Hospitalism

HOSPITALISM, a term that arose in the pre-antiseptic era to denote the incomprehensible and mysterious influence that hospitalization and medical institutions had on patients. With the introduction of antiseptic and aseptic practices into hospital work and with the disappearance from hospitals of 'hospital gangrene,' 'puerperal fever,' the mysterious nature of hospital H. was clarified, which turned out to be due mainly to nosocomial infections. However, in children's institutions, especially for young children, this reform initially had almost no effect, and the term 'H.' remained in pediatrics to express the sum of harmful influences to which a child is subjected in closed institutions, both therapeutic and those intended for care. Child mortality in these institutions was still extremely high at the turn of the 19th and 20th centuries. In the infant ward of the university clinic of Heubner in Berlin, the mortality rate for 1892-97 fluctuated between 68% and 80%; in Parrot's institution in Paris in 1890, 80% of all infants died; in Soltmann's in Leipzig in 1905, 52.6%. In the Ryazan zemstvo asylum in 1906, mortality was 77.8%; in the Minsk foundling asylum, 77.9%. In the Moscow Foundling Home, according to reports for 1907-10, mortality fluctuated between 30% and 40%. However, the mortality figures of the Foundling Home do not reflect the actual situation, as this percentage was artificially lowered by quickly sending children to the countryside for upbringing. The situation at one time seemed so hopeless that Heubner in 1897 seriously considered the question of whether it would not be better to close infant institutions altogether as clearly harmful, only increasing child mortality. A detailed study of the causes of this phenomenon showed that children died mainly from general infectious diseases, epidemic diarrhea, and various nutritional disorders, associated primarily with artificial feeding; at the same time, the harmful influence of overcrowding of children in the institution also became clearly apparent. The result of this study was a series of requirements put forward by pediatricians (Heubner, Schlossmann, Hutinel) for the prevention of infections and improvement of feeding methods. The fight against infections was carried out by reducing overcrowding of children, introducing isolation wards and boxes, increasing and better training of staff, and strict individualization of care items. Special attention was paid to sufficient light and air and strict observance of general cleanliness. The requirement of natural feeding (Schlossman, Czerny) and the presence of a sufficient number of wet nurses in infant institutions was also made mandatory. The implementation of all these reforms quickly reduced morbidity and mortality, especially in new, rationally organized institutions; in 1911-12, in Langstein's infant asylum in Berlin, 11% of children died. According to data from Kuklina, mortality in the reorganized post-revolution institutions in Leningrad was: in infant homes (infant houses) in 1922-16%, in 1923-11%, in 1924-10.8%; in toddler homes (children's homes) respectively 12%, 6.2% and 6.6%. In the Saratov infant home (according to the report of the Saratov subdepartment for the protection of mother and infant) in 1922-31%, in 1923-9.5%, in 1924-6.5%; in the children's home-28%, 4.4% and 7.2%. In Moscow institutions for children from 1 to 3 years of age, mortality was: in 1925-4.63%, in 1926-2.88% (Grebel'skaya-Al'bats). Progress in the field of artificial feeding further improved the situation. In the physiological departments of the Moscow State Institute for the Protection of Mother and Infant of the People's Commissariat of Health, with 4 wet nurses for 60 children, in 1926 out of 151 children under 1 year of age, 8 died (5.3%), in 1927 out of 135, 6 died (4.4%). The influence of H. was thus significantly reduced but not yet eliminated. Epidemics of diarrhea have almost ceased, diseases of measles, whooping cough, pyoderma, septic infections have significantly decreased, but influenza and influenza-like respiratory infections have not yet been banished from these institutions; the fight against them so far does not give successful results mainly because the source of infection is most often adults - the caring staff and visitors. According to Meyer's data, every child staying in an institution for more than a month has a chance to contract one influenza infection. And even now, with significantly reduced mortality, the development of children in closed institutions, especially children in the first 6 months, noticeably lags behind the norm. They lag in weight and height, are pale in skin and mucous membranes, are flaccid and weak in musculature, and have delayed teething. The development of their psychomotor functions noticeably lags: children start sitting, standing, walking late; involuntary urination persists for a long time; speech development is particularly delayed; by the end of the 2nd year, their vocabulary is often limited to 1-2 dozen words. In older children, the lag in physical development is manifested not so much in weight as in stunted growth, development of the chest, shoulder width, and muscular strength; they are pale and listless, lacking a cheerful, joyful mood. They poorly tolerate infections; mortality from measles, diphtheria and pneumonia among them is significantly higher than among other children (Pfaundler). Regarding the causes of this lag in children living in closed institutions, there are two opinions. Some (Meyer, Finkel'shtein) attribute main importance to infection, especially frequent influenza-like diseases that disrupt and slow down normal child development. But others (Pfaundler) rightly point to a second important cause - the lack of individual care in the broad sense. In an institution where there is one caring sister for 10-15 children, the child is left too much to himself. Almost the whole day, except for feeding and cleaning time, he spends in a crib, he is rarely held in arms, not played with₇ , not talked to, not entertained. Children have too few impressions and mental stimuli. This inevitably leads to a slowing down in the development of a number of organs and systems and prevents the timely formation of conditioned reflexes and accumulation of experience. The monotony of the surrounding environment also acts oppressively on the child - the same figures in white coats, the official and uniform furnishings of the ward. 'The atmosphere of the asylum,' writes Pfaundler, 'acts oppressively on the child's psyche, and through it on all nutritional processes.' Pavlov's experiments, the research of Feer and Birk, (B'еег, Birk) revealed the influence of the nervous system on nutritional processes. Even in the same institution, children who are there with their mothers develop better under otherwise equal conditions than others. According to data from Shastin, from the Voronezh children's home, wet-nursed children on average gained 10.2 g in weight per day; other children, also receiving female milk, only 4.6 g; in the first group, about 25% of children developed normally, in the second only 2%. But even maternal children in closed institutions lag in their development from the average norm. Freund, on the basis of numerous observations, notes that upon leaving the institution, in home conditions, even foreign (patronage) conditions, the condition of children, especially children with neuropathic constitution and exudative diathesis, quickly improved in all respects. The lack of communication with the outside world particularly affects the psyche of older children, which hinders the development of initiative and social skills. In severe cases, this is 'an obedient child, staring blankly at everything around, afraid of new people, unable to play, uninitiative' (Durnovo). Hospitalism has not yet been completely eradicated in hospital institutions, especially in infectious children's departments, where nosocomial infections (see) come to the fore, significantly increasing mortality compared to extra-hospital mortality from the same diseases. Hospitalism thus represents a combination of harmful influences: 1) infection, 2) deficiencies in feeding, 3) lack of individual care, and 4) abnormal environmental conditions, and manifests differently in individual institutions depending on the age composition of their population and the intensity and particular combination of these factors.