Sunday, October 19, 2014

Late-Nineteenth and Early-Twentieth Century Pediatrics: The Development of a Specialty

By Cynthia Connolly, PhD, RN, FAAN

A Nineteenth Century Innovation: Hospitals for Children
In early 1879, a concerned citizen using the name “Fireside” penned an impassioned letter to the editors of Boston’s Evening Transcript. The paper published the heartfelt appeal to the citizens of Boston on behalf of the city’s Children’s Hospital on January 22.

Fireside wrote of the poverty observed on Boston’s streets by the casual onlooker:

"Men whose brutal faces made me shiver, women from whom every grace of womanhood had departed; and oh! More pitiful than all, the child faces that looked at me as I passed---the poor, wan faces, so pinched and pale with want and sickness, yet with a childlike innocence in their eyes . . ." (“Fireside”, 1879).

Fireside begged those who could afford it to send money to Children’s Hospital. Donations were a necessity, since the institution received financial support wholly through private funds. The writer may have also wanted to publicize the hospital’s existence since the idea of an institution devoted to the needs of children was a new concept. Until the mid-nineteenth century, there were no facilities dedicated to the care of sick children in the United States. If they could not be cared for at home, children, like their parents, went to municipal almshouses, also known as poorhouses. Orphaned or abandoned babies often ended up in infant asylums, which had been patterned after similar British institutions where the mortality rate approached 100 percent. 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.

Public Health Nursing and Children’s Health
Although institutions were central to the development of children’s health care, many advances arose from the early twentieth century public health movement and reformers efforts to publicize the plight of poor children. When Jacob Riis, New York City police reporter turned social reformer, wrote his 1890 book, How the Other Half Lives, his descriptions of the poor, especially the children, appalled people: “Seventy-two dead babies were picked up on the streets last year. Some of them doubtless were put out by very poor parents to save funeral expenses . . . bodies of drowned children turn up in the rivers right along in summer whom no one seems to know anything about” (Riis, 1890, p 180). Riis’s tales of children dying from starvation and disease, exhausted from overwork, and fending for themselves on the streets, galvanized reformers and helped stimulate the reforms that created our modern child labor laws and systems of juvenile justice, foster care, and government aid to poor families.

These reforms were needed because the United States was experiencing profound social and cultural changes wrought by industrialization, urbanization, economic growth, and population increase. Moreover, people poured into American cities from overseas. Many of these new immigrants, arriving mostly from Eastern and Southern Europe, were poor, spoke little or no English, and engaged in cultural practices foreign to earlier arrivals and the native-born. Masses of immigrants ended up in the ghettos of large cities where they faced even more awful conditions than did American migrants to the same urban areas. Living conditions were usually squalid, and immigrants often were forced to accept jobs so arduous or unsafe that native-born Americans shunned them. Their language and cultural practices were frequently objects of ridicule and suspicion.

The incidence of urban poverty exploded as immigrants and native born migrants crammed into tenements. Inadequate living conditions led to overcrowding, poor sanitation, disease, and increased crime (Cravens, 1985). For reformers such as Riis, “child-saving” represented a meaningful venue through which to cure these ills. Child-savers argued that children were impressionable, possessing the capacity to be uplifted, to rehabilitate their morally questionable parents and other family members, and to be easily Americanized if they were immigrants (Katz, 1986). As one prominent physician noted: "Anyone who has had practical experience recognizes only too well the almost hopeless task of trying to train and educate in the rules of hygiene and right living, ignorant, stupid people from the slums . . . Children, however, are easily trained" (Hawes, 1910, p 904).

Because of the writing and photography of reformers such as Riis, the plight of vulnerable children became more difficult to ignore in the late nineteenth century. Poor children and those orphaned or abandoned, were highly visible in cities. Children played in the streets, increasingly becoming victims of accidents. Contagious diseases and hunger were rampant. Poor maternal nutrition helped keep infant mortality high. Record keeping was sporadic until the 1920s and '30s, but what records that do exist indicate that at the dawn of the twentieth century one in every seven babies died. In some New England industrial towns, the infant death rate was as high as 30 percent. (Klaus, 1993; Meckel, 1990).

A New York City nurse, Lillian Wald, pioneered the new nursing specialty of public health nursing, an important engine of child-saving. In 1893, she and a colleague merged the concepts underlying district nursing and settlement houses by creating the nurse-managed Henry Street Settlement. Wald believed that bringing subsidized nursing care to the poor in their homes—care similar to that which the middle and upper classes could afford for themselves—both heightened the chances for its success and made treatment more humane. Wald also strove to improve the daily living experiences of children. Many Henry Street ventures focused on children health plays, train rides, summer camps, organized sports, music classes, playground for children to be outside. Wald (1915) evocatively brought turn of the century children’s health risks to life:

"One night during my first month on the East Side, [which would have been 1893] sleepless because of the heat, I leaned out of the window and looked down on Rivington Street. . . Sitting on the curb directly under my window, with her feet in the gutter, was a woman, drooping from exhaustion, a baby at her breast. The fire-escapes, considered the most desirable sleeping-places, were crowded with the youngest and the oldest; children were asleep on the sidewalks, on the steps of the houses and in the empty push-carts;. . . I looked at my watch. It was two o’clock in the morning (p 69-79)!"

One of Wald’s most significant accomplishments for children was her idea for school nurses. In 1902, Wald convinced the Board of Education to hire a Henry Street nurse to work in the school system. New York City had begun having physicians inspect school children for acute or infectious diseases in 1897. However, the children physicians identified as “sickly” were simply barred from attending school. Wald argued that this practice was inhumane and arranged for Lina Rogers, a Henry Street Settlement nurse to provide follow-up and home care to children (Wald, 1915).

Wald's activism helped spur the creation of the Children’s Bureau, the first government agency to be dedicated solely to children’s welfare, which was established in 1912 (Markel and Golden, 2005). Wald and other public health nurses throughout the nation worked at health departments to implement Children’s Bureau initiatives such as those aimed at preventing infant mortality. They also worked through private agencies to secure such health benefits as pure milk for children and families. Their efforts established nurses as a critical societal resource for children’s health.

When, a few years later, Congress enacted the first federal legislation for children’s health and welfare, the 1921 Sheppard-Towner Act, nurses coordinated many of its educational and health-screening efforts (Sealander, 2003). At the height of the 1930s Depression, nurses again sprung into action, providing health care to children through the Child Health Recovery Program and later through the Social Security Act (Markel and Golden, 2005). The importance of nurses to the success of child health programs became clear again in the 1960s through their participation in Medicaid-funded programs and in the new infrastructure needed to support the 1975 legislation that guaranteed a quality education for all children, even those with mental and physical disabilities. Today, an essential site for children’s health care delivery is the school-based health clinic, where school nurses and pediatric nurse practitioners address epidemics of child obesity, asthma, and mental health and behavioral problems (Halfon, 2007).

Image: Student nurse and children, Jewish Hospital, Philadelphia, PA c. 1900


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