Ecology
Children's Hospital, 1913

Considering the odious reputation understandably enjoyed by the penmanship of physicians it probably will come as a surprise to find that this is a relatively recent mutation.

Some years back while a resident physician at The Children's Hospital of Philadelphia I found a file of bound medical records going back to the early years of the institution now approaching a century and a half of existence.

C.H.O.P. is the oldest such institution in the New World and the second oldest in the Western Hemisphere.

It was founded in the 1850's, just a year after the Great Ormond Street Hospital for Children in London. 

Medical records of hospitals are traditionally filed permanently, and before the day of photo-static duplication they were bound periodically into "hard-bound" volumes.

This was the small library into which I dipped one night while alone in the Medical Records Room and feeling weary from the tedium of finishing and signing off records of patients I had helped attend and who had now been discharged.

The volume I randomly chose to examine was from the summer of 1913, some 50 years before. 

I was in for a surprise.

First, I was amazed to find that the records were all rendered in Spencerian script, a style of very legible handwriting that in my generation was an attribute of trained office-workers, such as my father.

I had no idea at the time that this artful skill had also been taught to the so-called professions, and I wondered were it not part of the older tradition of teaching the "Three R's" -- reading, writing and 'rithmetic.

In any event, with the script being easy to decipher I spent about an hour reading of patients who had been in the hospital those many years past.

It went through my mind that we could do worse than return to the scrivening of an earlier age, though it's supposed that the word processing of the computer age will eventually replace the scrolls and scribbles that record reviewers of my day had to suffer.

Then, as I moved from attention to structure to the content of what I was reading, other factors registered.

All of the thirty or so consecutive cases I perused were of infants with "summer diarrhea."

In none of the cases was any particular therapy discussed and in all of them the patients died.

The Spencerian script was decorative and attractive, but was used only to describe the nature of the excrement of the patients, as if having nothing therapeutic to offer that something could be gained by meticulously and systematically recording their output.

I then looked back in the record book from the summer before and found the same thing in annotation, disorder and outcome.

So, about the time that World War I was starting there were perennial estival outbreaks of infant dysentery, the cause of which was obviously poorly understood, for which definitive treatment was unavailable, and the outcome of which was all but uniformly fatal.

In my day at C.H.O.P. diarrhea in young infants was still a major illness with which we contended, though then the cases occurred throughout the year and, though the babies were critically ill, they were seldom lost.

We also dealt with many other illnesses at the same time, and rarely was there a run of more than one or two admissions with the same problems.

We knew that in infants with such fluxes that we needed to correct the loss of bodily fluids and electrolytes -- that is, the salts within these fluids -- to bring the patients around.

As a matter of interest, this all reminded me of the first time I had ever heard of "The Children's Hospital."

Once on a car trip well before I had gotten into medicine I had picked up a radio dramatization describing discoveries in biochemistry by C.H.O.P.

This discovery had led to rational intervention in dehydration and was the first time it had been appreciated that the internal fluids in the bodies of animals reflected, more or less the composition of sea water, and that the dire results of water loss were largely traceable to the loss and shifts of salts within the body cells.

It was this insight that revolutionized the treatment of dehydration from various causes, and eventually to the formulation of "Gatorade."

As these various ideas played through my stream of consciousness it occurred to me that something had happened in the years since 1913 because the incidence of summer diarrhea had drastically reduced.

I wondered what had caused diarrhea to be so severe in those earlier years.  Obviously better treatment had reduced mortality, but why the reduced incidence.

I asked various senior staff, but in truth, though they had come along professionally a bit before me, they appeared long after the era in question.

No one had an answer.

I asked Dr. Joseph Stokes, Jr., chief physician and professor, and he did not have an answer even though he had been a medical student at the end of World War I.

The most senior physician to whom I had access was Dr. Rachael Ash, our cardiologist and she well remembered the summer illnesses having been young physician in the early 1900's.

She had a reasonable explanation, though it was somewhat conjectural.

Dr. Ash reminded me that the automobile didn't come into widespread use until after the end of World War I.

She had grown up in Philadelphia and remembered that until automobiles replaced horse-drawn vehicles the streets were constantly befouled with animal droppings.

She said that in the summer this contamination led to swarms of flies, everywhere, indoor and out.

To her mind these vermin and summer diarrhea had decreased as automobile use increased and horses left the scene.

To be sure cleaner water supplies, improved sewage disposal and better food preservation all had their roles, but Dr. Ash had probably put her finger in the prime mover.

Now this musing came to pass at a time when the current furor about global ecology was just gaining momentum, and a hot item was concern over automobile exhaust.

The scenario with summer infant diarrhea, horses and cars made me wonder just how well anyone understands the dynamics of the environment.

The earth has been polluting its atmosphere for billions of years.

From what I think I know of natural history, our atmosphere came from volcanic pollution and at first was mainly carbon dioxide.

The atmosphere fostered the proliferation of plants, which used carbon dioxide and polluted the atmosphere with oxygen.

A new line of living creatures emerged that used oxygen and put out carbon dioxide -- the animals.

One construction, which could be put on this, is that we are, indeed, the children of pollution.

Looked at this way, it's no small wonder that in one way or another we too will change the atmosphere we found.

Who knows what will come forth as our spray cans shrink the ozone layer, and can we do other than change what we do, but not really desist?

It's even said that flatus from millions of domesticated cattle effect the ozone shield, which seems somewhat akin to summer diarrhea and other animal befoulment such as the "pig ponds" now common in eastern North Carolina.

Watching how such things work out prompted an adage -- whereas every problem has a solution, every solution has three types of problems.

Has the problem being addressed been improved?

Has what has been done revealed a problem that could not have been noted before?

Has what has been done caused an entirely new problem?

I have no answers, but this does suggest an epigram.

Autos foul the air 'til gray
       but there's one thing for sure,
  On streets we stroll in towns today
       there's a lot less horse manure.

__________________

May 28, 1996

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