Pediatric hospitals began in the United States with the establishment of Nursery and Child's Hospital in New York City in 1854. Children's Hospital of Philadelphia opened its doors the following year. During the 1860s three other hospitals for children opened: Chicago Hospital for Women and Children (1865), Boston Children's Hospital (1869), and the New York Foundling Asylum (1869). Over the next thirty years most of the major cities in America created a children's hospital.
The establishment of children's hospitals paralleled the explosion of hospitals in the rest of the country. As historian Charles Rosenberg has pointed out, the rapid growth of American hospitals between the 1860s and the 1930s reflected changes in American cities as well as in the medical profession. The development of children's hospitals reveals as much about society's evolving perception of children as about the changing role of medicine in America. Many major cities still rely on children's hospitals as centers for care, not merely for inpatient services but also for outpatient care.
Children's Hospitals and Nineteenth-Century Reforms
Early children's hospitals began as coalitions between elite physicians, who sought the experience and prestige of hospital appointments, and influential laypersons, who sought to improve the lives of poor children. Antebellum reformers believed that poverty, disease, and morality were closely linked and therefore that hospitals should instill moral values as well as offer medical care. Because of their youth and innocence, children seemed particularly amenable to this form of social meliorism. Thus it was no accident that early children's hospitals espoused overtly religious missions.
Child saving was a prominent feature of many late-nineteenth-century reforms, including the movement to abolish child labor and the kindergarten movement, and optimizing child health played an integral role in these reform efforts. Hospitals were part of a larger societal move that turned to institutions and professions to solve social problems. Pediatrics and children's hospitals were typical of Progressive-era reforms.
In addition to appealing to charitable and religious motives, the movement to establish children's hospitals was a reaction to fundamental changes occurring in American cities. Historian Morris Vogel demonstrated how urbanization, industrialization, and immigration strained American cities and created a growing need for hospital services for poorer citizens. Families crowded into cramped tenements lacked both extended family members and space to care for seriously ill family members. As poor mothers entered the workforce, they too were unavailable to care for sick children. For many desperate families, the hospital was the only place for health care. Like other hospitals of the era, pediatric hospitals were designed specifically to care for the children of the "worthy poor." In reality, however, children were only turned away if they were deemed contagious or incurable. Wealthy families could afford private physician care in their homes; only the most destitute families brought their children to the hospital.
The hospital was not simply a response to societal changes. During the late nineteenth century, medicine was becoming increasingly cognizant of the unique medical needs of children. Doctors with a particular interest in children's diseases argued that sick children merited medical care separate from adults. Children were not little adults, these doctors argued. Not only did children react differently to common diseases, but they suffered from distinct diseases and presented unique diagnostic and therapeutic challenges. The appalling infant mortality rates witnessed in late-nineteenth-century American cities lent a sense of urgency to the issue of child health care. Blaming this atrocity on a combination of moral laxity among the poor, inadequate city resources, and the relative inability of babies to resist disease, doctors and reformers alike felt called to attack this serious problem.
The young field of pediatrics took the pressing health care needs of children seriously. Pediatrics formally began in the 1880s with the creation of the American Medical Association's Section on the Diseases of Children (1880) and the American Pediatric Society (1888). These early pediatricians witnessed first hand the benefits of separate hospital care for children. Their efforts at professionalization legitimized the young field of pediatrics, created a community of like-minded doctors, helped elaborate a scientific rationale for the field, and publicized the advantages of specialized care for children. The concentration of sick children in pediatric hospitals also provided a fertile training ground for young doctors interested in pediatrics. By working on pediatric hospital wards, these ambitious doctors refined surgical techniques, tested new therapies, and conducted research on childhood diseases.
Early Models of Children's Hospitals
Most nineteenth-century general hospitals occasionally admitted children. Typically, these youngsters were placed on adult wards, where they were cared for by nurses and doctors who lacked special training in children's health. Shortly after the turn of the twentieth century, general hospitals began to acknowledge the benefits of separate care for children and created pediatric wards. Typically, however, general practitioners–and not pediatricians–treated these children.
Although early hospitals for children promised distinct advantages over general hospitals, these institutions varied considerably in philosophy and services. Some evolved from older institutions for children, especially orphanages andfoundling homes for abandoned infants. Others began as babies' hospitals, concentrating on the health problems of infancy. Their medical mission focused on providing nutritious infant formula and treating diarrhea, the predominant disease responsible for the inordinate infant death rate. Because medicine could do so little to counteract infant mortality, most early children's hospitals limited their clientele to children over two. As urban sanitary conditions improved after 1900, however, infant mortality declined and babies' and children's hospitals merged into the modern institution that treats children of all ages.
The humble beginnings of children's hospitals reflected not only their meager financial resources but also their philosophy. The founders typically procured a small house, assigning separate wards for female and male patients. If space allowed, patients were further divided onto surgical and medical wards. Because contagion could close a hospital and threaten the lives of already weak children, an isolation room was commonly included. The hospital matron lived in the hospital and oversaw daily patient care. In this homelike environment the trustees believed that sick, poor children would receive the warmth, nurture, and comfort of a Christian home. Toward the end of the nineteenth century, as physicians began to play influential roles in hospital management, a more medical model of pediatric care emerged, and many children's hospitals expanded to freestanding buildings with up-to-date hygienic designs.
Hospitalizations frequently lasted weeks, even months. Despite an attempt to bar chronic and contagious diseases, many early hospital wards were filled with children with these complaints. A large number of children suffered from tuberculosis, a major and indolent killer of nineteenth-century Americans. Many children who entered the hospital were severely malnourished or near death's door; their recovery, if it occurred, was protracted. Because so much hospital care was supportive, nursing was critical. Members of religious sisterhoods often acted as nurses in early hospitals; by 1900 professionally trained nurses had replaced these volunteers.
Hospitals severely limited visiting hours, making it difficult for working parents to visit their sick children. These visiting hours reflected practical concerns that families would worsen homesickness, create behavior problems on the wards, introduce new infections and unsanctioned food, and adversely affect recovery. In addition, poor families were often held responsible for their children's illnesses and therefore frequent contact with parents was considered detrimental. Attention was paid, however, to entertaining sick children; photographs show rocking horses and dolls in the wards.
After discharge, children were either sent to a convalescent home or followed in the hospital's outpatient department. Because recovery from disease and surgery was often protracted, many pediatric hospitals established convalescent homes in the country, where recuperating children spent several weeks receiving fresh air and nutritious food. Beginning in the 1890s hospitals assigned social workers and nurses to visit convalescing children at home in order to teach families the principles of adequate home care.
One of the most unusual early pediatric hospitals was the floating hospital. Modeled in part after military hospital ships, the floating hospital took sick children and their families into the harbor, where they could breathe the supposedly salubrious sea air. While on board, children would be given carefully prepared formula and parents would be taught the benefits of proper nutrition and hygiene. Initially, the trips were day excursions; by the 1920s the sicker children stayed overnight as well.
A Unified Pediatric Model
Throughout the nineteenth century, pediatric hospital care largely consisted of nursing, nutrition, dressing changes, and general supportive care. As pediatrics became more professional and scientific in its approach, children's hospitals shed their image as supportive care providers and began to stress the acute medical and surgical services they could perform, as well as the medical research they conducted. As a result, these hospitals evolved into institutions with obvious benefits for rich as well as poor children. During the 1920s and 1930s these hospitals began to woo paying patients, especially for surgical procedures.
By the 1930s the diversity of pediatric hospitals had evolved into a fairly unified model of pediatric hospital care in which children from all walks of life received up-to-date medical and surgical care. Within the children's hospital, young medical graduates pursued advanced training in pediatrics and learned the latest medical and surgical techniques for children.
See also: Children's Spaces .
Evans, H. Hughes. 1995. "Hospital Waifs: The Hospital Care of Children in Boston, 1860–1920." Ph.D. diss. Harvard University.
Golden, Janet, ed. 1989. Infant Asylums and Children's Hospitals: Medical Dilemmas and Developments 1850–1920. New York: Garland.
Rosenberg, Charles E. 1987. The Care of Strangers: The Rise of America's Hospital System. New York: Basic Books.