WC 13335 Yikes
DRAFT VERSION
The “new” American Obstetrics as a surgical specialty, circa 1910
turned childbirth upside down, paving the way for the NEJM paper that recommended that vaginal birth be replaced by scheduled cesarean as the new obstetrical standard of care
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As a student of American obstetrics, its history and as an L&D nurse and professional midwife over the last half-century a personal witness of its practices, I believe the shockingly warped idea in this 1984 NEJM publication – the institutionalized and systemized idea of using “excess” maternal deaths as a strategy to reduce infant mortality. This was historically reprehensible, but right in line with our post-Roe world in which is promoting laws that choose death for the mother as preferable to termination of a pregnancy.
Guess it’s still true — the more things change, the more they stay the same!
The critical issues propagated and promoted in this “prophylactic Cesarean” paper are not really about Cesarean surgery per se, but about the dehumanizing and systematic exploitation of women. This can be traced directly back to the early 1900s, and the legacy of a handful of influential obstetricians of that era.
By far the most influential and prolific proponent of the “the new obstetrics” as a surgical discipline was the Dr. J. Whitridge Williams, the most famous and highly lauded American obstetrician of the 20th century.
Dr. Williams was the original author of “Williams’ Obstetrics” (now in its 27th printing). For the entirety of Dr. Williams’s professional life (1893-1923) he was employed by the famous and highly 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, and had a fine mind that greatly advanced the discipline of obstetrics in many important and life-saving ways.
But as a visionary, his ideas didn’t stop with 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.
NOTE-2-Self Critical background info on years immediately after he graduated from medical school and went to Europe to spent 4 years in two different clinical training (hands-on) programs in the biggest and best hospitals on the European continent.
This exposed him to the regional general hospital systems in most European countries open to all its citizens and able to provide comprehensive care 24-7-365 that included emergency services and in-patient medical, surgical, obstetrical, and pediatric care.
Dr. J. Whitridge Williams’s two-part plan to privately fund a nationwide system of regional general hospital owned and run by doctors that would put in new “lying-in” (maternity) wards for the elective hospitalizing of upper class white maternity patients, and then use the profits evenue generated by these chibirth services to upgrat and expaned their facilities
Dr. J. Whitridge Williams’s two-part plan began with encouraging small for-profit doctor-owned hospitals to all put in a new “lying-in ward”, which would creatw a new and dependable revenue stream for the hospital. This in turn would allow them to incrementally upgrade, remodel and expand their facilities. Over a decade or so a substantial percentage of these small hospitals would naturally “grow” into large privately owned general hopistals that the country so desperately needed and would be achieved without any “government money” that the AMA was so dead-set against.
He began by “inventing” the brand new category of elective hospitalization – a person who isn’t sick, but for various reasons believes its more convenient to be cared from in a hospital and can afford to pay the much higher fees associated with being a hospital patient.
Then Dr. JWW broadened this idea to include the elective hospitalizing of 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”.
What he was proposing – the elective hospitalization of a healthy, relatively wealthy demographic of childbearing women based on their ability to pay for being in the hospital — seems nuts and is easy to dismiss as some kind of smear campaign. But the records are plentiful in number, explicit in goal and included an elaborate blueprint for contriving a fanciful story for why this wealthy and better-educated class of maternity patients – often referred to as “intellectual”, “sensitive”, and “delicate”– that they, and they alone out of all categories of childbearing women, suffer from an evolutionarily fluke.
Being the product of what Dr. Williams describes as “the evolutionary hot-house of civilization”, this white, well-educated, “intellectual”, “sensitive”, and “delicate” affected certain genes that deprived them of the normal ability of women to tolerate the pains of labor and childbirth. This total inability to cope with “normal” labor means they will suffer intolerable levels of pain so sever that they may have a psychiatric break down and need to be admitted to an asylum for weeks, months, possibly much longer.
Dr. Williams not only uses this talking point with pregnant women, and his radio audiences, but also their husbands. He intimates that husbands would surely do anything to avoid having their to wives committed to a mental institution, since this would leave their husband with the 5 older kids and a newborn baby to care for while also trying to support his family. This is certainly one of the most effective (even if it is a lie) incentives for making sure your wife is taken to the hospital with the very first labor pain!
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, 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!
Dr. Williams is guilty of more than one “grey” lie, but there is no doubt that a genetic inability to tolerate labor that always and only affects the affluent is truly one of the top ten ‘big lies’ for the obstetrical profession, the other one being the silly idea that “midwives kill babies”.
If successful, it would result in an obstetrical monopoly that controlled all aspects of childbirth in the United States, while also (and fortuitously!) eliminating midwifery as a profession.
A Brilliant Plan Terribly Executed
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 (i.e., AMA, circa 1847) 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 it’s 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.
Reconciling the Irreconcilable — Learning to love the bomb?
Yes, we need to learn to love our maternity care system, dysfunctional as it seems. We need to own it, to think of it as ‘ours’, to believe that it can and will be returned to balance. We need to use our energies to transform our national maternity care policies and to reconfigure the system at its most basic and practical level. We need to promote ideas like
- Maximal results with minimal interventions
- Skillful use of physiological management
- Adroit use of medical interventions as necessary
- Fewest number of medical/surgical procedures
- Least expense
- Best outcome for mothers and babies
- Value to families – meeting their social, psychological and developmental needs as defined by the mother, father and others members of the family
The form of care recommended by W.H.O. for a healthy population integrates the principles of physiological management with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. This standard should apply to all categories of birth attendants and in all settings and include the use of standard obstetrical interventions to treat complications or if requested by the mother. When that is done, healthy women will no longer have to choose between an obstetrician and a midwife or between hospital and home. No matter who provides maternity care, they can be confident of receiving appropriate, physiologically-based care for a normal labor and spontaneous birth and having appropriate access to the best obstetrical services if or when they desire or require them.
Mind the Gap!
We rabble rousers believe that physiologically-based care should be the universal standard for healthy women with normal pregnancies unless the mother herself requests medicalized care. Many of us have worked our entire adult life to transform the narrow focus of our interventionist obstetrical system into a broad based maternity care model able to respond to the practical needs a healthy population. This is known as mother-baby-father friendly maternity care, thanks to the Coalition for Improving Maternity Services (CIMS).
But for all our idealism, enthusiasm and sustained effort, we remain locked out of the system by factors that are political rather than scientific. In the current configuration, we have to lose in order for them to win. The resurgence of independent midwifery and PHB was the result of our collective inability to make a positive impact on our hyper-medicalized system. We intended to meet just those specific needs the obstetrical profession couldn’t re address or wouldn’t acknowledge. None of us expected to create a free-standing parallel system of midwifery education and practice that remained permanently outside and separate from the health care system. Apartheid is never a satisfactory situation. Any one who gets pregnant or provides services relative to pregnancy and childbirth knows all too well that it is impossible not to be drawn back into the fray.
Even more than our frustration as activists, we continue to be personally affected by the painful schism between our values and our on-going experience of interventive obstetrics as applied to healthy women. Speaking as someone who has been doing this since the 1960s, when twilight sleep and episiotomy was still mandatory and universal, our activism has not been a happy or successful endeavor. Yes, we have won a few battles and I am grateful for that, but it is an illusion of progress. Added to our individual pain and collective experience is the expansive time frame for a dysfunctional system that manages to change but never actually fix the problem. For the entire 20th century and the first decade of the 21st, women and families have been swept along a conveyor belt that often took them to places they did not want or need to go.
The routine use of narcotics, scopolamine and general anesthesia in the1960s (over 90%) has simply been replaced by a 90% epidural rate; the routine use of forceps has been replaced by the liberal use of Cesarean, which is at 32% and still climbing. Birth is still conducted and billed as a surgical procedure. A monolithic obstetrical model continues to be characterized by routine interference in normal biology (such as routine inductions), unnecessary interventions mandated by liability issues or physician preference.
The risk of childbirth-related morbidity and mortality can be time-shifted, place-shifted and person-shifted, but no matter how much risk and cost-shifting is done, bad outcomes will never be totally eliminated. There is nothing that can be done or purposefully not done that can reliably, ethically and with economically sustainability reduce risk to zero for both mother and baby 100% of the time. In other words, increasing rates of pregnancy termination @ term via induction and Cesarean section may in some cases reduce perinatal morbidity & mortality rates but it does not reduce maternal m&m. Painful, invasive or humiliating procedures that we neither need or want continue to performed on our clients, our loved ones or on ourselves. We stand by helplessly as influential members of the medical profession and the media promote the idea of scheduled induction and elective Cesarean as the 21st century standard of care. We have been losing the intervention war for the last 100 years.
As members of consumer and professional groups working for mother-baby friendly maternity care, it’s impossible not to get angry about this. It’s hard to be generous in the face of such daunting circumstances. But if we let our anger divide us into eternally warring camps, we will spend our time perpetuating instead of fixing an out-of-balance system.
What we need is a change of heart, starting with an acknowledgment that none of these groups – mothers, midwives or obstetricians — asked for these contentious problems. Contemporary obstetricians inherited a difficult situation not of their own making. They were schooled by a system that taught female biology as destiny when it comes to reproductive. Childbearing is seen as an undependable patho-physiology that uses women up the way salmon are sacrificed during spawning. In must be remembered that without prenatal care and access to modern obstetrical services for those who develop complications during pregnancy or childbirth, high mortality rates are indeed the rule.
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Keep moving down @@@@ Before hospitals had to worry about protecting themselves from malpractice lawsuits, the addition of a delivery room and a postpartum ward for healthy new mothers and babies was very profitable. Since these women were not sick, all the hospital had to do was provided a dry bed, clean linen, three meals a day and a nurse to answer their questions or help a mother breastfeed for the first-time. During the traditional 14-day “lying-in” period, these maternity patients spend theirs days lying around with their babies while chatting and swapping gossip with other new mothers in the typical 8 or 12-bed maternity ward.
This may seem outlandish, but the records of this movement plainly state its outrageous goals, plentiful in number and the published blueprint for creating an obstetrical monopoly over all aspects of childbirth in the US confirm this conclusion and are available in the have been in the public domain. 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 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!
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!
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USE In the early 20th century, hospital maternity wards were the cash cow that took the place of federal money, allowing hospitals to slowly “self-finance” the country’s grid of general hospital. As the century moved on, our private- or corporate-owned hospital system realized that happy maternity patients were one of the best (and free) forms of advertising for their hospitals, as it was determined that women made 70% of the family’s decisions about medical care. If they had a “good” experience with a particular hospital, which included the story of how their life, or that of their baby’s, was saved by an emergency C-section!) then they would recommend one’s hospital to other family members, friends, neighbors, and social circle. This free advertising from maternity patients was pure gold from the standpoint of the administer, as measured by the hospital’s increasing daily patient census.
USE A statistic published in the 1990 on hospital profits clearly identified the extreme profitability of maternity wards compared to other categories of hospitalized patients. The profit margin on a dollar received from a maternity patient was 38 cents, the hospital’s profit on a cardiac patient was only 5 cents.
such as x-ray machines, clinical laboratory equipment, ceramic-tiled operating rooms with large overhead spot lights and large institutional autoclaves, as well as mundane items such as hospital beds and surgical instruments.
Since 1847, our allopathic medical system has been dominated by American Medical Association. Two of AMA’s primary goals has been preventing government “interference” in the practice of medicine and restricting the number of MDs that graduate from medical schools each year so the demand will always exceed the supply, which makes medical practice reliably profitable.
Fetus as the obstetrical profession’s Primary Patient – Williams Obstetrics, 1974
Another historical incident indictive of the obstetrical profession’s general lack of understanding or sympathy for childbearing women, came about with the 1974 publication of the 20th edition of Williams’ Obstetrics, a 1,547-page obstetrical textbook.
The book’s foreword enthusiastically welcomes the budding new technologies of obstetrical ultrasound and electronic fetal monitoring as finally providing the obstetrical profession with the tools they need to make the fetus the obstetrician’s primary patient.
According to the textbook’s many authors, the obstetrical profession had been long seeking this goal, and obstetricians were so obviously pleased to announce that it had finally, through the miracle of modern medical technology, the fetus as primary patient had become a reality!
However, as a brief historical aside, I must report that the authors apparently did not have the last word on the information presented in this edition of Williams Obstetrics. Under the letter “C” in the index of the 20th edition is an entry that reads:
Chauvinism, pages 1 to 1,547
No doubt this was an unauthorized addition made by an anonymous print shop employee and undoubtedly a childbearing woman who’d personally “been there and done that” and knew misogyny when she saw it!
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~© Obstetrical Profession as represented by the state chapter of the American Medical Association shuts down a successful hospital-based Nurse-midwifery program providing physiological management of normal birth to low-income women and reducing perinatal mortality in this cohort of women
Hospitals began counting on their lying-in wards to generate a steady revenue stream that made 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 paid for gradually upgrading and expanding their facility.
The undeclared medical experiment in normalizing childbirth as surgical procedure is not the only instance of the obstetrical profession working against evidence-based scientific principles. In 1963, lobbyists for the American College of Obstetrics and Gynecologists {ACOG) actually stopped a nurse-midwifery program that provided physiological management of normal childbirth in the hospital.
From July 1960 to June 1963, a pilot nurse-midwife program established at Madera County Hospital in California that served mainly poor agricultural workers. During the three-year program, prenatal care increased, and prematurity and neonatal mortality rate decreased at the county hospital.
After it was discontinued by the California Medical Association, the neonatal mortality rate increased even among those women who had received no prenatal care. This suggests that the intrapartum care by nurse-midwifes may have been far more skillful than delivery by physicians. Prenatal care decreased while prematurity rose from 6.6 to 9.8% and neonatal mortality rose from 10.3 to 32.1 per 1,000 live births. The study concluded that the discontinuation of the nurse-midwives’ services was the major factor in these changes. [Levy, et al, 1971].
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????? MOVE – Where????? The early the 20th century was a very unique point in the two-thousand-year long history of western medicine when, for the first time in human history, “palliative” medical care and fervent prayer was finally able to be replaced by science-based services that actually could cure disease and save lives. This was the result of technologically-based discoveries and inventions that brought about the harnessing of radiation for medical use via x-ray machines, new understanding of bacteriology, which required purchases of microscopes, and purchase of industrial sized “autoclaves” for sterilization instruments and everything ever touched by a patient.. into the newly-invented capital-intensive equipment that brought about –
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Make into a “stand-alone” file in “Pulitzer” folder
‘Vows of Silence’ ~ Mandatory for hospital L&D staff
Hiding the abusive nature of hospital labor wards was helped along by the big black letters on the swinging doors to the L&D ward that read: NO ADMITTANCE – Authorized Personnel Only.
No family members who was concerned for the physical and emotional well-being of their beloved wife or daughter was ever allowed to see what went on behind those infamous swinging doors – the abusive practices that were a routine part of elective hospitalization. Of course, no one, not even family members, would believe what a childbearing woman said about her experience in that House of Horrors while under the influence narcotics and hallucinogenic drugs.
The public was likewise screened off from the secret society of doctors and nurses who worked in hospital L&D units, and performed “baby-ectomies” every hour of every day as unborn babies were wrestled out of their mother’s unconscious body with obstetrical forceps – all in the name of safer, better, more humane care and the mirage of totally “painless childbirth”.
Only the hospital staff — the very L&D employees who administered these drugs and associated abusive practices — and who routinely carried out all those medically unnecessary operative deliveries were ever allowed to see what happened behind the closed doors of the labor ward. Yep, if you knock the mother out cold, she’ll never ever know what hit her, and just as “dead men tell no tales”, heavily drugged and unconscious labor patients are equally unable to point to those who committed crimes upon their bodies.
The stiff-armed policies of hospital labor wards remained a professional secret generation after generation after generation. Whenever their policies were challenged, an official hospital spokesman insisted that restricted access to the L&D ward was necessary to maintain the surgical unit’s sterility and prevent infections, allow nurses to do their jobs without distraction of visitors and to protect the privacy of laboring women from the gazes of men who were not their husbands.
It wasn’t until 1953 that a few brave L&D nurses blew the whistle on the “cruel and unusual” practices that were iron-clad hospital policy in virtually every labor ward all across American from 1910 to 1960 and in many small rural hospitals, until the 1990s. For the first time ever, these “tell all” letters were published in a popular women’s magazine and triggered a flood of letters from mothers who’d labored and given birth under these horrific conditions, with each woman recounting the substantial and/or sustained brutality she’d been subjected to while in labor or giving birth.
But even hundreds of letters published in a popular magazine with national circulations were not enough to abolish these practices, or even trigger a panel to “investigate” the systematic and institutionalized abuse of all laboring women in American hospital wards, so “the beat went on”, as obstetrics continued to insulate itself from any of the realities of the childbearing “patients” they served, but as a paternalist and myogenous profession, did not respect.
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An Undeclared Medical Experient ~ Normalizing Childbirth as Surgical Procedure Note to self maybe move to part two?
Dr. Williams publicly claimed that economically-secure white pregnant women were not getting enough narcotics and hallucinogenic drugs during labor, and not enough chloroform and ether during the birth, not enough episiotomies, not enough forceps deliveries, not enough manual removals of their placentas and not enough stitches after giving birth vaginally.
But as note earlier, Dr. JWW’s claims were not based on scientific evidence, but on a big, black lie invented by him to serve his two-part Plan (??). The central falsehood was companied by a bevy of less egregious lies and half-truths. Together, the false pretenses and lies of omission wove a dark and deeply menacing story that goes against our common sense, direct experience, and all the scientific facts of the 21st century. In plain English:
To replace the biology of normal childbirth in the affluent classes of white women with a series of obstetrical interventions, both medical and surgical, to be systematically employed during labor and normal childbirth as the new American standard of care for healthy childbearing women.
All this was unscientifically unproven, and dangerous in the early 20th century, and the current style of obstetrical interventions – particularly the routine use of continuous electronic fetal monitoring (EFM), prophylactic inductions of labor in healthy women with normal pregnancies and increased danger associated with the “liberal” and elective use of Cesarean surgery continues to be scientifically unsound and not evidence-based here in the 21st century.
The profession’s decision in the early 1900s to turn normal childbirth in healthy women into a series of surgical procedures was (and remains) a medical experiment that lacks any scientific evidence of safety or efficacy. Without the support of scientifically-valid conclusions, the obstetrical profession decreed that childbirth was to be defined as a surgical process attended by physicians with training in obstetrical surgery.
This medical experiment was conducted without the obstetrical profession publicly acknowledging the unproven and experimental nature of the policies and practices they had long been promoting as cutting edge in safety for American women. As a medical experiment, normal labor was turned into a hospital-based process that included repeated doses of narcotics and mind-altering drugs and the birth conducted as a surgical operation that included the frequently-repeated list of six major and independently dangerous medical surgical procedures – anesthesia, episiotomy, forceful fundal pressure, forceps, placental extraction, suturing the perineal incision.
During the pre-antibiotic era (prior to 1945) childbearing women were also not informed about the danger of lethal infection associated with hospitalization, which exposed these healthy women to the deadly bacterial diseases that lurked in every nook and cranny of hospitals. Bacteria in general and highly resistant strains that populated hospitals in particular were responsible for the virulent infections that accounted for 40% of maternal deaths. Instead obstetrical patients were told that if they would agree to elective hospitalization, they could trust their doctors and hospital L&D nurses to provide the very best modern, scientific, and state-of-the-art care. Simply put, this was a lie.
Perspective obstetrical patients were never provided with any of the information about their treatment that would now be legally required for a patient to provide “informed consent”. None of these routine interventions, either independently or as a unified protocol, had at the time, or in the hundred years since, ever been scientifically established to be (a) necessary, (b) beneficial or (c) safe to during the intrapartum care of healthy women with normal pregnancies.
One particularly egregious aspect of the way the virtually all-male obstetrical profession treated it women patients was the suturing of the new mother’s episiotomy incision while she was still unconscious and that is the infamous “husband stitch”. Doctors regularly sewed up the new mother’s vaginal incision “extra tight”, so the obstetrician would not have her husband coming back later and complaining to the doctor that:
“ever since my wife had the baby, having sex with her is like walking into a warm room.”
In the intervening 100 years, these policies and routine practice have been amply and repeatedly proven to be dangerous and have no redeeming value, either medically, socially or economically, when used as a protocol for obstetrical services provided to healthy women with normal pregnancies.
Instead they are:
- harmful
- unnecessary
- unproductively expensive
- dangerous when used on healthy women with normal pregnancies
Any contemporary obstetrician who employed these same protocols today would be stripped of his hospital practice privileges, the state medical board would revoke his/her license, and if s/he were sued, would be found guilty of egregious medical malpractice.
Two rationales used to explain and maintain the wrong use of obstetrics and increased rate of maternal mortality compared to developed in western European countries
Obstetrics is apparently the “Teflon” profession, as it continues to enjoy a special protection and freedom from accountability for the harm it does and the unproductive expensive it generates. Fifty percent of all births in America are billed to the federal Medicaid program and the rate of C-sections performed is higher for women who qualify for Medicaid than those who have private insurance, so this loosey-goosey system of very-low-to-no accountability for surgical interventions by obstetricians is easy and profitable.
The obstetrical profession obviously ignored or denied that the dramatical change it proposed in the early 1900s was radial, dangerous and indefensible. Instead it developed two rationales to be used by politically-influential obstetricians to justify this undeclared medical experiment.
The first was the “humanitarian” pitch that the act of categorizing childbearing women as surgical patients was simply a modern upgrade. As surgical patients, they would be provided with all the ‘advantages’ of “pain-annulling drugs” and “anesthetizing the patient with chloroform”. However, this rational left out the well-known fact that the invasive nature of hospital obstetrical care included more than a half a dozen surgical procedures.
Each one of these dramatically increased the likelihood of developing a life-threatening infection and the biological stress having several of these bodily assaults all at one time could easily overwhelm the body immune system and result in a massive infection. (Dr. DeLee’s 1924 textbook Principles and Practice of Obstetrics; look up page#),
Before the discovery of antibiotics, one of the major dangers posed by the indiscriminate use of obstetrical interventions was fatal infection. This kind of body-wide infection is often referred to by the lay public as “blood poisoning”. Its official name is “septicemia”, which is a life-threatening condition in which the bacterial load is so great in both in amount and virility that is causes body organs – kidneys, liver, lungs, heart, brain — to fail one by one until death intervenes.
If you study the statistics and other records for maternal mortality in American obstetrics you see the rate of maternal deaths climbed steadily upward in conjunction with the steadily increasing rate of hospital births from the early 1900s until the late 1930s. Then in the late 1930s and very early 1940s, the MMR begins to fall precipitously as a result of antibacterial sulfa drug, which was able to successfully treat many ‘hospital’ and ‘childbirth’ fevers. An even more dramatic drop in the MMR can be seen when the antibiotic penicillin became available in 1945.
After the availability of antibiotics, women exposed to these very same obstetrical interventions who developed “childbed fever” did not die because they could be treated with antibiotics. In essence, antibiotics made the indiscriminate use of obstetrical interventions “safer”, not because the interventions themselves were any safer or more useful, but simply because the harm they caused could be ameliorated with the administration of more drugs – in this case, the ‘wonder drug’ of antibiotics.
As citizens, we need to be especially skeptical when the use drugs and other medical and surgical methods become necessary to reverse or reduce the harm caused by the use of drugs and other medical and surgical methods.
The second justification for elective hospitalization of healthy maternity patients focused on the immutable fact that women who are expected to have a normal birth occasionally develop an unexpected complication requiring obstetrical intervention. In those case, obstetricians stressed the great advantage of having all “obstetrical patients” pre-emptively hospitalized even though only a small fraction of healthy women needed obstetrical interventions.
This not a medically valid reason for pre-emptive hospitalization, administration of drugs and anesthesia, performing forceps deliveries and placental extractions as the standard of care for 100% of the childbearing populations and doing so without patient consent. This treatment regime dramatically increases the risk of serious complications and maternal deaths, especially from anesthetics accidents (at the time the 3rd leading cause of maternal mortality) and postpartum hemorrhage due to placental extraction.
Consider what we’d think if a group of surgeons decided they would pre-emptively prevent breast cancers by routinely performing radical mastectomies on all adult women? This might would prevent the majority of breast cancers, but millions of unnecessary major surgeries each year would result in a great many iatrogenic complications and deaths in these patients, not to mention the physical and psychological harm to women themselves, burden on the healthcare system and economic expense to society.
Call to replace Vaginal Birth with Routine Cesarean Surgery ~
Unforgivable Insult to Logic, Reason & Childbearing Women
In 1985, a peer-reviewed paper was published in the prestigious New England Journal of Medicine by obstetricians George B. Friedman and Jennie A. Feldman ~ NEJM; May 1985, entitled: “Prophylactic Cesarean Section at Term?”
Its authors made a strong case for the routine use of “prophylactic” Cesarean at term as a way for the obstetrical profession to permanently eliminate the danger that vaginal birth can at times pose to the unborn and newborn baby.
The authors claimed this method for providing safer births to babies would entail only a small increase in the number of “excess” maternal deaths and “extra maternal mortality”. (p. 1266)
“….the number of extra women dying as a result of a complete shift to prophylactic cesarean section at term would be 5.3 per 100,000… [emphasis added]
… if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that a shift toward prophylactic cesarean section at term might save a substantial number of healthy infants at a relatively low cost of excess maternal mortality.” [emphasis added]
We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10 ….
Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure? [emphasis added]
….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery after fetal lung maturity has been reached? [emphasis added]
If a patient considers the procedure (i.e. routine CS @ term) and decides against it, must she then be required to sign a consent form for the attempted vaginal delivery?” p. 1267 [emphasis added]
The statement that strikes me as most absurd is the “probably” in this sentence:
“We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10…? ”.
If you really care about babies, the first and most important things you can do for the baby is to ensure the life and well-being of its birth mother. If society concludes that the mother’s life is “expendable”, I must ask: who will love, feed, care for, educate and raise the baby? In the real world, one in which single, divorced or widowed women frequently have babies, their orphaned children would be massively handicapped and become a financial burden to society.
Even if the birth father is able to both work and care for an infant, the death of one’s wife and mother of one child is both tragic and traumatizing. While the author describe their intentions as ‘protecting’ the lives of newborn babies, I suggest they think bigger than the baby’s 5-minute Agar and desire of obstetrical providers to avoid malpractice suits at all costs. These authors need to relate to newborn babies as having a long life beyond their hospital discharge sheet that lists them as a ‘healthy newborn’, because the very the best start in life for a baby is having one’s mother be alive and healthy.
New England Journal of Medicine – what were you thinking? or were you drinking?
But the bigger issue in this NEJM paper is far more than the stunningly stupid and offensive ideas of these two authors – that sacrificing childbearing women via “excess maternal mortality” as a way to contribute to the well-being of babies. After all, these are just the opinions of two people and not public ‘policy’. But unless they were meant as a Halloween joke by the NEJM, publishing such unspeakably vile opinions in the most prestigious peer-review medical journals in the United States is another matter.
Being a ‘peer-reviewed’ journal means these ideas were approved for publication by a significant number of other obstetricians, as well editors and other member of the NEJM professional staff. Approval and publications of a professional paper in the NEJM signifies that the ideas in it have been “vetted” as ethical, scientifically sound, functionally credible, to be considered seriously — in this case, that perhaps a system for generating ‘excess maternal mortality’ should become the standard of care in American hospitals. Really?
And perhaps even most inexplicable, there was no outcry by the hundreds of thousands of doctors who subscribe to the NEJM, university libraries all across American that subscribe to the NEJM, the public, the press or the broadcast media — zip, zero, zilch!
It seems to me that the warped ideas in this 1984 paper were only possible in the artificial world created by Dr. JWW’s 1914 business plan. His reason for electively hospitalizing affluent maternity patients had absolutely nothing to do with honestly serving the actual needs of healthy, wealthy childbearing women. Instead it all hinged on a lie – the actual purpose was to use income from thousands of medically-unnecessary hospitalizations to generate a dependable and profitable revenue stream year after year — an ATM that conveniently provided unlimited amounts of cash for turning small and medium-sized hospitals into general hospitals.
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!
@@@@@@@@@@@@@@@@ Temporary Parking / Barking lot @@@@@@@@@@@@@@@@@@@@@@@@
The excerpt below is from Dr. Guttmacher 1937 book “Into this Universe”, and describes the obvious dangers of using obstetrical interventions and invasive procedures such as forceps. He identifies a direct correlation between a country’s high rate of maternal mortality, compared to similar developed countries that rarely intervene in on physiological management typically by midwife between developed countries that in US that are associated with and noting the contrasting orders-of-magnitude lower MMR in Sweden, Netherlands, other countries where they do not “depend on artificial aid from steel or brawn” to drag the baby out.
“Though we cannot make an exact comparison between the maternal mortality in the United States and that in European countries, we can at least make a rough comparison. All who have studied the problem agree that the rate for Holland, Norway, Sweden, Denmark is far superior to our own.
Why? … it must be due to a difference in the patients themselves and differences in the way that pregnancy and labor are conducted in the two regions.” [1937-A Into the Universe by Dr Guttmacher, MD] p. 133-134
“What about the conduct of labor in the two regions? Here is where the major differences lie. In the first place, … at least 10 percent of labors in this country are terminated by operation. In the New York Report 20 percent of the deliveries were operative, with a death rate of more that 1 in each 100 of the operated, and 1 in 500 of those who delivered spontaneously. ” [1937-A Into the Universe; Dr Guttmacher, 1937]
“Let us compare the operative rates of these relatively dangerous countries (USA, Scotland) with those of the countries which are safer. In Sweden the [operative] interference rate is 3.2 percent, in Denmark it is 4.5, while in Holland ….. it is under 1 percent.” [1937-A]
“What is responsible for this vast difference in operative rates? … Analgesics [narcotic drugs] and anesthetics, which unquestionably retard labor and increase the necessity for operative interference, are almost never used by them in normal cases; and more than 90 percent of their deliveries are done by midwives unassisted.
And midwives are trained to look upon birth as a natural function, which rarely requires artificial aid from steel or brawn. [1937-A]