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AUTHORS:Andrew N. Williams, BA, BM, BCh, MSc, PhD, and Raman M. Sharma, BSc, MBChB

Virtual Academic Unit, CDC, Northampton General Hospital, Northampton, United Kingdom

Address correspondence to Andrew N. Williams, PhD, Consultant Community Paediatrician, Virtual Academic Unit, CDC, Northampton General Hospital, United Kingdom, NN1 1BD. E-mail: anw@doctors.org.uk

Accepted for publication Apr 23, 2014 KEY WORDS

18th-century child health care, voluntary hospitals, history of pediatrics

Dr Sharma carried out the initial analyses and reviewed and revised the manuscript; Dr Williams conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript; and both authors approved thefinal manuscript as submitted.

doi:10.1542/peds.2013-0746

Children in Hospitals Before There Were Children

s

Hospitals

Until recently, physician–historians of pediatrics have generally assumed that

“pediatrics as a specialized branch of medicine had no real existence before the middle of the nineteenth century.”1

This may be true if we equate pediatrics with professional organizations and specialized children’s hospitals.2,3But as

a body of knowledge and practices addressing the sick child, pediatrics has a much longer history.4,5Reconstructing

the history of what might be called“ pe-diatrics before pediatricians” entails go-ing beyond the rare books and treatises that were long the traditional sources for medical historians. In this article, we ex-plore 18th-century English hospital ad-mission registers with respect to the medical care of neurodisability.

We present analyzed data of 1483 chil-dren (defined as #18 years old) hospi-talized at 5 18th-century English hospitals whose records have survived. Com-piled from admission registers, this is the largest database of pre-1800 pe-diatric hospital admissions in exis-tence. Some of its implications for historians of medicine have already been explored in a previous historical article.6At the very least, this database

demonstrates that English hospitals provided inpatient care for substantial numbers of children long before the mid-19th century, as historians once assumed. Readers are invited to ex-plore the database itself, which is ac-cessible through the Duke University Libraries’DukeSpace (http://dukespace. lib.duke.edu/dspace/handle/10161/8915).

Hospital records such as these must be viewed through the grim perspective of 17th-century children. Contemporary records from St Martin-in-the-Fields Parish in London indicate that infant mortality rates exceeded 450 per 1000 infants in the early 1770s and averaged

.300 per 1000 infants before 1800. These extremely high mortality rates were mainly the result of infectious diseases, exacerbated by smallpox epi-demics.7

In England in the 18th century, 35 vol-untary hospitals were founded.8 These

hospitals were called “voluntary” be-cause they were entirely supported by charitable contributions from the local community through donation or sub-scription. These locally administered voluntary hospitals provided health care for the benefit of “the Sick and Lame

Poor.” For admission, which occurred every Saturday morning between 11AM

and 1PM, each patient needed a signed

letter of recommendation from a hospi-tal benefactor such as a donor or sub-scriber. Treatment was free, and inpatient stays of up to 3 months were common. The wards were separated by gender. Conditions were very austere. Patients were expected“to assist in nursing the patients, washing and ironing linen, washing and cleaning the wards.”9

Friendly Advice to a Patient(1748), a book published at that time, also encouraged patients “reading to others, and by teaching them to read; by learning some of them to write and cast accounts . . . or by assisting, in which duty you ought, under the direction of the Matron, in attending upon others.”10In this

18th-century infirmary there was equal em-phasis on an inpatient’s religious health, through strong encouragement of Chris-tian religious observance and practice in the hospital setting. The regulations made it clear that failure in this observance, such as nonattendance for prayers, was sufficient reason for discharge (Fig 1).9

Although a wide variety of conditions might lead to child hospitalization, our

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focus was on those whose illnesses were of neurologic origin. Although child neurology did not emerge as a specialty until the mid-20th century,11

physicians have long been interested in the conditions that have come to be known today under the umbrella of

“neurodisability.”

Cerebral palsy and epilepsy in childhood have been described for centuries.12–14

Most notably, 17th-century English phy-sician and neuroanatomist Thomas Willis described childhood epilepsy, palsy, coma, and mental retardation in the context of clinical histories and postmortems.15Willis made a distinction

between adult and pediatric epilepsy, with different causation, treatments, and outcome. Willis considered adult sei-zures to have started when puberty had finished, which he took to be 25 years of age. In the mid-18th century, William Buchan’s popular medical guide Do-mestic Medicine (1769) stated that for childhood epilepsy,“when the disease is hereditary, or proceeds from a wrong formation of the brain, a cure is not to be expected.” Buchan did suggest a treatment of seizures due to teething:

“The feet frequently bathed in warm water, and, if the fits prove obstinate blistering plaster may be placed be-tween the shoulders.”16 In other words,

medical therapy seems unlikely to have provided anything of potential benefit for a child with epilepsy.

In this 18th-century data set, 67 cases of pediatric neurodisability made up 4.5% of the total number of admissions. Of these, 25 had a diagnosis consistent with epi-lepsy, and the other 42 had a diagnosis consistent with a neuromuscular dis-ability. There is a wide range of de-scriptive terms in the data set. Epilepsy is described under the terms Spasmus clonica, Fits/Fitts, Epilepsy/Epileptic, and Convulsions (Most extraordinary). Neu-romuscular disability is described under the terms Palsy, Sciatica, Lameness, Weakness, Distorted spine, Chorea, and Hemiplaegia(Table 1).

What do we learn from the database that would not be apparent from tex-tual evidence such as that of Willis or Buchan?

First, we learn that in the 18th century there were pediatric inpatient stays, and these were typically for months, far longer than current inpatient stays of

,1 day.17 Such prolonged inpatient

stays would allow chronically mal-nourished children a sustained period of recovery on a hospital diet that more than met their nutritional needs, in a ward environment that emphasized cleanliness.9,10,18

We also learn how many of these patients were described as “cured,”

even with conditions that would be considered quite incurable today. For example, 1 entry in the database refers to James Ridings, an 18-month-old boy who was admitted on March 8, 1756 to the Manchester Royal Infirmary with a 15-month history of “lameness and fits,” implying recurrent seizures and some degree of disability. Two months later, on May 3, 1756, he was discharged

“cured.”It is hard to make sense of this story in terms of a medical cure. More likely, he simply remained seizure free. The choice of the wordcuremay have been more directed at present and po-tentially future hospital philanthropists to secure ongoing funding for children needing hospitalization. (Genealogical research suggests that a James Ridings died in Heywood Lancaster on August 22, 1836, aged 81 years, but it is impossible to be certain if this is the same per-son.19) Additional research is needed to

address these questions.*

FIGURE 1

Contemporary illustration of a ward round at Northampton General Infirmary in 1744. Dr Andrew Williams is the curator of the archive at Northampton General Hospital and gives per-mission for its use in this publication.

TABLE 1 18th-Century century Descriptive Statistics for Children With Epilepsy and Neuromuscular Disability

Variable Epilepsy Neuromuscular Disability

Mean (SD) age at admission, y 12 (4) 10 (6)

Male, % 40 49

Inpatient, % 23 23

Outpatient, % 77 77

Cured, % 67 47

Relieved, % 13 26

Incurable or died, % 8 12

Nonattendance or self-discharged, % 12 15

Median (interquartile range) duration of illness before admission (mo)

6 (1–24) 5 (2–9)

Median (interquartile range) duration of stay as inpatient (days)

60 (29–112) 95 (35–143)

Newcastle year 1779, % of total cases 13 14

Northampton years 1756–1757, % of total cases 21 5

Manchester year 1756, % of total cases 21 37

Chester year 1756, % of total cases 38 35

Bristol years 1756 and 1779, % of total cases 8 9

*Alternatively, is it possible that some 18th-century patients, their families, or their sponsors were not fully truthful when giving the patient histories, to access health care resources otherwise unavailable? Patients or their parents may also have become unhappy with further outpatient attendances or with long inpatient stays and declared themselves or their child“cured.”

426 WILLIAMS and SHARMA

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This database raises other areas for future inquiry, including referral path-ways, early pediatric hospital special-ization, and differences between hospitals. Additional exploration out-side the hospital can explore health networks at home and in the commu-nity, supporting the sick child and his or her family.

CONCLUSIONS

This important data set has identified for the first time that a large number of pediatric patients were being treated in a hospital inpatient setting before the establishment of children’s hospitals, often with a stay of many months. It demonstrates that pediatric neurodis-ability accounted for a significant per-centage of pediatric hospitalizations, and most strangely, they were often discharged as“cured.”Such a data set ultimately asks why, despite the clear need and demand, did it then take an-other 100 years before the founding of thefirst specialized children’s hospitals?

When taken with contemporary medical literature and other records, this data set allows an individually named sick child’s perspective to be fully placed in its social context. It is possible that other such admission registers exist, awaiting discovery. Thus, from a time of “pediatrics before pediatricians” to whatever future evolution child health care brings, the authors hope that present and future readers, in their time, build on such historical corner-stones improving the care delivered to sick children and their families.

ACKNOWLEDGMENTS

We thank Dr Alysa Levene and Professor Jonathon Reinarz, who (with A.N.W.) con-structed the original data set and who have declined authorship in this article. We would also like to thank the staff at the Northamptonshire County Record Office and the Richmond Library at Northampton General Hospital and Dr Corallie Murray for their assistance and Mrs Sheridan Friedman for her genealogical inquiries about James Rid-ing. We also thank the Wellcome Trust, which funded the original pilot study.

REFERENCES

1. Garrison FH, Abt AF.History of Pediatrics. London, England: WB Saunders; 1965:1 2. Cone TE. History of American Pediatrics.

Boston, MA: Little, Brown; 1979

3. Mahnke CB. The growth and development of a specialty: the history of pediatrics.Clin Pediatr (Phila). 2000;39(12):705–714 4. Newton H.The Sick Child in Early Modern

England, 1580–1720. Oxford, United King-dom: Oxford University Press; 2012 5. Levene A. Childhood and adolescence. In:

Jackson M, ed.The Oxford Handbook of the History of Medicine. Oxford, United King-dom: Oxford University Press; 2012 6. Levene A, Reinarz J. Williams AN. Child Patients

and voluntary hospitals in eighteenth-century England.Family and Community History. 2012; 15(1):15–33

7. Davenport R, Boulton J, Schwartz L. Infant and young adult mortality in London’s West End, 1750–1824. In: Boulton J, Black J, eds.Paupers and Their Experience of a London Workhouse: St Martin-in-the-Fields, 1725–1824. London, England: Pickering and Chatto; 2013 8. Granshaw L. The hospital. In: Bynum B,

Porter R, eds.Companion Encyclopaedia of the History of Medicine. London, England: Polity; 1993

9. Statutes Rules and Orders for the Govern-ment of the County Hospital for Sick and Lame Poor. Established in the Town of Northampton. Northampton, England: William Dicey; 1743

10. Stonhouse J. Friendly advice to a patient advice in case of amendment. Northampton July 9, 1748. In: Stonhouse T, ed.Religious Tracts On Various Subjects’A New Edition. London, England: Longmans; 1821 11. Fishman MA. Child neurology: past, present,

and future.J Child Neurol. 1996;11(4):331–335 12. Levinson A. Notes on the history of pediat-ric neurology. In: Kagan SR, ed.Essays on History of Medicine. Victor Robinson Me-morial Volume. New York, NY: Frosben; 1948:225–240

13. Williams AN. Chapter 22: a history of child neurology and neurodisability.Handb Clin Neurol. 2010;95:317–334

14. Bax M. Fifty years on–editorial.Dev Med Child Neurol. 1996;38(9):755–756 15. Williams AN. Thomas Willis’s practice of

paediatric neurology and neurodisability.

J Hist Neurosci. 2003;12(4):350–367 16. Buchan W.Domestic Medicine: or, a

Trea-tise on the Prevention and Cure of Diseases by Regimen and Simple Medicines. London, England; 1769:435

17. Gill PJ, Goldacre MJ, Mant D, et al. Increase in emergency admissions to hospital for children aged under 15 in England, 1999– 2010: national database analysis.Arch Dis Child. 2013;98(5):328–334

18. Denny G, Sundvall P, Thornton SJ, Reinarz J, Williams AN. Historical and contemporary perspectives on children’s diets: is choice always in the patients’best interest?Med Humanit. 2010;36(1):14–18

19. Family Search web site. https://familysearch. org/search/records/results#count5 20&-query5%2Bgivenname%3Ajames∼%20% 2Bsurname%3Aridings∼%20%2Brecord_ country%3AEngland%20%2Bbirth_place% 3Alancashire∼ %20%2Bbirth_year%3A1754-1756∼%20%2Bdeath_place%3Alancashire∼% 20%2Bdeath_year%3A1836-1836. Accessed January 13, 2013

FINANCIAL DISCLOSURE:The authors have indicated they have nofinancial relationships relevant to this article to disclose.

FUNDING:The Wellcome Trust funded the original pilot study that collected these data (grant 081351/Z/06). The analysis for the purposes of this article was unfunded, and no external funding was secured for this part of the study.

POTENTIAL CONFLICT OF INTEREST:Dr Andrew Williams was a coauthor on an earlier social historical article (Levene et al, 2012), that undertook a limited analysis of the 18th-century data set. This other article has been submitted with this manuscript for referees’view, together with an e-mail from Dr Alysa Levene, the senior author of the former article, disavowing involvement in this study. This submitted historical perspectives article is written up from a clinical medical perspective but using the same database as the Levene et al (2012) article. There clearly will be some overlap of data and results, but Drs Sharma and Williams have constructed a completely independent article. We believe our submitted article is materially different from the other article. Dr Raman Sharma has no conflict of interest.

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DOI: 10.1542/peds.2013-0746 originally published online August 11, 2014;

2014;134;425

Pediatrics

Andrew N. Williams and Raman M. Sharma

Children in Hospitals Before There Were Children's Hospitals

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DOI: 10.1542/peds.2013-0746 originally published online August 11, 2014;

2014;134;425

Pediatrics

Andrew N. Williams and Raman M. Sharma

Children in Hospitals Before There Were Children's Hospitals

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the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2014 has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

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Figure

FIGURE 1Contemporary illustration of a ward round atIncurable or died, %Nonattendance or self-discharged, %

References

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