Birth Story

Abraham Flexner, the author of a report that re-structured American medical education, and his brother Simon, who headed up the Rockefeller Institute for Medical Research, were two of the most influential men of their day. But they owed their success to some degree to their older brother Jacob.

Jacob Flexner

Their father, Morris, lost his haberdashery business in Louisville, Ky., in the Panic of 1873. Jacob, an intelligent young man who hoped to be a doctor, was forced to go to work immediately to help support the family. He became a pharmacist, as close as he could get to his dream, and eventually owned his own store, according to an account by Ward O. Griffen MD in The Annals of Surgery.

“Upon that choice my whole subsequent career and those of others of our family have depended," Abraham Flexner wrote years later in his autobiography.

Jacob "was throughout his life a person of quick and remarkable intelligence, and he must have realized that we were all destined to humble careers unless at the first opportunity a break was made," Abraham Flexner wrote.

Jacob Flexner was a Louisville pharmacist, but he too played a role in the birth story.

After Simon Flexner dropped out of the sixth grade in Louisville, Ky., in the 1870s, his father, Morris, arranged a tour for him of the town jail, warning that if he didn't straighten out, that was where he would wind up.

But after Simon, the fourth of nine children, nearly died of typhoid fever at the age of 16, he found his passion — infectious diseases.

Simon Flexner

Flexner went to work as an apprentice in his brother Jacob's pharmacy, where he learned to use a microscope. Doctors he knew from the store gave him tissue samples for his self-directed studies in histology, the study of microscopic structures in tissues, and pathology.

At 26, he earned his medical degree from the two-year program at the University of Louisville. His younger brother Abraham, a recent graduate of  Johns Hopkins University, arranged for Simon to study pathology there under William Henry Welch, who was helping to bring the scientific method to American medicine.

Flexner became a microbe hunter extraordinaire, helping to suss out the causes of meningitis among Maryland coal miners, bubonic plague in San Francisco's Chinatown, and a common dysentery that is now known as Flexner's bacillus. He also played a critical role in the conquest of polio.

In 1902, Flexner became the head of the new Rockefeller Institute for Medical Research, and this is where the birth story intersects his own. Flexner assembled an amazing team of scientists that included Alexis Carrel, Peyton Rous and Karl Langsteiner who, among other achievements, brought blood transfusion to reality.

In 1899, John Whitridge Williams, whose name lives on in the definitive textbook on pregnancy and childbirth, succeeded Howard Kelly as the head of obstetrics at Johns Hopkins Medicine.

Kelly had split off baby-catching from the more interesting (to him) department of gynecology, which he continued to head up.

Williams, a Baltimore native, came from a medical family -- his mother's forebears had been doctors for 160 years. He trained at the University of Maryland, and then in Vienna, Berlin, and other European cities, which exposed him to a different way of looking at medicine.

Williams' Obstetrics, first published in 1903, and still in print today, came out of Williams' desire to render everything about pregnancy and birth in scientific terms. The first edition contained more than 1,000 references to other medical publications.

Williams wrote five additional editions of the book before he died in 1931, of complications from abdominal surgery.

The departments of obstetrics and gynecology were finally reunited at Johns Hopkins School of Medicine in 1960.

The 23rd edition of Williams' Obstetrics was published in 2009.

The founding faculty of Johns Hopkins School of Medicine comprised some of the most respected medical men of their era. All were innovators with rigorous standards of practice, research and training.

They set the bar high for other medical schools, and many of their graduates went on to establish or transform other programs around the country.

William Welch, who helped the university's president, Daniel Coit Gilman, assemble the team, was a pathologist;  William Osler, the internist who oversaw the department of medicine, was a Canadian considered the finest doctor practicing in the United States; William Stewart Halsted headed up surgery; and Howard Kelly, gynecology and obstetrics.

The original "Big Four" are depicted here in John Singer Sargent's "The Four Doctors," which hangs in the medical library on the Johns Hopkins campus.

At a time when individual doctors could be institutions unto themselves, Osler introduced the concept of the medical residency, and Welch a training program in advanced techniques for full-fledged doctors that resembled a modern post-doctoral course. Welch also founded the country's first school of public health. Kelly established his own cancer clinic.

Halsted taught his students to operate at a new level of skill and care, and was responsible for introducing the use of surgical gloves, which in beginning were meant merely to protect doctors' and nurses' hands.

The writer-humorist Calvin Trillin has said that his idea of alternative medicine is a doctor who was not trained at Johns Hopkins School of Medicine in Baltimore, Md. To the extent that Johns Hopkins is considered the gold standard of medical care, the institution's excellence owes much to its beginnings.

Johns Hopkins

Johns Hopkins, the son of prosperous Maryland Quakers (his first name was his great-grandmother's maiden name), made a fortune investing in America's first important railroad, the Baltimore and Ohio.

In 1867, he established funds for a university and hospital to bear his name, and when he died in 1873, he left $7 million for the two institutions, the largest gift ever bequeathed in America up to that point.

John Shaw Billings, a major in the U.S. army who had distinguished himself as a surgeon in the Civil War, and for his writings on, and criticism of, the care of sick and injured soldiers, created a plan for the hospital that reflected his keen interest in infrastructure, and his assiduous research into the best hospital designs in Europe.

John Shaw Billings

For example, he had the hospital wired for electricity years before it was on the grid. Johns Hopkins was also the first hospital in the country with central heating.

The measures Billings took to prevent the spread of disease throughout the hospital ranged from the horizonal layout of the wards, to the decision not to include elevators, to the elaborate ventilation system that prevented patients from breathing each other's air.

Billings also came up with the idea of a four-year medical school and favored a tough curriculum to weed out all but the best candidates. According the John Hopkins Medicine website, history has not given this remarkable man his due.

Getting the hospital up and running took 12 years. Even though many of the revolutionary ideas the institution embodied were his, Billings decided it was time to move on. He ended his career as director of the New York Public Library.

An early view of the hospital

Opened in 1889, Johns Hopkins Hospital had 17 buildings (three of which remain today, part of a 22-acre campus) and cost $2 million.

Johns Hopkins Hospital had no religious affiliation, which made some people nervous. In 1896, William Wallace Spence, a wealthy Baltimore businessmen, donated a large statue of Jesus Christ that still stands in the rotunda of the Billings Administration Building.

Allow me one more post on this last day of Women's History Month about Anne Hutchinson, the midwife in the Massachusetts Bay Colony who was banished to Rhode Island for heresy.

The pregnancy Hutchinson had been carrying during her civil and ecclesiastical trials turned out to have been probably the first hydatidiform mole, or molar pregnancy, in New England, according to a 1959 article in the New England Journal of Medicine.

This freakish obstetrical event, which occurs in about 1 in 2,000 pregnancies in the United States today (it is 10 times more common in Asia), happens when a pregnancy goes awry and turns into a mass of tissue in the uterus. The mass might grow for several months, and lumps of tissue might eventually be "delivered." Such a "birth" event would likely be upsetting to anyone, but given the beliefs of the time, it carried a dark judgment on Hutchinson's state of grace.

She was safe in Rhode Island, but the event was sensational news. Imagine the response of her nemesis, Gov. John Winthop of the Massachusetts Bay Colony, when he heard that not only had Hutchinson attended Mary Dyer's "monstrous birth," but now had also delivered one of her own.

I can't stop wondering how Hutchinson felt about this. Although the austere religion practiced in the Massachusetts Bay Colony never allowed anyone to take salvation for granted, according to Calvinism, God's favorite people should be easy to spot: They prospered in this life as well as the next.

Hutchinson herself had had a comfortable life in England, and even in Massachusetts she was a member of the church, the wife of a prosperous textile manufacturer and the mistress of an elegant home right across the road from Gov. Winthrop's, according to Selma R. Williams in Divine Rebel: The Life of Anne Marbury Hutchinson.

Yet her life in America was one catastrophe after another. Hutchinson was a deeply religious woman. Did she feel God's presence so strongly that she was able to dismiss the evidence others saw of His disfavor? Or was she constitutionally unable to listen to people she judged unlikely conduits of the word of God? In any event, she spoke her mind, she stood for what she believed in, and she moved us all forward.

As the first woman doctor in the United States, Elizabeth Blackwell had the dubious honor of showing the way for women to qualify for and enter a profession in which, at the time, they were pointedly unwelcome.

Blackwell endured repeated rejections on her way into medical school, where she was shunned by the male students and shut out of clinical opportunities by the teachers. After she finished medical school, when no one would hire her, she founded her own hospital and made her own opportunities.

Elizabeth Blackwell

Blackwell was born in England; her father was a wealthy Quaker and sugar refiner whose business eventually fell on hard times. The large family moved to the United States when Elizabeth was 11 and settled in Cincinnati, Ohio.

Blackwell''s father died when she was a teenager and the family opened a small private school, where Elizabeth began teaching.

When she decided she wanted to be a doctor, she was turned away from 29 medical schools before being accepted by the Geneva Medical School in Geneva, N.Y. In spite of the hostility she encountered there, she graduated at the top of her class in 1849, with plans to become a surgeon.

Blackwell traveled to Paris to take a course in midwifery, where she contracted an infection that cost her the sight in one eye. That put an end to her hopes of becoming a surgeon. Back in the United States, Blackwell found she couldn't get work in a hospital, so she went into private practice.

In 1853, along with her sister Emily, and Marie Zakrzewska, two other early female doctors, Blackwell founded the New York Infirmary for Women and Children, now New York Downtown Hospital. During the Civil War, Blackwell trained nurses to treat soldiers injured on the battlefield.

The Blackwell sisters also founded the Women's Medical College of New York in 1869, but within a few years, Elizabeth went back to England. She was a professor of gynecology at the London School of Medicine for Women for the rest of her working life. Blackwell died at the age of 89, in 1910.

Virginia Apgar MD devised the simple observational test that bears her name after watching doctors swiftly give up on struggling newborn babies, leaving them to die, Atul Gawande writes in his book, Better. At the time, a few years after World War II, one in 30 births in the United States ended in the infant’s death.

Dr. Virginia Apgar

The Apgar score, introduced in 1953, is a 10-point scale for assessing how a newborn baby is doing — first with the birth process, and then with adjusting to the world. It is given in hospitals one minute after birth, and again at five minutes. A robust baby might garner 10 points, but a baby with an Apgar score of four or less draws serious concern and, likely, vigorous intervention.

Dr. Apgar’s scoring system transformed delivery, Gawande writes. “Even if only because doctors are competitive, it drove them to want to produce better scores—and therefore better outcomes—for the newborns they delivered,” he writes.

The daughter of a Westfield, N.J., insurance executive, Dr. Apgar graduated from Mount Holyoke College in 1929, and began medical school at Columbia University’s College of Physicians and Surgeons, where eight of her classmates were women and 81 were men. She began a surgical residency but, in the depths of the Great Depression, decided it might be difficult, especially as a woman, to make a living as a surgeon.

Dr. Apgar enrolled first in a course for nurse-anesthetists and then in Dr. Ralph Waters’ seminal residency program in anesthesiology at the University of Wisconsin in Madison, followed by a stint with Emery Rovenstine at Bellevue Hospital in New York — strong training for the day.

She founded the anesthesiology program at Columbia’s College of Physicians and Surgeons. However, when the program became a department, Dr. Apgar was passed over for the job as chairman, in favor of a man. She did become a full professor, though — in itself an accomplishment at the time — and was a pioneer in obstetrical anesthesiology.

Dr. Apgar saw a number of birth defects during the thousands of births she attended, and in 1958 she went back to school in public health at Johns Hopkins’ medical school in Baltimore. In 1959, Dr. Apgar joined the March of Dimes in its campaign to eliminate birth defects.

Dr. Apgar never married. Her entire life, she was famous for intelligence, energy, empathy and a great sense of humor. She was still working on behalf of the most vulnerable babies when she died in 1974, at the age of 65, of liver failure.

Gawande’s chapter about Dr. Apgar, “The Score,” also ran in the New Yorker.

Mary Breckinridge, a daughter of a prominent Kentucky family that included John C. Breckinridge, James Buchanan’s vice president, suffered the loss of both her children before they reached the age of 5. Instead of allowing these tragedies to ruin her life, she channeled her energy into a passionate campaign to improve the health of the children of Appalachia.

Mary Breckinridge at work

To Breckinridge, a healthy child required a safe birth, a living mother and a healthy family. Making childbirth safe was a primary goal when, in 1925, she founded the Frontier Nursing Service in Leslie County, Ky. The previous year, Breckinridge, 43 and already a nurse, had traveled to England to learn midwifery because she could find no adequate course in the United States. She continued to send FNS nurses to England until the outbreak of World War II.

The FNS deployed the first nurse-midwives to practice in the United States. Breckinridge had encountered nurse-midwives in Europe, and thought that the model was well suited not only for delivering babies but also for providing prenatal care and for assessing and helping to plan for the health needs of the whole family and, indeed, the whole community.

FNS nurses traveled by horseback to attend home births; high-risk patients went to the FNS hospital in Hyden, Ky. Clinics in the community served an average of 250 families. The FNS maternal mortality rate for its first 30 years was about one quarter of the rate for the United States as a whole.

Breckinridge died in 1965. The Frontier Nursing Service, based in Wendover, Ky., is still active, as its midwifery school, which was added in 1939.

Only one American midwife of the Revolutionary War era left a diary that has been recovered, Martha Ballard of Hallowell, Maine. It is a fairly basic document. Some entries are just a few words. Still, between 1785 and 1812, a time of incredible change in New England, Martha tended her diary regularly.

A Midwife's Tale

In 1990, the historian Laurel Thatcher Ulrich used her own considerable knowledge of the period to connect the dots in Ballard's diary. The result was A Midwife's Tale, which won the Pulitzer Prize and other awards. It is a terrific book, and it was made into a film for PBS's "American Experience."

One of the best things about A Midwife's Tale is the fact that Ulrich has given us a fully fleshed-out picture of Martha Ballard, and has at the same time retained her distinctive voice. Ballard was a religious, hard-working wife and mother who trained her daughters and other young women to assist her, understood the medicinal uses of the plants she grew in her kitchen garden, and in her prime delivered two-thirds of the children in Hallowell.

The town had more than one doctor, but in 816 births over the course of 27 years, Martha called a doctor in to help her with a birth just twice. In all those years, Martha saw 19 babies and five mothers die just before, during or just after birth.

While childbirth rested on a community of women when Ballard began her career, one of the tensions of the book comes out of the inroads male doctors were already making into midwifery by the time Martha died in 1812.