Excerpt:
Dr J. Whitridge Williams’ solution to the financial problems of American hospitals in 1914 — to promote the systematic “patronage” of healthy maternity patients — seems inexplicable at first glance.
Electively hospitalizing maternity patients was not because hospitals had been proven safer or better places for childbirth. In 1914, a third of the 25,000 maternal deaths each year in the US were from sepsis (childbed fever) in hospitalized maternity patients. During this post-germ theory, but pre-antibiotic era, not even Dr J. Whitridge Williams claimed that hospitalizing healthy childbearing women was primarily for their own safety.
While Dr Williams’ remarkable plan for the elective hospitalization of healthy maternity patients was a novel but nonetheless effective solution to the most troublesome issue plaguing hospitals in the US (but not in Europe) in the 20th century. This important healthcare problem was virtually invisible in Dr. Williams day, and has continued to be mostly unacknowledged in our own time.
Simply stated, sick people are the very worst possible demographic as a business model for any hospital that has to depend on its own ‘paying customers’ to keep the doors open and lights on.
The patronage of maternity patients had almost nothing to do with the biological needs of healthy childbearing women but everything to do with the financial needs of hospitals and the educational needs of the new surgical speciality of obstetrics and gynecology. Hospitals needed a business model that would provide a steady and profitable revenue stream, while obstetrical education needed dependable access to clinical teaching ‘material’. History ultimately proved that both of these situations could satisfactorily met by providing hospital-based maternity services to healthy women. (ref: “Birth Environments” 1982)
But these facts also have to be seen in the context of the time, which was the sudden and dramatic advances in medical science over the preceding 30 years. By the early 1900s, revolutionary discoveries in the new biological and physical sciences of microbiology, bacteriology, pharmacology, radiology, pathology changed the very fabric of society. The scientific practice of medicine was suddenly able to provide technologically-assisted diagnosis and effective cures for previously fatal or chronically painful and debilities conditions.
These scientific advances started in 1881 with the news that bacteria and other microscope pathogens had been proven to cause infectious disease and contagion. Pasteur’s “Germ Theory” brought about public sanitation law which dramatically improved the health of the population. His germ theory also lead to the discovery of aseptic principles and sterile surgical techniques by Sir Joseph Lister, which provided hospitals with effective ways to reduce to the spread of infection and made surgery a relatively safe.
This was soon followed extraordinary advances in physics (invention of x-ray as a medical diagnostic tool in 1895) and organic chemistry (first drug able to cure a disease in 1909). These and other early advances (such as blood typing and safer anesthetics) created the science-based discipline known today as ‘modern medicine’.
However, this required laboratory services, x-ray departments, operating rooms, and central supply unit to sterilize equipment and supplies, which in turn required hospitals to reorient themselves to the capital-intensive nature of “modern” medicine. Each new ‘medical miracle’ had it own expensive technology and equipment – microscopes, autoclaves, sterilizers, x-ray machines, tiled operating rooms, anesthesia equipment.
Every ‘state of the art’ piece of equipment purchased by the hospital came with a cascade of on-going expenses. This included office space, a specially trained professional staff and a plethora of specialty supplies – x-films, chemical developing solutions, lead aprons, petre dishes and glass slides, tanks of oxygen, sterile bandages, canisters of drop-ether, scrub gowns, oceans of antiseptics soap. This list was nearly endless, and would required hospitals to reorient themselves to the expensive nature of “modern” medicine.
As Dean of the Johns Hopkins University School of Medicine, Dr. Williams in a position to see the consequences this would have. He astutely realized that these revolutionary breakthroughs in scientific medicine depended on large capital outlays for specialized medical equipment far too expensive to be purchased by an individual doctor for his office, or a small privately-owned hospital.
A Hospital Revolution ~ from mere hospitality to power-broker for advanced medical technology
For the first time in the history of western civilization the classical function of hospitals changed dramatically and quickly. Historically it had always been the hospital building that was most important, since it served as a central location that put patients and providers of medical and nursing services together in one convenient place with running water and other basic necessities. During this stage of human history, the ability of medical doctors to diagnose diseases with jawbreaking Latin names far outstripped their ability to effectively treat these unpronounceable diseases.
Before the scientific era of medicine (pre-1881) there were virtually no cures for human diseases. With the exception of setting broken bones, the use of an herbal preparation of digitalis for heart conditions, opium-derived pain medications and a few types of minor surgery, medical care was primarily palliative and primitive by modern standards. Hospitals functioned as medicals hotel that housed the ill and injured, while providing hospitality (three meals and a bed, clean linens, someone to give back rubs and empty bedpans). Non-therapeutic support and opium medication was provided while waiting for nature to heal the patient, while palliative care eased the suffering of the elderly and terminally ill.
This new, scientifically-based role thrust 20th century hospitals into the forefront of what we now think of as “modern healthcare”. In this new paradigm, the hospital’s most important contribution was no longer just the building, but the administration’s financial purchasing power and its ability to house and organize expensive, specialized and sophisticated medical equipment and services, and providing a staff who was specially trained in its use. This core relationship with advanced medical technology is the crown jewel of 20th century hospitals.
But this new role also meant that running a hospital had just become ever so much more expensive (and simultaneously less profitable). Laboratories had to be equipped with microscopes and sterilizers; radiology departments needed pricey x-ray machines, lead aprons, oceans of photographic film and chemical baths to develop the x-rays. Last but not least, hospitals had to be remodeled to include new ceramic-tilled operating rooms equipped with OR tables, big spot lights and the latest in surgical instruments. Many of these new services also meant expanding or remodeling the hospital building itself.
While these laboratory equipment new technologies would themselves provide a new and profitable line of business for hospitals, the immediate effect was a miniature Tsunami in “must have” technologies. Obviously, the miracles of modern medicine did not come cheap! This was a big financial problem for the typical American hospital, which in 1914 was a 2-to 10-bed facilities owned and run by one or two doctors as a small business.
Dr Williams recognized the unique problem created by this new capital-intensive hospital system – a unique insight in 1914 that the American public and national policy makers have yet to acknowledge, much less address nearly a hundred years later. The idea is so simple it’s almost insulting – the very people that most need and benefit from capital-intensive, high-tech hospital services – the ill, injured, disabled – i.e., sick people – were the very least likely demographic to be able to pay these bills.
News Flash: ~ The ill and injured often died, or become so sick or disabled that they can never work again. Obviously any business model whose revenue stream depended solely on sick people to keep the doors open and the lights on would quickly go out of business. Think of billing school kids for educational services rendered, inmates to pay for their incarceration or the dead paying their own burial expenses. The blunt answer is just “no”, the lll and injured have never been and never will be a dependable business model.
In other developed countries, funding for hospital care was addressed in the same way they paid for military, police & fire departments, libraries, public schools and roads – by collecting small sums in the way of taxes from a huge number of healthy people.
But unlike Europe, the US did not have a national system of general hospitals, nor any kind of tax-supported system that could financially underwrite the huge expense of modernizing a system that consisted of thousands of privately-owned one-room hospitals. While these one-room hospitals were very numerous, they had very little medical equipment and could not provide state-of-the-art medical care to their own patients. Because they were for-profit businesses, they also did not provide emergency services to the general public.
Based just on the criteria in these two statements, well over 90% of American hospitals were pretty close to a total failure if judged by the sophisticated system of hospitals in Islamic parts of the Middle East, North Africa and the Iberian Peninsula (800-1100 CE) and the regional hospitals of Western Europe (after 1100 CE). It was obvious to leaders in the field of medicine in the US that our ill-equipped one-room hospitals needed to be upgraded and modernized, or bought out, merged so they could be turned into well-equipped regional hospitals that provided general medical services.
As already noted earlier, Dr J. Whitridge Williams’ goal was to make the same high quality of emergency and in-patient care already provided in Europe, and by big urban hospitals in the US (Johns Hopkins, Harvard, etc) available all across our wide country. While the implementation of these goals were very problematic for childbearing women, he was a visionary pursuing a very worthy goal and his insightful understanding of these complicated but very crucial times in the history of healthcare in America should be appropriately honored.
Who will pay, and where will the money go?
The controversy about who pays was the first problem. Should America have a national system in which a small annual contribution is made by every employed citizen to a tax-payer financed, government-run insurance fund ? Or should we have a private business model that required an often unemployed, and/or very sick or disabled patient, or family of an infant to personally pay an expensive hospital bill?
The second problem was what needed to be paid for and by whom? Should patients be billed only for the basis service provided to them personally, or should they also have to bear a share of the capital expenses of the system — the cost of building (or updating) hospitals and the equipping new facilities with all the bells and whistles required in the new era of technologically modern hospitals?
As for the question of how a hospital meets its expenses, there have historically been three organized methods: (a) charitable contributions provided by the king, private philanthropists, or the Catholic Church; (b) a tax-supported systems run by local or national governments; (c) depending on sick people as paying customers.
In the early 1900s, Europe had a national system of well-staffed general hospitals that provided emergency services and treatment all types of acute illness and injuries in patients of all ages, genders, and economic status. They also were able to provide high-quality clinical training to medical students.
These regional facilities were economically supported by a small annual tax on the entire population that went into a healthcare insurance fund that reimburse hospitals for services to individual patients. In the US we had a private, for-profit system which meant that sick and disabled patients were required to pay large hospital bill out-of-pocket, amounts that in some cases were more than the patient’s annual income. This privatized system also meant that the poor often had no access to emergency services or in-patient hospital care.
Logically, the European system seemed to be the better and certainly more humane choice, but it was not a viable option in the US. Organized medicine was organized around blocking anything that even hinted of a national, tax-supported system. As a political lobby the AMA had enormous influence over public health policy and would not tolerate any system other than the private (or corporate) ownership of hospitals, which they considered to be the bedrock of our free-enterprise system.
Until very late in the 20th century, a medical doctor’s private practice, which included medical offices, clinics, laboratories or small hospitals privately-owned and run by physicians, was the largest and most profitable category of ’small business’ (owner-run) in the US .
Dr. Williams’ solution to this economic dilemma — not enough paying customers to support the business model a first class hospital — was to devise a “plan” (sometimes referred to as a “scheme”) that would convince healthy middle & upper class white women to have their babies in a lying-in hospitals or lying-in ward in a larger hospital. According to him, lying-in facilities should be “as uniformly, if not quite as abundant, as schoolhouses and churches”, with at least one lying-in hospital or ward in every country seat and population centers over 3,000.
Unlike illness which is seasonable and unpredictable, and injury and major medical problems like heart attacks which are erratic and unpredictable, childbirth services (which also included the postpartum care of the new mother and nursery care of her newborn) were both predictable and steady. Regular hospital patronage by healthy maternity patients easily created a dependable year-round source of revenue that provided the sought-after stable income for hospitals, with a big enough profit margin to make those much anticipated capital improvements and purchased new equipment and medical technologies.
Using census records, Dr. J.W. Williams calculated that the average county had a population of 20,000 inhabitants and 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 (i.e., their husbands talked into paying a substantial hospital bill), it would create a solid economic basis for the business model of lying-in hospitals, which would: “provide laboratory, x-ray and other services necessary to provide for a well-equipped surgery department”.
Figuring the standard hospital stay for new mothers of 14 days, and a second billable 14-day hospitalization for her newborn’s nursery care, the lying-in ward would itself generate a minimum of 9,800 patient-days of business every year. With this kind of dependable patronage, lying-in hospitals would to able to generate the revenue required to finance a system of general hospitals and make possible the capital-intensive purchases of medical equipment this required.
Dr. Williams’ envisioned these well-equipped, well-staffed general hospitals becoming the center in each community for all aspect of its health and medical care. His plan to finance and organize a national system of well-appointed general hospitals started with, and depended on, the creation of lying-in hospitals all across the country.
He saw as a patient pipeline for a profitable business model that would completely revamp the way maternity care was provided, and change how the upper classes of society thought about the pain of normal childbirth. He also saw lying-in hospitals as an opportunity to improve obstetrical education by providing clinical training to medical students, and after graduation, employment for newly-trained physicians who were expected to replace the profession of midwifery.
Part One ~ Implementation of a Public Relations Campaign
Dr. Williams’ believed the demographic that could (and should) finance this hospital-centric healthcare system were native-born American women who were white, middle & upper-class, and educated. This segment of the population could afford to pay for such services. He also believed that such women would find hospital-based childbirth to be a great improvement compared to giving birth at home, since midwives they did not (and legally could not) give pain medication or anesthesia. He described childbirth under such ‘primitive’ conditions as:
“women bringing forth children in sorrow, quite after the ancient fashion, un-solaced 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.”
His plan for changing how the upper classes of society thought about the pain of normal childbirth was brilliant but also Machiavellian, a word that describes the “employment of cunning and duplicity in statecraft or in general conduct”. In this regard, it’s appropriate to disengage Dr. JWW’s “plan” for a nationwide system of fully equipped general hospitals, which was an important and very honorable goal, from the “scheme” (his word) he used to achieve his goals. His scheme depended on a PR campaign that dramatically misrepresented facts, provided dis-information and suffered a level of untruthfulness commonly associated with propaganda.
Having identified the upper classes of childbearing women as “paying-customers”, he set out to manipulate their beliefs about childbirth by systematically instilling fear by using a vocabulary that easily achieved the goal, describing the experience of childbirth as as marked by “agony, terror, torture, intense suffering, the most intense pain a human being can ever suffer, etc. He constructed a story for the public that misrepresented labor and birth in women of the upper classes (but only in economically advantaged while women) as so excruciating and intolerably painful it literally terrorized and helpless.
He also claimed that labor patients were sometimes driven mad and had to be committed to an insane asylum, which was a shocking thought for husbands. They imaged themselves being left with a newborn and several other small children and no wife to cook or clean or carry their other ‘wifely’ duties.
At the same time he repeatedly noted that this problem of pathological pain did not affect immigrants and poor working women.
Dr. Williams’ cited Darwin’s theory of evolution to explain the phenomenon of pathological pain in “cultured and intellectual types” of women. He ascribed this situation to the negative or “hot house” effects of civilization:
“Everyone knows that the law of natural selection, through survival of the fittest ,… does not fully apply to human beings living under the artificial conditions of civilization. These artificial conditions often determine that the less fit, rather than the most fit, individuals shall have progeny and that undesirable rather than the desirable qualities shall be perpetuated.”
…. “any trait or habit may be directly detrimental to the individual and to the race, and they may be preserved, generation after generation, through the fostering influence of the hot-house conditions of civilized existence.”
This unnatural level of pain was an ‘undesirable trait’ of evolution gone-wrong that (conveniently) only affected the affluent. He and other leaders of his day insisted that normal childbirth in these women caused mental or physical damage nearly 100% of the time, but hospitalization, medication and delivery under general anesthesia would be able to eliminate such problems. All he had to do was to convince these “delicate” and “intellectual types” of women to seek out elective hospitalized for normal childbirth, and get their husbands to agree to pay for such services.
It was not a coincidence that Dr. Williams’ PR campaign promoted the idea of ‘painless childbirth’ under narcotics and the Twilight Sleep drug ‘scopolamine’, hence his book “TWILIGHT SLEEP: Simple Discoveries in Painless Childbirth” (1914).
Part Two in Dr Williams’ PR Campaign ~ The “sacred function” of the white upper classes to “propagate the species”
Having described these financially desirable women as the “most delicately-organized” and ’’highly-developed, nervous and intellectual types”, he goes on to identify them as “precisely the individuals who should propagate the species and thus promote the interests of the race”.
This may seem like an odd choice to propagate the species, but many upper class men of Dr. Williams’ time (including Dr. Williams), feared the ‘browning’ of the American population due to the high birth rate amount black and brown ethnicities, and the flood of Irish Catholic immigrants. To Dr. Williams and those of like-mind, the answer was obvious — dramatically increase the birth rate among the desirable demographic of white, European, protestant, educated, and economically-advantage women. He and many others believed in the ‘sacred function of maternity’ for the female of the species, but in this case, a particular demographic of upper class women had a civic responsibility to out-populated the black and brown ethnicities and Irish Catholic immigrants.
Unfortunately for him, these “cultured women” did not agree. The very same group he identified as the most appropriate choice to “propagate the species and thus promote the interests of the race” often refused to have more than one or two children. A refusal by this demographic of women to fulfill their destiny — their “sacred function (and patriotic duty) of maternity” — was seen as general crisis that justified bringing out the big guns. For him, this meant using all necessary means including propaganda and he had plenty of ideas in that regard.
“Not-Tonight-I-Have-a-Headache”
In an era before effective contraception existed, Dr. JWW never mentions the other obvious issue — did refusing the “sacred function of maternity” also mean that such women were refusing to have sex with their husbands? He never says, so we will never know but its likely that husbands had a vested interest in seeing that the ‘little woman’ attended to all her wifely duties. It seem likely that he and other men would be grateful for anything that stacked the deck in their favor, even if it required a little collusion.
He frequently mentioned fear of childbirth-related pain as a major reason that so many women of the uppers classes were reticence to have more children. However Dr. JWW is never able to provide any statistical evidence that ‘pathological pain’ was responsible for the inadequate birth rate in this group. But his message to both men and women was clear — failing to be hospitalized for childbirth was to risk permanent psychic harm for women in this demographic.
Maybe the thought of feeding and caring for 5 or 10 kids was a bridge-too-far for these ‘sensitive’ and ‘intellectual types’. The actual answer is literacy — teaching women to read and write is the variable most associated with reduced size of families and improved economic conditions for their children.
But literacy did not factor into Dr. Williams’s “plan/scheme”, which was to guarantee the blessed “waters of forgetfulness” while laboring under Twilight Sleep drugs, and the blessings unconsciousness while giving birth general anesthesia” to women whose families could afford to pay for childbirth a hospital lying-in ward.
As part of a strategy to tip the scales toward a much higher birth rate by white American women, Dr. Williams assured the wealthy philanthropists that he was lobbying to fund his new lying-in wards that:
“… every patient who goes to the hospital may have full assurance that she will pass through what would otherwise be a dreaded ordeal in a state of blissful unconsciousness”
At least for another generation this would off-set the burgeoning birth rate of non-native, non-white immigrates by assuring that most ‘civilized’ women did their part to propagate the country with a genetically ‘more desirable’ population.
Dr. J. Whitridge Williams’ Legacy ~ a mixed bag but not all bad
In many ways Dr Williams succeeded beyond his wildest dreams — on his watch we began the process that eventually provided the US with a national-wide system of functional of general hospitals that are the rival of those in Europe, and yet he’s not remember for this extraordinary achievement.
As for his plant to re-program society’s thinking about normal childbirth, he certainly achieved that goal as well.
As medical science advances, and Dr JWW’s dream of nearly universal access to well-equipped hospitals became a fact of modern life, pregnancy and childbirth got progressively safer. Logically this should have reduce society’s realistic fears about childbirth, but paradoxically childbearing women become more and more afraid as the century progressed and a larger and larger percentage of them labored under Twilight Sleep drug and delivered under general anesthesia.
While Dr. Williams and others did a masterful job of vilifying the care of midwives, the actual elimination of the midwifery profession and access to childbirth services in any location other than an acute-care hospital were actually the collateral damage of this historical episode.
Given the undying and still extraordinary opposition of organized medicine, the thousands of ill-equipped one-room hospitals would never have coalesced into a nationwide system of well-equipped, well-staffed general hospitals without the revenue provided maternity patients.
Dr. Williams’ goal to finance a nationwide system of general hospitals was so obviously well intended, but unfortunately the unintended consequence of his PR campaign became part of a larger process that turned healthy women into the patients of a surgical specialty and normal childbirth into a surgical procedures.
Ultimately this new definition of childbirth as a pathological process that was so dangerous it justified any level of obstetrical intervention (including the casual use of Cesarean surgery) represents the most profound change in normal childbirth practice in the history of the human species.
Now is the time for us all to scream into our pillows in unison!
Additional comments by the good doctor:
“Nature provides that when a woman bears a child she shall suffer the most intense pain that can be devised! The pain of childbirth is the most intense, perhaps, to which a human be can be subjected. …the sacred function of maternity … causes her months of illness and hours of agony ….
“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.
“…. the cultured woman of to-day has a nervous system that makes her far more susceptible to pain and to resultant shock than was her more lethargical ancestors of remote generations.
… women of primitive and barbaric tribes appear to suffer comparatively little in labor, coupled with the fact that it is civilized women of the most highly developed nervous or intellectual type who suffer most.
Such a woman not unnaturally shrinks from the dangers and pains incident to child-bearing; yet such cultured women are precisely the individuals who should propagate the species and thus promote the interests of the race.
This seems to suggest that the excessive pains of childbirth are not a strictly a ‘natural’ concomitant of motherhood, but rather that they are an extraneous and in a sense an abnormal product of civilization.
Considered from an evolutionary standpoint, the pains of labor appear not only uncalled for, but positively menacing to the {caucasian} race.
…… any trait or habit may be directly detrimental to the individual and to the race and they may be preserved, generation after generation, through the fostering influence of the hot-house conditions of civilized existence.
Every one knows that the law of natural selection through survival of the fittest, which as Darwin taught us … does not fully apply to human beings living under the artificial conditions of civilization. These artificial conditions often determine that the less fit, rather than the most fit, individuals shall have progeny and that undesirable rather than the desirable qualities shall be perpetuated.”
The problem of making child-bearing a less hazardous ordeal and a far less painful one for these nervous and sensitive women is a problem that concerns not merely the women themselves, but the coming generations.
Let the robust, phlegmatic, nerveless woman continue to have her children without seeking the solace of narcotics or the special attendance of expert obstetricians, if she prefers.
But let her not stand in the way of securing such solace and safety for her more sensitive sisters.
Letting Dr JWW get the last words:
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.”
Ref: “TWILIGHT SLEEP: Simple Discoveries In Painless Childbirth”, 1914; as told to Dr. Henry Smith Williams, MD, JD (science writer) to Dr. J. Whitridge Williams, MD, Chief of Obstetrics, Johns Hopkins University Hospital and Dean of JH’s School of Medicine.
Reference: http://www.healthcare2point0.com/JWW-Quotes_Expanded_Aug2010.htm
http://www.healthcare2point0.com/JWWilliamsQuotes_OBOSversion_Aug2010.htm
