Against Medical Advice: Priscilla White and Diabetic Pregnancy
Several twenty-something women sit in a waiting room. One peruses an issue of McClure’s; another files her nails. They don’t know each other, and never will; although, after several encounters here, they may recognize each other. Upon hearing one’s name, they might muse about that woman’s life. Where does she live? How long has she lived with the condition? What does her husband do? They have little reason to believe that they are connected beyond these fleeting encounters.
In fact, these two women—and others whose faces and names they would never know—were counterparts in a movement bigger than any single one of them. It was a movement for reproductive rights, albeit not the sort that activists and scholars have tended to highlight. The year was 1928, several decades before “second wave” feminism and the firm centering of women’s reproductive rights within feminist politics. And it was seven years since the discovery of insulin, which transformed Type 1 diabetes from a fatal to a chronic condition. Thanks to this discovery, these women had hopes of living near-normal lives. For them, that included motherhood. With the help of a sympathetic physician named Priscilla White, they would traverse enormous social and clinical barriers to fulfill this goal.
In 1928, most medical authorities didn’t want diabetics to become mothers because American culture was obsessed with improving the human race though the “science” of better breeding. The Eugenics Records Office in Cold Springs Harbor and affiliate institutions routinely published literature warning of the dangers to society when “defectives” reproduce. These organizations did so with the support of government agencies, such as the Department of Agriculture, and generous donations from the Rockefellers, Carnegies, Kelloggs, and other philanthropic families who had shifted their charitable priorities from assisting the needy to “curing evils at their source.” Eugenics had the support of leading figures like Theodore Roosevelt and Calvin Coolidge, and its principles of “patriotic parenthood” inspired events such as Fitter Family contests at state fairs, which awarded ribbons based on the whiteness of participants’ pigment, the arch of their noses, and the straightness of their teeth. Just one year prior, the movement to protect America’s “stock” was codified into law with Buck v. Bell, the Supreme Court case upholding the state of Virginia’s decision to sterilize a woman who, along with her daughter and mother, was deemed “feebleminded.”
In such a society, insulin’s discovery caused some alarm. A Mount Sinai Hospital physician, who also served as the Vice President of the American Eugenics Society, remarked that insulin was a boon for the individual, but “certainly not a genetic blessing.” The zoologist Herbert Spencer Jennings bemoaned that insulin, among other novel treatments, would do away with natural selection by allowing diseased persons to reproduce and pass on their defects. Such anxieties led one physician to suggest in the British Medical Journal that insulin should only be provided to those who couldn’t afford it in exchange for their sterilization.
As it turned out, diabetics were spared from state-sponsored sterilization campaigns for the simple reason that those who presented with the condition (those with access to a physician) tended to be middle and upper class whites—precisely the individuals whom eugenicists desired to have children. But this did not mean that individual doctors did not attempt to dissuade diabetics from becoming pregnant “for society’s sake.”
A convenient reality for these physicians was the possibility of “dreadful outcomes.” In the years before and after insulin, physicians observed that diabetes (the autoimmune, metabolic, and gestational forms were not yet distinguished) greatly increased the risk of miscarriage, maternal or fetal mortality, and overweight babies with congenital abnormalities. Citing these risks, doctors recommended that diabetic women categorically avoid pregnancy. While some may have been genuinely concerned about patients’ safety, others were motivated by eugenic imperatives. This is evidenced by their slippage between the two mindsets when making the case against pregnancy.
In his popular manual on diabetes care, Robin D. Lawrence wrote, “Diabetic pregnancy is unadvisable and should be terminated at once, when detected.” He promptly added, “Unfortunately, we must leave the choice to the patient as there are no laws of national eugenics.” The above-mentioned Mount Sinai physician agreed that high fetal and postnatal mortality rates among diabetic women signaled the urgency of sterilization. “Nature seems to be crying: Don’t let the diabetic woman reproduce herself!”, Alan F. Guttmacher wrote in a 1954 issue of Eugenics Quarterly. Guttmacher actually argues for maternal choice, but insists that diabetics’ pursuit of motherhood is “illogical” and against the “welfare of the community.”
To dissuade diabetic women from conceiving, doctors often conjured images of dying mothers from the days prior to insulin. The most famous diabetes doctor in America, in whose clinic the above-mentioned women sat, was known to do just this. Elliott P. Joslin had a habit of recalling the tragic story of a patient who saw a mental healer, instead of him, and was later admitted to the hospital for an emergency delivery. “She died, the baby died, and the husband climbed the hill behind the hospital and shot himself,” he told countless wide-eyed patients.
But when it came to motherhood, many women like those above were not to be deterred. They became pregnant against medical advice—and then refused to have a therapeutic abortion when it was demanded of them. Their determination eventually compelled the medical profession to develop better standards of care.
Diabetic women did this with the support of Joslin’s colleague, Dr. Priscilla White. The daughter of a single mother, White had studied liberal arts at Radcliffe College and then attended Tufts Medical School, graduating third in her class. In the summer of 1924, she worked as a lab assistant for Joslin. Joslin, who had roots in Puritan New England, was so impressed with White’s work ethic that he offered her a permanent position. He believed diabetes doctors should embody the virtue (discipline) that they asked of their patients.
White was not married and not a mother herself, except to two dachshunds whose dark hairs always covered her lab coat. But she empathized with her women patients and vowed to help them safely deliver. Patients found something soothing in her manner and in the long letters she wrote to them after each appointment. “She is endearingly optimistic and happy with each of us individually,” one recalled. When word spread that a woman was overseeing diabetic pregnancies, people came from great distances to see her.
Together, White and the mothers-to-be formed the field of obstetrical diabetes. Each pregnant woman’s case became part of the physician’s extensive research, which eventually led to enlightening insights: “over-grown” fetuses have been exposed to excess sugar in utero; insulin sensitivity changes with pregnancy hormones, requiring modifications in therapy; giving smaller doses of insulin more frequently improves outcomes; and the duration of diabetes adversely affects outcomes. White shared her findings when Joslin invited her on his lecture tours. She also contributed chapters on diabetic pregnancy to his manual, The Treatment of Diabetes Mellitus, later editions of which she co-edited.
Within a decade, White’s findings reduced maternal deaths by 90 percent and fetal losses by 50 percent. Those figures further improved over time. In 1949, White published her classification system—the White Classification—for assessing and treating patients. Colleagues eventually adopted this rubric when they begrudgingly accepted her declaration that “diabetes is no longer a contraindication in pregnancy.” Some cited the rubric to recommend therapeutic abortions in cases classified as “E” or “F” (cases associated with early-onset diabetes and vascular complications), but White did not. Nor did she ever consider the mother’s race, social station, relationship status, or family size to make recommendations. The patient’s wishes about reproductive matters always prevailed.
Before her retirement in 1975, White supervised 2,200 diabetic pregnancies. Her patients often expressed gratitude by adding to the collection of ceramic dachshunds on the shelf in her office. But despite her success, Dr. White was never promoted to a distinguished research position. Nor did she receive the degree of accolades awarded to her male peers, with the noteworthy exception of the Banting Medal from the American Diabetes Association. And although it was transformative in establishing standards of prenatal care for women with diabetes, the field of obstetrical diabetes was never formally recognized by the American Medical Association.
While largely forgotten today, Dr. White and her patients demonstrated that authority-contradicting patients can improve health outcomes and shape clinical practices, even if they do so privately and with little to no formal organization. What is so remarkable about White’s patients, according to historian Marjorie Elvin Foy, is that they “probably had limited awareness of the size and scope of their efforts, yet they pursued pregnancy en masse in the face of intense opposition.” By pushing for diabetics’ right to prenatal care, they challenged the accepted science of eugenics. Thanks to this bold endeavor, most of the 10 perecent of pregnant women with some form of diabetes can now safely labor.
Elvin Majorie Foy, “Our Objective Wasn’t to Belittle People’s Behavior: The History of Gestational Diabetes 1921-1991” (PhD diss., UNC- Greensboro, 2013).
Arleen Marcia Tuchman, “Diabetes and ‘Defective Genes’ in the Twentieth-Century United States.” Journal of the History of Medicine and Allied Sciences 70 (2015): 1–33.
Image credit: Insulin sales kit, Eli Lilly and Company. Courtesy of the National Museum of American History.