"Twilight Sleep -- Simple discoveries in painless childbirth

Ideas by Dr J. Whitridge Williams
for a national system of Lying-in hospitals

The following is a synopsis of my latest and I think, one of the most important breakthroughs in my research to date. I recently discovered the actual smoking gun (more accurately, the most important missing piece) in a 1914 historical document by Dr. J. Whitridge Williams, in which he introduced his new 'business plan' 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,
August 31, 2010

Here are a few of the good doctor's ideas in his own words.

Pain associated with biologically normal childbirth
 as described by the Doctors Williams ~

 “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
segue to a perverse form of eugenics

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.”  

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