This small book was written in 1914 by Dr. Henry Smith Williams, an MD, attorney and science writer, at the request of Dr. J. Whitridge Williams, who was associate professor of gynecology in at Johns Hopkins University Hospital beginning in 1894, vice-president of the American Gynecological Society in 1903-04, and Chief of Obstetrics at Johns Hopkins University Hospital from 1911 to 1923. The theme of the book is Dr J.W.W’s new 'business plan' for using healthy maternity patients as the primary source of income for a national system of hospitals. The audience targeted by its authors were the philanthropists of the day (Carnegie and Rockefellers Foundations), as well as husbands, elected officials and influential trend setters in society.

The Stanford medical library copy of this book was digitized by the Google Library Project.  

URL for quotes by topics and longer excerpts organized by the original chapter
 50 pages - Intro and best excerpts from all 8 chapters of this book Download as WORD document "TWILIGHT SLEEP" ~ (1) Intro & Quotes, (2) lengthy excerpts from Chapter 6, 7, and 8, (3) Chapters 1 thru 5; (4) additional quotes and excerpts about obstetrical education by Dr. J. Whitridge Williams, Also additional documents by Dr. DeLee and other early obstetricians published in the transactions of the American Society for the Study and Prevention of Infant Mortality 1910-1914

 Read as an HTML document on-line "TWILIGHT SLEEP"  
http://collegeofmidwives.org/AMA-CME_Flexner_1846-2009/TwilightSleep_1914_Intro_excerpts_Rev-ch6-7-8.htm

Original Google Book ~ published 1914 ~ 133 pages  Entire Original Twilight Sleep: A Simple Account of the New Discoveries in Painless Childbirth ~ written by Dr Henry Smith Williams, MD, published in 1914   Has navigational "BOOKMARKS" if opened in Acrobat PDF program

The good doctor's story in his own words and organized by topic:

 “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;

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.

…the wonderful effort that has been made 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.

Even in this second decade of the 20^th 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.

 “…. 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 ancestor 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 (Caucasian & European) 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.

Everyone 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.

“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.
 

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

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.
 

Take, as a single illustration, the matter of displacement of the uterus. I have quoted Dr. Williams to the effect that no one knows just why such displacements occur, or in what cases they are likely to occur.  What we do know is that in a certain large proportion of cases, such a displacement does occur in the course of the few weeks succeeding delivery.  And 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.

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.         

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

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.

In time every mother in the community should come to patronize such a hospital; for it will come to be known that the home is no place for a woman during the ordeal of childbirth.

These comforts, it must be borne in mind, include the use of pain-annulling drugs.  In this country, it is customary to anaesthetize the patient with chloroform, though some competent practitioners prefer ether.  We have already seen that the merits of the morphine-scopolamin[e] treatment, inducing the Twilight Sleep, are to be fully tested at the Johns Hopkins Hospital…

Sub-heading in original -- “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 ….  

… the farm wife must be educated before she could be made to see the desirability of this arrangement.  The first thought of the average wife is that she cannot possibly be spared from home, and that the idea of going to the hospital is not even to be considered.  But as 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.

What a boon it will be, then, to the six 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.

p. 81 “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.

In a population of twenty thousand people, there will occur, on the average, about seven hundred births in a year.  So the obstetrical needs of such a community as this are by no means insignificant when considered in the aggregate.  There is ample material for the patronage of a small hospital, located, let us say, at the county seat, if even a large minority of the women of the community can be induced to patronize it.

….small lying-in hospital, with its average of one or two births per day, will be provided of course with a resident physician and with a staff of nurses competent to give the first doses of the drug [of scopalomine].  So the treatment may be carried out as it is at Freiburg, and a considerable proportion of patients will secure the hoped-for boon of the “Twilight Sleep.”

Recall that the average annual birthrate is about thirty-five to every thousand inhabitants; that is to say, about one in every six families, and that sooner or later there are children in every normal household.  We are dealing, then, with a project that concerns not here and there an exceptional family, but one 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 by the levying of a special tax.

In many places small public or semi-public hospitals already exist.  These can be enlarged at relatively small cost, or their existing wards, - which in many cases are now for the most part vacant, - may be utilized as lying-in quarters.         

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

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

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 dangers and practically annul the pains of the women of the community in the condition which he has hitherto contemplated with the utmost apprehension as a menace, present or prospective, to the loved ones of his household.

            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 in connection with these hospitals, wards or departments of general surgery, for the treatment of various diseases, in many places 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 even in districts relatively sparsely settled.

Recycling the Distain of Medical Men for the Normal Physiological

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 be considered seriously; and a function, moreover, 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 condition of woman through 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 well 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 woman in childbirth may be given the solace of the “Twilight Sleep,” with all the attendant blessings that the word in its wildest implications is here meant to connote.

            Is it not worth your while to have a share in this beneficent movement?

Secondary source – As indigent women were brought into the system as teaching cases 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 tendency to retard respiration on the part of the child may sometimes be beneficial, 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.

“As against an infant mortality of 16 percent [editor’s note: 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.”

~ " ..... 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 American Association for the Study and Prevention of Infant Mortality; Williams.MD - “The Midwife Problem and Medical Education in the US”

Preview of Coming Attractions

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

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

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

WHAT HALF A MILLION WOULD DO

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

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

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

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

            How much money would be required?          

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

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