12,107 word ~ 2nd Draft version w/ better wording of several topics to be transferred to appropriate chapter — don’t delete until finished moving text
The gender gap writ large, with women as mothers and midwives the historic losers. It’s also at the root of why the medical profession was so prejudiced against, and demeaning of, any doctor that provided obstetrical care!
Statue of Dr. Marion Sims, the famous 19th century gynecological surgeon. Also owner of a Southern plantation & slave-holder, he perfected his surgical techniques by “practicing” his operations without anesthesia on 3 of his female slaves. The statute of this misogynist doctor was recently removed from Central Park in NYC
Unfortunately, this part of the story begins with the male of the species assuming that men naturally do everything better than members of the female gender.
For obstetricians in leadership roles in the early 20th century, the specific gender-related target was midwives.
What they characterized as the “midwife problem”, was the problem that doctors were having in eliminating midwives. Typical opinions about midwives remind me of the disparaging comments that upper-class whites have always made about the poor, uneducated, immigrants, and people of color.
In 1906 an obstetrician by the name of Dr. Gerwin described midwives as:
“ the typical … midwife, her mouth full of snuff, her fingers full of dirt and her brain full of arrogance and superstition”
A paper published 1907 by Drs. Emmons and Huntington criticized midwives for:
“the overconfidence of half-knowledge, …unprincipled and callous for the welfare of her patients”
Dr J. Whitridge Williams, 1912:
“The question in my mind is not “what shall we do with the midwife?” We are totally indifferent as to what will becomes of her…[1912-B, p.225]. No attempt should be made to establish school for midwives, since, in my opinion, they are to be endured in ever-decreasing numbers while substitutes are being created to displace them.” [1912-B; p.227]
Dr. Joseph DeLee’s 1915 publication “The Teaching of Obstetrics“; American Association of Obstetrics and Gynecologists
“The midwife has long been a drag on the progress of the science and art of obstetrics. Her existence stunts the one and degrades the other. For many centuries she perverted obstetrics from obtaining any standing at all among the science of medicine.
The midwife is a relic of barbarism. In civilized countries the midwife is wrong, has always been wrong. The greatest bar to human progress has been compromise, and the midwife demands a compromise between right and wrong. All admit that the midwife is wrong.
If the profession would realize that parturition [childbirth], viewed with modern eyes, is no longer a normal function, but that it has imposing pathologic dignity, the midwife would be impossible of mention.” [TASPIM, 1915 p.117]
[Transaction of the American Society for the Prevention of Infant mortality (TASPIM) 1915, p. 114]
The gender-loaded title of “Medical Men”
Most people don’t know that in the early 1900s, medical doctors in the US didn’t like being called “doctors”, which was more strongly associated with college professors and the ministerial title “Doctor of Divinity”, and they hated being referred to as a “man-midwife”. Instead they preferred being the descriptive title of “medical men”. A comment by no less an icon of obstetrical wisdom than Dr. J. Whitridge Williams demonstrates the nature of this gender issue:
“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.” {Twilight Sleep: Simple Discoveries in Painless Childbirth; 1914}
During this formative period of American obstetric as distinct from its practice in other developed countries, the profession never doubted that Mother Nature, having blessed male MDs with the superior intellectual powers conferred by their “y” genes, meant it was their divine destiny to rescue the millions of white middle- and upper-class women who gave birth each year from a malicious Mother Nature.
American obstetricians believed it was both their right and their duty to be in charge of female reproduction, which meant that they controlled all aspects of pregnancy and childbirth in the United States.
“A Review of the Midwife Situation” ~ Boston Medical and Surgical Journal, 02-23-1911, page 261 {*} Arthur Brewster Emmons, 2d, M.D., Boston and James Lincoln Huntington, M.D., Boston.
“… we believe it to be the duty and privilege of the obstetricians of our country to safeguard the mother and child in the dangers of childbirth.
The obstetricians are the final authority to set the standard and lead the way to safety. They alone can properly educate the medical profession, the legislators and the public.”
These outspoken and politically-active obstetricians concluded that childbirth could safely be described as a relatively normal aspect of reproductive biology in women of color, immigrants and the working poor. The sheer size of the average poor or immigrant families – as 15 or even 20 children – attested to that. However, these same influential obstetricians insisted that normal labor and spontaneous childbirth in the upper classes of (white) women had somehow become a “pathophysiology”, that is, a dangerously dysfunctional aspect of female biology.
Having concluded that the lower classes of working poor did not particularly need, nor were able to pay for obstetrical services, the profession turned its attention to middle- and upper-class white women, whose families could easily afford an obstetrically-managed hospital birth. This serendipitously coincided with the more advent-guard ideas about making childbirth more “modern” by identifying obstetricians (i.e. not midwives) as the preferred birth attendant for the wealthier and whiter classes of women.
Articles by obstetricians published in newspapers and women’s magazines and broadcast on the radio, all described pregnancy and childbirth in the “modern” American (i.e. white) woman to as a “nine-month disease that required a surgical cure”. As spokesmen for the obstetrical profession, they were outspoken and relentless in promoting the idea of “always a doctor, never a midwife”.
Having defined normal childbirth to be pathology, professional services associated with the ‘disease’ of childbirth was, without question, to legally become the sole “property” of the obstetrical profession. Since ‘new’ obstetrics was defined as a surgical specialty, the proper way to refer to childbirth as attended by “medical men” was now referred to as “the delivery”, a term that defined childbirth to be a sterile surgical procedure conducted by an MD trained in obstetrical surgery.
This process began by putting labor patients to sleep with chloroform or ether and having the nurses cover the laboring woman with sterile drapes. Then the doctor stepped in to cut an episiotomy and extract the baby with the use of obstetrical forceps.
By defining childbirth as a pathology, the doctor was required to remove the placenta manually (i.e. to use his hand) instead of waiting for it to be spontaneously expelled. In order to detach the placenta from the uterine wall and bring it out in his hand, the doctor he had to put on a special sterile glove with a long cuff that went up to his elbow. Then he inserted his hand and forearm into the mother’s vagina in order to reach inside her uterus and peel the placenta off the inner surface of the uterine wall, grab the separated placenta with his fingers, and draw it out of the uterus and the mother’s vagina.
Last but not least, the surgical process of childbirth end when the doctor finished suturing of the episiotomy incision.
Note that childbearing woman were no longer described as “giving birth”, but seen as passive entitled whose baby was extracted from her unconscious body by forceps, and thus establishing that it was the doctor, and not the mother, who “delivered” the baby.
For healthy childbearing women, this was the most profound change in childbirth practices in the history of the human species.
Continue to Chapter 3 ~ The Historical Role of Dr. J. Whitridge Williams, most famous obstetrician of the 20th century and author of “Williams’ Obstetrics”
Dr. J. Whitridge Williams was the most famous and highly lauded American obstetrician of the 20th century. In addition to being influential within his profession peers, he was also revered by the public. He was the most outspoken, influential and prolific proponent of the “the new obstetrics” as a hospital-based surgical discipline.
It’s not surprising that historians identify Dr. Williams as the founder of academic obstetrics in the United States and recognized him as the leader of obstetrics in America during the first 3 decades of the 20th century. Personally, I would go much further and identify Dr. Williams as having almost single-handedly defined the discipline of obstetrics as a surgical specialty and promoted its “modern” practice as a highly interventive process that included giving Twilight Sleep drugs to all laboring women, the routine use of chloroform or ether (general anesthetics), delivering the baby with forceps and manually removing the placenta.
But before focusing on Dr JWW’s critical role in defining the “new” obstetrics, an overview of Dr. JWW’s professional background and positive contributions.
Dr. Williams was employed by the famous and highly respected Johns Hopkins University Hospital for his entire professional life, from 1893 to is untimely death in 1931. During that time, he was a practicing obstetrician, a professor of obstetrics, and in 1899, appointed Chief of Obstetrics. His famous obstetrical textbook “Williams’ Obstetrics” was published in 1904 and is currently in its 27th printing. He was appointed Dean of Johns Hopkins University School of Medicine in 1911 and served in that role until 1923. After that he resumed his role as a professor of obstetrics for the medical school and personally editing the next 5 editions of his obstetrical textbook.
Without a doubt, Dr. Williams was committed to modernizing obstetrical education, elevating obstetrical practice, eliminating midwifery care, which he believed was dangerous, and improving the status of obstetrical medicine in the United States. As a member of the American Association for the Study and the Prevention of Infant Mortality” (AASPIM) a new national organization founded in 1909 [1] — Dr JWW was also committed to reducing the embarrassingly high rate of infant deaths in the US compared to other wealthy industrialized countries.
How medicine changed from a “healing art” to a “modern medical science” early in the 20th century and the financial problems that created for hospitals
{A} As a medical doctor and Dean of a very prestigious medical school, Dr. JWW found himself living and working in one of the most extraordinary times in the history of medicine. Dr JWW and his contemporaries all played an important part in the most profound change in the practice of medicine in human history. For a variety of reasons, very few Americans know about this important period of history – the ‘birth’ of modern medicine as a science and the end of the pre-scientific “healing arts”.
From Hippocrates to Heart Transplants ~ the birth of medical science
Medical science was preceded by 2,000 years during which the practice of medicine in Western cultures was known as “the healing arts”. These traditional healing methods started with the famous Greek physician, Hippocrates, (460 — 375 BCE) and his theory of “four humors”. The standard treatment for disease was based on “balancing” the four humors, which consisted of repeatedly bleeding patients until they lost consciousness and purging them with strong laxatives.
Over many centuries, more accurate knowledge of human anatomy and biology greatly improved the ability of doctors to diagnose and treat their patients. But without our modern diagnostics testing and effective drug therapies, the practice of medicine continued to primarily be an intuitive “art”. These thousands of years old practices defined medical care until the mid 19th century, when a rapid series of world-changing scientific discoveries in Europe and America gave us “modern medical science” and slowly displaced the “healing arts” over the course of the next century.
Medical science jumped into high-gear in 1850 with the use of ether by Dr. Morton, a Boston dentist, as the first relatively safe anesthesia. This was followed in the 1860s by Pasteur’s many important discoveries that resulted in the new science of bacteriology. Pasteur showed that microbes were omnipresent – in water, in air, on objects, and on the skin, and that a type of microbe called “bacteria” is what causes infectious diseases. Pasteur first published the finding of his study in 1861 and a 2nd paper on contagion and infectious diseases titled “The Germ Theory” in 1879.
In 1881 Pasteur delivered an address to a group of physicians at the Paris’ Institute of Medicine. Standing at a blackboard, he picked up a piece of chalk and drew a picture of what looked like railroad tanker cars lined up in a row. Then he turned to his audience and pointing to his rendition of the pathogenic bacteria streptococcus pyogenes said:
“This gentlemen is what causes puerperal sepsis and the death of newly-delivered mothers”.
Understanding that certain bacteria caused fermentation and disease allowed Pasteur to develop vaccines against anthrax and rabies. Prevention of disease though public sanitation systems and aseptic principles of personal cleanness, in combination with vaccinations and immunizations, continues to be a cornerstone of our science-based healthcare system.
{ref a ~ https://www.pasteur.fr/en/institut-pasteur/history}.
In 1865, Sir Joseph Lister, royal surgeon to Queen Victoria and “Father of modern surgery”, used the principles set out in Pasteur’s bacteriological science to develop antiseptic medicine and sterile surgical technique. The principles asepsis and sterility continue to be one of the pillars of modern medical practice.
In 1895, the discovery of radiation led to the manufacture of the first x-rays machines. This was quickly followed by blood-typing in 1901 and the first pharmaceutical drug in 1909. At this point, the practice of medicine had become a modern science, one that would change the lives of millions of people for the better.
However, the scientific advances in late 19th and early 20th century were not restricted to diseases and their treatments. This particularly fertile period included the invention of electric lights, telephones, the x-ray machine (1895), aspirin and understanding blood types (1901), first manned plane flight (1903), Model T Ford (1908), the Hoover vacuum cleaner, an early version of an automatic dishwasher, and in 1909, the first pharmaceutical drug to treat African sleeping sickness.
The great “leap forward” even more important than landing on the moon
For the very first time in human history, the combining of scientific knowledge with technical abilities and human ingenuity allowed medical doctors to consistently cure formerly fatal diseases and successfully treat injuries that used to be deadly. All of this stands on the shoulders of the dedicated physician-scientists who brought the “miracles of modern science” into being in the late 19th and early 20th century.
Over the next century, medical science expanded exponentially to included antibiotic drugs, chemotherapy, organ transplants, reattachment of limps, laser surgery to restore sight, DNA-designed drugs and genetic engineering.
This change also dramatically impacted hospitals who suddenly had to figure out how to bring the scientific practice of medicine to their hospital without breaking the bank. The best guess by historians is that US had about 8,000 small, doctor-owned 2 to 10 bed hospitals in the early 1900s. Relative to the modern practice of medical science, these small private hospitals they were still on 19th century time.
The last gasps of 19th century hospitals as they were dragged into the 20th century
Prior to the scientific era, the basic function of hospitals was providing “hospitality”, that is, a medicalized version of a well-staffed hotel that provided clean dry linens, three meals a day, and help to the bathroom or a bedside commode. Basic nursing function were done by non-professionals (often members of a religious order) who provided nursing care to bed-ridden patients, bathing them, changing bandages, emptying bedpans, and feeding patients too ill to feed themselves. This category of “palliative care” was typically provided to patients with chronic or terminal diseases or recovering from a debilitating injury. No matter how sick these patients were, scientific medical treatments such as IVs, blood transfusions or chemotherapy drugs were not a possibility.
But as the healing “arts” morphed into a very modern medical science during the first three decades of the 20th century, the nature of hospitals in America changed dramatically. Among the many “gifts” produced by medical science was a tsunami of must-have medical equipment, specialized supplies and eventually various medical technologies. Hospitals of any size that wanted to be “modern” had to figure out how to afford the purchase of capital-intensive equipment like x-ray machines and other new and usually expensive medical equipment.
Over the course of a few decades, many these small 2-to-10 bed hospitals that provided palliative and “end of life” care morphed into vibrant institutions in which the idea of “medical science” had become an active verb. This gave rise to many different forms of effective medical and surgical treatments, which meant the majority of its seriously ill or injured patients not only lived, but they walk out of the hospital on their own two feet!
But who pays the bill that medical science runs up?
Note-2-self ~Economics from the hospital’s perspective (i.e. NOT pts as paying customers)
Further more, I think the following rendition is redundant and should be melded together into a single topic
For all of their lifesaving and world-changing properties, these scientific discoveries and new technologies had a substantial economics downside for hospitals. As already noted, modern medical miracles don’t come cheap. This was particularly a problem for the 8,000 small, private, doctor-owned hospitals that suddenly found themselves in a time warp that relegated them to the Dark Ages! It was like they’d been were doing a brisk business in horse-and buggy transportation, only to wake up one day and see the streets filled with cars! What to do?
This brings us back to Dr. JWW and his vision. As mention to earlier, he saw two different but intertwined problems. The first had to do with those 8,000 small privately-owned hospitals that were so out-of-step with the times. In order to catch up, they needed to purchase the latest medical equipment and upgrade or remodel their physical facilities. Keep in mind that these hospitals were all “for-profit” businesses that depended on relatively well-to-do patients as paying customers. Unless they found a way to increase their revenue – more patients, longer hospitalizations, maybe a generous endowment from grateful philanthropist — these small hospitals would remain stuck in 19th century “healing arts” as providers of palliative treatments to the chronically and terminally ill.
From Dr. JWW’s perspective as Dean of a famous medical school, the second and more difficult problem was the desperate lack of “general” hospitals in the United States. These are large regional hospitals, like Johns Hopkins in Baltimore, that are equipped to provide comprehensive medical and surgical care to patients of all ages, all stages of life, and across the spectrum of serious illnesses and injuries.
He wanted to solve both of these problems and do so without depending, in any way, on government funding, which the medical profession was afraid would lead to unwanted government interference. So he began by trying to find or invent a way to privately fund the modernization of small private hospitals. He saw this as a gradual process in which each hospital would be able to slowly upgraded or remodeled their facility, purchase new or better equipment and generally improve their technological capabilities. He believed that a significant number of these smaller hospitals would gradually, over a few decades, grow into a well-equipped “general” hospital that was able to provide “comprehensive” medical and surgical services to patients of all ages and all kinds of medical problems in a particular geographically area of the country.
{{redundant{{ This brings our story back to Dr. JWW and his dream of modernizing these the 8,000 or so small privately-owned hospitals and eventually developing a nationwide system of acute-care “general” hospitals }}}}}
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Wrong place MOVE ~ For healthy childbearing women, this was the most profound change in childbirth practices in the history of the human species!
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Hospitals during the pre-scientific era ~ medical hotels that provided “hospitality” services
Prior to the modern development of medicine as a science, the services provided by hospitals had little or nothing to do with “curing” diseases. Hospitals were in essence medical hotels that provided labor-intensive “hospitality” services” to the ill and injured. This is where the word “hospital” comes from – a place of caring that provides shelter, a dry bed, clean sheets, and marginally-skilled workers who change the linens, served meals, help patients to the bathroom, give back-rubs and empty bedpans.
Then suddenly, in the space of 10 or 20 years, “modern medicine” came on the scene and turned everything upside down. What had been essentially “hospice” care for the hopelessly ill was (gratefully!) replaced by modern medical science, which has able to actually cure many diseases and successfully treat many injures that would otherwise have been fatal or left the patient crippled.
And yes, this came with a ‘down-side’ – actually a double down-side. First, the kind of hospital that was equipped and staffed to provide these new scientific cures and treatments was obviously a large and very capital-intensive enterprise and such places were exceeding rare in America at the beginning of the 20th century. The entire country only had a few dozen fully-equipped and staffed general hospitals able to provide “comprehensive” care – an emergency department and in-patient medical, surgical, obstetrics and pediatric services. The vast majority of these general hospitals were on the upper East Coast, Chicago, New Orleans, Denver and larger metropolitan areas on the West Coast.
In stark contrast, historians estimate that in the early 20th century the US had about 8,000 tiny, doctor-owned, two-to-ten bed facilities, most of which were housed in aging 19th century mansions or old hotels. Their most modern technologies usually consisted of electric lights, a telephone, a microscope and perhaps a used x-ray machine. But the era of hospitals as places that proved “hospitality” services was on its very last legs and soon fade away altogether.
The Double Whammy of Medical Science
For the very first time ever, revolutionary and life-saving medical breakthroughs – that mystical quality called “medical cures” – now existed. However, “medical miracles” didn’t come cheap! Hospitals were required to make big cash outlays – i.e. “capital investments”—in order to upgrade or remodel their facility and purchase the expensive medical equipment necessary for the scientific version of “state of the art” care. This made running a modern hospital orders of magnitude more expensive than the 19th century “hospitality-hospice” care provided by the typical 2-to-10 bed doctor-owned hospital as a for-profit business.
To provide the full ranges of medical services, a hospital had to have a clinical laboratory, an operating room, and a central supply department. To house these new services and specialty areas, many hospitals either had to remodel or add new building. Better equipment and new medical technologies became available every year, creating a miniature Tsunami of things that hospitals would need to purchase such as an x-ray machines, x-ray film, developer solution, surgical instruments, and autoclaves to sterilize supplies and equipment. The miracles of modern medicine didn’t come cheap
It’s not hard to see the problem this represented – theoretically 20th century science provided the knowledge-based, medical and technological equipment and professional skills that effectively prevented needless suffering and deaths, but this ability had not yet become a practical reality.
A primer in Hospital Economics
As privately-owned for-profit business, hospitals depended on their patients being personally able to pay their hospital bills. But hospital bills are not the same straight-forward financial transaction as the purchase of most other services. By definition, hospitalized people (i.e. patients) are sick, injured, crazy or infected with communicable diseases. As a demographic, hospitalized patients are not able to generate income. If they are really ill or injured, require a lot of intensive and expensive medical and nursing care. Even worse, a significant number of hospital patients die without having first paid their hospital bill.
Sick people are the very worst demographic to depend on as paying customers. As an economic adventure, it became increasingly clear that technically enriched 20th century hospitals could no more depend on 100% of the seriously ill or injured to pay 100% of the cost of their care. The conclusion was inescapable — there were not enough sick people (as paying customers) to support the 20th century practice of medicine as a technologically-enhanced medical science. As a result, many small and medium-sized hospitals were just barely squeaking by.
Another big issue ~ Most Americans have no access to emergency services and comprehensive medical care at a large regional general hospital
Unfortunately, economics was not the only “hospital-related” problem on Dr. JWW’s mind. The other big problem was a near total lack of access to general hospitals for the vast majority of the American population, which didn’t happen live in one of the populations centers where most of these big well-equipped hospitals were located. In that regard, the US was very different from industrialized countries on the European continent.
Dr JWW happened to be familiar and extremely interested in this issue of regional general hospitals. when he graduated from medical school in 1889, the US had only a handful. Shortly after that, he enrolled in a two-year clinical training program in some of Western Europe’s the most famous hospitals and was thunderstruck to discover that most European countries had regional systems of well-equipped and well-staff general hospitals. These large facilities were able to provide comprehensive health care to people of both genders and all ages, which included emergency care and in-patient medical, surgical, pediatric, and obstetrical services.
Compared to other developed countries, America was still a backward and undeveloped country in in the early 20th century when it came to “state of the art” hospital services. Unlike the regional hospital systems in Western Europe, the US had no reliably effective system for providing emergent or comprehensive medical and surgical services. As Dean of the Johns Hopkins School of Medicine, Dr. JWW understood the magnitude of these medical problems at a practical level, whether it was an absolute lack of emergency medical services or great delay in accessing appropriate care.
It was crystal clear to Dr. Williams that Americans desperately needed a nation-wide system of general hospitals able to serve patients where they lived, rather than attempting to transfer the critically ill and injured to a general hospital a 100 miles or a day’s travel away. This was the fate of all desperately ill or injured patients, such as a farmer with a badly mangled arm, a pregnant woman who was hemorrhaging, a child in critical condition with 3rd degree burns, or an entire family badly injured in an automobile accident. While they lay in the back seat or an open flat-bed truck, each one of them had to be transported over long distances while the frantic driver dealt with rain and snowstorms, poor roads, flat tires, and no gas stations.
Obviously, this was a really serious problem that called for a coordinated national response and serious efforts to close the gap between where people lived and where major hospitals were located. But in addition to the functional lack of regional hospitals, small and medium-sized hospitals needed to purchase modern medical equipment so they could provide new technologically-enhances services. This left all but a lucky few hospitals bleeding red ink in their effort to “keep up with the Jones”.
This always brings us back to the issue of hospital economics in America, and its “Mission Impossible” — the crazy idea that depending on sick people as paying customers was a viable “economic” model. Historically, this model has been proven wrong over and over again. Since St Laundy established the first public hospital in Paris in 600 CE, all the large hospitals in Europe were charity institutions run by Catholic Church or the State government. The reason was simple: sick people are a poor (pardon the pun) demographic to depend on as paying customers. As the centuries passed, it become increasingly clear that hospitals could no more depend on the seriously ill or injured to pay for hospital care than orphanages can expect orphans to pay room and board, or prisons can expect inmates to reimburse the costs of their incarceration.
The 19th century business model for those 8,000 small doctor-owned private hospitals was profitable only because the cost of running a small medical hotel was so very low. These establishments were staffed by 27-7 by one or two nurses and a bevy of unskilled “helpers” who cooked and cleaned and helped patient to the bathroom. Nobody was hooking patients up to a cardiac monitor, giving blood transfusions or starting IVs to administer chemotheory drugs. But in the technology-intensive 20th century, those same small hospitals suddenly found the deck stacked against them, as they worked harder and harder to keep up with improvements in the practice of medicine as a constant advancing science.
That brings us back Dr. JWW and his multi-part, multi-generational plan for privately underwriting the modernization of smaller hospitals and helping to develop a country-wide general hospital system in ways that would not provoke the ire of organized medicine.
As noted earlier, Dr. Williams’ dream was finding a way to help small and medium-sized hospitals upgrade their facilities and medical equipment and ultimately to finance a nation-wide system of general hospitals in the United States like the ones on the Europe Continent. However, as judged by American doctors, who generally were self-employed entrepreneurs, the European system was fatally flawed in two aspects. First was the previously mentioned “meddling” associated with government funding. This inevitably paved the way for large insular bureaucracies that rewarded stogy cronyism and punished ingenuity. But the real deal-breaker was that the medical doctors on staff at all these European regional hospitals were government employees.
That was the exact opposite of the practice of medicine in the United States, where the idea of a doctor being a mere employee who worked for someone else was insulting. Why spend years in medical school only to become someone else’s lackie? In America, medical doctors are not hospital employees, but independent practitioners that apply for “admitting” and “practice” privileges at area hospitals.
American doctors, born and raised in the land of the free, home of the brave, saw the practice of medicine as an “entrepreneurial opportunity”. They dreamed of coming up with an ingenious discovery or important new treatment that would advance the practice of medicine and ultimately make them rich and famous. The word “bureaucracy” had long ago been stricken from their own vocabulary and that of the American Medical Association!
A Renaissance Man and Visionary who dreamed big!
?? Dr. Williams’ solution to this classic economic dilemma — not enough paying customers to support the business model for a first-class hospital, and not enough first-class general hospitals to serve the American population — was to devise rather complicated plan with many different moving parts that was to play out over several decades.
Without access to tax-based system like those in Europe, Dr. JWW’s home-grown American alternative was an ingenious and coordinated two-part plan. First, he had to convince doctors who owned and ran small hospitals that they should rededicate their facility to lying-in services. Then he had to convince doctors who owned medium-sized hospitals to add a lying-in ward in some unused room or to remodel a former storage area.
Second, he targeted a very specific demographic – healthy middle- and upper-class white maternity patients whose families could easily afford the modest fees for hospitalization. This would in turn generate a large and dependable revenue stream. Whether theses paying customers gave birth in a tiny lying-in hospital or the lying-in ward in a larger hospital, the result would a handsome profit for the facility.
These plans were described in great detail by Dr. JWW in the 1914 “Twilight Sleep” book referred to earlier. It seems likely that publication of this book was part of his plan. Obviously his incredibly ambitious goal would require “spreading the word”. Doctors who owned small private hospitals, administrators of larger hospitals, and above all, wealthy philanthropists all need to know what the ramifications of this financial plan were for them. To make the many changes that were necessary, thousands of smaller hospitals over the country would need join in this plan for modernizing themselves by generating revenue via lying-in services for healthy well-to-do women. Eventually this would create a “trickle-up” effect that would result in nationwide general hospital system. @@@@@@@@@@@ ???
This began with his urging the physician-owners of these 8,000 small and medium hospitals to either become a stand-along “lying-in” facility or expand their hospital as Dr JWW suggested by remodeling “an unused room” and using that a lying-in ward. According to Dr. Williams, these laying in hospitals would ideally be placed “as uniformly, if not quite as abundantly, as schoolhouses and churches”, with at least one lying-in hospital in every country seat. Then these doctors, as owners and administrators, had to figure out how to get healthy middle- and upper-class white women to electively hospitalize themselves when they went into labor and have their babies in this new system of lying-in hospitals.
When it comes dependably filling up hospital beds, childbirth is the “king-maker”. Unlike illness, which is seasonable, and injury which is erratic and unpredictable, childbirth in this pre-birth control era was a force of nature! Having transported childbirth from the mother’s home to a local hospital, lying-in patients and the 14-days of postpartum maternity care, as well as housing their neonates in newborn nurseries, made lying-in services a dependable and year-round source of patronage that provided the bread and butter income for hospitals.
??? ???? The book mentioned earlier — “Twilight Sleep: Simple Discoveries in Painless Childbirth” – provided Dr. Williams with the perfect platform for expounding on everything that was dear to his heart. He began by describing, the new modern practice of American obstetrics as a hospital-based surgical specialty and a far better and safer replacement for replacement for the old-fashioned, and in his opinion, dangerous care provided by midwives in the family’s home,
In glowing terms, he
He returned again and again to the desirability of giving Twilight Sleep drugs labor patients and general anesthesia to all and ability and of the “new obstetrics” that gave and for all “deliveries”, a term for replacing the a of the mother herself “giving birth”.
As recounted in the book “Twilight Sleep: Simple Discoveries in Painless Childbirth”, Dr. Williams calculated that the average county in the US 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 talked into paying of it), it would create a solidly profitable business model for lying-in hospitals.
Taking the standard hospital stay for mothers, which was 14 days, and another 14 billable days for the baby’s admission to the newborn nursery, would generate a minimum of 9,800 patient-days every year. With this kind of dependable patronage, lying-in hospitals would be on their way to becoming a bigger and better equipped hospital, as Dr. JWW’s noted in just one example:
“… 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 aggressively soliciting) was to point out the many benefits his new system of lying-in hospitals, both economically and in regards to the new hospital services this system would provide to men and boys, infants and children and the elderly population. In other words, elective hospitalization of healthy maternity patients was the “seed corn” or “leavening” that would give rise to full-service hospitals 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.”
Over the course of a couples of decades, maternity patients became each hospital’s “cash cow” and without knowing it, money taken from the pockets of well-off childbearing families was financing the technological modernization of thousands of small and medium-sized hospitals and the slow development of a non-governmental system of general hospitals in the Unites States that eventually would mirror the comprehensive care of the European system, but not without bring the federal government and large and meddlesome bureaucracies into the picture.
In a remarkable bit of reverse engineering, he turned the story as we think of it today on its head. To our modern perspective, we see this as a “tail wags the dog” story, believing that the hospitalization of maternity patients was the result of the success hospitals had already achieved. Only after they became fully equipped and able to provide expert care to the ill and injured did the idea of electively hospitalizing maternity patents come about.
But actually, it was the baby business that made everything else possible!
Orphan looking for a home
TOPIC#16_p27-29_Dr. JWW’s two-part “Plan” ~ the Devil was in the details!
Dr. JWW envisioned a free-enterprise process that would turn ten or twenty percent of the country’s small and medium-sized privately-owned hospital into general hospitals over the course of a couple of decades. His two-step plan for privately funding a nationwide system of privately-owned general hospitals carefully avoided federal funding, which he knew would be seen by organized medicine as outrageous government “interference”.
This plan had two distinctive parts:
Part one focused on a system of “lying-in” hospitals in every population center with a population of 3,000 or more. This was to be accomplished by either opening new “lying-in” hospitals or having hospitals already in operation put in new “lying-in wards, and then figure out how to fill up those beds with the pregnant or laboring bodies of middle- and upper-class white women as paying customer.
This required the obstetrical profession to aggressively promote the patronage of families could afford to pay for a 14-day hospital stay, in addition to the doctor’s professional fee.
Part two was a very well-thought out plan for using the revenue stream generated by their lying-in wards. This new income was significant in amount and dependable. Since maternity patients are not “sick” in the classic sense, and they do not need any expensive medical services nor do they require time-consuming care provided by the nursing staff. With healthy childbearing women playing the role of “cash cow”, hospitals could upgrade, remodel, and expand their physical facilities, as well as buying capital intensive medical equipment and new technologies and best yet, better salaries for hospital administrators and the executive staff. What’s not to like?
Dr JWW sincerely believed, and no doubt rightly so, that a significant number of small hospitals would happily use the revenue from their new lying-in ward to modernize their facilities. Over time, some of them would develop into general hospitals and become part of the nation-wide system hospital care that was able to provide medical services in close proximity to where their patients lived. This ability to have the hospital be within reasonable driving distance would mercifully avoid the dangers and unnecessary deaths associated with trying to transport acutely ill and injured patients over long-distances in order to get this same type of comprehensive medical services but hundreds of miles away.
Dr. Williams’ plan was for small and medium hospitals to put in new ‘lying-in’ wards to be patronized by paying customers. Obviously, this required convincing this demographic of middle and upper-class women and their husbands that the much “better” and more “modern” way for “sensitive”, “delicate” and “intelligent” (i.e. white) women to have a baby was to give birth in the hospital under the influence of Twilight Sleep drugs and general anesthesia.
American obstetricians in general and Dr. Williams in particular, boldly promised these women that:
“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
.… 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 described earlier, part two this plan/scheme was to provide small and medium-sized hospitals with a new revenue stream generated by an annual aggregate of million white maternity patients for. The plan was 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.
This was half a century before doctors and hospitals began to be plagued by the specter of malpractice suits. And since healthy maternity patients are not sick, providing the traditional 14-day “lying-in period” (i.e. postpartum period) in the hospital’s maternity wards turned out to be extremely profitable.
After plowing the profits of ten or twenty years of lying-in services into upgrading the hospital building and acquiring “state of the art” technologies of the day – x-ray machines, ceramic-tiles operating room with overhead electric spotlights, microscopes and institutional autoclaves, many of these smaller institutions would have gradually turned themselves into a general hospital able to provide comprehensive medical and surgical services a significant segment of their state’s population.
TOPIC#17_p29-30_The Two Faces of Dr. J. Whitridge Williams ~ good for “progress” but bad for the healthy women whose fees for hospital births would be underwriting his “plan”
As an L&D nurse, OOH midwife, activist for normalized normal childbirth and an academic researcher for nearly forty years, I have come to know more about Dr. JWW than some of my own family members.
So far I have identified Dr. JWW as an extraordinary individual and acknowledged his many laudable achievements, as well as recognizing how badly the use need for a national system of well-equipped general hospitals. What I haven’t done yet is described the consequence of his predilection for using the elective hospitalization of heathy, wealthy middle and upper-class labor patients as a revenue-generating endeavor.
Here is where we change modes from describing what happened to looking for information about why things were done in ways were both irrational and harmful to many mothers and babies. The era of Twilight Sleep drugs, general anesthesia, episiotomies and forceps deliveries was the obstetrical standard of care from 1910 to 1980. During that 70 years, approximately 160 laboring women were given narcotics and scopolamine drugs, general anesthesia for the birth and their babies were extracted from their unconscious bodies with forceps. As note earlier, these were primarily healthy women.
Approximately 75 % of all pregnancies are normal and these mothers give birth at term to heathy babies. But 120 million mothers and babies were subjected to a harmful and unnecessry form of obstetrical care between 1910 and 1980. This resulted in a very high level of preventable maternal deaths — the US had one of the highest MMR of any developed country during this period. The US had three times higher MMR than Sweden.
These same narcotic and hallucinogenic drugs were passed to unborn babies via the placenta and umbilical cord. The result was an increase in perinatal deaths from the resulting respiratory depression. Other babies were born with profound mental and physical disabilities from oxygen deprivation or brain injury from the use of obstetrical forceps. This results in a physical brain injuries that can cause mental and physical handicaps including speech impediments, cerebral palsy, mental retardation and difficulty walking.
This bring us back to the questions I stated with: Why treat two identical demographics of childbearing women in two such different ways? Also why doesn’t the American obstetrical profession acknowledge the two different categories of childbearing women? These are healthy women with normal term pregnancies as contrasted to women with serious medical conditions and high risk pregnancies. The form of care required by women who are seriously ill or have a high-risk pregnancy is totally different than the form of biological and psychological support that best services healthy women with normal pregnancies.
So it’s time to take out our magnifying glass and our lie-detector and take a really close look at exactly what he is doing and its consequences for childbearing women and their babies.
What he was teaching as a professor of obstetrics at his world-famous alma mater and preaching as an act of personal influence was central to the formation of American obstetrics as an extremely interventive, hospital-based process. ???
Of one thing I’m certain — Dr. Williams did never set out to be a villain, even though his actions and influence resulted in a century-long tragedy for every healthy woman who was “routinely” put to sleep and delivered by forceps, and also resulting in the US having highest maternal mortality rate in the developed world.
Unfortunately, the dictionary definition of the word “process” doesn’t tell us anything about its ‘recipients’ – the healthy childbearing women who were on the receiving end of this “process” and what all of these “procedures” were like for them. For example the feeling of isolation and abonnement as you were forced to kiss your husband “good-by”, and maybe your mother and sisters too, at the swinging double doors to the L&D room that said in big black letters: No Admission ~ Authorized Personnel Only”. Or what it was like to be put in 4-point restraint, forced to lie spread eagle and flat on your back for your entire labor.
And these deceptively bland words “process” and “procedure” don’t tell us anything about the experience of the first-time mother who leaves her family behind as she enteres the L&D unit and those swinging doors close behind her as she is greeted by howls, distress cries and yelled obscenities coming from laboring women who have been repeatedly medicated with Twilight Sleep’s special mis of narcotics and scopolamine.
But the “really bad”, followed by the “even worst” is yet to come as the mandated procedures of that “normal childbirth” in healthy, well-to-do women are to be implemented one by one, staring with being “put to sleep”. This “procedure” starts by putting big black mask over the mother’s nose and mouth and forces her to breath the general anesthesia.
As soon as the laboring woman is knocked out, the next part of the “process” is to strap her legs in obstetrical stirrups. That’s when the ‘surgical’ aspect of the “new obstetrics” triggers a series of “surgical procedures”. The word “procedure” sounds bland and harmless, but we’re actually talking about having someone a pair of surgical scissors cut the one vaginia with. However, “performing the procedure of episiotomy” sound so much better, less “bloody” and so much more professional.
Then there is the “joy” of having one baby pulled of our bodies with forceps. This is mechanically similar to using a corkscrew to pull the cork out of a wine bottle, only obstetrical forceps have don’t a pointy corkscrew since they function like ice tongs. Obstetrical forceps, which are made of stainless steel, weigh about 2 pounds and have 12” long steel blades designed to “cup” the baby’s head. They are inserted into the mother’s vagina to grab the baby’s head between the two blades, hopefully without accidently damaging the baby’s head or face.
The next in this series of surgical ‘procedures’ calls for the OB to put on an elbow length sterile glove, and after inserting his hand in lower part of his arm in mother’s vagina, uses his gloved fingers to carefully detach the placenta from the uterine wall and draw it out of the mother’s body cupped in his hand. Last but not least, the doctor has to put back together what he cut when “performed” the episiotomy by suturing incision.
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I put his functional truth telling into 4 buckets – sins of omission, half-truths, little white lies and very big, very black lies!
Dr. Williams’ ill-considered interventionist policies for healthy women were first implemented in 1910 and quickly became the standard of care for the next 35 years. Before penicillin and other antibiotics became available in the United States in 1945, a total of about 25,000 newly delivered mothers died each year in the US, with 10,000 of those deaths due to the fatal infection of septicemia or “blood-poisoning”. From 1910 to the early 1950s, approximately 320 million childbearing women endured these unnecessary and dangerously invasive obstetrical procedures and three times more of them died than women who give birth in the England, Sweden and other countries where healthy women are cared for by professional midwives.
Best estimate from available mortality data is that fatal infections killed one million new mothers died of infection during this time, when the US had the second highest in the developed world. {editor’s note: the US currently has the highest MMR of all developed countries.} The routine use of obstetrical interventions including vaginal exams during labor, and all the invasive maneuvers involved in surgical procedures such as episiotomy, forceps and manually removing placentas were the major contributors to the high rate of maternal deaths from infection.
Note-2-self_ Move / replace printed version of this same topic and describe the plan for financing a nationwide system for general hospital as a “brilliantly idea that was terribly executed and the targeting of middle and upper class women ripe for “elective hospitalization” and massively interventive childbirth practices of Twilight Sleep drugs, gen anes, episiotomies, forceful and dangerous fundal pressure, forceps deliveries and manully removing placentas as a: “Terrible idea that was brilliantly executed!
TOPIC#20_p32_Dr. JWW: Brilliantly Executed Terrible Idea
A man whose big dreamed was to find or create private funding for a badly-needed nationwide system of privately-owned general hospitals
As a man of “vision”, Dr. JWW’s dream was much bigger and more important than just the practice of obstetrics. As a brilliant, talented, and basically honorable, man he realized that the United States
?? modernization of small hospitals — nationwide system general hospitals like those in Western Europe
While this better “system” obstetrics it was not restricted to it but included all aspects of what we now call “health care”. This includes timely access to doctors for simple diagnoses and treatment and hospitals for complex diagnostic procedures and other forms of complex care.
Orphan had the best of intentions, but ultimately what he did is best characterized as
The burden of those terrible idea – a process that worked perfectly for the medical profession – sabotaged normal childbirth in the United States for the entire 20th century and its burdens specifically fell on healthy childbearing women who had no idea that where they gave birth, the way they gave birth, the Twilight Sleep drugs, general anesthesia and “delivery” as a series of surgical procedures that including the routine use of obstetrical forceps, absolutely had nothing to do with them or with “best practices” when it came to normal childbirth, but the fact that their husbands or families of origin or spouses were wealthy enough to pay for hospital instead as part of Dr. J. Whitridge Williams “plant to –– was to finance the building of a national
???? Part 2 move to where is already discussed ~ American obstetricians believed that because they were doctors (i.e. not mere midwives), they had both a right and a duty to control all aspects of pregnancy and childbirth in the United States
TOPIC#21_p33,34_Part 3: Dr. J. Whitridge Williams, most influential obstetrician of 20th century, inventor of “elective hospitalization” for healthy, well-off labor patients as paying customers
While he was extremely skilled in his field, he also was a visionary with ideas that were not confined to the practice of obstetrics. His biggest and boldest dreamed was figuring out how to finance a badly-need nation-wide system of privately-owned general hospitals. This was Dr. Williams’ personal attempt to fix a very serious, often fatal problem, which was an appalling lack of general hospitals in the United States. This category is a medium to large hospital that is staffed and equipped to provide comprehensive care – emergency services, acute medical, surgical, obstetric, as well as pediatric and newborn services — to patients of both genders and all ages.
Compared to other developed countries, America was still a backward and undeveloped country in 1910 when it came to “state of the art” hospital services. The vast majority of countries in Western Europe had a government-funded regional system of well-equipped general hospitals for a couple of centuries, with costs evenly spread across the population.
However, this was quite a different story in the US. At the beginning of the 20th century, the best guess by historians for the number and kind of hospitals in America was about 8,000 privately owned 2-10 bed “boutique” hospitals sprinkled all across the country, (think of the tiny private hospital in the Downton Abby series) with only about two dozen general hospitals in the entire country; these were mainly on the upper East Coast, and large metropolitan areas such as Chicago, New Orleans, Denver, and a few large cities on the West Coast. Unfortunately, the vast majority of Americans lived in places with no ready access to comprehensive hospital services.
If you lived on a family farm in rural Kansas and your husband got badly mangled by a piece of farm equipment, or your pregnant wife began to hemorrhage, or your baby started having convulsions, the drive to the nearest general hospital (assuming you had a car) would be somewhere between 50 and 400 hundred miles, which is to say that you or your loved ones were doomed before you left home.
Dr. Williams was trying to figure out how to finance one or more well-equipped general hospitals in each and every state and do so without running afoul of the American Medical Association. While Americans all over the country desperately needed immediate access to general hospitals, the American Medical Association (i.e. AMA, circa 1847) was irrevocably opposed to any kind “government interference”. This included any kind of ‘government funding’, in any aspect of the practice of medicine, under any circumstances, no matter how dire. From the moment of its founding, the AMA was anti-government “interference”, insisting that only MDs (i.e. not government bureaucrats!) should make decisions about medical matters of any kind.
Leaders in allopathic medicine related to the practice of medicine as one of America’s best entrepreneurial opportunities, it was what American Revolution and political independence was all about – the freedom to be in business for one’s self, be one’s own “boss”, and “sky is the limit” when it came to future fame and fortune. The privately-owned doctor’s office, clinic, or small 2-to-10-bed for-profit hospital — was seen by medical doctors as the American dream come true. As a result, the AMA jealously protected its professional autonomy. This is the root of the medical profession’s intense protection of what they describe as the “sacred” doctor-patient relationship. Realistically, they are protecting the monopoly they have over all aspects of mainstream healthcare in the US.
From the AMA’s perspective, any kind of government funding, no matter how small the amount of money or how big or bad the problem, is that it would just provide a dangerous opportunity for the government and its bureaucrats to invade their well-fortified ivory tower and exert some form of control over the entrepreneurial practice of medicine hiding behind claims about the “sanctified relationship between a doctor and all his patients.
Dr. Williams knew the AMA would see any kind of state or federal government funding, which included a building national system of general hospitals, as government ‘interference’. Since he did not want to wake this ‘sleeping giant’, he knew his only hope was to “think outside the box” – way outside the box! And that is how he came up with an economically brilliant two-step “plan” that, over the course of a few decades, would generate a dependable revenue stream able to finance a nation-wide system of general hospitals as good or better than those in Western Europe. He laid out this unique plan, sometimes referred by him as a ‘scheme’, in a small, 128-page book entitled “Twilight Sleep: Simple Discoveries in Painless Childbirth” published in 1914.
TOPIC#22_p34-35_Inventing economic new categories for hospital patients, expanding and redefining hospital services
His first “outside the box” idea was to invent a new category of hospital patient – electively hospitalized healthy people for who being care for in a hospital is more “convenient” or, in the days before the idea of “out-patient services” took hold, provides access medical and technological equipment. Dr. Williams’ first choice was for this category (no surprise!) was healthy middle- and upper-class maternity patients as paying customers.
Second on his To-do list was to convince a significant number of the 8,000 doctor-owned, 2-to-10 bed boutique hospitals to add a “lying-in” service that would to be patronized by healthy, relatively wealthy childbearing women. Any industrious doctor could open a lying-in facility in a large house with several bedrooms, an older mansion or a small hotel. If the doctor and his business partners already owned a 2-to-10-bed hospital, they could remodel or upgrade a part of the building to include a small room for conducting the delivery as a sterile surgical procedure under general anesthesia, and a lying-in ward for newly-delivered mothers for the traditional 14 day “lying-in period” and a newborn nursery. He envisioned a time in the near future when these lying-in wards would be:
“as ubiquitous, if not quite as abundant, as libraries and school houses”
Ref: Twilight Sleep: Simple Discoveries in Painless Childbirth; 1914
In a nut shell, Dr. Williams’s economic plan would permit the typical private, doctor-owned small hospital to first go into the ‘baby business’ by putting in a “lying-in” (maternity) ward, and then to use the ample revenue it generated to expand, build and upgrade their facility, staff and services. in the pre-litigious world of the early 1900s (i.e. no worry about being sued) providing hospital services to healthy maternity “patients” was extremely low-cost compared to the expensive and time consuming medical and bodily needs of the seriously ill or injured. Fortuitously, the revenue stream produced by lying-in wards was almost pure profit.
TOPIC#23_p35_A Marriage Made in Heaven ~ Pregnant women and profitable maternity wards
Dr. JWW estimated that each lying-in ward could be profitable with as few as 350 births a year — slightly less than one labor patient a day. After giving birth, these new mothers would be moved to the postpartum ward and their new babies admitted to the newborn nursery. Each new mother and newborn would remain hospitalized for the traditional 14-day “lying-in period”. But the even better news for hospitals was just how cheap it was to provide maternity care to a cohort of healthy, relatively well-off women and their infants.
Healthy childbearing women aren’t really “patients” in the sense of being sick or disabled; this is what makes their elective-hospitalization so dependably profitable. Seriously ill or injured hospital patients required time-consuming nursing care, a nurse or nurse’s aide to feed them and empty bed pans. In addition to time-consuming hospital services, the very ill or injured need expensive medical and surgical procedures. Worst yet, really sick hospital patients often die without paying their bills. When compared to the intensive and expensive care of ill or injured patients, maternity services were uncommonly lucrative!
The realistic needs of new mothers were more in the category of a hospitality service – the kind of care provided by a nice hotel for maternity patients — dry bed, clean linens, fresh bedside water pitcher, occasion help to the bathroom, hot meals, breastfeeding tips for first-time mothers. As for the care required by their healthy newborns, the new mothers breastfeed their babies, changed diapers and comforted them when they cried.
TOPIC#24_p35_Healthy maternity patients as the hospital’s “cash cow”
According to Dr. Williams, each county in America had an average population of 20,000 inhabitants and annual birth rate of 35 per 1,000. This would is 700 births a year. He concluded that was:
“ample material for the patronage of a small hospital, located … at the county seat, if even a large minority of the women of the community can be induced to patronize it.”
He went on to calculate that if only half of those 700 mothers-to-be (i.e. 350) could be convinced to go to the hospital to give birth, it would provide a steady revenue stream that would the facility with a handsome profit. The math was simple – with an average postpartum stay of 14 days for 350 mothers (4,900 hospital days) and additional charges for 14 days of nursery for 350 newborns (an additional 4,900 days) the annual census for the lying-in ward alone would be a total 9,800 patient days each year, which meant 9,800 paying customers every year even for low-volume maternity service.
As the lynch pin for his economic plan of a nationwide system of general hospitals, this would allow the typical private, doctor-owned small hospital to first go into the ‘baby business’ by putting in a “lying-in” (maternity) ward. Then the income it generated could be used to physically expand and upgrade their facility, staff and services.
He envisioned a time in the near future when these lying-in wards would be:
“as ubiquitous, if not quite as abundant, as libraries and schoolhouses“.
TOPIC#25_p36_The Eagle has landed!
These lying-in wards and maternity departments allowed small hospitals on a shoe-string budget to upgrading their facilities and purchase new capital-intensive medical equipment such as x-ray machines, microscopes and industrial autoclaves. Gradual expansion in physical facilities and accruing more sophisticated medical equipment, if continued over time, eventually allowed these small hospitals to provide increasingly “comprehensive care” that would better serve their community, such as a clinical laboratory and emergency “room” for providing some degree of urgent and out-patient care.
But among those thousands of doctor-owned “boutique” hospitals, were a few that aspired to greatness by using the profits from the “baby business” to “grow” themselves into medium-sized general hospitals that would be able to provide emergency, medical and surgical services on a grand scale to the ill and injured of all ages their geographic region – and all without a dime of “government” money! This was the answer to his dream and would indeed save many lives!
Unfortunately, this was a two-edged sword for laboring women. In the blink of an eye, they found themselves transported from the familiar environment of their homes, surrounded by family, friends and the familiar face of their midwife and her helpers or an “old-fashioned” country doctor, all of which was replaced by unfamiliar, sterile and socially-isolating environment of a “No Admittance” labor and delivery unit that banned the presence of their mother, husband, sister or midwife.
TOPIC#26_p36-37_A brilliant plan that was terribly executed!
Dr JWW’s plan began with his “invention” of the brand-new category of elective hospitalization – a person who isn’t sick, but for various reasons its more convenience to receive care in as a hospital patient, and is able to pay the much higher fees associated with being hospitalized. Then he broadened this idea to include the elective hospitalizing of healthy, white, middle- and upper-class maternity patients as paying customers. This plan, which he sometimes referred to as a ‘scheme’, was published in the book: “Twilight Sleep: Simples Discoveries in Painless Childbirth”, in 1914.
What he was proposing as financial strategy for underwriting a national system of privately-owned general hospitals – was the brand-new and very eclectic idea of electively hospitalizing a healthy, relatively wealthy, demographic of childbearing women based on their ability to pay for giving birth in a hospital. This may seem more than little nutty to us today, but the records are plentiful and explicit in listing the goal (nationwide system of general hospitals) and included an elaborate story – a version of “build it and they will come” for convincing this wealthier and better-educated class of maternity patients have hospital births.
TOPIC#27_37-39_Somewhere over the rainbow, way up high, was a very big lie!
Dr. Williams’ verbal and written efforts to convince healthy, relatively wealthy women to leave their homes and families when they went into labor and go to the hospital, where they could expect to have a very nice “modern” birth, is where the good doctor left truth, honesty and his ethical principles far behind in the dust.
Dr. Williams’ economically-solid (if morally suspect) financial plan suddenly ran off the rails, to be superseded by a contrived and fanciful story that, amazingly, only applied to one single categories of childbearing women — the class of healthy and well-off women whose families could easily afford to pay for hospital care. He described this class of women, who just also happened to healthy, economically stable and able to afford the higher cost of a hospital birth, as remarkably “intellectual”, “sensitive”, and “delicate”.
According to him, only unfortunately class suffered from an evolutionarily fluke that left these women physically unable to tolerate the pains of labor and childbirth. Dr. Williams attributed this to “the evolutionary hot-house of civilization” that affected certain genes in white, well-educated, “intellectual”, “sensitive”, and “delicate types” of women. This total inability to cope with “normal” labor meant they would suffer intolerable levels of pain so severe that these women risked having a mental break down and needing to be admitted to an asylum for weeks or months, and possibly longer.
Certainly it was by sheerest happenstance that these women, and only these women, all suffered from this flue of evolution that combined with their “delicate sensibilities” left just this one category of women – healthy and well-off – unable labor safely unless they were first medicated during labor with Twilight sleep drugs and rendered unconscious during the birth with an anesthetic gas such as chloroform and ether. For women that already had a sizable family with several children and a newborn, this kind of mental breakdown would leave their husbands in a terrible bind!
In a one-two punch, Dr. Williams’ explanation, which appeared to be based on solid scientific evidence, and address the question of why this particular category of healthy and well-off women should “patronize” the local lying-in hospital when they went into labor. Unfortunately, absolutely nothing about this non-sense story was true, except that money would surely change hands and the hospital (not the mother, baby or her family) would receive the Lion’s share of the benefit form her elective hospitalization.
After convincing this large, educated and well-paying demographic and their husbands that they have some truly awful genetic abnormality, Dr. Williams graciously informs them that they need not be afraid. All they have to do is have their husband drive them to the hospital as soon as they go into labor, and they will be given repeated injections of Twilight Sleep drugs during labor. Later on they will be put to sleep with chloroform and their baby gently “lifted” from their bodies with forceps. This is where the Heavenly hosts floats down with their harps and start singing the Halleluiah chorus!
On a more serious note, the only “cure” for the imaginary condition that Dr. Williams concocted was for these women to go immediately to a lying-in hospital when they went into labor and be given the Twilight Sleep drugs morphine and scopolamine. Morphine is a narcotic that naturally depresses respirations and sometimes is associated with neonatal death from respiratory depression. Scopolamine is an amnesic and hallucinogenic drug that does nothing at all to diminish the pain of labor, but its amnesic effect means the new mother will not memory anything that happened of her labor, including any experience of pain.
Unfortunately, Twilight Sleep drugs are directly associated with the need to use four-point leather restraints on laboring women under their powerful influence. This combination of drugs are sometimes described as the pharmaceutical equivalent of lobotomy. When the baby is about to be born, the mother-to-be will be taken to the sterile “delivery room” and rendered unconscious under general anesthesia. As before, she will not remember anything about the birth of her baby.
Dr. Williams, and other influential obstetrician-compatriots, not only used these talking points to convince pregnant women to have Twilight Sleep drugs, which were ONLY available in a hospital, but also when talking to husbands and a radio audience. Surely husbands would do anything to avoid having their wives committed a mental institution simply because she didn’t have appropriate access to these sanity-saving drugs and chloroform anesthesia. Suffering this tragic break with reality would also mean leaving their husband with the 5 older kids and a newborn baby to care for while also trying to support his family. For husbands, this was an extremely effective incentive for making sure that “the little woman” was taken to the hospital the minute she had her very first labor pain!
Here are a few of these extraordinary pronouncements, a general blend of racism, misogyny, ignorance, and self-serving misinformation (‘alternative facts’ and many big black lies) that helped promote his plan to electively hospitalize healthy and relatively wealthy white women as the “cash cow” for modernizing the country’s private hospital system:
“… the sacred function of maternity … causes her months of illness and hours of agony”
“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.
… 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.”
“…. the cultured woman of to-day has a nervous system that makes her far more susceptible to pain and to resultant shock than her more lethargical ancestor of remote generations.”
“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 (white) 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?”
“…the wonderful effort … 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 (via repeated injection Twilight Sleep drugs morphine and scopolamine) p.12
“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.
“… 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.
TOPIC#28_p39_Concluding Remarks
The ludicrous idea that some pregnant women are genetically unable to tolerate labor and that issue always and only affects the affluent, is the same kind of big black lie as the obstetrical profession’s insistence that “midwives kill babies”. If the opposition to midwifery by the obstetrical profession were to get what they want – elimination of midwifery as a profession – the result would be an obstetrical monopoly that controlled all aspects of childbirth in the United States. Fortuitously, this has not (thus far) occurred!
Nonetheless, Dr. J. Whitridge Williams, obstetrician extraordinaire, is personally responsible for one of the biggest of big lies in the history of childbirth practices. In our own time, an equally big and black lie is that continuous electronic fetal monitoring (EFM) makes normal childbirth safer in healthy women with normal pregnancies. EFM does not do this in 2022, any more than Twilight Sleep drugs and general anesthesia made childbirth safer in 1910.
In actual fact, routine use of EFM provides absolutely NO benefit to the unborn baby, but its mother’s likelihood of having a medically unnecessary C-section and suffering serious complications went through the roof the minute the mother was hooked up to the EFM monitor standing next to her hospital bed. What also went “up” was the immediate, delayed and downstream risk of maternal morbidity or mortality associated with having had a Cesarean and having additional pregnancies and births after a previous C-section.
