. JWW thought was all wrong. I have given birth normally to three children and I’m extraordinarily familiar with many other childbearing women over many decades. Neither Twilight Sleep drugs or the unconsciousness of general anesthesia would ever make any woman have more babies, because “real mothers” know that the “real labor” of childbearing begins when you have to get up half-a-dozen times a night to breastfeed a colicky baby and have to stand for hours over a hot stove cooking for half-dozen hungry kids and washing and ironing mountains of family laundry.
Apparently, Dr. JWW saw the situation from the perspective of 19th century husband and father — a breadwinner but not someone who ever personally cared for the children — so he failed to factor in the reality of the situation. After you have another of those plumb white babies, you have to feed, clothe, discipline, educate and raise them!
I suppose if you were the creme de la crème of the upper class, and in addition to your regular housekeeper your wealthy husband hired a bevy of round-the-clock lying-in nurses, a laundress to do the diapers and all the household washing and ironing, as well as a cook, then having more babies as a patriotic duty to one’s country might possibly be an OK thing to do with your body for nine months out of every year. However, not even Elenore Roosevelt, mother of six and wife of a US president, had an easy time of it and god know, she had a lot of domestic helpers (also an insufferably meddlesome mother-in-law).
As for women in the bottom half of the upper-class and the entire economic spectrum of the middle-class, Dr. JWW would have much better chance selling snake oil than the ludicrous idea that hours of memory-loss under Twilight Sleep narcotics and amnesia drugs, as well as drowning “the agonies of tortured humanity in the waters of forgetfulness”, would make up for having to raise another baby!
Let’s face it, neither the hallucinogenic drug scopolamine nor the anesthetic chloroform are known to have any mysterious or lingering aphrodisiac effect associated with it, not to mention the anti-aphrodisiac effect of an episiotomy and a forceps delivery!
After you give birth, you “have a baby”, like after you buy a car you “have a car”. You are your baby’s mother and are fully responsible for meeting the entirety of its needs for the next 20 or so years. Nothing in Dr JWW’s elective-hospitalization or his lying-in-wards ‘scheme’ was designed to help new mothers manage the gargantuan 24-7-365 job of raising their newborns after the drugs wore off and they left the hospital with their newborn baby.
However, convincing well-off white women to have more babies was not actually Dr. William’s primary goal in writing Twilight Sleep. The real purpose of Dr. Williams’ book – the idea behind it all — was to introduce and develop support for Dr. JWW’s plan for a nation-wide system of general hospitals and developing way to finance such this enormous undertaking without the feared “socialized medicine” of government funding.
ef
@@@@@@@@@@@@@@@@@@@ edit line @ 7:23 Wed 04-10-2024 @@@@@@@
&& the the “elective” hospitalize healthy childbearing women, give them Twilight Sleep drugs and conduct normal birth as a surgical procedure.
The purpose of providing hpspital-based childbirth services to the upper classes to generate dependable revenue stream that would fund the modernization and expansion of small privately owned hospitals and over the course of a few decades, as a eventually produce a nationwide system of privately-owned general hospitals Lying-in
$$ unfortunately, Dr. JWW’s attempt to achieve honorable goals ultimately used dishonorable means in an effort to that increased the maternal mortality rate by thousands of preventable maternal deaths every year for more than half a century. In fact, everything about the way the obstetrical profession is organized is still based o with
(and do so under circumstances that would self-pe.
by side-stepping for formulating in the private practice of medicine, which
For a privately-owned system of general hospitals to eventually arise in each geographical region while totally eschewing any and all forms of “government money” (and therefore prevent for some of the 8,000 small privately-owned hospitals in the US to gradually upgrade, expand and modernize their facilities, while also making capital-intensive purchased of expensive medical equipment was a series of ‘baby -steps’ the only way for
#####
For every dollar from a maternity patient (or insurance), 38 cents was profit for the hospital. Contrast that with each dollar from patients the cardiac ward only contributes 5 cents in profit.
#########
Original post ~ 2008
This post records one of the most important breakthroughs in my research to date — discovering the actual smoking gun (i.e. most important missing piece), which was my discovery of this “Twilight Sleep” book published in 1914. It was instrumental in setting the standard for so-called “normal” childbirth in healthy American women to be an obstetrically-based system of medical and surgical interventions that drastically interfered in
It begins with my brief a synopsis of Dr. JWW’s vision for a much-needed nationwide system of general hospitals is uplifting — a true stroke of genius!
Unfortunately, his plan for privately funding these desperately-needed general hospitals morphed into a slow-motion crime. He all began that began with his invention of a new class of hospital patient — the “electively hospitalized” maternity patient, and then urged the small hospitals (of which there were 8,000 in the US) to put lying-in wards and the “cash cow” that
— which he use .
disturbing
It is the of Dr J. W. Williams’s dream and “grand plan” and
This was during the era that organized medicine (AMA) literally “forbid” its MD-members to have anything to do with “government” funding.
But for reasons I have never fully understood and so far no one has been able to justify, the “horror” of government funding that sent AMA policy-makers into paroxysms of despair would simply mean that many millions of employed Americans would to pay a few dollars in taxes every year to do their small part in funding the regional general hospitals that would all Americans access to the level of comprehensive medical and surgical services that literally saved lives and prevented unnecessary suffering and permanent disabilities.
However, for the AMA, the idea of national funding of a comprehensive system of large regional general hospitals from tax-payers was a big fat “no way”, a knee-jerk reaction based on the AMA’s insistence that one penny of federal money would permit non-MD bureaucrats to illegally practice medicine by telling doctors how to practice medicine. Little did they know that the AMA’s worst fears/ best hopes would come true late in the 20th century and now in the 21st via reimbursement by the federal Medicare and Medicaid programs, to the utter delight of both doctors and private for-profit hospitals.
As a result, big regional hospitals in America had to be privately funded, which meant being privately-owned.
But having eliminated government funding,, to be financed by
the routine use of unnecessary and often harmful obstetrical intervention in normal childbirth became the American “standard of care” for middle- and upper-classes white women during the first 80 years of the 20th century
Unfortunately, this meant laboring under the influence of the hallucinogenic drug “scopolamine” and having the birth of their baby be conducted as a surgical procedure. This included the routine use of general anesthesia, episiotomy, and forceps extraction of the baby, which often did not breathe spontaneously due to the narcotics given to its mother during labor the chloroform or ether anesthetic given during the “surgical procedure” performed by an MD and billed as “the delivery“.
So-called ‘norma’ birth for these healthy childbearing women ended with the doctor reaching up into her uterus and pulling the placenta out and then the suturing of the episiotomy incision. This included the famous “husband stitch“, which described suturing up the mother’s post-childbirth vagina nice and “tight” for her husband, so he would not later complain to her OB that:
“every since my wife had a baby, having sex with her is like walking into a warm room“.
In this 1914 historical book: “Twilight Sleep: Simple Discoveries in Painless Childbirth”. Dr. J. Whitridge Williams described his new ‘business plan’ for funding a nationwide system of general hospitals that would take several decades to accomplish.
However, that began with the literal “inventions” of a brand new category of
for using healthy maternity patients as the primary source of income for a national system of hospitals.
These ideas were the subject of a small book called ”TWILIGHT SLEEP ~ Simple Discoveries in Painless Childbirth” that he co-authored with Dr. Henry Smith Williams, a physician colleague and science-writer. The Stanford medical library copy of this book was digitized by the Google Library Project. I have the URL if you are interested.
| Eventually I will combine this new material with my earlier research. I’d like to present it at the next CIMS conference or as a webcast. The working title is:”How Childbirth Got Trapped on the Wrong Side of History: How healthy women were turned into the patients of a surgical specialty and normal birth into a surgical procedure — the last and most important UNTOLD story of the 20th century”.
While his idea is inexplicable at first glance, Dr Williams was proposing a solution to a historical problem of great importance that has been invisible to all the rest of us (even my hero, Paul Starr). What is most surprising is that the problem Dr J. Whitridge Williams saw was very different from what you and I would have expected. It had virtually nothing to with today’s mantra about hospitals as places of safety for childbirth. Considering that i 1914, a third of all deaths in hospitalized maternity patients were from sepsis (10,000 out of 25,000 MM a year), no one, not even Dr J. Whitridge Williams, claimed that hospitalizing healthy women during this pre-antibiotic era was primarily for their own safety. What he said instead makes the story even more interesting, as it included the politics of eugenics in a quite perverse and upside down way. The theory behind his arguments could have literally been ripped from today’s headlines about “anchor babies” — the fear that the birth rate of the lower classes — working poor and non-white ethnic minorities — will outstrip the number of babies being born to the more desirable white population. In maddeningly creative ways, Dr Williams pursues his main goal — a national system of lying-in hospitals — by harking on the sacred duty of maternity, inventing a pathological origin for the pain of childbirth and then using this made-up story about pain as his main selling point for hospitalized childbirth (hence his book promoting ‘painless childbirth’). However, the actual problem that Dr. Williams’ identified was real and it was the direct result of the new, world-altering discoveries of biological science made during the late 1800s (Pasteur’s germ theory of infectious disease in 1881 and the discovery of x-rays 1895), creating a miniature Tsunami in “must have” technology. For the first time ever, revolutionary and life-saving breakthroughs in healthcare depended on large capital outlays for special equipment, which made running a hospital ever so much more expensive. Every hospital suddenly had to have autoclaves for their surgical instruments, laboratories had to be equipped with microscopes and sterilizers, and radiology departments needed several expensive x-ray machines, lead aprons, and oceans of photographic film. Of course, hospitals had to be remodeled to include operating rooms and other specialty areas and all these new services needed new buildings to house them in. The miracles of modern medicine didn’t come cheap! By 1910, hospitals of all kinds — big charitable institutions, teaching hospitals run by universities and small for-profit hospitals — were all bleeding red ink. For centuries, hospitals as charitably-run places of ‘hospitality’ were labor-intensive but was a host of unskilled and semi-skilled service worker who served hot meals, clean sheets, back-rubs and emptied bed pans, etc). In 15 or so years hospitals had become a very capital-intensive enterprise. In addition to the purchase of expensive equipment, hospitals had begun to promote themselves as able to cures disease (rather than just hotels with medical room service). This introduced the unwelcome burden of legal liability for bad outcomes and adverse events. Lacking a tax-supported national system as existed in many parts of Europe, the technologically-rich hospital business in the US was forced to look to their patients, which by definition are people that are sick, injured, crazy or infected w/ communicable diseases like TB. It became increasingly clear that hospitals could no more depend on the seriously ill or injured to pay for their care than prisons can expect their inmates to reimburse the costs of their incarceration. The conclusion was inescapable — sans a tax base, there were just not enough sick people (as paying customers) to support 20th century ‘modern’ medicine. Dr. Williams’ solution to this dilemma — not enough paying customers to support the business model a first class hospital — was to devise a plan to convince healthy middle & upper class white women to have their babies in a new system of lying-in hospital that ideally would be placed “as uniformly, if not quite as abundantly, as schoolhouses and churches”, with at least one lying-in hospital in every country seat. Unlike illness which is seasonable and injury which is erratic and unpredictable, childbirth, postpartum maternity care and nursery care of newborns is steady, dependable (pre-birth control) and a stable year-round source of patronage, thus providing the bread and butter income for hospitals. One can imagine Dr .J. Whitridge Williams as chief of obstetrics at Johns Hopkins University Hospital running down the hall yelling “Eurika! I’ve got it — revolutionary changes in the practice of medicine — hospitals as the new center for all dimensions of healthcare, improved obstetrical education, and completely revamping the way maternity care is provided and how society thinks about the pain of normal childbirth. I’m going to create a national system of lying-in hospitals that will provide clinical training to medical students and full employment to graduate obstetricians, while making sure that the birth rate of all the ‘highly developed nervous and intellectual types‘ and the ‘most delicately organized women’ goes sky high by guaranteeing every woman the blessings of unconsciousness while they are giving birth!.” Dr. J.W. Williams calculated that the average county had a population of 20,000 inhabitants, with an annual birth rate of 700. He reasoned that if even half of these childbearing women (350) could be convinced to have babies in the hospital (and their husbands cajoled into paying), it would create a solid economic basis for the business model of lying-in hospitals. Figuring the standard hospital stay for mothers, which was 14 days, with another billable 14 days for the baby’s stay in the nursery, this would generate a minimum of 9,800 patient-days of business every year. With this kind of dependable patronage, lying-in hospitals would be able to “… provide laboratory, x-ray and other services necessary to provide for a well-equipped surgery department”. Part of JWW’s inducement to husbands, pubic officials and philanthropists (whose capital endowments he was soliciting) was to promote the benefits his new system of lying-in hospitals to men and other segments of society. In other words, maternity care for a healthy population was seen as the seed or leavening that would give rise to a full service community hospital with a surgery department, labs, x-ray and other services used by healthy people from the community as well as the in-patient population. As for the cost of all this, JWW remarked: “There will arise the inevitable question of the monetary cost, and … how such institutions are to be financed. …. once public interest is aroused, the matter of monetary cost will prevent no serious obstacles.” In a remarkable bit of reverse engineering, he turned the story as we think of it today on its head. To our modern perspective, this seems like a “tail wags the dog” scenario, but in his version, the ‘tail’ was what we now think of as the full service community hospitals. It was the baby business that made everything else possible. I once heard a joke that sort of explains this. It was about a guy who worked in a big factory with guards on the gate> all employees were searched as they left work each day to be sure they were not stealing anything. However, one particular guy left with a wheelbarrow full of empty boxes everyday day and so guard carefully searched each and every container to be sure the was nothing of value in any of them. As in most good jokes, this activity went on for a ridiculously long time, accompanied by with every more exaggerated machinations. Years later, long after the guard and the factory worker quit their job, they bumped into each other on the street. The guard says: “Its been driving me nuts for years — I’m just sure you were pulling a fast one, but i never could prove it. Neither of us work there anymore so its safe to tell me the truth — what you were you stealing?” The worker says: “I was stealing wheel barrows”. In the 1990s i read a report on hospital economics that identified the most and least profitable of a hospital’s services, which was 38 cents profit on the dollar for maternity patients, but only 5 cents profit for patients that had cardiac surgery. I think they’re stealing wheel barrows. A 2.43 Trillion-dollar Healthcare Bill Out of our 14.6 trillion GDP The US spends 2.43 TRILLION every year on health care (25% of this is maternity services), making this more than just a story of obstetrics on steroids. It explains something that has been invisible to us, like the water in the fish bowl. We all swim around in the issue of modern technologically-enriched hospitals as the core of our ‘health care’ system. But we didn’t realize that the word ‘health’ had a hidden dimension — as an economic model, hospital administrators have to figure out how to market their services to healthy people who can afford to pay for them. In this model, sick people who can’t pay don’t get the care they need (no matter how urgent) and healthy people who can pay get care the didn’t need and don’t benefit from. Realistically, we must either to continue using healthy maternity patients as the economic backbone of our healthcare system or look for other ways to support our technologically-enriched system. In the end, we can all pay our fair share each year when we pay our taxes, or write out a check each month to our insurance company for our own plus an inflated share of the nation’s healthcare debt. Once you know that the real problem is an insufficient number of sick people, you can’t help but look differently at our current system in which EVERY hospital has to have one of EVERY machine. As a fan of “Royal Pains” — a TV series about a concierge’s doctor in The Hamptions — we might consider putting those big MRI machines in a classy 18 wheeler and sharing expensive equipment between smaller community hospitals. Just a thought…. faith gibson, Here are a few of the good doctor’s ideas in his own words. “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. …the sacred function of maternity … causes her months of illness and hours of agony; Even in this second decade of the 20th century, … women bring forth children in sorrow, quite after the ancient fashion, unsolaced by even single whiff of the beneficent anesthetic vapors, through the use of which the agonies of tortured humanity may be stepped in the waters of forgetfulness. Pain as pathology of modern civilization among the more cultured women of society ~ “…. the cultured woman of to-day has a nervous system that makes her far more susceptible to pain and to resultant shock than was her more lethargical ancestors of remote generations. … 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. Such a woman not unnaturally shrinks from the dangers and pains incident to child-bearing; yet such cultured women are precisely the individuals who should propagate the species and thus promote the interests of the race. This seems to suggest that the excessive pains of childbirth are not a strictly a ‘natural’ concomitant of motherhood, but rather that they are an extraneous and in a sense an abnormal product of civilization. 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? Abnormal pain as an evolutionary threat to the (white, Europen) race ~ Considered from an evolutionary standpoint, the pains of labor appear not only uncalled for, but positively menacing to the race. …… 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. Evolutionary pain in white women as a Darwinian Every one knows that the law of natural selection through survival of the fittest, which as Darwin taught us … does not fully apply to human beings living under the artificial conditions of civilization. These artificial conditions often determine that the less fit, rather than the most fit, individuals shall have progeny and that undesirable rather than the desirable qualities shall be perpetuated.” The problem of making child-bearing a less hazardous ordeal and a far less painful one for these nervous and sensitive women is a problem that concerns not merely the women themselves, but the coming generations. Let the robust, phlegmatic, nerveless woman continue to have her children without seeking the solace of narcotics or the special attendance of expert obstetricians, if she prefers. But let her not stand in the way of securing such solace and safety for her more sensitive sisters. … every patient who goes to the hospital may have full assurance that she will pass through what would otherwise be a dreaded ordeal in a state of blissful unconsciousness. The truth is that in assuming an upright posture and in developing an enormous brain, the human race has so modified the conditions incident to child-bearing as to put upon the mother a burden that may well enough be termed abnormal in comparison with the function of motherhood as it applies to other races of animate beings. Moreover, … the 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. That word ‘physiological’ has all along stood as a barrier in the way of progress. “ As part of Dr. Williams’ pitch for lying-in hospitals, he perpetuates the mythical ‘displaced uterus’ story. He claimed that midwives and GP could not diagnosis or treat, but a displaced uterus was suppose to affect one out of every three or four women who gave birth and if left untreated (without a pessary), would required the “most serious kind of surgery” (hysterectomy?). “Thousands of women go through life without enjoying a really well day, because of such a uterine displacement, undiagnosed or uncorrected. Yet it goes without saying that the woman who is attended by a midwife or by 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 other mother the normal involution, and retention of normal placement of her uterus, its service in the interests of the health and welfare of women would still be enormous. What an incalculable boon and blessing it would be, then, if conditions could be so altered that every woman brought to childbed might be insured efficient and skilful service in carrying her through the ordeal that the performance of this physiological function imposes upon her. And this can be accomplished in no other way than has been suggested, except by the extension of a lying-in service far beyond the bounds of anything that has hitherto been attempted. To meet their needs, it would be necessary to have a small lying-in hospital located in every town of three or four thousand inhabitants. At first thought, this seems an ideal impossible of realization. But if we consider the matter with attention, without for a moment overlooking the practicalities, we shall see, I think, that such a project by no means presents insuperable difficulties. Click here for a fuller set of quotes from Dr William’s book organized by topic Letting Dr JWW get the last words: 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.” |
Click on the photo to return to HealthCare_2.0 Home Page
