A Brilliantly ExecutedTerrible Plan ~ Dr. J. Whitridge Williams’ Goals, Motives & Dubious Methods ~
Information taken from “Twilight Sleep: Simple Discoveries in Painless Childbirth” by Dr. Henry Smith Williams (no relationship as far as can to determined. Today we would say this book was “told to Dr. H. S. Williams by Dr. J. Whitridge Williams to”.
At the time, Dr. H S Williams was more famous than Dr. JW Williams, in addition to being an MD, was also a JD and the most well-respected and popular science writer of the era. He and his brother published over 120 books that included extensive, multiple-volume tomes on topics such as The History of Science, (one of their best!). Here is link: https://en.wikipedia.org/wiki/Henry_Smith_Williams
The motive behind Dr. William’s decision to electively institutionalize healthy, well-off labors patients as paying customers as a new and dependable revenue stream for privately owned hospitals was just part of the systematic exploitation of women, which led to other a ways the female gender was dehumanizing of the female gender
A Terribly Executed Brilliant Plan
This small 128-page book outlined Dr. Williams’ economic plan to create a badly needed nation-wide system of privately-owned general hospitals to be financed by electively hospitalizing healthy, middle- and upper class maternity patients as paying customers. This was Dr. Williams’ attempt to fix a very serious and far-too-often fatal problem in the United States — an appalling lack of access to well-equipped and staffed general hospitals that were able to provide the emergency and acute-care medical and surgical services to patients of all ages. While his methods were very problematic (unnecessary interventions in the normal births of healthy women), his motives were honorable.
Compared to other developed countries, America was still a backward and undeveloped in 1910 when it came to “state of the art” hospital services. The 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, it was quite a different story in the US. At the beginning of the 20th century, the best guess by historians is about 8,000 privately owned 2-10 bed “boutique” hospitals sprinkled across the country, (think small village hospital in Downton Abby series) with only about (best guess) two-dozen general hospitals in the entire country and they were mainly on the upper East Coast, Chicago, New Orleans, Denver, and a few large cities on the West Coast. However, they were out of reach for the vast majority of Americans.
If you were a farm family living in Kansas and your husband got badly mangled by a piece of farm equipment, or your pregnant wife began to hemorrhage, or your baby had a high fever and started having convulsions, the drive to the nearest general hospital (that’s assuming you had a car) would be somewhere between 50 and two or three hundred miles, which is to say that you or your loved ones were doomed before you left home.
AMA turns a deaf ear and blind eye on the need for a national system of general hospitals
While Americans all over the country desperately needed immediate access to general hospitals, the American Medical Association (AMA) was irrevocably opposed to any kind “government interference”. This alluded to any kind of ‘government funding’, in any aspect of the practice of medicine, under any circumstances. From the moment of its founding in 1847, the AMA was anti-government “interference”, insisting that ONLY men who graduated from medical school and were MDs (i.e. not government bureaucrats!) were able to make informed decisions about medical matters of any kind. Total professional autonomy is the root of the medical profession’s intense protection of what they describe as the “sacred” doctor-patient relationship. Realistically, what they are protecting is their monopoly over all aspects of healthcare in the US.
In early 20th century America, the privately-owned practice of allopathic medicine– i.e. a doctor’s office, clinic or small 2-to-10-bed for-profit hospital — was seen by medical doctors as the American dream come true — what American Revolutions and independence was all about – the entrepreneurial 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.
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. J. Whitridge Williams Economic Plan – Brilliant but morally bankrupt
Dr. J. Whitridge Williams’ was making a genuine, and one assumes well-intentioned, attempt to meet these very real, often desperate, human need for “timely access” to comprehensive and life-saving hospital care. He was promoting a long-term financial scheme (his word, not mine) that would over the course of a few decades result in a new and functional system of acute-care general hospitals all across the country. The identified source of this revenue was the elective hospitalization of white, healthy, middle- and upper-class maternity patients as paying customers.
Dr. JWW’s plan promised doctors who owned one those 8,000 little 2-to-10 bed hospitals that the steady income generated by their brand-new lying-in ward would create a reliably profitable and self-sustaining revenue stream that could be used to finance the expansion and remodeling of the present facility to include one or more new operating rooms and purchase of capital-intense equipment such as x-ray machines, clinical laboratory industrial-sized autoclave necessary to transform itself into a medium-sized general hospital that served the acute medical, surgical, pediatric and obstetrical needs across a geographical area that could be accessed by car in less than an hour.
But for his plan to work, it had to be very carefully ‘finessed’ so as not to trigger any political landmines that would result in protracted opposition from the AMA. Equally important, the success of his scheme required some version of “build it and they will come” and that sales pitch had to “hook” husbands as well as “the little lady”. Both needed to be convinced, perhaps for different reasons, that a planned hospital under Twilight Sleep drugs and general anesthesia was the newer, nicer, more modern and all-around “better” way to have a baby, worth the considerable extra expense and inconvenience.
Luckily for Dr. JWW, the obstetrical profession embarked on a lengthy PR campaign in newspapers, women’s magazines and radio programs that convince many healthy, relatively wealthy women to be electively hospitalized for childbirth and the traditional 14-day lying-in period. The patronage of lying-in hospital ward and small lying-in hospitals by these paying customer generate such a dependable revenue stream that they became the “cash cows” hospital economics.
Unfortunately for Dr. JWW’s plan to produce a dependable revenue stream for expanding existing hospitals or building new ones, was to exploit healthy and wealthy white women achieved its goals by turning healthy women into the patients of a surgical specialty, labor into a medically managed ‘emergency’ that included Twilight Sleep drugs (morphine and scopolamine, which is both hallucinogenic and amnesic) and birth into a surgical procedure “performed” by the doctor on an anesthetized mother-to-be.
What has been historically defined for thousands of years as ‘normal childbirth’ was redefined by leaders in the obstetrical profession in 1910 to be a ‘pathophysiology. That would be a normal biological function that is normally abnormal. ’ As pathology, childbirth required a series of surgical procedures. This began by putting the laboring women to sleep with chloroform or ether and them putting her in obstetrical stirrups and covering her entire body with sterile drapes except for the five- by six-inch space over her genitals. Then the doctor routinely cut an episiotomy, followed by an extremely dangerous form of “fundal pressure” provided by the nurse to shove the baby farther down in the mother’s pelvis in order to help the obstetrician use forceps to extract the baby from its unconscious mother’s body.
As a surgical process, this new brand of childbirth as a pathology ended with the manual removal of the placenta. In order for the doctor to pull the placenta out with his hand (instead of waiting for it to be spontaneously expelled), he had to put on a special sterile glove with a long cuff that when up to his elbow. Then he insert his hand and forearm into the mother’s vagina so he could reach inside her uterus and peel the still implanted placenta off the inner surface of the uterine wall, grasp the separated placenta with his fingers and pull it out of the mother’s body. Last but not least was suturing of the episiotomy incision.
This was the most profound change in childbirth practices in the history of the human species!
bold, brave, innovative, and chief strategist for a brilliant idea that was terribly executed and resulted in hundreds of thousands of “excess” maternal deaths, as well as permanent brain damage and preventable deaths of newborn babies.
Dr. JWW’s economic plan identified
Dr JWW’s economic “plan” sa as a business and healthy, relatively wealthy, white childbearing
as remodel and
The kindest thing that can be said is that is was a brilliant idea terribly executed!
The “hook” was the classic claim that younger and therefore the more “modern” women shouldn’t have to put up with the bad old ways of the past. The “new obstetrics” as a new surgical specialty, told of these women in radio programs and women’s magazines that if they would just go to the hospital to have their baby, they would be given a shot that would not only make labor and childbirth painless, but they also wouldn’t even remember those awful hours of having to labor like farm animal and the degrading act of having to push a baby out of their vagina.
According to the “Twilight Sleep” book, they’d be given morphine and the drug “scopolamine” as soon as they got to the hospital and when it was time to give birth, they be put to sleep with chloroform or ether and the doctors would use forceps to gently life their baby out of their body and when they woke up from the begin “water of forgetfulness”, they wouldn’t remember a a single minute of moment of the .
the building of with the cost of would be underwritten by the “elective” of white middle and upper-class childbearing women as paying customers.
It may seem outlandish, but the goal of the obstetrical profession in the early 20th century was to control over all aspects of childbirth in the US. Published records of their plans for creating an obstetrical monopoly are plentiful in number and publicly available. The most influential proponent of the “the new obstetrics as a surgical discipline was Dr. J. Whitridge Williams, also was the most famous and highly lauded American obstetrician of the 20th century. As a visionary, he dreamed of a nation-wide system of privately-owned general hospitals to be financed by electively hospitalizing healthy, white, middle- and upper-class maternity patients as paying customers. In 1914, his plan, sometimes referred to by him as a ‘scheme’ was published in a book titled “Twilight Sleep: Simples Discoveries in Painless Childbirth”.
Dr Williams was the original author of “Williams’ Obstetrics” (now in its 27th printing). For the entirety of Dr. Williams professional life (1893-1923) he was employed by the famous and respected Johns Hopkins University Hospital. During those three decades he wrote “William’s Obstetrics”, was appointed Chief of Obstetrics, and then Dean of the Johns Hopkins’ School of Medicine. He was extremely skilled in his field, compassionate, had a fine mind that greatly advanced the discipline of obstetrics in many important and life-saving ways.
He dreamed big, and as a visionary, realized just how desperately the US needed a nationwide system of general hospitals like the ones Western European had developed more than two centuries ago. During the early decades of the 20th century, the best guess is that US had about 8,000 privately owned small hospitals (average of 2-to-10 beds) scattered all over the United States. Unfortunately, there were only a dozen or so big general hospitals in the US, mostly in NYC, the upper East Coast, Chicago, New Orleans, Denver and a few big cities on the West Coast. Most Americans live more than 50 miles, sometimes as much as 400 miles, from an acute care hospital.
Dr. JWW’s ultimate goal was a well-equipped, fully staffed general hospital in every population center with three thousand or more people. However, financing the project was the stumbling block because it was such a highly contentious and politicized issue. Leaders of organized medicine believed that entangling government money in privately-owned hospitals would be an invitation for the government to interfere in the practice of medicine, an anathema to be fought tooth-and-nail by the AMA. Dr. JWW would have to find a way to finance his dream without a drop of government funding.
- Electively hospitalization of healthy maternity patients as paying customers as plan for generating a profitable revenue stream for the hospital
Dr. JWW’s “work-around” for these political problems was to introduce the idea of “elective hospitalization” — healthy people as hospital “patients” for reasons of convenience. He chose as its first demographic healthy maternity patients as paying customers — middle and upper-class maternity patients whose family could afford to pay for a hospital childbirth services and the tradition 14-day “lying in” period.
Caring for healthy women as maternity “patients” in the pre-litigious world of the early 1900s (i.e. no worry about being sued) was extremely low-cost when 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.
The lynch pin of his 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 income it generated 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“.
A Man Molded by the Historical Racism and Misogyny of an Ignoble Era:
Unfortunately, Dr. JWW also was a “man of his times” – a fundamentally an honorable man living in an ignoble era, which is to say that the much revered icon of 20th century American obstetrics was a wealthy upper-crust white supremist who was blinded by his own misogyny (not to put too fine a point on it!). I’m sure he was nice to his wife and kids and a “good” doctor as defined by the time. However, he and his contemporaries inadvertently created a monster in 1910 by adopting as the universal standard of obstetrical care the highly interventive and invasive form of obstetrics as a surgical specialty that was originally developed and designed to treat abnormalities and serious complications, but now, with disastrous results, this dangerously invasive process was to be routinely applied to healthy women with normal pregnancies.
Practitioners of this interventive form of obstetrics convinced themselves that childbirth was a “patho– physiology”. Having declared childbirth to be a pathological process meant there was no such thing as “too much intervention”. The history of 20th century American obstetrics is to use more and more interventions at an earlier and earlier stage. Reminds me of the Zen Koan “Over-sharpen the knife and the blade will soon dull”.
Unfortunately, this aggressive form of obstetrics was systematically responsible for the preventable maternal deaths of more than a million mothers over the course of the 20th century, with 750,000 maternal deaths between 1916 and 1946. Having defined childbirth as “surgery”, the next logical step was to give labor patients general anesthesia for the “delivery”, so they’d be unconscious when the doctor used a pair of sterile scissors to cut an episiotomy, forceps to extract the baby and then reached up into the anesthetized woman’s uterus to remove the placenta.
It’s easy to see why 10,000 new mothers died of infection every year between 1900 and 1937, when antibacterial sulfa drugs first became available. However, the dangerous and unnecessary use of general anesthesia continued to be used routinely. In 1960, an obstetrical publication listed fatal “complications from general anesthesia” as the third leading cause of maternal death. It was still being used in the hospital where I worded when I resigned in 1976. This is what happens when “normal childbirth” is formally defined as a “surgical procedure performed by an obstetrically-trained surgeon”.
For more than a century, the maternal mortality rate in the US has always been 2 to 3 times higher than comparably wealthy developed countries and this excessive rate of maternal deaths has continued into the 21st century, only now its associated with increased use of Cesarean sections. Dr. JWW’s historic legacy can be seen in our current MMR, which is the highest in the developed world. We rank 128th out of 182 countries, right in the middle between the third world countries of Romania, Oman, Latvia, Moldova, Ukraine (United States), Turkey, Uruguay, Tajikistan, Saudi Arabia and Russia. We can take cold comfort for “beating the Russians”, but that’s not saying much!
Stand along text below is for later or elsewhere
Dr. J. Whitridge Williams as the main contributor to the 1914 book “Twilight Sleep: Simple Discoveries in Painless Childbirth ”
In 1914, a greatly admired, extensively published and eagerly read MD and JD science writer by the name of Dr. H. Smith Williams (no relation) interviewed Dr. JWW extensively in preparation for a 128-page book titled “Twilight Sleep: Simple Discoveries in Painless Childbirth”. I extensively researched the long and illustrious career of Dr. H. Smith Williams, and can say with confidence that Dr. HSW never before or after ever wrote a single word about childbirth, obstetric, the drug scopolamine or need for a nationwide system of general hospitals in over 200 of his publications. However, he and his brother did write a truly extraordinary 5-volumn “History of Science” which I highly recommend. It is available for free via the Internet Archive – Wayback Machine.
I believe the most likely explanation is that Dr. Williams privately engaged the services of this very talented and highly respected science writer in a joint effort to produce the kind of publication that today would be published under both names as an “as told by” book. In the book, the pronoun used when describing the source of information and activities of the obstetrical profession is always “we”. While Dr. JWW was not legally a co-author, his ideas are recounted in ways that clearly make him its “primary source”.
In the pages of extensively quoted conversations, Dr. JWW describes in great detail his opinions about the pain of labor in relation to “the cultured woman of to-day” and his assertion that so-called ‘normal childbirth’ had become pathological process in modern white women, a problem that he ascribes to “evolution” and the “abnormal” and “hot-house conditions of civilization”. This also includes the negative effects of higher education that made middle- and upper-class white women into “nervous intellectual types”. As a result, the “the cultured woman of to-day” had become more “sensitive” and “delicate” than their “primitive” and “barbaric” ancestors. He described normal childbirth as a “patho-physiology” (a type of biology that is normally abnormal), which he likened to Mother Nature’s cavalier process for spawning salmon that die after laying their eggs.
Dr. JWW spent considerable time on the American obstetrical profession’s new definition of itself as a surgical specialty, its plan to henceforth define healthy childbearing women as “surgical patients“ and to redefine normal childbirth as surgical procedure “performed” in a hospital by an obstetrically-trained surgeon on anesthetized women.
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.
In addition to Dr. JWW’s waxing poetic on the pains of labor and the wonders of chloroform, the majority of the long conversations between the two Doctors Williams were about Dr. JWW’s innovative economic model for financing a country-wide system of much needed general hospitals. The last (8th) chapter of the book is devoted entirely to his elaborate plea to wealthy philanthropists. The subheading of the very end of the chapter is “What a half million would do”, in which makes a case for why his alma mater and employer for the last 31 years Johns Hopkins, needs an endowment of a half a million dollars.
Government funding vs. the AMA
When Dr. JWW was recounting his economic “plan”, sometimes referred to as a “scheme”, in great detail, he began with his intention to scrupulously to avoid any “government” funding. Not only did he (along with virtually all allopathic doctors) see “the government” in as generally meddlesome, but the specific target of their theoretical and much trotted fear that the government would interfer in the “sacred” doctor-patient relationship”. In other publications by the AMA (Internet and elsewhere), one sees this supposed fear of government “meddling” in the doctor-patient relationship as a distraction or “mis-direction” that obscures the real issue.
Doctor-patient as a ‘sacred’ relationship is a code phrase invented by the AMA that refers to is a set of professional ambitions that became the bedrock of how medicine was practiced and how its status was defined in the US. This was a bifurcated concept that reflected a bone- deep desire by MD to never, ever be reduced to the humiliating status of someone else’s “employee”; would mean taking orders from someone else. Medical doctors are seen as the very pinacol of the food chain, which means At the same time they were running as fast and as far as possible from any situations that made then into someone else’s “lacky”, they were rushing to take advantage of that most American of all dreams – unlimited and unregulated entrepreneurial opportunity!
The second half of this equation set American doctors up to practice of medicine as independent entrepreneurs, with the assumption that “the sky’s the limit”! In the 1990s, a news program noted that the single largest “small business” in the United States was doctor’s offices.
Dr. JWW knew that American doctors all aspired to be both independent and to have one of those desirable “small businesses”. This started with working for one’s self, having an office and a few employees, including a nurse and a cleaning staff. But even bigger and better was to ownership (maybe a partnership) of a small private hospital in an older mansion with 2 to 10 beds and a small staff of nurses and other helpers. This preceded the current “group practice” but LLC of 6 to 12 OBs as a group practice that provides OB care under Medicaid to low-income women can generate annual profits north of a million dollars.
With this in mind, Dr. JWW knew the tiniest whiff of government money would trigger a deadly nuclear reaction by the AMA and end all possibility that the US would ever be able to match the marvelously functional European system of big, well-equipped and fully staffed regional hospitals. Having taken his clinical training in these same big hospitals in Vienna and Frankfort, Germany, he would have found it embarrassing to fall so far behind the many famous hospitals of Europe.
To skirt the contentious issues of government funding and AMA’s hair-triggered hysterical reaction, Dr. JWW did an “end run” around all that by introducing the brand new, previously undreamed-of-idea of “elective” hospitalization. Of course, the demographic was for elective hospitalization was the million or more healthy middle and upper-class maternity patients who gave birth every year and had husbands who could both afford and be convinced to pay for hospital-based childbirth services followed by a two-week hospital stay.
However, the joke turned out to be on medical profession, as the health insurance industry managed to do exactly what the AMA was most afraid of and did it in spades! Now doctors must get every aspect of the care they want to provide “pre-approved” by the patient’s insurance company. A for-profit insurance company clerk now stands squarely in the middle of that supposedly “sacred” doctor-patient relationship. God obviously likes a good laugh now and again!
Why healthy childbearing women or better for the hospital business that sick people
Hospitals have always been places of last resort for the critically ill, injured and dying starting with Hotel-Dieu, in Paris, France in 600 CE. When it comes to hospitalization, sick people are the worst possible demographic as “paying customers”. This is why virtually all hospitals from 600 to 1800CE (1,200 years) were all “charity” institutions supported by the State or the Catholic Church.
But Dr. JWW chucked this self-limiting model (depending on sick people as “paying customers”) in 1914 by proposing that we take a brand-new look at the economics of acute-care hospitals and think in creative terms of expanding their services to include a much larger and more dependable proportion of paying customers. Unlike illness, which is usually seasonable, and accidents, which are erratic in timing and frequency, childbearing women can be counted on to give birth every day of the year, all year round.
And wonder of wonder, every pregnant woman provides the hospital with a “second patient” in the form of newborn that is admitted to (and charged for) the hospital nursery. Couldn’t make that kind of a story up unless you were writing a science fiction script for Sigourney Weaver’s in “Aliens”!
As for the “build it and they will come” issue, elective hospitalization was promoted in local and national newspapers, radio programs and women’s magazines as the ‘better’ way to have a baby. It was also welcomed by most doctors, as it relieved them of middle-of-the-night house calls.
Elective Hospitalization ~ A better way to have a baby? Or greatly increased danger for their mothers?
Unfortunately, electively hospitalizing healthy women before the discovery of antibiotics was a really bad idea. Infection in a pre-antibiotic era was the most frequent cause of death for hospitalized patients. Childbed fever, now known as ‘septicemia’, was the most frequent cause of maternal deaths, accounting for about 10,000 women out of an annual total of maternal deaths of 25,000 (1900-1940).
Hospital birth in the United States did not become relatively safe (compared to early decades in the US but not as safe compared to Western Europe) until after sulfa and penicillin became available to the civilian population after WWII ended. Improved obstetrical safety was also the result of safer general anesthetics and the propagation of surgical skills developed by battle surgeons during WWII that were brought home and integrated into all the surgical disciplines, making surgery in general safer, including obstetrical operations such as Cesarean section.
A Reality Check ~
Dr. JWW’s “plan” for elective hospitalization healthy maternity patients had absolutely nothing to do with serving the actual needs (and preventing the deaths!) of these healthy, relatively-wealthy childbearing women. The ‘real-time’ (often desperate) need in the United States in the early 20th century was a nation-wide system of general hospitals able to provide emergency and in-patient medical, surgical, diagnostic services to all ages of acutely ill or injured patients in all geographical regions across our wide-open country.
Imagine that your family lives on a farm in Kansas and your husband or one on the children become desperately injured in a farming accident, or your 7-month pregnant wife suddenly begins to bleed profusely, but the closest general hospital is 400 miles away in another state and you don’t own a car! The 20th century advances of modern scientific practice of medicine are totally useless to those who don’t have any access to these life-saving services.
Over the previous centuries, a “regional acute-care hospital” model was developed and become the standard in most Western Europe countries. But as a 19th and early 20th century political ideal, our country never even aspired to the kind of comprehensive systems found in Europe. However, a few fully staffed and equipped general hospitals sprang up in NYC and the upper East Coast during the last half of the 19th and early 20th century. One of the most famous of those Johns Hopkins University Hospital in Baltimore, Maryland. It was financed by an exceptional generous endowment from a Quaker philanthropist by the name of John Hopkins, who used his wealth to establish a hospital that would provide care to anyone, regardless of sex, age or race. Johns Hopkins became and remains one of largest and most prestigious general hospitals in the country.
The Day the World Stood Still ~ when palliative care was replaced by medical science
Another important part of the economic story of hospitals during this era was the increasingly scientific practice of medicine whose therapeutic abilities were increasingly augmented by new and very effective medical technologies. The early the 20th century was a very unique pivot point in the two-thousand-year long history of western medicine when, for the first time in human history, “palliative” medical care and everyone’s fervent prayers was finally replaced by the “therapeutic” practice of medicine as the new standard of care. As a species, this new era of science-based services, which could and actually did cure disease and save lives, was the answer to humanity’s prayer!
This was the result of scientific and technologically based discoveries that quickly lead to the inventions of new medical technologies, many of which required purchase of capital-intensive equipment. Harnessing radiation for medical use required the hospital to purchase expensive x-ray machines the technology and supplies needed to develop the film; the new understanding of bacteriology required microscopes; fidelity to Louis Pasteur’s Germ Theory of Infectious Disease meant sterilizing instruments, and everything ever touched by a patient, which required purchase of sterilizers and industrial-sized “autoclaves” and a staff to run the show. Some of these newly-invented technologies were so expensive that hospitals would have to finance their purchase. But to stay competitive, hospitals had to purchase these “big-ticket” items, which made running a hospital of any size much more expensive.
Help Wanted: Ideas for financing a nation-wide system of general hospital without federal government funding
The most immediate and intractable barrier to hundreds of privately-owed general hospitals was economic – how do you finance a long-term national project of such magnitude without national financing? For the most part, regional general hospitals in Europe are government-financed, but the US still had “pay-to-play” model. (We still have a “pay-to-play” system.)
Dr. JWW spent considerable amount of his time and talents trying to find or figure out a way to generate a dependable and profitable revenue stream that would allow a significant number of small hospitals to remodel or upgrade their facilities and fund the purchase of capital-intensive medical technologies such as x-ray machines. According to the scantly records available on the number and nature of hospitals in the US in 1914, the “best guess” was approximately the 8,000 small, doctor-owned, 2-to-10 bed hospitals scattered all over the country. Most of these tiny institutions were housed in an old mansion and their ‘medical’ technology mainly consisted of electric lights and a telephone.
Creating a new nation-wide system of general hospitals all across America would require a significant portion of these small private hospitals to somehow turn themselves into a well-equipped and staffed general hospitals, with one in each community or region with a population of three thousand or more and to do all this without any government money.
However, one thing was very clear to Dr. JWW: Whatever “scheme” he came up with would not, could not include a single dime from the federal government. Those in leadership position in the AMA only saw the negative when it came to government funding. Not without cause, organized medicine equated government money was ponderous and meddling bureaucracies that would constantly interfering in the sacred “doctor-patient relationship” so it so jealously guarded.
Light at the end of the tunnel ~ an endless stream of healthy maternity patients as paying customers!
For Dr. JWW, the answer to his prayers turned out to be really simple, something that had been staring him in the face all along – an endless stream of healthy, white, middle- and upper-class maternity patients whose families could afford the modest cost of hospitalization for childbirth and the traditional 14-day “lying-in period in the hospital’s maternity ward. Over 2 million babies were born in 1914. If even a fraction of 2 million childbearing women – just a couple hundreds of thousands of paying customers each year — could be convinced to give birth in the hospital, Dr. JWW’s dream would have turned into a pot of gold at the end of his rainbow.
As recounted in the 1914 book Twilight Sleep, Dr. JWW’s “due diligence” included researching the demographics of the childbearing population, birth rates and the potential “patronage” for these new lying-in hospitals and maternity wards added to existing hospitals. He apparently studied demographic statistics for all the counties in the US and determined that the average population was 20,000, and that the average married woman had 6 children. From this he concluded that each country would have approximately 350 births a year.
When calculated on an annual basis, hospitalization for 350 lying-in patients, an equal number of newborns and average 14-day postpartum stay, came to an astounding 9,800 patient-days. Families would be billed the same daily room rate for the maternity ward as they would if they’d been desperately ill. This would be a total of 28 patient-days for 350 new mothers AND another 350 for their newborns. When viewed from their financial “bottom line”, hospital owners and administrators quickly realized that hospitalizing healthy people was much more profitable than acutely ill or injured.
Based on these statistics Dr. JWW had good reason to encourage each of those 8,000 tiny ill-equipped 2-to-10 bed hospitals to put in a new “lying-in ward” (i.e. maternity ward) in some unused corner of their facility, and then create various community events and notices in the local newspaper promoting its “patronage” as the new, better and much more “modern” way to have a baby, then sit back to watch the money roll in, and rarely would they be disappointed!
An unexpected benefit of the profitable revenue stream generated by lying-in wards was its ability to make up for financial losses in other departments of the hospital. It’s safe bet that more than one hospital administrator saw hospitalized pregnant women as the real-life answer to their prayers. But even more exciting from Dr. JWW’s perspective, this profitable income could and would pay for gradually upgrading and expanding their facility and way down the road, maybe even meta-morphasizing into a regional general hospital.
A Marriage Made in Heaven ~ Pregnant women and profitable maternity wards
Dr. JWW estimated that a lying-in ward could be profitable if they had at least 350 births a year, which is 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, which is what makes their elective-hospitalization so dependably profitable. Seriously ill or injured hospital patients required time-consuming nursing care, some to feed them and empty bed pans, plus medical and surgical procedures and more extensive, time-and-labor consuming hospital services. Worst yet, they sometimes died without paying their bills. Compared to the intensive care of ill or injured patients, maternity services were uncommonly lucrative.
The needs of these new mothers were more in the category of hospitality services, as would be provided by a nice hotel for maternity patients — dry bed, clean linens, fresh bedside water pitcher, 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. This is interesting, when you remember that the families of these maternity patients were also paying for nursery care but a lot of that was being provided by its new mother.
The Eagle has landed!
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. This kind of gradual “expansion” in physical facilities and more sophisticated medical equipment, if continued over time, eventually allowed these small hospitals to provide increasingly “comprehensive care” that would better serves their community, such creating an “emergency room” able to provide some degree of urgent and out-patient care.
Among those thousands of doctor-owned “boutique” hospitals, were many that aspired to greatness by using the profits from their maternity wards to gradually “grow” themselves into medium-sized general hospitals that would be able to provide emergency, medical and surgical services to the ill and injured of all ages their geographic region — 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.
The very positive reality that a system of general hospitals would provide to the potential patients of the as yet unbuild emergency department and operating room suites of these yet-to-be regional general hospitals was built on a simple but profound and self-serving lie — that normal birth was “the worst pain” any human could ever experience,
This was the result of a misogynist definition of childbirth by the most famous obstetrician of the 20th century, who had been employed for three decades by one of the most prestigious hospital in America – Johns Hopkins. During his metoric career, Dr. JWW had been Chief of Obstetrics for 10 years and in 1914 was Dean of Johns Hopkins’ School of Medicine.
and the corrupt and self-serving idea that healthy childbearing women should be isolated from their family during labor, medicated with morphine, and hallucinogenic-amnesic drug scopolamine and spend their entire labor lying in bed on their backs in a drug-induced state of semi-consciousness, and then be taken to an operating room, where they would be rendered unconscious with ether or chloroform while the doctor ‘performed’ a “baby-ectomy” via use of obstetrical forceps.
Instead, it all hinged on a lie. To replicate this successful European model in the US,
– the actual purpose was to use income from a million or more medically-unnecessary hospitalizations annually of healthy maternity patients as– a revenue stream that would generate a dependable and profitable revenue stream year after year providing revenue for slowly turning a significant portion of small and medium-sized hospitals into general hospitals.
From the institution’s “cost of care” standpoint, healthy maternity patients are the “cash cows” of hospitals as a money-making business. Compared to the expensive nursing care and other hospital services required by seriously and dying patients, maternity patients require little more than a than bed and board for themselves and their babies. As healthy new mothers, they can feed and take care of themselves and their babies, while paying the same the daily room rate as a cardiac patient that needed round-the-clock nursing services. But best of all for the “hospital business” maternity patients are the ONLY kind of patient that automatically brings the hospital “new business in the form of one (or more) new babies to be admitted (and charge a daily rate) to the hospital’s newborn nursery.
The logical, ethical and appropriate source of financing for general hospitals should have been the federal government. Dr. JWW’s unethical “work around” only became necessary because the American Medical Association was far more interested and committed to protecting the business opportunities of medical providers than safely and honestly meeting the actual medical needs of Americans.
While funding a general hospital system was a good thing for America, lying as the basic business model for hospitals was bad then and its bad now. Unfortunately, unethical thinking and slip-sliding around the truth got ‘baked into the cake’ of modern obstetrical care and poisoned the well for generations to come. The AMA needs to revisit its obstructionist policies and it’s not too late to replace Dr. JWW’s big lie with the simple truth – obstetrics is not meant for healthy childbearing women. Maternity care can and should work for everyone — mother, midwives, family practice physicians, obstetricians, hospitals, and the people who pay the bills should get what they are paying for!
