Few of you can recall the state of pediatrics in 1938, when I was an intern. As a pediatric intern, I was involved in the usual contagious diseases in all kinds of diarrheas, in typhoid, tuberculosis, eating problems, meningitis, for none of which we had any adequate training other than ineffective support. Bacterial meningitis in my internship consisted of a needle in the cistern, another needle in the lumbar space and the flushing of saline from top to bottom. This was a very unsuccessful method of treatment.
Hemorrhagic diseases of the newborn, of course, easily prevented by drawing bloods, usually from the father who was Rhesus (Rh)-positive, and injecting it intramuscularly into Rh-negative little girls, set a good stage for what we subsequently knew about Rh incompatibility. The fluids, of course, were not given intravenously. The ward was filled with infants who are lying there with outstretched arms because of all the saline we pumped into the subcutaneous spaces of the axillae. This was followed by a delightful day picking collodion off your fingers, because you kept the saline from pouring out by sealing the needle stick with collodion. While I was an intern, we watched the first cut down over a vein. We were all drawn together and assembled in the operating room amphitheater to watch this marvelous procedure. It was well before the emergence of small needles, particularly the butterfly needle that made pediatricians such great experts in venous access in even the small prematures.
Things began to improve with the availability of the sulfonamides. For the first time, we could treat a pneumococcal pneumonia with a drug that terminated the illness, instead of just waiting several days for the crisis to occur, which announced the recovery, or the death, of the child.
Penicillin did not become available to civilians until the early 1940s. In 1939, we had a 12-year-old boy with a very hot staphylococcal septicemia. At that point, I called Dr Chester Keefer in Boston. He listened to the story and sent up a supply of penicillin to treat this boy. He sent a 4-days supply of 5000 units per day. The boy recovered, but I paid the price by having to collect all of his urine and ship it back to Keefer so they could extract what little penicillin had come out in the urine.
It was with the advent of penicillin that I thought I would not go into infectious disease because it appeared to me as though there was no future.
In 1938, few medical schools in the United States required the study of pediatrics. In most of the schools it was an elective and it took some time before pediatrics began to thrive. For example, the Department of Obstetrics at Johns Hopkins controlled the newborn nurseries. As the chief resident, I could go to the newborn nurseries only when specifically invited by the obstetrician-in-chief. In the 1940s that began to change rapidly. Obstetrics reluctantly gave up its control of the newborn and pediatrics really began to “cook with gas.” The other subspecialties in pediatrics began to emerge, although for the longest period of time they were all under the control of the adult internal medicine or adult surgery.
Pediatrics really began to grow with the appearance of subspecialties. Many of the chiefs of pediatrics around the country encouraged house officers to go into research and into subspecialties, but the majority of trainees chose to go into general practice, several in the communities where they had been trained.
I think this began the great period of general pediatrics, with hospital services essentially controlled by pediatricians or physicians whose chief interest was in research and much of the teaching of pediatrics to medical students and pediatric house officers fell to the practicing pediatricians from the community.
They gladly contributed their time without pay and with modest academic appointments to teaching, which is only appropriate because they were much more confident than the academicians in dealing with the routine, day-to-day problems of pediatrics.
One other great change took place in general pediatrics at this point; women came into pediatrics. Children's Hospital is not very proud of it, but I remember the day when the house staff and the senior staff were told that one of the incoming pediatric interns was to be a woman. The entire house staff spent the day wearing black arm bands. Today, they would have been hustled off to the nearest judge.
Women coming into pediatrics is most appropriate. They are the ones who bear children, they know about being pregnant, and they have a kindness and understanding that makes it feel made-to-order for them.
Now everything has changed in pediatrics with the rapidly rising costs of health care, the need to reduce these costs, together with the great squeeze on research monies. Hospitals and medical schools in many cities are fighting for their very existence. To maintain staffs, children's hospitals and children's services are sending their staff out into the community to where general pediatrics is practiced. Where the subspecialists are attending, they are in direct competition with the practicing pediatricians.
The competition is for every patient, except uninsured ones, of course. This has essentially ended the relationship between the practicing pediatrician and community hospital or the children's hospital, which used to serve them. A patient who is now being admitted becomes the patient of the general pediatric service or the subspecialty service, and the practicing pediatrician is no longer welcome to take care of his or her patient who requires hospitalization.
Practicing pediatricians in general practice feel lost and neglected. If you feel depressed about the present and the future, stop and think for a moment. Would you change places with internists who must cope day in and day out with an aging population, every system of which is in decline?
We deal with newborns who become toddlers, children, probably horrible adolescents, and finally adults who are pleased with a warm relationship established with a pediatrician. It's a happy feeling. We are still extremely critical of all the health insurance plans, especially of the health maintenance organizations with their gatekeepers, but many of you are gatekeepers. The newspapers and television are full of horror stories of errors because of the unwillingness of a health maintenance organization or other insurer to approve a hospital admission or special laboratory tests.
What I think upsets us all is no longer being in full charge of a patient, not making all of the decisions. Let's stop for a minute and think back on our lost freedom. We must admit that pediatricians were economically wasteful and, despite the bad publicity, it will be quite some time before full evaluation by scientific groups will tell us if present day outcomes of care are any worse than they were before our independence was lost. Thus, we must hang in there until logical, clear answers are obtained. The least we can hope is for the present load of paperwork to be contained.
Finally, I think we are sustained by our membership in the American Academy of Pediatrics, to which we owe a great deal and whose efforts have lifted us from being just the baby doctors to members of a true specialty, and on a par, other than financial, with other specialties. With the increasing role of the Academy in national and political affairs, it sets standards of care that raise the level of health care of all children. This nation, which at least until election day, seems dedicated to seeking health care for all children and improved education, seems to offer a glimmer of hope for the future of children in this country and for us.
Whatever is planned for future health care in the United States, you may be sure it will be carried out with great input by the Academy, which means us. I'd like to close with a quotation from an old novel,Cloister on the Hearth, by Charles Reed, published in about 1843: “Courage, my friend, the devil is dead.”
I am not ready to believe that the devil is dead, not when you look around this whole world and see what's going on. But I do think that the devil is ailing. So I say to all of you, “Courage my friend, be of good cheer, and thank you.”