Sick babies, few choices: a historical geography of medical care and facilities for infants and children.

Imagine that a parent wakes up one morning and finds his/her child having a fever. The parent is likely to call a pediatrician for instructions about how to handle the situation. The pediatrician, in turn, might suggest watchful waiting, or bringing the child to the office or a clinic for an examination or tests. If there is sufficient concern, the pediatrician might instruct the parent to bring the child to the emergency room for hospital admission. Being able to make choices about how and where to treat sick children is a relatively recent phenomenon. Historically, infants and children had poor chances for survival and their access to any type of medical care was sorely limited. Physicians often refused to accept infants or children as patients, refused them access to hospitals, and generally considered them untreatable. We report here on the diffusion of access to medical care for infants and children in selected urban centers of both Europe and the northeastern United States, beginning with the initial concept of providing refuge for abandoned infants in the Middle Ages and ending at the turn of the 20th century. This paper provides a historical geography that should clarify how lucky today's parents are to have a range of options for medical care for their children. Refuge for Infants and Children The decline of feudalism and the rise of cities created massive social upheaval in Europe. Sanitation was abominable and disease ran rampant through densely populated areas that lacked sewers and access to clean water. Hunger and poverty were rampant. Trade routes expanded and they brought more than goods back to European ports they brought rats and disease. During the 14th century alone, the Black Death (bubonic plague) killed more than 25 million people (about 25 percent of the European population). The result was unparalleled social turmoil, with an enormous number of abandoned and orphaned infants and children left to fend for themselves. Their odds of survival were close to nil. One way of solving the problem of abandoned and orphaned infants and children was to create a place of refuge where they could receive basic food, clothing and shelter. The first recognized attempt to provide refuge for abandoned infants is credited to the Archbishop of Milan who, in the year 787, attached a cradle to a revolving exterior church door. An anonymous donor would place an infant into the cradle and ring a bell. The door then revolved, accepting the infant. The Church then took the responsibility of finding a wet nurse for the "little stranger" and offered a monastic life for any that survived. Over time, providing refuge for abandoned and orphaned infants and children in times of stress (such as during a war or after an epidemic) became acceptable. Many foundling homes and orphanages opened in Italy during the 14th and 15th centuries (see Figure 1 for an example from Italy), with more than 80 in operation across the European continent before 1700. As missionaries moved around the globe, they helped to diffuse the concept of refuge with them, creating facilities for abandoned and orphaned infants and children in Jerusalem in 1210, Arabia in 1283, Mexico City in 1524, Lima in 1563, Bogota in 1650, Pernambuco in 1650, and Beijing in 1662. [FIGURE 1 OMITTED] Urbanization and migration, as well as religious and cultural changes created economic, political and social turmoil in Europe. While explorers claimed new lands and opened new trade routes, children of the poor died of cold and hunger in the streets of European cities. The bodies of infants were recovered from the sewers and rivers of European cities in increasing numbers. The Hotel Dieu, the oldest hospital in France, began accepting abandoned children in 1523 so that they would not purposefully be maimed and sold as beggars. By 1547, infanticide was so rife in Paris that the Parliament decreed that nobles must care for foundlings left in their domains. Orphaned and abandoned infants and children and the children of the poor were not the only ones with poor chances for survival during this period. Even children of parents with means were unlikely to survive to adulthood. Diseases ran rampant through urbanized populations. A basic understanding of sanitation did not yet exist and there was no effective treatment for infectious agents. High death rates pushed the social system to its limits. A foundling hospital,...