Tuesday, March 4, 2014

A Nineteenth Century Innovation: Hospitals for Children

By Cynthia Connolly, PhD, RN, FAAN

By the 1860s in the United States, special hospitals for children were becoming a necessity, since many of the newly founded general hospitals simply refused to admit them (King, 1993).

The earliest children's hospitals admitted indigent or abandoned children, some of whom—but by no means all—were also ill. Many people during this era believed that immortality and poor character caused poverty. Since sickness and poverty often appeared together, providing spiritual guidance and moral uplift to the ill, in addition to offering food, clothing, and whatever other material provisions were needed, was supposed to help the poor rise above their condition and facilitate better health. Stratifying the needy into “deserving” versus “undeserving” categories helped charitable organizations and hospitals decide which individuals to aid. Because indigent children were considered the innocent victims of their parents’ bad choices or unsuitable lifestyles, they were, by definition, always deserving of assistance, and aiding them engendered little controversy (Katz, 1986).

Hospitalized children often resided at the institutions for months, and beyond fresh air and food, they were given few therapeutics, at least according to today’s standards. Those in charge of children’s institutions considered one of the most important interventions for the children to be their exposure to the wealthy trustees who ran the institutions. These individuals, usually socially prominent, were presumed to have better characters than the children's indigent parents, and they hired staff who they felt could help imbue the children with the qualities the trustees felt were important. Staff and trustees often discouraged or made it difficult for parents to visit their children, hoping that prolonged contact with staff would facilitate Americanization in immigrant children, and inculcate middle class behaviors and health practices among the native-born (Brosco, 1994; Vogel, 1980).

Fireside's description of the hospital’s environment, illustrated this practice:
While there, in addition to their medical treatment and nursing, they are carefully taught cleanliness of habit, purity of thought and word, and as much regard is paid to their moral training as can be found in any cultivated family. Think what a widespread influence this becomes when the children return to their homes . . . (“Fireside”, 1879).

Inventing Pediatric Medicine and Nursing
Physician Abraham Jacobi, considered by most to be founder of modern pediatrics, offered the first medical lectures on the diseases of childhood in 1860. Until the Civil War, pediatrics was considered part of obstetrics in the United States. Before Jacobi, medical specialties centered on a particular organ or technology. Jacobi felt that pediatrics should have a broader, more conceptual, focus. His vision was that pediatricians should concern themselves with child health well beyond mere disease. He advocated for the involvement of doctors who treated children in all aspects of child health including infant feeding, child hygiene, and disease prevention in well children. The pediatrician, he argued, could also use his talents to facilitate the Americanization of immigrants. Jacobi articulated a model for pediatrics with a focus well beyond specific diseases, one that involved disease prevention in healthy children, educating parents about child rearing, and social activism for children's rights.

In 1880, Jacobi and a few other interested physicians founded the American Medical Association’s section on the diseases of children. In 1888, they formed a new organization, the American Pediatric Society, which helped to solidify pediatrics as a distinct branch of medicine. Jacobi served as the first president of both groups. Framers of the American Pediatric Society recruited prominent physicians into their ranks to advance pediatrics’ acceptance. Early pediatricians such as Jacobi wrote prolifically in new journals and textbooks that focused exclusively on childhood diseases. They stressed the need for more children’s hospitals, and for the expansion of pediatric content in medical school curricula. By 1900, ten schools of medicine had full-time pediatricians (Halpern, 1988; Meckel, 1990; Viner, 2002).

Changing notions of disease causation synergized the development of pediatrics in the United States.  In the 1870s and 1880s, Robert Koch, Louis Pasteur, Joseph Lister, and others forged the germ theory of disease causation. These changes altered the role of the hospital in American life (Rosenberg, 1987) and reshaped pediatric nursing and medical care in the ensuing decades. By 1900, the organisms responsible for typhoid, leprosy, malaria, tuberculosis, cholera, diphtheria, and a host of other conditions were identified. Illness—at least infectious illness—left the realm of morality and religion. It gradually evolved, at least for infectious diseases, to receive its identity in the laboratory (Rosen 1958/1993).

An understanding of the bacterial origins of infectious diseases encouraged such advances as the use of surgical gloves and sterilization. When coupled with anesthesia, these interventions made pediatric surgery safer. Better surgical therapeutics helped make hospitals more medically oriented. As early as the 1870s, physicians at the Children's Hospital of Philadelphia, for example, pressured the lay trustees who managed the hospital to increase patient turnover and accept more acutely ill children, especially orthopedic surgical patients who had something to offer physician education and on whom new surgical techniques and therapies could be tried. This new emphasis on the medical needs of patients and the experimental needs of doctors and nurses conflicted with the social welfare role children's hospitals saw themselves as performing (CHOP, 1870-1880).

Children’s hospitals were highly visible in the communities in which they were founded. The individuals who worked there deservedly prided themselves for providing a social safety net for the ill or abandoned child who needed care. Moreover, children’s hospitals were also good for the burgeoning specialties of pediatric nursing and medicine (Brodie, 1998; Golden, 1989). The development of children’s hospitals helped pediatrics to evolve more quickly into a specialty branch of medicine and nursing because of the opportunities it afforded for training, the feeling of shared identity and unity it fostered in its staff, and the research opportunities indigent hospitalized children provided in an era in which no ethical guidelines governed research.

Over time, the proportion of children admitted for social welfare reasons began to fall while the number of those suffering from chronic medical conditions or requiring surgery rose. More hospitals also began to accept children with infectious diseases for the first time. For example, until the 1890s when the Children’s Hospital of Philadelphia developed accommodations to isolate potentially infectious children, the institution avoided admitting children with contagious diseases as well as infants for any reason (CHOP, 1893). As the hospital began to admit sicker patients, hospital trustees and physicians understood that trained nurses were essential for children to benefit from the burgeoning diagnostic and therapeutic modalities. The ongoing need for more and better-trained nurses resulted in the long anticipated inauguration of a nurse training school at the hospital in 1895, an advance that the Board noted answered  "a want, long felt" (CHOP, 1895).

Though the first pediatric nursing textbook was not published until 1923, articles addressing the needs of children appeared in nursing journals much earlier. (Farrar, 1906; Pierce, Cutler, & Bancroft, 1923). Florence Nightingale herself emphasized children's nursing care needs in her seminal 1859 book, Notes on Nursing, writing: "It is the real test of a nurse whether she can nurse a sick infant" (Nightingale, 1859/1992). Early publications highlighted such practices as infant feeding techniques and pediatric nursing procedures. Pioneering pediatric nurses such as Anna Haswell (1908) also stressed the special personality type required for children’s nursing asserting that:

The nursing of young children stands out as a division of our work needing special study. We have no branch that is more important . . . Let us be willing to do anything which will accomplish the greatest good for the child, and honor our profession by becoming more and more efficient in our ability to care for sick children (p 115).

Just what skills were necessary to ‘efficiently care for sick children’ in those days? Though the early nursing literature recognized that nurses needed educational preparation, the form that training took was different from today's. Until the twentieth century, nurses who specialized in children’s health trained in much the same way as their adult-oriented counterparts. Hospitals usually paid student nurses small allowances in addition to room and board, and in return these students worked, often largely unsupervised, on the wards caring for patients.

Students usually toiled twelve hours a day, six days a week for fifty weeks a year. The length of training was variable, ranging anywhere from eighteen months to three years. Nurses who wanted to specialize in child health tried to get their training either at a hospital with a children’s ward or at one of the few children’s hospitals. Once graduated, a few nurses assumed leadership positions in hospitals, but most sought private-duty positions in middle-and upper-class homes. The pay was poor and the hours irregular (Reverby, 1987).

Over the course of the twentieth century, hospital care for sick children of all classes became more commonplace, especially as new technologies and advances such as antibiotics made it possible to save the lives of more children. After World War II, an increasing number of subspecialties in children’s health care, such as neonatology and pediatric critical care, emerged from the rapidly expanding body of knowledge being generated.

Excerpted from: "Late-Nineteenth and Early-Twentieth Century Pediatrics: The Development of a Specialty"
From: nursing.upenn.edu


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