B. RECOGNITION OF SPECIAL HEALTH PROBLEMS OF CHILDREN
"The American practice" in the diseases of children, 1825
William P. Dewees, A Treatise on the Physical and Medical Treatment of Children (Philadelphia, 1825), II, i-iv.
Dewees (1768-1841) was lecturer on midwifery at the University of Pennsylvania. His Treatise was the first comprehensive work by an American to approach child health in a scientific manner.
The diseases of childhood have never until lately, sufficiently engaged the attention of physicians, however strongly they have claimed it. It would be difficult to explain satisfactorily, the causes of this indifference; it may however, chiefly be ascribed to the following; 1st. To the practice of midwifery being confined almost exclusively to women, until within the last fifty or sixty years; thereby preventing the physician from seeing much of the diseases of children. 2d. In Great Britain especially, to a by-law of the Royal College of Physicians, "by which its fellows are compelled to exclude themselves from practising midwifery," thereby operating like the first cause. 3d. To a belief, that the diseases of childhood are obscure, or even unintelligible. 4th. To parents supposing that nurses and old women are more conversant with these diseases than the most enlightened physician; whereby he is deprived of the opportunity of studying them with as much diligence and accuracy, as they deserve.
But fortunately for the little sufferers, an almost entire change has been made within the years just stated, by the practice of midwifery becoming almost entirely confided to the physician; and by the public mind inclining to the belief, that the diseases of infancy may be understood, by due attention and study; and that, there is rather more safety in the prescriptions of the physician, than in those of the nurse.
In consequence of the changes in public sentiment, the care of the diseases of childhood, has been committed to the physician; who now has the opportunity of watching them through all their changes, from the moment of birth, to that of puberty. Hence, we have within the last few years, some valuable treatises upon this subject; so many, they may appear to some, as to lead to the belief, that it is exhausted. Under this impression, the present undertaking may be thought to be unnecessary, or to require apology.
In our defence, however, we shall merely observe, that the profession of medicine must necessarily be a progressive one; and that its advancement must mainly depend upon the improvements its respective followers may make, in the exercise of its various departments; consequently, each one is bound to contribute his mite towards the general benefit. . .
We may urge another inducement to this undertaking; namely, that hitherto, no one on this side the Atlantic, has thought proper to give to the public at one view, the American practice in the diseases of children. This supineness of our physicians, is no less surprising than reprehensible; especially as many are so well qualified for the task by their talents, and experience, and moreover as such strong inducement was held out, by the peculiar character of our diseases, and in many instances, by the novelty and boldness, of the mode of treatment.
Hitherto, we have almost exclusively depended upon European publications for information upon almost every subject connected with medical science; and we acknowledge to have received much advantage from them; especially from their elementary works: but it must not be disguised, that the same advantage has not been derived from their practical works. This has not arisen from a deficiency either of opportunity, or of talent; for we confess both, in many instances, to have been great; but to the want of proper adaptation of their remedies, to the state, force, and peculiarity of our diseases. For it cannot escape the observation of any intelligent practitioner who may have visited both countries, how essentially our diseases are modified by climate, soil, manners, and habits; and that these modifications require corresponding changes of treatment. .
Most of the diseases of this country, have a peculiarity of character, an intensity of force, and a rapidity of march, altogether unknown to European climates; and were reliance to be placed upon the feeble practice of that portion of the globe, however well suited to the state of their diseases, we should but too often have the mortification to see our patients hurried to an untimely tomb.
The diseases of childhood in this country, like those of adult age, require to be met with promptitude, and with adequate force; a temporising treatment suits not the character of their diseases; and if adopted, is almost sure to end in defeat.
In our account of the diseases of childhood, we shall endeavour to separate the accidental, from the characteristic, or permanent symptoms; and only detail such, as are known to accompany the disease in this country. This determination will almost necessarily confine us, to the history and treatment of such diseases only as exist in this country; and especially to those, in this part of our continent. For the history of the diseases to which children in Philadelphia, and its neighbourhood are liable, will be, we are of opinion, a pretty faithful account of almost all in this country; since the heat of our summers will have nearly as decided an influence upon their constitutions, as the sun of the Carolinas or Georgia; while the cold of our winters, will produce consequences analogous to those of more northern latitudes.
At all events, very little mischief can arise from this mode of treating our subject; and none, which cannot be immediately repaired by any well instructed practitioner; for it will entirely consist in the proper adaptation of remedy, to the force of disease; taking it for granted, he understands its character; and in this country this is generally so uniform, as not to make him liable to much error.
Indeed, we may safely add, that the general simplicity of the diseases of children, renders their management more easy, as well as more certain than those of adults; their complaints are almost always acute, and of the sthenic kind...
Health problems of dependent children in institutions, 1831-1858
1. Ophthalmia in New York City
"Petition of the commissioners of almshouses [to the Common Council] for the accommodation of certain children affected with sore eyes, May 18, 1831," New York City Municipal Archives and Record Center, New York.
Purulent ophthalmia was a constant problem in nineteenth-century institutions for children. A serious outbreak occurred in 1831 in the children's department at Bellevue, the New York City hospital and almshouse.
The. . . commissioners of the almshouse respectfully report that they have accompanied Doctor Wood in an examination of the children at Bellevue. The whole number in the establishment is about 600 – say 400 boys and 200 girls from infants up to ten years old. About 140 of this number are affected with various degrees of contagious purulent ophthalmia or inflammation of the eyes – many are slightly affected while a great many others (principally boys) present the painful spectacle of total blindness and most appalling swellings, and redness. 25 eyes are seriously injured. Five children [are] totally blind and many [others] in . . . one eye.
This contagious inflammation was introduced from some unknown quarters about three years since. At times it has been reduced to a few cases, especially last year by separating them from the well children.
The [Commissioners] have been empowered by your predecessors to procure or erect a temporary place for these unfortunate children but have not been able to hire any suitable place, and as considerable time will be necessary to erect a permanent establishment for the children, they are of opinion that it is expedient and advise able to erect forthwith temporary accommodations whence to remove the children who are affected with the contagion and thereby prevent the continued spread of the disease amongst those who are taken in at Bellevue and also to afford a prospect of speedy restoration to those little objects whose very appearances make an irresistible appeal to the sympathy of every beholder. [1a]
1a. The Common Council acted favorably upon the proposal to erect separate lodgings for ophthalmia victims and purchased a property on Long Island, known later as the Long Island Farms. All the children at the Bellevue establishment were subsequently removed to the Farms.
2. Efforts to control ophthalmia in orphan asylums
"Report of the Board of Assistants to the Committee on Charity and Almshouses, September 24, 1832," New York City Municipal Archives and Record Center.
The 1832 cholera epidemic took more than 3,500 lives in New York City during the months of July and August. One result of the epidemic was that many children were orphaned and sent to asylums.
The committee on charity and almshouse to whom was referred the annexed resolution from the Board of Aldermen's appropriation of $1,000 to the orphan asylums in this city to aid in the support of the orphans who have been received into these institutions during the prevalence of the present epidemic, respectfully report. . .
In the Asylum at Greenwich were some 159 orphans, including both sexes – 56 of whom have been received during the existence of the cholera, some are refused admittance.
The ophthalmia still exists in this institution but this condition in this respect is much improved since May last. There are now probably fifteen or twenty in all whose eyes are affected in a greater or lesser degree.
The children are taught in the rudiments of an English education and when of proper age are bound to suitable persons. They were, at the time, at school and appeared cleanly and in good order. Their sleeping rooms were also cleanly and well ventilated.
Your Committee, however, beg leave to offer some remarks which they deem important in the preservation of health among so large a congregation of children and more particularly to prevent the introduction and spread of the ophthalmia. Children should never be permitted, whether sick or well, to sleep, work or rise in common.
Each child should be furnished with a separate bed, a separate basin of clean water and a separate napkin. In no other way can we fortify these poor children against the inroads of this distressing and hitherto obstinate disease.
The expense of napkins will be very inconsiderable inasmuch as a square yard of linen or diaper will make twelve napkins sufficiently large for all the uses necessary.
The children when this disease exists should then be divided into three classes, the healthy, the sick, and the convalescing which should never be permitted to intermingle.
The sleeping rooms should also be divided into wards and one of the nurses or superintendents should sleep in each ward with the children and always in readiness to attend to their wants during the nights.
Of the Catholic Asylum in Prince Street your committee can only speak in terms of the warmest approbation. It is an institution alike honourable to its benevolent supporters and highly creditable to the city.
The sisters of charity who have. . . the superintendance certainly merit the greatest praise for their unwearied attention to the education and wants of these helpless orphans. Their improvements in many. . . fine and ornamental branches of education would do honor to our most reputable boarding schools.
They have now in the institution 141 children including males and females – 32 of whom have been received during the existence of the present epidemic and they can accommodate 18 or 20 more when their rooms will be all filled.
They have it in contemplation to enlarge this establishment by erecting a building on the adjoining lot, where they will probably be enabled to receive all who may be offered.
The above institutions are both supported by private individual charity and are certainly deserving an encouragement from the public authority.
In recommending a concurrence with the Board of Aldermen in the adoption of the resolution, your committee are of opinion that the public moneys cannot be applied to a more charitable purpose.
3. "The smell of the almshouse will cling to them still," Philadelphia, 1836
Alfred Stille, "Reminiscences of the Philadelphia Hospital" and "Additional Reminiscences of the Philadelphia Hospital" in D. Hayes Agnew et al., History and Reminiscences of the Philadelphia Almshouse and Philadelphia Hospital (Philadelphia, 1890),pp. 56-57,58-59, 65-66.
Stille (1813-1900), author of Elements of General Pathology (Philadelphia, 1848), was professor of the theory and practice of medicine at the University of Pennsylvania, 1864-1883.
In 1836, the buildings composing the almshouse, except the additions to the southernmost one, were substantially the same as now, but the uses of some of them were different. The southern building was then entirely occupied by the hospital – its eastern half by the male, its western half by female patients – while in the centre was the lecturing and operating amphitheatre. The east return wing was filled with insane males, and the west with insane females . . . The lying-in wards were in the west end of the building forming the northern side of the quadrangle, and the children's asylum in the corresponding part of the east end.
I lived in the children's asylum, of which I had special charge, although I had also charge of medical and surgical wards in the hospital itself. If I were asked what half-year in my professional life was the happiest, I should reply the period that I lived in that asylum. I occupied a vast chamber that looked out upon green fields and a fair river, with a view of the city beyond them. I had no companions to disturb me; I was aflame with the desire of knowledge, and all my time was eagerly devoted to the study of disease and of books.
. . . It was a very interesting field for me from a humanitarian as well as a medical point of view. A hundred or more children were sheltered there on their way to the early grave to which most of them were destined: illegitimate and other outcasts formed the majority, and ophthalmia, that curse of children's asylums, made of them a blear-eyed, puny crowd, most pitiable to see. I soon became convinced of the causes that produced the crippling and mortality of these outcasts and waifs. I pointed out to the committee of the board how the disease was disseminated by the children washing in the same basins and using the same towels, and how it was maintained by their having no shaded places for exercise in the open air, and also by the insufficient food permitted them; for if the soup which they received one day was nutritious, the meat of which the soup had been made, and which formed their dinner on the following day, must necessarily be nearly devoid of nutriment. But, of course, the committee on the children's asylum and the guardians knew better than I, and at the time, at least, nothing was done to correct this wrong.
It seems to me that the almshouse smell must be immortal, or can only "by annhilation die." It is, or was, a smell sui generis, for every hospital has its specific smell. Certainly it has no resemblance to the smell of rose, or violet, or lily, nor, on the other hand, is it borrowed of asafoetida or cacodyl. It is a smell that one may recognize as a familiar acquaintance in the prisons of Naples or in the Edinburg infirmary. The smell of a civil or military hospital has its characteristics, but the effluvium of a pauper almshouse hospital has a much intenser quality. It is compounded of the exhalations of the habitually great unwashed; of effluvia generated by the decay of the sick, and the decomposition of their excretions; of the stale or rotting food that has been accumulated surreptitiously and hidden away; of steam from the meat caldron and emanations from the bake-house or the fresh bread; from the heaps of musty old boots and festering garments thrust out of sight and fermenting in unopened closets; and then, mingling with and overlaying all of these, a certain medicinal odor which may be traced to the accumulation of tinctures, and mixtures, and unguents, and plasters, upon the
bedside tables of many patients. It is not what perfumers call a bouquet, which plays a gamut of delight upon the olfactory sense, but an acrid, foetid, sickening, musty, fusty, and above all, frowsy smell, more complex in its combination than the most ingenious compound of the perfumer's art. It is the pervading genius loci, and never is to be encountered outside of the walls of a pauper hospital. You cannot sweeten it; you cannot altogether expel it.
"You may scrub, you may ventilate wards as you will,
But the smell of the almshouse will cling to them still."
It can "only by annihilation die," by a fire that should consume the whole building. But the remedy is too costly.
As everybody knows, one gets used to foul smells, and at last ceases to notice them. Indeed, some persons seem rather to thrive in a contaminated atmosphere. So it is said that scavengers and night-soil workers acquire an immunity to certain diseases. In like manner, the inhabitants of the Nile and the Mississippi basins are said to prefer the muddy water of those streams to clear and sparkling mountain brooks. But it does not follow that the ignorant and stupid and careless should be allowed to sacrifice either themselves or those who are under their care. I cannot doubt that the day will come. when it shall no longer be thought any more consistent with humanity and benevolence that almshouse paupers and hospital patients and their physicians and attendants should breathe a noisome and pestilent air, than it now is to chain maniacs to their cell walls, or strap them in "tranquillizing chairs," as was not long ago the custom.
4. Foundlings at Massachusetts state almshouses, 1858
Massachusetts, General Court. "Report on Public Charitable Institutions, 1858," p. 66.
One other objection to the State almshouses may be here urged, and that is the inducement they offer for mothers to have their little ones in them, or else close to them, when they. . . find their way there. Dr. Brown, of Tewksbury, thus alludes to this evil: –
The other subject to which I would refer is the mortality of our motherless infants. Most of these, no doubt, have mothers living, who have sent them to the almshouse by some one of the following expedients: – The mother may have abandoned her infant in the street, or left it with some family, without providing for its board; or, through the assistance of some friend, or would be benevolent individual, she may have obtained a situation at service, while the child, in such case, is sent to the almshouse, to almost certain death. Or she may have absconded from the institution, leaving her infant to its fate. No less than forty of these almshouse orphans, as they may properly be termed, have died the past year; thirty-two of which were less than one year of age, the others between one and two. No recorded statistics are at hand, but probably not more than three per cent of these orphans, of an age less than one year when they enter the almshouse, live.
Dr. Coggswell, of Bridgewater, in remarking upon the death of children, says:
A large number of "foundlings" and orphans are sent here during the year, from two or three days old, up to six months or a year of age. Some have lain in the streets through one night, and have gone without nourishment, no one can tell how long. They are mostly illegitimate and diseased. By the time they get here they are almost dead, and soon die; it is almost an impossibility to bring one up in one of these institutions, as the statistics too truly show. Some thirty of our deaths have been amongst this class.
Hospitals for children
1. Needed: a permanent hospital for sick children of the poor, 1852
Philopedos, pseudo ("An Ex-Dispensary Doctor") , A Few Remarks about Sick Children in New York, and the Necessity of a Hospital for Them (New York, 1852), pp. 11-13.
"Philopedos" has not been identified, but it is safe to assume that he was instrumental in establishing the Nursery and Child's Hospital which was organized in New York on March 1, 1854.
The sick children of the poor are so numerous – and with almost a never-ending pestilence among them – that it is proposed to establish a permanent hospital as one of the necessary measures for their relief.
For the children of the poor abundant provision is made for the peculiar wants attendant upon their condition in life. The juvenile criminal is sought that he may be reclaimed ere the habit of vice shall render him incapable of moral renovation. Schools are freely opened for the reception of all children, and in such numbers that no one, however poor, need grow up to adult age ignorant of the rudiments of knowledge; and instruction, extending even to literary and scientific accomplishment, is offered to all. Asylums for the utterly destitute offer their protection to multitudes of the helpless offspring of the city pauper, while thousands of parentless children are tenderly carried through that period of life when their very ignorance of a parent's care adds a touching interest to their claims for nurture, for protection and for guidance. Under all circumstances of ordinary destitution is the child cared for by some special method adapted to his needs, with the single exception of sickness.
It must be evident to all who will reflect upon the large amount of sickness there is among the children of the poor in our city, that hospital accommodations for them are among its most urgent wants. In the dwellings of the very poor there is almost always more or less absence of everything necessary for the ordinary relief of the sick, and especially of the unremitting attention that is needed by them. The necessity of constant occupation to obtain the means of existence, precludes the possibility, in a large number of instances, of devoting any time to the requirements of the sick; and it is from this want of attendance, next to want of pure air, that children suffer most. Often too, all the care and watchfulness bestowed may be rendered useless by the absence of the most necessary accommodations. This may be tolerated during health, but in sickness it is not only distressing, but positively injurious. For those who have the necessary comforts for the sick, or who have time that they may bestow upon their families, when they most require it, dispensary attendance is sufficient for their wants in sickness; but when it is known that many children are absolutely destitute of all these – indispensable as they are – the necessity of providing well-ventilated accommodations is evident; a place where all the wants of the sick may be supplied, and especially when personal care must form an essential part of the arrangement: – a need only to be supplied by the establishment of a well-organized hospital.
If it is thought by any that such children as may require removal from their homes could be accommodated in the hospitals already established, it will be necessary to state that there are not hospitals enough for the ordinary wants of our city, now containing more than half a million of inhabitants. Among so large a number of people, many more hospitals than now exist could be filled with distinct classes, either of people or of diseases. Where sickness among children exceeds to so great a degree sickness among adults. . . there will always be a sufficient number of applicants to fill any number of hospitals that will be established for their exclusive use.
The need, also, of a special hospital for children, is evident when it is considered that a large number is to be provided for, and that there should be an adaptation to the wants of a particular class of patients, who require a peculiar mode of management, and attendants adapted exclusively to them.
After a careful consideration of the truths here presented, surely no one can hesitate to do what is in his power to assist in the establishment and support of a Child's Hospital in New York.
2. Children's Hospital, Philadelphia, 1855
Children's Hospital of Philadelphia, Constitution and By-laws (Philadelphia, 1856), pp. 5-6.
"THE CHILDREN'S HOSPITAL OF PHILADELPHIA" owes its establishment to a conviction on the part of a few individuals that much of the mortality which prevails among the children of the poorer classes is owing to the want of careful medical attendance and nursing, and to the deprivation of pure and wholesome air in the narrow and densely crowded courts and houses, in which those of limited means are compelled to live. The bills of mortality of our city will show a large proportion of the deaths to have been of children under fifteen years. This will, of course, vary with the season. In winter it amounts to about one-half, while in summer, when diseases peculiar to our hot weather are so prevalent, the proportion rises to fifty-five to sixty per cent.
Most of these deaths must occur in the families of those unable to provide the necessary appliances for relieving pain and disease; and is it an unfounded supposition that some of them, at least, would have been prevented if prompt medical advice, careful nursing, and a healthy atmosphere could have been obtained?
The "Children's Hospital" was established to meet this want. It aims to supply to the children of the poor in sickness, a portion of the care and comforts which are enjoyed by the more favored classes – to surround them with circumstances favorable to recovery.
When the effort to establish the Hospital in this city was first made, funds were solicited to the extent of $1,800, – a sum amply sufficient, it was thought, to meet all the expenses of organization and support for the first year. This was promptly granted, and sufficient interest shown in the undertaking to warrant its projectors in starting the institution on a permanent basis, and in expecting the continued support of the benevolent.
A building has been rented and furnished, located in a central and accessible part of the city. It is not as well adapted to the purpose of a hospital as one built for the object, but it can be made to answer until our means will enable us to secure a larger and more convenient one.
It was a question among the founders of the Institution and its friends, whether the natural unwillingness of parents to intrust their offspring to the care of strangers, peculiarly strong in some classes of our poor, might not at first affect its influence, and check, to some extent, its career of usefulness. But this doubt is removed. The Institution is already, in two months from its opening, filled to its fair capacity, and with every reasonable prospect that each succeeding week will bring an increased demand on its accommodations.
If this is the fact at this comparatively healthy season of the year, what must be the case in summer, when the diseases peculiar to this climate, dysentery, diarrhea, and cholera infantum, are attacking the young, and sweeping them off by hundreds?
Many of these cases, we firmly believe, might be saved by the application of relief such as this Hospital would afford, and we earnestly desire to extend the benefit of the charity to all who need it. But to do this, we must add to our accommodations. The funds already collected will carry it on its present scale through the current year, but after that time we have no certainty of its continuance beyond a confidence that the benevolence of the community will not suffer a charity so deserving to fail for want of pecuniary support.
3. The children's hospital in New York City, 1857
New York State, Senate, "Report of Select Committee Appointed to Visit Charitable Institutions Supported by the State and All City and County Poor and Work-houses and Jails of the State of New York," Doc. 8, Documents, 1857 (Albany, 1857), 1,133-134.
Under the act for the incorporation of charitable and religious societies, a number of benevolent ladies associated about three years ago for the purpose of taking charge of the children of poor women, who were compelled to leave their homes during the day to seek employment to enable them to support themselves and those dependant upon them. Children, whose mothers had died in giving them birth, were also received and provided for by nurses in the institution, and thus saved from the alms house. [2a] A greater number than the society were able to accommodate asked for admission; and last year two hundred and sixty-seven children and one hundred and twenty-two women were benefited by this charity, nearly all of whom, during their residence there, required medical treatment. Mothers with infants, without a home, of good character, were received and places provided for most of them, and their children kept here at a small charge while the mother was enabled to obtain high wages in other parts of the city. Destitute, neglected and deformed children, far gone for want of proper care, were never refused admission, and often raised from an almost hopeless condition to a healthy state. It was soon found desirable to establish a hospital for the treatment of the sick children apart from those in health, and a small one was provided for the purpose, the benefits of which have been apparent the last summer, when a large number were attacked with scarlet fever; everyone of whom recovered, and by this separation the others escaped the disease. The hospital is found quite too limited in its accommodations, and it is in contemplation to build one of suitable dimensions, where the society may be enabled to receive all destitute children. who need hospital treatment, and which it is not to be supposed this class can find elsewhere.
The mortality in this institution is found to be about twenty per cent., which is less than in the foundling hospitals of Paris and other cities in France. The managers of this charity are assisted in their work by a board of eight distinguished physicians, some of whom are in daily attendance at the hospital, and all are serving without compensation.
It is understood the corporation of the city will give the grounds required as soon as the means are provided for the erection of the hospital; and they have already shown their estimation of the institution, by appropriating two hundred and fifty dollars towards its support. The Howard Association, of New Orleans, upon being acquainted with its objects, also sent a liberal donation for its encouragement and assistance. Large donations have been made by the citizens for the support of the institution, and upon these it must depend for current expenses hereafter; and it is supposed for this purpose they will be continued; but for carrying out the objects of the association, and providing a suitable Children's Hospital, larger means are required than the managers can at present command.
4. The impact of the Civil War on a children's hospital
New York City, Nursery and Child's Hospital, Eleventh Annual Report, 1865 (New York, 1865), pp. 3-4, 9-10.
The war has imposed upon "The Nursery," as upon all other public or charitable institutions, new and unusual trials. While the burdens of the war have diminished our income, by compelling many persons to retrench all their expenditures, including their usual annual outlay in the way of charity, it has seriously enhanced the price of all the supplies necessary to maintain our institution. But while it has thus curtailed our powers for good, the war has also multiplied the calls upon us for succor. By withdrawing the men of the laboring classes from civil life into the army, it has increased the number of women of those classes who are compelled to seek our sheltering wards, or leave with us their helpless children, while they devote themselves with unremitting toil to procure a bare subsistence from day to day.
The appropriations from the State Hospital Fund and the Common Council of the city, which from time to time have been made in aid of our institution, we cannot include in our estimate of this year. We do not by any means despair, however, of this source of revenue; but we should be unfaithful to our sacred trust, and to the mute appeals of the helplessness which looks to us alone for aid under heaven, if we forbore to press upon individual benevolence the necessity of putting beyond all chance or change our ability to discharge this trust.
Mothers! fathers! come with us to our Hospital wards, lean with us over the cribs of our patient little sufferers –
"Think what pain
Makes a young child patient."
Remember the happy homes left behind us; remember the joyous, healthful faces there, and let us endeavor, with God's help, to bring to these poor waifs on life's shore something of life's sunshine.