American Medical Association (birth control)

Though much of the contraceptive information of the past is known through medical writings, in the United States organized medicine, for the last part of the nineteenth century and first part of the twentieth, was among the major opponents of the dissemination of contraceptive information. In part, this was because American medicine in the nineteenth century was a battleground of various medical theorists, each of whom had a system to preserve health and overcome disease. These systems ranged from water cures to animal magnetism, from naturopaths to homeopaths, from the followers of Sylvester Graham to those of Samuel Thomson, to outright charlatans. Medical schools of various types sprang up all over the United States. State licensing laws were nonexistent and the patient was advised to beware. Some areas of medicine such as surgery required specialized skills, but surgery itself was limited to amputations and minor excisions; penetration of body cavities did not come until almost the twentieth century. Apothecaries, free of any medical interference, developed a wide variety of tonics, salves, and pills. Because the names and contents of these preparations could be patented, many makers of nostrums made a fortune, with their success often being more dependent on their advertising ability than on the efficacy of their cures. One of the more influential regular physicians of the nineteenth century, Oliver Wendell Holmes, tried to distinguish between the quacks and the real physicians. The quack, he said, pretended to be a trained physician when he was not; he fabricated testimonials, he created diseases, and he gave his nostrums foreign names and claimed they were imported from abroad or made of rare and expensive ingredients. Statistical evidence was usually faked. Still, people often turned to them.

Complicating the problem was that traditional medicine had relied upon heroic cures such as blood letting, harsh purgatives, and other treatments that often turned out to be ineffective and even harmful.The germ theory had not yet been established, and the knowledge of physiology among even the best of practitioners was still rudimentary. On the other hand the new medical sects were generally not invasive in their techniques but emphasized diet, regularity of the bowels, and especially hygiene. The result was that their recommendations of frequent bathing, eating whole grain cereals and more vegetables and less animal foods, wearing loose and warm clothing, getting fresh air and exercise, and avoiding tobacco and alcohol were often more sound than the advice of the “more learned” physicians. New health-oriented practitioners such as chiropractors, naturopaths, osteopaths, and Christian Science healers added to the distrust of traditional medicine. Individual practitioners of any school or group could set up in practice after attending only a few lectures or reading a few medical texts, although there were more traditional schools in Philadelphia, Boston, New York, and other areas that tried to keep abreast of the changing developments of medicine on the continent. Much of the information, both good and bad, about birth control formulas and abortions had been produced by those who have since been called irregular practitioners, and any move against them tended to deprive the public of any information about such topics.

The panacea of quick cures gradually lost support in much of the United States, and there were increasing demands for some kind of standards. Struggling to fulfill this need was the American Medical Association (AMA), which had been organized in 1847 by delegates representing what then passed for regular medicine. Their mission was to raise the standards of American medicine as well as the moral quality of Americans. The battle to achieve the first objective was not complete until well into the twentieth century, and the second, in spite of their efforts, was never quite successful. In their role as moral guardians, the physicians condemned many medical practices, including abortion and birth control, as immoral. As a group, they were strong supporters of Anthony Com-stock, the moral reformer, in his opposition to abortion.

The pioneer in the United States in this medical campaign was Hugh Lenox Hodge, chair of obstetrics at the University of Pennsylvania Medical School and a representative of the more orthodox medical practitioners. In 1839 he published a pamphlet, An Introductory Lecture to a Course on Obstetrics, in which he held that the embryo could think and perceive right and wrong. This is not accepted today, but from his conclusions it was clear that abortion was wrong. When Hodge republished the pamphlet thirty years later, he retitled it Foeticide, or Criminal Abortion, symbolic of the growing hostility to abortion by the AMA-affiliated physicians.

This hostility became institutionalized in the AMA through the leadership of Horatio Robinson Storer. Storer had begun his campaign to set a new moral tone on questions of abortion and birth control by gathering, from colleagues nationwide, material and statistics on still births, abortions, and maternal deaths. His report to the AMA in 1857 led the members to accept his recommendation that state legislatures and state medical societies make abortion more difficult, because he believed abortion was (and in this he was correct) a major cause of maternal deaths. He also believed that contraception was not only medically dangerous but criminal. He held that in the United States numerous instances of nervous disease and uterine problems had been caused either by abortion or the “systemic prevention of conception.” Contraception was not only dangerous for women but for men because the use of condoms or the practice of coitus interruptus was not only dangerous to male health but could cause impotency. By the 1870s the AMA had launched a major campaign against abortion and contraception, effectively equating such practices with quacks, medical irregulars, and others. For Storer, the true physician should become the moral arbiter of society, a role envisioned for physicians earlier by Benjamin Rush, the physician signer of the Declaration of Independence and a goal in which Storer and most other members of the AMA believed. Even though some of Storer’s colleagues disagreed with him, they did not organize any group to oppose the AMA stands. Some spoke individually against his notions and that of the AMA and so did advocates of free love, social reformers, and even for a time some of the emerging feminist leaders such as Elizabeth Cady Stanton. Stanton, in her speeches to small groups of women, emphasized the need for women to have “self sovereignty” over their bodies and their sexual lives, but she did not officially oppose the stands of the AMA, the social purity movement, or Comstock.

Giving strength to the AMA were changes in medical theory and practice brought about by discoveries made by Louis Pasteur, Robert Koch, and others. The discovery not only of germs but of particular bacteria causing specific diseases gave medicine a stronger scientific bent than it ever had before. New aseptic techniques and the development of anesthesia allowed physicians to do more direct interventions, aided by an emerging pharmaceutical industry that provided new drugs such as aspirin, which had been laboratory tested and had clear benefits. Almost all of these breakthroughs occurred in Europe, particularly in Germany, and the better U.S. medical schools were either reorganized or newly established on the German model. The best example of this new trend was the founding in Baltimore of the Johns Hopkins University Hospital, which was the first effort in a long campaign to raise the level and sophistication of medical education. Medical schools that had earlier identified with universities, but that operated more or less independently of them, were given stronger direction by the universities and their curricula radically reformed. The hospital, the traditional bastion of medical education, itself became more important in medical treatment, and literally thousands of new hospitals were established in the United States in the last two decades of the nineteenth century and first decade of the twentieth century. The emergence of modern nursing gave the hospitals free labor in the form of students, and increasingly more procedures once done in the home moved into the hospital. For the most part, control of who would be on the staff of the hospital fell to physicians who belonged to the AMA. Medical reform became a major agenda of many of the newly emerging charitable foundations in the United States such as those established by Andrew Carnegie, John D. Rockefeller, and others.

Part of the reforms required greater state intervention in licensing and registration of physicians, setting standards for hospitals, and requiring physician prescription for drugs, and the effect of all of these was to allow the physicians who were affiliated with the AMA to squeeze out most of their rivals. In the middle of the nineteenth century, for example, almost all babies were delivered by midwives, and only a few physicians regarded themselves as experts in this. The development of anesthesia, the establishment of maternity hospitals with only AMA accredited physicians, and the gradual disappearance of home deliveries rapidly increased medical control in the gynecological and obstetrical fields. But the AMA also mounted a campaign against what they called ignorant and untrained midwives with whom they associated abortion and dangerous use of contraceptives. The midwives were not organized well enough to counter the AMA assault, and for a time they almost disappeared in the United States. Those competitors who survived, such as the osteopaths, had to establish their own medical schools and hospitals to do so. Others, such as chiropractors, tried to find a niche they could fill and rarely challenged the AMA openly. It was not until after World War I with the massive closing of what were regarded as dubious medical schools and the setting of minimum standards for medical schools that the AMA had won the battle.

One effect was an appreciable decline in the quality of contraceptive advice literature. What existed, except underground, gave few specific descriptions of what to do. Edward Bond Foote, the physician son of Edward Bliss Foote, whose writing on contraception was among the most sophisticated in the last part of the nineteenth century, reported that regular physicians like himself could no longer legally prescribe or advise contraceptives to save a mother’s life, but that they could legally perform an abortion to do so. In effect the medical community had emerged to a position of legal control of reproduction, even if therapeutic abortion was the ultimate end.

One effect of the battle was official medical opposition to both abortion and contraception. In the process the practical midwife and many of the medical sectarians were accused of being abortionists or of secretly giving out to women recipes for birth control. From the first, the AMA was staunchly antiabortionist as much on moral grounds as was the medical belief that abortion was bad medicine because so many women were killed or maimed in the process. But the AMA also opposed contraception so strongly that they did not even pay attention to medical developments in the field. Morris Fish-bein, the editor of the Journal of the American Medical Association and the major voice for organized medicine, as late as 1925 wrote that there were no safe and effective birth control methods and classified such efforts among what he considered as medical follies.

Although there was always a handful of physicians who were open advocates of contraception, it was not until well into the twentieth century that the AMA finally accepted its important role in the lives of women. To gain medical backing, contraception too had to be put in moral terms, and William Robinson and Robert Latou Dickinson were important in doing so. The struggle for rights to contraception in the United States was waged by lay people, and the medical community was only reluctantly pushed and shoved to finally accepting contraception, but by the time it did, the birth control movement itself had to change to more or less rid itself of its radical background and its association with anarchy and socialism.

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