The pediatric shift

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THE JOURNAL OF PEDIATRICS

riculum and practice to one in which it is recognized as one of the four major clinical subjects. Incidentally the " S t u d y " of the Academy of Pediatrics which showed the amount of pediatrics in the daily work of the general practitioner played an important part in the inclusion of pediatrics as a major subject in Part I I I of the National Board examination. Now that one of the goals that we as pediatricians have been striving for has been reached, it becomes the responsibility of the pediatricians and our pediatric hospital services to cooperate fully and wholeheartedly with the local subsidiary boards of the Nationat Board. Otherwise the struggle will have been in vain and we could with justice be open to criticism. THE PEDIATRIC S H I F T to 1900, with a few exp RIOl~ ceptions (Escherich in V i e n n a, ~Iarfan and Nobecourt in Paris, Barlow and Still in London, Morquio in Montevideo, Bok@ in Budapest, Jacobi and Holt in New York, Rotch in Boston), pediatrics did not exist in the medical schools on this continent or in Europe. Not until 1911, when Pirquet transiently became professor of pediatrics or really not until 1912 when John Howland succeeded him, did pediatrics reach a university level at the Hopkins, and become worthy to be recognized as a separate entity by the curriculum committee. From 1912 to his death in 1926, Howland's thirty disciples became professors of pediatrics in many of the medical schools in the United States and abroad, and spread the gospel of university pediatrics. Similar awakenings and developments were occurring in other medical schools, under the leadership of Pirquet and Sehick in Vienna, Finkel-

stein and Czerny in Berlin, Debr6 in Paris, Thursfield in L o n d o n, and others. At present, there are approximately 3,500 pediatricians certified b y the American Board of Pediatrics, in addition to those who, though uncertified, confine their practice to children. However, in 1948 pediatricians provided only 11 per cent of child care in the United States in' contrast to 75 per cent by general practitioners. Therefore, it is the duty of teachers in medical schools to Study the pediatric shift and to provide the best modern instruction for the medical students who plan to enter general practice, as well as for those who are headed toward pediatrics. In fact, from the point of view of national child welfare, it is more important that the general practitioners understand pediatric methods, than it is to train pediatricians. In addition to this rapid rise in university pediatrics and ~he increase in pediatricians, the shift in the content of pediatrics has been even more dramatic. From 1900 to' 1920, pediatrics consisted ]argel2 of feeding babies, with the diagnosis and treatment of children's diseases as a side line. Starting in 1920, Marriott simplified infant feeding by the introduction of lactic acid evaporated milk, and the top-milk mixtures, the percentage formulas, Eiweis 3filch, Butter-Mehlnahrung, and others, which required a pediatrician and a slide rule, soon disappeared. The physician's time and energy which formerly were taxed by explaining complicated baby feedings to mothers now was available for immunizations and preventive pediatrics. In fact, by 1930', less than 50 per cent of their days (and nights)

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were devoted to the diagnosis and dicate it. l%outine tuberculin tests treatment of sick children, and pedi- and chest photofluorograms, the isoatric teachers taught more preventive lation of tuberculous patients in sanamedicine than did professors of public toria, and, more recently, streptomyhealth; and properly so, for most of tin therapy have reduced the incithe decrease in mortality and the in- dence and mortality of childhood crease in the expected span of life tuberculosis and pleurisy. Cod-liver have been due to the reduction in the oil, orange juice, thiamin, and niacin deaths of infancy and-early childhood have reduced rickets, scurvy, beriby pediatricians. Brig. Gen. James beri, and pellagra chiefly to historic Stevens Simmons, who was Chief of interest. Marked reduction in dysentery an d diarrhea at Duke followed the Division of ~Preventive Medicine the widespread use of lactic acid of the Army, stated that pediatricians evaporated milk for infant feeding. were among his best health officers. Perhaps the most important cause In 1930, before preventive measures, of the reduction in pediatric hospital sulfonamide, and antibiotic therapy patients has been the almost universal became so effective, the relative inciand usually successful use of suldence of children % diseases was fairly fonamide and antibiotic t h e r a p y,~ stable and in the following order: either at home or by the attending respiratory, intestinal, cutaneous, physician, for any and all febrile inneuropsychiatric, circulatory, metafection's, regardless of the diagnosis bolic, g]ar/dular, urologic, and orthopedic, with infections of all sorts pre- and often without one. Pnemnonia, dominating. B y 1950, however, the dysentery, empyema, erysipelas, masincidence of children's diseases had toiditis, otitis media, pyelitis, septiceentirely changed wherever there are mia, tonsillitis, etc., are cured without pediatricians or children's clinics. hospitalization and often before diagThis shift was primarily due to nosis. Certainly acute appendicitis specific preventive measures. Per- with and without rupture, brain abtussis, typhoid, and rickettsial vac- scesses, and osteomyelitis have become cines, diphtheria and tetanus toxoids, rarer hospital admissions since the adand smallpox vaccination have ahnost vent of chemotherapy. This practice eliminated those diseases. In 1930 Of giving sulfonamides, penicillin, when Duke H o s p i t a 1 was opened, streptomycin, aureomycin, chloramdiphtheria was responsible for 7 per phenicol, etc., for several days withcent of all of the pediatric hospital out examining the patient, and then patients, but in 1949 and 1950 onIy t r y i n g to diagnose those in whom the three cases occurred. Immune serum treatment is unsuccessful is appalling globulin (human) has red~ced the in- from the point of view of pediatric cidence and severity of m e a s 1 e s, instruction, though it simplifies the m u m p s, and rubella. Compulsory practice of medicine. Pediatric inpremarital and antenatal serologic structors should realize that, regardtests and rapid treatment centers have less of arguments to the contrary, *Cost a t D uke H o s p i t a l d u r i n g the p a s t six made congenital syphilis, not only months : illegal, but also a rarity in comparison Penicillin $20,000.00 Streptomycin 9, 263.00 with its frequency before Thomas Terramycin 7,885.00 Aureomycin 3, 574.00 Parran started the campaign to eraChloramphenicol 2,583.0{}

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THE JOURNAL OF PEDIATRICS

this practice will be continued as it usually is effective and rarely does harm. From a teaching point of view, the remaining pediatric conditions should be divided into those which still require hospitalization and those which should be treated as ambulant in a physician's office or in an out-patient clinic. When separated in this 'way, it will be readily seen that fewer pediatric hospital beds will be needed and that more space, a larger percentage of the pediatric teaching hours, and better instruction are necessary in pediatric out-patient clinics, both public and private. If more visiting nurses were available for home care, an even larger percentage of pediatric patients could be treated as out-patients and the number of pediatric hospital beds could be reduced even further. Out-patient teaching is more important and more desirable than thvt on the wards--a complete reversal of the usual concept. The most frequent conditions which still require hospitalization at Duke are: abnormalities of the newborn, ineluding premature infants, surgical conditions, cancer, which is now the second ranking cause of death from disease in children, congenital heart disease, rheumatic fever which kills so many children between the ages of 5 and 14 years, and last but not least, the increasing tide of accidents, the greatest killer of all. Practically everything else in pediatrics can be, and should be, treated in an ontpatient clinic. Eventually, children's h o s p i t a 1 s should be empty, except for newborn and premature infants, the ill children

of working mothers, accidents, and unpreventable surgical operations. However, home care and delay are still dangerous for children with stiff necks, " a e u t e abdomens," and respiratory obstructions, especially in those under 2 years of age. Keeping children out of hospitals and treating them in a physician's office or out-patient clinic not only is a great psychoiogic benefit to the mother and child but the financial saving is enormous, regardless of whether the child's parents or the taxpayers or university endowments pay the bill. In addition, pediatric departments must devote greater and more interesting efforts to teaching future general practitioners and pediatricians more about well children through the examination of school children, child guidance conferences, feeding clinics, and seminars on nutrition with the dietetic department. Family physiclans or pediatricians are tending to be occupied less and less with physical disease, and more and more with growth, development, behavior problems, school and social 5evelopment. Parents and physicians are becoming increasingly aware of the importance of the child's total development and adjustment. In this field of preventive psychiatry and psychosomatic medicine, social workers, nurses, teachers, pediatricians, psychologists, psychiatrists, and other physicians must work together, and the ideal place is in the o'ut-patient clinic or physician's office. In other words, the title of the Department of Pediatrics shou}d be changed to the Department of Child Life as at the University of Edinburgh. W . C. DAVIS0N.