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Hospitalism

Editorial by Floyd M. Crandall, MD
Archives of Pediatrics 14(6):448-454, June, 1897

 This term may seem to the general practitioner to be one of vague and uncertain meaning. Experience in an infant’s hospital would soon convince him that it well describes a very definite and grave condition. Even in general hospitals the attending staff soon learns that, except for certain incurable diseases, a prolonged stay is usually not advantageous. The younger the patient, the more marked does this become. Under one year, the death rate in all infants’ hospitals is excessive.

The causes for this condition of things are numerous. Some are clearly apparent, and may be easily remedied; others are obscure, and in actual experience are very difficult to correct. During recent years there has been a remarkable multiplication of hospitals for infants and children. The desire on the part of the charitable to provide for the shelter and care of sick babies is a most worthy one. No class of invalids appeals more strongly to the sympathies than do these helpless little sufferers. But it has been the sad fortune of many such benevolent givers to be seriously disappointed in the results, when viewed by the death rate alone. It is difficult for them to understand why infants placed in comfortable and beautiful surroundings should, after a time, begin to pine, and gradually waste away. Hospital physicians have not infrequently been blamed by lady managers for what seemed to them improper haste in sending children out of a comfortable hospital ward to an uncomfortable and perhaps unhygienic home. Yet such a course is necessary in most hospitals to save the baby from hospitalism, a disease more deadly than pneumonia or diphtheria. That this is not an exaggerated statement may be demonstrated by the records of every infants’ hospital situated within the limits of a large city. The condition is by no means a new one; it was described years ago by Jacobi.

The course pursued by these cases was well described by Dr. Henry D. Chapin in the last issue of the Archives. "The earlier the age," says Dr. Chapin, "the greater is the susceptibility to hospitalism, and the quicker it ensues. One of the first conditions to be noted is a progressive loss of weight that is not dependent on the original disease, as it often takes place after recovery when the child is not sent out soon enough. This ensuing atrophy bears an inverse ratio to the age, and is especially marked under six months. Older infants are less susceptible, but if kept long enough, they will surely show stationary, and then losing weight. This often takes place while the infant is apparently digesting its food, which may be the best that can be artificially produced. Beginning atrophy, not depending upon a lesion, should be an indication for immediate discharge from the hospital. If it gets beyond a certain point, no change of environment or food will save the infant."

As this condition develops, progressive anaemia appears, and the child frequently dies from marasmus, or simple wasting without organic disease. Not infrequently pneumonia, diarrhoea, or other acute disease supervenes, which the child is totally unable to overcome. Many such children might be saved by timely removal from the hospital, despite the apparent contradiction that their lives had been saved not many weeks before by admission to its wards.

Conditions Requisite for the Successful Rearing of Infants

A study of hospitalism, and the strange tendency shown by infants to waste away in apparently congenial surroundings, naturally leads to an inquiry regarding its causes. This in turn leads to an inquiry regarding the conditions essential to the successful rearing of infants. These conditions may be considered under three general headings, succinctly stated by Holt as "care, fare, and air."

The care of the infant involves the important subjects of clothing, housing, and personal hygiene. By modern methods perfection in clothing has been almost attained. Perfect personal hygiene may also be obtained. In the changeable and hostile climate of northern latitudes perfection of environment is almost impossible. In the home the very important question of exercise for an infant may be successfully settled. The healthy infant, when awake, is in constant motion. A certain amount of handling and changing of position is almost necessary for good health. This, it is true, may be easily overdone, but the holding in the arms and fondling which an infant receives from a judicious mother or nurse is decidedly beneficial. It is certain that nature never designed that a baby should lie quietly in a crib from morning to night.

The subject of infant feeding is altogether too large to be entered upon in this place. It is sufficient to say that it is not enough that the general plan of artificial feeding be good. Eternal vigilance is also necessary, lest the details be neglected. The life of many a delicate child has been sacrificed by the neglect of apparently trivial details, where the general plan has been beyond criticism.

If an infant requires one thing more than another it is air – fresh air, pure air, and plenty of it. Because the baby is small, it is often thought that it requires but little air space. As a matter of fact, an adult will thrive in a smaller air space than will an infant. The clothing and hygienic care may be perfect, the food the best that can be obtained, but if a child is confined in a small and poorly ventilated room, it will not thrive. It is quite true that many children seem to thrive under very unpromising conditions, but the conditions necessary for the successful rearing of the average baby are many, and the details are legion. The man of one idea can never be a successful pediatric practitioner. For the infant more than for the adult the general plan of management must be wise and judicious, and the multitudinous details must be carried out with unremitting care.

Are These Conditions Fulfilled in Infants’ Hospitals?

This question cannot be answered in a single sentence. Some of the many conditions are fulfilled to perfection, others very inadequately. The clothing and bedding are usually good; frequently they are of the best. Heating, lighting, and hygienic arrangements are often as perfect as skill can make them. Personal care, however, is frequently inadequate, owing to an insufficient number of nurses.

Personal care involves much; it is not limited to a bath in the morning, to changing the napkins, and to preparing a bottle at stated intervals. Every child should be taken in the arms when it is fed, and should be held until the feeding is completed. Feeble children should be frequently turned in their cribs, and kept in proper positions. All children should receive adequate opportunity for exercise of the limbs. All this requires constant attention. Dr. Chapin is very moderate when he says that one good nurse should be supplied to not more than four or five sick infants, and in some cases one nurse may be required for only two patients. Improper care of infants is far less common in hospitals than inadequate care. Lack of an efficient nursing force is one of the important causes of hospitalism. When the nurses are incompetent or indifferent, the results are always shown in the death rate.

Improper diet is the cause of many deaths in hospital children. Every physician has experienced the difficulty of impressing nurses with the importance of care in every detail of feeding. It is almost impossible to obtain a sufficient number of nurses for a large hospital, each one of whom will appreciate the vital importance of details, and will be strictly conscientious in carrying them out. After the greatest care has been exercised in obtaining a perfect milk supply, and instituting a perfect system in the diet kitchen, the ward nurses must be relied upon to handle the milk and administer it properly to the children. At some point in the long line between the dairy and the babies, error or carelessness is liable to creep in with its disastrous results. Unremitting vigilance on the part of some one is necessary to insure safety to the infants.

Ventilation and air space is another subject of cardinal importance in the hospital management of sick children. Every detail in hygiene and nursing may be perfect, the feeding may be of the best, but if the children are crowded too closely together, hospitalism is almost certain to appear. Large air space alone, however, is not sufficient; it will be futile if proper appliances for ventilation are not supplied. But without generous air space proper ventilation is almost impossible. The babies’ ward should be broad and high, to give sufficient space in cubic feet. But this measurement alone may be misleading if the cribs are placed too close together, side by side. Adequate floor space is also indispensable. The eighty-one square feet of floor and 1215 cubic feet of air allowed for each child by the Edinburgh Royal Hospital for Sick Children is none too much. Twelve hundred cubic feet must be considered the minimum compatible with safety; 2000 cubic feet, as allowed by St. Luke’s Hospital of New York, is far better.

There can be no doubt that the failure of many hospitals to obtain proper results has been largely due to this single cause – overcrowding. Beautiful buildings, good nursing, and adequate feeding, will be unavailing if the babies are crowded together without sufficient air space and proper ventilation. Hospital babies will continue to perish until they receive in generous amount each of the three great requisites for their proper maintenance – care, fare, and air.

Obstacles Encountered by Infant Hospitals

Before a hospital is condemned upon its death rate, the class of cases it receives should be considered. The charity or foundling hospital of a large city receives many cases beyond the possibility of human aid. Many are in the last stages of marasmus, or other fatal disease. Many are the offspring of diseased, drunken, or vicious parents, and are without constitutional stamina.

The last report of the Babies’ Hospital of New York refers to this subject in the following words:

"Fully two-thirds of the babies under six months old, who are brought to the Hospital, are suffering from marasmus when we first see them. Unless you have been in the receiving ward, and heard there the tale of poverty, often destitution, neglect, starvation, and not infrequently, abuse, at the hands of a drunken father or husband, which accompanies these little waifs when they are finally landed at our doors – unless you have seen and heard for yourself, you can form but a faint conception of what the previous life of these children has been, or, in many cases, what their mothers have suffered before they were born."

At this same hospital careful investigation showed that over half of the patients received under six months of age had been systematically drugged with opium in the form of paregoric or soothing syrup. Too much should certainly not be expected from a hospital with such material to work upon. However, if a hospital is devoted to true charity, no sick child whose disease is not contagious is turned away, and it is very unjust to judge by the mortality rate of the good accomplished.

The class of patients received by an infants’ hospital is peculiar. There are many general hospitals to which people of means repair during illness, or for surgical operations. The private apartments in some of these institutions are sumptuous, and command a large price. The inmates of an infants’ hospital, however, are always charity patients, for no mother will surrender her child who can give it suitable care at home, nor will she enter a hospital with it. Many of the infants are orphans or foundlings, or the children of drunken and criminal parents. Very few have received the care which is received by the child seen in ordinary private, and the results are only too apparent. The foundlings and orphans cannot be sent home when convalescence is established, but must be retained in the hospital without regard to consequences. On the whole, the inmates of an infants’ hospital are far inferior in constitution, and in the ability to withstand disease, to those received by the average general hospital. This is without question an important element in causing the large death rates common to those institutions. It should not be forgotten, moreover, that the mortality of all children during the first year of life is many times greater than that of any other similar period.


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