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.2,3 But as a body of knowledge and practices addressing the sick child, pediatrics has a much longer history.4,5 Reconstructing the history of what might be called “pediatrics before pediatricians” entails going beyond the rare books and treatises that were long the traditional sources for medical historians. In this article, we explore 18th-century English hospital admission registers with respect to the medical care of neurodisability. We present analyzed data of 1483 children (defined as #18 years old) hospitalized at 5 18th-century English hospitals whose records have survived. Compiled from admission registers, this is the largest database of pre-1800 pediatric hospital admissions in existence. Some of its implications for historians of medicine have already been explored in a previous historical article.6 At 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 explore the database itself, which is accessible 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 epidemics.7 In England in the 18th century, 35 voluntary hospitals were founded.8 These hospitals were called “voluntary” because they were entirely supported by charitable contributions from the local community through donation or subscription. 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 11 AM and 1 PM, each patient needed a signed letter of recommendation from a hospital benefactor such as a donor or subscriber. 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.”10 In this 18thcentury infirmary there was equal emphasis on an inpatient’s religious health, through strong encouragement of Christian 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