XYX *~* Dr. JWW: excerpt from Chapter 3 of “The Economic Story of Hospitals” {my unpublished manuscript}
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Part 3 – How Dr. J. Whitridge Williams’ plan to hospitalize healthy maternity patients created the foundation for our current, hospital-centric, healthcare system possible by providing seed money and a steady source of revenue for upgrading the American network of acute-care hospitals.
The elective hospitalization of healthy patients became the new business model and economic foundation for a 20th century, capital-intensive community-based hospital system in America
The claim (false) by Dr. JWW that middle and upper class (white) women had been severely harmed by modern civilization, and as a result of this evolutionary ‘fluke’, the ability of modern American women to withstand the otherwise normal pain of childbirth had been damage or even obliterated.
As a result, ‘allowing’ these ‘delicate’, ‘sensitive’ and ‘intellectually-talented’ women to labor and give birth at home under the care of a midwives would be irresponsible, as they would be so damaged by the ‘pathological’ pain of childbirth that many of them would suffer a nervous breakdown and have to be institutionalized in an asylum.
Certainly no responsible husband would run the risk of losing his wife’s services as mother, homemaker and consort if he could afford to pay for hospital-based childbirth services that could and would prevent such a tragedy by administering Twilight Sleep drugs during labor and putting the ‘little woman’ to sleep with general anesthesia for the surgical procedure of “delivery”, would be ‘performed’ by an obstetrically-trained doctor.
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In 1914, Dr J. Whitridge Williams, then chief of obstetrics at Johns Hopkins and dean of the University’s medical school, commissioned and personally participated in the writing of a book called “Twilight Sleep: Simple Discoveries in Painless Childbirth”. It’s target audience was the lay public and wealthy philanthropists that often provided generous endowments to hospitals.
Despite its provocative title, the main purpose of the book was to introduce Dr. JWW’s plan for a nation-wide system of general hospitals. He envisioned a coast-to-coast network of small and medium-sized community hospitals equipped to provide the same 20th century state-of-the-art medical services (quality if not quantity) as his alma mater, Johns Hopkins University Hospital.
In early 20th century America, there were only about a dozen hospitals that were equipped to provide scientifically-based 20th century medical treatments and aseptic surgery. Most of these big institutions were part of a medical school in urban areas of the east and west coast and the biggest cities in between. Americans who lived in small towns and farming communities daily risked dying from treatable injuries and curable diseases as they had no access to the life-saving abilities of ‘modern’ medical science.
Dr. Williams simply wanted to make modern ability to diagnose and treat serious injuries and illnesses and effectively cure previously fatal diseases available to the rest of the country. the trifecta of modern medical science — advanced understanding of the human biology, modern technologies and trained professionals
This required replacing the 19th century system of hospitals. This reflected the historic origin of hospitals, which pre-dated the invention of modern medicine by more than a thousand years. Except for setting broken bones and a few elemental surgical procedures, hospitals were simple buildings that provided non-therapeutic custodial care the first 1,500 years in the history of hospitals.
In the early 1900s over 90% of American hospitas were either very small (8-12 beds) private specialty institutions owned and run by a local doctor. True to their historic name, they mainly provided ‘hospitality’ — warm food, a clean bed and bathroom facilities — to the ill and injured. These medical hotels were staffed by unskilled workers who provided clean bed linens, hot meals, emptied bedpans, changed bandages and sometimes pushed patients in wheelchairs around the sun porch.
city or county institution to care for indigent or homeless residents, and sick travelers. This included medical attendance, but often crowded the ill together with the healthy poor, the insane, and persons who were permanently incapacitated.
“Care” vs. “Treatment”; Custodial vs. Therapeutic Services
The stark difference btw these two system was the how each of them defined the concept of ‘medical services’ based on the difference between “care” and “treatment”. Historic hospitals primarily provided *non-therapeutic* care that was custodial and palliative, while the emerging ‘modern’ hospital were equipped to provided effective therapies. This difference was reflected in whether the building simply aggregated and houses sick people or the hospital building aggregated and housed specialized equipment and trained professions who knew how to use it.
That all dramatically changed in the wake of Pasteur’s discovery of the microscopic bacteria (“the Germ Theory”) in 1881 and the invention of x-ray machine in 1895 and let to the break-through discoveries in the biological sciences that generated a steady stream of ideas for dramatically improving medical care that ultimately created 20th century medicine. But the practical application of these medical advances very often required new technologies and specialized equipment. The trifecta of modern medical science lay in its advanced understanding of the human biology, modern technologies and trained professionals
This required replacing the out-dated ideas and low-tech services of the 19th century hospitals with a system that reflected the new scientific discoveries we now call ‘modern medicine.
hospital as a building that housed the specialized equipment, modern technology and staffed by highly trained professional that were able to use the trifecta of modern medical science — advanced understanding of the human biology, modern technologies and trained professionals — to make ,
These small for-profit businesses What they lacked
The historic function of hospitals, which
The main reasons this was not happening ‘spontaneously’
and he had a solution that addressed both in a clever and sarindipitious way.
First step to was to promote the idea of community-based lying-in hospitals that andwere ““as uniformly, if not quite as abundantly, as schoolhouses and churches, with at least one … in every country seat”.
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This 20th century model combined the highly-evolved understanding of the these new sciences with specialized equipment and technologies and was already being used successfully at John Hopkins. Unfortunately, there were only a dozen or so fully-equipped hospitals like Johns Hopkins in all of the US.
This would require each general hospitals provide clinical laboratory services, an x-ray department, modern, ceramic-titled operating rooms and a big central supply that could churn out endless quantities of sterilized supplices. Dr Williams dreamed of a day when these general hospitals would
By , the effective medical therapies associated with modern medicine
To meet the new scientific standard for the practice of medicine, these new departments would need to be properly equipped. This entailed the purchase at least one of every new technological ‘gadgets’ of the day. Obviously this was very capital-intensive undertaking, that included microscopes, sterilizers, central supply autoclaves, x-ray machines, radiology film, oxygen tanks, operating room tables and special electric OR lights.
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The as they could not to
Instead of cures, the historical value of 19th century hospitals was the building itself — a physical place to house sick people, The good news is that such low-technology care was also (appropriately!) very low cost.
No matter who much these historic hospital wanted to provide new scientific abilities, they could they afford to purchase and maintain the capital-intensive technologies of ‘modern’ 20th century medicine, which was for the first time able, in the hands of a well-trained and astute physician, to provide effective medical treatment.
These upgrades were a capital-intensive endeavor required financing and convincing the bank that one’s business model provided sufficient steady revenue to meeting their operating budget – electricity, heating, salaries, medical supplies, food, etc — and still pay off their bank loan.
Dr. Williams’ understood this economic dilemma — a 19th century backwater business model that depended on sick people for its revenue being facing the astronomical economics of 20th century technology. JW Williams’ unique brilliance lay in figuring out how to fix what seemingly insurmountable problem, given that organized medicine in the US had resoundly rejected any type of nationalized medical care. — identified of the elective hospitalization of maternity patients as the first and most crucial step in this new system of 20th century, hosptial-centric healthcare.
He saw the elective hospitalization of maternity patients in lying-in wards of local hospitals as an untapped source of dependable revenue. This seed money was desperately needed so
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Hospital costs varied from a low of 22 cents to $2.76 per patient, per day. [The cost of running American city hospitals: the Gorgas 1910 survey. www.ncbi.nlm.nih.gov/pubmed/10701786by E Chaves-Carballo – 2000]
July 16, 1798 President John Adams signs into law, “An Act for the Relief of Sick and Disabled Seamen,” creating the Marine Hospital Service that later evolves into the Public Health Service. Federal customs collectors tax American ships arriving from foreign ports 20 cents per sailor per month to pay for construction and maintenance of marine hospitals.
March 1, 1799 The Lying-in Hospital of the City of New York is chartered, the first to provide obstetrical care for women in New York City.
If you are seriously ill today, you go to the hospital, where an array of doctors, nurses, technicians as well as advanced technologies will treat your ailments. But in the 1800s there were relatively few hospitals, they largely served the poor and had no medical services that a private physician could not provide. The hospital administration was not controlled by professionals, but by religious orders and laypeople.
By 1920, this system had changed. Like other aspects of life, such as welfare , work and education, health care had moved from the home into the institution and become much more organized, developed and bureaucratic. This change was driven by new technologies and practices that could be provided only in the hospital: the x-ray , antiseptic surgery and clinical diagnostics . Successful physicians saw the hospital as the place to administer treatment and convinced the middle class clientele of this as well. The transformation of hospitals and their desirability can be seen in the increase from 178 in 1873 to nearly 5,000 in 1923.
Robert C. Hinckley painting, “First Operation Under Ether,” 1882-1893.
The increasing complexity of medicine also heightened the power of doctors in hospitals as lay administrators increasingly deferred authority to the trained professionals. Hospitals also became the place where new professionals would be trained. As the number of paying patients grew, hospitals catered to their needs by placing them in more private spaces instead of wards and providing better food and services. As voluntary non-profit hospitals took in these new patients, poor and chronically ill patients were often sent to county, state and municipal institutions.
The late 20th century hospital did not wholly break away from its traditions of charity, but how it was funded changed radically, with the advent of Blue Cross and Blue Shield , third party insurance, Medicare and Medicaid and direct aid from all levels of government. As hospital costs have risen and insurers have greater cost controls, there has been a trend toward the creation of large hospital networks, the closure of public and smaller community hospitals and the growth of for-profit hospitals .
Surgeons performing one of the world’s first stopped-heart surgeries at the Cleveland Clinic, 1956.
[http://www.cuny.edu/archive/cc/health-in-america/milestones.html]
Hx Chicago Hospitals – website quote: Rush physicians soon incorporated another general hospital, called the Illinois General Hospital of the Lakes, which opened in 1850 with 12 beds in the old Lake House Hotel at Rush and North Water Streets.
The charge was three dollars per week per patient.
the early twentieth century as scientific medicine became more accurate and effective
Seen as part of a church’s mission, religious hospitals were shaped by a charitable imperative and a desire to save souls while caring for the sick. Religious symbols and the presence of religious nursing orders provided constant reminders of spirituality.
The influx of German immigrants into the Chicago area led to the 1883 founding of the German Hospital. It was renamed Grant Hospital during World War I. Baptists established the Chicago Baptist Hospital in 1891, and Methodists founded Bethany Methodist. By 1897, Lutherans had built Augustana, Swedish Covenant, the Norwegian-American Hospital, and the Lutheran Deaconess Home and Hospital. Early twentieth-century Catholic groups started St. Anne’s, St. Bernard’s, and Columbus hospitals.
Several Chicago hospitals have aimed at specific types of patients. The Illinois Charitable Eye and Ear Infirmary began in 1858 under the direction of ophthalmologist Edward Lorenzo Holmes. In 1865, Mary Harris Thompson founded the Chicago Hospital for Women and Children, chiefly to serve widows and orphans of Civil War victims. Renamed the Mary Thompson Hospital when she died in 1895, it opened on Rush Street, then moved to West Adams Street. Julia F. Porter endowed the Maurice Porter Memorial Free Hospital for Children in 1882 in memory of her son. In 1903 it took the name Children’s Memorial.
Joseph B. De Lee founded the Chicago Lying-In Hospital and Dispensary in 1895 in a tenement house on Maxwell Street in an effort to lower the high neonatal mortality rates. The Martha Washington Hospital advertised itself as a haven for alcoholics, and the Frances E. Willard National Temperance Hospital, named after the famous temperance advocate from Evanston, was for nondrinkers. It was dedicated to proving that diseases could be cured without the use of alcohol or alcohol-based medicines.
The influx of German immigrants into the Chicago area led to the 1883 founding of the German Hospital. It was renamed Grant Hospital during World War I. Baptists established the Chicago Baptist Hospital in 1891, and Methodists founded Bethany Methodist. By 1897, Lutherans had built Augustana, Swedish Covenant, the Norwegian-American Hospital, and the Lutheran Deaconess Home and Hospital. Early twentieth-century Catholic groups started St. Anne’s, St. Bernard’s, and Columbus hospitals.
Several Chicago hospitals have aimed at specific types of patients. The Illinois Charitable Eye and Ear Infirmary began in 1858 under the direction of ophthalmologist Edward Lorenzo Holmes. In 1865, Mary Harris Thompson founded the Chicago Hospital for Women and Children, chiefly to serve widows and orphans of Civil War victims. Renamed the Mary Thompson Hospital when she died in 1895, it opened on Rush Street, then moved to West Adams Street. Julia F. Porter endowed the Maurice Porter Memorial Free Hospital for Children in 1882 in memory of her son. In 1903 it took the name Children’s Memorial. Joseph B. De Lee founded the Chicago Lying-In Hospital and Dispensary in 1895 in a tenement house on Maxwell Street in an effort to lower the high neonatal mortality rates. The Martha Washington Hospital advertised itself as a haven for alcoholics, and the Frances E. Willard National Temperance Hospital, named after the famous temperance advocate from Evanston, was for nondrinkers. It was dedicated to proving that diseases could be cured without the use of alcohol or alcohol-based medicines.
The influx of German immigrants into the Chicago area led to the 1883 founding of the German Hospital. It was renamed Grant Hospital during World War I. Baptists established the Chicago Baptist Hospital in 1891, and Methodists founded Bethany Methodist. By 1897, Lutherans had built Augustana, Swedish Covenant, the Norwegian-American Hospital, and the Lutheran Deaconess Home and Hospital. Early twentieth-century Catholic groups started St. Anne’s, St. Bernard’s, and Columbus hospitals.
Until the mid-twentieth century, many Chicago hospitals refused to treat African American patients or employ black doctors and nurses.
Beginning in the last decade of the nineteenth century, groups of physicians and physician-entrepreneurs established for-profit hospitals such as the Lakeside Hospital, Garfield Park Hospital, Westside Hospital, and Jefferson Park Hospital. Later examples of this type included North Chicago, Washington Park, Ravenswood, South Shore, Washington Boulevard, Burnside, Chicago General, John B. Murphy, and Belmont hospitals. Most of these were small and some lasted only a few years. Others became nonprofit institutions and continued to serve without investor ownership.
a new understanding of the importance of cleanliness made the hospital a safer place for most patients by the end of the nineteenth century. Medicine began to incorporate developments in chemistry and biology, and aseptic surgery and clinical laboratories became effective tools in health care. Such changes in technology paralleled tremendous growth in population from immigration, which strained existing municipal services, including the provision of medical care. Hospital construction by both public and private agencies was one result. Tax-supported hospitals were built by the city, the county, the state, and federal government. Private hospitals included institutions owned or operated by medical schools, religious groups, individual doctors or groups of physicians, lay boards, and even companies such as railroads.
Insurance programs beginning in the 1930s encouraged hospital development, and as the Hill-Burton plan took effect after World War II, hospitals all over the United States were built or expanded. As the number of available beds increased, so did competition for patients among neighboring institutions. By 1950, with a population of 3.6 million, Chicago had 84 hospitals, including public and private sanatoria. The majority were nonprofit, receiving major funding from patient fees (often at least partly paid by insurance), donations, and endowments.
As government reimbursement programs initiated in the 1960s expanded to encompass so many patients that tax resources stretched thin, agencies demanded briefer hospital stays. *New technologies allowed patients to be discharged earlier. Beds began to go unfilled and hospitals faced declining revenues.*
Many closed or consolidated, and the number of hospitals in Chicago fell to approximately 50 by the late 1990s. The advent of health-maintenance organizations (HMOs) was another factor in the loss of hospital income, since these organizations typically contracted for care at lower fees than traditional insurance paid. Hospital ownership began to consolidate as large corporations or associations sought economies of scale by purchasing formerly independent institutions.
http://www.encyclopedia.chicagohistory.org/pages/602.html
The American Medical Association (AMA) was organized in 1847 in Philadelphia through the efforts of Nathan Davis and Nathaniel Chapman primarily to deal with the lack of regulations and standards in medical education and medical practice.
Wikipedia hx HC reform in the US: 1900-1920 –>
In the first 10–15 years of the 20th century Progressivism was influencing both Europe and the United States.[6] Many European countries were passing the first social welfare acts and forming the basis for compulsory government-run or voluntary subsidized health care programs.[7] The United Kingdom passed the National Insurance Act of 1911 that provided medical care and replacement of some lost wages if a worker became ill. It did not, however, cover spouses or dependents. U.S. efforts to achieve universal coverage began with Theodore Roosevelt, who had the support of progressive health care reformers in the 1912 election but was defeated.[8] Progressives campaigned unsuccessfully for sickness insurance guaranteed by the states.[9] A unique American history of decentralization in government, limited government, and a tradition of classical liberalism are all possible explanations for the suspicion around the idea of compulsory government-run insurance.[7] The American Medical Association (AMA) was also deeply and vocally opposed to the idea.[9] In addition, many urban US workers already had access to sickness insurance through employer-based sickness funds.
Early industrial sickness insurance purchased through employers was one influential economic origin of the current American health care system.[10] These late 19th century and early 20th century sickness insurance schemes were generally inexpensive for workers: their small scale and local administration kept overhead low, and because the people who purchased insurance were all employees of the same company, that prevented people who were already ill from buying in.[10] The presence of employer-based sickness funds may have contributed to why the idea of government-based insurance did not take hold in the United States at the same time that the United Kingdom and the rest of Europe was moving toward socialized schemes like the UK National Insurance Act of 1911.[10] Thus, at the beginning of the 20th century, Americans were used to associating insurance with employers, which paved the way for the beginning of third party health insurance in the 1930s.
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Next section – In the Beginning …
The book began by explaining that the biological ability of American women to withstand the pain of normal childbirth had become severely impaired due to the negative effects of civilization on the process of normal evolution. In this context, they expressed sympathy for the reproductive predicament of women, fated as they were to a role described as “the sacred function of maternity” that “causes her months of illness and hours of agony.”
As for the pain associated with childbirth these authors remarked:
“…how has it come about that this most natural and essential function should … be associated with so much seemingly useless suffering”
“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.
They jointly lamented the fact that “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.”
They went on to say:
“the excessive pains of childbirth are not a strictly a ‘natural’ concomitant of motherhood, but rather that they are … an abnormal product of civilization”
“… 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.”
still giving birth “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.”
However, this problem only affected the more affluent, American-born women, as the terms “delicate” and “intellectual” types referred to upper and middle-class whites of European descent. Poor and working-class women — mostly immigrants or ethnic minorities — appeared to tolerate normal childbirth quite well and typically had very large families.
As a result, the birth rate per 100,000 for American-born Caucasians was significantly less than that of the immigrant and non-white population. The authors — Doctors J. Whitridge and Henry Smith Willams– attributed the lower birth rate for white babies to the reluctance of their better-off mothers to suffer through another painful childbirth. According to their narrative, this was detrimental to the “race” and for them personally, an issue of patriotism:
” … any trait or habit may be directly detrimental to the individual and to the race and they may be preserved, generation after generation, through the fostering influence of the hot-house conditions of civilized existence.”
“Is there not fair warrant for the assumption that the pains which civilized women—and in particular the most delicately organized women — suffer in childbirth may be classed in this category?”
“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.”
“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.”
“Considered from an evolutionary standpoint, the pains of labor appear not only uncalled for, but positively menacing to the race.”
“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.”
“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.”
To illistrate the magnitude and seriousness of excessive pain in childbirth, these good doctors provide accounts of ‘delicate’ women who suffered a nervous breakdown after foolishly being allowed to endure the extreme suffering of an unmedicated labor. Women so afflicted sometimes had to be committed to a mental institution for the rest of their life.
According to these authors, the only way to avoid such catastrophes was through the “blessed unconsciousness” of Twilight Sleep drugs and general anesthesia for delivery. Dr. Williams’ tells his readers about “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.”
The solution proposed by Doctors J. Whitridge and Henry Smith Williams was routine and elective hospitalization of maternity patients so that narcotic and amnesic drugs could be administered during the labor and a surgically-conducted ‘delivery’ be performed on an unconscious mother-to-be while she was under general anesthesia.
In light of stories about women being driven mad by the excessive pain of a normal labor, it wasn’t hard for the authors to convinence husbands to pay the considerable additional cost for doctor-attended hospital birth. After all, this was a test of their love for the ‘little woman’ and a hedge against their wife becoming so mentally incompetent that husbands would be left to raise the children on their own.
Seen from our modern perspective, replacing the physiological process of childbirth with a massive level of intervention seems ‘excessive’ and unjustifiable, as it exposes healthy women to a number unnecessary and potentially –lethal risks. However, Dr. Williams’ dismissed all this concern with disbatch, remarking that:
“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.”
As for the issue of the “less fit” non-caucasian or immigrant woman, Dr. J. W. Williams remarked:
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 a paper by Dr. J. Whitridge Williams published in JAMA 1912, he was quoted as saying:
“In Johns Hopkins Hospital, no patient is conscious when she is delivered of a child. She is oblivious, under the influence of chloroform or ether.”
In closing, good doctors assured their readers that:
“every patient who goes to the hospital may have full assurance that she will pass through what would otherwise be a dreaded ordeal in a state of blissful unconsciousness”
As for the practical arrangements that would make this possible, 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.
Public Relations in the Vocabulary of Propaganda — 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.
Do the Math, Convince the People, Collect the Taxes
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.
The Trump Card – Convincing the Men
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.
A Call to Arms, Urging every man to “have a share in the beneficent movement”
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.
Famed scientists disputes fetal-neonatal damage as a result of the scopolamine narcosis of its mother :
“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.”
WHAT SOME PHILANTHROPIST MAY DO
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.
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Back to the beginning – closing the circle –> how to make the 20th century hospital reflect the best of ‘modern science while under the crushing burden of a business model — depending on sick people to pay the bill for their hospital care out of pocket — a price that not only reflected the expense of the care they personally received but the cost of upgrading the hospital with new and very expensive technology that they may or may not have directly benefited from.
during their stay in the hospital.
In the end, Dr. J. Whitridege Williams, who was first great love was surgery and his first job was as a GYN surgeon, got what he really wanted – to chance to change the business model of modern medicine in a profession that had viamently rejected as socialized medicine, that is, any form of state-sponsored, tax-support nationalized system.
J W Williams was intimately aware of two crucial realities:
1. ‘modern’ medicine required hospitals to make expensive and immediate upgrades their services, equipment and facilities
2. That depending on the ill, injured and elderly — sick people — as a business model was a very bad idea, one that was totally unworkable and uforgiving.
During its fledgling years when hosptial care as a scientific endeavor was first getting on its feet (1900 to about 1920) obstetrician JW Williams accurately diagnosed the intractable nature of their economic dilemma — how to create a steady and dependable source of revenue in a world that depended on sick people to pay their bills for hospital services? He rightfully gets to take credit for solving to the knottiest, most intractable problem of 20th century medicine.
In order to provide credible 20th care, they needed clinical laboratories, an x-ray department, ceramic-titled operating rooms and a big central supply that could churn out endless quantities of sterilized supplices.
Of course, the scientific practice of medicine also required these new departments to have all the new technological ‘gadgets’. This necessitated sufficient revenue to the purchase of capital-intensive equipment — microscopes, sterilizers, central supply autoclaves, x-ray machines, radiology film, oxygen tanks, OR tables and big electric OR lights.
to the seed money for a national system of fully-equipped, community hospital,
To pay for all this, (search for existing copy on how elective hospitalization paved the way for modern hospitals in .
Part 4 — The high MMR in the US compared to other developed countries, the claim by influential members of the ‘new obstetrics’ that midwives were to blame for this and the medicalization of normal childbirth was the magic bullet that would fix the problem.
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–>introduced his new ‘business plan’ for using healthy maternity patients as the primary source of income for a national system of hospitals. 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 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.
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“…. 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.
