The Scope and Limitations
Gentlemen of the American Pediatric Society: -- Our meeting this year completes the first decade of the Society. From the small beginning made by a little group in Washington in September, 1888, we have grown to an organization with fifty-four active members, and have done, as a Society, work which has made our name known on both sides of the Atlantic and reflected honor upon American medicine.
In the evolution of this comparatively new specialty, the American Pediatric Society has done much to mould medical opinion. To this body of men, made up largely of the teachers of pediatrics in America, the profession here still looks to work out many of the difficult problems presented by disease in early life. Something we have done, but how little in comparison with the great work yet to be accomplished.
Since our last meeting two of our most distinguished members, both of whom have filled the office of President of the Society, have died. Dr. J. Lewis Smith was one of the pioneers in this department, and his book has probably been more widely read than any book on pediatrics in the English language. Dr. Smith passed away in the fulness of his years, in the midst of the arduous work with which his life had been filled. And how can we express our loss in the death of Dr. Joseph O'Dwyer? Where shall we find another to fill his place? In his modest manner, his rare judgment, his mental balance, and his straightforward method of attacking a single problem and patiently working out its solution to the minutest detail, he was indeed an example to all of us. We miss his genial face among us today, and cannot but feel that our Society has met with an irreparable loss.
And now may I ask your attention for a few minutes to a subject which has for me the deepest interest and which must be of vital importance to every pediatrist, viz:
As the past thirteen years of my life have been intimately connected with such institutions I have thought that nothing which I could bring before you would be of more interest than some of the questions connected with their medical management. It has always been true in the history of medicine that special hospitals have followed the development of new departments, these hospitals being at once a cause and a result of such scientific interest. Europe has had its children's hospitals for nearly half a century, and now almost every continental city may boast of a well equipped one. In America, however, hospitals for children are still few, and in many of them the greater part of the service has been given over to the department of orthopedic surgery or to wards for contagious disease; while little room has been left for general medical cases, and usually none at all for children under two years old. Provision for the hospital treatment of sick infants has been the last to come, but it is coming fast, both in the organization of separate hospitals and in the addition to many of our general hospitals of a ward for infants.
The claim of pediatrics to be recognized as a special department of medicine must rest upon the fact that it is devoted to the problems connected with disease in the first years of life. I venture the prediction that the pediatrist of the future will not be he whose interest lies in whooping-cough, scarlet fever, diphtheria, measles, and other diseases which simply occur more frequently in early life than later, but he who devotes himself to diseases and conditions peculiar to the first three years of life. The hospital of the pediatrist, therefore, is not the hospital for contagious diseases, nor yet one where only children over four years are received, but the hospital for infants and very young children.
Hospitals are needed in this department, in the first place, as places of research. The question of the saving of infant life is fast becoming a vital one in social economics. In New York City during the past eight years, the mortality of infants under one year has been 86,738, being about one-fourth of the total death rate, and very nearly the same proportion as is maintained in the cities of Europe. But it is interesting to note that in New York, with increasing knowledge and better sanitation, there has been during the last few years a very decided reduction in this mortality. The year 1897 showed a death-rate under one year, nearly one thousand less than that of any recent year. These are actual mortality figures, it should be remembered, not percentages, and this reduction has been brought about in spite of a steady increase both in the population and in the number of births reported. These facts are certainly most encouraging and should stimulate all of us to do our utmost to improve city sanitation and to spread knowledge upon all subjects relating to infant feeding and care.
But still more encouraging are the results now obtained in private practice among the better classes. Of 151 children who, during the past eight years, have been under my care through practically their entire infancy, not one died before reaching the end of the second year. This is still more significant when we consider how they were fed: only thirty of the number were breast-fed either by the mother or wet-nurses through the greater part of the first year; thirty-three were partly nursed and partly fed, nursing being usually continued for two or three months alone, after which the bottle was added; ninety were entirely bottle-fed. This certainly makes a good showing for artificial feeding and indicates very clearly that among the class of people where artificial feeding can be properly done, it is extremely satisfactory.
During the past eight years while I have been practicing almost exclusively among children, I have had among my own patients but six deaths in children under two years; one from marasmus and a cerebral malformation; one from acute inanition, under observation but ten days; one each from general tuberculosis, intussusception, entero-colitis and pneumonia. I do not these these are exceptional results; for on inquiry I have learned from six professional friends in New York, all of whom practice among children, that their experience in the same class of patients was almost identical with my own. From the facts thus collected I judge that in the well-to-do classes, with the best care, the mortality from all causes during infancy does not exceed two or three per cent., as against a general mortality for this period among all classes of about twenty per cent. These are most hopeful signs and show the possibility of a very great reduction in infant mortality everywhere with a better understanding of all the conditions, but especially of infant feeding.
Referring again to the death-rate in the city of New York, we find that 34 per cent. of the entire number of deaths occur in children under two years, and only 12 per cent. in children from two to fifteen years. Or, in other words, as it is well known that morbidity and mortality figures correspond very nearly, three times as much serious sickness occurs in infants under two years as among all the other patients coming under the care of the specialist. Conditions hereafter to be considered make it undesirable, and in fact forever impossible, that any large percentage of these shall be treated in hospitals, although there are those who look forward to the time when most adult patients shall be treated in institutions, both obstetric, medical and surgical cases. But it is none the less true that only in hospitals can any great headway be made in the solution of many of the problems connected with infantile disease. Let it be clearly understood then from the outset, that hospitals for infants serve perhaps their highest function when they can determine from careful study and observation of the few what is the best treatment for the many.
As places for research, hospitals must be well equipped with pathological, bacteriological, and, if possible, chemical laboratories, in order to work out in the fullest and best way the problems constantly arising in the treatment of acute illness. The state spends without grudging large sums of money every year in the experiment stations of the agricultural department to determine the best conditions under which hogs, cattle, fruits, etc., shall be raised; why shall it not devote at least as much of its energy toward the solution of the problem how infants may best be reared, and how the great sacrifice of infant life which now exists may be diminished.
Hospitals are needed, in the second place, for the teaching of physicians and students. One of the greatest deficiencies in the curriculum of the medical schools of the day is the insignificant attention paid to subjects connected with infancy. In order to give students an opportunity for study, hospitals are absolutely necessary. Every hospital should be a teaching hospital. This work in no way interferes with its function of caring for the sick, and has a far wider value in philanthropy than the caring for the children in the wards. The selfishness of those hospital physicians in America who are content to enjoy for themselves the peculiar privileges and opportunities which their positions carry with them, with no thought of their obligation to advance the science of medicine, is unworthy of our profession.
Thirdly, hospitals are needed for the training of nurses. It is just as impossible for nurses as for physicians to learn how to take care of sick infants in the wards of a general hospital, and trained nurses are quite as important for the well-being of the public at large as are trained physicians.
Fourthly, hospitals are needed for the care of such cases as can be better treated in institutions than at home. Of this more will be said later.
The question naturally arises whether a department for infants in a general hospital may not be more advantageous than an institution specially established for this work. My own belief is in favor of special hospitals for the following reasons: It is hard to rouse in the average house physician proper interest in the nutrition and diseases of infancy while he sees around him on every side the brilliant counter-attractions of surgical work and an acute medical service among adults. It is only after the young physician has begun his private practice that he appreciates the value of a knowledge of diseases of infants. Again, it is usually the case that the attending physicians pass over the ward for infants with very scant attention. This may be remedied, of course, and always should be by the appointment of a special attending physician to these wards. But perhaps the chief difficulty is with hospital boards; it being difficult or impossible to make them appreciate the fact that the requirements in the hospital treatment of infants are very different than those for adults.
Hospital work for infants has its discouraging features; the first years of every such institution are sure to reveal many of these. One of the most prominent is the very high mortality -- something which was not previously expected and which, as compared with the mortality of ordinary adult hospitals, seems simply awful. This has often so discouraged boards of managers as almost to induce them to give up the enterprise altogether. It is difficult to determine what a reasonable mortality in hospitals for infants should be on account of the many different conditions which affect different institutions. It must be remembered that the mortality of infants under one year is high in all cities, even outside of hospitals; and that in institutions where chiefly cases of serious illness are brought, it must of necessity be very high. Of 1,217 cases under one year old admitted to the Babie's Hospital in seven years, there were 548 deaths, a mortality of forty-five per cent.; and if we should add those removed by friends when a fatal result was inevitable, in order that they might have the consolation of the child's dying at home, the mortality would run up fully fifty per cent. The reasons for this high mortality are to be found in a study of the class who make up the bulk of patients who are sent to a hospital for infants. These are:
Regarding cases which are hopeless on admission, like most of those just enumerated, one must admit that they have the same right to hospital care and shelter as have cases of cancer or advanced tuberculosis in adults. They are going to terminate fatally whether they are admitted to a hospital or not, but no institution which claims to be charitable or philanthropic can refuse to take its share of these hopeless cases. However, the fact that their proportion is so large, is what raises the mortality figures of an infants' hospital so high. But to judge of the usefulness of an institution by its death-rate where such material is received, is manifestly unfair; nor can it be in any way compared to the mortality in hospitals for adults.
Another discouraging factor for many hospital managers is the expense required. This consists largely in the care and nursing, since the cost of food and supplies play but a minor part. Our lowest expense in the Babies' Hospital has been about one dollar and twenty cents a day per capita, and as the work has been better done the expense has risen until it is now about a dollar and a half per day. It is hard to make hospital managers appreciate the fact that the value of work consists not in its amount but in its quality.
There are some peculiar conditions in infants' hospitals which must be considered; those which affect the nutrition of the patients are of the highest importance in modifying the results obtained and are in fact paramount to every other consideration. In private practice the outcome of ever acute illness among infants is determined chiefly by two factors. One of these is the patient's previous nutrition. While we do see infants, previously robust, who succumb to acute attacks of pneumonia or intestinal disease, by far the greater number of those who die, perish because they were previously feeble or delicate. The second factor is how well the patient's nutrition can be maintained during the acute attack. This relates not merely to food and feeding, but to all conditions affecting the nutrition -- air, bathing, clothing, and general care. It often happens that the disturbance of the patient's general nutrition is more profound and more serious than the local effects of the disease. Thus, a child may have an acute attack of pneumonia which runs its usual course; the lungs clear up; the cough disappears; but the child does not recover his previous health. Before this disturbance he was sufficiently vigorous not only to maintain existence but to increase in weight; now, however, the balance is against him and he cannot seem to make progress not matter what is done. Little by little he continues to lose in weight until he finally dies from marasmus. Not only do these results follow serious acute diseases but attacks of bronchitis, or indigestion, which are not very severe and sometimes such a mild thing as tonsillitis.
Another striking thing seen in hospitals is the frequency with which one acute attack is followed by a second, and perhaps this by a third, until the child is finally worn out. I have seen as many as six distinct attacks of pneumonia in the course of three or four months -- the lungs between the attacks in some instances clearing entirely, as shown by the signs, and in others great improvement taking place but never quite the evidences of local recovery. To be sure, one sometimes sees such things in private practice, but they are seldom met with unless hospital conditions are approached, both as to surroundings and the previous condition of the patients.
In adults, the prognosis in most acute infections depends upon the severity of the attack and the integrity of the important viscera -- the kidneys, heart, liver, etc.; but in infants, upon the nutrition of the patient, even more than upon the severity of the attack, since in a child with feeble resistance even the slightest attack may begin processes which go on to a fatal termination.
We come therefore to the conclusion that the first condition of success in hospitals for infants is a solution of this problem of nutrition, difficult in health often even under the most favorable surroundings, much more difficult in disease, but in disease and under unfavorable surroundings well-nigh insoluble. The things to be considered as affecting nutrition are mainly four: air space, ventilation and airing, nursing and care, feeding.
The Air Space. -- In most hospitals for infants the maximum allowance is only 600 or 700 cubic feet to each bed. At the Randall's Island Hospital, New York, it is in many wards much less than this; in one of their diphtheria wards it was but 400 cubic feet. At the Nursery and Child's Hospital, 650 cubic feet has been set by the Board of Health as the allowance. At the Babies' Hospital we began with this space but found it to be totally inadequate. For the last three years the allowance per bed has been 800 cubic feet, and it is now 1,000 cubic feet. With less than this I am sure the results will always be unsatisfactory with children under one year. For those who are beyond this age a little less may suffice except in cases of very acute illness. Our experience may be stated somewhat as follows: two infants in a ward of a given size do well; three may do fairly; four are sure to do badly, and, if the number is increased beyond this point all will fail rapidly and some will soon die. In the old Emigrant Hospital on Ward's Island, Dr. A. M. Thomas found that infant feeding could be conducted almost as satisfactorily in the ward of an institution as in private practice, but his experiment was conducted with an allowance of 2,500 cubic feet to each child.
The question of ventilation is a difficult one and it must be considered with that of airing infants. No matter how good the ventilation of the ward, infants must be taken from it once or twice a day to an apartment where an entire change of atmosphere is secured. Separate rooms for airing, protected balconies or sun-gardens must form a part of the equipment of every hospital if good results are to be obtained; some provision, however, must be made to get infants out of their habitual atmosphere. The youngest, and those most acutely ill, need it most, and should have a change of at least two or three hours a day, thorough airing and ventilation of the wards they have left being accomplished meanwhile. Nothing is quite so fatal as overcrowding in close, superheated rooms. The time of airing and the change of temperature allowed should be carefully regulated by the physician and made a distinct part of the child's treatment. In the wards, ventilation should be as perfect as possible, and there should be open fires whenever these can be secured. These things are often carefully looked after during the day, but entirely neglected at night.
Cleanliness in its minutest details should be secured at whatever cost. Under the artificial conditions of hospital life purity of the atmosphere is absolutely necessary. Nothing which contaminates the air of the ward should be permitted. Soiled napkins should be immediately removed. No gas should be used at night; but, if not electricity, the wax night-lamp of the nursery. Frequent fumigation of the rooms with formaline or sulphur should be practiced where cases of acute illness are continually treated. The floors should be wiped daily with cloths wrung out of aseptic solutions. All of these matters, of course, greatly increase the labor of hospital work, and consequently the expense. It costs to keep clean, but the surgeons have demonstrated to us that it pays. The essential hygiene conditions belonging to a well-appointed nursery are indispensable to good hospital work.
The temperature of the different wards should be suited to the nature of the cases treated. Thus 75° F. may be necessary for premature, very feeble and some marantic infants; 68° to 70° F. for ordinary cases of acute illness; 66° to 68° F. for those not acutely ill and for most children over one year old. For convalescent children provision should be made for additional outings on balconies, piazzas, and in hammocks and perambulators about the grounds whenever the weather will permit.
Nursing and Care are no less important than the matters already mentioned. Infants require fully four times as much care as any other class of hospital patients. No good results can be expected where a ward with twenty babies is given into the care of three or four nurses, however intelligent and industrious. It has been my experience that even in the case of infants who are not acutely ill, no more than three can be well cared for by a single nurse, and for those who are seriously ill one nurse to every two children is the minimum. This nursing must be constant and it does not consist simply in the administration of food and medicines, and the application of clean diapers; infants must be taken from their beds, held, given opportunities for change of position, and in most cases for a certain amount of exercise.
Feeding. -- To obtain the best results a hospital for infants should have command of every method of feeding; not only the most approved methods of artificial feeding such as can be furnished by a milk-laboratory in the hospital, but with wet-nurses for certain special cases. Nothing is more discouraging than the great difficulties in the way of artificial feeding in institutions of children under six months old. For those wasted specimens admitted with chronic indigestion and malnutrition practically nothing can be done by any method of artificial feeding that I have ever tried.
The greatest difficulties in the hospital's treatment of infants are met with in patients under one year. After this age the conditions of nutrition are usually not so hard to control, and the proportion of those children who do well is very much larger. The dangers of "hospitalism" are therefore inversely proportional to the age of the patient. in a very young infant whose organism has not yet acquired stability, resistance is so feeble that it can not long be subjected to hospital conditions without serious injury. In such patients it seems to be impossible to combat at the same time the effects of acute disease and a depreciated nutrition. But with every month of advancing age the problem becomes easier, and when their nutrition may be said to be established, they can withstand the deleterious influences of hospital life, and most diseases can be successfully treated.
According to my experience, the diseases and conditions during the first year which are especially suited to hospital treatment are acute pneumonia, empyema, acute forms of gastrointestinal disease, otitis and its complications, ophthalmia, acute surgical cases and most cases of eczema in children over six months old. In all acute diseases it is unwise to retain the infant in the hospital after the acute stage of the disease is past unless the hospital is in the country; and even here in a few weeks the baneful effects of hospitalism are frequently apparent. The retention during the whole period of convalescence is fraught with great danger and is very frequently followed by secondary attacks. In a large number of the cases above referred to the condition is somewhat like this: The disease can be cured provided the child is sufficiently strong and old enough to stand the strain of life in a hospital. This is a question to be considered in every disease which requires a prolonged stay. One of the most striking limitations which one encounters in the treatment of infants in hospitals is in the management of cases of chronic nutritive disorders. Complete restoration to health and vigor of such children in a hospital, although not impossible, is not to be expected. Perhaps the most that can be done for them is to keep them long enough to decide the question of the method of feeding best suited to the case, then care for them as outpatients.
During the second and third years the results in the treatment of all diseases are very much more satisfactory. Not only may all the diseases enumerated in speaking of the first year be successfully managed, but also many chronic nutritive disturbances, such as simple malnutrition, chronic indigestion, rickets, scurvy, cretinism, some chronic surgical cases, and under certain circumstances some of the contagious diseases, provided the hospital has facilities for their isolation. With reference to the admission of contagious diseases during infancy, however, great dangers and very bad results are usually seen from grouping many children together, particularly in measles, diphtheria and whooping-cough, where the tendency is so great to the development of broncho-pneumonia amid such surroundings. Many of the bad results attributed to the use of antitoxin in infants are simply the effects of hospitalism and were seen years before antitoxin was known. In a recent epidemic of measles seen in the Nursery and Child's Hospital, over one-third of all the cases were complicated with pneumonia, and in some wards almost every child with measles developed pneumonia. Dr. Crandall tells me that of thirteen cases of measles in one crowded ward in the Randall's Island Hospital, twelve were fatal, all from pneumonia. Results in measles and diphtheria during the first two years are, I believe, much worse in crowded hospitals than when children are treated separately in tenement houses, even under very bad surroundings. One of the reasons why cases like those mentioned above are not suited to hospital treatment is the prolonged stay which convalescence from infectious diseases requires. Under such conditions, complications like late pneumonia, entero-colitis, etc., are almost certain to develop, and to these many patients, who escape acute disease, succumb.
There are several peculiar phases of disease seen in infant hospitals. One of the most striking of these is hospital marasmus. While it occurs most frequently in children already suffering from malnutrition, or in those who have previously suffered from acute disease, it is seen in others who were perfectly well on admission. After gaining perhaps for a week or two, such children, as a result of hospital surroundings, begin to lose appetite and color; they show stationary weight, then a loss of a few ounces; then vomiting begins, and a more rapid loss continues, until a condition of marasmus is reached. Some of these children show no evident signs of indigestion, and may continue to have good, well-digested movements from the bowels. Gradually they become more and more anaemic, frequently there is general oedema, and at last they succumb to marasmus. Toward the end there may be an intercurrent attack of some acute process like bronchitis, acute diarrhoea, possibly broncho-pneumonia; but death often occurs without any of these, the autopsy showing no lesions to explain the fatal result. Hospital marasmus is rarely seen except in infants under eight months old, and occurs most frequently in those under four months old. It demonstrates beyond any question how injurious to infant life is the atmosphere of a hospital. As already stated above, one-third of the deaths in children under one year who are admitted have been, in my experience in the Babies' Hospital, due to marasmus.
A most distressing thing is the frequency with which children admitted for simple malnutrition or some slight ailment, develop some serious forms of acute disease while in a hospital. I need not dwell upon how often the contagious diseases are contracted amid such surroundings; this is well known and fully appreciated. I wish especially to refer now to other diseases, particularly pneumonia and acute intestinal diseases. The hospital records show that during the last ten years no less than thirty children, admitted for minor ailments, developed primary pneumonia, and many more developed inflammation of the gastro-intestinal tract. While without doubt the opportunities for infection from without are very great in a hospital, it is my belief that most of these attacks are to be regarded as examples of auto-infection, and are due to the fact that the child is placed under conditions which greatly diminish his resistance. Few things are more discouraging than to see a child, admitted in tolerably good condition, develop, after a stay of a week or two in the hospital, an acute pneumonia or entero-colitis which proves fatal.
From what has been said, the inference may be drawn that infants should not be sent to hospitals for minor ailments and kept there a long time, also that the effect of combining sick and well children in the same ward has a most injurious effect upon the latter; and, further, that after every form of acute illness, children should be removed as soon as possible from the hospital atmosphere.
The ideal infant's hospital, in my opinion, is not a large one. The general hospital with its two or three hundred beds can not be imitated here. The greater the degree to which infants are massed and crowded together, the more unnatural are the conditions under which they are placed, the worse are the results of treatment and the less valuable does the study of disease under such conditions become as a guide to practice elsewhere. As an illustration of this point, let one study the statistics of the large foundling asylums of Europe. A hospital of fifty or sixty beds is, in my opinion, greatly to be preferred to one of double or treble the size; but it should be provided with every appliance known for the relief of sick infants, and its work should be done under the most approved conditions for achieving the best results. Its hygienic surroundings should be more carefully considered and watched than those of a well-appointed nursery. Small wards containing from four to six patients are greatly to be preferred to those of fifteen or twenty, if for no other reason than to avoid the danger of contracting contagious disease. So far as work in large cities like New York is concerned, hospital work during the summer should be conducted in the country. With diarrhoeal diseases, I believe, the results obtained in close hospital wards in the city are quite as bad as in the tenements.
A reduction in hospital mortality is to be secured not simply by improving our methods of feeding, although this has been the aspect of the subject which has so far attracted most attention, I regret to say, to the neglect of the other phases of the question. This is not all the problem nor, to my mind, even the most important feature of it. Between ordinary methods of feeding and the best methods the difference in results in institutions is not great, indicating very clearly that this is not the factor of chief importance. It is a familiar experience to see an infant, who, in a hospital, has been losing in weight and showing all the signs of perverted nutrition, begin to improve at once and gain steadily when removed from the hospital ward, sometimes upon the identical food which it was receiving, and not infrequently when both the food and the manner of feeding have been greatly inferior. In hospitals not only the feeding, but all other conditions mentioned must receive due consideration as well -- the air space, ventilation, airing, temperature, nursing and care. When all these are fulfilled, I believe that the results obtained will fully justify the existence of separate hospitals for infants in bringing about a more accurate and wider knowledge of infantile diseases and their treatment.
Hospitals for infants are necessary, as I have already shown, but they must be conducted with a very definite knowledge of what can be done in them and what should not be attempted. By recognizing fully their limitations, as well as their advantages, they may be made of the greatest possible benefit to the profession and the public. The conditions of success are difficult and the discouragements are many. Those with experience will not say, I am sure, that I have over-stated the facts. The work must be well done to be of any value either to the patients treated or to medical science, and unless circumstances will admit of its being done well it should not be attempted at all.
14 West Fifty-Fifth Street.