Abstract
Perceptions of hospitalization for children shifted from late nineteenth-century care designed to uplift poor children and create better citizens to mid-century attention to children’s emotional and medical needs. In the last few decades, sick children have become objects of sympathy and outpourings of affection. The history of hospitalized children at the University of Michigan demonstrates change over time in involvement of caregivers and families, the role of education during sickness, and the value placed on illness. The hospital provided more than just medical interventions, and its history offers a window to changing ideas about children and society.
In 2011, to coincide with the opening of a new, high-tech children’s hospital, the public relations office at the University of Michigan released a series of print and video advertisements as part of an ongoing fund-raising campaign called the Michigan Difference. One of these ads featured an attractive blond girl in a bright purple dress, surrounded by decorative butterflies. While the text of the ad discussed the girl’s medical care at the hospital, it also emphasized that the technology used “helps her breathe, grow, run, jump, swim, dance and play like any other five-year-old, preschool-loving fairy princess.” 1 The caption on the ad, “Hail to the Conquering Heroes,” not only deliberately echoed the University of Michigan fight song but also provided the theme for the campaign—the heroism of the children receiving medical care at the hospital.
Modern images of sick children as heroes to be celebrated in the fight against disease appear to be ubiquitous in the United States today. But while they are intended to validate children’s strengths, they are potentially problematic because they can be seen as falsely positive (as a way to raise money), they obscure economic and social issues that play a role in illness, and because they imply a valorization of disease itself. 2 There is nothing inevitable or timeless about this illustration of disease in children, though. In fact, a historical review of the treatment of children in the hospital over the last century illustrates a major shift in understandings of sick children, their relationship to care providers, and their relationship to their families.
Much of the history of medicine and children in the United States has focused on pediatricians’ promotion of their professional expertise into well child care and child rearing. 3 Historians have also explored the social and cultural factors involved in reformist efforts to help children, especially in the late nineteenth and early twentieth centuries. 4 Yet, there has not been as much historical attention to the time sick children spent in hospitals, nor in the changes in conceptualizations of children and families in those care settings. 5 As historians of childhood have pointed out, it is challenging to uncover information about the youngest historical actors—as a group, they left relatively little independent documentary evidence. 6 But it is possible to understand something about children in the hospital based on the people involved in their care and the kinds of interventions that were offered.
In this article, I discuss the transformation in hospital life for young patients over the last 120 years using the University of Michigan hospital system as a window into the national picture. While caregivers within the hospital have always articulated the need to promote children’s welfare, how they understood children and their relationship to them shifted over time. In the late nineteenth century, children entered hospitals because of poor financial and physical health. As medical care for children evolved in the first third of the twentieth century, an increasingly specialized cadre of caregivers attempted to mold the children into citizens who could take their newly acquired knowledge of good habits of health and industrious employment to their home communities. By mid-century, hospital staffs were increasingly influenced by child psychology and psychiatry to view children as individuals who required experts to manage both their physical recovery and their emotional adjustment. Beginning in the 1970s, though, criticism of the hospital as impersonal and overly technical resulted in major shifts for children. Not only were they treated differently, with much more involvement with their families and a new focus on amusement and distraction, but also sick children became symbols of the humanity within rising medical technology.
We might expect that progress through history, especially in medical care, involves advancing technology. Yet, as Joel Howell has pointed out, the use of technology in the hospital has often depended as much on social issues as on technical ones. 7 The role of technology in the care of children has been even more complex. While Jeffrey Baker has illustrated the social and cultural context of the introduction of infant incubators, older children had relatively little technology directed toward them until the last several decades. 8 Further, when technology appeared, it seemed to be a potentially dehumanizing force that needed to be countered by images of sick children that would emphasize care rather than machines. Although technological changes affected children’s morbidity and mortality throughout the century, caregivers for pediatric patients focused on children’s needs (even as those needs changed) rather than the technology.
Certainly, shifts in child morbidity and mortality over time contributed to changes for children’s hospital stays over the last hundred years. In the late nineteenth and early twentieth centuries, infectious disease frequently struck down children, and emerging ideas about containment of infection helped to structure institutional care. By mid-century, infectious disease with long-term consequences, especially polio, helped to raise awareness that illness in children could result in lifelong disability. 9 And in the last several decades, the contrast between the majority of usually healthy children and those few who become very sick with illnesses such as cancer highlights the difference between normal childhood experiences and illness. Although the current medical treatment of a child undergoing a transplant is clearly more complex from our point of view than a mid-century treatment for rheumatic fever, academic medical centers have always done the most intervention possible for the sickest patients who could be treated at the time. Further, as we know, it is not disease itself but rather the social, cultural, economic, and political frame we place around sickness that shapes the experience of illness. 10 A hospital stay for a child has been a focused and often intense reflection of the cultural norms of childhood, parenting, and medical care.
Creating Citizens, 1890s–1940
As a number of historians have described, hospitals for children came into being in the United States in the last third of the nineteenth century at the same time as other institutions for people in need. 11 Children’s hospitals emerged from the practice of housing very poor children in orphanages or foundling asylums. 12 Groups of reformers in the nineteenth century endeavored to improve the lives of children and focused particularly on health. At the same time, a small but influential number of physicians articulated the need to develop a medical specialty around society’s youngest members. In many cities around the United States, particularly in the northeast, philanthropists (especially groups of women) came together to build hospitals for children and women. 13 Sometimes the managers of the hospital, who were often the women who put up the money for the building, came into conflict with physicians who were part of the emerging specialty of pediatrics. 14 Further, medical schools had to engage in ongoing negotiations with hospitals to provide for adequate training of medical students—and eventually residents. The result was that late nineteenth-century hospitals served a dual, and sometimes conflicted, mission of providing charity to the poor and medical training to physicians. 15
The hospital at the University of Michigan also had to both train medical staff and promote the health of the state by caring for its poorest citizens. One initial challenge for the University, though, was that it was located in a small town at a not inconsiderable distance from the closest urban center of Detroit. The medical school was founded in Ann Arbor in 1850, but since the local community was not large or complex enough to generate support for a community hospital, the medical school constructed its own hospital to allow for training opportunities for students. The first university hospital was built in 1869 and then expanded in the 1890s. But patient flow to Ann Arbor remained slow (until changes in transportation in the twentieth century), and in fact the medical faculty argued several times about whether to move the medical campus to Detroit before ultimately deciding to stay. 16 There was no children’s hospital, no one on the faculty who specialized in pediatrics until 1905, and no department of pediatrics until 1921. 17
There were children at the hospital, however. In the annual reports of the hospital in the 1890s and continuing into the early twentieth century, there were consistently more than a hundred patients under the age of ten, as well as several hundred between the ages of ten and twenty. 18 In fact, the numbers of children treated at the hospital might well have supported an independent children’s hospital. At Michigan, as at some other teaching hospitals, children were crammed into leftover space in the general hospital. 19 What was really missing in Ann Arbor was a network of women philanthropists who would make the cause of sick children (and women) their own. 20 A widow of a faculty member donated money in 1901 to create what was called the Palmer Ward or Hospital, a small building where some children received medical care. 21 But the space was too small to provide for the hundreds of children who passed through the doors of the University Hospital in the early twentieth century, and it was not dedicated space for children as it was also used as overflow for the rest of the hospital. In addition, the upper floor of the Palmer building acted as the nurses’ quarters. 22
Though there was not a group of reforming women in Ann Arbor in the late nineteenth and early twentieth centuries willing to build a hospital, several philanthropic groups were important to the lives of children in the hospital. In the annual reports for the hospital from the late nineteenth century, the hospital managers mentioned charitable donations by groups including the King’s Daughters—a local branch of a national group of church women who provided money for patients who could not pay, donated clothing for children, and also looked after children in the Palmer Ward (while also providing entertainment). 23
And while the hospital in Ann Arbor was owned by the medical school, charity was still an important function. Indeed, hospital staff believed that the hospital, like the University as a whole, needed to serve the state. From the time of its inception, the University Hospital accepted sick children who had no means to pay with the assumption that either philanthropic groups or the state would provide for their care. By the early twentieth century, the state had passed laws to allow “deformed” children to get care at the University of Michigan, while most of the patients (adults as well as children) were supported by their home counties during episodes of care in the hospital. 24 Providers inside the hospital, as well as lay visitors and philanthropists, attempted to provide social uplift as well as medical care.
Physician expertise structured the medical treatment and children were sent from all over Michigan (and other states) to take advantage of the specialized care at the University. But children in the hospital spent most of their time with other providers rather than the small faculty and house staff in pediatrics. In the early part of the century, nurses were the children’s primary companions. While nurses’ approach toward pediatric patients was not well articulated during this time period, nurses aimed to make the environment as healthful as possible for the children, particularly by helping them get fresh air. It would be hard to overstate the early twentieth-century reformers’ and health care workers’ enthusiasm for fresh air for both sick people and children—and especially for sick children. 25 As nursing historians have pointed out, reformer Florence Nightingale believed strongly in the importance of air circulation, even into the era of the germ theory. 26 Although children at the hospital were treated for a wide variety of ailments, fresh air seemed to be a universal element of the treatment. It was particularly important for patients with infectious disease. In 1914, the University of Michigan constructed a Contagious Hospital to try to prevent the spread of infection. This building had extensive porches and windows, and patients went outside on the porches and the grounds for long periods of time every day, even in Michigan’s less seasonable weather. 27
Children’s care in the hospital in the late nineteenth and early twentieth centuries, then, was comprised primarily of fresh air, nurses to take the children outside and help prevent infection, and lady philanthropists who helped fill in for the children's financial deficiencies. The children were admitted for a variety of medical conditions, from infectious disease such as scarlet fever to other kinds of issues including problems with feeding. The average length of stay for the whole hospital dropped in the first decades of the century from a high of twenty-nine days to fifteen to eighteen days by the 1920s. 28 By this time period, as Charles Rosenberg has pointed out, hospitals had many of the trappings we associate with modern institutions, including a bureaucracy run by professional staff. 29 In 1925, the University of Michigan built its first modern hospital and incorporated trained professionals in a variety of positions. In 1920, even before the building was completed, the hospital created a social service department. 30 The social service workers were experts in the numerous legal, financial, and legislative issues regarding health and illness. 31
Social workers at the University in the 1920s and 1930s framed their activities in terms of influencing the communities from which the patients came. One of the earliest duties of the social service department was to write letters to patients’ parents to let them know how they were doing. In 1920, the hospital’s annual report explained that “the children’s social worker, through correspondence, has kept the parents of our little patients informed each week of their condition. Consequently, the parents are most cooperative in allowing their youngsters to remain at the hospital as long as necessary.” 32 Many scientific experts of the time were convinced that parents, especially mothers, lacked the necessary expertise to appropriately care for the health of their children. 33 Hospital staff prided themselves on being a means by which parents could be educated about maintenance of the family’s health, and they imagined that their work with children would help improve the children’s communities when they returned home. 34
By 1922, the social service department began a Hospital School, emphasizing that sick children were like any other children and needed opportunities to continue their education. 35 For reformers of this time period, education was a critical part of comprehensive child welfare. 36 Personnel at the hospital school incorporated educational programs, health knowledge, and charity to try to reach children all over the state. The original funding for a teacher, as well as support for clothing for the children, was provided by the King’s Daughters, while playground equipment and books were donated by the Kiwanis, a men’s social service group. 37
The Hospital School developed a complete and creative system for making sure that staff reached all of the children at the hospital. In 1922, the head of the social service department emphasized that “During the time the child is in the institution not only the medical and surgical care must be considered but the intellectual and general development of the child must be borne in mind.” 38 Teachers made a point of looking for children who had been admitted, even those who were being cared for on surgical or medical wards rather than just children’s wards. They attempted to get children into group classroom settings whenever possible, but noted that the unpredictable nature of the children's treatment for illness—including the risk of being quarantined to prevent the spread of infection—made it necessary for the hospital teachers to have individualized school plans for the children. 39 And teachers made a point of engaging with all the children, even if it was only for a day or two during a brief hospitalization. 40
The interventions available in the hospital were more organized around healthful living rather than specific technologies. Teachers in the school used publications from the National Tuberculosis Society to try to inculcate good health habits while the children were in the hospital. 41 Some patients had their beds outside—which physicians thought was especially important for individuals with tuberculosis. Advocates of hospital design insisted that good air and plenty of windows were essential for treatment of children even into the 1940s. 42 And University of Michigan hospital personnel adapted their facilities to the need for fresh air by making the roof of the hospital the place where children could go to get air and play outside.
Children’s time outside was framed in terms of inculcation of good health habits. School staff believed that children needed to be well regulated in terms of both school and recreational time. As the head of the social service department reported in 1931, “Recreation is important and lack of it is unusually significant. Certain cases present marked problems due to this lack of play outlet. Wholesome play and well-balanced use of leisure time develop in a child a happy personality and promote growth into a valuable, well-adjusted citizen who has a lasting capacity for real enjoyment.” 43 Playtime was not just an outlet or a distraction, but rather an essential component of a well-regulated life.
In the first third of the twentieth century, hospital staff explained that what they were doing for children in the hospital was creating better citizens for the state. 44 This endeavor was to be undertaken matter-of-factly, without undue emotion. Social service workers and teachers wanted the children to look as “normal” as possible, despite being in the hospital. Further, as one volunteer remarked in 1923, she learned that “the sentimental attitude has no more place in dealing with the handicapped child than with the physically normal child, but that all alike must be taught the value of self-confidence and self-help.” 45 The head of the hospital school, L. W. Keeler, emphasized that the intent of the school was utilitarian: “The philosophy underlying this institution holds that a hospitalized patient should have the opportunity to carry on his school work so far as his condition will permit, since it is the purpose of the State to enable its future citizens to prepare themselves for the exercise of their citizenship.” 46 At the same time that he linked the instruction from the school to improving students’ recovery from illness, he also congratulated the school for making sure that students kept up on their studies compared to their peers in their home schools. 47
Teachers understood their role as contributing to the comprehensive care of the child and ensuring that children did not fall behind in school, just because they were sick. 48 Further, even physicians who described their patients as case material understood the broader mission of improving the state through care of its youngest citizens. 49 Every person, regardless of physical condition, had certain obligations to society. As the head of the social service department explained in 1935, the goal was to teach the hospitalized children “to face situations, and make their own decisions, analyze the situation and become intelligently self directing persons rather than encumbrances upon families and society in general. They must learn to function within the definitions set by the illness which may be a chronic or acute, temporary or permanent handicap.” 50 The social service department, the teachers, and the pediatrics faculty all stressed an idea of citizenship—that proper care of children at the University of Michigan Hospital would strengthen the state through promoting healthy, capable, and contributing members of society. 51
Imagining the Psychology of the Child, 1940–1970
Caregivers viewed hospitalized children in the first part of the century as a class of patients in need of social and educational, as well as medical, improvement. But by the late 1930s, many hospitals across the country had shifted their focus from uplift of needy populations to treatment of patients who could pay for treatment, though hospitals associated with medical schools continued to provide more care to poorer classes of patients. 52 By the 1940s, more of the American population experienced medical treatment at hospitals rather than through home visits by physicians. Although the University of Michigan Hospital continued to primarily take care of patients from all parts of the state who were supported by their home counties, patients were asked to contribute some of the costs and private rooms were available. 53 Not only was the hospital population increasingly comprised of a more diverse mix of patients, but also they were perceived by staff less in terms of class and more as individuals. For children’s care, theories of child development and the emotional needs of children increasingly permeated mainstream pediatrics, and textbooks emphasized the need to promote both physical and mental health. 54 While theorists of children’s emotional development, such as psychologist G. Stanley Hall and psychiatrist Sigmund Freud, were well known among laypeople as well as professionals, the implications of this work for mainstream care of children were not clear until the work of Dr. Spock and others in the 1940s. 55 In addition, the insights of attachment theorists such as John Bowlby and Anna Freud were increasingly important in the years after World War II. 56 Hospital staff used psychological theories in their efforts to attend to the children’s physical, education, and emotional needs.
But an awareness of children’s emotional needs did not necessarily translate into a more emotional program for children. Indeed, as Daniel Wilson has pointed out, caregivers of children with polio at mid-century expected children to overcome their disability and move on with their lives, despite what were clearly emotional challenges. 57 Mental health experts on American childhood articulated a fairly narrow range of appropriate, healthy attitudes and behaviors for children. 58 For these experts, institutions for children, including schools, needed to train children to grow into balanced, well-adjusted adults. At the University of Michigan, the hospital school provided intensive services to take care of children’s social and emotional needs, even though the overall length of stay at the hospital was twelve to seventeen days. 59 The children at the hospital were scattered all over the hospital, cared for by a variety of different medical and surgical services depending on their illnesses. While there were a few wards designated for children, the unifying experiences for children at the hospital were provided by the teachers and took place in educational and recreational spaces rather than medical ones.
The Hospital School program, which had grown from one full-time teacher in 1922 to dozens of full-time and part-time teachers, aides, assistants, and volunteers by the 1940s, became increasingly specialized and creative in the care of children in the hospital. 60 While the pediatrics services only took care of a fraction of the children, the hospital teachers saw just about every child who passed through the door. The emphasis for the school was in making sure that children did not fall behind in their studies, just because they happened to be sick and in the hospital. As school staff reported in 1947, “In spite of discouragement from interrupted home and school life, as a result of debilitating illnesses, these students were encouraged to continue with their school instruction and select an occupation suitable to their abilities, within their limitations.” 61 The school proudly boasted that they not only helped children during brief hospital stays but also enrolled some children in a full hospital school program. The school was able to point to large numbers of high school graduates, as well as former students who went on to succeed in college. 62
Hospital teachers developed extensive educational programs for children and created classrooms where they brought any children who could be moved from their beds, and sometimes brought the beds themselves in order to get the children there. Teachers and assistants worked with children on academic subjects as well as occupational and recreational therapy work. Teachers also worked hard to make sure that the children had as much fun as they could in atmosphere that they described as “home-like.” The school program emphasized individual achievement, as well as attention to social, emotional, and occupational issues. Social service workers, who remained intimately involved with the program, assumed that all children would want to grow up to be productive adults and that they would need assistance in that goal. 63 The creativity and initiative needed for the hospital school allowed teachers in the program autonomy and flexibility well beyond the teaching standards of the time. 64
Hospital School staff did not see what they were doing as a supplement or a bonus to children, nor did they view themselves as ordinary teachers. Instead, they identified themselves as educators who would take care of the special needs of hospitalized children. In the 1940s, the funding for the hospital school at the University of Michigan moved from a state commission that reimbursed the hospital for children’s medical care to the Michigan Department of Public Instruction. As a result, the school was visited by a state education representative who was flabbergasted that the Hospital School made a point of communicating individual students’ progress to their home schools and that they also sought input on material that would be helpful to keep the students caught up in school. While Hospital Staff members were frustrated that their methods were being questioned, they took the opportunity to ally themselves closely with the University of Michigan School of Education and to purse accreditation for the hospital school. 65 They also explicitly framed their work with patients in terms of helping to meet their social and emotional needs while the doctors were taking care of their medical treatment. 66 The University School received national press coverage for its innovations in education for this population of students—including a 1956 Life Magazine spread. 67
Although teachers at the hospital school understood that they were providing education in a special setting, they did not initially frame their work as special education. Instead, they assumed they would be seeing children whose primary barrier to learning was their medical illness. 68 By mid-century, this had shifted somewhat, particularly as the University of Michigan School of Education began to have a more clearly defined role in supervising the Hospital School and as the concept of special education began to evolve within broader education. In the 1950s and 1960s, some of the teachers within the hospital school were specifically trained in special education, and the Hospital School became a location for University education students to learn to work with broadly defined handicapped children. 69
One of the areas in which the hospital staff brought children together was in the collective play and occupational therapy areas. At the University Hospital, teachers and nurses had been taking children outside on the roof of the hospital for healthful activities since the opening of the main hospital in 1925. Even when the hospital was expanded by the construction of two additional floors, the roof-top playground was reconstituted on the new roof. 70 Play was serious business in this time period, and the hospital school leaders put forth significant effort soliciting donations from the Kiwanis Club (both in Ann Arbor and in the state) to provide funding. 71 As a 1946 annual report about the Kiwanis Recreation Program explained, “The participation in play brings experience and socializing contacts with others for a useful and accepted goal. It is a very real factor encouraging maturity in interpersonal exchange, deepening and broadening the grasp of a child made lonely by separation and illness.” 72 While activities on the roof had originally been intended to ensure that children spent as much time as possible outside, over mid-century the roof became critical because of worsening space constraints in the hospital. Teachers constructed classroom space anywhere they could find it, and shaped it to be of educational and social value. In 1959, they redid a former storage porch for elementary children to use—“the possibilities for group work and a more home-like school setting have been greatly enhanced by this new arrangement, with the result that even greater numbers of children are able to enjoy the school facilities and to ‘keep up' with home classes.” 73 Space, which was perpetually an issue in the hospital, was an ongoing challenge for the teachers who were determined to create areas for children so they could learn from their instructors and engage with one another.
As in earlier years, philanthropists were willing to step up and provide funding and materials to enrich the experiences of children in the hospital. Donors both large and small believed they were contributing to a more normal existence for the children who happened to be in the hospital. One of the major donors to the children’s programs in the middle of the century was the Galens Honorary Medical Society. 74 These men (the group did not admit women until 1971) initiated Tag Day drives in 1927, in which they gave paper tags to people who had already donated money; this arrangement helped advertise the drive and kept donors from being solicited multiple times. The Galens Society initially gave money to provide a nice Christmas to children in the hospital whose families might not be able to afford to give them presents. By the 1940s and 1950s, Galens and other groups were providing activities—including Christmas—to all children to make it just like being at home. 75
Donations by groups such as Galens provided much of the material for pediatric patient care in the middle of the century. While there were certainly some technologies important in medical care in this time period—the iron lung for the treatment of polio, for example—most of the patients’ time and energy was spent doing activities in places such as the Galens Workshop, a room set aside with woodworking and other tools for boys and girls to constructively use their time and energy. 76 The King’s Daughters and the Kiwanis also kept up their support of programs at the hospital, and these donations made sure that children had teachers, books, materials, and toys so that they could continue to grow and develop while in the hospital.
Volunteers also helped make the environment pleasant for the children. A formal volunteer program began at the hospital in 1941 and provided essential assistance during the staff shortages caused by World War II. In the decades after the war, many volunteers—primarily housewives and University of Michigan college students—provided hours of assistance in the hospital. 77 Some helped in the hospital school, while others endeavored to make patients feel more as though they were at home. On the children’s ward in the evenings, volunteers helped children get ready for bed. 78 As historian Rosemary Stevens has pointed out, hospital volunteering helped create a sense of community and provided an outlet for women who had worked for pay during the war. 79 Volunteers at the University of Michigan Hospital made sure that the children had the opportunity to have what they believed were essential toys (such as dolls for girls) and to celebrate holidays such as birthdays, Halloween, Easter, and Christmas. 80
Hospital staff worked hard to create a therapeutic community for patients. They put tremendous time, energy, and effort into special occasions, particularly Christmas celebrations. Although part of this was clearly governed by their expectation that white, middle-class, Protestant views were the norm, celebrations such as Christmas in the hospital brought people together and helped them feel like part of a big family. And part of the spirit of Christmas for hospital workers was in illustrating that big family events could continue, even though patients were ill in the hospital. As the formidable head of the social service department, Dorothy Ketcham, explained in 1945, “In spite of the distressing illnesses and the many difficulties which accompany them, we try to stretch out searching fingers of cordiality and friendly concern to every patient in the Hospital.” Donations by philanthropic groups allowed the hospital to give sick patients what staff believed were their rightful presents at Christmas—stockings and gifts for the children, and as well as cigarettes to some of the adults. 81 Ketcham congratulated hospital staff, especially the teachers, for being able to select gifts for each individual child that would make him or her happy in the season. 82
The idea of a hospital community as a large extended family was widespread within therapeutic literature. 83 During this time period, as in earlier decades, children were deposited at the hospital by their families or agents of their home counties. 84 Families were not expected—or really allowed—to visit for more than very limited times. It was perhaps not surprising that the assumption that the hospital would function as a family meant that nurses would be expected to act like mother figures. Some of the literature made it clear that nurses and mothers were not the same, though the descriptions of nurse–child interactions depended on the insights gained from child psychology and psychiatry about interpersonal interactions in child development. One 1944 nursing text remarked that nurses need to not undo a good mother’s work by spoiling her trained and friendly child. On the other hand, “If a child has been poorly trained or treated unkindly at home, the nurse who is interested can sometimes help to start him and his parents off on more promising pathways.” The nurse should not smother but treat the child as an individual. 85
Other texts glamorized the role of the nurse, and suggested that perhaps nurses were better qualified than parents to take care of children. Parents (especially mothers) had little obvious role in the care of their hospitalized children. As Rima Apple has pointed out, pediatricians by mid-century expected mothers to be passively obedient to dictates from medical staff. 86 A nursing school bulletin from the University of Michigan in the mid-1950s illustrated a student nurse teaching a mother how to take care of her baby. The student nurse handled the baby while the mother looked on. If the student nurse had not been wearing a uniform, it would have been difficult to tell which was the mother, since the student nurse had a bigger smile on her face and looked more confident with the baby. 87
Parents were peripheral to patient care through the 1960s, and they were not often mentioned in descriptions of hospital activities or procedures. It was the responsibility of the medical students and residents to get a history from parents when they brought their children into the hospital. 88 But trainees evidently needed to be told, as they were in a 1949 procedure manual, to “Treat the parents with courtesy and patience, trying to make them feel that you are sincerely interested in helping their child and them.” 89 Parents also needed to be told to make a point of talking to the hospital staff. A guidebook for parents from around this time period explained the procedures of the hospital, and also said that “It is important that you wait for your interview with the doctors. They will want a detailed history about your child and you may want to ask them questions before you leave.” 90 During the time of their children’s hospitalization, parents were expected to get out of the way and let their children join the hospital family for treatment.
As the same time that nursing literature emphasized the individual relationships between nurses and patients, the patients themselves began to be perceived more in terms of individual stories. 91 In particular, during the 1940s and 1950s, a number of disease advocacy groups began to use poster children, a single child chosen to represent a whole group of children (or class of illness), in order to raise money. 92 Media coverage of individual children in need often garnered an emotional outpouring of financial support. 93 For example, in 1950, the story of an eleven-year-old girl and her battle with rheumatic fever was covered in a radio story in Ann Arbor. As a result, she received mail (including more than a thousand letters in one day), toys, gifts, and offers for travel. As the hospital newspaper reported, “Even though as yet she cannot run and play, nor even walk without the aid of crutches, Myrna is her old cheerful self, and now is planning to study through the summer with the hope that she can join her old classmates in the fall. May we add our good wishes to a gallant, little girl who has the admiration of the entire country.” 94 In 1953, another story about a little boy who needed a wheelchair was run in the Ann Arbor News—he got his chair, thanks to the public response to the heart-rending story. 95 In 1957, the March of Dimes poster child was a patient from the University of Michigan. The hospital newspaper coverage of him emphasized his experience of having an extended family in the hospital: “It is said that Bobbie has a thousand mothers and fathers here in the hospital and every body makes a real fuss over him when he makes his appearance.” 96 These human interest stories highlighted the individual care and attention hospital staff promoted for their young patients.
But while most of the literature on the care of children in the hospital during this time period focused on individuals, it appears that the patients themselves may have perceived themselves more as a part of a community of peers. In 1948, a young man wrote to his former caregivers at the hospital to recollect his experience of years of going back and forth for multiple foot surgeries:
I vividly remember the delight of ice cream for dessert on Wednesday and Sunday, and movies on the wall every Thursday night. I remember the excitement in the ward every morning as the nurses received their assignments to the different boys: even then each of us hoped that his nurse would be kind and pretty. I remember the time my favorite ward helper stooped over my bed during the afternoon rest period and kissed me. She thought I was asleep. But really I was only playing possum. I remember the mornings when the orderlies lined our beds up train style for the trips to the flat sunny roof. Much to our boyish delight they wheeled us down the corridor to the elevator and soon we were on our way up to ‘paradise.’ The ‘Roof' held everything to capture a young boy's heart: a work shop with all sorts of handicraft materials and tools; two raccoons which daintily rinsed their food in a water dish; a Scottie pup that romped whenever children were playing; and all kinds of games and recreation equipment. What fun!
97
Unfortunately, there are not many records of this time that so clearly speak to the experiences of patients. What is apparent from this recollection, though, is that this young man thought of himself first as part of a group of boys—and only second as a patient in a hospital.
During the middle part of the century, it was so common for caregivers to discuss the physical and emotional needs of children together that it seemed natural to include the insights of child psychiatry within the medical care of pediatric patients. 98 At the University of Michigan, child psychiatry had a structural, as well as ideological, effect on the care of children. In fact, a children’s psychiatric hospital became the first part of what was supposed to be a comprehensive children’s hospital. Members of the pediatrics department from the early part of the century wanted to have a dedicated hospital for children. When James L. Wilson took over as chairman of pediatrics in 1941, he was promised that he would get a new hospital. In the early 1950s, Wilson and other members of different departments (including psychiatry) who treated children met together to plan for a comprehensive children’s hospital. Architectural drawings were completed for a hospital with two wings—a pediatrics wing and a psychiatric wing. 99 In 1955, the first wing of the Children’s Hospital was opened—the component dedicated to psychiatric care. The hospital was officially designated the Children's Psychiatric Hospital (or CPH), though hospital publications from 1955 to the early 1960s just referred to it as Children’s Hospital. It was designed with one wall that could be knocked down to make room for an expansion for the general pediatric wing. 100
The issue of the home-like environment was the major difference between CPH and the children on medical wards. For the psychiatrically hospitalized children, the environment was supposed to be warm and supportive, but not too much like the home that likely helped to create the problem that led to hospitalization. 101 But in general, hospital programs at the University of Michigan during this time period did not distinguish between children hospitalized for psychiatric reasons and those receiving medical care. From the 1950s through the 1970s, psychiatrically hospitalized children received the same attention from the Hospital School as children from the medical services, though their average length of stay in the hospital was significantly longer. 102 Pictures of children from CPH, as well as adolescents from the adult psychiatric hospital, appeared alongside medically ill patients in hospital school publications. As the Hospital School staff emphasized in 1960, the school program operated in three major areas: the main hospital, the CPH, and the teenage program at the adult psychiatric hospital. The school program at CPH was fully integrated into the treatment program, and patients engaged in active, creative collaborative work. 103 Not only did the school publications show psychiatric patients, but also the Galens Tag Day fund-raising drives raised money for Christmas parties and other activities for children on both medical and psychiatric units, as the Galens students explicitly noted in their fund-raising literature. 104
The integration between psychiatric and medical care became a bragging point for the hospital in the 1950s. 105 As a hospital staff member explained, “The hospital will seem like something out of a fairy tale to the emotionally disturbed delinquent and sometimes destructive youngsters, many of whom will come from the slum areas of Michigan’s larger cities.” But the benefit would not just be for the children. Once the pediatric medical wing was attached, “The completed building will constitute a children's medical center, unduplicated elsewhere. Any supposed stigma attaching to a child being treated for mental illness will be removed.” 106 Treatment for mental illness was part of a complete project of care for children at the hospital.
But the plan to expand the CPH with a pediatric wing never materialized. Hospital leaders were desperate to generate pressure for funding for a new children’s hospital by the early 1960s. The Hospital Star, the newspaper for the hospital staff, published a supplement in January 1962 outlining the many problems caused by the antiquated facilities for children’s medical care. The editor encouraged readers to show this issue around to anyone in the state who might be able to help. Within the supplement, the medical school dean explained that “In April, 1953, when the University Regents accepted responsibility for creating and staffing a Children’s Psychiatric Hospital, they did so with the positive understanding that CPH was to be the first unit of a sorely needed Children’s Hospital.” But the legislature did not fund money for the expansion, and the situation had become critical. Children were scattered throughout the hospital, sometimes next to geriatric patients, and the training program in pediatrics had become endangered. 107 In 1964, the chair of pediatrics and the medical school leadership turned to private philanthropy, including the Charles Stewart Mott Foundation to solve the problem. 108 In 1969, a new C. S. Mott Children’s Hospital was opened to great fanfare. The pediatrics department was thrilled that they would finally have charge of all the children from the whole hospital—though they shared management (with internal medicine) of an adolescent ward that was still located in the main hospital, and psychiatrists from the adolescent unit at the main psychiatric hospital provided psychological counseling for the teenagers. 109
A Mott Foundation investment in a children's hospital in Ann Arbor in the 1960s was somewhat unexpected. Mott was from Flint, not Ann Arbor, and his foundation did not routinely give grants to build hospitals (as they tried to explain to the many organizations that approached them after the gift to the University of Michigan in the 1960s). The public information officer at the University of Michigan was strongly advised to emphasize Mott’s interest in sick children in Flint and a cooperative relationship with the University of Michigan Pediatrics Department, not the building itself. 110
Further, the University of Michigan in the 1960s was an unlikely location in which to invest in the care of youth. During this decade, much of the campus was convulsed by the physical and emotional turmoil of student protest movements. 111 The youth movements, which were comprised of people some of whom were very much within the purview of pediatrics and children's hospitals, were highly contentious and conflicted. Some physicians nationwide tried to cope with this social chaos by creating medical structures. As Alexandra Stern and Howard Markel have pointed out, the subspecialty of adolescent medicine arose in the context of the social disruptions of youth protest. 112 But sickness in children provided more than just a way of capturing professional turf, it also became a symbol for unity.
During this time period, images of sick children seemed to be able to break down barriers between people in a way that demonstrated a major shift in understandings of illness in children. In the early part of the century, philanthropists gave to poor and sick children hoping to uplift them and their families. In the middle of the century, philanthropy focused on individual children but also helped support them to continue their lives, despite being sick. But beginning in the late 1960s and 1970s, sick children seemed to be something special and different. Mott’s rationale for supporting a new hospital was engraved on a plaque at the entrance: “We approach all problems of children with affection. Theirs is the province of joy and good humor. They are the most wholesome part of the race, for they are freshest from the hands of God.” 113 As a University of Michigan hospital publication pointed out in 1969, “There is nothing more appealing than the big shiny eyes of a child. And if those eyes happen to belong to a sick child, the combination can touch the most hardened heart.” 114 Providing care to sick children was a sort of a haven in an otherwise tumultuous world.
Family-centered Care, 1970 to the Present
The hospital in the first two-thirds of the twentieth century served as a home for patients, complete with surrogate parents and an extended family, even when patients were not there for prolonged periods of time. By the 1960s, though, a growing number of social scientists, using the same insights from child psychiatry and psychology that had informed earlier relationships with children, became increasingly concerned about the emotional effects of separating children from their parents in the hospital. Instead of framing the hospital experience as a time to keep going with normal activities (including school), critics emphasized the abnormality of children’s illness. And rather than accept that illness was part of life, social scientists became highly attuned to the psychological issues that afflicted children who experienced physical ailments. 115 Further, in the context of a political battle over the primacy of government or family for children’s welfare, the hospital became a place that focused on strengthening family connections.
In 1965, a consulting psychologist in Berkeley, California, remarked that the older hospital routines had been based on the convenience of the hospital staff rather than on thoughts about the patient’s family.
It used to be thought that from every professional aspect—medical, nursing, and administrative—the hospital course was smoother, more effective, and less disturbing if parents were excluded from visiting, as much as possible. Pediatricians and house officers felt that procedures were more easily carried out, medicines more readily taken, and their harried and harassed days less trying when they dealt directly with their little patients, without interference by tearful, anxious, and questioning parents. They were convinced that the hospitalized child, who is separated from his mother, submits to the needle with less noise and squirming and feels more secure and more at ease when his parents are not present. The constant demand for information and assurance, by questioning mothers, is a nuisance to many physicians and the zenith of chaos reigns as the tearful mothers leave their screaming children when the loud speaker emits the fateful sentence, “Visiting hours are over.”
116
Instead, Geist argued that these health care imperatives were wrong and that children did better with their parents (especially their mothers). Indeed, the hospital was a traumatic place for children because they were both sick and separated from their family supports. The sick children’s experiences of being isolated worsened their overall physical and emotional health. In response to concerns raised about emotional issues for children in the hospital in the 1970s, pediatrician A. Frederick North Jr. proposed criteria for children to be in the hospital based on services they might require there (rather than their diagnosis). The goal was to minimize children’s time away from their families in a potentially difficult environment. 117
Critics’s focus on children’s emotional health in the hospital came at the same time that increasing technology threatened to make the hospital a cold, mechanical, impersonal place. As historian Paul Starr pointed out, technology in the hospital seemed to be a major problem for those who were concerned about the humanity in medical care in this time period. 118 Pediatrics became increasingly specialized and hospital care involved more and more technical interventions. 119 While there was no doubt in anyone’s mind that increasing medical advances were valuable, pediatric program directors suggested the need to go “beyond the provision for adequate medical services to an approach that promotes the general adaptation of the family (its ability to cope during the crisis of illness) and that serves to bolster the family’s emotional state to a level where it can perform as a stable unit and its members can function as stable individuals.” 120 Hospital leaders expressed a need to pay attention to the child’s social context—but only through a focus on his or her immediate family, not the broader community.
In 1972, two California nurses explained that “Today there is ample evidence that, while many children in American hospitals receive high-quality technical care, their social and emotional development may be permanently damaged because little attention is paid to their reactions to separation from the family.” 121 The nurses cited a number of children’s hospital programs around the country that were engaged in new and creative methods for incorporating sick children’s parents into their care. The University of Michigan was not one of them. Indeed, a reader commented in the margins that Mott Hospital still had a way to go to include families and flexible child-centered programs. But they were certainly trying. When Mott Hospital opened in 1969, it was advertised that accommodations had been built in to allow parents to stay as much as they wanted. 122 Further, in 1980, the health system annual report enthused that the culture had shifted regarding other family visitors in the hospital: “Children can now be visited in the Hospital by their brothers and sisters of any age in a program initiated this year at Mott Children’s Hospital. The program helps maintain family bonds while working to dispel the well child's myths about hospitalization and what's happening to his or her sick or injured sibling.” 123 The program rapidly evolved to link families with their children’s hospital care.
By the 1970s and 1980s, parents appeared as central figures in the care of pediatric hospital patients, as other providers moved more to the background. But while this was presented as a way of treating children more humanely by allowing them to be with their families, the shift toward incorporating parents was likely also to be related to staffing issues. As Rima Apple has pointed out, increasing technology in hospitals pulled nurses away from the bedside of their pediatric patients. Parents then became the substitute caregivers, especially as an increasing number of third party payers (including the federal government) pressured hospitals to decrease lengths of stay and costs. 124 Teaching hospitals in particular felt pushed by government regulations and funding constraints, as their costs were often not covered by state and federal reimbursement, and their lengths of stay were longer because of the teaching activities at the hospital. 125
Not only were families invited into the hospital to keep costs down but also the increased expectation of parents’ involvement in their children’s illness reflected shifts in parenting styles over the 1970s and 1980s. Although parents were still dependent on expert opinion, new generations of parents were more likely to be involved in every detail of their children’s lives. 126 Nursing textbooks from this time period reflected a change in the role of parents. In the 1960s, nursing instructors made a point of explaining to their students that the nurse “no longer replaces the mother in the hospitalized child’s life; she now helps the mother to provide nursing care for her child when he is well and when he is ill.” Nurses should not try to compete with the mothers for who can be better with the children, but rather nurses should become the mother’s friend. 127 By the late 1980s, nursing textbooks stressed the value of the family: “The family is the basic unit of society. The integrity of the family unit and the child's relationships within it must be maintained…. The pediatric nurse seeks to promote, maintain, and restore health in both children and parents.” 128 Nurses increasingly took on the role of educators for patients and families, and some nurses nationwide made a push toward greater professional autonomy and responsibility as pediatric nurse practitioners. 129 At the University of Michigan, the nursing school began a pediatric nurse practitioner program, and photos of nurses in pediatrics shifted from ones that showed relationships between nurses and children to ones that illustrated nurses as educators and demonstrators to the whole family.
There was initially still room for teachers in the treatment team, though. As Arkansas special educators explained in a book for parents whose children were going to the hospital, the teachers at the hospital were likely to be comforting reminders of their home routines—including the usual pattern of going to school. But while the teacher could be a helpful presence in the hospital, things were clearly different than at home: “Her job is not to keep the child up with his studies, merely to provide familiar diversionary tactics which will ease the tension and fear already present in the situation." 130 The same shift happened at the University of Michigan. While teachers had been central for many years, even for children in the hospital for a short time, by the 1970s and 1980s the teachers only engaged with students when they were in the hospital for a prolonged period. 131 Instead of being a constant feature for hospitalized children, the hospital school became one of many available supports, and staff spent as much time trying to entertain the children as they did educating them. 132
In 1985, the Hospital School changed its name to the Child Life Department—which reflected its change in mission to focus on the special needs of sick children. They explicitly “shifted from a heavy emphasis on teaching academics to one in which the emphasis is on education and recreational activities that assist patients in coping with the hospitalization.” 133 Instead of photos from classroom settings, photos especially from the 1980s onward were of special activities, such as a 1987 visit by Ronald McDonald. And while more and more philanthropic groups became involved in supporting children’s activities, there was a shift in emphasis. Instead of trying to give the children a sense of normality during illness, the hospital began to provide more special entertainments, such as visits by the circus, because the children were sick. 134 This was also the time period when—according to legend—football coach Bo Schembechler encouraged his players to begin to visit children in the hospital. 135
The growing variety of diversions and entertainments for hospitalized children in the last several decades has been part of a widespread, increasingly sentimental view of sick children. But emotional portrayals of children have obscured several tensions within modern medical care. First, at the same time that families were incorporated into children’s treatment in the hospital, hospital staff began to note more of a contrast between idealized and problematic parent involvement. In the 1970s, parents of children at Mott Hospital went from only visiting very selected hours (or only a few days a week) to being encouraged to room in if they wanted. 136 Hospital administrators emphasized that the hospital’s goal was to take care of sick children while supporting the family. But families became more involved with the care of their children at the same time that physicians nationwide were beginning to worry about the abuse of children at the hands of their parents. Activist physicians increasingly focused attention on the need to scrutinize children’s injuries and evaluate for potential abuse. 137 At the University of Michigan, a Child Protection Team was formed in 1970 to assist hospital staff with suspicions they might have about patients’ parents. 138
Not only did the ideal of parent involvement in the hospital obscure the reality of increased surveillance of parents, but also the emphasis on care of sick children was mobilized to minimize conflicts in the medical setting. In 1984, the University of Michigan Health System annual report had a picture on the cover with a toddler (and a dim, shadowy figure of a health care worker with her). The title of the report was “The Human Touch in a High-Tech World.” In the introduction to the report, the hospital director discussed the fact that medicine was becoming increasingly technical, but that at the University of Michigan, patients remained the primary concern. 139 In this context, a focus on children’s emotional needs helped to gloss over the mounting costs of medical treatment, an increasingly complex and segmented medical force, and potentially troubling uses of technology.
As a number of historians have pointed out, American reformers over time have invested tremendous emotional, political, and social energy in promoting children’s welfare. But the idea of children’s welfare always contained assumptions about social and political power, as well as a critique of some families’ lives. In the late nineteenth century, children were seen as the entry point to social control. 140 Hospital staff viewed children’s time in the hospital as an opportunity to educate them and return them to their communities as ambassadors of uplift. By mid-century, experts promoted the best way to creatively nurture a complete human being. And, of course, the experts at the hospital viewed their care to be as good—if not better—than that provided to children in their own homes.
By the last third of the century, children—especially sick children—seemed to provide a safe common image for groups that otherwise could not agree on anything about society. For example, in the late 1970s, when the University of Michigan Health System was convulsed by turmoil around issues of minority and gender discrimination and affirmative action, all could look in fond sympathy on the story of a little girl from Cass City, Michigan, who was saved by the treatment teams at Mott Hospital. 141 Today, just about all political groups agree about the need to care for sick children, and most will allow that someone has to take responsibility and pay for at least their medical care. And images of sick children have become powerful and popular objects for widespread philanthropy.
Conclusion: Gratifying Wishes
For centuries, sick children have promoted benevolent efforts to take care of them, even as the major sicknesses shifted from infectious diseases to conditions that require ongoing management such as diabetes or cancer and the mortality rates among populations of children dramatically declined. 142 Further, sick children have always been perceived as having needs to be filled by hospital providers. But in the last several decades, sick children’s needs have been primarily framed by their illness, not by their social class or their stage of development. In the last twenty years, the creative energy and resources put toward special activities for sick children have been extraordinary. Numerous foundations have sprung up to provide special opportunities for kids with serious illnesses, such as the Make-a-Wish Foundation for children with a life-threatening medical condition. 143 Children in pediatric hospitals have a steady stream of important visitors and donors—including professional football players. And some of the projects created by and for sick children are incredible, such as a 1995 University of Michigan effort to have all the hospital children paint cloths that were later assembled to create a reproduction of Georges Seurat’s painting, “Sunday Afternoon on the Island of La Grande Jatte.” 144 Although sick children in the hospital still have problems with adjustment to their illness, as well as time on their hands when not engaging in medical treatments, modern answers to these problems involve treats and distractions, not instruction and schoolwork. Indeed, in 1973, a hospital teacher at the University of Michigan expressed some concern that, with the multitude of entertainments and diversions for the children, they might become too attached to the hospital: “The goal is happy kids—and it occasionally poses an extraordinary problem for the Hospital itself. ‘Many of our kids,’ says teacher Dana Lanning, ‘just don’t want to leave.’” 145 And how much more attached might children be to modern hospitals that offer flat-screen TVs, Internet computer access, DVDs, and gaming systems? 146
The evolution of care assumptions for hospitalization in behaviorally disturbed children provides a sharp contrast to the situation within contemporary pediatric hospitals. Although the average length of stay at the University of Michigan CPH decreased from a high of 300-plus days in the 1970s to a level now comparable with the general pediatric hospital, the school program remained engaged and teachers still try to keep children caught up in school. CPH at the University of Michigan was torn down in 1990 and the child and adolescent units were moved into a Maternal Child Health Center. But psychiatrically diagnosed children do not have the same diversions and entertainments during their hospital stay. And when the University built a new and glamorous children’s hospital in 2011, the one children’s area that did not move into the new building was the child psychiatric unit. The University of Michigan football players do not visit the psychiatric unit nor do mentally ill children evoke the kind of outpouring of sympathy that has become commonplace for children on the medical floors. The University’s tremendously successful fund-raising campaign omits mention of the needs of children with mental health issues, even though hospitalization for behavioral health problems is the only type of hospitalization that is increasing among children. 147
Children’s Hospitals have come a long way in the last century and a half. They were once places of last resort for poor and sick children. Some of them are now glittering and exciting, with elements of a theme park. 148 How we see sick children has also changed. Most do not question the expectation that we pull out all the stops for a sick child—no diversion, no entertainment, no gift may seem excessive to compensate for what the child experiences when ill. Yet, this was not always the case—at mid-century, the hospital was a place where staff helped children with a focus on maintaining normal lives (even while ill). Now, a child’s illness has become front and center. This is particularly apparent in the contrast between the popular attention and gifts showered on medically sick children and increasingly invisible psychiatrically ill children.
Images of sick children in America still unite policy makers and politicians from multiple political perspectives. But do these images distract from children’s other needs that evoke less sympathy, such as problems around access to education, mental health and behavioral disturbances, as well as the enormous problems of poverty? And how does the increasing opulence of children’s medical centers affect the ever-present issues of the cost of medical care and inequality of access? It is wonderful that a picture or story of a sick child can generate sympathy and donations, but is there any way to harness that giving for other causes? In the meantime, even if we recognize the potential pitfalls to the trajectory of modern children’s hospital care, who in this divisive political climate could possibly challenge the overwhelming sympathy for sick children?
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship, and/or publication of this article.